The Global Ministerial Forum on Research for Health was held In Bamako, Mali From 17-19 November 2008, significantly the first time in Africa. The 'Bamako Call to Action' declared at the end of the meeting is the outcome of four years of meetings, dialogue and survey of key stakeholders the three days of the conference. As many researchers from the region would not have been present in these processes, this editorial, drawn from various public sources, captures some key features of the Call to Action, and provides a “fly on the wall” snapshot of some of the comments and reflections around it. The call and editorials cited are provided in more detail in this newsletter.
In the opening statement to conference delivered by the WHO Regional Director for Africa, Dr Luis Sambo, WHO Director General Dr Chan underlined the key role of research in keeping health high on the political agenda saying: ”We must have evidence and we need the right kind of evidence … because in most countries, an appeal to health equity will not be sufficient to gain high-level political commitment. It will not be enough to persuade other sectors to take health impacts into account in all policies.”
The Call to Action recognises that “Research and innovation have been and will be increasingly essential to find solutions to health problems, address predictable and unpredictable threats to human security, alleviate poverty, and accelerate development;” As one focus the call proposes establishing November 18 each year as a World Day of Research for Health.
National governments are called on to
• give priority to the development of policies for research and innovation for health, especially related to primary health care, in order to secure ownership and control of their research for health agendas;
• allocate at least 2% of budgets of ministries of health to research;
• improve capacity in institutions, ministries, and throughout systems for the implementation of research policies; and to
• develop, set, and enforce standards, regulations, and best practices for fair, accountable, and transparent research processes.
Further recommendations are made to promote the translation and exchange of knowledge and the build research capacities, including in young researchers.
Institutions at the regional level are encouraged to assist countries through international collaboration, where needed, to build and strengthen research for health capacity and to network researchers to promote the quality, ethics and sustainability of research. Meanwhile all stakeholders are called on to implement the recommendations from the WHO Commission on the Social Determinants of Health, especially those related to health equity, including to promote research on technologies addressing neglected and emerging diseases which disproportionately affect low- and middle-income countries and to ensure civil society and community participation in the entire research process.
To support this, funders and international development agencies are called on to better align and harmonize their funding and programmes to country research and innovation for health plans and strategies, and the global health research architecture and its governance to improve coherence and impact, and to increase efficiencies and equity in research. At least 5% of development assistance funds it was felt should be earmarked for the health sector in research, including for support to knowledge translation and evaluation and for national research institutions, especially in low- and middle-income countries.
From many quarters there has been a positive response to the call as a relevant step forward. The Lancet in its 29 November editorial declares that substantial advances have been made at Bamako on previous discussions, and the journal calls for 2009 to be “the year when the promises of Bamako are acted upon”. According to the Science and Development Network of 20 November 2008, the WHO has said that the Call to Action would be "used as a blueprint for research development approaches, with commitments made to submit the communiqué to the 2009 World Health Assembly and to the UNESCO General Conference. Ok Pannenborg, a senior health advisor at the World Bank, said: "The World Bank Group is extremely happy with the outcome, with its focus on research and innovation and research for health. This call will play a huge role in World Bank workings in the next four years".
The process itself was already reported by some to have had an impact. Aissatou Touré from the Institute Pasteur Dakar in Senegal reported in the conference, for example, that after the Algiers meeting, a decision was made to create a commission for research in the country’s health ministry, incorporating all the different actors involved in research for health to define the national research agenda for years to come.
But others were more critical: On SciDev.Net's blog on the conference one delegate asked ““We’re not saying anything new – what is the progress we’ve made?”
"There are no mechanisms in the call," said Damson Kathyola, director of research at the Malawian Ministry of Health, cited in the Science and Development Network review. "The WHO should [now] create innovation mechanisms for the monitoring and evaluation of the implementation of the strategies in the call. "We know that we need research to improve the health situation of our people in our countries. But there is a disconnect between policy and the implementers. Who's going to implement this?"
The World Bank, WHO, UNESCO, the Council on Health Research for Development (COHRED) and the Global Forum for Health Research have committed to set up a multi-stakeholder governance mechanism for research for health, including civil society, as a platform to take Bamako beyond 2008. The intention is to better network and support existing organisations. Will this work, or will it add another player to the increasingly populated work of initiatives and alliances? And how long will this take to be felt by researchers, health workers and communities in the lowest income countries?
The need to move more rapidly to action was perhaps the most common of the frustrations voiced. On the blog site for “Tropical Diseases Research to foster innovation and knowledge application (TropIKA ) “, Chris Bateman, News Editor of the South African Medical Journal is quoted as saying “Lots of fine words have come out. But, as a wild thought, how would it be if each of the 42 ministers were to tell the conference what they intended to do in the next year in terms of applying research to service delivery and filling the gaps where the needs are? That to me would give the conference real bite.” Dr Lindiwe Makubalo, Ministry of Health, South Africa, added further that “…..it’s really time to look at where the blockages are and try to move them”.
