Worldwide, according to World Health Organisation (WHO) in 2001, mental and behavioural disorders affect 450 million people and account for 15% of the overall burden of diseases from all causes. Yet, nearly two-thirds of those affected do not receive adequate care due to stigma, discrimination, neglect and poverty. Mental health is an integral part of the whole health of a person. Even when physical illness predominates, the mental health status of the person can influence the course and outcome of physical illness. While the prevalence and pattern of mental health disorders are similar in high and low income countries, for low income countries the challenges of providing mental health services are myriad. They range from mental health being given low priority by policy makers, to poor or unavailable services in terms of infrastructure and services, to inadequate health workers oriented to mental health care needs.
Health worker shortages have received increasing attention of late as one of the most critical gaps in the provision of services. Too often, however, the critical gap in mental health personnel is overlooked. There is a particular shortage of mental health workers in low income countries. Estimates show that there is an average of one psychiatrist for two million people in low-income countries compared to one for every 10,000 people in the high-income countries. In Kenya for example, there is one psychiatrist per four million people and mental health services at the primary level are largely left to general nurses and clinical officers. Kiima and colleagues in 2004 found that these personnel readily recognise psychosis, but are less able to recognise learning disorders, emotional disorders and conduct disorders in children and adolescents. Primary care staff who feel uncertain of their skills in this area may not adequately diagnose mental health problems, or may refer cases to higher level facilities. Besides being expensive, this leaves a large number of mentally ill patients untreated. The social and economic cost, as with other areas of unmet need, then falls on the individual, family and community.
It seems unlikely, in the foreseeable future, that we will achieve the psychiatrist: population ratio levels in developing countries that compare to what has been attained in developed countries. This is especially so as internal and external migration draw specialized personnel out of our health systems and out of services in poorest communities where health needs are high. How then can we meet the significant deficit in addressing a public health burden like mental health, at a time of major shortfalls in our health systems?
WHO has in recent years proposed task-shifting as one way of filling the gap in availability of health workers. This implies transferring skills to less academically qualified but more available personnel to provide key services. There are some emergent efforts in Kenya to replicate this for mental health services. The various mental health issues and service roles in different stages of the cycle of prevention, treatment and care are explored to assess where task-shifting provides a feasible possibility to reach the community and improve service provision. These efforts must still be shown to make a real difference in effective services for communities. They need to link skilled health personnel with those in frontline care through supervision and support so still demand these high skill personnel for leadership, and in research and higher training. So task shifting makes it even more important to find effective options for retaining these high skill personnel in their own countries and to link their own desired career paths to the needs of the health system. Kenya has been notable in the region for its production and retention of psychiatrists and could make a very interesting case study on the success of national retention psychiatrists, even though these personnel may not be equitably distributed in the country.
The task shifting debate also draws attention to wider, primary health care (PHC) oriented and innovative options that integrate mental health into other promotive, preventive and curative services at community level. A holistic approach is in accordance with the WHO definition of health, that encompasses physical, social and mental wellbeing. Wiley-Exley in 2007 in a 10-year review of community mental health care in low- and middle-income countries showed that community based care can provide improvements in mental health, even though more work is needed in specific areas such as services for children and adolescents. Preliminary work by Jenkins in Kenya shows that retraining of primary health workers in mental health can have an impact in the number of correctly diagnosed mental health cases and the quality of referrals. Othieno and colleagues, with Department of psychiatry, University of Nairobi and with EQUINET support, have worked with community members in Kariobangi in the suburbs of Nairobi using participatory methods to recognize and find ways of dealing with cases of mental illness in their community. A similar approach has been used to encourage compliance among those with HIV infection who engage in harmful alcohol use. These case reports, both found in more detail on the EQUINET website, suggest that participatory action research methods could be effective in detection and management of mental health issues at primary care services and in the community. More work is needed in this area and if replication in other parts of the country proves its efficacy, it could be included in the curriculum for the health workers at all levels. As noted with the task shifting discussion, however these approaches should be complemented by developing referral and tertiary services, and skilled personnel. This is not only needed to support the implementation and supervision of PHC approaches to mental health, but also because as the needs are recognized, referrals from the primary care facilities are bound to increase.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit EQUINET: www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
The Regional Meeting of Parliamentary Committees on Health in Eastern and Southern Africa, Munyonyo, Kampala, Uganda, 21 September 2009, gathered members of parliamentary committees responsible for health from twelve countries and from regional bodies in Eastern and Southern Africa, together with technical, government, civil society and regional partners, to promote information exchange, facilitate policy dialogue and identify key areas of follow up action to advance health equity and sexual and reproductive health in the region. The meeting was held as a follow up to review progress on actions proposed at the September 2008 Regional Meeting of Parliamentary Committees on Health in Eastern and Southern Africa hosted by the same organisations. This document outlines the commitments to follow up action made at the meeting.
The promotion of universal coverage means that health systems should seek to ensure that all citizens have access to adequate health care (adequately staffed with skilled and motivated health workers) at an affordable cost and which improve both income cross-subsidies (from the rich to the poor) and risk cross-subsidies (from the healthy to the ill) in the overall health system. This stems from our understanding of equity, which requires that people should contribute to the funding of health services according to their ability to pay and benefit from health services according to their need for care. Prior work in the fair financing theme in the network indicates that there is still a heavy dependence on donor funding in some east and southern African (ESA) countries and heavy burdens on poor people through high levels of out of pocket financing. There have been efforts to increase domestic funding of health services, and a number of countries are increasing government funding of health services. The Health Economics Unit, University of Cape Town and HealthNet Consult Uganda used evidence from work done in the past 5 years on tax and mandatory health insurance sources of domestic resource mobilisation as inputs to a regional research and policy review meeting in September 2009. The meeting presented and reviewed research, implemented in and beyond the network, on domestic public resource mobilisation; examined policy options, and country experiences in and barriers to improving domestic public resource mobilisation, with a focus on ‘success stories’ where countries have been successful in motivating for greater allocation of public resources towards the health sector. The meeting was held in Uganda just prior to the EQUINET Regional conference to connect delegates to the conference and to input into the wider network of equity actors and debates at the conference. The meeting identified knowledge gaps for follow up research, including on gender dimensions.
Over the last five years the Regional Network For Equity In Health In East and Southern Africa (EQUINET) has generated a range of analyses of specific policy experiences in Southern and Eastern Africa and has developed the understanding and skills necessary to conduct this sort of work. Other work conducted by EQUINET, such as around governance and participation, is also relevant to understanding how to strengthen health system decision-making in ways that support health equity goals. It is time, now, to take stock of the range of health policy analysis work in Africa – and to draw out lessons from past experience, as well as identify new challenges for the years ahead. This workshop took place as part of the pre-conference activities of the EQUINET conference September 2009 on Reclaiming the Resources for Health. It was convened by Lucy Gilson, School of Public Health and Family Medicine, University of Cape Town and Ermin Erasmus, Centre for Health Policy, The University of the Witwatersrand. The workshop aimed to: reflect on health policy analysis and its role in health system development; share experience in the use of health policy analysis to support policy development and implementation; share experience in teaching health policy analysis (in short course, post-graduate programmes etc); and develop shared ideas of how to strengthen this field of work in Africa. It provided an opportunity to reflect on health policy analysis and its role in health system development. Participants shared experience in the use of health policy analysis to support policy development and implementation and on teaching health policy analysis. In the workshop participants shared ideas of how to strengthen this field of work in Africa. The workshop was held as a pre-conference workshop to the EQUINET Regional Conference and involved delegates drawn from the conference and thus the wider regional work on equity in health.
