Throughout Southern Africa, there are few programmes to protect the health of workers, or occupational health. Public funding in the region for occupational health services and the enforcement of occupational health laws generally comes from tax or social security funds. However these funds are inadequate to do more than run basic systems. Programmes to develop personnel, do research or expand services into new areas such as for informal sector workers or for women, rural or other marginalised workers, often relies on aid from high income countries.
These areas are some of the more challenging areas of occupational health, and often those with greatest burdens to population health. They are thus important for workers, communities and countries. Yet as aid funded, the developmental objectives for such programmes are often set by funders, with little in-country stakeholder consultation, and with relatively unpredictable financing.
Two recent Southern African regional programmes have deviated from this. These are the Swedish International Development Agency funded Work and Health in Southern Africa (WAHSA) programme and the Fogarty International Centre funded University of Michigan Southern African programme in Occupational and Environmental Health. To their credit, and strongly contributing to positive features noted in the evaluation of these programmes, the international partners involved in both the WAHSA and Michigan programmes made efforts to consult with relevant stakeholders in the region. Nevertheless their objectives and support are still subject to the priorities of their funding agencies.
The “Paris Declaration on Aid Effectiveness” (the “Paris Declaration”) in 2005 established new ground rules. At the 2005 conference convened by the high income OECD countries, but also including developing country representation, a revised and co-ordinated approach to development aid was promised. The Paris Declaration aimed to better manage the process of providing aid; ensure alignment with national development strategies and encourage beneficiary control and leadership in development programmes.
There is already recognition of some gaps between the noble promises and the outcomes to date. A 2009 OECD report commented on some fragmentation of effort, observing that ‘‘the international development effort now adds up to less than the sum of its parts’’. Sixteen Sub-Saharan countries were noted to have between 24 and 30 external funders, and eight of these to have between 15 and 20 external funders, suggesting that the rationalisation intentions of the Paris Declaration have not been met. The north – south network ‘Reality of Aid’ (http://www.realityofaid.org/) noted that there has been limited community participation in setting in-country agendas for aid. In their January 2007 newsletter, the network argue that the influence of external funders in recipient country policies has persisted through funder -imposed conditions on funding. This was highly contentious during the discredited Structural Adjustment Programmes of the 1980’s, and a United Nations Conference on Trade and Development report in 2000 identified eighty two governance-related conditions out of an average of one hundred and fourteen conditions for each IMF and World Bank agreement in Sub-Saharan Africa.
Despite the promise of better co-ordination, the Paris Agenda has also left a significant gap in partnership on occupational health, despite recognition of the contribution of employment and workplace risks to health equity in the recent report of the WHO Commission on the Social Determinants of Health. Funding for occupational health does not seem to be on the agenda of any major bilateral funder (excluding foundations such as the US Fogarty International Centre and the US National Institutes of Health). Given negative experiences of early termination of long term external funding support to occupational health in the region in the 1990s, the Paris Agenda offered optimism for sustained predictable support to this neglected area. Instead, since 2005, two bi-regional externally funded programmes in Southern Africa (WAHSA) and in Central America (SALTRA) met early termination, as the funding agency realigned from regional to country support.
As the Paris Agenda discussions recognised, achieving meaningful impacts in health outcomes or in institutional policies, capacities and practices calls for long-term time frames and commitments to plans, backed by predictable resources and clear processes for monitoring, evaluation and reporting. Uncertain funding leads beneficiaries and funding partners alike to focus on quick returns, rather than deeper impacts. Funding agencies, partners and local recipients may thus set and focus on meeting targets that seem feasible in short term time frames to justify use or continuity of funding, while not adequately yielding the long term gains from these investments. So, for example, numbers trained may be given more attention as targets than longer term structural outcomes, such as the integration of trained personnel into positions in institutions where they are able to influence policy and practice.
Past experience with development aid in this area has raised more questions than answers. How do national and regional organisations involved in a neglected area like occupational health strengthen self determined planning, resourcing and negotiation of programmes and partnerships in conditions of volatile external aid? How can unpredictable, limited and often inadequate funding be organised to support longer term capacity development? How can just demands for accountability and effectiveness be aligned to equally just demands for predictability and recognition of complexity? How best can the self interests of different partners be made explicit, negotiated and factored into partnerships from the beginning?
One way of addressing national leadership must be for countries to improve their own resources for occupational health, not just to run the systems, but to enhance and improve them. If we pursue “fair trade not aid”, then occupational health could be funded in a sustainable manner from improving returns on economic activities and strategic resources in the region. During the structural adjustment era, occupational health responsibilities were deregulated and corporate obligations and taxes reduced to attract foreign investment (which often did not materialise). The public health costs of structural adjustment in Africa are now recognised through the Macroeconomic Commission on Health. Claims for improved public funding for the health sector have had greater recognition, such as in the 2001 Abuja commitment made by African heads of state. There has not been a similar recognition for improved regulation and funding for occupational health. Yet as production and financial activities are increasingly globalised, with recognition of the environmental, economic and social obligations this generates, so too should investment in occupational health be prioritised and located as a matter of international responsibility, in line with fair trade, economic justice and rights to health.
It is time for a movement from within and beyond the trade unions, occupational health, economic and trade justice communities to link with the public health and health justice activists to raise occupational health within global, regional, national and local agendas. To support this with sustained and self determined action within the region, we need to strengthen regional organisation and networking to provide evidence for and engage with local and regional policy, including with intergovernmental forums such as SADC, to ensure sustainable domestic and regional resourcing of occupational health, and to advocate on the priorities for occupational health in the region within the international community.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For more information on occupational health in the region visit the EQUINET website and the WAHSA website at www.wahsa.net
1. Editorial
2. Latest Equinet Updates
This paper was commissioned under the umbrella of the Regional Network for Equity in Health in east and southern Africa (EQUINET), led by the Institute of Social and Economic Research, Rhodes University (ISER) to map and review documented (secondary) evidence on capital flows in the health sector and their implications for equitable access to health care services between 1995 and 2007 in South Africa. The paper finds that private intermediaries channel more funds than the public ones, yet a significant proportion of the population meets health service costs through out-of-pocket payments, and for many this is catastrophic expenditure. There have been successful pro-equity measures to increase access to both public and private health care services e.g. through removal of barriers, such as user fees at primary health care (PHC) facilities, increased coverage of medical aid and through regulation of the private sector. However, inequities in access persist, as do geographical barriers to access. The period reviewed is one where expansion of both public and private sectors has taken place. The challenge remains to translate this into equitable use of available resources, or increased access to health services, especially for those with higher health need. Improved monitoring of health systems impacts of trends described in this paper is urged, given the significant share of private sector services in the public-private mix in health in South Africa.
While there is much promotion of private capital flows into the health sector in Southern Africa in reality these flows have been minimal. Private health is the fifth most promoted sector in African after tourism, hotels and restaurants, energy, and computer services. To understand flows of private capital behind the growth of the for-profit health care sector in SADC, EQUINET working through Rhodes University Institute of Social and Economic Research (ISER) and other institutions in the region are examining health sector capital flows in ESA. Despite the minor movements of capital in the ESA health sector, Mauritius, South Africa, Botswana and Namibia appear as the growth points for big capital, with the rest of the region relegated to the margins in terms of large investments. Investment potential exists in the pharmaceutical, hospital and hospital services sectors, but most of new FDI in health is in the pharmaceutical sector often for the production of ARVs to absorb large donor funds. The pharmaceutical sector has also had the most significant amounts of overt privatisation of all health-related sectors, either through selling fixed assets or transfer of equity. The report argues that South Africa is likely to be the biggest destination for investment in health care, and the major regional source of private FDI flows to the health sector in ESA countries.
Policies in Malawi explicitly mention the need for focus on services for commercial sex workers (CSWs) because of their susceptibility to HIV infection and the potential risk they have of spreading the virus. This study aimed to explore and address barriers to coverage and uptake of HIV prevention and treatment services among CSWs in Area 25 Lilongwe district, Malawi, using Participatory Reflection and Action (PRA) methods. The work was implemented within a programme of the Regional Network for Equity in Health in east and southern Africa (EQUINET co-ordinated by Training and Research Support Centre (TARSC) in co-operation with Ifakara Health Institute Tanzania, REACH Trust Malawi and the Global Network of People Living with HIV and AIDS (GNPP+). An initial baseline survey in 20 health workers and 45 CSWs showed high knowledge but poor rating of access and uptake of HIV prevention, testing and treatment services, due to both barriers in the community and in the services themselves. A PRA process drew out further detail and experiences of the barriers faced, with priorities identified as: lack of early treatment seeking practices amongst CSWs; ill treatment of CSWs at health facilities by health practitioners; and lack of adherence to treatment by most of CSWs. The PRA process raised issues of the gender violence and abuse that CSWs face (including through attitudes and practices in health care services) that dehumanise them and perpetuate their own harmful behaviours. The group of CSWs and health workers as a whole identified interventions that were immediate and feasible to address the three barriers they prioritized. An intensive intervention, involving door to door counseling, engagement at places of work, formation of joint committees between CSWs and health workers and sensitization of health workers was implemented, steered and reviewed by the team with the CSWs and health workers themselves. Health workers and CSWs reported in a follow up survey improvements across all areas in the assessed baseline, except for quality of health services. Health workers reported improvements in the same areas noted by the CSWs, although their rating of improvements were generally a little more modest than the CSWs. We suggest that a public health PHC oriented approach to services for CSWs recognize, listen to, involve and build capacity in CSWs and ex-CSWs, and the civil society organisations that work with them, as a primary group for reaching and mobilizing uptake of services in CSWs.