One blockage observed was the relative inequality in power in research– between international funders and countries and between researchers and communities, affecting how time and resources are applied. “Could there have been more representation from the groups we (researchers + communicators about health research) claim to represent? It would have been good to know the views of such groups as well,” asked one delegate.
Unless these blockages to implementing practices that are increasingly called for in documents and conference rooms are honestly identified and addressed, then perhaps BMJ Editor-in-Chief, Fiona Godlee, has basis for her more skeptical fears that in four years time, delegates will be having the same conversations at the next conference. Indeed, perhaps this caution, and concerns that resources now be directed to action, often at more local levels, lay behind the clause in the Bamako call to “evaluate the effectiveness and value of the four-yearly ministerial fora prior to convening a further high-level inter-sectoral forum to discuss global research for health priorities”.
1. Editorial
2. Latest Equinet Updates
This meeting provided an opportunity for discussion of evidence in the draft Zimbabwe equity watch from the perspective of people from community and primary health care levels of the health system. Evidence in the Zimbabwe equity analysis provided input to civil society plans within the CWGH and to the resolutions from the CWGH meeting. The discussion on the Zimbabwe equity analysis was a build up to the launch of the book ‘Reclaiming resources for health: A regional analysis for equity in Health in East and Southern Africa’. The event was attended by more than hundred people from Parliament (MPs), Ministry of Health, Ministry of education, academics, representatives from the Health Service Board, private sector, civil society, health worker unions, labour movement, and delegates from the region (Uganda, Malawi, South Africa).
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3. Equity in Health
Théodore MacDonald's latest book, ‘Removing the Barriers to Global Health Equity’, presents an urgent call to bolster international organisations and cooperation in healthcare. Its shocking findings demonstrate how profitable it has become for corporate interests to undermine the UN Universal Declaration of Human Rights, this week celebrating its 60th anniversary. The book indicates steps which can be taken to avert disaster, involving a much higher level of international cooperation than the world has known before. The book provides a meticulously critical analysis of the written record and sharply probing interviews with key figures in UN agencies. It will be officially launched on 21 January.
Overall, child well-being as improved by 34% since 1990, but progress is slow. Leaders must consider how children are doing and how their decisions impact them. Children are doing worse in sub-Saharan Africa than any other region. Africa scores 35 in the Index, reflecting the high level of deprivation in primary schooling, child health and child nutrition. It is also making the slowest progress, improving child well-being by only 20% over 1990-2006. However, progress has been very mixed; some countries in Africa have done incredibly well, while others did spectacularly badly. Countries like Malawi cut child deprivation in half, enrolling more than 90% of primary school children. Some of the poorest children in Africa live in countries suffering from conflict and poor governance, such as Zimbabwe, Somalia and the Democratic Republic of Congo.
4. Values, Policies and Rights
AIDS activists in Uganda have slammed a proposed new law that will force HIV-positive people to reveal their status to their sexual partners, and also allow medical personnel to reveal someone's status to their partner. The HIV Prevention and Control Bill (2008) is intended to provide a legal framework for the national response to HIV, as well as protect the rights of individuals affected by HIV. The bill in its current form could worsen the difficulties many HIV-positive people experience. Certain sections of the bill needed to be revised, for instance, the provision that HIV status disclosure would be mandatory for couples planning to marry, which can only have serious repercussions in a male-dominated society; at least three women have been killed by their husbands this year because they were positive.
This paper identifies some of the right-to-health indicators of health systems, such as a comprehensive national health plan, and proposes 72 indicators that reflect some of these features. It collected data on these indicators for 194 countries. Data was not available for 18 indicators for any country, suggesting that organisations that obtain such data give insufficient attention to the right-to-health features of health systems. Where available, the indicators show where health systems need to be improved to better realise the right to health. Although not perfect, the indicators provide a basis for the monitoring of health systems and the progressive realisation of the right to health. The right to health is not just good management or justice, it is an obligation under human-rights law.
The authors provide ten reasons why criminal laws and criminal prosecutions for people transmitting HIV to others are a bad strategy. First, criminalisation is ineffective. Second, what is really needed are measures that really protect those at risk of contracting HIV. Third, criminalisation victimises, oppresses and endangers women. Fourth, criminalisation is often unfairly and selectively enforced. Fifth, criminalisation places blame on one person instead of two. Sixth, these laws are difficult and degrading to apply. Seventh, many of these laws are extremely poorly drafted. Eighth, criminalisation increases stigma. Ninth, criminalisation is a blatant disinducement to testing. And tenth, criminalisation assumes the worst about people with HIV and, in doing so, it punishes vulnerability.
More than 40 national, regional and international human rights, gender and HIV organisations convened in Cape Town on 27-28 November to discuss trends, implications and realities of HIV criminalisation. Recent global and regional legislative trends indicate a strong call for criminalisation of HIV transmission as one of the measures in response to the growing HIV and Aids pandemics. Whereas supporters of criminalisation reason that it is the only possible response to halt the HIV pandemic, since ‘reckless’ behaviour needs to be ‘criminalised’, opponents of these legislative changes are united in the view that any form of criminalising the transmission of HIV is a gross human rights violation. Moreover, the criminalisation of HIV transmission will further deter people, particularly from vulnerable and marginalised groups, from using HIV testing services.
