The Trade Related Aspects of Intellectual Property Rights (TRIPs) Agreement of the World Trade Organisation came into effect on 1 January 1995 and set standards for intellectual property systems. Least Developed Countries (LDCs) have until 2016 to bring their systems into line with TRIPS for pharmaceutical patents. Five years may seem a long time. But how far have we come in the 15 years since the agreement was passed?
One of the most important steps taken after the agreement was the successful advocacy at the WTO Ministerial conference in Doha in 2001 to include flexibilities in the TRIPs agreement so poorer countries could address their public health crises, especially given the AIDS epidemic. Paragraph 17 of the Doha Declaration provided that the TRIPS Agreement be interpreted in a manner supportive of public health by promoting access to existing medicines. The flexibilities provided for compulsory licensing or the right to grant a license, without permission from the license holder; for parallel importation or the right to import products patented in one country from another country where the price is less; for exceptions from patentability and limits on data protection and for early working, known as the Bolar Provision, allowing generic producers to conduct tests and obtain health authority approvals before a patent expires, making cheaper generic drugs available more quickly at that time. The World Health Organisation (WHO) in its 2008 Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, urged for these flexibilities to be implemented in national laws and international agreements, including facilitating, through export, access to pharmaceutical products in countries with insufficient or no manufacturing capacity.
Nine years after Doha, a review of legislation shows that the intellectual property regimes in place in many east and southern African (ESA) countries have not been significantly changed. Patenting laws in many countries (eg Botswana and DRC) were passed before the TRIPS agreement or Doha round. Some (such as Zimbabwe and Zambia) already provided for the flexibilities, but some still have gaps, such as in South Africa, where flexibilities enabling production and export of medicines to the region are still to be enacted. Some countries, such as Kenya, have enacted new laws providing for flexibilities, while in others (such as Uganda and Namibia), these proposals still remain in draft form. While WTO provides for countries to provide the TRIPS Council with "as much information as possible on their individual priority needs for technical and financial cooperation in order to assist them in taking steps necessary to implement the TRIPS Agreement, " so far in ESA only Uganda has taken this step. LDCs in ESA do not have to give exclusive marketing rights to pharmaceuticals that are subject of a patent application until 1 January 2016, but it is unclear how many countries have yet conducted self-assessments to prepare negotiating positions for possible extension of this waiver.
Even those ESA countries that have the flexibilities in their laws are not fully implementing them. They face a number of constraints. Most ESA countries lack domestic pharmaceutical research and manufacturing capacities and have insufficient technical and infrastructural capacities to effectively regulate medicines. Countries have weaknesses in their pharmaceutical management and procurement systems, and in accessing pricing and patent status information. Countries also face economic and political pressures. Stronger property rights (including of intellectual property) is urged as necessary for foreign direct investment and countries face trade and investment pressures not to use the TRIPS flexibilities.
African configurations are at various stages of negotiating comprehensive Economic Partnership Agreements with the European Union, for example. While the underlying 2000 Cotonou Agreement does not oblige ESA countries to negotiate IPR rules and aims for “co-operation” in the field of IPRs, the overall intention of the agreement is to protect intellectual property rights. EU business seeks to open new markets for its exports and this includes protecting intellectual property, given the heavy involvement of EU companies in research and development. The African Growth and Opportunities Act (AGOA (2000) has unilaterally extended market access to ESA countries, with one of the requirements for eligibility being that the country should commit itself to eliminating barriers to US trade and investment by “protecting intellectual property rights,” and desist from interfering in the economy through measures such as price controls, subsidies and government ownership of economic assets. Most recently, anti-counterfeit laws, such as those passed in Kenya, under debate in Uganda and effected through amendments to existing law in Tanzania, while seeking to prevent the damage caused by fake medicines, have the potential to limit the legal production and distribution of generic medicines. When Anti-Counterfeit Laws define a counterfeit as a good that is identical or substantially similar to a good protected under an intellectual property right, they appear in effect to include legal generic products. It seems these states have not designed their anti-counterfeit laws to adequately take into account the protection of TRIPS flexibilities.
A lack of vigilance to protecting the ground won at Doha is now apparent in a new problem. The 2001 public health related aspects of the TRIPS flexibilities now have to be formally adopted at the World Trade Organisation. For this two thirds of countries need to propose the formal adoption. By December 2009, according to the WTO (http://www.wto.org/english/tratop_e/trips_e/amendment_e.htm), only Mauritius and Zambia in ESA had added their names to this proposal. In other words the ESA countries have not added their names to the critical mass needed to enable a formal adoption of the protocol amending the TRIPS agreement at the WTO. This formal adoption should have been implemented by December 2007. The deadline was extended to December 2009, and on 17th December 2009, WTO members agreed to a second extension to December 2011. It is important for ESA countries to now formally propose adoption to avoid the unnecessary renegotiation of these critical amendments to the TRIPs agreement.
Advances can never be taken for granted in a rapidly changing world, and neither can the five year period we have left before TRIPS is fully enforced, for us to put in place a self determined legal, institutional and investment environment for drug manufacture and procurement in ESA countries. For now there is an urgent need for all ESA countries to endorse the protocol on the TRIPS amendments that the flexibilities are entrenched. In the next five years we still appear to have much to do to take advantage of the flexibilities through our laws, policies and capacities, including with respect to the production and export of medicines within the region, and to set the terms for discussions on intellectual property regimes (IPRs) with trade and development partners in a manner that puts us in a stronger position to produce and procure medicines and to protect public health. Our national health strategic plans in ESA should all include clear roadmaps of how we will effectively use the next five years to achieve this.
