Health systems throughout sub-Saharan Africa have been in a state of decline since the debt crisis of the 1980s and the subsequent effects of structural adjustment, chronic public under-investment and health sector reform. In this context, with the fragile health systems resulting, the proliferation of global health actors and initiatives (GHIs), that we have witnessed over the past decade, presents a risky strategy for catalyzing sustained and equitable improvements in health.
Vertical, selective GHIs could either establish a ‘virtuous cycle’ of positive synergies with health systems strengthening, or enter a ‘vicious cycle’, where they perpetuate or accentuate existing health system deficiencies, creating a greater dependence on vertical programmes for the rapid delivery of life-saving interventions. The publication in the Lancet this year (2009; (Vol 373 pages 2137 – 2169) of a review of the impact of GHIs on health systems by the World Health Organization’s Maximizing Positive Synergies (WHO MPS) initiative has therefore attracted attention and controversy.
The review noted the positive association between GHIs and improved outcomes, particularly in terms of HIV/AIDS, TB, Malaria and vaccine-preventable child deaths. However, it did not adequately answer the question of whether vertical and selective disease-based GHIs have had a positive or negative effect on health systems more broadly, nor whether they could have been better designed or implemented to optimize across-the-board health improvements.
This is because the review faced many methodological limitations. The first was a lack of good quality studies and evidence on the issue. This is a consequence of the minimal resources invested in establishing the monitoring systems needed to assess the effects of GHIs on health systems. Further, there is limited appreciation in the health community of the kinds of methods needed to study complex and large socially-mediated systems.
A second limitation was the lack of quality control of the data used by the WHO MPS collaborative group. Good, moderate and poor quality data appear to have been treated equally, including potentially biased information provided by GHIs themselves. On top of this, most members of the writing group had a direct conflict of interest with the subject matter, so the conclusions and recommendations read as a result of political negotiation, rather than an independent synthesis of the available evidence.
As a third limitation, the review only examined four actors: the Global Fund to Fight Against AIDS, TB and Malaria, GAVI, the World Bank’s Multi-Country AIDS Programme (MAP), and the US President’s Emergency Plan for AIDS Relief (PEPFAR). It therefore didn’t capture the effects of more than a hundred other global health actors and initiatives, despite the fact that one of the biggest problems for countries is the cumulative effect of numerous GHIs.
Finally, the conceptual framework of the review was designed to examine the effect of GHIs on health systems, but the conclusions of the review muddled the assessment of the impact of GHIs on health systems with impacts on health outcomes and outputs. Clearly, the Global Fund, GAVI, PEPFAR and MAP have had a positive impact on health outputs and outcomes. It would have been hard to avoid doing so considering the billions of dollars spent by these four GHIs, and the general four-fold increase in development assistance witnessed since 1990, described by Ravishankar and others in the same issue of the Lancet (2009, Vol 373, pages 2113 – 2124).
The question of whether vertical and selective disease and vaccine-based GHIs have had a positive or negative effect on health systems is perhaps academic. What is more important is that GHIs are henceforth able to maximize their positive synergies with broader health systems needs.
In this regard, in spite of its limitations, the WHO MPS initiative has been an important and valuable exercise. It has drawn attention to the need for further monitoring and assessment of the relationship between GHIs and health systems strengthening. This should include paying greater attention to the global health architecture as a whole, and efforts such as the International Health Partnership launched by some bilateral and multilateral health funding agencies to reduce the wasteful fragmentation, duplication, competition and conflicts amongst different actors and initiatives. Secondly, it has highlighted the need for GHIs to ensure that external development assistance for health is invested in a more coherent, equitable and comprehensive manner.
However, for GHIs, health sector and civil society actors, including those in east and southern Africa, the challenge is in knowing how to move forward. For example, if GHIs are to pay more attention to health systems strengthening, who will coordinate this? As a follow-up to the work and deliberations of the High Level Taskforce on Innovative Financing for Health, the World Bank, the Global Fund and GAVI are now discussing how they can create a shared platform for financing and supporting health systems strengthening.
But what will this mean? Will the World Bank take the lead in defining the policy agenda, and if so, will it promote a conservative and neoliberal policy agenda? Or will an expanded and modified version of the Global Fund and GAVI take charge? What of the role of the WHO, the International Health Partnership and countries themselves? With a global health architecture that remains over-populated, disorganized and competitive, there is a danger that countries may experience a series of uncoordinated and selective health systems strengthening initiatives. Agreeing to the fact that GHIs must pay more attention to health systems strengthening is only the start of a process.
While there is welcome attention to how official aid can be better managed to support health systems strengthening, there has been little discussion about how private finance will be harnessed to support equitable health systems development. The Gates Foundation, working with the International Finance Corporation, the African Development Bank and a German development finance institution have recently created a new private equity fund that will invest in small- and medium-sized private health companies in sub-Saharan Africa. Such an initiative runs contrary to the evidence that expanding commercialized health care will be harmful to equity and health systems strengthening.
Furthermore, the attention placed on health systems strengthening does nothing to plug the existing resource gaps of many countries. How do we campaign for a comprehensive Primary Health Care agenda when there is are still too few health workers, or inadequate funds for medicines? With the economic recession and signs of some donors cutting back on development aid, the competition for scarce resources may get worse.
This situation calls for the global health community to develop a set of positions and campaign on three distinct, but inter-related issues: The first is the architecture of development assistance for health, to work towards a coherent system for funding equitable health systems development and on-going improvements in access to effective health care. The second is that of health systems policy itself, particularly in relation to the appropriateness and fairness of different health financing strategies, as well as the role of markets and the private sector. Finally, the third, resonating with the call to meet the full content of the 2001 Abuja commitment at national and international level, is that of expanding both domestic and international resources for health in Africa.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For papers on health systems (fair financing, health worker retention) effects of GHIs visit the EQUINET website and the Economic Governance for Health network website at www.eg4health.org
1. Editorial
2. Latest Equinet Updates
This work was implemented in Kasipul Division, Rachuonyo District, Kenya, where high poverty levels lead to food insecurity exacerbated by rising food prices, by the consequences of two devastating tropical storms and soaring transportation costs. Few PLWHIV own farms, or produce a marketable surplus, and illness and malnutrition interact in a vicious cycle. KDHSG and RHE implemented a participatory action research programme, within EQUINET, to explore dimensions of (and impediments to delivery of) Primary Health Care responses to HIV and AIDS. It used a mix of PRA and quantitative approaches to; • Identify the nutritional needs, issues and responses for PLWHIV on treatment • Increase voice and participation of PLWHIV and communication with health workers on their nutritional needs in relation to treatment and on responses to these needs in the clinics and community • Increase the capacity of health workers and community to identify specific areas for engagement of partners outside the health sector on intersectoral responses to support nutritional inputs for PLWHIV on treatment. This work indicates that expanding access to treatment services needs to be embedded within a wider framework of wider health support, including the intersectoral action to address food needs, if availability is to translate into effective coverage. Nutrition support is a vital element of the chronic care and health management strategies needed for PHC responses to AIDS. This includes shifting perception of PLWHIV from that of disabled dependents of emergency support to people able to know and address their nutritional needs through local food resources.
This paper explores and presents the current patterns of AIDS, TB and Malaria (ATM) financing within the health sector, and investigates the extent to which GHI financing for ATM has influenced heath care financing reforms. We obtained information for this paper through key informant interviews and extensive literature review. There is fragmentation between government and donor project funding, and also within donor project funds, which negatively impacts on creation of larger pools. Donor funding channelled through projects and global health initiatives targeting specific diseases may undermine equity between geographic areas. The lack of effective coordination of donor project funds is a breeding ground for inefficiencies and inequity. We recommend that the Ministry of Health should double its efforts to improve co-ordination and harmonisation of all development aid, including support from global health initiatives (GHIs). Long term institutional arrangements are a starting point for this process, but more buy-in is required in order for it to be accepted by all stakeholders. Government should design mechanisms that will help integrate GHIs resources to allow for greater cross-subsidisation and to reduce overlaps and inefficiencies.
A reminder to all who have registered that the third EQUINET Regional Conference on Equity in Health in East and Southern Africa is coming up next month! It provides a unique opportunity to hear original work and debate on the determinants of, challenges to and opportunities for equity in health in this region. The programme is broad and covers a range of topics including claiming rights to health, equitable health services, women’s health and social empowerment in health systems. Other main topics include retaining health workers, primary health care, developing and using participatory approaches, resourcing health systems fairly, building parliamentary alliances and people's power in health, policy engagement for health equity, trade and health, access to health care and monitoring equity. We will also show how to build country alliances and conduct regional networking. A post-conference workshop will be held on BANG (bits, atoms, neurons and genes), billed the Next Technological Challenge to Africa’s Health and Well-being. Further activities associated with the conference include photographic displays and skills meetings.