Over 200 government officials, parliamentarians, civil society members, health workers, researchers, academics and policy makers, as well as personnel from United Nations, international and non-governmental organisations from East and Southern Africa and internationally met at the Third EQUINET Regional Conference on Equity in Health in East and Southern Africa, held 23–25 September 2009 in Munyonyo, Kampala. This document presents the resolutions of the conference for action on equity in health.
As part of its ongoing skills development programme, the Regional Network fort Equity in Health in East and Southern Africa (EQUINET) has committed to developing the writing skills of health equity researchers in the region, particularly with regards to writing for peer-reviewed journals, as well as for improving writing skills on EQUINET discussion papers. This workshop took place as part of the post-conference activities of the EQUINET conference September 2009 on Reclaiming the Resources for Health. It was convened by Rebecca Pointer under the auspices of the Training and Research Support Centre. The workshop used the EQUINET writing skills raining manual found as its core resource material. It sought to equip researchers with a basic step-by-step approach to writing for peer-reviewed journals, and to approach scientific writing as a routine process. The participants were those working on publications in areas related to health equity from countries in east and southern Africa.
3. Equity in Health
The purpose of this paper is to explore the socio-cultural context of cardiovascular disease (CVD) risk prevention and treatment in sub-Saharan Africa (SSA). It discusses risk factors specific to the SSA context, including poverty, urbanisation, developing healthcare systems, traditional healing, lifestyle and socio-cultural factors. It found that the epidemic of CVD in SSA is driven by multiple factors working collectively. Lifestyle factors such as diet, exercise and smoking contribute to the increasing rates of CVD in SSA. Some lifestyle factors are considered gendered in that some are salient for women and others for men. For instance, obesity is a predominant risk factor for women compared to men, but smoking still remains mostly a risk factor for men. Additionally, structural and system level issues such as lack of infrastructure for healthcare, urbanisation, poverty and lack of government programmes also drive this epidemic and hampers proper prevention, surveillance and treatment efforts.
In the current climate change debate, the perspective of the developing countries that will be worst affected has been almost completely ignored by the scientific literature. This deficit is addressed by this paper, which analyses the first 40 National Adaptation Programmes of Action reports submitted by governments of least-developed countries to the Global Environment Facility for funding. Of these documents, 93% identified at least one of three ways in which demographic trends interact with the effects of climate change: faster degradation of the sources of natural resources; increased demand for scarce resources; and heightened human vulnerability to extreme weather events. These findings suggest that voluntary access to family planning services should be made more available to poor communities in least-developed countries. The paper concludes by calling for increased support for rights-based family planning services, including those integrated with HIV and AIDS services, as an important complementary measure to climate change adaptation programmes in developing countries.
This is one of the session reports from Forum 2009, convened by the Global Forum for Health Research on 17–20 November 2009. The issue was finding synergies in policy between environmental health and equity agendas. Climate change has had a negative effect on health equity since it affects the most vulnerable populations. However, climate adaptation policies can sometimes make the situation even worse. For example, biofuels policies were intended to reduce the reliance on fossil fuels. In the past few years though, farmers have abandoned crop production in favour of growing biofuel crops, exacerbating the food crisis. Understanding the geographical components of the link between climate change and health is crucial. Data from geographical information systems (GIS) should be integrated with health information systems to provide a cohesive look at changes in disease spread, for example. Health researchers who study the effects of climate change cannot be content with just understanding the changing epidemiology of disease – they need to stay familiar with the latest technologies of monitoring climate change.
Five leading risk factors identified in this report (childhood underweight, unsafe sex, alcohol use, unsafe water and sanitation, and high blood pressure) are responsible for one quarter of all deaths in the world, and one fifth of all DALYs. Reducing exposure to these risk factors would increase global life expectancy by nearly five years. Eight risk factors (alcohol use, tobacco use, high blood pressure, high body mass index, high cholesterol, high blood glucose, low fruit and vegetable intake, and physical inactivity) account for 61% of cardiovascular deaths. Combined, these same risk factors account for over three quarters of ischaemic heart disease, the leading cause of death worldwide. Reducing exposure to these eight risk factors would increase global life expectancy by almost five years. Low- and middle-income countries now face a double burden of increasing chronic, non-communicable conditions, as well as the communicable diseases that traditionally affect the poor. Understanding the role of these risk factors is important for developing clear and effective strategies for improving global health.
Despite considerable progress in the past decades, societies continue to fail to meet the health care needs of women at key moments of their lives, particularly in their adolescent years and in older age. These are the key findings of this report. The World Health Organization (WHO) calls for urgent action both within the health sector and beyond to improve the health and lives of girls and women around the world, from birth to older age. The report provides the latest and most comprehensive evidence available to date on women's specific needs and health challenges over their entire life-course. It includes the latest global and regional figures on the health and leading causes of death in women from birth, through childhood, adolescence and adulthood, to older age.
This report focuses on two key aspects of disaster risk reduction: early warning and early action. Advances in science and technology, in forecasting techniques and the dissemination of information are major contributors to reducing mortality. However, the development of a more people-centred approach is also essential. The report gives a more comprehensive explanation about the different interventions in disaster management and risk reduction such as: an introduction to early warning systems for different hazards and early action; emphasising the link between early warnings and early actions; taking a people-centred approach by finding out how individuals and communities can understand the threats to their own survival and well-being, share that awareness with others and take actions to avoid or reduce disaster; and, in terms of food insecurity, knowing what actions should follow the early warning. A system of data collection to monitor peoples' access to food, in order to provide timely notice when a food crisis threatens and thus to elicit an appropriate response should be developed in order to mitigate the occurrence of the disaster.
Africa will fail to achieve most UN Millennium Development Goals unless countries adopt effective family planning programmes and control rapid population growth, said Khama Rogo, World Bank senior adviser, speaking at a three-day international conference on family planning, organised by the Gates Foundation and Johns Hopkins and Makerere universities and held (from 16–18 November) in the Ugandan capital, Kampala. More than 1,000 policy-makers, researchers, academics and health professionals from 59 countries attended the event. Various speakers warned that the rate of Africa's population increase was too rapid, with women in some countries having on average seven children each. ‘Family planning improves maternal health, thereby increasing women's productivity and reducing dependency at both family and national levels,’ said Chisale Mhango, director of reproductive health at Malawi's Health Ministry. ‘Fewer children means manageable education targets; more children means that parents will mainly educate sons, which promotes gender inequality,’ he added. ‘The fewer the children the better the care, the more the food, the lower the child mortality and there will be savings for health provision.’
4. Values, Policies and Rights
This African international agreement has opened the door to a debate on the rights and protection of people displaced by natural disasters, with a nod to migration as a result of climate change. The African Union Convention for the Protection and Assistance of Internally Displaced Persons in Africa, also known as the Kampala Convention, is a ground-breaking treaty adopted by the African Union (AU) that promises to protect and assist millions of Africans displaced within their own countries. Significantly, the treaty recognises natural disasters as well as conflict and generalised violence as key factors in uprooting people. In Africa, more people are likely to be displaced as the continent experiences more frequent droughts and floods brought about by climate change. The inclusion of displacement by natural disasters was informed by the global debate on the need to develop a framework for the rights of ‘climate refugees’ – people uprooted from their homes and crossing international borders – because the changing climate threatened their survival. The treaty also calls on governments to set up laws and find solutions to prevent displacement caused by natural disasters, with compensation for those who were displaced.