A regional meeting was held to bring together the cross section of stakeholders from WHO/AFRO, SADC, ECSA-HC, EQUINET, government officials and researchers from the region to develop a harmonized approach for follow up research on health worker migration. The workshop report outlines the discussions and protocol developed to: highlight the key policy issues arising nationally, regionally and globally on the impacts of health worker migration on health systems; and identify key evidence gaps in negotiation of policy and agreements relating to protecting negative health systems impacts of health worker migration; review existing conceptual frameworks, parameters and indicators used for assessing health worker migration flows and for assessing dimensions of health systems; propose a conceptual framework and parameters for measuring impacts of health worker migration on health systems; review existing research initiatives on health worker migration in the region, the methodologies (design, tools) used, their limitations, and discuss and develop a shared standardised method for capturing evidence and analysing the impacts of health worker migration on health systems; and identify research capacities (research teams, funding, and political will) for the follow up work on health worker migration in the region, and a coordinated and harmonised approach to follow up research on health worker migration in the region.
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. Registration has closed, but the abstract book for the conference will be posted to the EQUINET website after the conference and a report will be produced from the conference that will also be on the site. Registered conference delegates should have received information on their delegate status, an information sheet on the conference arrangements and delegates sponsored for travel should have received their e tickets. Letters have been sent to those who need visas. For any queries around visa's or local arrangements please contact gloevents@infocom.co.ug. Speakers have been briefed by their session convenors. If you have not received relevant information above please contact admin@equinetafrica.org. To see the conference programme visit www.equinetafrica.org/conference2009/programme.php.
3. Equity in Health
The World Health Organization (WHO) says the full impact of the swine flu outbreak in Africa has yet to be seen. The African Region was the last to experience the pandemic amongst the six WHO regions, and concerns are mounting about its potential effect. ‘What is of particular concern to us as Africans is that, although the pandemic has spread to our continent last, we may be more severely affected by it,’ said South African health minister Dr Aaron Motsoaledi. The concern is exacerbated by Africa’s burden of disease. ‘It is well known that this continent has always been worst affected by any outbreak of communicable diseases – whether it is HIV, tuberculosis, malaria, one or more of the haemorrhagic fevers. It is, therefore, essential for all countries within the continent to ensure that we are adequately prepared for all of these, but in the present context prepared to deal with the influenza pandemic’, he added.
Africa’s informal sector is still largely unknown. Some reports have suggested that approximately 60% of those employed in the Southern African Development Community region may be in the informal sector, while others report that up to 20% of all African workers were employed in this sector in 1992. Provision for occupational health and safety (OHS) in the sector is generally scanty, and non-existent in some countries, even if policies exist. This brief recommends that a systematic regional approach is needed to protect the health of workers in the informal sector, including collect basic data on the state of the informal sector, state support for infrastructure in developing the informal sector and insist that health and safety issues form part of business plans that are submitted for funding. Governments must play an active lead role and take responsibility for the provision of health and safety support to this sector, as well as ensure that basic health and safety training for employers and workers is provided.
This article notes that almost 400 million of the world's indigenous people have low standards of health. This poor health is associated with poverty, malnutrition, overcrowding, poor hygiene, environmental contamination, and prevalent infections. The authors argue that this precarious situation is aggravated by inadequate clinical care and health promotion, and poor disease prevention services. As indigenous groups move from traditional to transitional and modern lifestyles, they are rapidly acquiring lifestyle diseases, such as obesity, cardiovascular disease, and type 2 diabetes, and physical, social, and mental disorders linked to misuse of alcohol and of other drugs. To correct these inequities, the authors recommend increased awareness, political commitment, and recognition rather than governmental denial and neglect of these serious and complex problems. Additionally, the authors recommend that indigenous people should be encouraged, trained, and enabled to become increasingly involved in overcoming these challenges.
This second article on the health of indigenous people delves into the underlying causes of health disparities between indigenous and non-indigenous people, providing an indigenous perspective to understanding these inequalities. The authors present a snapshot of the many research publications about indigenous health, with the aim to provide clinicians with a framework to better understand such matters. By applying this lens, placed in context for each patient, the authors argue that more culturally appropriate ways to interact with, to assess, and to treat indigenous peoples shall be promoted. The topics covered in this article include indigenous notions of health and identity; mental health and addictions; urbanisation and environmental stresses; whole health and healing; and reconciliation.
Occupational health and safety (OHS) provision for public servants is southern Africa is poor. Many factors may contribute to this grave situation. Managers of government departments often lack knowledge of their responsibilities regarding occupational health and safety. Training in health and safety for managers and workers is limited by inadequate budgets, bureaucratic obstacles to procuring the training and lack of available approved trainers. Resources to improve the working conditions in the public sector are scarce. What is needed to ensure the health and safety of the public sector in Southern Africa are adequate policy and legislation, enforcement and monitoring of compliance in public service departments, OSH programmes in public sector workplaces, access to adequate treatment and rehabilitation for those affected by workplace hazards, and adequate social security for those disabled and the survivors of those who die on the job. Even if they are motivated to act against unsafe conditions, many categories of worker are precluded from the right to strike as they are considered providers of ‘essential services’.
The aim of the research was to assess current and historical surveillance of the pneumoconioses in former miners, in particular silicosis, silico-tuberculosis and tuberculosis, and to assess the functioning of the Occupational Diseases in Mines and Works Act (ODMWA) surveillance and compensation system, which is a responsibility of the Department of Health. The research also aimed to assess the impact of the burden of lung disease and disability on the public health system and on the labour-sending communities from which the miners come and to which they return. The main objective was thus to investigate health systems surveillance of the pneumoconioses in former underground gold miners, and to assess diagnostic and compensation systems under the legal framework of the Occupational Diseases in Mines and Works Act 78 of 1973 as Amended (ODMWA). The main finding was that this is a historically neglected subject, under-researched and undocumented.
4. Values, Policies and Rights
The Southern African Development Community (SADC) Protocols on Health (1999), and Mining (1997) requires member states to co-operate in delivering and improving occupational health in the region’s mining sector. But the rights of mineworkers and other workers to health and safety have not been realised, according to this policy brief. Harmonisation of standards in the region, and monitoring of compliance with standards, is now more critical in the age of free trade agreements. These agreements should not impact negatively on workers’ health, through the exporting of hazardous processes within the region to where regulation and enforcement is less stringent, as well as through pressure to reduce occupational health requirements to allow companies to become more competitive. Stakeholders should hold SADC and member states to the realisation of workers’ health and safety rights and take action when rights are not upheld and targets are not met. They can also identify issues and areas in which collaboration is necessary and ensure that resources and strategies are in place to deliver what is needed.
These guidelines recognise that all types of work are hazardous and persons at work are exposed to situations that may result into injury, disease or even death. In Uganda, the authors argue that the health sector is loaded with a wide variety of situations where health and safety issues are crucial. Additionally, while the economic cost of occupational risks is high, public awareness of safety and health tends to be quite low. The Ugandan health sector requires a standardised framework for workplace safety and health, including responding specifically to HIV as a workplace hazard. The first chapter gives background information on occupational health and safety (OHS). The second addresses the basic OHS principles and interventions. The third deals with management of HIV and AIDS as a specific workplace hazard, while the fourth covers management of the other common hazards that exist at the health workplace. The final chapter deals with implementation of a workplace safety and health programme, including aspects of monitoring.
This report by the Special Rapporteur on the Right to Food, Olivier de Schutter, examines the contribution of development cooperation and food aid to the realisation of the right to food. Interventions include both long-term support for food security and short-term answers to emergency situations. This report makes a number of suggestions on how to reorient both types interventions by better integrating a perspective grounded in the human right to adequate food at three levels: in the definition of the obligations of donor states; in the identification of the tools on which these policies rely; and in the evaluation of such policies, with a view to their continuous improvement. At its core, a human rights approach turns what has been a bilateral relationship between donor and partner, into a triangular relationship, in which the ultimate beneficiaries of these policies play an active role. Seeing the provision of foreign aid as a means to fulfil the human right to adequate food has concrete implications, which assume that donor and partner governments are duty-bearers, and beneficiaries are rights-holders.
