It is increasingly clear that without accessible, equitable, quality health services we will continue to fall short on delivering on the health Millennium Development Goals or commitments made on access to treatment for AIDS and other major diseases. So the negotiations currently underway on services under the Economic Partnership Agreements (EPAs) between the European Union (EU) and East and Southern African (ESA) countries are a matter for wide public interest. In August last year we pointed to issues for concern in these negotiations. With the negotiations underway, these issues become an even greater matter for public and parliamentary concern: Will they bring new resources and partnerships in building our health services, or will they blow new holes in already fragile systems?
The EPAs were supposed to have been concluded in 2008, but when none of the African negotiating groups was able to reach a final agreement, most initialled Interim EPAs (IEPAs) with the EU to avoid trade disruption. Many countries, the African Union and the Economic Commission for Africa observed that the EPAs needed to more explicitly put development at the centre, and civil society called for more explicit protection of public health. The IEPA with SADC explicitly protected health by providing, in Article 3, that the application of the agreement should take into account the human, cultural, economic, social, health and environmental interests of the population and of future generations. The IEPA with other ESA countries did not. So countries are going into negotiations on specific trade issues, including trade in services, with different levels of protection in their framework agreement.
ESA countries have already been very cautious about liberalising trade in health services, given the need for public sector health services to be delivered outside the market to populations living below the poverty line and the need for additional government measures and subsidies to staff, and provide these services. Few ESA countries have thus committed their health services to liberalisation in the World Trade Organisation (WTO) GATS agreement, preferring to determine the pace and nature of any market opening within reversible domestic policies. In ESA, only Malawi and Zambia have made GATS level commitments in the health sector.
Meanwhile the EPA services negotiations are going on largely below the radar. While the umbrella Cotonou Agreement of June 2000 explicitly commits EU and ACP states to the development of the social sector, there are also strong signals that the liberalisation of all services will be actively promoted.
So it depends largely on what the negotiators agree in the coming months. ESA countries have no obligation to trade in health services and may elect, without prejudice, to explicitly exclude trade in health services. Under conditions of unequal access and differentials in coverage, ESA governments may justly feel that they cannot reduce government authorities to regulate providers, to compel cross subsidies, increase risk pools, manage health worker migration and other measures needed to ensure universal health care coverage. Hence the 2006 AU Conference of Ministers of Trade stated: “We shall not make services commitments in the EPAs that go beyond our WTO commitments and we urge our EU partners not to push our countries to do so.”
There are numerous arguments negotiators should be raising for excluding health services from EPA compelled trade liberalisation.
Both ESA and EU countries are signatory to international treaties, conventions and constitutional obligations to health and health care that create obligations to be discharged by the State Parties. Negotiators should be cautious about clauses in the services negotiations appear to undermine these commitments. Using the precautionary principle that applies in public health, those promoting clauses that appear to undermine these commitments should be asked to prove why they do not do so.
As raised in previous debates on trade and health, ESA countries need to protect the flexibilities already won under WTO agreements. the TRIPS agreement allows for government authorities to compulsory licensing and parallel importation. The GATS agreement provides for flexbility for governments to follow “a reasonable time-frame”, to bar foreign services suppliers from operating at the same conditions with local providers where this is necessary to protect health, or to grant more favourable treatment to service suppliers from regional bodies of only developing countries like SADC. ESA negotiators should resist any liberalisation process which forces them to take on obligations or a faster pace of liberalisation than that which obtains currently under the WTO process.
However we could go further. Protecting public health and access to health services demands more than a defensive posture in the negotiations. ESA countries could use the services negotiations to more explicitly protect public health and recognize state obligations to protect universal and equitable access to health services. For example, negotiators could include clauses that
 Recognize the priority for protection of public health as a guiding principle, as provided for in the EU-SADC IEPA.
 Commit parties to allowing government authorities and availing specific resources to the public health sectors of the ESA countries as part of the development dimension of the EPA.
 Commit the parties as in Article 25 of the Cotonou Agreement to make available adequate funds for improving health systems and primary health care, including for regulating the operations of the private health sector.
 Commit the parties to co-operation on ensuring ethical practice on the migration of health workers, including in terms of making technical and resource investments to address the costs to ESA countries of permanent health worker migration to the EU;
 Commit the parties to provide overseas development aid for health programmes in a manner that integrates with national financing arrangements and that avoid outflows of critical health personnel from public health services, in line with the principles of the Paris Declaration on Aid Effectiveness.
