She has walked for 10 kilometers now. She can hear the child on her back, the harsh crying of an hour ago fading to exhausted whimpering. Her local clinic has not had a qualified nurse for some months, so she is walking the 20 kilometers to the nearest district hospital, hoping that by the time she gets there, the child will not have succumbed to the fever that she could not dampen with home treatment.
For this woman, as for many others in the region, the long walk to care is a consequence of inadequate numbers of critical and skilled health personnel, high levels of external and internal migration and poor distribution of staff in areas of high health need. Even where health workers are in place there is report of low staff morale. In 2005 health ministers in the Southern African Development Community (SADC) identified the non availability of skilled health professionals as a key factor undermining achievement of health Millennium Development Goals.
With the reality of poor communities bearing the brunt of a yawning gap between need and supply of health workers, health ministers in the East, Central and Southern African Health Community (ECSA-HC) resolved in 2007 to have in place by 2008 national strategies to recruit, motivate and retain health workers, using both financial and non-financial incentives. Since then both ECSA-HC and SADC have developed strategies for responding to the health worker crisis. A number of countries in the region have also developed and began to implement strategies, adding new measures to existing incentives. In March 2009, the ECSA-HC Ministers met again in Swaziland to review how far these commitments had been addressed.
Towards this, in February 2009, EQUINET and the ECSA-HC held a regional meeting, hosted by University of Namibia, to review evidence gathered from countries on how well incentives for health worker retention were working. These incentives are not always cash payments. The studies showed that dealing with poor working conditions, poor communication, unsupportive management and inadequate recognition is also important to attract health workers and to motivate them to stay.
As Hon Petrina Haingura, Deputy Minister of Health and Social Services in Namibia noted in opening the meeting, “We all know and understand that our governments are not in positions to provide huge salaries to our health workers but much more can be done within working environments. Health workers frequently complain and express dissatisfaction with management, poor leadership, lack of support and recognition; supervisors do not even know the word ‘thank you’ for good performance.”
The studies carried out in Kenya, Tanzania, Uganda, Swaziland and Zimbabwe gave evidence that the incentives most valued by workers were training and support for their career paths; improvements in services and working environments; housing mortgages / loans; recognition and reward for performance and accessible health care. Delegates at the meeting suggested that these be planned for and costed as a core set of strategies in health worker retention strategies in all countries in the region, even while further locally relevant strategies are considered.
Some of these strategies are being applied, but on a targeted or piecemeal basis, for selected health workers, or in specific programmes. Leaving it to individual facilities to set and apply these incentives seemed to lead to a vicious cycle of poorly resourced facilities, with weak management, having the least ability to attract staff, despite greater need. The evidence suggested that retention packages should preferably be health sector wide, with career path and training support based on analysis of responsibilities and tasks.
Prof Yoswa Dambisya of University of Limpopo summarised the learning from the region: “Non-financial incentives have been successful when they have been deliberately planned, with consultation across the board, as in Uganda; when they meet immediate needs through top-ups and allowances as in Malawi; when a combination of financial and non-financial incentives is used as in Zambia and Uganda; when incentives are used to attract health workers from private to public sector as in Uganda; when incentive programmes are integrated with SWAP or budgets as in Uganda and Malawi; and when national and donor funding were mobilised for an emergency human resource programmes in Malawi and Zambia”.
Moving from cash top-ups for selected personnel as an emergency response, to supporting career paths, health services and long term housing as an investment for retention moves us, therefore, from the realm of quick fixes to longer term change. It calls for long term planning of needs and services, and the information to support this. It demands management capacities, tools and guidelines, delivered through procedures and processes that build trust and participation. These features are often under-developed in health systems in the region, yet without them, even the best designed incentives remain largely on paper. Indeed one of the findings of the studies was that while many of the countries had made progress in setting policy measures for dealing with incentives for retention, delivery on the ground was still limited, in part due to gaps in these capacities. One sign of weak support for these capacities is the ironic exclusion from incentives schemes, training and professional exchanges of the very personnel who manage human resources for health.
These deeper, system wide changes are not just good for health worker retention, but for the quality and performance of services as a whole. But they do demand more than short term, ad hoc injections of project funds. One requirement is that governments in the region should increase the budgets for health to meet the Abuja commitment of 15% government spending on health. Analysis of experience with international and global funding suggests also that these funds are best pooled into sector wide funds, if they are to support system wide incentive schemes for health workers, with plans for their use harmonized with national plans.