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 SEATINI website at http://seatini.org/ and the EQUINET website at www.equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
The workshop on participatory approaches to people centred health systems was held on the 22nd of September 2009 in Munyonyo Uganda before the EQUINET regional Conference held at the same venue on 23rd -25th of September 2009. This gave participants from the workshop an opportunity to engage with the wider regional community working on health equity, but also to feed input from the participatory work into the conference process and resolutions. The regional review workshop gathered researchers from the PRA research programme since 2005. The workshop reviewed the learning from, policy issues and knowledge gaps from the research studies, to inform planning of future work on empowerment and health and on people centred health systems in the ESA region and to explore the role of PRA approaches and community photography in advancing health equity. The workshop gathered those who had led the studies, community photographers and others involved with work on empowerment and health. This report documents the proceedings of the meeting.
This regional methods workshop was held to gather potential lead institutions of country teams and resource personnel to build on existing work done on the Equity Watch to date and 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
By framing human health and wellbeing in the context of an ecosystems approach, this paper recognises that healthy people and healthy environments are inextricably linked. However, in most African countries, there is still inadequate assessment and monitoring of the dynamics of human activities and their impact on local ecosystems and this paper notes that the degradation of ecosystem services constitutes an important barrier to achieving Millennium Development Goals. It urges governments to recognise the links between environment and health, from the perspective of the vital services that ecosystems provide to human health and wellbeing, and to promote integrated policies that value these services. Solutions require political commitment, concerted action and shared responsibility between different government sectors and the civil society. Countries should take steps to mitigate the underlying causes of ecosystem damage, while simultaneously improving human health. Intersectoral collaboration among government departments and the civil society, capacity-building, dissemination of knowledge and good practices, and integrated action for health and the environment are also critical.
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.
The Students and Youths Working on Reproductive Health Action Team (SAYWHAT) hosted 60 students from 30 tertiary institutions during its 4th National Students Conference from the 16th to the 18th of December 2009 under the theme 'Healthy Students for a Prosperous Nation' Through presentations, parallel sessions and group discussions, the conference covered major areas of sexual and reproductive health rights (SRHR) for young people. Among the key issues that came out was the need for a universal curriculum on SRHR for tertiary institutions. The delegates also reiterated that there is a need for clear monitoring and evaluation and coordination of SRHR programs within tertiary institutions. In light of the risk posed by multiple and concurrent partnerships, they called for behavioural change amongst all students and a focus on life skills and livelihoods training to sustain the change. Generally there was a call for commitment among all students, college authorities and SAYWHAT’s membership for more effective responses that addresses the real health challenges in tertiary institutions.
Over the past ten years, frequent outbreaks of emerging and re-emerging infectious diseases and mosquito-borne diseases have occurred in Africa. Electric and electronic waste (e-waste) is also a fast-growing concern. There have been significant radiation incidents reported, and new and more toxic substances (dioxins, furans and heavy metals) are creating environmental and health problems and new occupational risks in Africa. According to this paper, the management of hazardous wastes must focus on environmentally sound treatment and/or long-term storage. It notes that a renewed and stronger commitment to the implementation of the Stockholm Convention on Persistent Organic Pollutants is needed. African governments may wish to consider including the following actions: monitoring of new and emerging environmental threats; reviewing their emergency preparedness plans; developing and implementing awareness-raising campaigns on the most important risks factors; and undertaking community sensitisation and education.
This publication covers a number of areas relevant to indigenous people around the world. Chapter 5 deals specifically with health. It points out that the commitment of United Nations Member States to the Millennium Development Goals (MDGs) is an important step forward in improving the health of millions of people who live in poverty around the world. However, by failing to ground the goals in an approach that upholds indigenous peoples’ individual and collective rights, the MDGs fall short in addressing the health disparities that persist between indigenous peoples and other poor, marginalised groups. By advancing the dominant paradigms of health and development rather than an approach based on individual and collective human rights, the MDGs also promote projects that are potentially detrimental to indigenous peoples, and which violate their rights to their collective land, territories and natural resources. Moreover, because the cultures and worldviews of indigenous peoples are not taken into account in the formulation of the MDGs, the goals do not consider the indigenous concept of health, which extends beyond the physical and mental well-being of an individual to the spiritual balance and well-being of the community as a whole. To improve the health situation of indigenous peoples, this report notes that there must thus be a fundamental shift in the concept of health so that it incorporates the cultures and world views of indigenous peoples as central to the design and management of state health systems.
The authors of this paper propose a pluralist notion of fair distribution of health that is compatible with several theories of distributive justice. It consists of the weak principle of health equality and the principle of fair trade-offs. The weak principle of health equality offers an alternative definition of health equity to those proposed in the past. It maintains the all-encompassing nature of the popular Whitehead/Dahlgren definition of health equity, and at the same time offers a richer philosophical foundation. This principle states that every person or group should have equal health except when: health equality is only possible by making someone less healthy, or there are technological limitations on further health improvement. In short, health inequalities that are amenable to positive human intervention are unfair. The principle of fair trade-offs 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 further reduction in weak health inequality would result in unacceptable sacrifices of other important goods, such as education, employment, and social security.
Unsafe water bodies, poor access to safe drinking water, indoor and outdoor air pollution, unhygienic or unsafe food, poor sanitation, inadequate waste disposal, absent or unsafe vector control, and exposure to chemicals and injuries have been identified as key environmental risks to human health in most countries in Africa. The underlining reasons for this situation include inadequate or flawed policies, weak institutional capacities, shortage of resources and low general awareness of links between the environment and health. This paper suggests that governments re-orient their national policies to foster a greater contribution of environmental management towards public health. Specifically, governments may consider creating national frameworks and mechanisms for inter-sectoral action to adequately address the links between health and the environment, invest in the required infrastructure related to health and environmental services, build from past and current experiences, revitalise expertise in environmental management for health, and increase communication and community education to raise awareness of how individual practices can impact upon human health and the environment.