The services negotiations are an opportunity to raise again that the health sector should be part of the development chapter of a comprehensive EPA, as envisaged under article 34 of the Cotonou Agreement, and not simply a matter for market trading. Concluding the services negotiations before this is clarified would seem to be a case of the cart pulling the horse. Even more importantly, the cart should not be pulled in the dead of night. Given the significant ‘life or death’ impact for millions of people in the region of any discussions that affect health services, the negotiators should bring such issues to public and parliamentary forums for debate and feedback, before they conclude.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on the health issues in the EPA negotiations please visit the EQUINET website- www.equinetafrica.org. or SEATINI website (www.seatini.org)
1. Editorial
2. Latest Equinet Updates
This study, commissioned by EQUINET, ECSA-HC and WHO, aimed to review and critically analyse the literature and secondary evidence on the impact of HIV and AIDS programmes on health care worker (HCW) retention in east and southern Africa. Early studies reported negative effects of HIV and AIDS and the delivery of HIV and AIDS services on HCW morale with stigma, burn-out, resignation and deaths due to HIV and AIDS, while more recent ones speak of hope, high prestige, high motivation and better retention of HCWs in HIV and AIDS programmes, largely due to effective antiretroviral therapy (ART) which has improved the prognosis of AIDS. Global Health Initiatives have contributed to the expansion of HCW numbers through training, higher salaries or salary supplements, such as better furnished facilities or appointment at higher levels, often to the exclusion of other HCWs. Selectively applied incentives tend to demoralise and discourage those who are excluded; as illustrated by examples from programmes in South Africa, Tanzania and Guyana. But well funded HIV and AIDS programmes are attractive to HCWs and may contribute to internal brain drain. In contrast, more inclusive approaches, such as in Malawi where MSF supplemented salaries of all health workers in the operational districts, and Namibia where the Ministry of Health and Social Services applied uniform terms and conditions of service for all HCWs, reportedly experienced no problems. Some countries have an ‘emergency response’ approach to HIV and AIDS; hence they accept any help, usually on the funders’ terms, leading to fragmented vertical programmes. The lack of integration of HIV and AIDS services into other health programmes is a problem in many countries. Where successfully integrated programmes do exist - such as HIV and TB, HIV and sexual and reproductive health, and even those where HIV and AIDS services are fully integrated into the public health system - integrated programmes benefited the whole system. There have been fears that existing inequalities in health care may be intensified in scaling up HIV and AIDS services. There are, however, reports showing that a public health and equitable approach to the roll-out of ART is possible across all socio-economic groups with similar outcomes. HIV and AIDS programmes have the potential to benefit the health system by attracting and retaining HCWs in the health system; and indeed, innovations such as task shifting and the integrated management of adult and adolescent illness have been applied to more efficiently use available HCWs. Many vertical programmes recruit their own HCWs, especially counsellors and home-based caregivers. This can increase the pool of HCWs. By relying on the health system for the more skilled health professionals, however, HIV and AIDS programmes may also undermine other health programmes. We recommend that country-level case studies be undertaken to document the various approaches, such as engagement between countries and funding agencies, country perspective on NGO roles, the implementation of the ‘Three Ones’, SWAP and public health approach; and the impact of national and project specific initiatives on HCWs.
Negotiations are underway on the services agreements towards concluding a full and comprehensive Economic Partnership Agreement (EPA) between East and Southern African countries (ESA) and the European Union (EU). The services negotiations will impact on health services and access to health care. The brief outlines the issues affecting health services, and presents options for ESA negotiators to ensure that the negotiations meet international and African health and human rights commitments, use available trade flexibilities, promote public health and ensure adequate assessment and information to support the negotiations.
3. Equity in Health
Health security must be addressed with great urgency, and health-system strengthening is one of the surest routes to health security. We are not secure when the difference in life expectancy between the poorest and the richest countries exceeds 40 years, or when annual governmental expenditure on health ranges from US$20 per person to well over $6000. We are not secure when more than 40% of the population in sub-Saharan Africa is living on less than a dollar a day. Medicine has never before possessed such sophisticated treatments and procedures for curing disease and prolonging life. Yet, each year, nearly 10 million young children and pregnant women have their lives cut short, largely by preventable causes. Economic development will not automatically protect people who are poor or guarantee universal access to health care. Health systems will not automatically gravitate toward greater fairness and efficiency. International trade and economic agreements will not automatically consider effects on health. Deliberate policy decisions are needed in all these areas.
Estimates suggest that achievement of the Millennium Development Goal targets would require Kenya, Lesotho and Zambia to spend more than 40% of their gross domestic product on health by 2015. This can only be achieved if donor countries honour their commitment to developmental assistance. But, by 2010, the G8 countries will have only delivered US$3 billion of the US$21.8 billion committed in 2005 for Africa. the authors assert that it is difficult to convince politicians and bureaucrats about the long-term benefits of social interventions when they are focused on biomedical interventions that impact their status in the short term. Africa. It is difficult to attribute causation to social interventions for long-term outcomes. It is also difficult to conduct randomized controlled trials of social interventions designed to reduce inequities, generalize findings from one research context to another, or generate evidence for the cost-effectiveness of the social interventions. Given the scarcity of resources, such evidence is sorely needed.