The South African cabinet has approved a new policy prohibiting discrimination against soldiers and would-be recruits on the basis of their HIV status. Previously, HIV-positive members of the South African National Defence Force (SANDF) could be excluded from recruitment, international deployment and promotion, but a 2008 high court decision declared such policies unconstitutional and gave the SANDF six months to amend them. The AIDS Law Project (ALP) expressed disappointment about the length of time the SANDF took to comply with the court order and the persistence of unfair discrimination against HIV-positive soldiers and recruits, but in October one of the men, Sergeant Sipho Mthethwa, became the first known HIV-positive soldier to be deployed on international service. The SANDF had argued that people living with HIV were unfit to withstand the stress and physical demands of foreign deployments. An estimated 25% of SANDF employees are HIV positive, higher than the national adult prevalence of 18%.
CIVICUS, the World Alliance for Citizen Participation, condemns the introduction of the Anti-homosexuality Bill 2009 in the Uganda Parliament on 14 October 2009. The Bill seeks to roll back international human rights obligations undertaken by Uganda by declaring that the provisions of any international legal instrument contradictory to the spirit of the Bill shall be null and void. It seeks to criminalise the work of civil society organisations that promote the rights of lesbian, gay bisexual and transgendered persons through cancellation of registration and punishment of the head of the organisation with seven years imprisonment. Other provisions of the Bill identified as repugnant by Civicus include punishment by death for HIV infected persons if they have sexual relations with a person of the same gender; life imprisonment for attempting to contract a marriage with a person of the same gender; deportation from Uganda of citizens or permanent residents if they have sexual relations with a person of the same gender; and life imprisonment for sexual relations between people of the same gender. CIVICUS urges the Parliament and the Government of Uganda to respect the human rights of its people and uphold commitments to the International Bill of Rights and the Ugandan Constitution.
International Affairs Directorate, Health Canada: March 2009
The United Nations Convention on the Rights of Persons with Disabilities (CRPD) should be used as a tool to improve access to HIV services for disabled people, who are often marginalised in national HIV policies, according to this new report. People with disabilities (PWDs) experience all the risk factors associated with HIV, and are often at increased risk because of poverty, severely limited access to education and health care, lack of information and resources to facilitate 'safer sex', lack of legal protection, increased risk of violence and rape, vulnerability to substance abuse, and stigma. HIV and AIDS were implicitly included in the CRPD under article 25a, where ‘State Parties shall provide PWDs with the same range, quality and standard of free, affordable health care and programmes as provided to other persons, including in the area of sexual and reproductive health and population-based public health programmes’. It was also noted that disabled people could not claim their right to health services unless they were educated about these rights.
The purpose of the research programme introduced in this article is to provide new knowledge regarding comprehensive multisectoral approaches to breaking the negative cycle of poverty and mental ill-health. The programme undertakes an analysis of existing mental health policies in four African countries (Ghana, South Africa, Uganda, Zambia), and evaluates interventions to assist in the development and implementation of mental health policies in those countries, over a five-year period. The four countries in which the programme is being conducted represent a variety of scenarios in mental health policy development and implementation.
The aim of this analysis is to describe the content of mental health policy and the process of its development in South Africa. Quantitative data regarding SA's mental health system was gathered using the World Health Organization (WHO) Assessment Instrument for Mental Health Systems. Semi-structured interviews provided understanding of processes, underlying issues and interactions between key stakeholders in mental health policy development. The study found that the process of mental health policy implementation has been hindered by the low priority given to mental health, varying levels of seniority of provincial mental health coordinators, limited staff for policy and planning, varying technical capacity at provincial and national levels, and reluctance by some provincial authorities to accept responsibility for driving implementation. National leadership in the development of new mental health policy is required, with improved communication, provincial-level responsibility for implementation and commitment to capacity building.
5. Health equity in economic and trade policies
Migration to and from mines contributes to HIV risks and associated tuberculosis (TB) incidence. Health and safety conditions within mines also promote the risk of silicosis (a TB risk factor) and transmission of tuberculosis bacilli in close quarters. In the context of migration, current TB prevention and treatment strategies often fail to provide sufficient continuity of care to ensure appropriate TB detection and treatment. Reports from Lesotho and South Africa suggest that miners pose transmission risks to other household or community members as they travel home undetected or inadequately treated, particularly with drug-resistant forms of TB. Reducing risky exposures on the mines, enhancing the continuity of primary care services, and improving the enforcement of occupational health codes may mitigate the harmful association between mining activities and TB incidence among affected communities. A number of immediately available measures to improve continuity of care for miners, change recruitment and compensation practices, and reduce the primary risk of infection may help reduce South Africa’s TB burden.
Uganda is considering an anti-counterfeit bill which analysts say will impair the country’s ability to import and export cheap but effective generic medicines. Activists fear that the bill, once enacted, will deny Ugandans access to safe, effective, quality and affordable generic medication, which currently forms the bulk of Uganda’s medicine imports. Edgar Tabaro, a Ugandan lawyer specialising in trade-related matters, questions the necessity of the bill, saying that whatever it ostensibly seeks to address is covered by different laws like the Trademarks Act, Copyright Act, the Patents Act and the Trade Secrets Act. Rosette Mutambi, executive director of the Coalition for Health Promotion and Social Development (HEPS-Uganda), regards the bill as a threat to the lives of many Ugandans who largely depend on generic anti-retroviral drugs and other medicine. She said only about 10% of the medicines used in Uganda are locally manufactured. And only about 5 to 7% of the imported medicines are original brands, meaning that about 93% of imported drugs are generics, mostly imported from India.
African and Pacific countries continue to negotiate the challenging Economic Partnership Agreements (EPAs) with the European Union. These new agreements have the potential to help African countries accelerate their economic growth and develop more resilient economies. However, the presence of negotiating deadlocks or a sense of fatigue as well as the lack of real appetite for these agreements among many African, Caribbean, and Pacific (ACP) negotiators, raise legitimate questions regarding their structure and content, as well as their ability to constitute instruments to leverage economic growth.
This report examines the range of contingency measures available in trade agreements and the role that these measures play. These measures allow governments a certain degree of flexibility within their trade commitments and can be used to address circumstances that could not have been foreseen when a trade commitment was made. The tension between credible commitments and flexibility is often close to the surface during trade negotiations. One of the main objectives of this report is to analyse whether the World Trade Organization (WTO) provisions provide a balance between supplying governments with necessary flexibility to face difficult economic situations and adequately defining them in a way that limits their use for protectionist purposes. The report also discusses alternative policy options, including the renegotiation of tariff commitments, the use of export taxes, and increases in tariffs up to their legal maximum ceiling or binding.
Critics of 'me-too' innovation often argue that follow-on drugs offer little incremental clinical value over existing pioneer products, while at the same time increasing health care costs. This study examines whether consumers view follow-on and pioneer drugs as close substitutes or distinct clinical therapies. For five major classes of drugs, it found that large reductions in the price of pioneer molecules after patent expiration – which would typically lead to decreased consumption of strong substitutes – have no effect on the trend in demand for follow-on drugs. The findings are likely unaffected by health insurance, competitive pricing of me-toos, marketing, and switching costs.