This raises issues of sustainability and of shared international and national responsibility that need to be addressed. When a draft code of practice on the International Recruitment of health personnel was tabled at the January World Health Organisation Executive Board, however, the debate reported on it suggested that there is some way to go in reaching a shared understanding of how international responsibilities should be managed. In 2007, African countries, many of whom are source countries for migrating health workers, had requested a code that was more than voluntary. The WHO secretariat chose instead to stick to international practice of a non-binding agreement and presented a voluntary draft code, with some high income countries receiving health workers echoing this choice. African countries at the 2008 Executive Board thus again raised the need for an enforceable code, for the rights of communities in source countries to be considered and for a compensation mechanism to address losses. So the code was referred for more consultation.
As we follow the woman and her baby into the district hospital from the long walk, her hope is focused on the fact that she has come in time to save her baby. Our hope is that she will not need to make this walk again, and that African health systems provide the environments, task alignment, career paths and long term security to ensure that their health workers are found in the services where they are needed, backed by the wider economic improvements and political stability needed to keep them there.
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 worker retention issues please visit the EQUINET website- www.equinetafrica.org. Information on the ECSA-HC resolutions and programme on health workers can be found at http://www.ecsahc.org/
1. Editorial
2. Latest Equinet Updates
This workshop will take place after the EQUINET Regional Conferebce September 23-25 2009. It will draw on the experiences of the African Population and Health Research Center (APHRC) to strengthen skills in effective and innovative strategies of communicating health research evidence to effect policy change. It will be an interactive workshop, and will address some major challenges in communicating health research in an accessible and compelling manner. The workshop will use evidence from APHRC's research in the area of sexual and reproductive health in the sub-Saharan Africa region. The workshop will be useful to people charged with communicating research in their organizations, researchers, advocates/activists, and anyone else who finds the issues above interesting. Visit the conference website to register for the workshop and for the conference.
This document presents the recommendations of the EQUINET–ECSA HC regional meeting on health worker retention in east and southern Africa (ESA) was held in Windhoek, Namibia from 25-27 February 2009 hosted by University of Namibia, and involving delegates from government, academic and research institutions, health worker organisations, parliament and civil society from ten ESA countries and from regional organisations including SADC and WHO. The recommendations cover proposals for policy options, guidelines and further research on health worker retention, migration, on health worker orientation and roles in primary health care and task shifting.
3. Equity in Health
Leading aid models focus on economic growth and poverty reduction, but the well-being approach aims for more comprehensive change, said a new group studying the problem. Well-being requires us to go beyond the macro statistics on growth, poverty and inequality and get a more fine-grained understanding of the distributions of resources and relationships that constitute the barriers to successful development in particular contexts. This is what development policy must engage in. The work of the group brought together four major bodies of thinking about development, each of which has been adopted with some success by developing countries and development agencies: theories of human need, Nobel laureate Amartya Sen’s ‘development as freedom’, the ‘participation’ and ‘livelihoods’ frameworks, and the work of social psychology on subjective well-being.
4. Values, Policies and Rights
In this paper, grounded theory procedures were use to analyse literature pertaining to dignity and to conduct and analyse 64 semi-structured interviews with persons marginalised by their health or social status, individuals who provide health or social services to these populations, and people working in the field of health and human rights. The results showed that the taxonomy presented identifies two main forms of dignity – human dignity and social dignity – and describes several elements of these forms, including the social processes that violate or promote them, the conditions under which such violations and promotions occur, the objects of violation and promotion and the consequences of dignity violation. Together, these forms and elements point to a human rights-based theory of dignity that can be applied to the health sector.
Healthcare providers' conscientious objection to involvement in certain procedures is grounded in the right to freedom of religion, conscience and thought. However, such conscientious objection can have serious implications for the human rights of healthcare users, including their sexual and reproductive health rights. This briefing paper examines the implications of conscientious objection, by healthcare providers, for the protection of sexual and reproductive health rights, and concludes with a set of recommendations for States' policies and laws.