4. Values, Policies and Rights
This paper explores the legal and normative potential of the right to health to mitigate the restrictive impact of trade-related intellectual property rules on access to medicines, as evidenced by the global outcomes of the seminal pharmaceutical company litigation in South Africa in 2001. The author argues that the litigation and resulting public furor provoked a paradigm shift in global approaches to AIDS treatment in sub-Saharan Africa. She argues further that this outcome illustrates how human rights in concert with social action were able to effectively challenge dominant claims about the necessity of stringent trade-related intellectual property rights in poor countries, and ergo, to raise the priority of public health needs in related decision-making. The author explores the causal role of rights in achieving these outcomes through the analytical lens provided by international legal compliance theories, and in particular, the model of normative emergence proposed by Martha Finnemore and Kathryn Sikkink. She suggests that the AIDS medicines experience offers strategic guidance for realizing the right to health’s transformative potential with regard to essential medicines more generally.
South African researchers and traditional leaders are reported to have raised concern that scientists could patent the genes of local ethnic groups who have donated blood samples as part of a worldwide genome-mapping project. Several lawyers, researchers and community leaders have denounced an American patent application for unique gene mutations found in DNA samples collected in Tanzania, Kenya and Sudan. The applicants from the University of Pennsylvania, are reported to have collected more than 2,000 samples in East Africa and to have a blood bank of more than 5,000 samples in total, taken from 80 African ethnic groups.
Despite the cholera epidemic in Zimbabwe continuing for more than six months, sanitation remains poor and lack of access to safe drinking water persists against the backdrop of a collapsed health system with degraded infrastructure and very few health workers. Health in Zimbabwe is presently largely unavailable, unacceptable, inaccessible and of poor quality. This report concludes that Zimbabwe will require long term commitment of the humanitarian and donor agencies working in the country with large scale, multi-faceted assistance to address the situation. It urges the government of Zimbabwe to formulate an emergency health response plan to restore the public health system must be produced and implemented. The authors argue that government should also ensure the supply of clean drinking water and adequate sanitation.
Access to medicines forms an indispensable part of the right to the highest attainable standard of health. Numerous court cases, as well as resolutions of the United Nations (UN) Commission on Human Rights, confirm that access to essential medicines is a fundamental element of the right to health. This briefing examines the issue of access to medicines in the context of sexual and reproductive health. Sexual and reproductive health are key elements of the right to the highest attainable standard of health. The briefing considers the responsibilities of pharmaceutical companies for enhancing access to medicines. The briefing also introduces the background and content of the Human Rights Guidelines for Pharmaceutical Companies in Relation to Access to Medicines ('the Guidelines'). Based on the right to health responsibilities of pharmaceutical companies, the Guidelines provide a framework for enhancing access to medicines.
5. Health equity in economic and trade policies
The ambassadors to the World Trade Organization (WTO) from Brazil and India charged that other WTO members had no grounds to block legitimate shipping of generic medicines on the basis of potential intellectual property (IP) rights conflicts in the transit country and said recent cases of doing so in the Netherlands call into question WTO rules. The complaint was supported by seventeen other developing country governments at the recent WTO General Council meeting. The Brazilian ambassador was gravely concerned with the setting of a precedent for extraterritorial enforcement of IP rights. Attempts to extend the rights granted by patents beyond national borders have critical systemic implications, he said. Furthermore, extraterritorial enforcement of patent rights violates a nation’s sovereign right to take measures to protect its public health, including access to medicines.
The generic industry is in trouble again, and the issue is now becoming a major non-tariff barrier against developing countries like India. Two large drug consignments of generic medicines were seized in Netherlands by its customs authorities recently. The drugs, while in transit to Peru, were held at Rotterdam port because they infringed patents in EU. Sources said that recently many essential drugs have been held at European ports on way to Africa or Latin America from India by EU customs for intellectual property infringement or by labelling them 'counterfeits'. India is a source of affordable life saving medicines for many African and developing countries, and companies use the established trading route passing through EU ports for supplying essential medicines to millions across the world, potentially jeopardising the lives of those needing drugs in those countries.
With regard to The Lancet’s series of articles on the inter-relations between the two policy spheres of trade and health, the author of this paper expresses his disappointment with the hazy direction and lack of leadership of the global governance in addressing inadequate access to essential medicines for the poorest population as a result of market exclusivity and patent protection, rendering statements and declarations made by heads of states and leaders of international organisations as rhetoric. The paper draws this conclusion from lessons learned from the experience of compulsory licensing in Thailand and the management of disptutes between Thailand and patent-holding companies and their parent-country governments.