3. Equity in Health
The Economic and Social Council (ECOSOC) has adopted a number of resolutions, including a resolution urging the Joint United Nations Programme on HIV/AIDS (UNAIDS) and other relevant organisations and bodies of the United Nations system to intensify their support to governments in dealing with HIV and AIDS. It also reaffirmed its commitment to the implementation of the Programme of Action for the Least Developed Countries for the Decade 2001–2010, which calls on the UN Secretary-General to step up appropriate measures for effective and timely implementation of the Programme in coordination with all relevant stakeholders, and submit an analytical and results-oriented annual progress report on the further implementation. The Council also recommended mainstreaming information and communication technologies in the economy as a driver of growth and sustainable development and encouraged all stakeholders to continue engaging in people-centred partnerships as an effective way forward.
The International Federation of Red Cross and Red Crescent Societies (IFRC) has launched a US$ 8 million initiative to help build the disaster resilience of 600,000 people living along the Zambezi river in seven southern African countries. The Zambezi River Basin Initiative (ZRBI) is a response to ‘a dramatic increase in the numbers of floods along the river basin’, according to Farid Abdulkadir, IFRC disaster management coordinator for the southern Africa region. The focus of the ZRBI is on disaster preparedness rather than post emergency relief operations, as in the past. It is a joint programme between the Angolan, Botswana, Malawi, Mozambique, Namibia, Zambia and Zimbabwe Red Cross Societies, combining risk reduction efforts with food security, health, HIV prevention and capacity building activities. The US Agency for International Development (USAID) has already committed US$1 million to the project.
Zimbabwe and Botswana have reported their first suspected cases of swine flu as the H1N1 virus begins to establish a foothold in southern Africa. Neighbouring South Africa has reported 54 laboratory confirmed cases of swine flu so far, 32 of which have been linked to a squash tournament at a university in Johannesburg. No deaths have been reported in the region as yet. Dr Lucille Blumberg, head of epidemiology at South Africa's National Institute for Communicable Diseases, said that most cases of the illness were ‘mild’, and that it was too early to tell whether people living with HIV and AIDS (PLWHAs) would be affected to a greater degree by the flu. Most PLWHAs are in southern Africa, where most countries also have severely stretched health services, and the effects of the virus on their populations remain uncertain. Blumberg said in other parts of the world swine flu had killed healthy people, as well as those suffering from underlying illnesses.
This study set out to assess the effect of educational attainment and other factors on the risk of HIV in pregnant South African women. Repeated cross-sectional surveys were used. Pregnant women, who were attending public antenatal clinics were tested for HIV annually between 2000 and 2005, provided demographic information. Among women aged 15-24 years, HIV risk in those who had completed secondary education was significantly lower than in those who had only primary education – it increased by 8% per annum in those with no secondary education but did not increase those with secondary education. Together with other evidence, this study suggests that higher educational attainment did not protect against HIV in the early stages of the South African HIV/AIDS epidemic. But in recent years, the risk of HIV infection in young South African women with completed secondary education has reduced significantly relative to that in young women with primary education, suggesting that HIV prevention strategies may have been more effective in more educated women.
This paper documents the impact of the AIDS crisis on non-AIDS related health services in 14 sub-Saharan African countries. The authors, using multiple waves of Demographic and Health Surveys (DHS) for each country, examined antenatal care, birth deliveries, and rates of immunisation for children born between 1988 and 2005. They found deterioration in nearly all of the above dimensions of health care over this period. Using data collected on HIV prevalence in the most recent DHS survey for each country, they noted that erosion of health services is highly correlated with increases in AIDS prevalence. Consequently, regions of countries that have light AIDS burdens have witnessed small or no declines in health care, using the measures noted above, while those regions currently shouldering the heaviest burdens have seen the largest erosion in treatment for pregnant women and children. Finally, the authors estimate that the beginning of the divergence in health services between high- and low-HIV regions took place in the mid-1990s.
4. Values, Policies and Rights
The Amnesty International Report 2009 is a record of the state of human rights during 2008 in 157 countries and territories around the world. It depicts the systemic discrimination and insecurity that hinders the application of the law, where states pick and choose the rights they are willing to uphold, and those they would rather suppress. The report presents five regional overviews highlighting the key events and trends that dominated the human rights agenda in each region in 2008. It further takes a country-by-country survey of human rights, summarising the human rights situation in each country. The regional overviews reveal that, in Africa, there is still an enormous gap between the rhetoric of African governments and the daily reality where human rights violations remain the norm: violent protests and poverty continued in many African countries, exacerbated by repressive attitudes of governments towards dissent and protest. Governments have failed to provide basic social services, like health services, address corruption and be accountable to their people.
The aim of this report is to see how gender and AIDS concerns could be better mainstreamed in Zambia’s Norwegian Embassy portfolio. It indicates that gender inequalities exist at all levels in Zambia, and challenges remain critical and fundamental to the country’s achievement of its vision and goal on gender. Four programmes were reviewed, and the researchers noted that good opportunities existed for better synergies and learning. They give four key recommendations. First, internal organisation is required at the Embassy – responsibility should be placed at management level, and gender and AIDS competence should be secured. Second, at programme level, selection and focus should be on only one or two gender and AIDS mainstreaming topics. Third, at programme level, the main focus should be on only one programme or sector (in addition to improved quality work on the others). And fourth, at policy level, further work is needed to integrate the gender and AIDS aspects in the political dialogue with the government of Zambia and key development partners.
Three HIV/AIDS patients in Kenya announced Tuesday they will petition the country’s Constitutional Court to declare a new anti-counterfeiting act illegal because it could deny them access to generic medicines. The move, which has the support of public health groups across the country, seeks to have the 2008 Anti-Counterfeiting Act made unconstitutional on the grounds that it could rob them of their right to life. The anti-counterfeiting law’s definition of counterfeits is so vague that it could include generic drugs and allow a pharmaceutical company to charge patent infringement in Kenya even if its patent is not registered there. International donors who fund much of the drug distribution, including the US President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria, rely almost exclusively on generics manufacturers for their supply. The Kenyan act has gained widespread attention abroad because it is being used as a partial template for similar anti-counterfeiting bills in Uganda, Tanzania and other African nations.
This study looks at how sub-Saharan Africa’s three main HIV and AIDS donors have incorporated gender issues into their policies, and to what extent they have been put into practice and monitored. Although PEPFAR, the Global Fund and MAP have all made high-level commitments to address gender issues in their programming, these commitments have ‘not yet produced concrete and systematic action on the ground’. The study found 61% of people living with HIV in sub-Saharan Africa are women, up from about 33% in the 1980s, and argues that gender inequality seriously undermines efforts to curb the epidemic and has actually fuelled the spread of HIV in the region, making women vulnerable to sexual violence, hindering their ability to have safe sex, and limiting their access to health, education and employment. It urges the three donors to collaborate on gender issues to make the most of their individual strengths and avoid duplication by helping countries establish gender-related goals in their HIV and AIDS responses, and sharing research and knowledge.
Two HIV-positive Namibian women who allege they were sterilised against their will in public hospitals are seeking redress through the courts, the first of more than 20 known cases, according to the International Community for Women Living with HIV/AIDS (ICW). The ICW raised the alarm over what it terms forced or coerced sterilisations among HIV-positive women more than a year ago, after hearing accounts of it through its regular forums for HIV-positive young women. Another six cases could potentially go to trial this year, and a further 20 are being looked into by the ICW. However, legal action has been hampered by difficulties in collecting evidence and statements from women involved, who are often reluctant to come forward due to fears that both their HIV status and their inability to bear children will be made public. The ICW believes informed consent was not sought, as the majority of these women are rural or illiterate.
5. Health equity in economic and trade policies
At a panel discussion on Africa-EU relations organised by the Friedrich Ebert Foundation on 8 July 2009, participants discussed four scenarios for ongoing economic partnership agreements in West Africa, ranging from a full liberalisation agreement on all trade in goods and services, to no agreement whatsoever. While European Commission representatives favoured full liberalisation, regional stakeholders called for a partial, phased liberalisation, covering only trade in goods. This approach would provide greater flexibility for national and regional trade policy, protect local agricultural and industrial sectors, and facilitate regional integration. Participants also discussed the Joint Africa-EU Strategy (JAES) process. They noted that respect for JAES’s fundamental principles such as ‘treating Africa as one’ and ensuring the ‘harmonisation of existing policy frameworks’ will be more effective than emphasising ‘functional deliverables’ only.
Aid for Trade is an initiative that started in 2005 through the WTO framework in recognition of the fact that developing countries lack the basic infrastructure and capacity to take advantage of the market access opportunities resulting from trade negotiations – normal aid programmes have not been able to deal with these. This second global review aimed to evaluate the progress of the initiative and implemention on the ground. It says the initiative has achieved remarkable progress in a short time, as partner countries are mainstreaming trade in their development strategies and clarifying their needs and priorities, and donors are improving aid for trade delivery and scaling up resources. In 2007, aid for trade grew by more than 10% in real terms and total new commitments from bilateral and multilateral donors reached US$25.4 billion, with an additional US$27.3 billion in non-concessional trade-related financing. But maintaining the momentum will be difficult in this current economic recession, and that the quantity and the quality of aid, including aid for trade, are now more important than ever for economic growth and human welfare.
