Since the 2005 World Health Assembly resolution calling for member states to pursue universal health systems, there has been growing interest in how this can be achieved in low- and middle-income countries.
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) and financial protection from the cost of using health care. Universal coverage requires 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 EQUINET indicates that there is still a heavy dependence on external funding in some east and southern African (ESA) countries and heavy burdens on poor people through high levels of out of pocket financing.
A key impetus for the World Health Assembly resolution was the growing evidence on the extent to which households in many countries were being impoverished by having to pay for health care on an out-of-pocket (OOP) basis. This has led to an international consensus that prepayment health care financing mechanisms (tax funding and health insurance) should be the preferred sources of funds and that reliance on OOP payments should be reduced, if not completely eliminated. A number of ESA countries have removed user fees at some or all public sector facilities (e.g. South Africa, Uganda and Zambia). While there have been positive effects, such as dramatic increases in the use of public facilities particularly by poorer groups, this has been hard to sustain where there is inadequate funding of public facilities from tax revenue and/or grants from overseas development aid. This has meant that some facilities do not have medicines available and have too few staff to cope with the increased number of patients. Where this has occurred, patients have had to increasingly rely on private health services, paid for on an OOP basis and again face the possibility of impoverishment if costs were high relative to their income levels.
This experience has demonstrated that while it is critical to reduce out-of-pocket payments for health care, it is equally important to improve public funding of health services. This is particularly so, if we are to progress toward universal health systems that provide financial protection and access to needed health care for all. Although private health insurance is a form of prepayment financing, it does little to contribute to universal coverage in low- and middle-income countries. This is because very few people can afford the premiums for such insurance and only those who contribute benefit from the services funded by private insurance schemes. Instead, what is required is the creation of as large a pool of funds as possible that can be used to fund health services that will benefit the entire population. This can be achieved through allocations to the health sector from tax funds, which can be supplemented by mandatory (i.e. compulsory) health insurance contributions by those with the financial means to contribute in this way. Development aid funds can also contribute to this integrated pool of funds, but given the unreliability of external funding and that this source is unlikely to be sustainable in the long term, it is critical that the emphasis increasingly is placed on domestic public funding for health services.
For many years, we have been told that this is simply not possible. The reality is that unless we take steps to make increased domestic public funding of health care possible, we will never achieve universal health systems in Africa. What steps are required? There is a need to increase tax revenue. A number of African countries (including Kenya, South Africa and Uganda) have managed to dramatically increase tax revenue without increasing tax rates, through improved tax collection. Consideration is also being given by some countries to introduce new taxes whose burden falls on the wealthy (such as levies on foreign exchange transactions). Equally importantly, the allocations from tax revenue to the health sector should be increased. Most ESA countries are very far from the Abuja target of devoting 15% of government funds to the health sector. The ability of governments to allocate more funds to the health sector is enhanced greatly by debt relief. Malawi is one country that has made progress towards the Abuja target. This has occurred due to active lobbying by parliamentarians, who put forward a private members bill to secure a government commitment to move towards this target. From the Malawian experience, it is clear that it is important to emphasise that it was the Heads of State that signed the Abuja Declaration (rather than simply Ministers of Health). Many parliamentarians and government officials are unaware or ill-informed about the Abuja target. In addition to improved general tax funding of health services, mandatory health insurance contributions (which are often very similar to a dedicated health tax) could be introduced. The key lesson from other low- and middle-income countries, particularly in Latin America, is that it is critical to integrate general tax allocations for health and mandatory insurance contributions in a single pool of funds to be used for the benefit of the entire population if universal coverage is to be achieved.
While improved domestic public funding of health services will not happen overnight, we need to start moving in this direction as a matter of urgency. We need to understand better how countries have managed to improve their tax collection and how some have managed to successfully motivate for increased allocations to the health sector. We need to continue to mobilise for debt cancellation to free up limited domestic resources for funding social services. We need to protect our health systems from interventions promoted by international organisations that will take us further from achieving universal coverage (such as efforts to commercialise health care delivery and funding). We need to convince our policy-makers that universal health systems can only be achieved through improved domestic public funding of health services.
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 the Health Economics Unit website at http://heu-uct.org.za/ and the EQUINET website at www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
The third EQUINET regional conference was held in September 2009 and brought together parliamentarians, professionals, civil society members, policy makers, state officials, health workers and international agency personnel. It provided an opportunity to exchange across areas of work on different dimensions of health equity in east and southern Africa. The conference theme, ‘Reclaiming the Resources for Health: Building Universal People Centred Health Systems in East and Southern Africa’ was chosen to share experience and evidence on alternatives through which: poor people claim a fairer share of national resources to improve their health; a larger share of global and national resources are invested in redistributive health systems, to overcome the impoverishing effects of ill health; and countries in east and southern Africa (ESA) claim and obtain a more just return from the global economy, to increase the resources for health. The report follows the abstract book, also available on the EQUINET website, and provides the proceedings of the conference.
The Regional Meeting of Parliamentary Committees on Health in Eastern and Southern Africa, held in Munyonyo, Kampala, Uganda, 21 September 2009, gathered members of Parliamentary Committees responsible for health from 12 countries and regional bodies in Eastern and Southern Africa, with technical government and 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.
The fifteen-minute pre-recorded show, ‘Public healthcare financing’, was produced by WWMP, in conjunction with labour journalists in east and southern Africa. The show examined the lack of public health care financing in Africa in the context of health worker shortages, poor working conditions for health workers, provision of medicine for tuberculosis and AIDS, and poor access to care for patients (long queues, poor facilities, lack of equipment etc), as well as the impact of the current global economic crisis and neo-liberal government policies. The show discussed the purpose of the Abuja 15% target agreed by African heads of state, and financing mechanisms (tax funding and health insurance) appropriate to funding public health care.
The EQUINET steering committee has proposed to take forward the production of an Equity Watch at country and regional level to gather evidence on, analyse and promote dialogue on equity in the context of country and regional opportunities and challenges. It held a regional methods workshop in September to gather potential lead institutions of country teams and resource personnel to build on existing work done on the equity watch to date to develop the design and plan implementation of the equity watch work at country level in participating countries and at regional level. The workshop aimed to: review and agree on the purpose, intended targets, process and outcomes of an equity watch at country and regional level; discuss the questions about equity to be addressed, and the dimensions of equity to be included; review and agree on the parameters, indicators, targets/progress markers/stratifiers for the analysis and organisation of the analysis to address these questions/ dimensions; review types, quality and sources of evidence for the analysis; and discuss and set the next steps and roles for the work at country and regional level, including mentoring and regional review.
3. Equity in Health
The methodology of priority setting in health care has reached an advanced stage of development, but it is difficult to integrate public health and social interventions into the traditional cost effectiveness approach. Priority setting tends to be drawn towards cost-benefit rather than cost effectiveness analysis, a much more demanding methodology. Furthermore, analysis of equity requires modelling differential responses by subgroup, again increasing complexity. There has been some work by economists on how society values identical health gains for different population groups. In principle, this research can be used to adjust cost-effectiveness ratios for equity concerns. However, studies so far have been relatively small scale and tentative in their conclusions. Given the methodological challenges, policy makers (including the UK government) have developed a more pragmatic approach towards priority setting, in the form of descriptive health impact assessments. These are likely to be especially helpful when examining cross-departmental initiatives.
This report presents progress made since the last report in 2007, discusses how far the continent still needs to travel, at what speed, and what needs to be done further. It is an abridged version of a much more comprehensive joint Economic Commission for Africa (ECA), African Union Commission (AUC), and African Development Bank (AfDB) report to the July 2008 African Union Summit. The conditions for accelerating growth and development to meet the targets of the Millennium Development Goals (MDGs) are largely in place. Since the last report, the number of African countries with MDGs-consistent poverty reduction strategies or national development plans has risen to about 41. Growth, fueled in large measure by appropriate policy reforms, favourable primary product prices and a marked improvement in peace and security, notably in the west and south central regions remains strong. In 2007, for example, more than 25 African countries achieved a real GDP growth rate of 5% or above while another 14 grew at between 3 and 5%. However, the continent’s average annual growth rate of approximately 5.8% still remains significantly lower than the 7% annual growth rate required to reduce poverty by half by 2015. This growth is increasingly coming under threat from new developments. Rising food and oil prices, as well as climate change, pose significant risks to the preservation and acceleration of growth and to progress towards the targets of the MDGs in the region.