The World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) set global minimum standards for the protection of intellectual property, substantially increasing and expanding intellectual-property rights, and generated clear gains for the pharmaceutical industry and the developed world. The question of whether TRIPS generated gains for developing countries, in the form of increased exports, is addressed in this paper. The authors consider the importance of pharmaceuticals in health-care trade, outlining the essential requirements, implications, and issues related to TRIPS, and TRIPS-plus, in which increased restrictions are imposed as part of bilateral free-trade agreements. TRIPS has not generated substantial gains for developing countries, but has further increased pharmaceutical trade in developed countries. The unequal trade between developed and developing countries (ie, exporting and importing high-value patented drugs, respectively) raises the issue of access to medicines, which is exacerbated by TRIPS-plus provisions, although many countries have not even enacted provision for TRIPS flexibilities. The paper focuses on options that are available to the health community to advance negotiations to their advantage under TRIPS, and within the presence of TRIPS-plus.
Developing countries have voiced concerns at a meeting of the Executive Board of the World Health Organization (WHO) over the Secretariat using the term ‘counterfeit’ to describe problems relating to the quality, safety and efficacy of medical products, and addressing such problems through the International Medical Products Anti-Counterfeit Taskforce (IMPACT). Some countries felt the WHO's anti-counterfeit taskforce, IMPACT, was unsuited to address the issue of quality, safety and efficacy (QSE) of medical products because it lacked a mandate from the WHO's governing bodies; and because of its emphasis on counterfeits; the involvement of the private sector in its activities raising issues of conflict of interest; and its lack of transparency.’
6. Poverty and health
Gender equality is essential for poverty reduction and sustained economic growth, yet lack of money remains one of the greatest impediments to achieving it. In a new compilation of essays from around the world, gender experts and development practitioners examine how to ensure that sufficient financial resources are available to make the changes that not only affect the lives of millions of women, but also impact on society as a whole. One of the biggest impediments to gender equality is lack of money. Although countries have signed up to the Monterrey Consensus and have developed plans of action for women, national and state budgets have not reflected the same priorities. The Monterrey Consensus is distinguished by its recognition of both the need for developing countries to take responsibility for their own poverty reduction and the necessity for rich nations to support this endeavour with more open trade and increased financial aid. Lack of access to land, credit, information, lack of participation in decision-making within the family and community and their reproductive role mean that women's capacity to take advantage of economic opportunities is inhibited. Although it has been recognised that these issues have serious costs to society, there has not been solid progress in formulating and implementing policies and programmes that are gender-sensitive. The paper calls for governments, bilateral and multilateral organisations to scale up their commitments to financing gender equality, making a real difference to the lives of women, reduce poverty and promote sustainable development.
Unlike the other developing regions of the world where poverty has been on the decline, the proportion of people living below the poverty line in Africa increased from 42.6 percent in 1980 to 44.1 percent in 1990 and 45.7 percent in 2003. Consequently, an increasing number of Africans have suffered from insufficient income and capacity to access food and other basic amenities such as potable water, minimum health care and education. The poor performance of the continent in achieving sustained economic growth and poverty reduction is also manifest in that, although most African economics remain essentially agrarian with about 60 percent of the total labor force being employed in agriculture, the continent has failed to feed its growing population. This paper attempts to understand how the African continent found itself into this loop of poverty. The author analyses the causes that have brought Africa to its present state of poverty and food insecurity.
Despite the lack of reliable trend data on maternal mortality, some investigators now believe that progress in maternal health has been very slow in sub-Saharan Africa. This study uses a unique combination of health facility- and individual-level data collected in the slums of Nairobi, Kenya to: describe the provision of obstetric care in the Nairobi informal settlements; describe the patterns of antenatal and delivery care, notably in terms of timing, frequency, and quality of care; and draw policy implications aimed at improving maternal health among the rapidly growing urban poor populations. It shows that the study area is deprived of public health services and that despite the high prevalence of antenatal care (ANC), the proportion of women who made the recommended number of visits or who initiated the visit in the first trimester of pregnancy remains low. Household wealth, education, parity, and place of residence were closely associated with frequency and timing of ANC and with place of delivery. There is a strong link between use of antenatal care and place of delivery. The findings of this study call for urgent attention by Kenya’s Ministry of Health and local authorities to the void of quality health services in poor urban communities and the need to provide focused and sustained health education geared towards promoting use of obstetric services.
The study seeks to improve understanding of maternity health seeking behaviors in resource-deprived urban settings by identifying factors which influence the choice of place of delivery among the urban poor, with a distinction between sub-standard and “appropriate” health facilities. Methods The data are from a maternal health project carried out in two slums of Nairobi, Kenya. A total of 1,927 women were interviewed, and 25 health facilities where they delivered, were assessed. Facilities were classified as either “inappropriate” or “appropriate”. Although 70% of women reported that they delivered in a health facility, only 48% delivered in a facility with skilled attendant. Besides education and wealth, the main predictors of place of delivery included being advised during antenatal care to deliver at a health facility, pregnancy 'wantedness', and parity. The influence of health promotion (i.e., being advised during antenatal care visits) was significantly higher among the poorest women. Interventions to improve the health of urban poor women should include improvements in the provision of, and access to, quality obstetric health services. Women should be encouraged to attend antenatal care where they can be given advice on delivery care and other pregnancy-related issues. Target groups should include poorest, less educated and higher parity women.