This report considers implementing and monitoring human rights with specific reference to economic, social and cultural rights. It addresses the specific challenges posed by the complex array of obligations that stem from economic, social and cultural rights, including progressive realisation and non-discrimination, outlines various ways of monitoring legislation and other normative measures, such as regulations, policies, plans and programs, and elaborates on monitoring the realisation of rights, paying particular attention to human rights impact assessments. Monitoring the realisation of economic, social and cultural rights can be achieved through assessing progress, stagnation or retrogression in the full enjoyment of those rights over time. The report also provides useful indicators and benchmarks for budget analysis and addresses the issue of monitoring violations of economic, social and cultural rights. Monitoring violations of these rights can be achieved through recording complaints filed before judicial and quasi-judicial mechanisms.
The Universal Periodic Review mechanism of the UN Human Rights Council, which came into effect in 2008, has established itself as a mechanism with huge potential and which promotes dialogue and a level playing field for all countries undergoing the review of their human rights record. Building on the Commonwealth Secretariat’s observations and analysis of the process, and the seminars it has conducted with member states, Universal Periodic Review of Human Rights consolidates the lessons learned so far, speaking equally to the three major stakeholders in the process – to states, to national human rights institutions, and to civil society organisations. An effective UPR mechanism will enhance the promotion of human rights across the world. It is therefore essential for the key players to understand and advance the UPR process including at the implementation phase. This publication describes UPR, shares experiences and provides analysis of the Commonwealth countries that reported in the first year of the UPR process.
5. Health equity in economic and trade policies
This policy paper deals primarily with the effect of globalisation on Botswana’s workforce and includes a discussion of occupational health and safety (OHS) within this framework. It notes that, in general, the effective monitoring of health standards is absent in Botswana. The Labour Inspectorate is a government unit under the Ministry of Labour and Home Affairs. It operates under the Factories Act that came into force in 1979. However, there are only a handful and overburdened of labour inspectors carrying OHS inspections to verify compliance with the relevant law. In other cases, some international labour standards ratified have not been backed up by legislation. For example, despite being a heavily mining dependent country, the International Labour Organisation’s convention 176, which deals with health and safety in the mines, has not been enacted at all, notwithstanding its ratification almost a decade ago. The government, like in many other cases continues to gloss over this very serious matter.
With governments looking to close the long-stalled Doha Round of trade liberalisation talks in 2010, what will happen to remaining disagreements on intellectual property issues is still unclear. A coalition of governments seeking IP amendments is determined to have some kind of result at the end the round. The coalition, a group of 110 countries, is often referred to as “W/52” supporters after a compromise document the group created uniting states who were fighting for disclosure of origin on genetic resources with states fighting for stronger genetic information (GI) protection. A great deal of hope is being placed in this informal process by the W/52 proponents, who seek changes they argue are critical to prevent the misappropriation of genetic resources and traditional knowledge, and to protect key agricultural products. But those who do not support W/52 say the connection between GI extension and the disclosure of origin amendment, which emerged from a mandate to examine the relationship between TRIPS and the UN Convention on Biological Diversity, is not justified, as the issues are too different.
Construction health and safety has long been the focus of attention of many industry stakeholders and role-players in South Africa, and while it is acknowledged that many industry associations and professional societies, contracting organisations and others have made significant efforts to improve health and safety within the construction industry, overall, construction health and safety is not improving significantly. Notably, construction continues to contribute a disproportionate number of fatalities and injuries, and there continues to be a high level of non-compliance with the health and safety regulations in South Africa. Against this context, the Construction Industry Development Board (CIDB) has undertaken this report on the status of construction health and safety in South Africa, so as to provide a context for the efforts and actions of industry stakeholders and role-players in improving construction health and safety – including those of the CIDB.
The United Nations Economic and Social Council (ECOSOC) has concluded a month-long coordinating body meeting in Geneva by adopting resolutions on a range of public policy issues such as internet connectivity, science and technology, and HIV/AIDS. However, the digital divide and the lack of global access to AIDS treatments seriously hinder developing countries’ prospects for development, participants say. They underlined the importance of information and communications technologies (ICTs), as well as science and engineering, in the context of development and in the implementation of the Millennium Development Goals. ECOSOC recommended mainstream ICTs to promote growth and sustainable development as it adopted, without a vote, a resolution on the assessment of the progress made in the implementation of the outcomes of the World Summit on the Information Society and its follow-up. The Council asked its stakeholders to assist developing countries to reduce the digital divide.
To contribute to regional objectives, the content and scope of the economic partnership agreements (EPAs) between the European Union and the African, Caribbean and Pacific nations should reflect the specific national and regional interests of countries concerned, and should not impose pressure on these countries to pursue pro-active and counter-cyclical development policies. In spite of the potential merits of regional integration and EPAs in the medium and long term, they offer little prospects to address the immediate consequences of the crisis. In the short run, special attention should thus be given to the scope of commitments and their sequencing to reflect the specific current conditions and development approaches of each country and region. Without such flexibility, EPAs may add to the pain of the crisis. The current crisis also calls for special effort to adequately address the short- and medium-term adjustment needs of ACP countries to bring about longer-term development.
This new book was launched on 10 July and has been called the ‘most progressive agenda we’ve ever had at the World Intellectual Property Organisation.’ Implementation of the ‘Development Agenda’ will be complicated, however. First, there is a divergence at the national level between different stakeholders whose work touches on intellectual property (IP). There are ‘very few delegations that can say there’s a consensus domestically,’ notes the author. And countries must also close the gap between what is said at the international level and what is done at home. A development agenda will ‘never have legs on the ground unless member states go home and implement it.’ But IP laws must also be sensitive to cultural norms and context, lest they alienate key stakeholders. Laws that have lost touch with reality are ‘less likely… [to] be enforced,’ he said. More moderate IP laws, with flexibilities, could increase enforcement. The author also affirms the need to develop good partnerships and good governance.
The metal mining industry employs about 15% of formally employed workers in Zambia, but there is little information about the magnitude of occupational injuries among the miners. This paper aimed to determine the frequency rates of occupational injuries and fatalities among copper miners in Zambia. A retrospective study of occupational injuries and fatalities at one of the largest copper mining companies in Zambia was undertaken for the period January 2005 to May 2007. In the selected period, 165 injuries and 20 fatalities were recorded. The most common cause of fatal injuries was fall of rock in the underground mines. The most frequent mechanism of injury was handling of tools and materials, and the most commonly injured body parts were the hands and fingers. The fatality rate is high compared to reported values from the metalliferous mining industry in developed countries, strongly suggesting that measures should be taken to reduce risks, particularly at underground sites.
This paper outlines the challenges facing environmental and occupational health and safety in Tanzania. It is mainly focused on challenges facing the growth of environmental and occupational health and safety based on chemicals’ management. Environmental and occupational health and safety was found to be very weak, largely due to lack of awareness, high level of illiteracy, weakness in the enforcement of environmental laws, and lack of environmental departments in small and large-scale enterprises. Other challenges include misdistribution of worldwide collaborating centres for World Health Organization/International Labour Organization joint efforts and standards that are not focusing on the safety and health of workers. Recommended strategies include the provision and access to information on safe handling of chemicals, training programmes for environmental health and safety, hazard and accident prevention techniques, risk and safety assessments, and promoting cleaner technologies. There should be an emphasis on development of proper materials safety data sheets based on targeted audience, cost-benefit analysis and auditing of environmental and occupational health and safety.
6. Poverty and health
This collection of articles includes an article on food security in Kenya. Since 2006, the rains in Kenya’s Central Highlands have become less reliable. The March and April rains regularly arrive late, and the season is much shorter. In 2008, there were only four days of rain. The seasonal rivers that provide water for irrigation, livestock and domestic uses have mostly dried up, leading to water and food shortages. These burgeoning problems are pointing in one direction – poverty, malnutrition and health problems for the nation’s poor. Declining production, and the limited access and affordability of imported food, mean food security has declined, with many impacts. The government should store grain during bumper harvests to provide food in poor seasons; processing this surplus can also add value and avoid wastage.
If the South African government wants to alleviate poverty, it should increase the number of people accessing social grants, according to recent submissions by a coalition of non-governmental organisations before the South African Human Rights Commission. The coalition, dubbed the National Working Group on Social Security, pointed out that President Jacob Zuma acknowledged that social grants remain the main effective form of poverty alleviation. However, they noted that no extension of the child support grant to children aged 15 to 18 has been announced, despite the importance of secondary school enrolment. Some people with HIV were alleged to be defaulting on their antiretroviral treatment to retain disability grants, because if they regain their health and their CD4 counts improve, social security stops issuing their HIV and AIDS grant. The Steve Biko Centre for Bioethics has called for a basic income grant and other poverty alleviation programmes that will include sex workers.