After a century of failed tuberculosis (TB) control strategies on South Africa’s mines, and three major but ineffective enquiries and commissions, a government-led ‘TB in Mines Task Team’ is being set up to address the deepening HIV-driven crisis. The HIV-fuelled TB epidemic, compounded by rising drug resistance, is now estimated at 3,500 per 100,000 mine workers, with 40% of all autopsies on men who die working on the mines revealing they had TB. Worker migration from rural areas throughout southern Africa to Gauteng and surrounding industrial areas to work in the mining, building and other dominant sectors is a major driver of the rampant TB epidemic. National TB prevalence has increased nearly threefold in the past decade. South Africa was among the 10 worst performing countries on TB control, and Statistics SA had found that, for every 100 deaths in 2006, 13 were from TB, making it the leading cause of death. Less than 1% of all HIV-infected individuals in this country were accessing proven safe and effective Isoniazid Preventative TB Therapy.
Global life expectancy could be increased by nearly five years by addressing five factors affecting health – childhood underweight, unsafe sex, alcohol use, lack of safe water, sanitation and hygiene, and high blood pressure, according to this report. These are responsible for one-quarter of the 60 million deaths estimated to occur annually. The report describes 24 factors affecting health, which are a mix of environmental, behavioural and physiological factors, such as air pollution, tobacco use and poor nutrition. More than a third of the global child deaths can be attributed to a few nutritional risk factors such as childhood underweight, inadequate breastfeeding and zinc deficiency. Eight risk factors alone account for over 75% of cases of coronary heart disease, the leading cause of death worldwide. These are alcohol consumption, high blood glucose, tobacco use, high blood pressure, high body mass index, high cholesterol, low fruit and vegetable intake and physical inactivity. Most of these deaths occur in developing countries.
Sub-Saharan Africa is off-track to achieve the Millennium Development Goals (MDGs) for maternal and child health by 2015. Each year 265,000 mothers die due to complications of pregnancy and childbirth, 1,243,000 babies die before they reach one month of age and a further 3,157,000 children die before their fifth birthday. Nevertheless, there is clear evidence demonstrating that progress can be achieved even in low-income countries. This evidence, together with the unprecedented new investments in maternal and child health from continental leaders and increasingly from development partners, offers new hope for the future. Improving health systems and promoting high impact interventions are crucial and require partnerships between scientists, health care providers with government, development partners, policy makers, civil society and communities. Four key actions include: further investment and tracking of resources; equitable implementation of programmes; innovation in research; and using evidence as a basis for health policy and resource allocation.
The most widely cited definition of health inequity is: ‘Health inequalities that are avoidable, unnecessary, and unfair are unjust.’ This paper argues that this definition is useful but in need of further clarification because it is not linked to broader theories of justice. It proposes an alternative, pluralist notion of fair distribution of health that is compatible with several theories of distributive justice, based on the principle of equality, which states that every person or group should have equal health except when health equality is only possible by making someone less healthy, or if there are technological limitations on further health improvement. In short, health inequalities that are amenable to positive human intervention are unfair. This principle is offset by the principle of fair trade-offs, which states that weak equality of health is morally objectionable if, and only if, further reduction of weak inequality leads to unacceptable sacrifices of average or overall health of the population, or if further reduction in weak health inequality would result in unacceptable sacrifices of other important goods, such as education, employment and social security.
The era of the Convention on the Rights of the Child has seen marked advances in child survival and development, expanded and consolidated efforts to protect children, and a growing recognition of the importance of empowering children to participate in their own development and protection. One of the most outstanding achievements in child survival and development has been the reduction in the annual number of under-five deaths, from 12.5 million in 1990 to less than 9 million in 2008. In particular, immunisation against major preventable diseases has been a life-saving intervention for millions of children in all regions of the world. However, Africa and Asia present the largest global challenges for child rights to survival, development and protection, with the regions of sub-Saharan Africa and south Asia well behind other regions on most indicators. Their progress in primary health care, education, and protection will be pivotal to accelerated progress on child rights and towards internationally agreed development goals for children.
4. Values, Policies and Rights
Twenty-four ex-miners are seeking compensation from Anglo-American after contracting silicosis, an incurable and fatal lung disease. In court papers, the 24 men allege that they contracted silicosis while in the employ of Anglo-American South Africa Ltd. The case is the first of its kind in South Africa. One of Britain’s leading personal injury and human rights law firms, Leigh Day & Co, is consulting for the Legal Resources Centre (LRC), which is representing the plaintiffs. ‘The litigation has two objectives. First, to compensate miners who contracted silicosis on the gold mines, and secondly, to deal with the problem of ex-miners whose health continues to be at risk of bouts of Tuberculosis,’ said Richard Meeran, a lawyer from Leigh Day & Co.
AIDS researchers, scientists and activists have welcomed the changes to South Africa's HIV and AIDS treatment policy, announced by President Jacob Zuma on World AIDS Day. The changes will mean antiretroviral (ARV) treatment can begin earlier for certain vulnerable groups, but stop short of raising the treatment threshold for all HIV-positive patients, as recommended by the World Health Organisation (WHO). Zuma said that from April 2010, all HIV-positive children under the age of one would be eligible for treatment, regardless of their CD4 count. Pregnant women living with HIV, and patients co-infected with tuberculosis (TB), will qualify for ARVs if their CD4 count falls to 350 or less. Pregnant HIV-positive women with higher CD4 counts will be given treatment from the 14th week of pregnancy to prevent mother-to-child transmission. Currently, treatment is only given in the final trimester. Zuma also committed the government to ensuring that all health facilities in the country are equipped to offer HIV counselling, testing and treatment. At present only health facilities accredited as ARV sites by the health department can administer ARVs, which has created bottlenecks and long waiting lists at some hospitals.
This report aims to show that the humanitarian challenge of the twenty-first century demands a step-change in the quantity of resources devoted to saving lives in emergencies and in the quality and nature of humanitarian response. The report recommends that governments, external funders, the United Nations and humanitarian agencies must ensure that humanitarian needs are properly assessed, and that aid is implemented impartially, while donor governments must increase the volume of humanitarian assistance. Governments, international humanitarian agencies and local civil society must recognise the limitations of providing relief and address the underlying causes of human vulnerability. International humanitarian agencies must work much more consistently to build states' capacity to discharge their responsibilities towards their citizens as well as citizens' capacity to demand that their rights are respected. Governments, acting both bilaterally and through multilateral organisations, also have a clear duty to support other states to realise the right to life and security through exerting diplomatic pressure, as well as by offering financial aid and technical assistance.
Members of the United Nations (UN) High Level Task Force on the Right to Development, which is reviewing different development initiatives using a set of criteria it developed, have said that ensuring the right to development should become more integral to debates over intellectual property (IP) policy. The World Intellectual Property Organization (WIPO) Development Agenda will play a crucial role in ensuring this integration if it happens, they added. It is ‘ironic that there is this gap between the fora that discuss intellectual property rights and [those that discuss] right to development. They follow an overlapping agenda in terms of substance,’ said Sakiko Fukuda-Parr, a member of the Task Force. ‘The core essence that levels of development need to be taken into account is still new to IP policy discussions,’ said Mohammed Gad, from the permanent mission of Egypt. WIPO should also pay more attention to its role as a UN agency, and therefore its responsibility to the Millennium Development Goals (MDGs), he said. In addition, WIPO should let the UN General Assembly, which is the guardian of the MDGs, know how the Development Agenda is progressing.
The World Wide Fund (WWF) has expressed its disappointment over the results of the Copenhagen Climate Summit and considered its results as ‘a gap between theory and application’. In a statement, it said: ‘The end of the summit does not mean the end, but fighting global warming requires political will to implement what was agreed upon’. Leader of the WWF Global Climate Initiative, Kim Carstensen, said: ‘They tell us it's over but it's not. The latest Copenhagen Accord draft mainly reproduced what leaders already promised before they arrived to the Danish capital. The biggest challenge, turning the political will into a legally binding agreement, after years of negotiations we now have a declaration of will which does not bind anyone and therefore fails to guarantee a safer future for next generations.’ He added: ‘A gap between the rhetoric and reality could cost millions of lives, hundreds of billions of dollars and a wealth of lost opportunities. We are disappointed but remain hopeful. Civil society will continue watching every step of further negotiations.’
5. Health equity in economic and trade policies
Macroeconomic stability, monetary and financial integration are crucial for successful regional cooperation and integration. Both processes make decisive contributions to the creation of a conducive environment for economic growth, promotion of trade and boosting of investor confidence, hence the importance of pursuing prudent fiscal, monetary, exchange rate and debt policies at the national level and of harmonising these policies at the subregional and regional levels. Arguably, these policies should be situated within the socio-political, technological and international development setting of the countries, and indeed of the continent at large. The strengthening and deepening of the financial sector, including the establishment of vibrant capital markets, will also greatly facilitate the flow of funds and help anchor macroeconomic policies. Moreover, strong national and subregional capital markets would play a catalytic role in attracting foreign direct investment and promoting cross-border investment flows. This report also provides a brief ‘progress report’ on the developments in Africa’s regional integration.