This briefing considers the responsibilities of pharmaceutical companies for enhancing access to medicines in the context of sexual and reproductive health. To provide some substance with which to shape the responsibilities of the pharmaceutical industry, the briefing first examines the issue of access to medicine in the context of both HIV/AIDS and the human papillomavirus (HPV). Various statistics are provided to convey the severity of the situation, and the intersection with the fundamental rights to sexual and reproductive health. Having provided this context, the authors outline the responsibilities of States to ensure that medicines are available, accessible, culturally acceptable, and of good quality. However, they stress that the pharmaceutical sector has an indispensable role to play in relation to the right to health and access to medicines; this is a shared responsibility.
The IFHHRO Africa Regional Training on Monitoring the Right to Health took place in Kampala, Uganda, in December last year. It was organised by AGHA and IFHHRO's Africa Regional Focal Point. The objectives of the training were to bring health professionals and their organisations together to share experiences on monitoring the right to health, to develop an understanding of health related human rights, to make health professionals aware that they have responsibilities regarding the realisation of the right to health, particularly through monitoring, to show the practical meaning and significance of monitoring the right to health in the day-to-day work of health professionals and their organisations, and to develop practical action plans for the future.
In the first ruling of its kind in the world, the Geneva Court of Justice has quashed an 18-month prison sentence given to a 34-year-old HIV-positive African migrant who was convicted of HIV exposure by a lower court in December 2008. This was done after accepting expert testimony from Professor Bernard Hirschel – one of the authors of the Swiss Federal Commission for HIV/AIDS Consensus Statement on the Effect of Treatment on Transmission – that the risk of sexual HIV transmission during unprotected sex on successful treatment is 1 in 100,000. The ruling suggests that, in Switzerland at least, effectively treated HIV-positive individuals should no longer be prosecuted for having unprotected sex. With advocates from around the world taking interest in the case, it is possible that this ruling will have consequences for other countries with HIV exposure laws.
5. Health equity in economic and trade policies
In this policy brief, the author argues that the world Intellectual Property Organisation (WIPO) development agenda is a valuable opportunity to place the notion of the 'public domain' at the centre of the intellectual property debate. In this regard, she proposes the creation of an international register for public domain matters that countries, particularly developing countries and least developed countries (LDCs), should be able to rely on in order to boost their local innovation and creativity. The author recommends that governments and other stakeholders preserve the public domain and support norm-setting processes that promote a robust public domain, initiate discussions on how to further facilitate access to knowledge for developing countries and LDCs in order to foster creativity and innovation, and establish a forum for exchange of experiences on open collaborative projects such as the Human Genome Project.
Oxfam International, Health Action International (HAI) and Knowledge Ecology International (KEI) have voiced their alarm over recent seizures by the Dutch government of shipments of legitimate generic pharmaceuticals passing through Europe on their way to developing countries. The recent seizure of legitimate generic antiretroviral medicines in transit from India to Nigeria by Dutch customs authorities could lead to HIV-positive Nigerian patients missing critical treatment. They have called on the European Union to review and modify its regulations on counterfeiting that are prompting the seizures. They also urged the EU to reconsider inclusion of its regulation in regional free trade agreement negotiations. If it does not, ‘this could prove disastrous for access to medicines in some regions,’ they said.
Developing nations, led by Brazil and India, continue to press strong concern over seizures of legitimate shipments of generic pharmaceuticals destined for poor patients in the developing world. Brazilian Ambassador to the WTO, Roberto Azevêdo, told reporters that flexibilities developing countries have under WTO rules on intellectual property rights may be ‘jeopardised’ and that the possibility of a dispute settlement case was not ruled out. He said that as many as a dozen developing countries made statements in support of the concerns, and two of those countries spoke on behalf of the African Group and the Least Developed Countries group, each of which have dozens of members. However, the European Union denies any conflict with WTO rules in its efforts to catch shipments of counterfeits.
We are falling behind in meeting the Millennium Development Goals. Answering this challenge, a new initiative, Economic Governance for Health (EG4Health), aims to harness the voice and public health mandate of the global health community. In partnership with other civil society groups, the initiative seeks fundamental reforms of the global economic system in favour of just, climate-friendly and pro-health development. At the root of EG4Health are three simple points: the global economy is critically important to health, especially in developing countries; if we hope to achieve global health equity, we must first restore democracy and fair play to global economic governance, free from the undue influence of wealth and power; and the voice of the global health community can and should help to inform, stimulate, and shape the required reforms to the governance of the global economy.