The World Intellectual Property Organization’s (WIPO) committee on the protection of indigenous knowledge, expressions and genetic resources failed to reach consensus on future work at their meeting held from 29 June to 3 July, effectively postponing the issue till the WIPO General Assemblies in September. The mandate of the Intergovernmental Committee on Intellectual Property and Genetic Resources, Traditional Knowledge and Folklore (IGC) expires this year and deciding the next mandate of the group was the key task at the meeting. Some countries wanted to see the text of a possible agreement before deciding what kind of form it might take (such as an instrument or a database), while others wanted to set a goal of a legally binding international instrument and then work on its text. Informal consultations are planned in the interim between now and the assemblies in late September, though details are unclear. Whether the committee still had a mandate after the meeting was a point of confusion, though it appears that the mandate may carry until the end of December.
A conference at the World Intellectual Property Organization (WIPO), held on 13 and 14 July, explored and clarified the connection between its work and several major public policy issues, ending with a look at public health and food security. The meeting addressed the issue of traditional knowledge. The ‘African renaissance can only be borne on the role of indigenous knowledge systems,’ said Yonah Seleti, director general of South Africa’s Department of Science and Technology. The current intellectual property system fails to protect the knowledge of indigenous people, he said, highlighting his office’s ‘farmer to pharma challenge’, which is intended to unlock the value in biodiversity and traditional medicines. But this means that intellectual property (IP) must be seen as having environmental and social benefits, as well as economic ones. Collaborative research between traditional knowledge and modern medicine can yield great public health benefits, but IP agreements must find ways to protect traditional knowledge.
Many people in developing countries lack access to health technologies. This paper presents seven findings about processes that shape access, based on analysis of six case histories: praziquantel to treat schistosomiasis (a parasitic worm disease), hepatitis B vaccine, the Norplant contraceptive, malaria rapid diagnostic tests, vaccine vial monitors and the female condom. Each case study is assessed with a comprehensive framework that examines the effects of architecture, availability, affordability and adoption on creating access. The analysis shows that access to health technology in poor countries is difficult to achieve because of multiple obstacles, but it can be created under certain conditions.
In response to the report by the United Nations Economic and Social Council (ECOSOC) on their high-level meeting held from 6–9 July in Geneva, Lumumba Di-Aping of Sudan, who spoke on behalf of the Group of 77 and China, said the international community should not let the patent holders deny the right to health. Patent holders should not ‘seek to restrain and unreasonably impose measures that affect the supply chain of medicines and transfer of technology relating to health products.’ Mike Boyd, acting director general of the International Federation of Pharmaceutical Manufacturers and Associations, asserted that pharmaceutical industry made a very significant contribution to helping achieve the health-related UN Millennium Development Goals. International cooperation should be improved in order to ensure access to affordable, good quality and effective medicines, said Maria Nazareth Farani Azevedo of Brazil. Intellectual property rights play a determinant role in the access, affordability, innovation, local production, and trade, she said, adding that member states should resolve the intellectual property agenda.
The World Trade Organization’s (WTO) Doha Development Round was meant to rebalance decades of unfair rules in agriculture and address the needs of developing countries. Instead, the negotiations have betrayed this promise. It has become a ‘market access’ negotiation, in which developing countries are expected to give disproportionately more and will receive little but stale promises of the general benefits of liberalisation. In order to put the Doha Round back on the ‘development’ track, Oxfam recommends that WTO members take actions to: improve the process of negotiations to make them more transparent and inclusive; ensure special and differential treatment for developing countries; promote development by enabling the realization of rights, such as the right to food, ensuring that trade rules respond to the needs of the most vulnerable people first; and strengthen the WTO as an institution to build greater confidence in its ability to achieve fairer trade rules for developing countries.
Pharmaceutical companies are manipulating the intellectual property rights system and are ‘actively trying to delay the entry of generic medicines onto their markets,’ a top EU official has said. As a result, there has been a decline in the number of innovative medicines getting to the market. The European Commissioner for Competition, Neelie Kroes, has announced that the first antitrust case resulting from the inquiry is now open. It alleges breaches of European rules on ‘restrictive business practices’ and ‘abuse of a dominant market position,’ and is filed against French company Les Laboratoires Servier and five generics with which it had made deals, according to a separate press release. The slowdown in novel medicines entering the market – 27 annually since 2000 as compared to 40 annually between 1995 and 1999 – was a systemic problem and the causes need to be identified.
An influential manufacturers’ lobbying group in Kenya is pushing the government to start enforcing an anti-counterfeiting law, despite fears from public health advocates that the new rules will impede access to generic drugs and set an unwanted precedent in East Africa. The Kenya Association of Manufacturers (KAM) says it wants the Anti-Counterfeit Act to be implemented as soon as possible and has been in talks with the government to make sure that happens. The law was passed last year but has not yet taken effect because of budgeting and procedural delays. The association claims that counterfeits cost companies 50 billion shillings (US$650 million) and the government 19 billion shillings (US$250 million) in taxes in 2008. Yet public health advocates argue that the Act’s definition of what constitutes a counterfeit product is too vague and could be used to block the import and local manufacture of generic drugs. Civil society organisations also want the two issues of counterfeiting and patent rights to remain separate.
In the United States, the complex process of getting health care technologies into practice takes place in a competitive health system that is driven by technological innovation. Federal, state and local governments’ roles in the diffusion process are limited. In low-income countries, where competitive markets are not as prominent, diffusing medical innovations requires an alternative understanding of how new technologies are adopted. This paper describes how, in low-income countries, the lack of functioning markets serves as a barrier to the transfer of necessary health technologies and why governments must act as stewards in promoting technologies there.
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6. Poverty and health
Increasing the accessibility of health services to poor people requires overcoming the well-known obstacles of travel time, convenient hours and trust. These obstacles differ in importance for urban and rural poor people. For example, spatial obstacles to care are less important for urban poor people, but convenient hours matter more. In rural areas, solutions to increased travel time bring tradeoffs between more clinics in more locations and better clinics in fewer places. There are no universal solutions, but there are universal ways of finding them. Tracking the socioeconomic status of clients served is needed to make poor people were more visible in health system data, contributing to an understanding of how poverty interacts with epidemiology in the course of disease, and also how treatment is sought and complied with. This raises the importance of making solid measurements in future research to show where poor people are and what their barriers to health care access are.
Poor rains have heightened food insecurity in Kenya's northwestern region of Turkana, where malnutrition rates in children under five have risen above the emergency threshold, according to humanitarian officials. About 74% of the population (550,000) already depends on food aid, according to the International Rescue Committee (IRC). It said at least half of child deaths in the region were due to malnutrition or had malnutrition as an underlying cause of death. ‘In [the north-central] Samburu district, the percentage of children under-five considered at risk of malnutrition increased to 29.4% from 21.8% in June. In Moyale [in the northeast], the nutrition status of children below five years declined, with the percentage of children rated at risk of malnutrition rising to 35% in June from 30.6% in April.’ The decline was attributed to higher food prices and reduced availability of food, with pneumonia, malaria and diarrhoea as the three main diseases responsible for deaths among under-fives in Turkana.
This bulletin provides a sketch of urban health in developing countries, documenting the intra-urban differences in health for a number of countries and showing how the risks facing the urban poor compare with those facing rural villagers. It notes that, to better understand urban health in developing countries, the situations of the urban poor and near-poor must be distinguished from those of other city residents. Even among the urban poor, some live in communities of concentrated disadvantage (slums) where they are subjected to a daily barrage of health threats. The author recommends geographic targeting as an effective health strategy for reaching slum dwellers, though other approaches should be devised to meet the needs of the poor who live outside slums. Public health agencies need to work in tandem with other government agencies, and public health programmes should draw on the social capital that is embodied in the associations of the urban poor.
The number of poor and food-insecure people in developing countries is increasing more quickly in urban areas than in rural areas, and could be dropping off the policy radar, according to new research by the US Department of Agriculture (USDA). By 2030 the majority of people in all developing countries will live in urban areas, and UNFPA estimates that about 60 percent of the urban slum population will be under the age of 18. Sub-Saharan African countries have the world's highest rates of urban growth and highest levels of urban poverty – the slum population in these countries doubled from 1990 to 2005, when it reached 200 million. Health hazards emanating from food in urban areas are a critical concern: buying pre-cooked food from street vendors, close contact between humans and poultry and other domestic animals for slaughter, and generally unhygienic conditions in urban markets can have significant health consequences.
7. Equitable health services
This paper, covering the period 2002–2008, describes how multisectoral teams at district level in Kenya have provided post-exposure prophylaxis, physical examination, sexually transmitted infection and pregnancy prevention services. These services were provided at casualty departments as well as through voluntary HIV counselling and testing sites. In 2003 there was a lack of policy, coordination and service delivery mechanisms for post-rape care services in Kenya. Post-exposure prophylaxis against HIV infection was not offered. The paper also found that, between early 2004 and the end of 2007, a total of 784 survivors were seen in the three centres at an average cost of US$27, with numbers increasing each year. Almost half (43%) of these were children younger than 15. The paper outlines how the lessons learned were translated into national policy and the scale-up of post-rape care services through the key involvement of the Division of Reproductive Health.