Leaders of the industrialised nations that attended the United Nations Climate Change Conference in December 2009 have produced a revised draft agreement, which they hope will break a deadlock between rich and developing countries that threatens to scuttle the talks. The new draft has stronger emission targets, more robust language supporting poverty eradication and clarifies the importance of the science of climate change in the accord. It also recognises the equal right of all nations to ‘access to atmospheric space.’ The accord states that only developing countries that accept financial support for their reduction projects have to accept international monitoring and verification of their reductions. In the draft, all nations would agree to cut emissions globally by 50% below 1990 levels as. Industrialised countries would agree to reduce their emissions ‘individually or jointly’ by 80% by 2050. The draft accord also commits developing countries to emission reductions, but only in the context of future development.
The Economic Report on Africa 2009 is organized into two parts. Part I examines global economic developments and their implication for Africa, analyses recent economic and social trends and highlights emerging development challenges to the continent in 2008. Part II is devoted to the issue of regional value chain development and starts with a discussion in chapter 4 of the need to address challenges to developing African agriculture in the context of the Comprehensive African Agriculture Development Programme (CAADP) of the African Union’s New Partnership for Africa’s Development (AU/NEPAD). The report focuses on the question of how to enhance structural transformation of African agriculture through systematic efforts to develop regionally integrated value chains and markets for selected strategic food and agricultural commodities. Finally, the report urges African governments to operationalise commitments to develop agriculture, and suggests strategies that promote viable value chains at the national and regional levels.
The aim of this paper is to enable African, Caribbean and Pacific (ACP) countries to understand how trade policy related to the environment has been introduced in economic partnership agreements (EPAs), and how those policies might impact sustainable development in ACP countries. Some of the issues for ACPs examined by the paper include a discussion of the difficulties of managing and coordinating the various regional groupings in the negotiations, the potential complementarities and conflicts with other existing international agreements (multilateral environmental agreements and WTO agreements), the challenges related to the implementation of new environmental standards, and the settlement of disputes as well as the strengthening of environmental capacities. The main conclusion of the paper is that the incorporation of environmental provisions within the EPAs may present some benefits to ACP countries. However, ACP countries will need appropriate packages of technical assistance, capacity building, and environmental cooperation to meet this new environmental agenda in their trade agreements.
The High-Level United Nations Conference on South-South Cooperation, which was held from 1–3 December in Nairobi, Kenya, encouraged developing countries – with support from developed countries and international organisations – to take concrete steps to make their cooperative efforts work better in tackling the serious challenges they faced in achieving socio-economic advancement. The conference highlighted the growing political and economic ties within the developing world as countries of the global South assumed leading roles in handling global issues ranging from economic recovery to food security and climate change. By adopting the final text of the Conference – known formally as the Nairobi Outcome Document – the participants recognised the increasing power of South-South cooperation over the past few decades. The document urges United Nations funds, programmes and specialised agencies to take concrete measures to support South-South cooperation.
The recent successful renewal of the mandate of the World Intellectual Property Organization Intergovernmental Committee on Intellectual Property and Genetic Resources, Traditional Knowledge and Folklore (IGC) has inspired attempts to push discussion on biodiversity out of other fora. The World Trade Organization TRIPS discussions and the November 2009 meeting of the UN Convention on Biological Diversity specifically dedicated to traditional knowledge heard proposal that all legal issues related to traditional knowledge should be dealt with by the World Intellectual Property Organization.
6. Poverty and health
In order to ameliorate poverty among tuberculosis (TB) sufferers, a few initiatives to support patients with TB have been made in KwaZulu-Natal, South Africa, including free treatment at government hospitals and clinics, and nutritional supplementation and social grants. Although these programmes have been functioning for a number of years, they have never been formally assessed in terms of the costs involved, the effects on the target populations, and the responses of patients. A recent study in Brazil (Belo et al, 2006) investigated a range of support strategies for patients with TB that included material and financial assistance, improved health services support and better administrative organisation – from the patient's perspective. Such a study has not been undertaken in South Africa, however, and given the large amount of money spent on support to TB patients, this is necessary to better inform such programmes.
This study examined child disability screening and its association with nutrition and early learning in countries with low and middle incomes. Cross-sectional data for the percentage of children screening positive for or at risk of disability were obtained for 191,199 children aged 2–9 years old in 18 countries. Screening results were descriptively analysed according to social, demographic, nutritional, early-learning and schooling variables. A median 23% of children aged 2–9 years old screened positive for disability. For children aged 2–4, screening positive for disability was significantly more likely in children who were not breastfed and who did not receive vitamin A supplements. Children aged 6–9 who did not attend school screened positive for disability more often than did children attending school. These results draw attention to the need for improved global capacity to assess and provide services for children at risk of disability. Further research on childhood disabilities is needed in countries with low and middle incomes to understand and address the role of nutritional deficiencies and restricted access to learning opportunities.
In a statement, the Commonwealth Association of Paediatric Gastroenterology and Nutrition (CAPGAN) calls for maternal, neonatal and child health to be more closely linked to improve child survival from HIV, diarrhoea and malnutrition. Colleges of Health Sciences, Nursing and Medicine should become important backbones of maternal and child health systems, through education and implementation research, and through training and retaining of their staff in HIV, diarrhoea and malnutrition in the widest sense. The statement presents that leadership, collaboration and country-capacity support, development of evidence-based guidelines and systems must be stimulated, to ensure coverage and monitoring of equity and progress in achieving Millennium Development Goals 4 and 5.
Up to half of all children presenting to nutrition rehabilitation units (NRUs) in Malawi are infected with HIV. This study aimed to identify features suggestive of HIV in children with severe acute malnutrition (SAM). All 1,024 children admitted to the Blantyre NRU between July 2006 and March 2007 had demographic, anthropometric and clinical characteristics documented on admission. HIV status was known for 904 children, with 445 (43%) seropositive and 459 (45%) seronegative. Associations were found for the following signs: chronic ear discharge, lymphadenopathy, clubbing, marasmus, hepato-splenomegally and oral candida. Any one of these signs was present in 74% of the HIV seropositive and 38% of HIV-uninfected children. HIV-infected children were more stunted, wasted and anaemic than uninfected children. In conclusion, features commonly associated with HIV were often present in uninfected children with SAM, and HIV could neither be diagnosed nor excluded using these. The study recommends HIV testing be offered to all children with SAM where HIV is prevalent.
Rotavirus gastroenteritis is a major health problem among Malawian children. Studies spanning 20 years have described the importance, epidemiology and viral characteristics of rotavirus infections in the country. Despite a wide diversity of circulating rotavirus strains causing severe disease in young infants, a clinical trial of a human rotavirus vaccine clearly demonstrated the potential for rotavirus vaccination to greatly reduce the morbidity and mortality due to rotavirus diarrhoea in Malawi. This new enteric vaccine initiative represents a major opportunity to improve the health and survival of Malawian children.
More than 178 million children are currently suffering from chronic malnutrition, which contributes to a third of all child deaths globally. According to this report, a total of £150 would give a hungry child the right kind of food and support to stop them from dying from malnutrition and protect their brains and bodies from being permanently damaged by hunger. Half of the world’s hungry children live in just eight countries: Afghanistan, Bangladesh, the Democratic Republic of Congo (DRC), Ethiopia, India, Kenya, Sudan and Vietnam. The Hungry for Change report reveals that it would cost £5.25 billion a year to combat child hunger in these countries and dramatically reduce the number of children who are stunted or malnourished.
Eight nutrition studies from rural Malawi are discussed in this paper. Their aims were various, for example, to describe typical growth pattern of children, analyse occurrence and determinants of undernutrition and evaluate a community-based nutritional intervention for malnourished children in rural Malawi; to determine the timing of growth faltering among under three-year-old children; to characterise the timing and predictors of malnutrition; and to compare the effect of maize and soy flour with that of ready-to-use food in the home treatment of moderately malnourished children. Some of the findings of the studies included: growth of children under three years old followed an age-dependent seasonal pattern; intrauterine period and the first six months of life are critical for the development of stunting, whereas the subsequent year is more critical for the development of underweight and wasting; supplementation with 25 to 75 g/day of highly fortified spread (FS) is feasible and may promote growth and alleviate anaemia among moderately malnourished infants; and one-year-long complementary feeding with FS does not have a significantly larger effect than micronutrient-fortified maize–soy flour on mean weight gain in all infants, but it is likely to boost linear growth in the most disadvantaged individuals and, hence, decrease the incidence of severe stunting. In a poor food-security setting, underweight infants and children receiving supplementary feeding for twelve weeks with ready-to-use FS or maize–soy flour porridge show similar recovery from moderate wasting and underweight. Neither intervention, if limited to twelve-week duration, appears to have significant impact on the process of linear growth or stunting.