6. Poverty and health
This report provides the first summary by the UN of how climate change, water stress, invasive pests and land degradation may impact world food security, food prices and how we may be able to feed the world in a more sustainable manner. It offers short-, mid- and long-term recommendations for improving food security, such as regulating food prices and providing safety nets for the impoverished by reorganising the food market infrastructure and institutions that regulate food prices and provide food safety nets, avoiding biofuels that compete for cropland and water resources, reallocating cereals used in animal feed to human consumption, supporting small-scale farmers, increasing trade and market access, limiting global warming by promoting climate-friendly agricultural production systems and land-use policies, and raising awareness of the ecological pressures of increasing population growth and consumption.
Research into childhood diarrhoea has declined since the 1980s, keeping pace with dwindling funds for a disease that nonetheless accounts for 20% of all child deaths, the WHO said. Funds available for research into diarrhoea are much lower than those devoted to other diseases that cause comparatively few deaths. Nearly two million children die of diarrhoea each year, even though treating the ailment is relatively simple. WHO estimates some 50 million children have been saved thanks to the Oral Rehydration Solution mixture (salt, sugar, cleam water), which costs about (US)25c per child. The international Red Cross also warned that diarrhoeal diseases, such as cholera, are on the rise and increasingly a major cause of diseases and deaths throughout the world.
Kenyan anti-poverty campaigners have launched the Piga Debe for Women Rights Campaign at a well-attended concert held at the Carnivore grounds in Nairobi as part of mobilisation for International Women’s Day. The Piga Debe concert was organised by the United Nations Millennium Campaign Africa Office, Kijiji Records and the Global Call to Action Against Poverty (Kenya) and started a month-long awareness campaign seeking to draw attention of African governments to the outrageous fact that thousands of women continue to die needlessly during child birth. Millennium Development Goals will not be realised unless and until women’s empowerment, rights and development are achieved. Addressing inequalities based on gender greatly reduces poverty and increases levels of well-being for the entire population.
The One Million Campaign report that babies below 3 years were fed milk powder contaminated with melamine, an industrial chemical used in fertilisers and plastic production. If they had been fed on their mother’s milk, they could have been saved from this unnecessary catastrophe. The One Million Campaign seeks signatories to support women to breastfeed and stop the push towards feeding babies with milk formula.
Scientists at Bulawayo's National University of Science and Technology (NUST) have embarked on research to develop simple and affordable water purification methods, as more than a billion people live without safe drinking water in developing countries. They are currently investigating if a powder made from the seeds of a tree, Moringa oleifera, commonly known as the drumstick or horseradish tree, can be used as a filter to purify water. So far, the treatment of water with Moringa seed powder has proven to be an effective method of reducing water-borne diseases and correct pH. Test results also showed that household bleach is a very strong disinfectant and raised the levels of free and total chlorine in the water, while the simple filtration columns resulted in almost 85% reduction in total suspended solids. Further research is needed, however.
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 paper found that the percentage in health workers that are trained in IMCI case management varies between districts – Bunda at 44% and Tarime at only 5%. The relatively high levels of training in Bunda might be due to early sensitisation of key actors, a higher health budget per capita, local facilitators and strong external support. However, funding is low and IMCI suffers from poor visibility and challenges of monitoring impact compared to vertical programmes, reducing the potential for attracting donor investment.
This policy brief looks at the challenges of implementing the Integrated Management of Childhood Illness (IMCI) strategy in Kenya. It shows that Kenya has made some progress in rolling out the IMCI strategy; however, implementation remains highly inadequate. The three main challenges to implementation are low training coverage, health workers not following guidelines and barriers to accessing services. These challenges reflect a range of IMCI-specific and broader health system constraints. The authors outline recommendations for increasing IMCI coverage and implementation. They argue that urgent action is needed to review pre-service training, scale up in-service training, address facility-level implementation challenges, improve IMCI supervision and build support for the strategy.
Public health facilities in Africa currently stock only about half of a core set of essential medicines, such as those used to treat malaria, pneumonia, diarrhoea, HIV, TB, diabetes and hypertension, which are among the highest causes of death in Africa. The Stop the Stock-outs Campaign is calling on governments and health departments to end stock-outs by providing financial and operational autonomy to the national medicines procurement and supply agency, giving representation of civil society on the board of the agency, ending corruption in the medicine supply chain to stop theft and diversion of essential medicines, providing a dedicated budget line for essential medicines, living up to commitments to spend 15% of national budgets on health care and providing free essential medicines at all public health institutions.