7. Equitable health services
This research report analyses the Integrated Management of Childhood Illness (IMCI) policy in Tanzania. Two districts in North-Western Tanzania, Bunda and Tarime, in Mara region, were picked to examine the issues around introduction, planning and implementation by district health managers and at facility levels. The authors found that the percentage in health workers trained in IMCI case management varies between districts, probably due to differing levels of early sensitisation of key actors, a higher health budget per capita, local facilitators and strong external support. However, the cost of case management training is high and it is difficult for districts to finance more than one training session per year. IMCI suffers from poor visibility and challenges of monitoring impact compared to vertical programmes, reducing the potential for attracting donor investment. Therefore, the status of IMCI vs other health programmes at district and national levels needs to be enhanced and key managers need to be equipped with better resources to monitor overall implementation. Strengthening health systems remains a pillar for success of IMCI. Without required drugs, effective supervision, sufficient numbers of health workers with appropriate skill-mix and geographical distribution, it will be difficult to effectively deliver IMCI. Communities need to participate to enable them to know what to expect from facilities and their role in completing IMCI.
Growing awareness of the need for health systems and GHIs to operate in ways that are mutually supportive has prompted those who are responsible for health systems to actively adopt measures that can help integrate and maximise the impact of global health initiatives (GHIs). This report looks at a number of country-specific interventions. In sub-Saharan Africa, political commitment and creativity have helped Malawi to negotiate a successful collaboration with GHIs to strengthen and expand human resources for health – a key element of the health system. Faced with a severe HIV epidemic and crippling health workforce shortages, Malawi has collaborated with GHIs and other donors to overcome fiscal constraints and to implement an Emergency Human Resource Plan. Through task shifting, training and salary top-ups Malawi has been able to expand the health workforce to deliver HIV services and has also been able to meet new demand for a range of health services at the community level. There are widespread concerns around the effects of the proliferation of actors in global public health and the complexity of the channels and systems through which funds and commodities are now provided. The need for coordination, harmonisation and alignment is strongly felt. In particular, countries face the challenges of excessive reporting requirements, conflicting time frames in planning and funding cycles and parallel bureaucracies.
This report provides an update of the cholera situation in the region from the United Nations Office for the Coordination of Humanitarian Concerns (OCHA). According to OCHA, cholera and acute watery diarrhea cases (AWD) increased by 23,485 cases and there have been 649 deaths (CFR 2.7%) reported since 23 January 2009. Zimbabwe and South Africa remain the most affected with more than 67,500 and 6,000 cases respectively. Concerns remain on under-reporting. An additional 24,202 cholera cases and 683 deaths (CFR 2.8%) were reported from 23 January to 5 February 2009. Of the nine countries affected by cholera, Malawi (49 additional cases), South Africa (1,343 additional cases) and Zimbabwe (19,322 additional cases) have reported a significant increase compared to the last OCHA report issued on 23 January 2009. Three countries reported an increase in the number of cholera related deaths; these include Botswana, Namibia and Zimbabwe. The total numbers of people affected by cholera in Botswana and Namibia are reported to be low.
8. Human Resources
In Malawi, mid-level cadres of health workers provide the bulk of emergency obstetric and neonatal care. These cadres undertake roles and tasks that are more usually the province of internationally recognised cadres, such as doctors and nurses. While several studies address retention factors for doctors and registered nurses, data and studies addressing the perceptions of these mid-level cadres on the factors that influence their performance and retention within health care systems are scarce. This exploratory qualitative study undertook focus group discussions and semi-structured interviews at in four rural mission hospitals in Malawi among mid-level providers of emergency obstetric and neonatal care. Participants confirmed the difficulties of their working conditions and the clear commitment they have to serving the rural Malawian population. Although insufficient financial remuneration had a negative impact on retention and performance, the main factors identified were limited opportunities for career development and further education (particularly for clinical officers) and inadequate or non-existent human resources management systems. The lack of performance-related rewards and recognition were perceived to be particularly demotivating. For optimal performance and quality of care mid-level cadres need to be supported and properly motivated. A structured system of continuing professional development and functioning human resources management would show commitment to these cadres and support them as professionals. Action needs to be taken to prevent staff members from leaving the health sector for less stressful, more financially rewarding alternatives.
South Africa is failing to produce more nurses to deal with its health demands, according to the Democratic Nursing Organisation of South Africa (Denosa). The closure of some nursing colleges by the government, citing 'funding' as a reason, did not assist in the production of nurses, it reported. Denosa called on government to re-open the training colleges that were closed, to accommodate those who were interested in pursuing this career. The union said one of the contributing factors to the shortage was that school-leavers lacked interest in becoming nurses because of the unsavoury working environments that nurses face daily. Poor salaries also drive nurses away from the profession and the country. Denosa called on the state to improve health services nationwide.