The consequences of malnutrition for the efficacy of anti-retroviral therapy (ART) are poorly understood, and evidence regarding the impact of food supplementation on ART outcomes is still limited. The World Health Organization and World Food Programme have issued guidance on food support in ART programmes: every newly enrolled patient should have a nutritional assessment that includes measurement of weight and body mass index, along with nutritional counselling and monitoring. Promotion of activity that increases ability to maintain and expand food supplies, either through growing crops or trading (`livelihoods`) may be a more appropriate response to malnutrition in people with less-advanced HIV disease, with cash transfers also being used as a means of addressing food insecurity. Households affected by HIV often experience multiple threats to their livelihoods. All nutritional support programmes need realistic strategies to avoid dependency and promote long-term food security.
The return of cholera to Zimbabwe is not a matter of if, but when, said Rian van de Braak, head of mission of the medical non-governmental organisation, Médecins Sans Frontières. ‘The threat is definitely not over. Everyone expects cholera to be back, at the latest with the next rainy season [in September or October], because the root causes of the outbreak [in 2008] have not been addressed adequately yet,’ he said. The first case of the cholera epidemic that swept through Zimbabwe, killing more than 4,000 people and infecting close to 100,000 others, was reported in August 2008 and lasted almost a year until it was officially declared at en end in July 2009. Broken sanitation and water systems, the cause of Africa's worst outbreak of the waterborne disease in 15 years, are unlikely to be repaired in time. ‘Several aid agencies are drilling new boreholes in cholera hotspots, which is an important contribution to safe drinking water. Dealing with those causes before the next rainy season is a race against the clock,’ said van de Braak.
7. Equitable health services
African first ladies have vowed to raise awareness on cervical cancer, one of the leading causes of death among women on the continent. Taking the lead, Tobeka Madiba-Zuma, one of South Africa’s first ladies appealed to everyone attending the third Stop Cervical Cancer in Africa conference in Cape Town to join her in paying tribute to millions of women who lost their lives to the illness. ‘A healthy nation consist of a healthy working class and women are very important part our economy’, she said. Madiba-Zuma said she hoped to use her position to advocate for more attention to be paid to breast and cervical cancer. The focus of this year’s conference was on improving cervical cancer prevention through vaccination, pre-cancer screening and treatment. Delivering the keynote address at the conference, Molefi Sefularo, Deputy Minister of Health, revealed that the National Department of Health was considering making available two cervical cancer vaccines in the public sector. ‘We still need to do a cost-benefit analysis and decide which of the two vaccines would be more beneficial to the country,’ he added.
Almost US$1 million worth of anti-malaria drugs are missing or have expired in Tanzania's medical warehouses, this audit has found. Artemisinin combination therapy (ACT) drugs worth US$819,000 are missing and stock worth US$130,000 has expired, highlighting problems with internal control mechanisms. In addition, glitches in the procurement process led to an oversupply and the consequent expiry of ACTs - which have a relatively short shelf-life - in warehouses around the country. The Global Fund has asked the Tanzanian office of international audit firm Price-Waterhouse-Coopers to investigate.
This study reviewed 26 randomised controlled trials of preventive, oral iron supplementation in young children (aged 0–59 months) living in developing countries to ascertain the associated health benefits and risks. It found that among iron-deficient or anaemic children, haemoglobin concentrations were improved with iron supplementation. Reductions in cognitive and motor development deficits were observed in iron-deficient or anaemic children, particularly with longer-duration, lower-dose regimens. With iron supplementation, weight gains were adversely affected in iron deficient children; the effects on height were inconclusive. Most studies found no effect on morbidity, although few had sample sizes or study designs that were adequate for drawing conclusions. More research is needed in populations affected by HIV and tuberculosis. Iron supplementation in preventive programmes may need to be targeted through identification of iron-deficient children.
A Chronic Disease Outreach Programme (CDOP), based on the chronic care model was used to follow patients with diabetes and hypertension, support primary health care nurses (PHCNs), and improve health systems for management in Soweto. A group of 257 diabetes patients and 186 PHCN were followed over two years, with the study including the evaluation of ‘functional’ and clinical outcomes, diary recordings outlining program challenges, and a questionnaire assessing PHCNs’ knowledge and education support, and the value of CDOP. CDOP was successful in supporting PHCNs, detecting patients with advanced disease, and ensuring early referral to a specialist centre. It improved early detection and referral of high risk, poorly controlled patients and had an impact on PHCNs’ knowledge. Its weaknesses include poor follow up due to poor existing health systems and the programme’s inability to integrate into existing chronic disease services. The study also revealed an overworked, poorly supported, poorly educated and frustrated primary health care team.
Several African governments have launched a drive to strengthen the continent's laboratories to a standard that will enable them to gain accreditation from the United Nations’ World Health Organization (WHO). Only a few African laboratories have WHO accreditation. Experts at a launch of the initiative in the Rwandan capital, Kigali, said better-quality laboratory services would help lower the death toll from treatable diseases like HIV and AIDS, tuberculosis and malaria, which kill more than five million Africans annually. One of the reasons so few African laboratories have gained accreditation is the time-consuming nature of current procedures. The launch was attended by policy-makers and experts from Botswana, Cameroon, Cote d'Ivoire, Ethiopia, Kenya, Malawi, Nigeria, Rwanda, Senegal, Tanzania, Ghana, Uganda and Zambia. ‘Stronger laboratories with better systems and practices in place will mean better patient care and treatment and, through the use of high-quality laboratories, can be swifter,’ said a spokesperson.
Using the data from the South African World Health Survey (WHS), this study aimed to evaluate the degree of health care service responsiveness (both out-patient and in-patient) and comparing experiences of individuals who used public and private services in South Africa. Data was used from a population-based survey of 2,352 male and female participants, which was conducted in South Africa in 2003. Major components identified for out-patient care responsiveness in this survey were highly correlated with health care access, communication and autonomy, secondarily to dignity, confidentiality and quality of basic amenities, and thirdly to health problem solution. The degree of responsiveness with publicly provided care was in this study significantly lower than in private health care –16.8% versus 3.2%. Health care access, communication, autonomy, and discriminatory experiences were identified as priority areas for actions to improve responsiveness of health care services in South Africa.
Risk communication guidelines widely used in public health are based on the psychometric paradigm of risk, which focuses on risk perception at the level of individuals. However, infectious disease outbreaks and other public health emergencies are more than public health events and occur in a highly charged political, social and economic environment. This study examines other sociological and cultural approaches from scholars such as Ulrich Beck and Mary Douglas for insights on how to communicate in such environments. It recommends developing supplemental tools for outbreak communication to deal with issues such as questions of blame and fairness in risk distribution and audiences who do not accept biomedical explanations of disease.
South Africa witnessed a 20% increase in maternal deaths between 2005 and 2007, when compared to the previous three-year period, with HIV and AIDS accounting for 43.7% of all deaths. Almost four (38.4%) out of every 10 deaths were ‘clearly avoidable within the health care system’, according to researchers, which means they could have been prevented with proper care. The report recommends that the department of health addresses maternal deaths by: improving health care provider knowledge and skills in providing emergency care and ensuring adequate screening and treatment of the major causes of maternal death; improving the quality and coverage of reproductive health services, namely contraceptive and termination of pregnancy services; better management of staffing and equipment norms, transport and availability of blood for transfusion; and community involvement and empowerment regarding maternal, neonatal and reproductive health in general.
When considering the declining quality of emergency obstetrical surgery in Tanzania, lack of access to facilities, not a shortage of qualified staff, is the issue, argues this paper. Five countries in sub-Saharan Africa use non-physicians to perform major emergency obstetrical surgery. In Tanzania, assistant medical officers (AMOs) – secondary school graduates with several years of medical training – perform most of this type of surgery outside the cities. The researchers compared obstetrical surgery performed by Tanzanian AMOs with surgery performed by medical officers (MOs) – medical school graduates with at least one year of internship and a licence to practice medicine and surgery. They found no significant differences between AMOs and MOs in outcomes, risk indicators or quality of care indicators. With 1,300 AMOs now trained for this kind of surgery, there are enough surgeons to meet the need in Tanzania. But hospitals are widely spaced and transport is difficult, so that fewer than one-third of Tanzanian women in need of major obstetrical surgery make it to a hospital that can do the job.