Sixty years ago this week, the United Nations adopted the Universal Declaration of Human Rights, the first international proclamation of the inherent dignity and equal rights of all people. Yet the Declaration’s enlightened vision of individual freedom, social protection, economic opportunity and duty to community is still unfulfilled. Genocide, torture, domestic violence and discrimination in employment are a daily reality. Above all, poverty is our greatest shame. At least one billion very poor people, 20% of humanity, are daily denied basic rights to adequate food and clean water. As long as gross inequalities between rich and poor persist, it is not possible to claim to be making adequate progress toward fulfilling the ambitions set down 60 years ago. In marking this anniversary, the question raised is how to protect the dignity and equal rights of all.
This publication is a situational assessment, carried out between May and June 2008, of the sexual health and rights of sex workers in Botswana, Namibia, and South Africa, where sex work is illegal. It is based on interviews and focus groups with 87 female, transgender, and male sex workers, as well as 11 non-governmental organisations (NGOs) in the region that work with sex workers. Sex workers suffer unequal access to health care and social services, lack of access to reproductive health, including HIV prevention and treatment, and discrimination by health workers, police and communities. The report highlights opportunities for NGOs, governments, donors and UN agencies to expand rights-based approaches to sex work that will ultimately improve the health and well-being of sex workers.
The Global Call to Action against Poverty Africa (GCAP Africa) secretariat celebrated the 60th anniversary of the Universal Declaration of Human Rights on 10 December. In partnership with the Every Human Has Rights campaign (EHHR) – spearheaded by the Elders, like Nelson Mandela and Desmond Tutu – GCAP is calling for true reflection on the universality of these celebrated rights. It is calling on all humanity and even more so those in power to re-look their interactions and perceptions of those that are extremely marginalised and have absolutely no voice. Africans are well aware of the disparity in the application of all documents regarding human rights. The continued exodus of African people toward the West in search of ‘better lives’ is one clear manifestation of dissatisfaction in Africa.
5. Health equity in economic and trade policies
The Global Call to Action Against Poverty (GCAP) has urged every government attending Doha to reform the global economic system in more democratic forums so the people affected by poverty have a full and equal say. A new financial architecture must deal with global imbalances, the need for government regulation and interventions for each developing country. GCAP was represented at the Financing for Development meeting in Doha by members of the Feminist Taskforce and Arab region, African, Asian and European coalition members and co-chairs. The long-term solution to the financial crisis requires much more than re-establishing rich countries’ economies and bailing out banks. The world needs solutions for a new financial and trade architecture that could provide for the poor and often voiceless people in the world.
The top executives of the World Bank and the International Monetary Fund (IMF) – both Bretton Woods Institutions – have decided not to attend the much-vaunted UN-sponsored Doha conference on Financing for Development. The decision is all the more startling because there remains a clear need for a swift and broad-based response to the financial crisis. By failing to attend the summit, both institutions certainly undermine their claims to leadership. Some observers have interpreted this as a show of contempt for the issues the poorest countries – especially those who did not participate in the G20 Summit on November 15 – may raise about international financial reform. Their conspicuous absence is typical of an approach that favours elitism and ‘club-based’ decision-making over inclusive processes.
This paper seeks to explain the policy-based lending progamme of the World Bank (WB), and the significance of its engagement with developing economies, Africa in particular. The authors find that the Bank, through its policy-based lending, dictates key policies to borrowing countries, thus eroding their autonomous police space and their ability to evolve economic policies best suited to their particular ecologies and peculiar circumstances. The risk of incurring the wrath of the Bank – which will make it to declare such a country non-creditworthy – is often too much for borrowing countries to bear. Clearly, a new model of development will have to emerge from popular political and class struggles at all levels of national and international communities, including the African Union (AU) and the enlarged G77.
This new book provides extensive evidence and data in accessible format for researchers and policymakers in the field of intellectual property rights and gives background information on the origins of the TRIPS Agreement for readers new to the subject. For scholars of international political economy and law, it is the first detailed exploration of the links between global IP politics and the implementation of IP reforms. It exposes how power politics occur not just within global trade talks but afterwards when countries implement agreements. The Implementation Game will be of interest to all those engaged in debates on the global governance of trade and intellectual property.
Confronted with longstanding assertions that World Trade Organization rules intended to bring greater access to medicines to poor countries are not working, WTO Director General Pascal Lamy said discontented members should use the annual review of those rules if they have a complaint. In August 2003, the WTO General Council called for a resolution to the problem of countries lacking pharmaceutical manufacturing capabilities but who need to obtain cheaper medicines through a compulsory license. They created a waiver to the WTO rule that products manufactured under compulsory license must be substantially all for the domestic market. Only Rwanda has so far used the Paragraph 6 process and Lamy said no country had raised any significant concern in the annual review. But an official at the speech questioned the validity of the review process and suggested that no real review had taken place. Health activists have repeatedly said the waiver is too cumbersome to be useful and effective.