The objective of this paper was to document the inclusion of key medicines for children in national essential medicines lists (EMLs) and standard treatment guidelines, and to assess the availability and cost of these medicines in 14 countries in central Africa. Surveys were conducted in 12 public and private sector medicine outlets in each country’s capital city. Data was collected on medicine availability on the survey day and on the cost to the patient of the lowest-priced medicine in stock. It found that there was considerable variation in prices, which tended to be higher in retail pharmacies, and the availability of key essential medicines for children was poor. Better understanding of the supply systems in the countries studied and of the pattern of demand for medicines is needed before improvements can be made.
In the run-up to International Women's Day, 8 March, the International Committee of the Red Cross (ICRC) warned that the specific health-care needs of women are often ignored or insufficiently taken into account in war situations. ‘People wounded in fighting are given priority for medical treatment, but women, even pregnant mothers, are often given scant attention despite their special needs,’ said the ICRC's adviser on issues relating to women and war. In the world’s least developed countries, many of which are at war, women are 300 times more likely to die in childbirth or from pregnancy-related complications than in developed countries, according to UNICEF. In war time, women are particularly at risk of rape and other forms of sexual violence and they have no means of transportation to reach a health-care facility so as to give birth safely.
8. Human Resources
This is a series of facility-based surveys using a common approach in six countries, including Mozambique and Zimbabwe. The objectives were twofold: to inform the development and monitoring of human resources for health (HRH) policy within the countries; and to test and validate the use of standardised facility-based human resources assessment tools across different contexts. The findings revealed that, with increasing experience in health facility assessments for HRH monitoring comes greater need to establish and promote best practices regarding methods and tools for their implementation, as well as dissemination and use of the results for evidence-informed decision-making. The overall findings of multi-country facility-based survey should help countries and partners develop greater capacity to identify and measure indicators of HRH performance via this approach, and eventually contribute to better understanding of health workforce dynamics at the national and international levels.
Heads and implementing workers of fifty HIV and AIDS programs and institutions accredited to offer antiretroviral services in Uganda, Kenya, Tanzania and Rwanda were key informants in face-to- face interviews guided by structured questionnaires. Inadequate human resource capacity including, inability to select, quantify and distribute ARVs and related commodities, and irrational prescribing and dispensing were some of the problems identified. A competence gap existed in all the four countries with a variety of healthcare professionals involved in the supply and distribution of ARVs. There is inadequate capacity for managing medicines and related commodities in East Africa. There is an urgent need for training in aspects of pharmaceutical management to different categories of health workers. Skills building activities that do not take healthcare workers from their places of work are preferred.
Human resources for health (HRH) is a critical component of health systems Many governments of our member states have expressed the need to determine the status HRH in relation to supply, utilization and management systems. The DJCC meeting of July 2003 recommended the establishment of the Human Resources for Health Technical Advisory Group to oversee the implementation ofthe many recommendations and the resolutions of health ministers at their 38thRegional Health Minister’s Conference of November 2003, all aimed at addressing the HRH Crisis in ECSA. To address this resolution, ECSA Health Community has conducted a series ofrelated studies addressing the issue of HRH in the region. Three studies have been on the impact of HIV/AIDS on the health workforce and this study focused on establishing the situation of HRH in the region. The findings of this study will assist not only in identifying further areas of research in relation to HRH but aid in developing both regional and national level strategies on training, deployment and retention.
Worldwide mobility of health professionals is a growing phenomenon, impacting the health systems of receiving, transit, and sending countries, so the need to develop European policies to adequately address these issues is urgent. At the same time, reliable and differentiated knowledge and findings as a basis for such policy are lacking. MoHProf will contribute to improving this knowledge base and facilitate European policy on human resource planning. The general objective of the project is to research current trends of mobility of health professionals to, from and within the EU. The project comprises four phases over a three-year period starting from November 2008. There will be four project meetings, starting with a kick-off meeting and project launch and concluding with an international conference, and roundtables as appropriate.
9. Public-Private Mix
In many countries people use a wide variety of market-based providers of health-related goods and services ranging from highly organised and regulated hospitals and specialist doctors to informal health workers and drug sellers operating outside the legal framework. The boundary between public and private sectors is often very porous, with people either paying government health workers informally or consulting them outside their official hours. Unregulated markets, in particular, raise problems in terms of safety, efficacy and cost. Understanding health markets and improving system performance is central to accelerating action to scale-up coverage and use of health services and deliver improved outcomes against the health-related MDGs and universal access commitments.