Despite widely acknowledged WHO guidelines for the integration of tuberculosis (TB) and HIV services, heavily burdened countries have been slow to implement these and thus significant missed opportunities have arisen. The individual-centred, rights-based paradigm of the national AIDS policy remains dissonant with the compelling public-health approach of TB control. The existence of independent and disconnected TB and HIV services wastes scarce health resources, increases burden on patients' time and finances, and ignores evidence of patients' preference for an integrated service, resulting in ongoing missed opportunities, such as failure to maximise collaborative disease surveillance, voluntary counselling and testing, adherence support, infection control, and positive prevention. The full potential of an integrated TB-HIV service has not been fully harvested. Missed opportunities discount existing efforts in both programmes, will perpetuate the burden of disease, and prevent major gains in future interventions. This paper outlines simple, readily implementable strategies to narrow the gap and reclaim existing missed opportunities.
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8. Human Resources
This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. A comprehensive search of the English literature was conducted, 1,261 references were identified and screened and 110 articles were included. The study argues for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. There remains an urgent need to evaluate the impact of untested interventions in a scientifically rigorous fashion in order to identify winning strategies for guiding future practice and policy.
Hundreds of lay health care workers are deployed in Kenyan communities to fill the gap caused by severe staff shortages in the health sector – but could they be doing more harm than good? Some lay health workers even dispense antiretroviral (ARV) drugs, but health experts have warned that using unqualified personnel to perform medical functions may not be such a good idea. Dr Andrew Suleh, chairman of the Kenya Medical Association, said lay counsellors should not become a long-term replacement for professional health workers. ‘The government must be pressured to train, employ and retain health professionals to ease the disease burden exerted on the health care workers by the twin challenges of HIV and TB – the management and care of HIV and AIDS is very labour intensive,’ he said. Most lay counsellors were volunteers employed by non-governmental organisations whose projects could end, leaving the country with even bigger shortages of health workers. ‘You cannot base health management on volunteerism; it is not sustainable,’ Suleh added.
This paper draws on studies of financial incentive programmes and other initiatives with similar objectives to discuss seven management functions that are essential for the long-term success of financial incentive programmes aimed at retaining staff in underserved areas: using innovative financing; promoting health as a career; introducing specific selection criteria to ensure programme success and achieve goals; ensuring correct placement of new employees; offering support by staying in close contact with participants throughout enrolment and assigning them mentors; enforcement (programmes may use community-based monitoring or outsource enforcement to existing institutions); and routine performance evaluation of programmes. To improve the strength of the evidence on the effectiveness of financial incentives, controlled experiments should be conducted where feasible.
This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. It forecasts that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totalling approximately 800,000 health professionals. It further estimates the additional annual wage bill required to eliminate the shortage at about US$2.6 billion, more than 2.5 times current wage-bill projections for 2015. Additional funds would be required to hire health care support staff, train and support staff, and pay for expenses. Raising the money required to eliminate the shortfall would be difficult for the countries involved, even under the most optimistic assumptions regarding economic growth and governmental commitments to the health sector. Global aid can help but will still not provide enough resources, the researchers say. They call for changes in the skills mix, worker incentives and improvements in training for health care workers.
Ugandan health workers are dissatisfied with their jobs, especially their compensation and working conditions, says this study. It found a shocking statistic – about one in four health workers, which includes half of all physicians, would like to leave the country. What can be done about this medical brain drain? The researchers urge that strategies for strengthening the health care workforce in Uganda should focus on salary and benefits, especially health coverage. Poor working conditions and excessive workloads should also be dealt with. Facility infrastructure needs to be upgraded to provide a decent work environment, including the supply of water and electricity. Management needs to be improved, as well as workforce camaraderie.
9. Public-Private Mix
This report focuses on the contribution of AIDS-related public-private partnerships to the six building blocks of health systems: service delivery; human resources; information; medicines and technologies; financing; and leadership. A desk review and interviews were conducted with representatives of private and public organisation stakeholders, as well as development partners. Interviewees identified mutual understanding as an important precondition for the implementation of efficient and successful partnerships. The private sector at times lacks profound knowledge of the complex stakeholder landscape in the HIV response and health care provision. To develop flourishing partnerships, honest and wide-ranging dialogue to inform and secure agreement in joint planning is essential from the very earliest stages. Such planning will of course consider issue such as sustainability, follow-up, and monitoring, essential to flourishing partnerships. Health financing mechanisms, HIV and tuberculosis treatment and mobile health technology are areas which are of interest to the private sector and which require further technical expertise and promotion.
The author describes events in Lesotho and South Africa where public-private health partnerships have not produced the desired results and notes that these incidents are not isolated, but part of a wave of new privatisation initiatives that uses donor dollars for public health by shuttling them into private contractors in poor countries. Advocates of private-public partnerships are noted to cite selective data from specific privatisation schemes, ignoring the costs of contracting and the broader impact of their initiatives on communities. The author questions the idea that foreign health policy analysts know better than local providers and patients, and points to the irony of poorer performance in public health relative to resources in the United States, the country with the greatest number of health policy analysts per capita.
10. Resource allocation and health financing
The African National Congress has released a rough outline of how it sees the proposed National Health Insurance scheme on its website. But the document is short on detail and has no timelines. The broad objective of the NHI is to put into place the necessary funding and health service delivery mechanisms, which will enable the creation of an efficient, equitable and sustainable health system in South Africa. It will be based on the principles of the right to health, social solidarity and universal coverage.
In response to the problem of aid fragmentation, joint country assistance strategies have emerged as a preferred method to coordinate and harmonise aid. This paper determines that, to date, donor teams and recipient governments have come together in at least twelve countries to prepare joint strategies. A number of lessons were learnt and conclusions drawn. Lack of communication between stakeholders was identified, especially regarding strategy processes. Poverty reduction strategy processes should ideally be separated from the joint country strategy process to reduce government workload. An inclusive, thorough and effectively managed process has a greater chance to create the trust, cooperative spirit and follow-through during the implementation phase than one that stresses the production of a quality report without adequate venting of differing views and interests. In countries where government lacks capacity or will, the donor community may wish to identify one agency as the presumptive leader among donors for aid coordination on the ground.
This paper looks at whether aid partnerships established early or late matter significantly for aid quantities, and how this in turn affects aid fragmentation. It also details how aid partnerships have evolved over time and how donors have, if at all, shifted priorities. Furthermore the authors seek to evaluate the effect of current aid reform on aid fragmentation. It found that donor countries allocate larger shares of their aid budgets to recipients that entered early in their portfolios, while they have allocated smaller aid quantities to new partnerships. This has direct consequences for aid fragmentation, with many donors disbursing small amounts to a recipient. Fragmentation appears to be a product of portfolio expansion and it increases direct transaction and indirect costs creating dysfunctional bureaucracy and political behaviours by lowering the level of bureaucratic quality. Aid is less efficient in countries when it is fragmented. Donors' decisions to give less aid to late recipients, coupled with the sheer expansion in the number of their partnerships, has direct consequences on aid fragmentation.
This research shows that funding for health in developing countries has quadrupled over the past two decades – from US$5.6 billion in 1990 to US$21.8 billion in 2007. Private citizens, private foundations and non-governmental organisations are shifting the paradigm for global health aid away from governments and agencies like the World Bank and the United Nations and making up an increasingly large piece of the health assistance pie – 30% in 2007. However, health aid does not always reach either the poorest or unhealthiest countries. Overall, poor countries receive more money than countries with more resources, but there are strong anomalies. Sub-Saharan Africa receives the highest concentration of funding, but some African countries receive less aid than South American countries with lower disease burdens – like Peru and Argentina. HIV and AIDS took the lion’s share of funding, receiving at least 23 cents out of every dollar going into development assistance for health, while tuberculosis and malaria received less than a third of that.
This paper notes that post-conflict countries face enormous development challenges and substantive policy consequences. It calls for appropriate responses for conflict-affected nations such as financial assistance from donors, private investment and capacity building. Arguments given for resource transfers to post-conflict countries are that by increasing income, they reduce the risk of renewed conflict and also mitigate humanitarian crises left by the conflict. The second argument assumes that the humanitarian needs of conflict countries are due to conflict. The paper outlines the political market imperfections, which make post-conflict countries vulnerable – rendering political incentives to pursue long-run development and peace weak. These imperfections should shape the goals and modalities of foreign assistance to facilitate the delivery of social services, infrastructure, and capacity-building. To achieve development goals, government officials must have incentives to pursue the broad public interest in order to reduce political market imperfections that distort decision-making and deter accountability.
The Ugandan government is investigating whether a nationwide shortage of antiretroviral (ARV) drugs led to the reported deaths of HIV-positive people in northern Uganda in July. Health workers in Apac district reported that at least 17 people known to have been HIV-positive died over the past month after failing to receive their life-prolonging medication due to supply shortfalls. Health centres around the country are reporting out-of-stock ARVs, which the health ministry attributes to a lack of funding. An estimated 170,000 people are enrolled in government ARV programmes. After a massive countrywide testing drive in January, 100,000 new HIV patients were registered, many of whom needed ARVs –government and donor funding, however, had not increased correspondingly. According to officials at the health ministry, funding delays from donors, such as PEPFAR and the Global Fund, have also contributed to national ARV shortages.