6. Poverty and health
In this article exploring the history of socio-economic inequality, the author calls for an interpretation of the current food crisis over the historical long term. As a direct consequence of an entrenched, centuries-old capitalist system, the market as a ‘modernising’ force has consistently enriched the lives of a few while impoverishing a poor majority. Understanding the food crisis rests first and foremost on re-considering humanity’s relationship to nature and championing historical narratives true to the voices and experiences of the global poorest of the poor. Up till now, analysts have been discussing the current food crisis from the perspective of the last few decades, which is very short term, suggesting that the problem is momentary and conjunctural. It is neither and has been in the making for a very long time, as far back as 1491.
This study analyses the report, Circumstances of Orphan and Non-orphan Children and their Care Providers in Mwanza, Tanzania, which sampled 1,960 children aged 6–19. It focuses on vulnerability indicators in children's living arrangements, education, paid work and psychosocial well-being, particularly girls, who are most vulnerable. Particular emphasis should be paid to girls within situation analyses. Vulnerabilities associated with widespread and chronic poverty underlie vulnerabilities related to demographic factors and household restructuring. Their complex interplay reiterates the need for AIDS impact mitigation measures to be built on a comprehensive and robust social protection programme that is driven by poverty reduction objectives.
7. Equitable health services
Four days into one-week 'critical' negotiations on pandemic influenza preparedness, World Health Organization members had yet to tackle areas of core disagreement and participants were expressing doubt as to whether consensus can be achieved before the end of the meeting. Details on the definition of 'Pandemic Influenza Preparedness (PIP) Biological Materials', on the content of a standard material transfer agreement for virus sharing and on the interconnection between a mechanism for virus-sharing and a mechanism for sharing of benefits from vaccine development have yet to be discussed or have been pushed until later in the meeting for more substantive discussion and hoped-for consensus. These interrelated topics represent core differences between member states and thus are likely to be most difficult to resolve at the WHO Pandemic Influenza Preparedness Intergovernmental Meeting.
This study explores caretakers' experiences of care-seeking for childhood febrile illness with fatal outcome in rural Uganda to elucidate the most influential barriers to adequate care. A mixed methods approach using structured Verbal/Social autopsy interviews and case narratives was employed with 26 caretakers living in the Iganga/Mayuge Demographic Surveillance Site who had lost a child 1–59 months old due to acute febrile illness between March and June 2006. The main barriers to care were misdiagnosis by the caregiver, gender and household financial constraints, and dissatisfaction with providers, reflecting inadequate levels of service. Poverty was identified as the underlying theme. Any improvements in basic health care for children suffering from acute febrile illness are likely to substantially reduce mortality.
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8. Human Resources
Ugandan radiography, medical, nursing, dentistry and pharmacy students are sent to community health facilities where they are expected to participate in community services and other primary healthcare activities for training (COBES). This study was designed to obtain the opinions of radiography teachers and students of the significance and relevance of this community-based training to radiography training. Both students and teachers (91.4%) affirmed the community training to be significant and relevant to radiography training. In total, 71.4% of the students had participated in X-ray services and 39.2% in ultrasound services during COBES; and 68.6% of the students reported the need to be better prepared for the COBES training. They confirmed community-based training to be relevant to Ugandan radiography training.
This study systematically reviewed and consolidated existing evidence of the impact of financial and non-financial incentives on the motivation and retention of health workers. Four literature databases were searched, as well as grey literature studies and informational papers. Twenty qualitative and quantitative studies were selected. There was some evidence to suggest that the use of initiatives to improve motivation had been effective in helping retention. While motivational factors are undoubtedly country specific, financial incentives, career development and management issues are core factors. Nevertheless, financial incentives alone are not enough to motivate health workers. Workplace recognition and adequate resources and infrastructure can also improve morale significantly.
The main objective of this study was to evaluate acceptability and feasibility of reinforcing the role of traditional birth attendants (TBAs) in family and child health services through their participation in prevention of mother-to-child transmission (PMTCT) programmes in Zimbabwe. A community based cross-sectional survey was undertaken in two rural districts through interviews and focus group discussions among women who delivered at home with a TBA and who had an institutional delivery and TBAs. More than 85% of women agreed that TBAs could participate in all activities related to a PMTCT programme with the exception of performing a blood test for HIV. There is a need to reinforce the knowledge of TBAs on MTCT prevention measures and better integrate them into the health system.
Underlining the Alliance vision that 'All people everywhere will have access to a skilled, motivated and supported health worker, within a robust health system', the strategic directions and priorities 2009-2011 confirmed the two main objectives within which the Alliance operates: to enable country leadership in national planning and management to improve the human resources for health (HRH) situation and respond to shortages of skilled and motivated health workers; and to address global policy challenges through evidence-informed actions to tackle trans-national problems in areas such as insufficient and inefficient use of resources, fiscal restraints on health sector spending, migration, priority research and cooperation among all stakeholders.