In responding to the goal of rapidly increasing access to antiretroviral treatment (ART), the government of Botswana undertook a major review of its health systems options to increase access to human resources, one of the major bottlenecks preventing people from receiving treatment. In mid-2004, a team of government and World Health Organization (WHO) staff reviewed the situation and identified a number of public sector scale up options. The team also reviewed the capacity of private practitioners to participate in the provision of ART. Subsequently, the government created a mechanism to include private practitioners in rolling out ART. At the end of 2006, more than 4500 patients had been transferred to the private sector for routine follow up. It is estimated that the cooperation reduced the immediate need for recruiting up to 40 medically qualified staff into the public sector over the coming years, depending on the development of the national standard for the number and duration of patient visits to a doctor per year. Thus welcome relief was brought, while at the same time not exercising a pull factor on human resources for health in the sub-Saharan region.
10. Resource allocation and health financing
The heads of GAVI and the Global Fund have written a letter to Gordon Brown and World Bank head Robert Zoellick seeking an expansion of their mandates to cover all health MDGs. The letter was sent to the two co-Chairs of the High Level Taskforce on Innovative Finance and asks for GAVI and the Global Fund to 'refocus on all of the health-related MDGs as a renewed commitment to meeting the basic health service delivery needs in poor countries'. The letter goes on to state that both GAVI and the Global Fund are prepared to make this move promptly if they are given donor support. The letter has been posted on the web page of the High Level Taskforce on the IHP+ site.
States' obligations under some international treaties extend beyond their national borders to international assistance and cooperation for human rights, including the rights to sexual and reproductive health, in other countries. This paper focuses on what is expected of donors in the context of this responsibility. It shows how many donors are taking important steps towards fulfilling this duty through measures they are taking to integrate the rights to sexual and reproductive health into their policies and programmes, but also argues that many donors can also do more. The publication concludes with a set of recommendations addressed to donors and their developing country partner governments.
The objective of this paper was to investigate the effect of survey design, specifically the number of items and recall period, on estimates of household out-of-pocket and catastrophic expenditure on health. It used results from two surveys – the World Health Survey and the Living Standards Measurement Study – that asked the same respondents about health expenditures in different ways. In most countries, a lower level of disaggregation (i.e. fewer items) gave a lower estimate for average health spending, and a shorter recall period yielded a larger estimate. However, when the effects of aggregation and recall period are combined, it is difficult to predict which of the two has the greater influence. Therefore, it is crucial to establish a method to generate valid, reliable and comparable information on private health spending.
11. Equity and HIV/AIDS
This article examines the dynamic role of law as a tool, and potential barrier, to public health interventions designed to ameliorate the negative impacts of HIV and AIDS globally. Laws may empower public health authorities, reinforce the human rights of persons living with HIV or AIDS and protect them from social risks, stigma and other harms by respecting privacy and prohibiting unwarranted discrimination. However, laws can also create legal barriers by penalising HIV+ people through criminal sanctions or other policies. As a result, it is recommended globally that laws should facilitate the prevention and treatment of HIV/AIDS consistent with scientific and public health practices and with a human rights framework.
A shortage of free female condoms in public hospitals in Kenya's Coast Province is compromising the ability of women to protect themselves from unwanted pregnancy and sexually transmitted infections. Female condoms are available in private hospitals and pharmacies in the province, but at a cost of up to US$5 – five times the cost of a male condom – they are too expensive for most women, especially in a time of famine, where every penny goes towards food. Sex workers are among those affected most by the shortage. Some have reported that that the female condom was a key part of their business. If customers refuse to wear a condom, sex workers at least have the option of wearing a female condom to protect themselves against sexually transmitted diseases like HIV.
The layering of HIV-related stigma with stigmas associated with gender, race, and class poses a methodological challenge to those seeking to understand and, thereby, to minimise its negative effects. In this meta-study of 32 reports of studies of stigma conducted with HIV-positive women, the researchers found that gender was hardly addressed despite the all-female composition of samples. Neither sexual orientation nor social class received much notice. Race was the dominant category addressed, most notably in reports featuring women in only one race/ethnic group. The relative absence of attention to these categories as cultural performances suggests the recurring assumption that sample inclusiveness automatically implies the inclusion of gender, race, and class, which is itself a cultural performance.