9. Public-Private Mix
This paper shows there is an urgent need to reassess the arguments used in favor of scaling-up private-sector provision in poor countries. The evidence shows that prioritising this approach is extremely unlikely to deliver health for poor people. The paper recommends that donors should rapidly increase funding for the expansion of free universal public health-care provision in low-income countries, including through the International Health Partnership. Developing countries must resist donor pressure to implement unproven and unworkable market reforms to public health systems and an expansion of private-sector health-service delivery. Civil society must also act together to hold governments to account by engaging in policy development, monitoring health spending and service delivery, and exposing corruption.
10. Resource allocation and health financing
States emerging from protracted crises struggle to provide basic services. This is no more crucial than in the health sector where vulnerable ‘post-conflict’ populations are frequently in dire need of care. However, development actors are frequently faced with difficult choices – particularly how much emphasis to place on ‘humanitarian’ emergency health relief in the face of a need for health systems building. Yet is it possible to simultaneously provide basic health services whilst also developing local health provision? This paper considers how aid mechanisms can engender a ‘twin approach’ and sustain a continuous flow of resources during the progression from humanitarian to development aid. A paradigm shift is required which allows for an integrated mix of modalities in early recovery settings. Better coordination of donor agencies at country level is also needed to determine the choice of aid instruments and their complementarity, in order to ensure that health service coverage for vulnerable populations is maintained while simultaneously (re)building the health system.
The author, working for the medical humanitarian organisation Médecins Sans Frontières (MSF), which uses the medical relief paradigm, has argued that the health development paradigm and its focus on sustainability – defined as the aim of replacing foreign assistance with domestic resources within a foreseeable future – is one of the main reasons we are not able to realise universal coverage. A new global health aid paradigm would aim for technical sustainability, as in the health development paradigm, but without aiming for financial sustainability. It would tolerate open-ended external financing, but without relying on external human resources for management and implementation. The Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund)distinguishes between technical and financial sustainability: it has abandoned financial sustainability, not technical or ‘programmatic’ sustainability. When countries use their Global Fund grants wisely and effectively, they can count on continued support from the Global Fund. In adopting this approach, the Global Fund is – implicitly – using a human rights based approach. Foreign assistance, aimed at the realisation of essential human rights, is not a matter of charity; it is a matter of fulfilling international legal obligations. There is no reason to assume that global health aid will disappear (which is the underlying assumption of the aim of financial in-country sustainability). On the contrary there are many reasons to insist that global health aid should continue and increase.
Estimated funding needs for the implementation of the World Health Organization strategy on global public health and intellectual property total more than US$2 billion for the years 2009 to 2015 in order to build capacity to innovate and to deliver health products, engage in technology transfer and in the application and management of intellectual property, promote new research and development and sustainable financing mechanisms for that research and development (R&D), and establish monitoring systems. It also budgets an additional US$147 billion for the actual cost of research, including education of researchers and infrastructure building, noting that this number is difficult to determine ahead of time.
11. Equity and HIV/AIDS
Complementary breastfeeding represents an important source of risk of HIV infection for infants born to HIV positive mothers. The World Health Organisation recommends that infants born to HIV positive mothers receive either replacement feeding or exclusive breastfeeding (EBF) followed by early weaning. Beyond the clinical and epidemiological debate, it remains unclear how acceptable and feasible the two options are for rural populations in sub-Saharan Africa. This qualitative study aims to fill this gap in knowledge by exploring both the socio-cultural construction and the practice of breastfeeding in the Nouna Health District, rural Burkina Faso. Information was collected through 32 individual interviews and 3 focus group discussions with women of all ages, and 6 interviews with local guérisseurs. The findings highlight that breastfeeding is perceived as central to motherhood, but that women practice complementary, rather than exclusive, breastfeeding. Women are reported to recognise both the nutritional value of breast milk and its potential to act as a source of disease transmission. Given the socio-cultural importance attributed to breastfeeding and the prevailing poverty, the authors suggest that it may be more acceptable and more feasible to promote EBF followed by early weaning than replacement feeding. A set of operational strategies are proposed to favour the prevention of mother to child transmission of HIV in the respect of the local socio-cultural setting.
The female condom is reported to have resurfaced in Uganda's prevention programme almost one and a half years after the government halted distribution of the prophylactic due to poor uptake by women. The Ministry of Health carried out a situation analysis to gauge the acceptability of the female condom by women across the country before it was reintroduced. It found that women wanted a method that would give them control in protecting themselves from sexually transmitted infections and unwanted pregnancy. However, women in western Uganda felt it went against their culture. The Ministry is reported to have plans to embark on a sensitisation campaign to ensure the prophylactic is accepted in all parts of the country and to distribute one hundred thousand female condoms to target groups that have showed interest in them, mainly in the eastern and central parts of the country.