4. Values, Policies and Rights
Despite the increased efforts of the international community, including civil society, in promoting sound, equitable, humane and lawful conditions of migration, migrants continue being exposed to commoditisation and human rights violations. Building on recommendations by the Committee on Migrant Workers, December 18 strongly recommends that all states implement gender-sensitive legislation that extends the protections of international labour standards to migrant workers. It also calls on Governments to curb abuses of recruitment agencies, enhance legal channels for migration and open up judicial mechanisms to victims of abuse, regardless of their immigration status. The situation of migrant children also remains a particular concern, especially those who are unaccompanied and at risk of being smuggled or trafficked. All migrants are protected by human rights and labour standards, including the International Convention for the Protection of the Rights of All Migrant Workers and Members of their Families, regardless of immigration status. Migrant children—whether accompanied or not and whatever their migratory status—are equally entitled to all the rights under the Convention on the Rights of the Child. December 18 urges all states to ratify and implement the International Convention for the Protection of the Rights of All Migrant Workers and Members of their Families, which will celebrate its 20th anniversary in 2010.
More than two-thirds of African countries have laws criminalising homosexual acts and, despite accounting for a significant percentage of new infections in many countries, men who have sex with men tend to be left out of the HIV response. '[They] are going underground; they are hiding themselves and continuing to fuel the epidemic,' said UNAIDS executive director, Michél Sidibé. 'We need to make sure these vulnerable groups have the same rights everyone enjoys: access to information, care and prevention for them and their families.' Human rights violations against gays include a number of countries in east, southern and central Africa, such as Malawi, Uganda – which recently tabled the Anti-homosexuality Bill – and Tanzania, where more than 40 gay and lesbian activists in Tanzania were arrested in 2009. And in South Africa, in April 2008, Eudy Simelane, the openly gay star of South Africa's Banyana Banyana national female football squad, was found murdered in a park on the outskirts of Johannesburg. She had been gang-raped and brutally beaten before being stabbed to death. Since then there has been a spate of similar attacks on lesbians in the country, but few ever reach the courts and only one prosecution has been successful.
In the generalised epidemics of HIV in southern Sub-Saharan Africa, men who have sex with men have been largely excluded from HIV surveillance and research. Epidemiologic data for MSM in southern Africa are among the sparsest globally, and HIV risk among these men has yet to be characterised in the majority of countries. A cross-sectional anonymous probe of 537 men recruited with non-probability sampling among men who reported ever having had sex with another man in Malawi, Namibia, and Botswana using a structured survey instrument and HIV screening with the OraQuick© rapid test kit. The HIV prevalence among those between the ages of 18 and 23 was 8.3%; 20% among those 24–29; and 35.7% among those older than 30 for an overall prevalence of 17.4%. In multivariate logistic regressions, being older than 25 and not always wearing condoms during sex were significantly associated with being HIV-positive. Human rights abuses were prevalent, with 42.1% reporting at least one abuse. Concurrency of sexual partnerships with partners of both genders may play important roles in HIV spread in these populations. Further epidemiologic and evaluative research is needed.
The cultures of indigenous peoples have frequently been ignored when global standards on intellectual property have been set, says a new United Nations report, The State of the World's Indigenous People. It notes that global intellectual property (IP) standards are mainly based on Western legal and economic principles that emphasise private ownership of knowledge and resources. Such principles, it says, 'stand in stark contrast to indigenous worldviews, whereby knowledge is created and owned collectively and the responsibility for the use and transfer of the knowledge is guided by traditional laws and customs.' As a result, IP rules leave 'most indigenous traditional knowledge and folklore vulnerable to appropriation, privatisation, monopolisation and even biopiracy by outsiders,' the report says. Some indigenous peoples believe, the report says, that the World Intellectual Property Organization is 'not an appropriate forum to set standards because it is limited by its mandate to promoting intellectual property rights as the only viable path to protecting traditional knowledge'.
Over the past two decades, legislative and regulatory frameworks have been developed that address links between the environment and health. However, the extent to which these instruments have been streamlined within existing national legislation has not been formally documented and, according to this paper, these instruments are not currently deployed or adequately equipped, notably in Africa. It reveals weaknesses in the international and national regulatory mechanisms and their implementation, and brings to light institutional and operational deficiencies and a dramatic lack of capacity to manage hazardous wastes in an environmentally sound manner. It points to the need for an integrated institutional framework addressing human health and the environment. The Revised International Health Regulations (2005), now being implemented in all African countries, should provide a more cohesive approach to health and environment risk management. Despite the many efforts undertaken by African countries, the level of awareness and understanding of these environmental agreements among country-level policy makers remains limited.
The Kenyan government has created the first ever tribunal to handle legal issues relating to HIV, including discrimination against people living with HIV and protecting the confidentiality of medical records. The new tribunal, under the office of the Attorney General, has the status of a subordinate court, with the right to summon witnesses and take evidence. It will handle issues relating to the transmission of HIV, confidentiality, testing, access to healthcare services, discriminatory acts and policies, and HIV-related research. Networks of people living with HIV have welcomed the formation of the new court. 'Setting up the tribunal is the clearest indication by the government that it is ready to entrench the rights of people living with HIV,' said Nelson Otuoma, chairperson of the Network Empowerment of People Living with AIDS. 'It is, however, important to let people know that the tribunal exists and further educate them on the roles and mandates of it.' Those living with HIV hope the tribunal will be an effective tool in ending discrimination, and groups like Otuoma's are already compiling lists of grievances to present to it.
Confidential documents related to the World Health Organization (WHO) Expert Working Group on Innovative Financing for Research and Development have been leaked to the public, apparently revealing improper participation by the pharmaceutical industry in preparing WHO policy. The documents appear to have come from the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), and include draft reports on innovative financing mechanisms from the working group as well as an analysis by the IFPMA on the reports’ contents. 'IFPMA was not supposed to have working drafts of the expert working group in their possession and they were not given these documents,' said Precious Matsoso, director of Public Health Innovation and Intellectual Property (PHI) at WHO, under whose auspices the expert working group falls. 'It was understood by the working group that its report is intended for the director general and WHO members [only],' she added. Public health advocates reacted strongly to the leaked documents, raising issues of public accountability and transparency in policymaking.