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6. Poverty and health
The epicentre of the child health emergency is sub-Saharan Africa and South Asia but, without a concerted and sustained effort in their countries, there’s little prospect of Millennium Development Goal 4 being met at a global level. The causes of this emergency vary according to the local context, and will require tailored responses by governments, donors and international institutions. Examples of good leadership exist in countries like Liberia, where President Ellen Johnson Sirleaf has used the peace dividend to triple health spending, withdraw user charges and focus on the prevention of malaria. The first tier of healthcare for children is the household level, and beyond that the immediate community. Yet relatively little attention is paid by most governments to low-cost and easy-to-deliver measures that can be taken at this level, which can have a decisive impact on child health, from hand washing and breastfeeding to early identification of pneumonia. World Vision estimates that a comprehensive package of family and community care alone could prevent 2.5 million child deaths each year. What’s needed is a redefinition of health systems to incorporate family- and community-level care, in tandem with a fundamental rebalancing of public spending placing much greater emphasis on prevention. Safe water and sanitation and basic hygiene are necessary to achieve this aim – the World Health Organization estimates that they could together save US$7 billion in health care costs each year.
Asthma has been a public health issue since the 1960s. Factors associated with asthma are environmental and genetic. This study is based on a random sample of 742 students aged 13–14 attending various schools at Polokwane, in the province of Limpopo in South Africa. Survey logistic regression and multi-level analyses were used for data analysis. The study identifies three key determinants of asthma at the district, school and individual levels. The study shows that persistent cough, exposure to smoke at the household level and lack of access to flush toilets at the household level are key predictors of asthma in children. Variability at the level of districts accounts for 46% of total variance. Variability at the level of schools accounts for 33% of total variance.
Donors have spent very little on nutrition – barely 1.7% of development and emergency food aid between 2004 and 2007 actually addressed malnutrition, says this report. The analysis suggests that donors should maximise the value of funding by ceasing in-kind donations and provide cash instead, allowing aid agencies to source cheaper or more appropriate food in the region or beneficiary country. However, donor countries in the European Union (EU) and Canada, which had recently moved to provide cash, were not spending enough on nutrition. Malnutrition should in recent years have benefited both from the global renewed interest in the problem, and from the emergence of a broad consensus within the nutrition community enabling the scale up of activities in high-burden countries. Yet the analysis finds that funding has remained more or less flat, stuck at roughly the same level since 2000–2004. A tiny percentage (1.7%) of the interventions reported as ‘development food aid-food security’ and ‘emergency food aid’ in the OECD database actually address nutrition. The authors argue that if interventions such as these are to be considered as a means to address malnutrition, then food security and food assistance projects (namely food transfer, cash or voucher programmes) must be targeted more precisely on nutrition as a main objective and be designed accordingly.
Humanity has made enormous progress in the past 50 years toward eliminating hunger and malnutrition. Some five billion people – more than 80% of the world's population – have enough food to live healthy, productive lives. Agricultural development has contributed significantly to these gains, while also fostering economic growth and poverty reduction in some of the world's poorest countries. This book examines how policies, programmes and investments in pro-poor agricultural development have helped to substantially reduce hunger across Africa, Asia and Latin America. The 20 success stories presented here provide both lessons and inspiration for continued efforts to eradicate hunger and malnutrition among the one billion people still facing this scourge.
Dismal global figures hide the fact that the number of hungry people has been declining in 31 countries during the fifteen-year period from 1991 to 2005. This paper analyses four examples of countries that are on track to achieve 2015 food security targets: Armenia, Brazil, Nigeria and Vietnam. Based on these examples, it argues that success in the battle to halve hunger will usually be characterised by: creation of an enabling environment for economic growth and human wellbeing; outreach to the most vulnerable and investment in the rural poor; protection of gains; and planning for a sustainable future. Several developing countries have succeeded in transforming their agriculture sectors, turning them into important sources of growth and export earnings, and thus increasing their contribution to poverty and hunger reduction. The paper studies examples of countries that have transformed their sectors, concluding that supporting smallholder farmers is one of the best ways to fight hunger and poverty. It is estimated that 85% of the farms in the world measure less than two hectares, and that smallholder farmers and their families represent two billion people, or one-third of the world’s population.
In 2009, students from more than 90 countries tackled the intersection of poverty and climate change. For the past two years, the Global Debates have focused on several climate change issues - water rights, carbon emissions, action plans, obligation of developed nations and more. However, these issues relate also to the impact that global warming has on international development and our ability to end extreme poverty. These facts are a part of the growing evidence that students will bring to Global Debate activities this year, through writing blogs on the UN’s response to climate change and poverty, and collaborating with elected leaders on the importance of a comprehensive climate treaty in Copenhagen.
This report presents the latest statistics on global undernourishment and concludes that structural problems of underinvestment have impeded progress toward the World Food Summit goal and the first Millennium Development Goal hunger reduction target. This disappointing state of affairs has been exacerbated by first the food crisis and now the global economic crisis that, together, have increased the number of undernourished people in the world to more that one billion for the first time since 1970. This crisis is different from those developing countries have experienced in the past, because it is affecting the entire world simultaneously and because developing countries today are more integrated into the global economy than in the past. In the context of the enormous financial pressures faced by governments, the twin-track approach remains an effective way to address growing levels of hunger in the world. Investments in the agriculture sector, especially for public goods, will be critical if hunger is to be eradicated.
Ending poverty is almost certainly doomed to fail if it is driven solely by the imperative of boosting economic growth through investment, trade, new technology or foreign aid, according to this book. Fighting poverty is about fighting deprivation, exclusion, insecurity and powerlessness. People living in poverty lack material resources but that more than that, they lack control over their own lives. To tackle global poverty, we need to focus on the human rights abuses that drive poverty and keep people poor. Giving people a say in their own future, and demanding that they be treated with dignity and respect for their rights is the way to make progress. Through personal reflection and case studies, Khan shows why poverty is first and foremost not a problem of economics but of human rights. As the numbers of people living in poverty swell to upwards of two billion, she argues that poverty is the world's worst human rights crisis. Slums are growing at an alarming rate condemning a billion people to live in dismal conditions. More than half a million women are dying every year due to complications related to pregnancy and childbirth, and 99% of these are in the developing world because of discrimination and denial of essential health care.
7. Equitable health services
This book documents the largest-ever independent, laboratory-based evaluation of rapid diagnostic tests (RDTs) for malaria. It shows that some tests on the market perform exceptionally well in tropical temperatures and can detect even low parasite densities in blood samples, while other tests were only able to detect the parasite at high parasite densities. Testing was performed at the US Centres for Disease Control and Prevention (CDC). Forty-one commercially available RDTs went through a blinded laboratory evaluation. The findings will serve as a tool for countries to make informed choices, from among the dozens of tests commercially available, on the purchase and use of rapid diagnostics that are best suited to local conditions. This performance evaluation will also inform procurement and prioritisation for diagnostic test entry into the World Health Organization (WHO) Prequalification Diagnostics Programme and WHO Procurement Schemes. Donor agencies also regularly refer to WHO recommendations on diagnostics when making their own purchases.