On 2 December, the first meeting of the enlarged Health Cluster was held at the WHO office in Harare. Afterwards, a working group met with the Ministry of Health and Child Welfare (MoHCW) to work out details of a plan to disburse a £500,000 grant from the UK Department for Development Funding DFID to attract health workers back to their posts. This money could be used to kick-start the planned incentive scheme for health workers to be launched in January 2009. Immediate aims include ensuring effective coordination among all health partners providing cholera-related interventions; increasing capacity to provide more clean drinking water in health facilities; strengthening disease reporting, monitoring and assessment under WHO leadership; and procuring more supplies. This will be followed by longer-term support for the health sector’s revitalisation.
9. Public-Private Mix
Richard Smith and colleagues are forceful advocates for a greater role for the private sector in the health systems of low-income countries. Unfortunately, as they also recognise, the evidence to support their position is limited. First, Smith and colleagues pay insufficient attention to the diversity of the private sector in developing countries. Second, they place considerable weight on the proportion of private spending in total health financing. However, this is an imperfect measure of the size of the private sector. Third, it is not true to say that governments and donors have completely ignored the private sector. What is needed is for the global public health community to commit to developing a strong evidence base on private sector engagement so that future debates can be grounded in better understanding.
Danone, the world’s second largest baby food company, now sits on the governing body of the Global Fund for Improved Nutrition (GAIN). But there is no mention of Danone’s interest in baby foods on the GAIN website nor any mention that it is a systematic Code violator. GAIN claims to be working to improve nutrition by building markets for fortified foods in the developing world and has now launched a project on infant and young child nutrition. Concerned about this unacceptable conflict of interest, 53 experts from 24 countries, attending the World Alliance for Breastfeeding Action (WABA) workshop in October, have written to WHO and UNICEF calling on them to reconsider their partnership with GAIN. GAIN is bound to undermine breastfeeding and the use of indigenous, traditional and low-cost foods, they say.
These two viewpoints agree much more than they disagree. Both agree that the public sector cannot be ignored and both agree that there is a role for the private sector in improving the health of the world's poorest. The disagreement is about emphasis. Smith et al believe that many countries will benefit more from harnessing the energy of the private sector rather than continuing to invest solely or mainly in the public sector. The public sector, growing evidence of the effectiveness of the private sector, and energetic non-state organisations, are already working to harness the power of the private sector to achieve better health care for all. Evaluation will be crucial, but the most important research question is not ‘Can the private sector help?’ but ‘How can public–private partnerships be made most effective and equitable?’
Is private health care the answer for the world's poor? This article’s starting point is that there are no strong grounds for assuming the superiority of either public or private health care. Theory dictates that it is not whether a health facility is publicly or privately owned that determines health provider performance. Instead, what influences performance is the nature of incentives that providers face and the quality of management and oversight. Theory does, however, suggest that the profit-making incentive dominant in much of the private sector is likely to be problematic for health care. Is there then scope for private providers to be paid through public financing? Past experiences all point to the significant transactions costs of such arrangements and the need for strong and capable contracting units within health ministries.
This article argues that, with a complicated problem such as improving health care under constrained resources, two heads are better than one. The public and private sectors have different strengths and weaknesses, and a judicious blending of the two can produce optimal results. Indeed, there is no health system that is entirely public or private. The reality is that, in most low-income countries, most people receive most of their care from the broadly defined private sector. About 60% of the US$16.7 billion spent on health in sub-Saharan Africa in 2005 was private, most of it out-of-pocket spending by individuals, and about half of this went to private providers. Some countries are now exploring pluralistic models that partner with the private sector to serve public policy goals. These models should be encouraged and supported.
10. Resource allocation and health financing
The Free State health department has announced that its financial situation has reached ‘dire proportions’ forcing it to postpone all non-emergency surgery until January next year and stop all non-critical staff appointments. HIV clinics are coming under increasing threat of being closed down, as they are considered part of the outpatient services that are being stopped. The Treatment Action Campaign said it also continued to receive reports from doctors who are turning critically ill patients away from their clinics because of antiretroviral shortages. Doctors predict a large number of people are going to die over Christmas, notably poor people, because government won’t commit money to solving the problem. The measures apply to all of its 31 health facilities, including hospitals and clinics.
Millions of people in low- and middle-income countries cannot afford or obtain the medicines they need, according to this study. It is based on findings from 45 surveys carried out since 2001 in 36 countries, using a standardised methodology developed by the Health Advance Institute (HAI) and World Health Organization (WHO). Across the surveys, public sector availability of generics averaged a disappointing 38%. Even in the private sector, the availability of generics was far from ideal and sometimes unaffordable to many, yet implementing policies that increase the use of low-priced quality generics would help significantly. Policies to ensure competition and incentives for pharmacies to dispense low-priced generics are needed. Governments could also review all policies affecting medicine prices and availability.