In this letter to Kenya's minister for public health, Human Rights Watch (HRW) has called on the Kenyan government to ensure that human rights are protected during the country's national door-to-door voluntary HIV testing and counselling drive. 'We... urge the inclusion of a strong human rights component into this ambitious testing programme. In particular, we are calling for clear attention to principles of counselling, consent and confidentiality,' it said. HRW noted that large-scale home-based testing would likely result in better access to testing and treatment and give a chance to those who could not afford the transport costs to health facilities or lacked information or the willingness to seek a test. But testing also reached into the family, where many abuses occurred, posing challenges for human rights protection, it added. 'Our research on access to testing and treatment in Kenya has shown that HIV-positive mothers and HIV-positive children frequently suffer stigma and abuse when their status becomes known,' the letter said. 'HIV-positive mothers – among them girls under the age of 18 – sometimes suffer violence, mistreatment, disinheritance and discrimination from their husbands, families-in-law or their own families.'
This paper discusses a number of important policy frameworks for addressing health and environmental challenges, such as the 1992 United Nations Conference on Environment and Development in Rio de Janeiro (also known as the Earth Summit), the Millennium Development Goals (Goals 4, 5 and 6), the Johannesburg Plan of Implementation for the World Summit on Sustainable Development, the Strategic Approach to International Chemicals Management (SAICM) and the New Partnership for Africa’s Development (NEPAD)’s Human Resources Development Initiative, which urges the integration of health and environment policies. In many African countries, national health-sector policies have been developed separate from those on environment. Planning and service delivery also takes place without deliberate integration. For more effective responses to the health and environment challenges facing the continent, this paper urges governments in Africa to mainstream health and environment into national development agendas, and develop the human capacity for assessment, regular monitoring and evaluation of the process.
5. Health equity in economic and trade policies
Kenya and Tanzania have recently passed anti-counterfeit laws and regulations that risk blocking legitimate generic medicines instead of fake products, which is the purported purpose of these laws. Uganda is now considering a similar bill. Like the other East African legal provisions, Uganda's draft bill defines counterfeiting in such a way as to criminalise manufacturers and importers of safe, high-quality generic medication. Critics say Uganda already has adequate legislation against fake products. To explain what is spurring the adoption of these new laws on intellectual property rights, intellectual property rights expert, Sisule Musungu, points to the politics of global trade. In this interview, he notes: '…Intellectual property rights don't guarantee quality or certification of quality. And that is why talking about quality and intellectual property does not add up because they are two different things: the latter confers rights to intellectual property owners and has nothing to do with the quality of products.'
Access to medicines in developing countries continues to be a significant problem due to lack of insurance and lack of affordability. Chronic myeloid leukemia (CML), a rare disease, can be treated effectively, but the pharmaceutical treatment available (imatinib) is costly and unaffordable for most patients. GIPAP is a programme set up between a manufacturer and a non-governmental organisation to provide free treatment to eligible CML patients in 80 countries worldwide. In this study, data for 13,568 patients across 15 countries, available quarterly, were analysed over the 2005-2007 period. Four waves of patients entering quarterly in 2005 were used to evaluate patient survival over the sample period. Having controlled for age, location and occupation, the analysis showed that patients were significantly more likely to move towards a better health state after receiving treatment irrespective of their disease stage at the point of entry to the programme.
According to this book, the first certain trade between Africa and China may be dated from the fourteenth century, but east African city-states may have been trading with southern China even earlier. In the mid-twentieth century, Maoist China funded and educated sub-Saharan African anticolonial liberation movements and leaders, and China then assisted new sub-Saharan nations. Africa and China are now immersed in their third and most transformative era of heavy engagement, one that this book believes will promise to do more for economic growth and poverty alleviation than anything attempted by Western colonialism or international aid programs. Robert Rotberg and his Chinese, African and other colleagues discuss this important trend and specify its likely implications. Among the specific topics tackled here are China’s interest in African oil; military and security relations; the influx and goals of Chinese aid to sub-Saharan Africa; human rights issues; and China’s overall strategy in the region. China’s insatiable demand for energy and raw materials responds to sub-Saharan Africa’s relatively abundant supplies of unprocessed metals, diamonds, and gold, while offering a growing market for Africa’s agriculture and light manufactures. As the book illustrates, this evolving symbiosis could be the making of Africa, the poorest and most troubled continent, while it further powers China’s expansive economic machine.
According to this paper, environmental risks arise largely from unsustainable development policies related to the use of water and land resources, transportation and energy. The health impacts of environmental pollution and ecosystem degradation disproportionately affect the disadvantaged and vulnerable socioeconomic groups, such as children, the rural and urban poor, and informal-sector workers. Economic, institutional, political and social factors present barriers to more sustainable environment and health policies, while macroeconomic considerations tend to be the major drivers of policy-making on the continent. Health ministry policies are generally focused on health care services and may not systematically address the related broader environment and development agendas. Environment ministries are often newer entities, and lack the power or resources to steer government investments towards sustainable development. African countries need to be able to monitor, prevent or mitigate risks that might develop into full-scale environmental and health crises.
At an informal meeting between the World Health Organization and a number of countries, held on 20 January 2010, the importance of having a fully realised framework for handling pandemic influenza was discussed. The meeting made progress on virus and benefit sharing, but it needed to cover pandemic risk response as well as pandemic risk assessment, said the Indonesian delegate. There was also some discussion on the way to handle virus and benefit sharing. India wanted assurance that the WHO does not commit to terms and conditions that might get set as precedents and upset the balance between virus and benefit sharing. Japan said that the agreement should focus on voluntary, not mandatory, benefit sharing but that states should do more to contribute as much as they can in terms of financial and technical resources to countries that need them. Sangeeta Shashikant of the Third World Network said, 'the inequity of a system that delivers vaccines to developed countries but requires developing countries to rely on ad hoc measures such as donations is apparent.'