This paper examined the Global Fund database for elements and indicators of sexual and reproductive health in all approved HIV-related proposals (214) submitted by 134 countries, from rounds 1 to 7, and in an illustrative sample of 35 grant agreements. At least 70% of the HIV-related proposals included one or more of the four broad elements: sexual and reproductive health information, education and communication; condom promotion/distribution; diagnosis and treatment of sexually transmitted infections; and prevention of mother-to-child transmission of HIV. Between 20% and 30% included sexual health counselling, gender-based violence, and the linking of voluntary counselling and testing for HIV with sexual and reproductive health services. Less than 20% focused on adolescent sexual and reproductive health, the rights and needs of people living with HIV, or safe abortion services. Country coordinating mechanisms and national-level stakeholders see in funding for sexual and reproductive health a means to address the problem of HIV infection in their respective national settings. However, the paper highlights some missed opportunities for linking HIV and sexual and reproductive health services.
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8. Human Resources
This paper contributes to the economics literature on nursing market shortages by putting forward two new models that suggest three new explanations for perceived nursing shortages. The first model focuses on hospitals hiring both permanent staff nurses and temporary contract nurses. It shows that hiring both classes of nurses can represent optimising behaviour, and that an interesting kind of perceived nursing shortage results from this dual hiring. The second model posits two classes of hospitals – premier and funds-constrained – and generates two distinct kinds of nursing shortages: economic shortages, involving unfilled, budgeted positions, and non-economic professional standards shortages. The paper argues that the perceived existence of professional standards shortages may be a significant explanation for the widespread impression of persistent shortages.
The National Organisation of Nurses and Midwives of Malawi’s position paper is a response to the proposed introduction of fees for student nurses and midwives. It has been submitted to top leadership in government, parliament, civil society organisations, media, community and religious leaders, professional organisations, trade unions and other opinion leaders. The organisation asks for ‘revision of government decision on payment of fees by students and parents towards training in nursing and midwifery. Specifically, the fees are very high costing over K1 million per student for a three-year course of study. This is prohibitive to selected candidates who aspire to study nursing/midwifery… [ ] … Existing and alternative funding options can be maximised to address funding for nurses and midwives’ training.’ It notes that civil society has a critical role in ‘complementing government efforts to develop the country socio-economically, taking it from “Poverty to Prosperity”’ and hopes to build on the economic prosperity achieved by Malawi in the past six years, referring to ‘meaningful and sustainable funding… [ ] … for the training of nurses and midwives.’
9. Public-Private Mix
This paper examines the experiences of private sector participation (PSP) in the water supply and sanitation (WSS) sector. The paper argues that publicly owned water utilities have not always been successful in both developed and developing economies. However, non-market failures in supplying water are much more severe in developing economies. On grounds of efficiency, public WSS services have remained wanting. Large proportions of the population remain with little or no access to public services, and the quality of services for those who receive them are often poor, characterised by frequent breakdowns and unreliable supply. The author argues that while private sector participation has made more progress in high-income and middle-income countries, it has failed considerably in low-income developing countries. Success in wealthier countries is attributed to investment by private capital. The report concludes by recommending that private sector participation in the WSS sector in developing countries should not be introduced without rigorous prior assessment of its feasibility. When prevailing conditions are not suitable for introducing PSP, reforming the public utility should be given due consideration as a viable alternative.
10. Resource allocation and health financing
This study explores how globalisation is challenging activist groups that use a human rights framework that has traditionally been used to hold national governments accountable for human rights violations. In the absence of any positive movement towards unconditional debt cancellation, Africa continues to be burdened with an unmanageable debt overhang, which is hampering the continent's economic growth. Resource outflows, including debt service, are a drain on financial resources for development. With no convincing solutions offered by international creditors there is clearly a need for a continued focus on the debt problem. Various strategies need to be adopted by civil society organisations in the future, including strengthening the options for establishment of global governance structures such as the international arbitration court, finding channels and institutions to whom such issues as illegitimate debt, the plight of debtor countries in terms of debt repayment against access to health and education as a rights issue.
This report details a meeting by the Network of African Parliamentarians for Health Development and Financing held in Addis Ababa, Ethiopia, 7–9 September 2009, which met to deliberate on: accelerating African domestic health financing; implementing health priorities in an integrated manner; strengthening collaboration; preparations for the July 2010 African Union Summit; and coordinating global and African resource mobilisation. They determined that, without delay, further meetings should take place at three levels in the 53 African Union member states: at pan-African Parliament level; at each Regional Economic Community Parliament; and at country level. These joint working meetings should consist of chairs and secretaries/rapporteurs of the Parliamentary Committees of: health; finance/budget; women/gender; social development and Millennium Development Goals (MDGs) and others, including children and youth; water resources; environment and sanitation; education; food and agriculture; labour and human resources; planning and economic development. They will assess the state of health-based and related MDGs at each level. These committees should form health and social development financing clusters in parliaments to facilitate coordination and accelerated action on health and development financing.
Recent literature has been pessimistic about the ability of foreign aid to foster economic growth. This paper attempts to provide a balanced assessment of the recent aid-growth literature. It also delves into framing the aid-growth debate in terms of potential outcomes, drawing on the programme evaluation literature. Following its analysis, the paper concludes that aid has a positive and statistically significant causal effect on growth over the long run with point estimates at levels suggested by growth theory. The methodological advances highlight the serious challenges that must be surmounted in order to derive robust causal conclusions from observational data. The authors argue that the bleak pessimism of recent aid-growth literature is unjustified and the associated policy implications drawn from the literature is inappropriate and unhelpful.
This paper set out to explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone. Cross-sectional data was derived from three randomly selected matched clusters in rural South Africa. A total of 1,409 participants were enrolled, all female, with a median age of 45. After two years, both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group. However, only the IMAGE group demonstrated consistent associations across all domains with regard to women’s empowerment, intimate partner violence and HIV risk behaviour. In conclusion, the addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits.
The political economy of aid agencies is driven by incomplete information and multiple competing objectives and confounded by principal-agent and collective-action problems. Policies to improve aid rely too much on a planning paradigm that tries to ignore, rather than change, the political economy of aid. A considered combination of market mechanisms, networked collaboration and collective regulation would be more likely to lead to significant improvements. A ‘collaborative market’ for aid might include unbundling funding from aid management to create more explicit markets; better information gathered from the intended beneficiaries of aid; decentralised decision-making; a sharp increase in transparency and accountability of donor agencies; the publication of more information about results; pricing externalities; and new regulatory arrangements to make markets work. The aid system is in a political equilibrium, determined by deep characteristics of the aid relationship and the political economy of aid institutions. The priority should be on reforms that put pressure on the aid system to evolve in the right direction rather than on grand designs.
Karel De Gucht, the European commissioner for development, has warned the ministers of European Union member states that just five of the 27 member states are on course to meet a self-imposed target of giving 0.56% of national income in aid to developing countries by 2010. That target was an interim benchmark on the way to a pledge agreed by the member states that they should give 0.7% of gross national income in aid by 2015. De Gucht has sent, to development ministers, papers that show projected assistance levels for 2009 and 2010 for each member state. So far, four countries – Denmark, Luxembourg, the Netherlands and Sweden – are above the 0.7% level and Ireland is above 0.56%.