Publish What You Fund is a new initiative to promote transparency of international aid. It consists of civil society groups from around the world, including organisations working on aid effectiveness and groups working on access to government information. They believe that, for aid to be effective, accountable and participatory, it must be transparent. Information must be available to recipient governments, affected communities and other stakeholders, as well as the general public. The campaign has been busy drafting a first set of principles. These principles have had one round of consultation (between July and August 2008) and were presented at the Accra High Level Forum on Aid Effectiveness (Ghana, 2–4 September 2008). You can add your comments on their website.
The Currency Transaction Tax (CTT) proposes a small levy on foreign exchange transactions and uses the money raised to finance development projects for the global public good. CTT is basically a tax on the benefits of globalisation. This study claims the tax would be easy to operate and difficult to evade since all foreign exchange transactions are completed in a few large centralised settlement structures. It estimated that a CTT of 0.005% on each transaction in major currencies would yield approximately US$ 33 billion. The money could be allocated for development and administered multilaterally. Critics say this tax will reduce foreign currency transactions and create inefficiencies in trading markets; however, it is specifically designed to raise money without disrupting the market.
Aid is ineffective and donors should raise the effectiveness of their aid by reducing the amount of ‘aid’ that is actually spent in donor countries themselves and by reducing the number of sectors and countries each donor tries to support. Thanks to today’s financial crisis, global trade might contract for the first time in decades and demand for poor countries’ exports will decline, while credit dries up, devastating poor producers’ livelihoods. Rich countries should start by eliminating wasteful agricultural policies that only help their own farmers at the expense of poor people elsewhere. Limitations to market access for the poorest and most vulnerable economies must be lifted. Rich countries may promise to provide 100% free market access, but maintain restrictions that make a mockery of their commitments.
11. Equity and HIV/AIDS
This paper investigated antiretroviral-treatment strategies in the Children with HIV Early Antiretroviral Therapy (CHER) trial. HIV-infected infants 6 to 12 weeks of age with a CD4 percentage of 25% or more were randomly assigned to receive antiretroviral therapy until the CD4 percentage decreased to less than 20% (or 25% if the child was younger than 1 year), specific clinical criteria were met or the child needed to immediately start on limited antiretroviral therapy. The children were followed up after 40 weeks and, after a review by the data and safety monitoring board, some of the infants were reassessed for the initiation of antiretroviral therapy. The paper concluded that early HIV diagnosis and early antiretroviral therapy reduced early infant mortality by 76% and HIV progression by 75%.
Between 26 November and 1 December (World AIDS Day) the AIDS Healthcare Foundation (AHF), a US-based NGO, set a goal of testing one million people around the world. More than 1,000 people were tested for HIV at a busy marketplace in the Ugandan capital, Kampala, kicking off a nationwide drive that aims to help at least 20,000 people across the country know their status. HIV prevalence is around 6%, but only 21% of Ugandans know their HIV status. The large turnout for the testing event proved that many people wanted to know their status but hadn't had the opportunity to get tested. The campaign sees AHF partnering with 972 organisations in 72 countries around the world. A standard model is used at all sites, involving pre-test counselling, a one-minute test, post-test counselling and treatment referral.
South Africa has flunked with an E-symbol (0-20%) when it come to the amount of money spent on HIV/AIDS, but attained an overall B-symbol for its response to the epidemic on the AIDS Reporting Index, an AIDS Accountability International (AAI) scorecard. South Africa scored a D for data collection, which the AAI said was largely due to poor reporting, with no improvement since the last time the country was assessed. The country showed an improvement in antiretroviral coverage (2% in 2004 to 28% in 2008), but the AAI noted overall performance remained poor (D-symbol) with only just over a quarter of those needing treatment getting it. The overall low score is due to poor performance rather than poor reporting, it added.
KwaZulu-Natal Health MEC, Peggy Nkonyeni, is attempting to introduce traditional medicine for AIDS patients at a hospice with the help of traditional healers. The Treatment Action Campaign said African traditional healers have a role in combating HIV but they are concerned that disreputable stakeholders are included, especially those who are not traditional healers and who have caused harm with so-called ‘alternative’ remedies.
This study investigated a theoretical strategy of universal voluntary HIV testing and immediate treatment with ART, and examined the conditions under which the HIV epidemic could be driven towards elimination. Data from South Africa was used as the test case for a generalised epidemic, and it was assumed that all HIV transmission was heterosexual. The study found that the strategy could greatly accelerate the transition from the present endemic phase, in which most adults living with HIV are not receiving ART, to an elimination phase, in which most are on ART, within five years. It could reduce HIV incidence and mortality to less than one case per 1,000 people per year by 2016. Universal voluntary HIV testing and immediate ART, combined with present prevention approaches, could have a major effect on severe generalised HIV/AIDS epidemics.
The United States government policy has violated the human rights of people living with HIV and AIDS through its ‘moral’ restrictions prioritising abstinence-only sex education, restricting condom distribution and stigmatising sex workers. The government’s close ties with pharmaceutical companies and manipulation of trade in medicines have also infringed on the human right to health by undermining international efforts to enshrine access to essential medicines as a human right. By sanitising and de-sexualising the politics of HIV and AIDS, and focusing on technocratic approaches such as biomedical quick fixes, like the recent emphasis on male circumcision, it ignores the deeply gendered, racial and sexual dimensions of the disease or its social, economic and cultural pathology.