The author notes that, given the magnitude of Western debt and the need to reduce it at a rate that does not disrupt any signs of growth, 2010 may well be the most benign year for development between now and 2015. He believes that the big cuts will come in 2011 onwards and makes ten predictions that may help inform development decisions during 2010. 1. China's view will become the bellwether of all development agreements. 2. ‘Minilateralism' is the wave of the future. 3. Copenhagen will energise, not demoralise, those fighting for climate issues to be higher up the agenda. 4. The Commonwealth will become more important in development. 5. USAID will become more relevant to international development. 6. Food and nutrition will slowly slip from the top table of the development agenda. 7. Africa will get back onto the international agenda, albeit briefly. 8. Economics will change, but only at the margins. 9. The UK Department for International Development (DFID) will undergo evolution not revolution. 10. People power in development will move into a new age.
Finding financing to develop medicines for under-researched diseases, regulatory harmonisation and pandemic influenza preparedness topped the agenda at the World Health Organization's (WHO) Executive Board meeting, held from 18–23 January 2010. Its recommendations will be sent to the annual WHO member decision-making World Health Assembly, which meets in May 2010. Regulatory harmonisation, such as streamlining processes for ensuring drug safety, is one of the major recommendations of the Expert Working Group to increase efficiency in the research and development system. Strengthening regulation is also one of the activities the WHO secretariat has said it is undertaking as part of the implementation of its global strategy, which requires a 'strengthening of the WHO prequalification programme'. Drug regulation may become a key discussion point on public health and intellectual property this year, according to sources. And there is recent concern from several members of the Parliamentary Assembly of the Council of Europe that the threat of pandemics, specifically the flu epidemics, may have been exaggerated 'in order to promote … patented drugs and vaccines'.
6. Poverty and health
In 2006, a paediatric diarrhoea outbreak occurred in Botswana, coinciding with heavy rains. Surveillance recorded a three-times increase in cases and a 25-fold increase in deaths between January and March. Botswana has high HIV prevalence among pregnant women (33.4% in 2005), and an estimated 35% of all infants under the age of six months are not breastfed. This study followed all children <5 years old with diarrhoea in the country's second largest referral hospital at the peak of the outbreak by chart review, interviewed mothers and conducted laboratory testing for HIV and enteric pathogens. Of 153 hospitalised children with diarrhoea, 97% were <2 years old; 88% of these were not breastfeeding. HIV was diagnosed in 18% of children and 64% of mothers. Many children who died had been undersupplied with formula. Most of the severe morbidity and mortality in this outbreak occurred in children who were HIV negative and not breastfed. Feeding and nutritional factors were the most important determinants of severe illness and death. Breastfeeding is critical to infant survival in the developing world, and support for breastfeeding among HIV-negative women, and HIV-positive women who cannot formula feed safely, may prevent further high-mortality outbreaks.
The lack of adequate sanitation facilities in the Ugandan capital, Kampala, has led to increased use of polythene bags – known as 'flying toilets' – for human waste disposal, local officials said. The situation is worse in slums where infrastructure is basic. The few private and public facilities that exist charge up to USh200 [US 10 cents] per use of a toilet. 'These areas are characterised by poor drainage systems and, in the rainy season, the problem becomes worse,' said Bernard Luyiga, a councillor in Kampala district. 'We have not invested enough in this area.' About 6.2% of households in the city have no toilet facilities at all. Most, according to chief health inspector Mohammed Kirumira, are in the slums. And only about 65% of Kampala’s two million residents have access to clean water. The rest use water that is sometimes contaminated by pit latrines. According to Uganda's Lands, Housing and Urban Development Ministry, the high cost of piped water has forced some city dwellers to rely on springs and wells. 'Over 50% of household occupants in Kampala are hospitalised every three months due to malaria while contamination of water by prevalence of micro-organisms is evident in the water sources of the city,' it said.
This issue of Poverty in Focus reviews the Millennium Development Goals (MDGs) to date and asks what can be done to accelerate MDG progress in the years 2010–2015 and beyond. There have been numerous calls for a new development narrative/paradigm from developing countries, international civil society organisations and development agencies. The contributing authors believe this changing context will affect the debate on the MDGs, past and future, in ways that perhaps only now are starting to become clear. They also believe that impact of the current financial crisis is likely to continue to frame debates over the next five years, and will be critical in determining the economic and social environment. Economic uncertainty in donor countries is also leading to declining public support for aid budgets. They predict the coming period is likely to be much less certain as developing countries, especially in sub-Saharan Africa, face several interconnected crises to which climate change is central, and which will change the context for achieving the MDGs.
Even if, in terms of income, there are still today a higher number of poor people in the countryside than in Kenya’s cities, poor urban-dwellers face an alarming (and growing) range of vulnerabilities. Oxfam GB Kenya’s report highlights the mutually reinforcing dimensions of vulnerability in Nairobi’s slums. It launched a new Urban Programme Strategy in 2009 that aims to build on the organisation’s strategic comparative advantages, bringing its experience elsewhere into the urban sector in Kenya. These advantages include: coordinating partnerships with key stakeholders, bringing Oxfam GB’s experience in peace and conflict transformation in other parts of rural Kenya into the urban arena; capitalising on its international status in terms of resource mobilisation; and utilising its expertise on water, sanitation and food security to support local organisations in delivering basic urban services. The strategy will be implemented on a phased basis over a fifteen-year period, and will focus on three strategic priority areas: urban governance, sustainable livelihoods, and disaster preparedness and risk reduction.
7. Equitable health services
In this study, 167 people (59 people with epilepsy [PWE], 62 relatives of PWEs and 46 villagers) were interviewed at a local hospital and in the community with a semi-structured validated questionnaire regarding the prevailing attitude towards traditional medicine for treatment of epilepsy in a rural area of northern Tanzania. Various traditional healing methods (THM) could be ascertained, namely traditional herbal medicine, spiritual healing, scarifications and spitting. In total, 44.3% the interviewed people were convinced that epilepsy could be treated successfully with THM. Interestingly, 34.1% thought that Christian prayers could cure the cause and/or treat symptoms of epilepsy. Significantly more PWE and their relatives were in favour of THM compared to villagers not knowing about or not immediately affected by epilepsy. Further factors influencing people’s attitudes towards THM were gender, tribe, religion and urbanity of people’s dwellings. This study demonstrates that not only THM but also prayers in the Christian sense seem to play an important role in people’s beliefs regarding successful treatment of epilepsy. Factors influencing this belief system have been identified and are discussed.