7. Equitable health services
This paper reviews the costs and cost-effectiveness of vaccination programme interventions involving lay or community health workers (LHWs). Articles were retrieved if the title, keywords or abstract included terms related to 'lay health workers', 'vaccination' and 'economics'. Reference lists of studies assessed for inclusion were also searched and attempts were made to contact authors of all studies included in the Cochrane review. Of the 2,616 records identified, only three studies fully met the inclusion criteria, while an additional 11 were retained as they included some cost data. There was insufficient data to allow any conclusions to be drawn regarding the cost-effectiveness of LHW interventions to promote vaccination uptake. Studies focused largely on health outcomes and did illustrate to some extent how the institutional characteristics of communities, such as governance and sources of financial support, influence sustainability. Further studies on the costs and cost-effectiveness of vaccination programmes involving LHWs should be conducted, and these studies should adopt a broader and more holistic approach.
An unsafe environment is a risk factor for child injury and violence. Among those injuries that are caused by an unsafe environment, the accidental ingestion of corrosive substances is significant, especially in developing countries where it is generally underreported. By reviewing current literature and field trials from developing countries, the authors of this study developed a flowchart for management of this clinical condition. Timely admission was observed in 19.5% of 148 patients studied. A gastrostomy was performed on 62.1% of patients, 42.8% had recurrent strictures and 19% were still on a continuous dilatation programme. Perforation and death rate were respectively 5.6% and 4%. The majority of oesophageal caustic strictures in children are observed late, when dilatation procedures are likely to be more difficult and carry a significantly higher recurrence rate.
Asthma is the eighth leading contributor to the burden of disease in South Africa, but has received less attention than other chronic diseases. This audit of asthma care targeted all primary care facilities that managed adult patients with chronic asthma within all six districts of the Western Cape Province. The usual steps in the quality improvement cycle were followed. Data was obtained from 957 patients from 46 primary care facilities. Only 80% of patients had a consistent diagnosis of asthma, 11.5% of visits assessed control and 23.2% recorded a peak expiratory flow (PEF), 14% of patients had their inhaler technique assessed and 11.2% a self-management plan. In conclusion, the availability of medication and prescription of inhaled steroids is reasonable and yet control is poor. Health workers do not adequately distinguish asthma from chronic obstructive pulmonary disease, do not assess control by questions or PEF, do not adequately demonstrate or assess the inhaler technique and have no systematic approach to or resources for patient education. Ten recommendations are made to improve asthma care.
This study assessed whether home-based HIV care was as effective as was facility-based care. It undertook a cluster-randomised equivalence trial in Jinja, Uganda. Forty-four geographical areas in nine strata, defined according to ratio of urban and rural participants and distance from the clinic, were randomised to home-based or facility-based care by drawing sealed cards from a box. The trial was integrated into normal service delivery. Of the total patients, 859 patients (22 clusters) were randomly assigned to home and 594 (22 clusters) to facility care. During the first year, 93 (11%) receiving home care and 66 (11%) receiving facility care died, 29 (3%) receiving home and 36 (6%) receiving facility care withdrew, and 8 (1%) receiving home and 9 (2%) receiving facility care were lost to follow-up. Mortality rates were similar between groups, and 97 of 857 (11%) patients in home and 75 of 592 (13%) in facility care were admitted at least once. In conclusion, this home-based HIV-care strategy is as effective as is a clinic-based strategy, and therefore could enable improved and equitable access to HIV treatment, especially in areas with poor infrastructure and access to clinic care.
Many practitioners may dismiss systems thinking as too complicated or unsuited for any practical purpose or application. But many developing countries are looking to scale-up ‘what works’ through major systems strengthening investments. With leadership, conviction and commitment, systems thinking can accelerate the strengthening of systems better able to produce health with equity and deliver interventions to those in need. Systems thinking does not mean that resolving problems and weaknesses will come easily or naturally or without overcoming the inertia of the established way of doing things. But it will identify, with more precision, where some of the true blockages and challenges lie. It will help to: explore these problems from a systems perspective; show potentials of solutions that work across sub-systems; promote dynamic networks of diverse stakeholders; inspire learning; and foster more system-wide planning, evaluation and research.
Using case studies, the authors of this study collated and analysed practical examples of operational research projects on health in sub-Saharan Africa that demonstrate how the links between research, policy and action can be strengthened to build effective and pro-poor health systems. Three operational research projects met the case study criteria: HIV counselling and testing services in Kenya; provision of TB services in grocery stores in Malawi; and community diagnostics for anaemia, TB and malaria in Nigeria. The authors found that building equitable health systems means considering equity at different stages of the research cycle. Partnerships for capacity building promotes demand, delivery and uptake of research. Links with those who use and benefit from research, such as communities, service providers and policy makers, contribute to the timeliness and relevance of the research agenda and a receptive research-policy-practice interface. The study highlights the need to advocate for a global research culture that values and funds these multiple levels of engagement.
The overarching aim of this study was to develop a GIS-based planning approach that contributes to equitable and efficient provision of urban health services in cities in sub-Saharan Africa. The broader context of the study is the 'urban health crisis'; a term that refers to the disparity between the increasing need for medical care in urban areas against the declining carrying capacity of existing public health systems. The analysis illustrates how more sophisticated GIS-based analytical techniques can be usefully applied in support of strategic spatial planning of urban health services delivery. The study offers two frameworks for analysis. Its evaluation framework appraises the performance of the existing Dar es Salaam governmental health delivery system on the basis of generic quantitative accessibility indicators, while its intervention framework explores how existing health needs can better be served by proposing alternative spatial arrangements of provision using scarce health resources. When used together, these two planning instruments offer a flexible framework with which health planners can formulate and evaluate alternative intervention scenarios and deal with the most important problems involved in the spatial planning of urban health services.
8. Human Resources
Throughout the world, countries are experiencing shortages of health care workers. Policy-makers and system managers have developed a range of methods and initiatives to optimise the available workforce and achieve the right number and mix of personnel needed to provide high-quality care. The literature review for this study found that such initiatives often focus more on staff types than on staff members' skills and the effective use of those skills. The study describes evidence about the benefits and pitfalls of current approaches to optimisal roles of health workers in health care. It concludes that health care organisations must consider a more systemic approach – one that accounts for factors beyond narrowly defined human resources management practices and includes organisational and institutional conditions.
This commentary paper highlights changing patterns of outward migration of Zambian nurses. The aim is to discuss these pattern changes in the light of policy developments in Zambia and in receiving countries. Prior to 2000, South Africa was the most important destination for Zambian registered nurses. In 2000, new destination countries, such as the United Kingdom, became available, resulting in a substantial increase in migration from Zambia. This is attributable to the policy of active recruitment by the United Kingdom's National Health Service and Zambia's policy of offering voluntary separation packages. The dramatic decline in migration to the United Kingdom since 2004 is likely to be due to increased difficulties in obtaining United Kingdom registration and work permits. Despite smaller numbers, enrolled nurses are also leaving Zambia for other destination countries, a significant new development. This paper stresses the need for nurse managers and policy-makers to pay more attention to these wider nurse migration trends in Zambia, and argues that the focus of any migration strategy should be on how to retain a motivated workforce through improving working conditions and policy initiatives to encourage nurses to stay within the public sector.
The WHO Secretariat has redrafted the code of practice in order to take into account, as requested, the views and comments expressed by members of the Board in January 2009 and the outcome of the subsequent sessions of the regional committees. Two core themes identified by the regional committees and incorporated in the revised draft code were that member states should strive to achieve a balance between the rights, obligations and expectations of source countries, destination countries and migrant health personnel, and that international health worker migration should have a net positive impact on the health system of developing countries and countries with economies in transition. The revised draft text emphasises that international health personnel should be recruited in a way that seeks to prevent a drain on valuable human resources for health. It also recommends that countries should abstain from active international recruitment of health personnel unless equitable bilateral, regional, or multilateral agreement(s) exist to support such recruitment activities.
This report is a summary of six years of investigation into migration policy and practice. Its findings indicate that, for migration to have its full developmental impact, the most beneficial policy change would be to reduce barriers to migration, at all levels and particularly for the poorest. This paper examines the changing dynamics of migration, impacts of migration on poverty and livelihoods, new initiatives in international migration, and how the findings in relation to the development of policy on migration. It found that poor people are more likely to move over shorter distances, either within or between poor countries, and where poor people have a greater choice in terms of migration destinations, the net effect on inequality is more likely to be positive. In addition, skilled migration is largely a symptom, not a cause, of underdevelopment. Diaspora engagement can contribute to the development of countries of origin, but this is a highly politicised arena.
This paper found that, until recently, researchers and policymakers paid little attention to the role of health workers in developing countries but a new generation of studies are providing a fuller understanding of these issues using more sophisticated data and research tools. Recent research highlights the value of viewing health workers as active agents in dynamic labour markets who are faced with many competing incentives and constraints. Newer studies have provided greater insights into human resource requirements in health, the motivations and behaviours of health workers, and health worker migration. The authors note that they are encouraged by the progress but believe there is a need for even more, and higher-quality, research on this topic.