At least 6,000 people have been displaced by inter-clan fighting in Kenya's southwestern district of Kuria East, on the Tanzania border, according to humanitarian officials. The Red Cross has provided emergency relief aid for the displaced. The worst affected areas include Wagirabosi/Targai location in Ntimaru Division, inhabited by the Buirege clan; and Girigiri sub-location, and the villages of Nguruna, Getongoroma and Kebaroti in Kegonga Division. The Kenyan Red Cross said there were reports of gunshots along the Nyabasi-Buirege border on 22 June and that attacks and counter-attacks since late May had resulted in the displacement of at least 6,290 people and the burning of 765 homes. According to the Red Cross, health services have taken a knock, as there is no ambulance in Kuria East to support referrals and patients, while water and sanitation facilities remain critical, especially in camps for internally displaced people.
This study examines the effectiveness of the current methods for the diagnosis of malaria in Uganda. Diagnosis has mainly been through presumptive management, namely diagnosis on the basis of episodes of fever. However, this paper argues that presumptive management has significantly contributed to the misdiagnosis of malaria. Interviews were conducted with patients at 188 facilities and laboratory samples were taken to assess the accuracy of existing diagnoses. Overall prevalence of malaria was around 24.2%, with a rate of 13.9% in adults and 50.5% for children under five, with 96.2 percent of patients with a positive diagnosis receiving treatment, as well as 47.6% of patients with a negative result. The study authors therefore argue for changes in existing public health policy to include the use of laboratory methods such as microscopy and the introduction of malaria rapid diagnostic tests.
In an effort to tackle the challenges related to a severe shortage of human resources, and geographic and financial barriers, that prohibit patients from accessing care and treatment, a decision was taken to decentralise HIV and AIDS services in Lesotho to the primary health care level. This report outlines the community-based approach to the decentralisation of HIV and AIDS services. The Wellspring of Hope was the first programme in Lesotho to provide HIV and AIDS treatment and care through an entire health service area as a result of this initiative. The report discusses a range of topics: the delivery of HIV and AIDS services, specifically testing and counselling, prevention of mother-to-child transmission and antiretroviral therapy, a nurse-driven approach to the provision of antiretroviral therapy at the community level, and gives activities aimed at health systems strengthening challenges associated with the implementation of this model. This innovative approach has proven to be successful in delivering quality HIV and AIDS and TB services integrated into existing primary health care structures for a population living in remote, rural areas.
Researchers are launching a clinical trial with 1,500 people infected with onchocerciasis (river blindness) in Liberia, Ghana and the Democratic Republic of Congo to test a remedy that could help stop transmission. Onchocerciasis is one of the leading causes of blindness in Africa, according to World Health Organization (WHO), and more than 100 million people, mostly in Africa, are at risk of infection, according to WHO, which estimates that there are about half a million people, mostly in Africa, who are blind due to onchocerciasis. The primary prevention method is black fly control, while treatment has been through annual doses of ivermectin, which might successfully treat individuals, but it does not stop the infection from spreading. If adult worms are not killed they continue to lay eggs in the skin and the disease can be passed on. The drug moxidectin is being studied for its potential to kill adult worms carrying the disease and to wipe out the disease in any high-risk area within six years. The upcoming clinical trials are expected to last two and a half years and will cost about US$6 million.
Poor ventilation, overcrowding and HIV co-infection make prison an ideal breeding-ground for tuberculosis (TB), but a new study will be among the first in South Africa to quantify TB among inmates and personnel. ‘Herisa Rifuba’, or ‘Stop TB’ in Setswana, will include about 3,500 prisoners and staff at the Johannesburg Central Prison, with around 12,000 existing inmates and about 500 new prisoners arriving daily. So far this year, the prison has recorded more than 100 cases of TB (an infection rate of about 10%). In 2006, Johannesburg Central became one of the first prisons accredited to offer antiretroviral (ARV) treatment on site. About 530 of were receiving treatment from the prison clinic, said Joyce Lethoba, a project manager at The Aurum Institute, which helped the prison obtain accreditation. If a prison does not have its own clinic, inmates on ARVs have to be transported to nearby state hospitals to fetch their medication, which carries a greater risk of escapes.
8. Human Resources
The successful continuation of existing HIV care and treatment programmes is threatened by health care worker burnout and HIV-related illness. This study, conducted between March to June 2007, looks at occupational burnout and utilisation of HIV services among health providers in the Lusaka public health sector. Providers from thirteen public clinics were given a 36-item, self-administered questionnaire and invited for focus group discussions and key informant interviews. Focus group participants described burnout as feeling overworked, stressed and tired. In the survey, 51% reported occupational burnout. Risk factors were having another job and knowing a co-worker who left in the last year. Both discussion groups and survey respondents identified confidentiality as the prime reason for not undergoing HIV testing. In Lusaka primary care clinics, overwork, illness and death were common reasons for attrition. Programmes to improve access, acceptability and confidentiality of health care services for clinical providers and to reduce workplace stress could substantially benefit workforce stability.
Participatory research approaches such as the Health Workers for Change (HWC) initiative have been successful in improving provider-client relationships in various developing country settings, but have not yet been reported in the complex environment of hospital wards. This study evaluated the HWC approach for improving the relationship between nurses and parents on a paediatric ward in a busy regional hospital in Tanzania. Six workshops were held, attended by 29 of 31 trained nurses and nurse attendants working on the paediatric ward. Two focus-group discussions were held with the workshop participants six months after the intervention. Some improvement was reported in the responsiveness of nurses to client needs (41.2% of parents were satisfied, up from 38.9%). But nurses felt hindered by persisting problems in their working environment, including poor relationships with other staff and a lack of response from hospital administration to their needs.
Financial-incentive programmes for return of service, whereby participants receive payments in return for a commitment to practise for a period of time in a medically underserved area, can alleviate local and regional health worker shortages through a number of mechanisms. First, they can redirect the flow of those health workers who would have been educated without financial incentives from well-served to underserved areas. Second, they can add health workers to the pool of workers who would have been educated without financial incentives and place them in underserved areas. Third, financial-incentive programmes may improve the retention in underserved areas of those health workers who participate in a programme, but who would have worked in an underserved area without any financial incentives. Fourth, the programmes may increase the retention of all health workers in underserved areas by reducing the strength of some of the reasons why health workers leave such areas, including social isolation, lack of contact with colleagues, lack of support from medical specialists and heavy workload.
According to this survey, more than half of nurses (53%) in South Africa said their workload was worse today when compared to five years ago. Nurses in South Africa indicated that the least favourable aspects of their profession were overwhelming workloads (32%), insufficient pay and benefits (22%), lack of recognition (11%), budget cuts and inadequate health care systems (11%). In contrast, the most favourable aspect was patient contact (39%). In South Africa, as in other countries surveyed, most nurses (85%) said they faced time constraints that prevented them from spending as much time with individual patients as they thought necessary. Some 87% of the nurses surveyed in South Africa said spending more time with individual patients would have a significant impact on patient health. On the plus side, they saw their professional associations as effective in advancing their interests (86%) and supportive of their needs (87%), and 63% perceived the nation's health care system as better than it was five years ago.
Migration has been one of the more important means of greater global integration, and, as the economic crisis has gripped the developed world, many have worried about its impact on such integration, especially falling remittances. A closer examination of the nature of migrant workers' role in the economy suggests more complex outcomes, with somewhat less of an impact than feared. It is true that most of this migration has been driven by economic forces and has given rise to rapidly expanding remittance flows, which have become the most important source of foreign exchange for many developing countries. The International Monetary Fund estimated total remittance flows to developing countries to be nearly US$300 billion in 2009, significantly more than all forms of capital flows put together. In any case, one of the basic pull factors still remains significant: the demographic transition in the North that is increasing the share of the older population that requires more care from younger workers, who must therefore come from abroad. So the current crisis may temporarily slow down the ongoing process of international migration for work, but it is unlikely to reverse it.
This study analysed data from a human resources health facility survey conducted in 2005 in 52 health centres and 22 public hospitals (including all provincial hospitals) across all eight provinces in Kenya. The study looked into the status of attrition rates and the proportion of attrition due to retirement, resignation or death among doctors, clinical officers, nurses and laboratory and pharmacy specialists in surveyed facilities. Results showed that overall health workers attrition rates from 2004 to 2005 were similar across type of health facility: provincial hospitals lost on average 4% of their health workers, compared to 3% for district hospitals and 5% for health centres. The main reason for health worker attrition (all cadres combined) at each level of facility was retirement, followed by resignation and death. Appropriate policies to retain staff in the public health sector may need to be tailored for different cadres and level of health facility. Further studies, perhaps employing qualitative research, need to investigate the importance of different factors in the decision of health workers to resign.