South Africa's Medicines Control Council (MCC) is sitting on a seven-year backlog of nearly 3,000 medicines, which could take another two years to be registered for use in the country. The medicines include treatments for life-threatening conditions such as HIV and AIDS, cancer, tuberculosis and diabetes, as well as antibiotics for bacterial infections. Pharmaceutical companies need to have their drugs registered with the MCC after being licensed to produce them. Only then can they be sold in the country. A task team, put in place by former health minister Barbara Hogan late last year, is busy clearing the backlog and transforming the MCC, and has registered about 200 medicines so far. The team, led by Nicholas Crisp of Benguela Health, includes 12 technical assistants and 24 clerks and has already audited the entire backlog and clinically evaluated nearly 800 medicines. About R13.5 million has so far been spent on the backlog project. Pharmaceutical representatives said they welcomed the task team's work. 'We have seen an increase in the numbers of medicines corresponded to the MCC,' said Shivani Patel, a regulatory affairs pharmacist at Merck's. Part of the project was the development of a new public entity, the South African Health Products Regulatory Authority, although what its role would be was unclear.
In this study, reports were reviewed from nationally representative surveys in African malaria-endemic countries from 2006 through 2008 to understand how reported intervention coverage rates reflect access by the most at-risk populations. These included 27 demographic and health surveys (DHSs), multiple indicator cluster Surveys (MICSs), and malaria indicator surveys (MISs) during this interval with data on household intervention coverage by urban or rural setting, wealth quintile, and sex. Household ownership of insecticide-treated mosquito nets (ITNs) varied from 5% to greater than 60%, and was equitable by urban/rural and wealth quintile status among 13 (52%) of 25 countries. Malaria treatment rates for febrile children under five years of age varied from less than 10% to greater than 70%, and while equitable coverage was achieved in 8 (30%) of 27 countries, rates were generally higher in urban and richest quintile households. Recent efforts to scale up malaria intervention coverage have achieved equity in some countries (especially with ITNs), but delivery methods in other countries are not addressing the most at-risk populations.
According to this report, timely sharing of surveillance information about highly pathogenic avian influenza viruses, as well as ensuring equitable access to effective vaccinations, medicines and related technology, are important ingredients of global readiness to respond to the influenza pandemic. The Pandemic Influenza Preparedness Framework is an international mechanism designed by the World Health Organization to implement a fairer, more transparent, equitable and efficient system to improve pandemic influenza preparedness and strengthen the protection against the spread of pandemic influenza. It is intended to result in sharing H5N1 and other influenza viruses with human pandemic potential and sharing the benefits arising from the use of H5N1 and other influenza viruses with human pandemic potential, including the generation of information, diagnostics, medicines vaccines and other technologies. In developing countries, critical success factors include support for national integrated human and animal influenza action plans and building national minimum core capacity for detection, risk assessment, laboratory confirmation and rapid containment.
This report presents results from a total population survey of malaria infection and intervention coverage in a rural area of eastern Uganda, with a specific focus on how risk factors differ between demographic groups in this population. In 2008, a cross-sectional survey was conducted in four contiguous villages in Mulanda, sub-county in Tororo district, eastern Uganda, to investigate the risk factors of Plasmodium species infection. All permanent residents were invited to participate, with blood smears collected from 1,844 individuals aged between six months and 88 years (representing 78% of the population). Overall, 709 individuals were infected with Plasmodium, with prevalence highest among 5-9 year olds (63.5%). In total, 68% of households owned at least one mosquito net, although only 27% of school-aged children reported sleeping under a net the previous night. These findings demonstrate that mosquito net usage remains inadequate and is strongly associated with risk of malaria among school-aged children. Infection risk amongst adults is influenced by proximity to potential mosquito breeding grounds. Taken together, these findings emphasise the importance of increasing net coverage, especially among school-aged children.
This study conducted an audit of outcomes of cervical cancer screening and prevention services for HIV-positive women in Cape Town, South Africa. It took the form of a retrospective review of clinic registers, patient records and pathology databases at three HIV primary health clinics and a tertiary colposcopy referral centre. The proportion of women undergoing at least one Pap smear at HIV primary health clinics after HIV diagnosis was low (13.1%). Women referred for colposcopy tended to be HIV-positive and over the age of 30 years, and in most (70.2%) cytological examination revealed high-grade cervical dysplasia. HIV-positive women treated with excision for precancerous lesions of the cervix were significantly more likely than their HIV-negative counterparts to undergo incomplete excision, experience persistent cervical disease after treatment, and be lost to follow-up. The study concludes that cervical cancer screening efforts must be scaled up for women with HIV. Treatment and surveillance guidelines for cervical intraepithelial neoplasia in HIV-positive women may need to be revised and new interventions developed to reduce incomplete treatment and patient default.
8. Human Resources
Mobile phone companies have announced a US$10 million initiative to help health workers in Africa deliver quality services to HIV and AIDS patients. The Phones for Health project will equip workers in remote areas of Rwanda with mobile phones and software for exchanging information on patients. Paul Meyer, chairman of US-based Voxiva who designed the software, said workers would also be able to order medicines, receive news alerts and download treatment guidelines and training materials. According to the National Institute of Statistics of Rwanda (NISR), health workers in remote areas of the country rely on paper records – often out of date – to track diseases' spread and have no transport for gathering field data or collecting medicines. The project aims to make things easier. Workers in the field can use phones to record patient information and send it to a central database via a high-speed network or text message. The information is then made available to health officials via the internet and can be sent to field staff by text message. The initiative is a partnership between the Global System for Mobile Communications Association (GSMA), the US President's Emergency Plan for AIDS Relief, the Accenture Development Partnership, and mobile phone operators. If it is successful it will be extended to other countries in Africa.