Donors have many competing claims on scarce resources, and many statistics and reporting units are vastly under resourced. Much of the core project information required is already captured within donors' central management information/financial systems. For all donors, there will still be a significant amount of information that is required by users, but not currently captured in a systematic way. It is likely that to fully comply with IATI, many donors will need to consider an investment in improving their reporting systems. This scoping paper makes a few recommendations. Further analysis should be undertaken to better understand the costs and benefits to donors of complying with the potential IATI standards, and to understand what support they may require. Agreed mechanisms should be established for updating the common standards over time and arbitrating disputes. Detailed consultations with partner countries, civil society organisations and other key stakeholders should be done to determine their priorities in terms of aid information.
The author observes that there are problems with the way in which discussions concerning South Africa’s new national health insurance (NHI) are being conducted behind closed doors. A top-down management approach is seen to be not working, excluding consultation with stakeholders, especially civil society. The challenges government and civil society now face on the issue are related to leadership and accountability (visible leadership at the highest possible level and one single voice and proposal from government), positioning and values (to what extent should principles of solidarity be applied in the design of the new system), the process followed in developing the provisions (extensive and in-depth consultation and a clearly defined process with milestones and deadlines), as well as delivery (especially in administration and management to ensure sustainable benefits).
11. Equity and HIV/AIDS
A new government initiative to boost local HIV and AIDS research has been launched. The South African HIV/AIDS Research (and Innovation) Platform (SHARP), with backing from the Department of Science and Technology (DST), will support the development of new treatment options and prevention approaches such as microbicides, vaccines, and the role of genetics in controlling HIV infection. ‘The South African government had to revisit its expectations of HIV vaccine research in the light of growing national and international deliberations on the need to modify basic HIV/AIDS research and development strategies,’ the DST noted. So far SHARP has committed R45 million (US$5.8 million) to fund nine research projects over the next three years. One of the projects will validate a method for testing resistance to antiretroviral drugs that is cheaper and more accurate than the current method; another will investigate the role of natural ‘killer’ cells that prevent HIV transmission.
Observational studies have reported an association between male circumcision and reduced risk of HIV infection in female partners. This study assessed whether circumcision in HIV-infected men would reduce transmission of the virus to female sexual partners. Nine-hundred and twenty-two uncircumcised, HIV-infected, asymptomatic men aged 15–49 years with CD4-cell counts 350 cells per μL or more were enrolled in this unblinded, randomised controlled trial in Rakai District, Uganda. HIV-uninfected female partners of the randomised men were concurrently enrolled and followed up at 6, 12 and 24 months to assess HIV acquisition by male treatment assignment (primary outcome). The trial was stopped early because of futility. Seventeen (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up. It appears circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months – longer-term effects could not be assessed.
While efforts have been made to assess the costs of providing antiretroviral therapy (ART) via accredited service points, little information is available on its downstream costs, particularly in public secondary level hospitals. This paper aims to determine the cost of care for inpatients and outpatients at a dedicated antiretroviral referral unit, the GF Jooste Hospital, during March 2005. This prospective costing study on 48 outpatients and 25 inpatients was conducted from a health system perspective. Incremental cost per outpatient was found to be R1,280 and R5,802 per inpatient. Costs were dominated by medical staff costs (62% inpatient and 58% outpatient, respectively). As the costs of providing secondary level care for patients on or immediately preceding ART initiation can be significant, the study recommends that they should be included in the government’s strategic planning so that the service can be expanded to meet current and future needs and to avoid crowding out other secondary level health services.
This paper seeks to describe the associations between socio-demographic, behavioural and social characteristics and knowledge of HIV status among a nationally representative population in South Africa. A multistage, representative probability sample involving 16,395 male and female respondents, aged 15 years or older was selected. From the total sample 27.6% ever and 7.8% knew their HIV status in the past 12 months. In multivariate analyses, being female, the age group 25 to 34 years old, other than African Black population group (White, Coloured and Asian), higher educational level, being employed, urban residence, awareness of a place nearby where one could be tested for HIV, impact of HIV on the household and having had two of more sexual partners in the past year were associated with knowledge of HIV status. Education about HIV and AIDS and access to HIV counselling and testing in rural areas, in particular among the Black African population group needs to be improved, in order to enhance the uptake of HIV counselling and testing services, an essential step for the initiation of treatment.
This report on international AIDS assistance provides data from 2008, the most recent year available. As such, it represents funding levels reflecting budgets largely set in place before the acceleration of the current global economic crisis. The analysis is based on data provided by donor countries. It found that international AIDS assistance from the G8, the European Community and other donor governments reached its highest level to date – new commitments totalled US$8.7 billion, of which US$6.7 billion was through bilateral channels. Disbursements have increased by more than six-fold. In 2008, the United States was the largest donor in the world, accounting for 51.3% of disbursements by governments. The United Kingdom accounted for the second largest share (12.6%), followed by the Netherlands (6.5%), France (6.4%) and Germany (6.2%). Still, there was a gap of US$6.5 billion between resources available from all sources and resources needed in 2008, as estimated by UNAIDS.
The Global Fund to Fight AIDS, Tuberculosis and Malaria has granted Zimbabwe US$37.9 million, resuming support after getting assurances from the new unity government that the money would not be misused. The head of the Global Fund's Africa Unit, Fareed Abdullah, said the money, previously managed by the state-appointed National Aids Council, would now be overseen by the United Nations Development Programme (UNDP) in Zimbabwe. ‘We're glad that today marks a turning point in the relationship between Zimbabwe and the Global Fund, after the troubled history of the past 18 months,’ Abdullah said. Last year, the Fund alleged that Zimbabwe's central bank had confiscated US$7.3 million in 2007 meant for health programmes – the bank has returned the money since then. ‘The reason behind getting the UNDP as the principal recipient is to do with that history, no doubt.’ Apart from helping in the fight against HIV and AIDS, the money would also be committed to tuberculosis and malaria programmes.
This study in the Kenyan capital, Nairobi, noted reduced HIV risk when the male partner of a pregnant woman attended antenatal clinic visits and was also tested for HIV. The study enrolled 532 HIV-positive pregnant women, 140 of whom were accompanied by their male partners on antenatal visits. Results showed that the one-year-old children of women whose partners had attended the clinics had an HIV-free survival rate 59% higher than those whose partners did not attend. These findings indicate that promotion of programmes aimed at increasing male attendance in antenatal care could function to reduce the risk of vertical transmission and infant mortality. About 80% of antenatal clinics in Kenya offer prevention of mother-to-child HIV transmission (PMTCT) services, but the uptake of counselling and testing is below 50%. The government is considering various incentives, such as waiving maternity fees for couples who attend PMTCT sessions together, to boost male participation.
A large clinical trial of anti-retroviral therapy (ART) for people with HIV infection in Africa has found that regular laboratory tests offer little additional clinical benefit to populations when compared to careful clinical monitoring. The DART trial aimed to find out whether the lab-based strategies used to deliver ART to people with HIV infection in resource-rich countries were essential in Africa, where around four million people still need ART urgently and resources are limited. The trial was carried out in three locations: Entebbe and Kampala in Uganda, and Harare in Zimbabwe, from 2003 to 2008. The results suggest that many more people with HIV in Africa could be treated for the same amount of money as is currently spent if lab tests are not routinely used to monitor ART. ART can be delivered safely and effectively by trained and supervised health workers in remote communities where routine laboratory services are not available – good news for low-income or resource-poor countries that are prioritising ART access over investment in expensive laboratory facilities.
While a number of countries in southern Africa have made great strides in improving access to antiretroviral (ARV) treatment for HIV-infected adults, progress in rolling out treatment for HIV-positive infants and children has lagged behind. Namibia is a notable exception. Over 7,600 children are receiving ARV treatment – 100% of those estimated to be in need of the life-prolonging medicine. Mother-to-child HIV transmission (PMTCT) programmes are available at 202 health facilities. ‘We are meeting targets for children on ARVs, but they are starting late,’ said Dr Agostino Munyiri, chief of health and nutrition at the United Nations Children’s Fund. Children born to HIV-positive mothers should ideally be tested when they are six weeks old, but the median age for testing is currently 17 weeks. ‘Many present with malnutrition and only then are tested for HIV, and even then not all are tested,’ Munyiri added. ‘We know they come back for immunisation [against various diseases]; we need to catch them at that stage.’