South African (SA) public servants, including doctors and nurses, are demanding a 15% wage increase across the board and want this year's pay talks to centre on the creation of ‘decent work’. Although SA is now under a new administration, one which is considered to be worker friendly, government spokesman Themba Maseko said after a Cabinet briefing earlier this month that the state would make its shrinking spending power known when the wage negotiations started. This year's wage negotiations are likely to be intense considering SA is in its first recession in seventeen years and that the state has still not made good on its occupation specific dispensation (OSD) offer on pay structures agreed to during the last talks in 2007. If the state spent all its money on wage increases, nothing would be left for essential services like textbooks and medical supplies, Maseko said. The state has not yet made known what increases it is willing to offer its employees and is expected to respond to their shortly.
This study attempts to assess if and how informal payments occur in Kibaha, Tanzania. Moreover, it aims to assess how informal earnings might help boost health worker motivation and retention. Nine focus groups were conducted in three health facilities of different levels in the health system. In total, 64 health workers participated in the focus group discussions (81% female, 19% male) and, where possible, focus groups were divided by cadre. Participants mentioned that they felt enslaved by patients as a result of being bribed and this resulted in loss of self-esteem, with fear of detection as a main demotivating factor. Informal payments were not found to be related to retention of health workers in the public health system. The findings suggest that the practice of informal payments contributes to the general demotivation of health workers and negatively affects access to health care services and quality of the health system. Policy action is needed.
9. Public-Private Mix
Many local government authorities in Tanzania have reformed their tax collection systems in recent years in order to increase their revenue. This paper examines how systems of privatised tax collection performed with respect to revenue generation, administration and accountability, based on evidence from urban and rural councils in Tanzania. The paper concludes that outsourcing is not a “quick fix” for increasing local government revenues or reducing tax administration problems.The results showed a mixed outcome; while some councils increased their tax collections, others experienced problems of corruption. The process is susceptible to corruption since local councils have limited capacity to conduct analyses of the tax base and the amounts agents are expected to remit are much less than the revenues they actually collect. The paper suggests that where appropriately managed and monitored, outsourced revenue collection may provide a foundation for more efficient and effective local government revenue administration.
10. Resource allocation and health financing
The global fight against malaria has been continually challenged by poor access to affordable, effective medicine. Growing resistance to chloroquine, the traditional treatment, has worsened the situation. Artemisinins, the successor therapy to chloroquine, are at least ten times more costly than the older drug. In developing countries, most malaria medicines are purchased in the private sector, where traditional aid mechanisms do not reach. So a new aid approach was needed. The Affordable Medicines Facility-malaria (AMFm) will efficiently supply publicly subsidised drugs to meet public- and private-sector demand in malaria-endemic countries. If artemisinins are priced more competitively, resistance to them will be delayed.
Koos Richelle, who heads the EuropeAid Cooperation Office, the principal aid agency of the European Commission, said that, while rich nations were not about to pull the plug on donations, they were more actively monitoring whether the funds were producing desired results. The 27-nation European Union remains committed to aid, he promised, although he warned that recipients would be treated as ‘partners’, obliged to provide key improvements in terms of achieving targets set under the Millennium Development Goals. Before the crisis, rich nations simply gave away funds without making clear what results they wanted, he said. But as western countries experience financial problems, the attitude has shifted and they now demand ‘tangible results’ from development partners. ‘I see modern development cooperation not as a continuum of post-colonial hang-ups, or charity, but more as a contract. If you don't deliver, like in a normal contract, we are not supposed to pay. That is a more businesslike approach to development cooperation.’
The Department for International Development’s (DFID) new White Paper presents a shift in the way the United Kingdom (UK) delivers development aid, refocusing resources onto fragile countries and for the first time treating security and justice as a basic service alongside health, education, water and sanitation. Fifty percent of new bilateral funding will be committed to fragile countries. Key announcements include a renewed commitment to 0.7% of the UK Gross National Income (GNI) for international development (totalling £9bn per year by 2013), measures to reduce maternal mortality rates to save the lives of six million mothers and babies by 2015 and doubling of funding to £1bn for African infrastructure, including transport, energy and trade in the region. Regarding growth and trade, DFID proposes a quadrupling of funding to promote fair and ethical trade and a new International Growth Centre to offer world-class economic expertise and practical advice to poor countries.
The notable increases in funding from various donors for health over the past several years have made examining the effectiveness of aid all the more important. This study examines the extent to which donor funding for health substitutes for – rather than complements – health financing by recipient governments. It found evidence of a strong substitution effect. In fact, the proportionate decrease in government spending associated with an increase in donor funding is largest in low-income countries. The results suggest that aid needs to be structured in a way that better aligns donors’ and recipient governments’ incentives, using innovative approaches such as performance-based aid financing.
According to the European Commission’s annual report, overall spending in 2008 was 937 million euros (about US$1.302 billion) across 60 countries. Of that, about three-quarters went to the top 25 recipient non-profit agencies and an aviation contractor. United Nations (UN) agencies took 46% of the overall spend, while 44% went to non-governmental organisations (NGOs). NGOs from the UK, France and Germany account for over half of NGO funding. More than half was spent in Africa. The top five countries and territories receiving the most funding, including food aid, were (in millions of euros) Sudan (161.3), Occupied Palestinian Territories (75.1), Democratic Republic of Congo (53.9), Ethiopia (48.5) and Kenya (36.7). The top five organisational recipients were (in millions of euros) the UN World Food Programme (228), the International Committee of the Red Cross (78.9), the UN Refugee Agency (53.5), the UN Relief and Works Agency (38) and the UN Children’s Fund, UNICEF (32.6).
Years after graduating from dependence on the International Monetary Fund (IMF), many African countries are having to call upon the fund for assistance to cope with a global economic crisis that is not their fault. African economies are struggling against collapsing demand for their products, volatile commodity prices and falling foreign investment. Among countries seeking IMF aid are Kenya and Tanzania – two of Africa's biggest economic reformers. The IMF on Friday approved a total of US$545 million in emergency funding for the pair of East African countries. Meanwhile, Ghana and Mozambique are in talks with the fund to secure financing support. Other countries that have sought fresh help from the IMF in recent months include Ivory Coast, Ethiopia, Sao Tome and Principe and Zambia.
To compound the apparent inadequacy of the G8, the meeting in Italy got off to an inauspicious start. The Italian hosts were not only under fire for not preparing a constructive agenda, preferring the US to take the lead, but were threatened with expulsion from the G8 for unabashedly reneging on aid pledges to double aid to Africa made at the Gleneagles summit in 2005. According to ActionAid, Italy is US$1.037bn behind in aid arrears, France is further in arrears with US$1.249bn, Germany US$497m, the United States US$263m, Canada US$186m and Japan US$138m. Only Britain is on course to hit its target. This lack of spending is having a devastating effect on Africa’s ability to reach its Millennium Development Goals’ (MDGs) targets. As the new UN MDGs 2009 report states ‘for many developing countries, lower levels of aid would not only impede further progress, but could reverse some of the gains already made.’ Indeed, the proportion of undernourished per population is rising again in sub-Saharan Africa after concrete advances had been made.
An inability to access adequate funding is crippling efforts by community-based organisations (CBOs) to help some of Malawi's most vulnerable children. For example, Monkey Bay, 125km east of the capital, Lilongwe, has some of the highest poverty and HIV-prevalence rates in the country, according to the government's National Statistics Office. Yet a recent report by the Regional Network for Equity in Health in East and Southern Africa (EQUINET), ‘Promoting and protecting health of orphans and vulnerable children in Monkey Bay, Malawi’, said many community-based organisations (CBOs) in the area could not access government funding to support interventions targeted at orphaned and vulnerable children. Donald Makwakwa, programme officer for the Malawi Network of AIDS Service Organisations (MANASO), which provides technical support to CBOs, explained that many grassroots bodies could access technical assistance, but faced periodic funding shortages due to late allotments by the National Aids Council.
The South African government has proposed a national health insurance (NHI) system, but it will face three key challenges as it seeks to re-build trust in the health system. First, discussions so far about NHI have been highly technical and held behind closed doors, will little civil contribution except for interest groups. Second, many public health workers are tired of frequent workplace changes and may view having to adapt to NHI systems as simply making their work more difficult, especially when employees note that their employees often fail to deliver on promises made: ‘I don’t trust them,’ said one nurse. Third, implementing an NHI remains a complex exercise and cannot be achieved with just legislation. The steps of policy implementation must be laid out so that initial actions build the basis for success in subsequent actions. For NHI to succeed, we must strengthen the public health system by increased investment, despite the current global economic downturn.
Taskforce on Innovative International Financing for Health Systems: 2009
The Taskforce's proposals aim to meet a US$10 billion funding gap through a number of means including the expansion of a mandatory solidarity levy on airline tickets, the increased use of the International Financing Facility for Immunisation and the strengthening in capacity of government in their health sector. Following the success of a series of meetings and consultations in Doha, London, Johannesburg, Abuja and Paris over the past seven months the Taskforce has finalised its recommendations on innovative international financing for health systems, which it calls on the participants of the G8 summit to support. The intention is spur world leaders on to strengthen the urgency for a combined effort to tackle the issue of providing adequate health systems for developing countries and increase vital aid flows. Strong political backing for each of the initiatives recommended is critically important. Successful implementation of these recommendations requires purposeful engagement with civil society, both in donor countries and recipient countries.