This report compared prevalence rates in Blantyre and Lilongwe, Malawi’s two major cities. It found that the rates in Blantyre were higher than those in Lilongwe, but these differences could not easily be explained, even though other sources of data, namely 2004 DHS data and 2005 and 2006 screening data from ANC clinics, confirmed the findings. Although incidence studies among the general population have not been conducted, there is some evidence from available data that the difference is caused by a real difference in HIV incidence. In-migration may have diluted prevalence, but data is inadequate to assess this issue. Lack of male circumcision was ruled out as a contributing factor. Possible contributing factors include a younger age of sexual debut and a longer gap between first sex and first marriage, as well as sex with a non-cohabitating partner, which was more common in Blantyre. Marital stability was found to be protective for women.
Candidate microbicide PRO 2000 cuts HIV transmission by 30%, falling just short of the one-third required to be deemed a success. But scientists say this trial offers proof that the concept of a vaginal gel to block HIV is possible. The gel was tested on over 770 women in a huge three-year study involving over 3 000 women in southern Africa and the USA. Only 36 women using PRO 2000 became HIV positive in comparison with around 50 women in the other three groups, who were given either a gel called BufferGel, a water-based placebo gel or no gel at all. This translates into a success rate of 30% for PRO 2000 and a success rate of zero for the other microbicide candidate, BufferGel. Researchers are waiting for the results of another study involving PRO 2000, which will be released in December, and this may push up the success rate of PRO 2000.
Total HIV and AIDS expenditure in 2005 in Zimbabwe was around 20.9 trillion Zimbabwe dollars, an equivalent of US$209.4 million, which represents about US$150.50 per adult living with HIV, according to an assessment of HIV and AIDS spending. The largest contributors to this expenditure were donors at 49% of the total HIV and AIDS expenditures. This is similar to that found in studies undertaken in other countries prior to the surge of external targeted funds for HIV and AIDS, such as in Kenya, Malawi, Rwanda and Zambia. From this analysis, it can be concluded that most of the funds from Ministry of Health and Child Welfare, local NGOs, UN agencies and international NGOs were used for the provision of prevention and public health programmes for HIV and AIDS, whereas spending by people living with HIV went directly to health facilities for treatment and care of opportunistic infections. The Ministry of Health and Child Welfare and PLWHA through direct out-of-pocket payments were those principally responsible for paying for treatment and care of opportunistic infections. Donors, international NGOs and Local NGOs, on the other hand, were mainly responsible for the payment of provision and administration of prevention and public health programmes for HIV and AIDS and for Anteretroviral treatment in 2005.
12. Governance and participation in health
This paper describes an innovative knowledge translation project involving researchers and key stakeholders commissioned by the World Health Organization (WHO) for the Commission on Social Determinants of Health (CSDH). The project aimed to develop 'cameo' reports of evidence-based policies and interventions addressing social determinants of health, intended for use by leaders and advocates, as well as policy and programme decision makers, to advance global action. The iterative process of developing the framework and content of the cameos, in the context of a limited evidence base, is described, and a number of issues related to the integration of multiple sources of evidence for knowledge translation action are identified.
Malawi was the only sub-Saharan African country examined in these case studies. The Malawian presenter recommended follow-up programmes for monitoring political party manifestos vs their actual delivery in government, with independent budget analyses. Independent civil society budget research for evidence-based advocacy and continued strong advocacy around political and socio-economic developments in the country are also required. In conclusion, the author asserts that the greatest danger facing democracy is the exclusion of the people from real power. Citizens cannot wait passively for the government to educate them. They need to be active and critical: at a local level, organised community groups, with the help of civil society organisations, should engage in controlling local government decision making.
13. Monitoring equity and research policy
The potential for research to influence policy, and for researchers to influence policy actors, is significant. The purpose of this qualitative study was to explore the experiences of health services researchers engaging in (or not able to engage in) policy-relevant research. Semistructured telephone interviews were completed with 23 experienced researchers. The results paint a complex and dynamic picture of the policy environment and the relationship between government officials and academic researchers. Elements of this complexity included diverse understandings of the nature of policy and how research relates to policy; dealing with multiple stakeholders in the policy-making process; and identifying strategies to manage the different cultures of government and academia.
Promoting the use of research-based knowledge in public health becomes more complex when public health includes interventions on health determinants. This article examines strategies for knowledge synthesis, translation and exchange (KSTE) in the context of public health in Canada, making reference to the work of the recently established National Collaborating Centres for Public Health (NCCs). NCCs simultaneously pursue KSTE and study how KSTE strategies meet different needs. Because NCCs are focused on interventions and policies, they must address the relationship between knowledge and policy, and how amenable it is to change. KSTE can seek to respond to and inform an existing policy agenda, but it can also seek to shape, frame and change that agenda. The two paths might call for different approaches, and for expanding the boundaries of KSTE in health.