Global health analysts have debated whether donor prioritisation of HIV and AIDS control has lifted all boats, raising attention and funding levels for health issues aside from HIV and AIDS. This paper investigates this question, considering donor funding for four historically prominent health agendas: HIV and AIDS, health systems strengthening, population and reproductive health, and infectious disease control-over the decade 1998–2007. It employed funding data from the Development Assistance Committee of the Organization for Economic Cooperation and Development, which tracks donor aid. The data indicates that HIV and AIDS may have helped to increase funding for the control of other infectious diseases; however, there is no firm evidence that other health issues beyond the control of infectious diseases have benefited. Between 1998 and 2007, funding for HIV and AIDS control rose from just 5.5% to nearly half of all aid for health. Over the same period, funding for health systems strengthening declined from 62.3% to 23.9% of total health aid and that for population and reproductive health declined from 26.4% to 12.3%. Also, even as total aid for health tripled during this decade, aid for health systems strengthening largely stagnated. Overall, the data indicates little support for the contention that donor funding for HIV and AIDS has lifted all boats.
In recent years, new global initiatives responding to the AIDS crisis have dramatically affected how developing countries procure, distribute, and manage pharmaceuticals. A number of developments related to treatment scale-up, initially focused on AIDS-related products, have created frameworks for widening access to medicines for other diseases that disproportionally impact countries with limited resources and for strengthening health systems overall. Examples of such systems strengthening have come in the areas of drug development and pricing; policy and regulation; pharmaceutical procurement, distribution, and use; and management systems, such as for health information and human resources. For example, a hospital in South Africa developed new tools to decentralise provision of antiretroviral therapy to local clinics-bringing treatment closer to patients and shifting responsibility from scarce pharmacists to lower level pharmacy staff. Successful, the system was expanded to patients with other chronic conditions, such as mental illness. Health experts can likely take these achievements further to maximise their expansion into the wider health system.
Efforts to finance HIV responses have generated large increases in funding, catalysed activism and institutional innovation, and brought renewed attention to health issues and systems. The benefits go well beyond HIV programmes. The substantial increases in HIV funding are a tiny percentage of overall increases in health financing, with other areas also seeing large absolute increases. Data on health funding suggest an improved pro-poor distribution, with Africa benefiting relatively more from increased external flows. A literature review found few evidence-based analyses of the impact of AIDS programmes and funding on broader health financing. Conceptual frameworks that would facilitate such analysis are summarised.
The author argues that the accusation that those who developed the policy on National Health Insurance (NHI) will be depriving South Africans of choice is very much unfounded. The development of the NHI policy is evidence-based; in a national survey South Africans were asked if they would support a NHI scheme if it limited their choice of doctors or if waiting lists for non-emergency services were introduced and half of the respondents indicated that they would not support it. Those who prepared the policy on NHI took into account the sentiments of the public by recommending that individuals will choose a provider within their district, whether in the public or private health sector and register for service delivery. They also proposed that the benefits must be portable, meaning that patients are covered even when they are away from their usual place of health care. Long waiting lists for non-emergency care are largely due to a shortage of health workers, particularly doctors in some areas. For this reason, the ANC proposal recommends a set of actions to mitigate overcrowding, which will reduce waiting times; these are increase of doctors through retention, increased intake of students into medicine and importation of doctors.
11. Equity and HIV/AIDS
This paper reviews published quantitative research on the mental health of HIV-infected adults in Africa. Twenty-seven articles published between 1994 and 2008 reported the results of 23 studies. Most studies found that about half of HIV-infected adults sampled had some form of psychiatric disorder, with depression the most common individual problem. People living with HIV or AIDS (PLHIV) tended to have more mental health problems than non-HIV-infected individuals, with those experiencing less problems less likely to be poor and more likely to be employed, educated and receiving antiretroviral treatment (ART). While some key findings emerged from the studies, the knowledge base was diverse and the methodological quality uneven, so studies lacked comparability and findings were not equally robust. Priorities for future research should include replicating findings regarding common mental health problems among PLHIV, important issues among HIV-infected women, and the longer-term mental health needs of those on ART. Research is also needed into predictors of mental health outcomes and factors associated with adherence to ART, which can be targeted in interventions.
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12. Governance and participation in health
In varying degrees, most developing regions have formally embraced the democracy and development agenda and recognised the ‘democratic advantage’ in terms of delivering development. In Africa, a stream of policy declarations have been issued, pointing to the positive links between democracy and development. Both the NEPAD and the Africa Peer Review Mechanism (APRM) are premised on this belief. This analysis confirms that there are few dissenting voices when it comes to formally recognising the potential added value of democracy for development. Yet do these high expectations resist the test of reality? How do democratic processes actually operate in third countries? Admittedly, the impact of democracy on development is not simple and straightforward. Challenges include the current trend for democracy to be on the defensive, doubts about the delivery capacity of democracy and the difficulty of initiating and continuing dialogue on democracy. This paper offers key insights on the link between democracy and development.
This review seeks to detail recent initiatives by non-governmental organisations (NGOs) and civil society organisations in improving development practice. There are several attempts to provide a ‘civil society or NGO’ parallel to the Paris Declaration. These initiatives seek some form of standardisation and evidence that NGOs are as effective as they claim to be, and to counter criticism that they have not been diligent in ensuring the quality of their delivery. However, seeking to justify oneself is not the best use of time and resources. Accountability needs to be improved. The survey indicated that many of the initiatives do not go far down the route of participation, despite a theoretical (rhetorical) commitment to beneficiary participation. Improved quality control is also required. Some of the models now available seek to improve the quality of delivery rather than the quality of impact. Thus an emphasis on things like complaints procedures, transparent, consistent and shared procedures, deal with how aid is delivered not what is delivered and whether it has any real impact. Regular assessments of efficiency, effectiveness and impact should be done. However, efficiency is not the same as effectiveness or impact. Improved efficiency does not automatically lead to more effective development or greater impact.
The 2009 edition of the Right to Food and Nutrition Watch focuses on the question: ‘Who controls the governance of the world food system?’ For the first time in history, the number of undernourished people in the world has surpassed the tragic figure of one billion. The gap between promises and reality is increasing as the international community and national governments are far from realising the World Food Summit targets to halve the proportion of chronically hungry people in the world by the year 2015. It is clear that the global governance of the world food system needs to be remodelled in order to effectively overcome hunger and its causes. As an evidence-providing monitoring tool, this book pursues two aims: to put public pressure on policy makers at national and international levels to take the human right to food seriously and to provide a systematic compilation of best practices for the realisation of the right to food, while documenting where violations take place.
This brief asserts that research relating to humanitarian crises has largely focused on what international aid agencies and donor governments do in response to disasters. Instead, this paper focuses on the role of the affected state in responding to the needs of its own citizens. It found that one of the goals of international humanitarian actors should always be to encourage and support states to fulfil their responsibilities to assist and protect their own citizens in times of disaster. Too often, aid agencies have neglected the central role of the state, and neutrality and independence have been taken as shorthand for disengagement from state structures, rather than as necessitating principled engagement with them. States should invest their own resources in assisting and protecting their citizens in disasters, both because it is the humane thing to do and because it can be politically popular and economically effective. The roles and responsibilities of states in relation to humanitarian aid are four-fold: they are responsible for 'calling' a crisis and inviting international aid; they provide assistance and protection for themselves; they are responsible for monitoring and coordinating external assistance; and they set the regulatory and legal frameworks governing assistance.
This briefing paper aims to distil the core questions which the fragile states literature and experiences in fragile states present, with the aim of structuring space for discussion of these issues in non-governmental organisation (NGO) practice and exploring directions for further research. It found that networks are not guaranteed to work better solely by having increased resources and in many cases are not a genuine solution. NGOs must work in and strive to ameliorate the environment of mistrust through building trust and social cohesion at a community level. Underlying all fragile states discussion must be a thorough and continuous contextual analysis, as cases of fragility vary greatly and are individually extremely dynamic. There is clearly a need for civil society to innovate and pursue alternative solutions in fragile states where traditional methods do not seem to be working. The challenge for civil society is to engage more effectively in policy dialogue on fragile stages, building on their programmatic experience of working directly with poor communities.