The KwaZulu-Natal Health Department has banned nurses and doctors from moonlighting, saying the practice is being abused. Two major health workers' unions have rejected the move, saying their members in the public sector are poorly paid and rely on after-hours work to help them make ends meet. Department spokesman, Chris Maxon, said that it was policy that health workers could not engage in remunerative work while employed by the department. Exceptions had been made in the past with a number of stipulations, among them that extra work should not be undertaken during working hours and there should be no conflict of interests. Nurses' union, Denosa, said that although some staff members might have abused the system, the department should have investigated each case. 'There have been cases, for example, where staff use their days off for extra work and they are tired when they go back to work and book off sick,' Denosa said. 'But (abusing the system) should not be dealt with as a blanket ruling. This type of restriction is not fair. There is a reason why people do extra work and it is because they need to supplement their income.'
9. Public-Private Mix
This report highlights how changes in the legal and regulatory environment can facilitate expanded access to family planning and reproductive health services through Africa’s private health sector. Using laws and regulations from three Africa countries - Ethiopia, Kenya and Nigeria - this report presents a road map on how to review the most important laws governing the private sector, as well as key issues to assess.
The private health sector in the developing world is poorly understood, best practices are not documented, promising initiatives are not scaled for broader application, and there is mistrust between the public and private sectors. Yet all acknowledge a comprehensive approach to the critical health worker shortage must involve the private sector. The private health sector in resource-poor settings relies on an enabling environment of civil society, financial and operational resources. How that interrelationship between society and the private sector operates and potentiates greater scaling of innovative responses to the HRH crisis is not understood. Scaling and implementation of innovative private sector responses will require greater understanding of this relationship. The Alliance has agreed to support the development of a Task Force on private sector involvement in human resources for health to ensure that identified innovative private sector models will gain broader attention and implementation and scaling up of these models into other locales can be facilitated. The overarching goal is to accelerate the scaling and cross-border movement of initiatives in the private health sector, which can increase the supply of new workers, improve the efficiency and effectiveness of existing health workers and reduce the attrition of health workers out of the field of practice or movement out of region.
The International Finance Corporation (IFC), a member of the World Bank Group, the African Development Bank, the Bill & Melinda Gates Foundation and the German development finance institution, Deutsche Investitions und Entwicklungsgesellschaft (DEG), announced that it has created a new private equity fund that will invest in Africa’s health sector. The Health in Africa Fund, managed by Aureos Capital, will invest in small- and medium-sized companies in sub-Saharan Africa with the goal of helping low-income Africans gain access to affordable, high-quality health services. The fund will be measured not only by fiscal performance but also by its ability to cultivate businesses serving the poor. It will target commitments between US$100 to 120 million over two closings. The fund will make long-term equity and quasi-equity investments in socially responsible and financially sustainable private health companies with the aim of scaling up successful businesses, taking proven business models into new regions, and identifying and investing in areas where there are critical gaps. It will invest in a wide range of companies that deliver, among others, health services (clinics, hospitals, diagnostic centres and laboratories); pharmaceutical and medical-related manufacturing companies; medical education; and providers of medical education.
The main objectives of this study were to document the role of the private for-profit sector in voluntary counseling and testing (VCT) service delivery and to establish whether there are significant differences in the quality of VCT services, particularly in counseling and referral practices, between public, private for-profit, non-governmental (NGO) and mission health providers. Copperbelt and Luapula were selected, which are urban and rural provinces. HIV prevalence among adults is approximately 17% in Copperbelt and 13% in Luapula. Geographic proximity and the cost of transportation were found to be important factors for clients in selecting a facility, as well as the specialised reputations of NGOs. Clients were drawn to the private sector because of its ability to offer high-quality general health services, in comparison with other medical sectors. This finding suggests that the private sector may be uniquely positioned to pilot more extensive integrated HIV services. However, no one sector emerged as providing overwhelmingly higher quality services than another and, overall, rural sites performed on par in quality with the urban sites. However, the findings revealed less than optimal counseling practices across the sectors.
10. Resource allocation and health financing
In this paper, the authors state that the micro-macro paradox has been revived. Despite broadly positive evaluations at the micro and meso-levels, they note that recent literature has turned decidedly pessimistic with respect to the ability of foreign aid to foster economic growth. Policy implications, such as the complete cessation of aid to Africa, are being drawn on the basis of fragile evidence. This paper first assesses the aid-growth literature with a focus on recent contributions. The aid-growth literature is then framed, for the first time, in terms of the Rubin Causal Model, applied at the macroeconomic level. Its results show that aid has a positive and statistically significant causal effect on growth over the long run with point estimates at levels suggested by growth theory. It concludes that aid remains an important tool for enhancing the development prospects of poor nations.
This paper sets out and explores the link between donor aid and recipient country budgets, and the role greater transparency about aid can play in improving budget transparency, the quality of budgetary decisions, and accountability systems. The paper goes on to explore how current initiatives to improve aid transparency can best support better budgets and accountability in aid dependent countries. These efforts provide an important opportunity to enhance the effectiveness of both the recipient governments’ own spending and the aid they receive from donors. It concludes that publishing better information on aid requires compatibility with recipients’ budgeting and planning systems. The research findings suggest that recipient budgets bear many similarities, but this is not reflected in current formats for reporting aid. Finally, it concludes that the poorest countries will lose out if donors do not publish aid information that is easy to link with recipient government budget systems.