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11. Equity and HIV/AIDS
AIDS activists have reported that public health facilities in South Africa's Free State Province are experiencing serious shortages of condoms, with some clinics reporting complete stockouts. The Treatment Action Campaign (TAC), an AIDS lobby group, contacted 41 clinics in the province: four reported shortages of condoms and eleven said they had none at all. One clinic in the provincial capital, Bloemfontein, said the depot that normally supplied them with condoms had run out. Free State attracted controversy in November 2008 after the provincial health budget had been overspent to such an extent that the authorities stopped initiating HIV-positive patients on antiretroviral treatment. The national department of health blamed a countrywide shortage in December 2008 on a delay in awarding a new tender. TAC speculated that the delay might still be affecting supply, as it used to receive about one million condoms a month from the health department for distribution, but could now only get hold of about half that quantity.
In this study, the main objective was to estimate the impact of global strategies, such as pooled procurement arrangements, third-party price negotiation and differential pricing, on reducing the price of antiretrovirals (ARVs). Researchers estimated the impact of global strategies to reduce ARV prices using data on 7,253 procurement transactions from July 2002 to October 2007. They found that large purchase volumes did not necessarily result in lower ARV prices. Although current plans for pooled procurement will further increase purchase volumes, savings are uncertain and should be balanced against programmatic costs. Third-party negotiations by the Clinton HIV/AIDS Initiative resulted in lower generic ARV prices. Generics were less expensive than differentially priced branded ARVs, except where little generic competition exists. Alternative strategies for reducing ARV prices, such as streamlining financial management systems, improving demand forecasting and removing barriers to generics, should be explored.
This study set out to determine the incidence of HIV during pregnancy as defined by seroconversion using a repeat HIV rapid testing strategy during late pregnancy. It adopted a cross-sectional design within a prevention of mother-to-child transmission programme. Pregnant women were retested between 36 and 40 weeks of gestation, provided that they had been tested HIV negative at least three months prior. Single women were at 2.5 times higher risk of seroconverting during pregnancy. In general, HIV incidence during pregnancy was four times higher than in the non-pregnant population. Public health programmes need to continue to reinforce prevention strategies and HIV retesting during pregnancy. The latter also offers an additional opportunity to prevent mother-to-child transmission and further horizontal transmission. Further research is required to understand the cause of primary HIV infection in pregnancy.
Little is known about the stage at which those infected with HIV present for treatment in sub-Saharan Africa. This study conducted a cross-sectional analysis of initial visits to the Immune Suppression Syndrome Clinic of the Mbarara University Teaching Hospital, Uganda, totalling 2,311 patients with an initial visit between February 2007 and February 2008. The median age of the patients was 33 years and 64% were female. More than one third (40%) were categorised as late presenters (stage three or four, according to the World Health Organization disease levels). Late presentation was associated with a lower education level, unemployment, living in a household with others or being unmarried, whereas being pregnant, having young children and consuming alcohol in the prior year were associated with early presentation. Targeted public health interventions to facilitate earlier entry into HIV care are needed, as well as additional study to determine whether late presentation is due to delays in testing vs. delays in accessing care.
Health experts and scientists have accused the world's wealthiest countries of abandoning the goal of universal access to HIV prevention, care and treatment by 2010. ‘We must hold the G8 leaders accountable for their failure to deliver on their promises,’ said Julio Montaner, president of the International Aids Society (IAS), on opening the Fifth IAS Conference on Pathogenesis, Diagnosis and Treatment in Cape Town on 19 July. Montaner, who is also director of the British Columbia Centre for Excellence in HIV/AIDS, was sharply critical of the world's most powerful industrialised countries, who in 2005 committed to developing a comprehensive response to the AIDS pandemic that would achieve universal access to treatment by next year, yet have failed to renew these promises at the G8 summit held from 8–10 July. ‘HIV/AIDS was indeed the elephant in the room,’ he said. ‘In 2009, the eight most powerful economies in the world left HIV off their priority agenda.’
Pharmaceutical giant GlaxoSmithKline has announced plans to invest up to US$97 million over 10 years in improving antiretroviral (ARV) treatment for children and adults in sub-Saharan Africa. The world's second largest drug manufacturer has already pledged US$16 million in seed funding to a public-private partnership that will develop new paediatric formulations of ARV drugs. Less than 10 percent of patients on ARVs in Africa are children and, although thirteen ARV formulations specifically for children are available, they are not adapted for use in resource-poor settings. Most are in liquid form, and come as three, often unpalatable, separate drugs that children find difficult to take. The company has also launched a new ‘Positive Action for Children’ fund of US$80 million over 10 years to help prevent mother-to-child transmission of HIV, and to support orphans and vulnerable children. It made the announcement after activists and governments put pressure on drug companies to do more to make life-saving medicines available in developing countries.
This study’s main aim was to determine what US$577 million in funding from the US President’s Fund for AIDS Relief (PEPFAR) between 2004 and 2008 has achieved in Zambia. Its findings are based on interviews with HIV and AIDS organisations, activists, medical professionals, community leaders, policymakers and programme participants. PEPFAR followed the ABC (abstain, be faithful and use a condom) approach to HIV prevention in Zambia but, according to this report, in 2008, US$20.5 million was channelled to programmes focused on abstinence and being faithful, compared to only US$12.4 million allocated to programmes promoting other approaches, including the use of condoms. Only four organisations received funding to promote condom use. ‘The disproportionate emphasis on abstinence-until-marriage [...] has created a distinctly anti-condom atmosphere,’ the authors noted. They recommended more extensive sex education programmes.
Widespread early therapy for HIV is intellectually compelling because it targets viral load, the major biological risk factor for transmission and disease progression. Delaying treatment until HIV has inflicted severe damage on the immune system and further transmission occurs is a different practice to the approach of other infectious diseases such as tuberculosis. Earlier diagnosis and treatment offer opportunity for ‘positive prevention’, emphasising other health interventions, as well as enhancing the sexual and reproductive health and rights of persons living with HIV. Papers published in 2008 suggested anti-retroviral therapy (ART) may be considered a means of limiting HIV spread, as it reduces viral load. One paper reported that annual universal voluntary HIV testing followed by immediate ART could reduce HIV incidence by about 95% within a decade, with cost-saving over the medium term. Nonetheless, the world requires stronger evidence before policy development on ART for HIV prevention can be envisaged.
The objective of this study was to gain a greater understanding of published safety data for candidate vaginal microbicides. It systematically reviewed twenty-one human safety trials in peer-reviewed journals, involving the use of 11 vaginal microbicides by a total of 1,465 women. There were few findings of significant difference between women in active and control arms of trials. Confidence intervals in the analyses were generally very wide, and most studies were unable to exclude differences of a substantial magnitude between treated and control women. Larger and longer safety studies are necessary to detect clinically important toxicities, including those that indicate a potential increase in HIV risk, before they are ready for large-scale effectiveness trials and use in the public sector.
It is becoming clear that HIV/AIDS spreads most rapidly among poor, marginalised, women, colonised and disempowered groups of people more than others. The HIV/AIDS epidemic is exacerbated by the social, economic, political, and cultural conditions of societies such as gender, racial, class, and other forms of inequalities. Sub-Saharan African countries are severely hit by HIV/AIDS. For these countries the pandemic of HIV/AIDS requires them to go the extra mile in their efforts. The objective of this paper is to promote the need to go beyond the biomedical model of ‘technical fixes’ and the traditional public health education tools, and come up with innovative ideas and strategic thinking to contain the epidemic. It argues that containing the HIV/AIDS epidemic and improving family and community health requires giving appropriate attention to the social illnesses that are responsible for exacerbating biological disorders.
12. Governance and participation in health
At their meeting in Sirte, Libya, held from 1–3 July, nearly half of the 53 African Union (AU) heads of state and government reached consensus to establish the African Union Authority to replace the African Union Commission. Libyan Leader Mouamar Kadhafi, supported by Senegal’s President Abdoulaye Wade, argued to speed up continental integration but others, notably Nigeria and Tanzania, argued against it. Commenting on the consensus reached, Jean-Marie Ehouzou, the Benin Foreign Minister noted, ‘African leaders are in agreement with ceding a little of their sovereignty to the AU Authority’. To enter into force, the AU Authority must be approved by the Parliaments of all AU countries. African leaders also discussed the integration of the New Partnership for Africa’s Development (NEPAD) into the organs of the AU and adopted a resolution ending cooperation with the International Criminal Court in the Hague. They also decided to reinforce agriculture and food security and to enlarge the powers of the AU Commission into foreign, trade and defence areas.