12. Governance and participation in health
Volunteers and volunteer-involving organisations around the world celebrated International Volunteer Day on 5 December in order to increase recognition of the contribution of volunteerism to peace and development. International Volunteer Day was adopted by the United Nations General Assembly on 17 December 1985. Since then volunteers and volunteer-involving organisations have joined with governments, NGOs, UN agencies and other partners to celebrate volunteerism and lay the ground for future activities. Yet volunteerism remains under-recognised and under-utilised as a resource for development, lamented the UN Secretary-General in his message this year. He urged all to continue to make every effort to raise awareness, measure impact and recognise that their efforts are making a positive difference.
The poor have not been consulted about the current global financial crisis. So far, all gatherings have been of the rich, from the World Economic Forum to the G8 Summit. At some point in the future, poor countries will merely be requested to endorse the decisions already taken by rich countries and to pick up the remaining crumbs. Ironically, the five powers that decide on war and peace within the UN Security Council are also the five biggest arms dealers of the planet (China, USA, Russian Federation, France and the UK). Rich countries are also the sole decision-makers in the reform of the Bretton Woods institutions (World Bank and International Monetary Fund) that take money from poor and indebted countries. It’s time for poor countries to be given an opportunity to take part in these crucial decisions.
The Bill and Melinda Gates Foundation, which spends billions on global health, is taking a direct route to ensuring global health coverage for all. NewsHour with Jim Lehrer in the United States received a Gates Foundation grant of US$3.5 million to help its correspondents produce 40 to 50 reports over three years on malaria, AIDS, tuberculosis, measles, neglected diseases and other global health issues. It came with ‘no strings’, reported the managing producer of NewsHour, which is seen on 315 PBS stations, noting that, if her reporters found a story critical of the Foundation’s work and Mr Gates objected, she’d let him defend it, of course, but was still determined to proceed with the story.
13. Monitoring equity and research policy
Adopted on 19 November – the final day of the Global Ministerial Forum on Research for Health hosted by the government of Mali in Bamako – the Call to Action urges national governments to allocate at least 2% of budgets of ministries of health to research. In parallel, funders of research and innovation, together with international development agencies, are urged to invest at least 5% of development assistance funds earmarked for the health sector in research, according to recipient country-led research strategies, instead of allowing the current situation to continue, where donor countries push their own agendas, thus shaping the agenda on behalf of recipient countries. The signatories have called for greater equity by increasing spending on researching the health challenges that disproportionately affect the poor, marginalised and disadvantaged.
An important focus of the Bamako Call to Action was to ensure that research priorities were determined by countries, not global institutions. To this end, the multilateral contributors to Bamako – WHO, UNESCO and the World Bank – were asked to promote, expand and implement research strategies with an emphasis on listening to country agendas and responding to their priorities. The idea of 18 November as an annual World Day of Research for Health was proposed as one means to maintain attention on this lever for health improvement. The Call to Action will now go to WHO’s Executive Board in January 2009, where they will do their utmost to ensure implementation of these urgent country requests. 2009 needs to be a year of action, not empty promises.
Progress since the last WHO ministerial summit in Mexico in 2004 is not striking, though there is the clinical trials platform, as well as new initiatives for knowledge translation networks like EVIDnet, and other local and regional projects that have achieved fragmented success. The Mexico declaration called for health ministries to dedicate at least 2% of their budgets to research. For most developing countries this remains an aspiration, with most still well below 1%. The problem is that research is a hard thing to sell where resources are tight. Convincing the public that research is not a luxury can be difficult. Hopefully, by the next ministerial summit in 2012, the discussion will no longer be about research for the world’s poorest nations but research by them for themselves. But, sadly, it seems all too possible that four years from now participants will be having exactly the same conversations.
This study looks at the enduring issue of how to strengthen the informational base on which funders make their social investment decisions. It asks two questions: How can we help donors make smart philanthropic decisions? How can we ensure that the strongest, most effective nonprofits get the resources they need? The report complements the recommendations in Keystone's report, Online Philanthropy Markets: From Feel-good Giving to Effective Social Investing, by enabling donors to think as social investors, providing comparative data on the performance and impact of social purpose organisations, and working towards a common reporting framework. However, unlike Keystone's report, this study puts the strategic focus on major donors.
Ministers and representatives of ministries of health, science and technology, education, foreign affairs, and international cooperation from 53 countries signed the Bamako Call to Action to promote health research in Africa. This document contains many references to improving the current state of affairs in Africa, where Africans are the objects of foreign research instead of conducting the research themselves. Efforts to build capacity, ensure equity, co-operate regionally, use knowledge translation, include all stakeholders and put appropriate legislation in place will be needed urgently if things are to change for Africa. The Call to Action pledges many grand promises for Africa’s future and the scope of action is wide indeed.