14. Useful Resources
This resource guide contains a comprehensive compilation of international funding opportunities in biomedical and behavioral research, separated by category.
The Regional Capacity Building Partners (RECABIP) is a network of professional organisations and individuals who have combined their skills and experience to explore cost-effective ways of strengthening the response to HIV and AIDS, Climate Change, Governance and Leadership issues, among other development concerns. It does this through tailored capacity building workshops, seminars, symposia, conferences and consultancy services. Their professionals have an average of 15 years experience in designing, implementing, monitoring and evaluating HIV and AIDS, Climate Change, Governance and Leadership programmes. For a programme of short courses offered by the network in 2009, visit their website. You also can register online on their website.
15. Jobs and Announcements
The APORDE initiative is supported by The Department of Trade and Industry (the DTI) and the French Development Agency (AFD) with the French Institute of South Africa (IFAS) and will be held in Durban (South Africa) from 3–17 September 2009. They are seeking applications from talented African, Asian and Latin American economists, policy makers and civil society activists who, if selected, will be fully funded. For further information on the criteria required and your eligibility, visit the website address given below. Note that entry into this high-level programme has been very competitive in the past and only 26 applicants will be selected. The main body of participants will be drawn from Africa, but applications from Asians and Latin Americans who have research or work experience related to Africa are welcomed.
The Southern African Network of Nurses and Midwives (SANNAM) is calling for suppport for Zimbabwean nurses at a critical time of deepening political and socio-economic crisis. SANNAM can provide further information on the network and the support it aims to mobilise.
The theme of the conference this year is ‘Health equity: Our global responsibility’. The conference will examine inequities of health status, and the impact on the health of marginalised, vulnerable and indigenous populations of changing environments, whether these changes are due to climate, technology, the economy or threats to human security. Presentations exploring lessons learned and new ways of understanding health equity and social justice locally, nationally and globally are invited. Anticipated outcomes of the conference will be evidence of improvements in social determinants and their impacts on health and social outcomes, evidence of the impact of environmental technological and economic change on health equity, and consideration of the need for a paradigm shift in intersectoral policy and practice, locally, nationally and internationally.
The 8th International Conference on Urban Health is being organised by the International Society for Urban Health (ISUH) in partnership with the African Population and Health Research Center (APHRC) and the Government of the Republic of Kenya. This will be the first time the Conference is held in Africa, and not North America or Europe! The annual ICUH meetings provide an international forum for knowledge exchange among urban health stakeholders. They address issues pertaining to urban health, with an emphasis on interventions that help to alleviate barriers to urban health care and to promote strategies and policies that enhance the health of urban populations. The ultimate goal of the ICUH is to mobilise and energise like-minded professionals addressing the effects of urbanisation and urban environments on the health of urban populations.
The Ivan Toms Memorial Lecture will coincide with the week of Human Rights Day and thus call to attention Ivan's commitment to justice and humanity. Ivan was an exceptional South African and a true champion of primary health care and the right to health. From his role as a doctor in the SACLA clinic in Crossroads, through his management roles in the National Progressive Primary Health Care Network and SHAWCO, to that of his most recent post as Director of Health Services in the City of Cape Town, Ivan campaigned for many things: one of which was to secure the effective delivery of accessible health services to all based on the principles of primary health care. The lecture will take place on Wednesday, 18 March 2009 at 18h00–20h00, at the New Learning Centre Auditorium, Faculty of Health Sciences, UCT Medical School, Anzio Rd, Observatory.
The ICN 24th Quadrennial Congress, its first in Africa, will showcase the key role nursing plays in leading the way to healthier nations. The Congress will permit access to and dissemination of nursing knowledge and leadership across specialities, cultures and countries. The three ICN pillars - Professional Practice, Regulation and Socio-economic Welfare - will frame the Congress sessions and programmes. To share your ideas and expertise you are invited to submit an abstract for a concurrent session, a symposium or a poster. The submission guidelines and abstract form will be available on the Congress website http://www.icn.ch/congress2009/abstracts.htm as of Monday, 17 March 2008.
All interested parties are invited to the 6th Annual Scientific Conference of TICH. The Conference theme is ‘Revitalisation of primary health care towards Millenium Development Goals’. The sub-themes are: ‘Community strategy: Enhancing stewardship in health systems strengthening’; ‘Health systems financing: Reducing out of pocket expenditure in health’; and ‘Human resource for health: The role of community health workers in improving health outcomes’. This conference will differ from the conventional paradigm of conferencing by: creating multi-voice sessions in order to capture experiences from different communities such as marginalised groups; addressing deficiencies in research to policy; and focusing on the quest for practical, proven and effective solutions.
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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