9. Public-Private Mix
This paper describes the changes in utilisation of health services that occurred among the poor and those in rural areas in Uganda between 2002/3 and 2005/6 and associated factors. Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset-based index derived from principal components analysis (PCA). The study found that the rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access. The risk of not seeking care due to high costs did not change significantly. Poor people, females, rural residents and those from elderly headed households were more likely to use public facilities relative to private for-profit (PFP) providers. Although overall utilisation of public and private not-for-profit (PNFP) services by rural and poor populations had increased, PFP providers remained the major source of care. Policy makers should consider targeting subsidies to the poor and rural populations. Public-private partnerships should be broadened to increase access to health services among the vulnerable.
10. Resource allocation and health financing
According to this brief, aid effectiveness refers to how effective aid is in achieving expected outputs and stated objectives of aid interventions. In contrast, the brief observes, aid actors are also interested in development effectiveness, a term which lacks clarity leaving it open to considerable scope for interpretation. The brief suggests four categories to help in understanding the term development effectiveness: as organisational effectiveness; as coherence or coordination; as the development outcomes from aid; and as overall development outcomes. The latter overlaps with other understandings of the term but is the most comprehensive approach of the four categories. Here, it is seen as a measure of the overall development process, and not just the outcomes from aid. The brief recommends that a successful agenda on development effectiveness should depend on concerted efforts between developing country governments and official aid funders basing on their willingness to reformulate the current effectiveness agenda, and that the creation of a development effectiveness agenda will require a level of agreement on the operational meaning of the term.
The idea of a Tobin tax is suddenly popular amongst many who have long opposed it. The United Kingdom’s Prime Minister, Gordon Brown, has even come out in favour of the tax and the G20 have asked for further research to be done in this area. But this interest from the dominant institutions and governments running the global economy could act to prevent discussion on other much-needed reform. So what lies behind the interest in a Tobin tax? One response is that it is quite simply a good idea. It has the potential to raise billions of dollars and would help control a finance industry that has floated free of ideas of needing to benefit wider society. A second response then to what lies behind the talk of a Tobin tax is that while it would be a radical reform, it may be a politically handy ‘trick’ to cover the lack of even more radical reform. Institutions like the International Monetary Fund (IMF) and Gordon Brown could see implementing the Tobin tax as a useful way of escaping a deeper scrutiny of the flaws in the global economy and how it is run. Meanwhile, the unequal system that perpetuates ill-health and poverty continues.
The national health insurance (NHI) plan, due for legislation in June 2010, will be phased in one facility at a time over the next five years, costing higher income earners more (via a payroll tax) but in no way limiting their choice of provider. That was the assurance given by the chair of the NHI Ministerial Advisory Committee, Dr Olive Shisana, who said the incremental accreditation of healthcare facilities was to ensure the delivery of quality health care based on agreed standards. The Ministerial Advisory Committee of 24 experts drawn from the entire healthcare spectrum, is required to deliver draft proposals on NHI legislation to Health Minister Dr Aaron Motsoaledi by March 2010. Public input will happen as soon as cabinet approves the policy proposals, so that the ensuing and legally required three-month consultation process can be completed in time for Motsoaledi’s review. That would leave just enough time for legal crafting for presentation to parliament by June 2010.
This article addresses considerations about resource use and costs. The consequences of a policy or programme option for resource use differ from other impacts (both in terms of benefits and harms) in several ways. However, considerations of the consequences of options for resource use are similar to considerations related to other impacts in that policymakers and their staff need to identify important impacts on resource use, acquire and appraise the best available evidence regarding those impacts, and ensure that appropriate monetary values have been applied. The article suggests four questions that can be considered when assessing resource use and the cost consequences of an option: What are the most important impacts on resource use? What evidence is there for important impacts on resource use? How confident is it possible to be in the evidence for impacts on resource use? Have the impacts on resource use been valued appropriately in terms of their true costs?
In early 2009, the Ugandan health ministry made an emergency appeal to the Global Fund for $8.9 million to purchase ARVs for three months as an advance on $70 million awarded in Round Seven of its grants, but the world body could only offer $4.25 million in June 2009. The Global Fund was forced to cut funding by 10% in 2008. A recent World Bank report advised nations heavily reliant on foreign aid to prepare for any impending cash and drug shortages by implementing early warning systems, and work to avoid treatment interruptions as far as possible. Health minister, Stephen Mallinga, said it would be virtually impossible to expand ARV programmes. ‘We would rather sustain those that have started the treatment ... because the ramifications ... [of not accessing drugs] are grave, including resistance to drugs and therefore a requirement to change the combination ... which will lead to an increase in our treatment bill, which we cannot afford,’ he said. AIDS activists are concerned that funding woes will make it impossible for Uganda to achieve universal access to treatment, in other words, giving drugs to at least 80% of people who need them.
This study set out to examine how health aid is spent and channelled, including the distribution of resources across countries and between subsectors. It aimed to complement the many qualitative critiques of health aid with a quantitative review and to provide insights on the level of development assistance available to recipient countries to address their health and health development needs. A quantitative analysis of data from the Aggregate Aid Statistics and Creditor Reporting System databases of the Organisation for Economic Co-operation and Development was carried out. The analysis shows that while health official development assistance (ODA) is rising and capturing a larger share of total ODA, there are significant imbalances in the allocation of health aid, which run counter to internationally recognised principles of ‘effective aid’. Countries with comparable levels of poverty and health need receive remarkably different levels of aid. Although political momentum towards aid effectiveness is increasing at global level, some very real aid management challenges remain at country level.
11. Equity and HIV/AIDS
In what is being hailed as a boost for African involvement in AIDS research, Uganda has been selected to host the African AIDS Vaccine Programme (AAVP), formerly based in Geneva, Switzerland. The AAVP, a network of African HIV vaccine stakeholders whose mission is to promote HIV vaccine development for Africa, has operated under the stewardship of the World Health Organization's department of immunization vaccines and biologicals since its formation in 2000. The transition to a fully functional African programme began more than a year ago and will be completed in 2010. The Uganda Virus Research Institute (UVRI), a leading research institute based in Entebbe, will be its new headquarters.
This annual report examines evidence of progress in four key areas in 2008: prevention of mother-to-child transmission (PMTCT), paediatric HIV care and treatment, prevention of HIV among adolescents and young people, and protection and support for children affected by HIV and AIDS. The most significant progress was in PMTCT, with 45% of HIV-positive pregnant women globally receiving antiretroviral (ARV) treatment to prevent them passing HIV to their children; up from 24% in 2006. Several countries with high HIV prevalence expanded PMTCT coverage to most pregnant women needing treatment: 73% in South Africa, 91% in Namibia and 95% in Botswana. Other countries lagged behind: for example, in Nigeria only 10% of pregnant women with HIV were tested and treated to prevent transmission to their babies. The countries most successful at scaling up PMTCT incorporated their programmes into existing maternal and child health services, the report noted. The authors conclude that in the near future, it is not impossible to envisage a generation of children who are free of HIV.
Thanks to the international recession, the author argues that external funders are either decreasing or opting not to increase their funding of AIDS treatment. Medecins Sans Frontieres (MSF) recently reported that two key international programmes supporting AIDS treatment in the developing world are not increasing their grants: For two successive years the Global Fund Against AIDS, Tuberculosis and Malaria has reduced funding for approved grants, while the American President’s Emergency Plan for AIDS Relief (PEPFAR) is now practicing what it calls ‘flat-funding’, which ‘basically means that you can only recruit when someone dies, when someone empties a seat or a treatment slot’, as explained by Dr Erci Goemaere, co-ordinator of MSF missions in South Africa and Lesotho. The authors warn that a funding crisis could lead to the reversal of gains made since the start of antiretroviral treatment in developing countries.
This study took the form of a systematic review and meta-analysis of randomised trials of directly observed versus self-administered antiretroviral treatment. Duplicate searches of databases were conducted, as well as searchable websites of major HIV conferences and lay publications and websites, to identify randomised trials assessing directly observed therapy to promote adherence to antiretroviral therapy in adults. Twelve studies met the inclusion criteria. Four of these were done in groups that were judged to be at high risk of poor adherence (drug users and homeless people). Ten studies reported on the primary outcome – the study calculated a pooled relative risk of 1.04, and noted moderate heterogeneity between the studies for directly observed versus self-administered treatment. The study found that directly observed antiretroviral therapy seems to offer no benefit over self-administered treatment, which calls into question the use of such an approach to support adherence in the general patient population.
Conflation of HIV and alcohol disease in African settings is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.