Stepping Stones, a 50-hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. This article details the results of a randomised trial to measure the impact of the programme on HIV and herpes rates in rural South Africa. The trial also measured unwanted pregnancy, reported sexual practices, depression, and substance misuse. The article shows how there was no evidence that Stepping Stones lowered the incidence of HIV. However, it significantly improved a number of reported risk behaviours in men, with a lower proportion of men acting violently towards their intimate partners and less transactional sex and drinking problems. In women, desired behaviour changes were not reported.
A self-administered survey was distributed to a convenience sample of church-goers in both urban and rural areas, which included questions about religious beliefs, opinions about HIV, and knowledge and attitudes about anti-retrovirals (ARVs). Results indicated that shame-related HIV stigma is strongly associated with religious beliefs such as the belief that HIV is a punishment from God or that people living with HIV/AIDS (PLWHA) have not followed the Word of God. Most participants said that they would disclose their HIV status to their pastor or congregation if they became infected. Although most respondents believed that prayer could cure HIV, almost all said that they would begin ARV treatment if they became HIV-infected. So, the decision to start treatment was hinged primarily on education level and knowledge about ARVs, rather than on religious beliefs.
HIV serostatus disclosure to community members has been shown to have potential public and personal health benefits. This study examined the impact of bonding and bridging social capital (i.e. close and distant ties) on public disclosure. Data was collected from a public sector ART programme in the Free State province in the form of semi-structured, face-to-face interviews with 268 patients. The study identified bonding social capital as a leverage to maximise potential benefits and minimise potential risks so as to shift the balance toward consistent public disclosure. Furthermore, the importance of bridging social capital initiatives is demonstrated, especially for the most vulnerable patients, namely those who cannot capitalise their bonding social capital by disclosing their HIV serostatus to family and friends at the start of treatment.
Fifteen percent of South African school children between the ages of 12 and 17 years would knowingly spread HIV, the South African Broadcasting Corporation has reported. This was revealed in a study of more than 15 000 school children by an international group of epidemiologists based in Canada. The organisation's Nobantu Marokane said that most of the learners who said they would spread the virus had been abused. 'These learners were not tested so they did not know if they were HIV positive. In most cases, these learners have been exposed to some kind of abuse.'
12. Governance and participation in health
The paper reports on a framework for health systems governance (HSG). Key issues considered included the role of the state vs. the market; role of the ministries of health vs. other state ministries; role of actors in governance; static vs. dynamic health systems; and health reform vs. human rights-based approach to health. The framework permits ‘diagnoses of the ills’ in HSG at the policy and operational levels and points to interventions for its improvement. The principles of the HSG framework are value driven and not normative and are to be seen in the social and political context. The framework relies on a qualitative approach and does not follow a scoring or ranking system. It does not directly address aid effectiveness but provides insight on the ability to utilise external resources and has the ability to include the effect of global health governance on national HSG.
Active and informed participation is an integral component of health systems, as well as the right to the highest attainable standard of health. Despite its critical importance, health and human rights have not given participation the attention it deserves. While some health researchers have made more headway than those working in human rights, neither community has a widely accepted understanding of what the process of participation means in practice. This monograph is an accessible, practical, timely and original introduction to the process of participation; the need for a variety of participatory mechanisms; the relationship between fairness and transparency of the process; the relationship between participation and accountability and participation in accountability.
This paper from Oxfam focuses on how the right-to-be-heard concept can strengthen public participation in policy making and accountability. Recommendations for those supporting poor and marginalised people to lobby for changes in their situation include recognising that change is long-term, understanding that attitudinal change is important, putting local priorities first, working at a number of levels and building alliances, bringing people face to face, taking different perspectives into account, recognising that international agencies can play an advocacy role, understanding that NGOs are important as role models of accountability and integrity. A number of case studies are used to illustrate these points including the fostering of local accountability in Malawi.
13. Monitoring equity and research policy
A disparate series of contemporary lists of health service providers were used to update a public health facility database in Kenya, last compiled in 2003. These new lists were derived primarily through the national distribution of antimalarial and antiretroviral commodities since 2006. A combination of methods were used to map service providers and analyse disparity in geographic access to public health care. The update shows that, with concerted effort, a relatively complete inventory of mapped health services is possible, with enormous potential for improving planning. Expansion in public health care in Kenya has resulted in significant increases in geographic access, although several areas of the country need further improvements. This information will be key to future planning for Kenya’s public health sector.