By not preparing for the changing treatment needs of people living with HIV, the sustainability of treatment programmes in developing countries is doomed. Over the next decade, an increasing number of patients on inexpensive first-line antiretroviral (ARV) drugs in low-income countries will need second-line ARVs, which currently cost at least seven times more. Many patients will also need to be switched to newer, less toxic first-line drugs, which have fewer side-effects but are at least double the price. This report argues that action is needed now to bring down the price of second-line and less toxic first-line ARVs if a crisis is to be averted later. It supports an alternative approach that would see pharmaceutical companies putting their ARV patents into a single pool, from which manufacturers or researchers could draw in exchange for a royalty fee. Patent pools not only have the potential to reduce the price of existing ARVs, but can stimulate the production of urgently needed new medicines and formulations, such as paediatric ARVs and fixed-dose combinations.
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12. Governance and participation in health
The AIDS and Rights Alliance for Southern Africa (ARASA), a Namibia-based partnership of health and human rights groups from the Southern African region, today launched a YouTube video clip entitled ‘Lords of the Bling’, linked to a public petition that presents a ‘moral challenge’ to African leaders regarding their commitments to funding health. The clip highlights the cost of lavish expenditure and corruption among various African leaders and calculates how many people could, for equivalent sums of money, have received life-saving treatment for HIV and TB, which jointly claim almost two million African lives every year. The video clip and petition are intended to serve as an awareness-raising campaign and a platform for solidarity on holding African governments accountable for their commitments to health. ARASA is seeking sign-ons from organisations and individuals, which will be presented to leaders on International Human Rights Day in December 2009. ARASA intends to mobilise civil society around this critical issue and claim the right to health.
This 2009 edition of the Commonwealth Local Government Handbook is a complete reference book to local government in the Commonwealth. Updated and revised, it details the systems of local government in the 53 countries of the Commonwealth, looking at how local government is structured, how elections take place, what services local government is responsible for, how local government is financed and what reforms are envisaged. The profiles are in a format that allows easy country-to-country comparison. The 2009 Handbook includes a preface by CLGF Secretary-General Carl Wright, a foreword by CLGF Chairperson Basil Morrison, and an introduction by Hubert Ingraham, Prime Minister of the Bahamas.
In 2007 a group of HIV-positive people in Machaze founded Tchitenderano (‘accord’ in the Ndau language) to campaign against stigma and discrimination in their district, where HIV prevalence is 16.7%, slightly higher than the national average of 16%. So far the group has helped more than 3,000 people. Tchitenderano has 25 activists who hold lectures at various public institutions to educate people about HIV and other sexual and reproductive health issues. They also visit health facilities to encourage patients to adhere to their antiretroviral (ARV) treatment, and provide home-based care. Samuel Doris Campira, president of the organisation, said they were slowly helping to free Machaze district of discrimination and stigma. ‘There were people who would spit at us when they walked by where we were meeting, but today there are families with HIV-positive individuals at home who seek us out to become better informed,’ he said. ‘The stigma is still very strong, despite the legislation and the campaigns,’ he noted, but with time, information and patience, he believed communities would eventually change their attitudes.
Effective management of public health emergencies demands open and transparent public communication. The rationale for transparency has public health, strategic and ethical dimensions. Despite this, government authorities often fail to demonstrate transparency. A key step in bridging the gap between the rhetoric and reality is to define and codify transparency to put in place practical mechanisms to encourage open public health communication for emergencies. The authors demonstrate this approach using the example of the development and implementation process of a public health emergency information policy.
13. Monitoring equity and research policy
A mine safety audit report detailing the high number of injuries and fatalities in South Africa’s mines each year has been released by the Department of Minerals and Energy, revealing serious gaps in the safety standards in the mining industry. In the past three years, unsafe working conditions have led to the death of 200 mine workers annually, in addition to the almost 5,000 people who are injured annually. Many of these injuries are so severe that limbs need to be amputated which leads to a significant reduction in standards of living and ability to earn an income. In terms of Occupational Health and Safety, the mining industry scored a dismal 59% compliance, while also scoring only 56% for health risk management, while public health and safety in mines received 65% compliance. Singling out particular mining sectors, the diamond sector scored a low 47% compliance with health risk management regulations. The gold industry also scored a dismal 53% compliance when it came to health risk management.
So will open access build a bridge to reduce health inequity? The potential is certainly great but the digital divide remains large, with estimates that only 13% of the developing world uses the internet, often on slow and expensive connections. Therefore, the inequity in accessing information and communication technology infrastructure will need to improve to allow people to get a foot onto the information bridge. But even once they are there, they will still only be able to access information that has been paid for – even when that information was created using taxpayers’ money. There is a role for more research funders and donors to support open access as an integral cost of undertaking the research itself to ensure public access. While the United Nations might be seen as having a ‘slow bandwidth’ approach to this issue, things are moving ahead with the work of the International Telecommunications Union on promoting greater access to information and communication technology worldwide and the newly developed World Health Organization strategy on research for health.
This study assessed the completeness and accuracy of routine prevention of mother-to-child transmission of HIV (PMTCT) data submitted to the district health information system (DHIS) in three districts of Kwazulu-Natal province, South Africa, covering 316 clinics and hospitals. Data elements were reported only 50.3% of the time and were ‘accurate’ (within 10% of reconstructed values) 12.8% of the time. The data element ‘Antenatal Clients Tested for HIV’ was the most accurate element (consistent with the reconstructed value) 19.8% of the time, while ‘HIV PCR testing of baby born to HIV positive mother’ was the least accurate, with only 5.3% of clinics meeting the definition of accuracy. Data collected and reported in the public health system across three large, high HIV-prevalence districts was neither complete nor accurate enough to track process performance or outcomes for PMTCT care. Systematic data evaluation can determine the magnitude of the data reporting failure and guide site-specific improvements in data management. Solutions are currently being developed and tested to improve data quality.
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. Major inequities were noted between urban and rural areas, as rural areas were usually underserved. Some of the inequities highlighted by the District Health Barometer (DHB) can be traced to differences in health spending, with different districts spending different amounts. The uneven distribution of HIV infection in South Africa also influenced ratings: higher rates of Caesareans were linked to higher HIV rates in pregnant women. Writing in the DHB, Dr Tanya Doherty 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,’ she wrote.
What is the current status of occupational health and safety (OHS) in southern African? Of an estimated 14 million injuries per year, a mere 93,000 injuries are reported. This brief notes that more data is needed, which should be analysed and reported regularly. In existing compensation systems, there is too much focus on financial governance and not on the production of information to prevent accidents and disease. It recommends that social security/compensation and reporting systems need to be introduced where these do not exist. Active surveillance methods need to be introduced through surveys already carried out by national statistical offices, or by adding occupational health components to future labour force or health and demographic surveys. In addition, targeted research needs to be funded and supported. It will take many years and a lot of resources for southern African countries to develop information systems as sophisticated as those in Western countries.
Impaired access to research information in health-related fields is not solely the preserve of developing countries but it is hugely exacerbated in poorer regions of the world. Why are such influential bodies as the Australian National Health and Medical Research Council, the Canadian Institutes of Health Research, the Centre for Disease Control and the National Institute of Health in the USA, the United Kingdom Medical Research Council and the Wellcome Trust promoting open access? Because it brings such benefits to health research including: increased visibility for research outputs; a concomitant increased usage and impact; an increase in the speed at which scientific research progresses; the facilitation of interdisciplinary research; and the enabling of new semantic computing tools to create new knowledge from existing knowledge. Open access is a key piece of the jigsaw for improving world health. All stakeholders in that vision should commit themselves to its implementation.
Access to health research publications is an essential requirement in securing the chain of communication from the researcher to the front-line health worker. As the diagram of the knowledge cycle from the Canadian Institutes of Health Research shows, health knowledge generated in the world’s laboratories is passed down the information chain through publications, through its impact and application, its subsequent “translation” into appropriate contexts for different user communities, arriving finally with health workers and the general public. This article focuses on the first link in the chain, from research author to reader, and the free online access to peer-reviewed published articles that are the building blocks for future health innovation developments.
14. Useful Resources
The main aim of this counselling handbook is to strengthen counselling and communication skills of health providers including skilled birth attendants, helping them to effectively discuss with women, their husbands/partners and families and communities the important issues surrounding pregnancy, childbirth, postpartum, postnatal and post-abortion care. The handbook relies on a self-directed learning approach. Although it is designed to be used by groups of health workers with the help of a facilitator, it can also be used by an individual. All topical sessions contain specific aims and objectives, clearly outlining the skills that will be developed and corresponding learning outcomes. Practical activities have been designed to encourage reflection, provoke discussions, build skills and ensure the local relevance of information. There is a review at the end of each session to ensure that the learner has understood the key points before progressing to subsequent sessions.