In a bid to reduce the rate of HIV transmission from mother to child, Uganda will now give all pregnant women highly active antiretroviral therapy (HAART). Second deputy Prime Minister, Kirunda Kivejinja, said the government was committed to scaling up interventions that prevent HIV infections in children by improving prevention of mother-to-child transmission (PMTCT) services. ‘We shall also ensure scale-up of access to services for early infant HIV testing and treatment, and for care and support for all children that are affected by HIV,’ he added. ’We have proven that when pregnant women receive HAART, the rate of transmission from mother to child is less than 2%; this should go full-scale in Uganda,’ Addy Kekitiinwa, executive director of the Baylor Uganda Children's Foundation, said. A recent Ugandan study of 1,829 women found a 1.67% infection rate among infants born to mothers who received HAART during pregnancy, compared with an 11.75% infection rate among infants whose mothers received single-dose Nevirapine, and 3.73% and 5.02% of those who received two types of combination therapy.
New data presented at the IAS Conference for 2009 is already having an impact on HIV policy and practice on a global scale. Results of several basic research studies provided the field with a better understanding of the elevated HIV infection risk among African women due to chronically activated T-cells in genital tract mucosa, how complex genetic variables may affect HIV acquisition and disease progression, and how early antiretroviral therapy (ART) can substantially reduce the size of latent HIV reservoirs, a significant clinical issue in chronic HIV infection. Findings demonstrating that maternal triple-drug ART used throughout pregnancy and breastfeeding reduced vertical transmission to 1% are expected to inform revised World Health Organization (WHO) and South African national guidelines on antiretroviral prophylaxis. Also, research delineating the impact of antiretroviral therapy on reducing coincident tuberculosis and malaria epidemics in HIV-prevalent regions argued for wider and earlier access to treatment.
The Kenyan government has launched an ambitious HIV campaign to test at least one million people across the country over a three-week period. The programme is the first step in a national campaign that intends to test 10 million people by June 2010. According to the 2007 Kenya AIDS Indicator Survey, 80% of HIV-positive adults in the country do not know their status. The initiative, dubbed ‘Jitambue leo, ni haki yako’, Swahili for ‘Know yourself today, it is your right’, was launched on 23 November in the Kenyan capital, Nairobi. ‘We want to target everybody in our campaigns...no group is safe; the youth are becoming increasingly vulnerable, the old initially thought of as safe are equally at risk, and those in marriage account for 50% of new infections,’ said Dr Nicholas Muraguri, head of the National AIDS and Sexually transmitted infection Control Programme. ‘Infants and unborn children benefit too when their parents are tested.’
The world needs a dramatic change in thinking – and action from external funders, policymakers, and programme managers in the public, private and nongovernmental (NGO) sectors – to focus on strengthening health systems in the countries most affected by HIV and AIDS. To meet the Millennium Development Goal of reversing the epidemic by 2015, stakeholders must change how services are designed and delivered. A lesson learned in the 1990s and 2000s was that a host of separate activities cannot be scaled up in a sustainable way and that strengthening health systems is essential for long-term sustainability. The time has come to take a systems approach to HIV & AIDS programming. This holistic approach will create a strong foundation by focusing all efforts on integration, effectiveness and sustainability.
The Scorecard rates countries on their reporting of six key elements in an AIDS response tuned to the needs of women, including the collection of HIV data specific to women; progress in ensuring that women have equal access to HIV services; and the impact of national responses on reducing infections among women and facilitating their access to treatment. The overall score reflects the extent of data provided on each element. Countries with the highest HIV burdens were doing the best job of reporting data detailing their female-centred AIDS efforts, with 67% earning a high rating. However, the authors noted that a high score for reporting did not necessarily reflect good performance in delivering HIV services for women. Relatively good reporting by South Africa, for example, contrasted with a poor record in improving the maternal mortality of HIV-positive women, or curbing high rates of violence against women. There was also a disturbing lack of data on the situation of young girls, and what countries were doing to address their particular vulnerabilities.
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12. Governance and participation in health
This case study describes a multisectoral adolescent sexual and reproductive health (ASRH) programme with three main components: clinical youth-friendly health services (YFHS), inschool interventions and community-based outreach. It has been written for programme and project managers at national, district and local levels interested in the implementation and scale-up of multisectoral programmes that encompass YFHS. It outlines the process used to design, implement, monitor and evaluate the Geração Biz programme in Mozambique. The steps taken during the pilot phase and subsequent scale-up of the programme are described, as well as key lessons learned. This case study is intended to provide an example of how to design and implement a multisectoral programme that is intended to be scaled up from the beginning. Although other countries have different political, social and cultural contexts, the experience and lessons learned here could be adapted and applied to help other countries that wish to establish or scale up YFHS within multisectoral programmes.
Despite several years of implementation, prevention of mother-to-child transmission (PMTCT) programmes in many resource poor settings are failing to reach the majority of HIV positive women. This study reports on a data-driven participatory quality improvement intervention implemented in a high HIV prevalence district in South Africa. The intervention consisted of an initial assessment undertaken by a team of district supervisors, workshops to assess results, identify weaknesses and set improvement targets and continuous monitoring to support changes. Routine data revealed poor coverage of all programme indicators except HIV testing. One year following the intervention, large improvements in programme indicators were observed. Coverage of CD4 testing increased from 40 to 97%, uptake of maternal nevirapine from 57 to 96%, uptake of infant nevirapine from 15 to 68% and six week polymerase chain reaction (PCR) testing from 24 to 68%. It is estimated that these improvements in coverage could avert 580 new infant infections per year in this district.
The University of Oxford's Global Economic Governance Programme has launched an independent Expert Taskforce on Global Knowledge Governance to propose a set of principles and options for the future of global knowledge governance. The Taskforce's Honorary Advisors emphasised the scope of global knowledge governance challenges at hand. The Taskforce will be led by a small, core team of experts participating in a personal capacity, supported by several distinguished Honorary Advisors. The Taskforce will consult widely, interviewing a diversity of academics, policy experts, and stakeholder communities around the world. The report will be peer-reviewed by a group of leading international scholars working on the intersection of issues covered in the study. The findings of the Taskforce will be published in late 2010 and presented to governments, relevant international organisations, stakeholders and academics working to shape how the future of global knowledge governance unfolds.
Policy briefs are a relatively new approach to packaging research evidence for policymakers. Drawing on available systematic reviews makes the process of mobilising evidence feasible in a way that would not otherwise be possible if individual relevant studies had to be identified and synthesised for every feature of the issue under consideration. This article suggests questions that can be used to guide those preparing and using policy briefs to support evidence-informed policymaking: Does the policy brief address a high-priority issue and describe the relevant context of the issue being addressed? Does the policy brief describe the problem, costs and consequences of options to address the problem, and the key implementation considerations? Does the policy brief employ systematic and transparent methods to identify, select, and assess synthesised research evidence? Does the policy brief take quality, local applicability, and equity considerations into account when discussing the synthesised research evidence? Does the policy brief employ a graded-entry format? Was the policy brief reviewed for both scientific quality and system relevance?
Increasing interest in the use of policy dialogues has been fuelled by a number of factors, such as recognition that: there is a need for locally contextualised 'decision support' for policymakers and other stakeholders; research evidence is only one input into the decision-making processes of policymakers and other stakeholders; having many stakeholders can add significant value to these processes; and many stakeholders can take action to address high-priority issues, and not just policymakers. This article suggests questions to guide those organising and using policy dialogues to support evidence-informed policymaking: Does the dialogue address a high-priority issue? Does the dialogue provide opportunities to discuss the problem, options to address the problem, and key implementation considerations? Is the dialogue informed by a pre-circulated policy brief and by a discussion about the full range of factors that can influence the policymaking process? Does the dialogue ensure fair representation among those who will be involved in, or affected by, future decisions related to the issue? Are outputs produced and follow-up activities undertaken to support action?
This article addresses strategies to inform and engage the public in policy development and implementation. The importance of engaging the public (both patients and citizens) at all levels of health systems is widely recognised. They are the ultimate recipients of the desirable and undesirable impacts of public policies, and many governments and organisations have acknowledged the value of engaging them in evidence-informed policy development. The potential benefits of doing this include the establishment of policies that include their ideas and address their concerns, the improved implementation of policies, improved health services, and better health. Public engagement can also be viewed as a goal in itself by encouraging participative democracy, public accountability and transparency. The article suggests three questions that can be considered with regard to public participation strategies: What strategies can be used when working with the mass media to inform the public about policy development and implementation? What strategies can be used when working with civil society groups to inform and engage them in policy development and implementation? What methods can be used to involve consumers in policy development and implementation?