The World Health Organization has called on governments to prioritise health research and echoed a proposal by the Commission on Social Determinants of Health for the inclusion of health in the policies of all government ministries and departments. The call was made by WHO Director-General, Dr Margaret Chan, in a statement to the Global Ministerial Forum on Research for Health Research in Bamako, Mali. Dr Chan underlined the key role of research in keeping health high on the political agenda saying: 'We must have evidence and we need the right kind of evidence … because in most countries, an appeal to health equity will not be sufficient to gain high-level political commitment. It will not be enough to persuade other sectors to take health impacts into account in all policies. In matters of health, equitable access to care is a matter of life or death. When equity is at stake, the health sector must take on a proactive role, even if this means stepping into territories outside the usual domain of public health.'
14. Useful Resources
The ability to define and measure humanitarian impact is essential to providing operational agencies with the tools to systematically evaluate the relative efficacy of various types of interventions. This guide aims to provide practitioners with a broad framework for carrying out project-level Participatory Impact Assessments (PIA) of livelihoods interventions in the humanitarian sector. The PIA approach consists of a flexible methodology that can be adapted to local conditions. It also acknowledges local people, or project clients, as experts by emphasising the involvement of project participants and community members from the outset. The proposed framework provides an eight stage approach, and presents examples of tools which may be adapted to different contexts.
STAR is a scheme which makes scholarly publications more widely available to those who have difficulty affording them. It is aimed at Individual academics in sub-Saharan Africa who would like to gain access to cutting-edge research in a wide variety of subject areas. Benefits include FREE access to over 300 Taylor & Francis Group journals online, including all physical science and technology titles, reduced rate personal print subscriptions to over 100 Taylor & Francis journals, covering subjects from archaeology to women's studies, and ongoing special offers. If you register at the address above, you’ll also receive regular news updates on the benefits available.
This is the fourth in a series of technical briefings, produced by the Association of Public Health Observatories (APHO), designed to support public health practitioners and analysts and to promote the use of public health intelligence in decision making. APHO Technical Briefings looks at key issues to consider when setting targets in a multi-agency environment, including the choice of appropriate methodologies, indicators and statistics, and consideration of the wider political and ethical context.
This guide is intended to be a short, practical resource for anyone in any health system who is responsible for using indicators to monitor and improve performance, systems or outcomes. After reading this guide, you should be able to assess the validity of the indicators you are working with, allowing you to exert more control over the way your organisation is properly judged, regulated and run. Underlining all this is the reality that anyone working in a health system is working in a complex and political environment. This guide aims to balance what is desirable, in terms of using indicators in the most correct and most rigorous way, with what is practical and achievable in such settings.
15. Jobs and Announcements
The Fifth International Conference of the International Society for Equity in Health will be hosted by the Greek School of Public Health in Crete from 9-11 June 2009. It will bring together, researchers, policy-makers, practitioners and others concerned with equity in health to develop and international health agenda for governments, universities and organisations all over the world. The theme is ‘Social and Societal Influences on Equity in Health’. Abstracts should ideally reflect a multidisciplinary conceptualisation of health equity, analyse or compare (rather than just describe), address issues of generalisability of findings beyond the particular population studied, include and compare different age groups and both genders, and address access/utilisation/appropriateness of health services across populations.
The Canada Gairdner Global Health Award is directed at health issues pertaining to developing countries. It recognises those who have made major scientific advances in basic science, clinical science, population health or environmental health. These advances must have, or have potential to make a significant impact on health outcomes in the developing world. Nominations for leadership and administration, however outstanding, do not fall within the parameters of this award. The long-term goal of this prize is to reward and stimulate members of the global scientific and medical community to undertake research that will lead to advances valuable to the health of nations. The Global Health Award consists of $100,000 (Canadian), a framed certificate with appropriate citation and a specially designed sculpture.
The Open Society Initiative for Southern Africa (OSISA), the Open Society Initiative for East Africa (OSIEA), and the Open Society Institute’s (OSI) Public Health Programme are requesting proposals from coalitions of women’s rights and HIV/AIDS organisations in southern Africa that wish to develop proposals for submission to the Global Fund to Fight AIDS, TB and Malaria addressing the specific vulnerabilities of women and girls. A detailed proposal must be submitted to the Global Fund that outlines and estimates costs for specific, evidence-based interventions to improve women's and girls' access to health treatment, educate them about HIV and AIDS, meet their sexual and reproductive health needs and promote their human rights.
Registration for activities proposed for the World Social Forum (WSF) 2009 ended on 21 November and more than 2,400 activities were registered by organisations and movements from 60 countries. Now it's time to start convergences and merging among the participant organisations. The WSF is a space for exchange and strengthening of alternatives built by networks and movements from all over the world, so it's very important that all the initiatives and organisations try to build alliances. If you have registered for the Forum, it's strongly recommended that you check the list of activities proposed by other organisations before you confirm your activity (18 December) to try to establish contacts to unify activities or to build a common programme with similar initiatives.
Published by the Regional Network for Equity in Health in east and southern Africa (EQUINET) with technical support from Training and Research Support Centre (TARSC).
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