EuropeAid organised a consultation meeting in June on the second Strategy Paper of the 2007–2013 European Union (EU) programme, the European Partnership for Democracy and Human Rights (EIDHR). Currently in draft form, this paper will provide the basis for European Community (EC) multi-annual programming and annual action programmes for the period 2011–2013. The European Commission (EC) identified specific changes in the new strategy as including: a stronger emphasis on difficult countries as apposed to difficult situations; a higher number of countries eligible for increased support; greater decentralisation of decision-making to EC delegations; a greater focus on links between thematic and geographical instruments; and more clarity on EC human rights priorities and their link to political dialogue. The Commission noted, however, that it does not plan to provide details on the draft EIDHR strategy ahead of its publication and, while written civil society submissions are welcome, only minor changes would be made at this stage since the EC considered it premature to undertake an evaluation of the programme.
The author, on behalf of CIVICUS, expresses deep concerned about certain restrictive aspects of the Non-governmental Organisation (NGO) Bill of 2009, which the Zambian government is planning to introduce in Parliament. Some of the concerns raised by civil society in the 2007 version of the Bill have been addressed, but key provisions of the Bill restrict the independence of NGOs and subject them to excessive and unwarranted controls which serve to impede rather than enable the freedom of association guaranteed by the Constitution of Zambia, the International Covenant on Civil and Political Rights, and the African Charter on Human and People’s Rights, to which Zambia is a party. If passed in its present form, the Bill will seriously restrict the activities of NGOs. Key areas of concern include problematic registration procedures, excessive government control and unnecessary curbs on independence through forced self-regulation and peer monitoring.
This study attempts to distil lessons learned by a handful of African civil society coalitions on the dynamics of demanding improved governance of governments that are often averse to governance reform. The project admittedly tackles an ambitiously formidable subject, largely due to the dearth of compelling, contemporary African examples of civil society leading noteworthy policy or social change. Governance and policy reform in several African countries continues to be driven by African governments, through initiatives such as the African Peer Review Mechanism (APRM), as the South African Institute of International Affairs’ (SAIIA) six years of research into the APRM suggests. As such, the study broaches a subject starved of compelling material. However, it creates an accessible set of lessons from civil society activists, academics, diplomats, representatives of donor agencies and civil society experts that have played leading roles in a few – but notable – episodes of civil society-led policy reform.
13. Monitoring equity and research policy
New drugs, vaccines and diagnostics for the diseases of the developing world could save millions of lives and prevent enormous suffering and economic loss. Despite substantial new funding from the Gates Foundation and other donors, financing for the research and development (R&D) of these new health technologies remains inadequate. New approaches are needed to generate more resources, make funding more stable and flexible, and further engage the expertise of the pharmaceutical industry. Several new financing mechanisms have been launched recently, and others are being proposed. This paper summarises some of the most promising new ideas and offers a framework for evaluating them.
As long as standards and norms governing international research partnerships remain undefined in the legal environment, contractual matters will consume excessive energy, detract from the real work of health research professionals and set up collaborating institutions as potential adversaries rather than partners with a common research agenda. Agreed standards and norms for research contracting provide a framework for guidelines for equitable partnerships that can be put into practice in low- and middle-income countries to address the needs of local populations. The recently established International Collaboration on Equitable Research Contracts is conducting a global assessment of research contracting by developing and disseminating model contracts in which the rights, responsibilities and requirements of all partners are recognised. This evidence will inform the development of practical tools to achieve more equitable results in international research partnerships.
The quality of health care, including access to HIV prevention and testing services, depends to a large extent on which of South Africa's 52 districts you happen to live in. Some of the inequities highlighted by the District Health Barometer can be traced to differences in health spending, with districts in Western Cape Province spending the most on primary health care and districts in Free State Province spending the least. In the report, Dr Tanya Doherty of South Africa's Medical Research Council attributed a lack of improvement in child and maternal mortality rates to the HIV epidemic – under-five mortality barely shifted from 60 per 1,000 births in 1990 to 59 in 2007, while maternal mortality actually increased. Prevention of mother-to-child HIV transmission (PMTCT) is vital to reducing maternal and child mortality and combating HIV, but health authorities have failed to properly monitor PMTCT interventions. ‘This is indicative of management neglect of the programme from national to facility level,’ Doherty wrote.
South Africa's management of tuberculosis (TB) has significantly improved compared to what it was in 2005, according to this joint review of the TB programme by the World Health Organisation (WHO), development partners and non-governmental organisations (NGOs). Specifically, the TB defaulter rate has declined and cure rate has increased. The review included observations of provision of care in clinics and hospitals, and interviews with TB services managers and health workers. It found major improvements on quality and access to TB services (TB diagnosis and treatment available in all health facilities) resulting in increased case detection and treatment success. However, staffing levels were found to be sufficient in some provinces but insufficient in others and staff were very often not adequately trained in TB control, while drugs were generally available and in sufficient quantities. The Review recommended that infection control measures should be improved, as these was found to be weak.
The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) annually review data on immunisation coverage to estimate national coverage with routine service delivery of commonly used vaccines. The estimates are based on government reports submitted to WHO and UNICEF and are supplemented by survey results from the published and grey literature. Local experts are consulted for additional information on the performance of specific immunisation systems. Estimates are derived through a country-by-country review of available data informed and constrained by a set of heuristics – no statistical or mathematical models are used. Draft estimates are made, sent to national authorities for review and comment and modified in light of their feedback. While the final estimates may not differ from reported data, they constitute an independent technical assessment by WHO and UNICEF of the performance of national immunisation systems. These country-specific estimates, available from 1980 onward, are updated annually.
This World Bank Independent Evaluation Group (IEG) report on almost $18 billion worth of health, nutrition and population work covered projects from 1997 to 2008 by the World Bank. It rated 220 projects according to how well they met stated objectives, regardless of how good those objectives were. Highly satisfactory outcomes were almost unheard of, and only about two-thirds of projects had moderately satisfactory outcomes or better. Projects in Africa were ‘particularly weak’, with only 27% achieving satisfactory outcomes. Overall only 29% of freestanding HIV projects had satisfactory outcomes, falling to 18% in Africa. Repeating a consistent criticism of past reports, the IEG found that monitoring and evaluation (M&E) ‘remains weak’, while ‘evaluation is almost nonexistent’. Only 27% of projects had ‘substantial or high’ M&E structures. This has led to ‘irrelevant objectives, inappropriate project designs, unrealistic targets, inability to measure the effectiveness of interventions.’ Even those projects that meet their objectives ‘may be performing at substantially lower levels than their outcomes would suggest’.
14. Useful Resources
Originally developed for Gendernet, this online guide is intended to support the design and delivery of gender training. As a resource, the guide provides ‘building blocks’ that facilitators can use to design customised training workshops and has been designed with the assumption that potential learners have little or basic understanding of gender and development concepts. Training modules cover topics like gender inequity and poverty, gender analysis and planning, gender-aware designing, planning, monitoring and evaluation in terms of gender, gender mainstreaming and organisational change, including policy approaches to addressing gender and equality in development and developing advocacy strategies. Facilitators’ tools include ice-breakers and energisers. There are also suggested workshop plans that provide ideas for how this guide can be used to design workshop outlines.
The latest edition of Eldis OnDisc is out now and focuses on Manuals and Toolkits. It contains over 400 full-text publications from 150 development organisations. Eldis OnDisc is freely available to subscribers with poor internet connection who struggle to access the full Eldis online services. Designed with the busy development professional and researcher in mind, publications on this CD-Rom have been categorised into key subject and skills areas for quick reference. There is also an easy-to-use Search function, helping you get right to the publication you need and each publication is accompanied by a short abstract. To receive your copy of Eldis OnDisc Manuals and Toolkits edition, please complete the registration form at the website address given here. If you are experiencing problems with this form, you can request a Word version at the email address provided.
The new EU online platform, Capacity4Dev, is part of the European Commission’s ambitious ‘Backbone Strategy’ to reform technical cooperation. The Commission envisions the new portal as an essential tool in reforming technical cooperation programmes that support capacity development, public sector reform and other themes. The site, which will be developed through 2009, provides a forum for all Commission staff, partner countries, other donors, academics and civil society representatives to share ideas and expertise. By joining Capacity4Dev, you get access to useful capacity development tools, feature articles on current topics of interest and academic papers. Registration is free.
Under a new initiative, international donors are backing Africa-based policy research to improve local decision-making on complex global issues with potentially enormous humanitarian consequences like food security and climate change. Led by Canada's International Development Research Centre (IDRC) and funded by IDRC, the Bill and Melinda Gates Foundation and the Hewlett Foundation, the Think Tank Initiative will provide core funding for 24 African think tanks over 10 years. About US$30 million has been made available for the initial five years. Retaining top quality staff is a challenge, according to Jean Mensa, executive director of the Institute of Economic Affairs (IEA), a Ghanaian think tank and a grant recipient. Many of the best and brightest researchers look for employment abroad or in international development projects that offer better conditions and more job security. But if African think tanks are to be effective, Mensa said, long-term investment is essential.
Many development interventions appear to leave no trace of sustained positive change after they have been terminated. This guidance document was developed by the Network of Networks on Impact Evaluation to support its focus on sharing methods and learning-by-doing to promote the practice of impact evaluation. It shows you how to identify the type and scope of the intervention by agreeing on the objectives of the intervention that are valued, articulating the theories linking interventions to outcomes, addressing the issue of attribution and building on existing knowledge relevant to the impact intervention. It also shows you how to manage impact evalulations by determining the feasibility of impact evaluation, gathering data and conducting front-end planning. It puts forward the idea that rigorous impact evaluation is not merely about specific methods and designs, but also about addressing the issues given above, in particular the core methodological and conceptual issues.