This essay begins by describing various areas of volunteering, such as volunteering to build social capital and skills-based volunteering, where volunteers offers specific skills, such as medical skills. It goes on to outline the benefits of volunteering. Volunteering contributes to the development agenda by strengthening the voice of civil society organisations so they can influence policy, both at local and national levels, for the promotion of sustainable development and the improvement of livelihood security. Volunteering also helps to support communities to participate in development at local and national levels, as well as support communities to gain access to resources for local development and the improvement of essential services and to respond effectively to the HIV pandemic through programmes of prevention, care and support. Volunteering can support communities to realise their human rights, especially those of women and children.
13. Monitoring equity and research policy
This paper aims to assess current priority setting methods and the extent to which they adequately include health policy and systems research (HPSR) and to draw out lessons regarding how HPSR priority setting can be enhanced to promote relevant HPSR and to strengthen developing country leadership of research agendas. Priority setting processes can be distinguished by the level at which they occur, their degree of comprehensiveness in terms of the topic addressed, the balance between technical versus interpretive approaches and the stakeholders involved. When HPSR is considered through technical, disease-driven priority setting processes it is systematically under-valued. More successful approaches for considering HPSR are typically nationally driven, interpretive and engage a range of stakeholders. There is still a need however for better defined approaches to enable research funders to determine the relative weight to assign to disease specific research versus HPSR and other forms of cross-cutting health research. While country-level research priority setting is key, there is likely to be a continued need for the identification of global research priorities for HPSR. The paper argues that such global priorities can and should be driven by country level priorities.
Performance targets for global TB control were first formulated in 1991 at the 44th World Health Assembly. National TB control programmes were encouraged to achieve CDRs of at least 70% and cure rates in excess of 85%. However, even in situations where both targets were reached and achievements sustained, incidence rates failed to decline as predicted. The vast differences that exist between endemic and non-endemic areas (in other words, case density) and the impact this has on transmission dynamics within communities are rarely appreciated. Most source cases have fairly fixed circles of social interaction. This implies that once the majority of close contacts have been infected, the risk of infecting new people may decline even though the source case remains highly infectious. This phenomenon is referred to as transmission saturation. There is a need to reconsider the accuracy and applicability of current mathematical models and to identify pragmatic ways of quantifying additional factors that may be at play in endemic areas. The incorporation of case density and transmission saturation in future mathematical models may assist.
This article addresses considerations of equity. Policies or programmes that are effective can improve the overall health of a population. However, the impact of such policies and programmes on inequities may vary: they may have no impact on inequities, they may reduce inequities, or they may exacerbate them, regardless of their overall effects on population health. Four questions are proposed as useful to guide equity analysis: Which groups or settings are likely to be disadvantaged in relation to the option being considered? Are there plausible reasons for anticipating differences in the relative effectiveness of the option for disadvantaged groups or settings? Are there likely to be different baseline conditions across groups or settings such that that the absolute effectiveness of the option would be different, and the problem more or less important, for disadvantaged groups or settings? Are there important considerations that should be made when implementing the option in order to ensure that inequities are reduced, if possible, and that they are not increased?
This article addresses the use of evidence to inform judgements about the balance between the pros and cons of policy and programme options. It suggests five questions that can be considered when making these judgements: What are the options that are being compared? What are the most important potential outcomes of the options being compared? What is the best estimate of the impact of the options being compared for each important outcome? How confident can policymakers and others be in the estimated impacts? Is a formal economic model likely to facilitate decision making?
This article addresses the issue of decision making in situations in which there is insufficient evidence at hand. Policymakers often have insufficient evidence to know with certainty what the impacts of a health policy or programme option will be, but they must still make decisions. The article suggests four questions that can be considered when there may be insufficient evidence to be confident about the impacts of implementing an option: Is there a systematic review of the impacts of the option? Has inconclusive evidence been misinterpreted as evidence of no effect? Is it possible to be confident about a decision despite a lack of evidence? Is the option potentially harmful, ineffective or not worth the cost?
The term monitoring is commonly used to describe the process of systematically collecting data to inform policymakers, managers and other stakeholders whether a new policy or programme is being implemented in accordance with their expectations. Indicators are used for monitoring purposes to judge, for example, if objectives are being achieved, or if allocated funds are being spent appropriately. Sometimes the term evaluation is used interchangeably with the term monitoring, but the former usually suggests a stronger focus on the achievement of results. When the term impact evaluation is used, this usually implies that there is a specific attempt to try to determine whether the observed changes in outcomes can be attributed to a particular policy or programme. This article suggests four questions that can be used to guide the monitoring and evaluation of policy or programme options: Is monitoring necessary? What should be measured? Should an impact evaluation be conducted? How should the impact evaluation be done?
This article discusses three questions: What is evidence? What is the role of research evidence in informing health policy decisions? What is evidence-informed policymaking? Evidence-informed health policymaking is an approach to policy decisions that aims to ensure that decision making is well-informed by the best available research evidence. It is characterised by the systematic and transparent access to, and appraisal of, evidence as an input into the policymaking process. The overall process of policymaking is not assumed to be systematic and transparent. However, within the overall process of policymaking, systematic processes are used to ensure that relevant research is identified, appraised and used appropriately. These processes are transparent in order to ensure that others can examine what research evidence was used to inform policy decisions, as well as the judgements made about the evidence and its implications. Evidence-informed policymaking helps policymakers gain an understanding of these processes.
This article addresses ways of organising efforts to support evidence-informed health policymaking. Efforts to link research to action may include a range of activities related to the production of research that is both highly relevant to – and appropriately synthesised for – policymakers. Such activities may include a mix of efforts used to link research to action, as well as the evaluation of such efforts. The article suggests five questions that can help guide considerations of how to improve organisational arrangements to support the use of research evidence to inform health policy decision making: What is the capacity of your organisation to use research evidence to inform decision making? What strategies should be used to ensure collaboration between policymakers, researchers and stakeholders? What strategies should be used to ensure independence as well as the effective management of conflicts of interest? What strategies should be used to ensure the use of systematic and transparent methods for accessing, appraising and using research evidence? What strategies should be used to ensure adequate capacity to employ these methods?
Regardless of whether the support for evidence-informed policymaking is provided in-house or contracted out, or whether it is centralised or decentralised, resources always need to be used wisely in order to maximise their impact. Examples of undesirable practices in a priority-setting approach include timelines to support evidence-informed policymaking being negotiated on a case-by-case basis (instead of having clear norms about the level of support that can be provided for each timeline), implicit (rather than explicit) criteria for setting priorities, ad hoc (rather than systematic and explicit) priority-setting process, and the absence of both a communications plan and a monitoring and evaluation plan. This article suggests questions that can guide those setting priorities: Does the approach to prioritisation make clear the timelines that have been set for addressing high-priority issues in different ways? Does the approach incorporate explicit criteria for determining priorities? Does the approach incorporate an explicit process for determining priorities? Does the approach incorporate a communications strategy and a monitoring and evaluation plan?
A number of constraints have hindered the wider use of systematic reviews in policymaking, including a lack of awareness of their value and a mismatch between the terms employed by policymakers when attempting to retrieve systematic reviews, and the terms used by the original authors of those reviews. Mismatches between the types of information that policymakers are seeking, and the way in which authors fail to highlight (or make obvious) such information within systematic reviews have also proved problematic. This article suggests three questions that can be used to guide those searching for systematic reviews, particularly reviews about the impacts of options being considered: Is a systematic review really what is needed? What databases and search strategies can be used to find relevant systematic reviews? What alternatives are available when no relevant review can be found?
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14. Useful Resources
With the goal of improving health service delivery on a global scale, this new portal offers a one-stop-shop where users can efficiently search for, organise, adapt and use up-to-date, evidence-based health information. The portal features a search tool, powered by Google Search Appliance, that enables users to quickly find resources from select sources, including the K4Health site, a range of health databases, and top quality health web sites, in addition to the web. Toolkits are available to give users access to specialised collections of resources on family planning, reproductive health, and population and environment. A toolkit application has also been supplied that allows users to design, develop, and share their own toolkits. Discussion forums have been set up to provide users with access to a community of experts around the world.
The Africa4All project will provide the participating African countries of Kenya, Lesotho, Namibia, Tanzania and Uganda with an information and communication technologies (ICT) solutions that will enable citizens and politicians to better appreciate the impact of legislation, making the complex political debate meaningful and interesting for all citizens. The overall objective of the Africa4All project is to help African, Caribbean and Pacific (ACP) governments build sustainable capacity to adapt and implement international good practice in leveraging ICT in Parliaments of ACP States. The specific objectives of the project are to educate members of Parliament, Parliamentary ICT staff and citizens to leverage technology to support collaboration and active engagement in decision making processes in society, to identify the challenges and barriers from the introduction of ICT in everyday functioning of Parliaments and to contribute to the bridging the digital divide, enhancing the use of ICT as key enablers for poverty reduction.