Civil society organisations (CSOs) are facing increasing pressure to demonstrate their accountability, legitimacy and effectiveness. In response, a growing number are coming together at national, regional and international level, to define common standards and promote good practice through codes of conduct, certification schemes, reporting frameworks, directories and awards. This project provides the first comprehensive inventory of civil society self-regulatory initiatives worldwide. What does the database offer? The map and initiative search pages provide information on each initiative. Available information includes summaries, contact information, lists of participating organisations, full texts of initiatives, analysis of compliance mechanisms, similar initiatives, and assessments of the role of many initiatives within the CSO sector. Users can filter their search according to their particular needs, using criteria such as the location, type, and areas addressed of the initiative.
This training manual on mainstreaming gender into Water, Sanitation and Hygiene (WASH) programmes is an integrated approach to both gender and WASH issues. It aims to provide participatory gender-sensitive training to water professionals at the policy, project and administrative levels through building their capacity for mainstreaming gender into WASH programmes. The authors hope this manual will be useful to other public, private and civil society training institutions and agencies, both in Rwanda (where this manual was written) and in other countries around the world. The manual aims to provide participatory gender-sensitive training to water professionals at the policy, project and administrative levels and promote an understanding of and commitment to the importance of participation of both women and men in sustainability of these programmes. It is divided into three modules, which cover WASH programmes, theoretical concepts of gender, gender mainstreaming and analysis tools, and gender-sensitive indicators and a log-frame for WASH programmes.
Social issues should be addressed socially and in multi-stakeholder mode, not by private interest and experts alone in processes of knowledge production, planning and decision-making. This guide is an important step in the creation and mobilisation of practical, authentic knowledge for social change. The guide has been divided into two parts. Part 1 outlines the concepts and skillful means needed to support multi-stakeholder dialogue. It also provides detailed instructions on how to integrate and ground collaborative inquiry in the projects, plans, evaluations and activities of multiple stakeholders. Part 2 highlights a selection of techniques and learning for collaborative inquiry and examples of real life applications in South Asia and Latin America. Examples focus on a range of issues including land tenure, local economic development, agriculture, forestry, fisheries, and organisational development. Techniques include using Action Research Training (ART), problem tree, force fields, CLIP social analysis (collaboration, conflict, legitimacy, interests and power).
15. Jobs and Announcements
Many delegates from across the Commonwealth are expected to attend the Commonwealth People's Forum (CPF), which has the theme 'Partnering for a more equitable and sustainable future.' Eight assemblies will form the core of the CPF programme. Topics of discussion will cover: human rights; financial crisis and economic development; environment and climate change; gender; health and HIV and AIDS; peace and conflict; deepening democracy and governance; and creativity and innovation. Cross-cutting areas include: youth, media, education, disability, gender and Millennium Development Goals. Make your voice heard at CHOGM by attending the Forum. Registration costs US$100 for delegates from outside of Trinidad and Tobago.
The Global Development Network is now accepting submissions for its annual competition for development research proposals/papers and development projects. Researchers and non-governmental organisations from developing and transition countries are invited to participate in the competition. The competition is funded by the United Kingdom’s Ministry of Finance, the government of Japan and other donors. It focuses on key issues such as globalisation, regional integration, climate change and international migration against the backdrop of the current global economic and financial crisis, the political and economic repercussions of which can already be felt across countries and regions. The impact of these crises on the architecture of developing countries cannot be understated. They have prompted many to challenge globalisation and they are also likely to hasten the structural shift in global economic power from Western countries to emerging markets.
The British Medical Association's (BMA) International Department runs the BMA Information Fund, which helps to provide health information to organisations in developing countries. The Fund donates educational materials, such as books and DVDs, and is run in association with Teaching Aids at Low Cost (TALC). It is currently inviting applications for 2009 from health care institutions, health non-governmental organisations, medical school libraries and other related organisations. (Please note that it is unable to consider requests from individuals.) To submit an application, please download the application form and TALC book list from the Fund’s website. Please note that the maximum award per application is £2,000. Completed application forms and booklists should be sent to the email address provided.
All interested parties are invited to submit abstracts in the form of oral presentations and posters exploring the overall theme of the Conference ‘Sexuality and HIV and AIDS in Africa’. The theme may be explored through the following objectives and sub-themes: identifying new, emerging and existing vulnerabilities and vulnerable/marginalised people that are critical to sexual health and rights/HIV and AIDS interventions using a sexuality- and rights-based approach; exploring how the application of human rights framework to sexuality might provide new insights in developing interventions to reduce the spread of HIV and AIDS and provide a more comprehensive sexual health to all persons; and reviewing and mapping out new and existing innovative strategies, programming and funding that best addresses the links between sexuality, sexual health/rights and HIV and AIDS for future interventions.
The International Conference on Healthcare and Trade, organised by the Erasmus Observatory on Health Law, will focus on the influence of the law of both the European Union and the World Trade Organization on trade in health services, health insurance services and health goods (pharmaceuticals). The application of the EC Treaty, the GATS and the TRIPS to national regulation of health services, health insurance services and pharmaceuticals raises questions of applicability of, compatibility with and possible exceptions to the provisions of these instruments. In these areas, these questions have not yet been answered conclusively and further research and discussion in this area is ongoing. The conference aims to contribute to the discussion, attempting to formulate both legal and economic answers to these questions. Prepaid advanced registration must be electronically submitted, faxed or mailed no later than 1 December 2009. The conference fee is 250 euros (concessions are available for students).
The Fund for Gender Equality is a multi-donor initiative designed to advance high-impact gender equality programmes that focus on women’s economic and/or political empowerment at local and national levels. It provides grants to civil society and governmental agencies in Africa, Asia and the Pacific, the Arab States, Latin America and the Caribbean, Central and Eastern Europe, and the Commonwealth of Independent States. The Fund is unique in its focus on turning local and national laws and policies into tangible gains for women’s rights. Potential grantees may apply for one of two types of grants. Implementation grants will range from US$2 million to US$5 million distributed over a period of two to four years. Catalytic grants will range from US$100,000 to US$500,000 distributed over a period of one to two years. Once a plan, policy or law is developed and endorsed, successful institutions will be eligible to apply in the future for a larger implementation grant.
The Global Symposium is an annual event that has developed a worldwide movement through a global partnership with civil society and educational organizations to establish sustainable development, world unity and world peace. This is an opportunity for many to meet some amazing people, aside from being able to directly help address major issues confronting the world today. The purpose of this international gathering is to strengthen cooperation among the civil society to unite their efforts in world interest and to act and achieve our common goals by laying a strong foundation of a nuclear-free, democratic, sustainable, just and peaceful world order and creating a widespread awareness about issues like scarcity of safe drinking water and more equitable distribution of resources. Register now. There is no registration or participation fee. All delegates from abroad will be provided with complimentary boarding and lodging (accommodation and meals) facilities.
On 13 August 2009 the Rural Health Advocacy Project was launched at the University of the Witwatersrand in Johannesburg, coinciding with the launch of the Wits Centre for Rural Health. A renewed focus on access to health care in rural areas is vital in a context of worsening key health indicators in South Africa, a 34% national vacancy rate for doctors and inequitable access to quality health care. The Advocacy Project aims to tackle these inequities by achieving measurable improvements in rural health services through: contributing towards policy development including human resources policies for rural health at provincial, national and international levels; advocating for improvements in rural health care in cooperation with rural communities and stakeholders such as government, academic institutions and the private sector; and highlighting challenges and achievements in rural health care.
The Second Access to Healthcare in Africa Conference will concentrate on challenges to quality, product availability, access and management in effective health care, with a focus on HIV and AIDS, tuberculosis and malaria. Participants will be able to share their experiences in health care management with their peers while tapping into the knowledge and insight of experts in this field. Topics include the current global recession, donor’s responses and the challenge to make choices regarding accessibility, quality control, efficiency efficacy and health economics around health intervention programmes. These issues are not addressed properly at the global conferences but they are the difference between success and failure of the intervention at ground level. The Conference aims to put those topics on the table for discussion. Key international speakers will introduce each theme, followed by a high-level interactive panel and participant discussion.
It's time to register for the 16th Canadian Conference on International Health (CCIH). This year's conference is being held on October 25–28, 2009 in Ottawa, Canada. The Conference convenes more than 500 participants from 44 countries. It also creates a unique networking forum for practitioners, researchers, educators, policy makers and community advocates working at the intersection of health and development within and outside Canada, to share knowledge, experience and promote innovation and collaborative action. It provides a peer review process for individuals and organisations involved in health development, building knowledge and strengthening programmes in international health. The themes of the Conference are: Pathways to Global Health Competence; An Ethical View of Health Equity: Trends and Challenges; Global Health Diplomacy: A Tool for Global Health and Justice; and Thinking Globally/Acting Locally: The Reality and Challenges for the Future.
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