Current systematic reviews have a utilitarian bias – they tend to be concerned more with the effects on populations and average effects than with distributional effects and impacts in disadvantaged sub¬groups. the author poses that systematic reviews should routinely consider the effects of interventions on health inequities. The Cochrane Health Equity Field was set up explicitly to further this agenda, to encourage systematic review authors to explicitly assess the effects of interventions not only on the whole population, but on the disadvantaged. Evidence on interventions to improve public health is in short supply, partic¬ularly evidence on social determinants. Public health systematic reviewers need to continue to develop new methods and better frameworks to inform decision-making.
The World Health Organization is soliciting new ideas for funding sources to stimulate research and development on diseases predominantly afflicting developing countries, with some in developed countries. The web-based public hearing, being held online from 7 March to 15 April 2009, will contribute to an intergovernmental mandate to come up with ways to address the shortage of research in this area. The expert group hopes to solicit additional ideas from member states and other stakeholders for its consideration. The final report will be presented at the May 2010 Health Assembly. The web-based public hearing is open to individuals, civil society groups, government institutions, academic and research institutions, the private sector and other interested parties. The link to the online public hearing is: http://www.who.int/phi/public_hearings/third/en/index.html
14. Useful Resources
AFSUN was established in 2008 as a network of African and international universities, non-governmental and community organizations, and municipal governance networks. It aims to improve the knowledge base on urban food security in Africa; to build African human resource capacity and expertise in food security policy and management; to develop and advocate policy options to improve the environment within which households make decisions about food security; and to grow the capacity of community change agents to plan, implement and evaluate food security projects and programmes. AFSUN also recognises the critical importance of the global food system and the links between town and countryside in affecting the food security of urban populations in Africa.
Increasingly, countries in east, central, and southern Africa are integrating nutrition and food security interventions into HIV services. As the number, variety and reach of these programmes expand, identification and documentation of promising practices become valuable in order to help understand what works, to replicate successful approaches and to incorporate lessons into programmes. The Regional Centre for Quality of Health Care (RCQHC) in Uganda and the FANTA Project organised extensive in-country reviews by local teams of nutrition, food security and HIV programmes in Kenya, Malawi, Tanzania, Uganda and Zambia. Nutrition, Food Security and HIV: A Compendium of Promising Practices compiles, analyses and describes the promising practices identified through the reviews.
Although there has been a significant amount of work done to promote women’s empowerment, most of it has been geared towards the experiences of adult women. This manual, part of an initiative called Program M, includes a series of group educational activities to promote young women’s awareness about gender inequities, rights and health. It also seeks to develop their skills to feel more capable of acting in empowered ways in different spheres of their lives. All the activities draw on an experiential learning model in which young women are encouraged to question and analyse their own experiences and lives, in order to understand how gender can perpetuate unequal power in relationships, making young women and men vulnerable to sexual and reproductive health problems, including HIV/AIDS.
15. Jobs and Announcements
The research project Mobility of Health Professionals (MoHProf) is a European Union funded project that aims to contribute to an improved knowledge base and to facilitate European policy on human resource planning. The general objective of the project is to investigate and analyse current trends of the mobility of health professionals (such as nurses and doctors) to, from and within the European Union, including return and circular migration. The Consultants will conduct empirical socio-scientific field studies on migration of health workers, each in one of the countrises listed, and participate in two meetings with the Regional Research Coordinator and other national consultants. For further information visit the website.
The Alliance for Health Policy and Systems Research, World Health Organization, is hiring a technical officer, P4, in the areas of pharmaceutical policy and use of evidence to inform policy making. Based in Geneva, the officer will lead a programme of work that engages research users to identify and build consensus around global research priorities in the access to medicines field; manage calls for proposals, administer and provide technical support to grants focused on synthesising and generating new knowledge on access to medicine issues; promote networking between research institutions working in the pharmaceutical policy field and help build capacity in the field through workshops and other interventions; monitor and support Alliance grants to country teams that aim to promote the use of evidence in policy making; and act as the point person for the Alliance on coordination with the EVIPNet (Evidence Informed Policy Networks).
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