Debates and struggles over how to define a problem are a critically important part of the policymaking process. The outcome of these debates and struggles will influence whether and, in part, how policymakers take action to address a problem. Efforts at problem clarification that are informed by an appreciation of concurrent developments are more likely to generate actions. These concurrent developments can relate to policy and programme options (e.g. the publication of a report demonstrating the effectiveness of a particular option) or to political events (e.g. the appointment of a new Minister of Health with a personal interest in a particular issue). This article suggests questions that can be used to guide those involved in identifying a problem and characterising its features: What is the problem? How did the problem come to attention and has this process influenced the prospect of it being addressed? What indicators can be used, or collected, to establish the magnitude of the problem and to measure progress in addressing it? How can the problem be framed (or described) in a way that will motivate different groups?
Policymakers and those supporting them may find themselves in a number of situations that will require them to characterise the costs and consequences of options to address a problem. For example, a decision may already have been taken and their role is to maximise the benefits of an option, minimise its harms, optimise the impacts achieved for the money spent, and (if there is substantial uncertainty about the likely costs and consequences of the option) to design a monitoring and evaluation plan. Research evidence, particularly about benefits, harms, and costs, can help to inform whether an option can be considered viable. This article offers questions that can be used to guide policymakers: Has an appropriate set of options been identified to address a problem? What benefits and harms are important to those who will be affected? What are the local costs of each option, including cost-effectiveness? What adaptations might be made? Which stakeholder views and experiences might influence an option's acceptability and its benefits, harms and costs?
Evidence about local conditions is evidence that is available from the specific setting(s) in which a decision or action on a policy or programme option will be taken. Such evidence is always needed, together with other forms of evidence, in order to inform decisions about options. Global evidence is the best starting point for judgements about effects, factors that modify those effects, and insights into ways to approach and address problems. But local evidence is needed for most other judgements about what decisions and actions should be taken. This article suggests five questions that can help to identify and appraise the local evidence that is needed to inform a decision about policy or programme options: What local evidence is needed to inform a decision about options? How can the necessary local evidence be found? How should the quality of the available local evidence be assessed? Are there important variations in the availability, quality or results of local evidence? How should local evidence be incorporated with other information?
After a policy decision has been made, the next key challenge is transforming this stated policy position into practical actions. What strategies, for instance, are available to facilitate effective implementation, and what is known about the effectiveness of such strategies? This article suggests five questions that can be considered by policymakers when implementing a health policy or programme: What are the potential barriers to the successful implementation of a new policy? What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes among healthcare recipients and citizens? What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes in healthcare professionals? What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary organisational changes? What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary systems changes?
Now in its third phase, the Municipal Services Project (MSP) is exploring and evaluating models of service delivery that are deemed to be successful alternatives to commercialisation, in an effort to understand the conditions required for their sustainability and reproducibility. The focus is on the water, electricity and primary health care sectors in Africa, Asia and Latin America. The project is composed of academic, labour, NGO and social movement partners from around the world. The site features a diversity of publications and materials, from academic journal articles to video and audio documentaries. MSP is an inter-sectoral and inter-regional research project that systematically explores alternatives to the privatisation and commercialisation of service provision in the health, water, sanitation and electricity sectors. Having spent the first two phases of the project (2000-2007) critiquing privatisation, this phase of the project (2008-2013) will analyse service delivery models that are successful alternatives to commercialisation in an effort to better understand the conditions required for their sustainability and reproducibility. The website for the project has been updated and provides new resources on this issue.
15. Jobs and Announcements
Africa has a new continental body, the African Governance Institute (AGI), based in Dakar, Senegal. AGI interim director, Georges Nzongola-Ntalaja, explained that the main ‘added-value’ of the Institute is ‘to institutionalise African reflection on governance in Africa […] because we think that it is important that the people who live the realities of African societies and African states are better placed to understand what is going on and to propose solutions for a better future.’ He announced that AIG will convene a series of Conferences in 2010, including one with Liberian President Ellen Johnson-Sirleaf on democracy and human rights ‘...to make this added-value a reality.’ The AGI’s programme of action was formally launched at an inaugural workshop on 3-4 November in Dakar. On 24 November, the AGI and ECDPM signed a Memorandum of Understanding for a strategic partnership, which aims to enhance both organisations’ work in supporting the African Governance Architecture and enhancing the dialogue strategies and development support of Africa’s European partners.
Abstract submission for IPA 2010 is still open. Participants wishing to propose papers for oral or poster presentations are invited to submit their abstracts via the Congress website address given here. Abstracts should be limited to 250 words. Topics include: child health and survival; Millennium Development Goals; neurology; cardiology; dermatology; endocrinology, diabetes, obesity and adolescent medicine; genetics, congenital anomalies; infectious diseases; allergy and immunology; development, neurodevelopmental disability and other long term outcome studies; pulmonology; nephrology; nutrition, gastroenterology and metabolism; pharmacology; neonatology; haematology and oncology; education and training; paediatric surgery and surgical sub-specialties; and miscellaneous topics. Only abstracts of authors who have paid their registration fees by 31 March 2010 will be scheduled and included in the final programme.
Carleton University’s Centre for Media and Transitional Societies (CMTS), in collaboration with Canada’s International Development Research Centre (IDRC), is launching a call for concept notes, in French or English, outlining proposed research examining the impact of convergence between traditional radio and new information and communications technologies (ICTs) in sub-Saharan Africa. Ultimately, the purpose of this competitive research project is both to generate important research and to support African researchers in their efforts to produce rigorous and analytical social science research findings on the ways that radio and the growth and penetration of new ICTs, such as mobile phones, the Internet and other digital technologies, have affected social, cultural, political and economic development. All interested applicants are required to submit a concept note outlining a synopsis of a proposed research idea. Based on the assessment of the concept notes, shortlisted applicants will be invited to submit a full proposal in early 2010.
UNITAID is a global health initiative, established to provide sustainable, predictable and additional funding to significantly impact on market dynamics to reduce prices and increase the availability and supply of high quality medicines, diagnostics and related commodities for the treatment of HIV/AIDS, malaria and tuberculosis, primarily for populations in low-income and lower-middle income countries. This is a transparent "call for interest" from individuals wishing to apply for membership of their Proposal Review Committee ("PRC"); an independent, impartial team of experts tasked with providing technical expertise to UNITAID on proposals and related projects submitted to UNITAID for funding. Details of how to submit an application are at http://www.unitaid.eu/en/Requests-for-proposals-RFP.html with individual TORs and expertise criteria.
HEARD at the University of KwaZulu-Natal, Durban, South Africa is offering to support up to 12 young researchers by linking you to an international academic mentor who will support your writing of an article for submission for publication. If you are a young researcher (35 or under on 1st January 2010), resident in the SADC and EAC region and have exciting and original research on universal access to prevention, treatment, care and support, now is your chance to submit an article to a reputable peer reviewed international journal. Submissions need to include the application form (available on the website address given below) and a 10,000-word paper on a topic engaging with universal access. Papers should be no longer than 10,000 words and must be written in English. All disciplines may submit papers on universal access but topics should focus on social science, humanities or economics issues. Bio-medical topics will not be considered for support. Based on regional priorities, particular attention will be given to papers on issues faced by women – including sexual and reproductive health and rights; prevention topics in general and topics of health and economics.
The MA or Masters in Participation, Power and Social Change (MAP), offered by the University of Sussex, United Kingdom, is an 18-month programme providing experienced development workers and social activists with the opportunity to critically reflect on their practice and develop their knowledge and skills while continuing to work or volunteer for most of this period. The MA combines academic study, practical experience and personal reflection. Students carry out an action research project related to their work, inquiring into the challenges of participation and power relations, reflecting on their actions and assumptions, and exploring what it means to facilitate change. Designed for development workers and social change activists, this course combines academic study, practical experience and personal reflection. Students are able to continue with their work or volunteering activities while pursuing an MA degree, which includes a 12-month period of work-based learning in which they carry out an inquiry into their own practice. IDS is seeking interested people with at least three to five years of experience to join the October 2010 intake.
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.
A growing group of health advocates and activists are engaging to promote during 2010 issues relating to accountability and transparency, within a rights and responsibilities approach in health. In common cause, in a collective vow of non-silence, all agree to speak up and voice concerns of questionable practices by both authorities and civil society. According to a petition circulated by the group, they are calling for greater accountability and transparency from institutions, organizations, and individuals in public sector health services.
With the recent establishment of two separate World Health Organization (WHO)/Stop TB task forces – one on ethics and the other on human rights – a number of issues have been raised that should have wider input. This survey is the first of a series of quick questionnaires to 'Take the Pulse' of the broad based tuberculosis (TB) community – patients, professionals, programmers and public in affected communities – on ethical and rights issues. The World Care Council invites individuals to fill in the questionnaire on the World Care Council website.
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