13. Monitoring equity and research policy
The author notes that the key debate over what indicators to use to measure progress seems to regarding complexity. Hundreds of different indicators are already being used to measure progress and hundreds more have been proposed. The Stiglitz Commission proposes ‘dashboards’ of indicators, allowing different people and institutions to combine them in different ways to measure and track the things that matter most to them (mental health, carbon emissions, citizen participation or whatever). But decision makers and ordinary people can only keep a limited number of indicators in their heads. Composite indicators could rapidly become a political football, as member states argue for the combination that puts their own performance in the best light, and each successive government changes them, meaning you lose comparability both between countries and across time. The answer is to combine the merits of simplicity and complexity by picking three to five standardised indicators, each of which would be at the centre of a cluster of disaggregated numbers allowing policy makers and researchers to drill down into the relationships between different aspects of people’s lives (for example between income inequality and child well-being).
South Africa’s first bio-bank, a cold storage facility where samples from HIV clinical trials and other diseases can be stored for years to support future medical research, was launched in Johannesburg. Bio-banking is a novel concept on the African continent and South Africa is the first country to introduce it. ‘Bio-banking ensures that the integrity of the samples is kept so that when you do run the test, you’re able to get sense out of the result’, explained Jessica Trusler, medical director of Bio-analytical Research Corporation (BRAC) South Africa. Peter Cole, chief executive officer of BRAC, noted: ‘The ability to store samples long term, including the RNA and DNA of these infectious pathogens means that we can do things like look at resistance patterns to drugs, we can use the DNA in the future for vaccine development, we can store TB DNA looking at resistance patterns against the various drugs and the role of what we call MOTTS, the non-tuberculous organisms in the immuno-compromised patients. So, there’s a lot of unique stuff that we can do here’, he added.
The aim of this study was to investigate research priorities in mental health among researchers and other stakeholders in low- and middle-income (LAMI) countries. A two-stage design was used that included identification, through literature searches and snowball technique, of researchers and stakeholders in 114 countries of Africa, Asia, Latin America and the Caribbean; and a mail survey on priorities in research. The study identified broad agreement between researchers and stakeholders and across regions regarding research priorities. Epidemiology (burden and risk factors), health systems and social science ranked highest for type of research. Researchers’ and stakeholders’ priorities were consistent with burden of disease estimates. However, suicide was underprioritised, compared with its burden. Researchers’ and stakeholders’ priorities were also largely congruent with the researchers’ projects. The results of this first-ever conducted survey of researchers and stakeholders regarding research priorities in mental health suggest that it should be possible to develop consensus at regional and international levels regarding the research agenda that is necessary to support health system objectives in LAMI countries.
The main pattern of research funding is driven by the interests of research funders, who are often external rather than domestic actors. When priority-setting processes do occur, they are typically disease-driven and without a broader, more integrated systems-level perspective (for example, determining how research might address one or more health-system building blocks). As a result, there is rarely consensus on national evidence needs, few national research priorities are set, and research in low- to middle-income countries (LMICs) continues to follow the fleeting and shifting priorities of global funders. This brief discusses the fundamental concepts of priority setting exercises; explores the priority-setting dynamic between the national and global levels; describes priority setting exercises specific to health policy and systems research; and details the work of the in driving global priorities based on the evidence needs of LMIC policy-makers through a three-step approach. It concludes with recommendations for how researchers, LMIC policy-makers and the global community might increasingly promote, fund and convene priority-setting exercises in health policy and systems research.
In this conceptual article, the authors compare and contrast the evolution of climate change and AIDS research. They demonstrate how scholarship and response in these two seemingly disparate areas share certain important similarities, such as the "globalisation" of discourses and associated masking of uneven vulnerabilities, the tendency toward techno-fixes, and the polarisation of debates within these fields. They also examine key divergences, noting in particular that climate change research has tended to be more forward-looking and longer-term in focus than AIDS scholarship. Suggesting that AIDS scholars can learn from these key parallels and divergences, the paper offers four directions for advancing AIDS research: focusing more on the differentiation of risk and responsibility within and among AIDS epidemics; taking (back) on board social justice approaches; moving beyond polarised debates; and shifting focus from reactive to forward-looking and proactive approaches.
International comparisons show that the average South African will not live longer than 50 years. South Africa was one of only six out of a group of 37 developed and developing countries that had a decreasing life expectancy between 1990 and 2007. South Africa’s life expectancy decreased from 62 years in 1990, to 50 years in 2007. Only Zimbabwe had a worse trend for life expectancy. The statistics in this report show that, in 2009, the average life expectancy at birth for South Africans was 51 years. Between 2001 and 2006 the life expectancy at birth was 51 years for males, and 55 years for females. This is expected to decrease between 2006 and 2011 to 48 years for males, and 51 years for females. KwaZulu-Natal had the lowest life expectancy at birth in 2009 at 43 years, followed by the Free State and Mpumalanga at 47 years each. These three provinces also had some of the highest HIV prevalence rates at 16%, 14%, and 14% respectively. International comparisons also show that in 2007, some 27% of males and 33% of females in South Africa would survive to age 65. Out of a comparison group of 37 developing and developed countries, only Mozambique and Zimbabwe had lower survival rates.
Researchers and innovators in developed countries seeking authoritative information on how to solve a particular technical problem or develop a new product generally turn either to scientific journals or patent information. However, patent information enjoys certain advantages over scientific journals, according to William Meredith, head of the World Intellectual Property Organization Patent Information and IP Statistics Section. Despite the stated benefits of patent disclosure, Gakuru Muchemi, a senior lecturer at the Department of Electrical and Information Engineering of the University of Nairobi, noted in an interview that ‘the use of patent disclosure information either as a research tool or teaching aid in our institutions of learning and research still remains unused or underutilised.’ On the other hand, Meredith added that, ‘even where the innovators in developing countries may not be able to reproduce the latest cutting edge technology contained in patent documents, they may be still be able to use information contained in the specifications about the technology to adapt to local situations.’
Policy-makers and health system managers routinely face difficult decisions around improving health and promoting equity. They must consider complex, core questions about particular programmes to implement and effective strategies for organising the overall health system. For instance, does contracting out services to the private sector improve access to health care? How could the health system best retain trained health care providers in underserved areas? Do conditional cash transfers improve the uptake of health interventions? This brief provides essential background information to systematic reviews: how they are conducted, what they entail and their theoretical roots. It discusses tools like GRADE (Grading of Recommendations, Assessment, Development and Evaluation) and organisations like the Cochrane Collaboration. The brief calls for increased funding to support systematic reviews, improved methodological development in the reviewing process, increased networking and the need to promote training of end-users. The use of knowledge translation is highlighted.