This training manual, published by the Food and Nutrition Technical Assistance II (FANTA-2) Project, recognises that nutrition interventions are an important component of comprehensive care and support for people living with HIV. They help to manage symptoms, promote response to treatment and improving functioning and quality of life. The authors argue that equipping nurses, who in many settings play a critical role in HIV care, with nutrition and HIV knowledge and skills enables them to provide effective nutrition care and support. The manual is organised into three parts: Part I includes introductory sessions with basic information about HIV, Part II aims to build technical knowledge and Part III provides guidance on nutrition care for different clients living with HIV. This training manual is designed to be used for pre-service training, but it can also be used or adapted for in-service training – an advantage considering the fact that nursing school curricula in the East, Central and Southern Africa region often includes little or no information on the subject.
This operations manual provides guidance on planning and delivering HIV prevention, care and treatment services at health centres in countries with high HIV prevalence. It gives an operational framework to ensure that HIV services can be provided in an integrated, efficient and quality-assured manner. It is based on the decentralised public health approach to scaling up HIV services in resource-constrained settings, which includes simple, standardised regimens and formularies; standardised supervision and patient monitoring approaches; as well as integrated delivery of care at primary health centres within a district network. This manual is written as a learning aid and job aid for the health centre team, and in particular the health centre manager (often an in-charge nurse). The authors, however, contend that district management teams, which supervise and support health centre services, should also find this manual helpful, as should national Ministries of Health and other partners responsible for planning and supporting the decentralisation of HIV services.
Complex policy issues cannot be solved by government alone. Delivering high-quality public services at the least cost and achieving shared public policy goals requires innovative approaches and greater involvement of citizens. This book is a valuable source of information on government performance in fostering open and inclusive policy making in 25 countries. It offers rich insights into current practice through 14 in-depth country case studies and 18 opinion pieces from leading civil society and government practitioners. It includes 10 guiding principles to support open and inclusive policy making and service delivery in practice.
The website for the Taskforce on Innovative International Financing for Health Systems has re-launched with a new range of applications designed to improve the navigation and accessibility of information hosted on the site. The Taskforce report and Working Group reports are currently available to download in five languages: English, French, German, Italian and Spanish, with other languages, including Chinese mandarin, Indonesian, Japanese, Korean and Portuguese due to be added in the forthcoming weeks. The website encourages interactivity with video footage of recent consultation events and speeches from Gordon Brown, Dr Margaret Chan and Glenys Kinnock. A blog page and feedback form have also been added to ensure that a constant stream of communication can be maintained between the Taskforce, civil society and other interested parties.
This is a practical, do-it-yourself guide for leaders and facilitators wanting to help organisations, such as social movements, function and develop in more healthy, human and effective ways. The guide, with its supporting website, includes tried and tested concepts, approaches, stories and activities, and was developed by a global team of collaborating practitioners and activists. It offers a perspective on why organisations exist and the real role they play, and the importance of supporting local sovereignty of local organisations and social movements for meaningful social change. It provides a range of approaches to self-understanding as well as understanding the role of leaders and facilitators aiming to facilitate change in organisations. It looks at the significance of relationships and power dynamics, including tracking how organisations move through various phases of development, how change can be facilitated and the challenges faced in implementing or sustaining change.
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15. Jobs and Announcements
The World Health Organization is inviting authors to submit articles as a contribution to a special theme issue that will explore the challenges of health worker retention in remote and rural areas. Much is known already about the factors that influence health workers’ choices of location and their decisions to go to, stay in or leave these areas. However, there is very little evidence on specific operational solutions and recommendations that countries can adapt to their specific context in responding to this challenge; in particular evidence is lacking on the design, implementation and evaluation of these strategies. Papers should aim at filling the gaps in the current knowledge on costs of implementing rural retention strategies and incentive schemes, and the extent to which context influences the design, implementation and the impact of various strategies. Innovative methodological papers that examine the monitoring and impact evaluation of various strategies are also encouraged, in particular with a view to understanding the long-term effects and sustainability of retention strategies.
Poverty and inequality are getting worse in developing countries as a result of the global economic crisis. Poor families are eating less, being evicted from their homes, and having to pull children out of school. All of this is exacerbated by the effects of high food prices, the failure of rich countries to deliver on their aid promises, and the growing harmful impacts of climate change. Oxfam was at the G8 Summit in Italy lobbying to get rich country heads of state to boost development aid, tackle climate change, and invest in developing country agriculture so that poor countries are less reliant on food aid. Once again, the G8 leaders let down the world's poorest by reneging on the promises made at the previous Summit. Take action – join Oxfam's Big Promise and let's all show world leaders how to keep a promise!
The theme for the Geneva Health Forum 2010 is 'Globalisation, Crisis, and Health Systems: Confronting Regional Perspectives'. Abstract submission is now officially open. The list of abstract themes has been finalised: health threats and access to health at times of crisis, health governance and policies, healthcare delivery and access to medicines, mobility and migration, trade and health, and health information, training and technologies. For more information on the Geneva Health Forum in general, you can visit their website: www.genevahealthforum.org
If you are an aid worker and have an opinion on how poorly (or well-) funded your organisation is, how competent your fellow aid workers are or how well the international humanitarian system works with local authorities, the Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP) is looking for your input in their new ‘state of the humanitarian system’ review. Despite various evaluations and analyses of the humanitarian system some ‘very basic information’ on its size, reach, scope of action and capability remains unknown, said Paul Harvey, a humanitarian aid expert leading the review for ALNAP. The report will provide a descriptive mapping, a general performance assessment, and an analysis of major new developments in the humanitarian aid sector over the past three years. Any contributions to the online survey are welcome.
The International Development Research Centre (IDRC) internship awards provide exposure to research for international development through a program of training in research management and grant administration under the guidance of IDRC programme staff. The internships start in January 2010 and are designed to provide hands-on learning experiences in research program management in the creation, dissemination and utilisation of knowledge from an international perspective. The intern will undertake a program of research on the topic submitted when competing for the internship award, and will be trained in the techniques of research management through hands-on experience with the Centre's policies and practices for grant administration under the mentorship of a Programme Officer. IDRC’s research activities focus on four programme areas: social and economic policy; environment and natural resource management; information and communication technologies for development; and innovation, policy and science.
The short film, Flight 208, which deals with health and related issues of inequality, is participating in the Humanity Explored Film Festival 2009. This is an online film festival. The festival is unique in the sense that the films are judged on the basis of how the audience rates them. We will be hapy if you could watch and rate and popularise these films which are connected with all the issues we care for. The film is satirical and shot across the globe with more than 208 persons from across the world. The film idea was triggered while the director was in Ecuador to attend and document the second People’s Health Assembly in 2005. It has already won awards and been screened at many prestigous film festivals. It’s seven minutes long.
Registration is now open for the South African Monitoring and Evaluation Association (SAMEA) Conference Workshop. The programme consists of a number of workshops dealing with gender and rights-based participatory monitoring and evaluation (M&E), participatory outcome mapping, understanding project logic model as a tool for conducting clarificatory evaluation, theory-based impact evaluation, the dynamics in building M&E systems to enhance the utilisation of M&E practices and findings in programme development, management and implementation, and a systematic approach to evaluate M&E systems to enhance system strengthening for effective management and utilisation of information. The workshops have been developed to offer training opportunities to beginners as well as seasoned professionals who wish to sharpen their skills and are offered by competent and reputable trainers based locally and internationally.
The central focus of this conference, organised by the Federation of European Societies for Tropical Medicine and International Health (FESTMIH), will be ‘Equity, Human Rights and Access to Care’. This event aims to deal with the classical aspects of tropical medicine including basic science, diagnostics/therapeutics and disease control, and will include an emphasis on transferability of research results into actual practice. Discussions will also address the North-South gap in health research, in all main aspects, such as how much space is devoted to global health in medical journals, the role of researchers from the South in relevant publications, what share of research is actually devoted to priority areas, important gaps that remain to be filled in research in tropical medicine and international health, and difficulties experienced in financing health system research.
The 2009 Pan African Health Expo and Conference will take place concurrently with the ACSA Disability and Special Needs Expo and Conference, and its main objective is promoting the medical industry, including medical technology and pharmaceuticals throughout Africa. The Pan African Health 2009 Healthcare Funding conference is a one day event and centres around how South Africa will fund it’s hospitals and other medical needs with economists and government advising on how it will be achieved. Exhibitors at the show include healthcare solution providers, medical technology and equipment, diagnostics and medical supplies, disposables, pharmaceutical products, surgical products and devices, medical information technology and education, and medical service providers. The expo is aimed to attract visitors from various sectors like private clinics, government hospitals, government health officials, medical professionals, donor funding organisations, non-governmental organisations involved in healthcare and medical aids and administrators. Register at the website address provided.
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