14. Useful Resources
It is thirty years since the Alma Ata Declaration which outlined an international consensus on the need to provide universal access to primary health care (PHC). During the ensuing years some countries established and consolidated well-organised government health services in which PHC played an important role. Many others were less successful. Some countries have experienced major reversals in life expectancy after a long period of steady improvement and their health systems have deteriorated. There is a growing concern by national governments and the international community to expand access to PHC and they have committed a lot of money for this purpose. But there have been many major changes in these last three decades that pose big challenges for the future configurations of PHC. This key issues guide unpacks some of the challenges for the future of PHC and highlights promising models of health system arrangement and service delivery that are improving access for the poorest and most marginalised. It focuses on four main areas: the increasing marketisation of health and how governments respond; the challenge of responding to progressive and chronic illnesses; the emergence of new epidemics and the globalisation of public health responses; and the pressure to keep up with new treatments and technologies.
This is an online ten-unit short course on health systems and their functioning. Like organ systems, health systems break down in predictable patterns and lead to syndromes that can be diagnosed and addressed. Dysfunctional health systems are why thousands of effective low-cost health interventions remain on the shelves while people suffer and die. Dysfunctional health systems leave people vulnerable to financial catastrophe. Failure to manage health resources judiciously permits not just waste, but the delivery of inappropriate or harmful services. While many lament how little research addresses the development of ‘new cures’ for the diseases of the poor, the inexcusable tragedy is the world’s failure to deliver affordable and effective ‘old cures’ to treatable and preventable diseases. Diarrhoea, pneumonia, tuberculosis and malaria are all easily and cheaply treatable. Their persistence around the world is a testament to failed health systems more so than a lack of scientific prowess.
The International Budget Partnership (IBP) has released It's our money. Where's it gone?, a new documentary film on the work one of its partners, Muslims for Human Rights (MUHURI), is doing to involve communities directly in monitoring the Constituency Development Fund (CDF) in Mombasa, Kenya. The CDF allocates approximately one million dollars annually to each member of Parliament to spend on development projects in his or her constituency but provides for no meaningful independent oversight. This is the story of ordinary Kenyans stepping in to do something about it. MUHURI uses social audits to involve communities in monitoring and holding their government accountable for managing the public's money and meeting the needs of its people, especially the poor and most vulnerable.
What can be done to ensure that the poorest Africans have access to a healthcare system that charges user fees? A team of researchers from the University of Montreal has produced a thorough compilation of all existing knowledge on this subject in four bilingual policy briefs. The briefs present options that have been shown to promote access to care: abolition of user fees for healthcare services, case-by-case exemptions for the worst-off, health equity funds, and health insurance that includes coverage for the poor. The objective of this project was to give leaders a comprehensive overview of actions that have already been undertaken to evaluate what options are best suited to their context. With the assistance of an international NGO (HELP – Hilfe zur Selbsthilfe e.V.), consultations were carried out in Burkina Faso to strengthen the relevance of these policy briefs. Starting in November, these four documents will be distributed in Burkina Faso as part of a HELP project that will test a trial of user fees abolition.
15. Jobs and Announcements
The Poverty and Economic Poverty (PEP) Research Group is looking for proposals for 2010, valued up to Can$50,000 each. PEP provides financial and scientific support to teams of researchers in developing countries studying poverty issues. Its specific aims are to better understand the causes and consequences of poverty, propose pro-poor policies and programmes, improve the measurement and monitoring of poverty, strengthen local research capacity in poverty issues, develop new concepts and techniques for poverty analysis. To maximise capacity building, PEP favours teams consisting of at least one senior member supervising a gender-balanced group of junior researchers. All team members must originate from and reside in a developing country during the course of the project. Grants are awarded in four programmes: community-based monitoring systems; modeling and policy impact analysis; policy impact evaluation research initiative; and poverty monitoring, measurement and analysis. Decisions will be communicated by 30 April 2010.
The United Nations Democracy Fund invites civil society organisations to apply for funding for projects to advance and support democracy. The thematic categories for applications are: democratic dialogue and support for constitutional processes; civil society empowerment, including the empowerment of women; civic education and voter registration; citizen’s access to information; participation rights and the rule of law in support of civil society; and transparency and integrity. The selection process is expected to be highly rigorous and competitive – last year, fewer than 70 project proposals were selected out of more than 2,100 received. UNDEF funding ranges from US $50,000 to US $500,000, with most projects in the mid-range. It is anticipated that the vast majority of applicants and short-listed project proposals will emanate from local civil society organisations.
From 7–18 December, more than 15,000 people, including government officials and advisers from 192 nations, civil society and the media from nearly every country in the world, will come together in the Danish capital, Copenhagen, for the Copenhagen Climate Conference. The Conference will negotiate agreements for countries to reduce greenhouse gas emissions, as their current commitments under the Kyoto Protocol expire in 2012. Two years ago, at a previous United Nations (UN) climate conference in Bali, all UN governments agreed on a timetable that would ensure a strong climate deal by the time of the Copenhagen conference. The implications of not achieving this goal are massive, and nearly unthinkable. The meeting – which should include major heads of state for the last three days – will attempt to reach a massively complex agreement on cutting carbon, providing finance for mitigation and adaptation, and supporting technology transfer from the North to the South.
The Fourth Africa Conference on Sexual Health and Rights is part of a long-term process of building and fostering regional dialogue on sexual rights and health that leads to concrete action to influence policy particularly that of the African Union and its bodies. The purpose of the conference is to examine the interrelationship between sexuality and HIV and AIDS. In particular, it aims to open up discourse on sexuality in Africa and how this might lead to new insights in reducing the spread of HIV in Africa. The focus will be on identifying new and emerging vulnerabilities and vulnerable people using the concept of sexual rights and sexuality in the fight against HIV and AIDS. It will also explore how the application of human rights framework to sexuality might provide new insights in developing interventions to reduce the spread of HIV and map out new and innovative strategies, programming and funding best suited to deal with those most vulnerable to infection. The conference will provide a framework of how sexuality and the application of sexual rights may lead to openness, responsibility and choices for all people, particularly young people, on sex, sexuality and sexual behaviour.
Cape Town, South Africa will host the 13th International Congress on Medical Informatics from 12–15 September 2010. This is the first time the Congress will be held in Africa. It promises to boost exposure to grassroots healthcare delivery and the underpinning health information systems. This will open the door to new academic partnerships into the future and help to nurture a new breed of health informaticians. The theme is ‘Partnerships for Effective e-Health Solutions’, with a particular focus on how innovative collaborations can promote sustainable solutions to health challenges. It is well recognised that information and communication technologies have enormous potential for improving the health and lives of individuals. Innovative and effective change using such technologies is reliant upon people working together in partnerships to create innovative and effective solutions to problems with particular regard to contextual and environmental factors. The Congress seeks to bring together the health informatics community from across the globe to work together and share experiences and knowledge to promote sustainable solutions for health.
Three leading paediatric associations are uniting to host the 26th IPA Congress of Pediatrics in Johannesburg, South Africa from 4–9 August 2010. More than 5,000 participants are expected to attend this landmark event, the first IPA congress to be held in sub-Saharan Africa. It will unite paediatricians and health professionals working towards the target set by Millennium Development Goals (MDGs) to reduce child mortality by two thirds before 2015. The scientific programme is designed to meet the needs of general paediatricians from both the developed and the developing world. Plenary sessions will include: the MDGs and the current state of health of children in the world, and progress towards the MDGs; the state of the world’s newborns, including major issues determining maternal and newborn health in developing and developed countries; the determinants of health, such as genetics, nutrition and the environment; disasters and trauma affecting child health, such as disasters, crises and the worldwide epidemic of trauma; and the global burden of infectious diseases affecting children and the challenge of emerging infections.
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