Having considered a wide range of options, the Expert Working Group put forward the following fundraising proposals based on the likelihood they can generate new funds for health research and development in a sustainable way: a new indirect tax (a consumer-based tax); voluntary business and consumer contributions; new donor funds for health research and development; and a new indirect tax. The High-Level Taskforce on Innovative International Financing for Health Systems estimates that additional funding for health might grow to some US$7.4 billion per annum by 2015 from traditional donors (under optimistic assumptions and if donors meet their commitments to aid) and that developing country contributions might be in the range of US$9.5–12.1 billion per annum. However, there would be a gap in available additional funds until then, as additional resources rise from US$2.8 billion in 2009 to US$7.4 billion in 2015. The following five proposals should provide funding allocation across most research and development stages and developers in a manner that is best designed to maximise public health returns in the developing world: funding via product development partnerships; direct grants to small and medium-sized enterprises and grants for developing country trials; milestone prizes; end-prizes (cash); and purchase or procurement agreements.
According to the authors of this study, the global economy is passing through a period of profound change. They identify three global crises. The immediate concern is with the financial crisis, originating in the North. The South is affected via reduced demand and lower prices for their exports, reduced private financial flows and falling remittances. This is the first crisis. Simultaneously, climate change remains unchecked, with the growth in greenhouse gas emissions exceeding previous estimates. This is the second crisis. Finally, malnutrition and hunger are on the rise, propelled by the recent inflation in global food prices. This constitutes the third crisis. These three crises interact to undermine the prosperity of present and future generations. Each has implications for international aid and underlines the need for concerted action.
11. Equity and HIV/AIDS
Ten months after being re-launched, a new brand of female condom has proven popular among Ugandan women. FC2 was launched in February; the government stopped distributing the original female condom, FC1, in 2007 on the grounds that women had complained it was smelly and noisy during sex. 'The new condom has improved features and will enable women to have a procedure within their control to give them more choices for prevention [of HIV and unwanted pregnancies],' said Vashta Kibirige, the coordinator of the condom unit at the Ministry of Health. The UN Population Fund and the NGO, Programme for Accessible health Communication and Education, are spearheading the re-launch of the female condom, which is still in the sensitisation stage and will become available to the public in 2010. The women questioned said the new condom was less noisy, more comfortable and well lubricated, increasing their sexual pleasure. It also has no smell and can be inserted in the vagina at least eight hours before sex, which the women liked a lot.
Despite emerging evidence that HIV-positive mothers should breastfeed to maximise their babies’ health prospects, South African health workers face a battle to change attitudes and habits. The 2003 South African Demographic Health Survey found that fewer than 12% of infants are exclusively breastfed during their first three months and this drops to 1.5% for infants aged between three and six months. Some health workers themselves have yet to be convinced of the benefits of breastfeeding, even for mothers who aren’t HIV positive. 'There exists the general idea that it is not important, that there is no critical reason to breastfeed, especially when you can formula feed,' says Linda Glynn, breastfeeding consultant at Mowbray Maternity Hospital in Cape Town. 'Some [health workers] think breastfeeding is a waste of time and an inconvenience.' Yet, the risks of not breastfeeding often go unrecognised. Most children born to HIV-positive mothers and raised on formula do not die of AIDS but of under-nourishment, diarrhoea, pneumonia and other causes not related to HIV. The World Health Organization recommends that all new mothers, regardless of their HIV status, practise exclusive breastfeeding for a minimum of six months.
Highly active antiretroviral therapy (HAART) drastically reduces mother-to-child transmission of HIV, but where breastfeeding is the only safe infant feeding option, HAART for the prevention of mother-to-child transmission needs to be evaluated in relation to both HIV transmission and infant mortality. One hundred-and-two >=18-year old women on HAART in rural Uganda who delivered one or more live infants between 1 March 2003 and 1 January 2007 were enrolled in a prospective study to assess HIV transmission and infant survival. Of 118 infants born during follow-up, 109 were breastfed. In total, 23 infants died during follow-up at a median age of 3.7 months; 15 of whom with severe diarrhoea and/or vomiting in the week preceding their death. The study concludes that, in resource-constrained settings, HIV-infected pregnant women should be assessed for HAART eligibility and treated as needed without delay, and should be encouraged to breastfeed their infants for at least six months.
Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked, says this study. Conflation of HIV and alcohol disease in these setting 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. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. According to this study, 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. It recommends that brief interventions for people with problem drinking must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Additionally, 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.
This study estimates mean life years gained using different treatment indications in low-income countries. It carried out a systematic search to identify relevant studies on the treatment effect of highly active antiretroviral therapy (HAART) and data was applied to a hypothetical Tanzanian HIV population. It found that providing HAART early when CD4 is 200-350 cells/μl is likely to be the best outcome strategy with an expected net benefit of 14.5 life years per patient. The model predicts diminishing treatment benefits for patients starting treatment when CD4 counts are lower. Patients starting treatment at CD4 50-199 and <50 cells/μl have expected net health benefits of 7.6 and 7.3 life years. Without treatment, HIV patients with CD4 counts 200-350; 50-199 and < 50 cells/μl can expect to live 4.8; 2 and 0.7 life years respectively. This study demonstrates that HIV patients live longer with early start strategies in low-income countries. Since low-income countries have many constraints to full coverage of HAART, this study provides input to a more transparent debate regarding where to draw explicit eligibility criteria during further scale up of HAART.
This study strategised a way to integrate mobile telephony into the health management of subjects receiving anti-retroviral (ARV) medications. It took the form of a randomised controlled trial to assess health, social, and economic outcomes, involving two sub-studies in Nairobi, Kenya, and two surrounding districts. Significant time and cost are often incurred for patients to personally attend the clinics. However, the majority of subjects screened reported being comfortable with using cell phones for communicating their health issues. Note that the average travel cost to attend the clinic was US$3 (return). The current cost of an SMS is US$0.08 and a one-minute voice call is US$0.23. The most positive feedback from early enrollees in the SMS-protocol is that the participants feel 'like someone cares'. Many participants suggested that they would prefer more frequent SMS reminders. However the most common barrier to responding to the clinic SMS on time is lack of network credit at the time they are intended to respond. Overall, the once weekly protocol appears agreeable to most. Several instances of health problems have already been identified by the protocol and hence triaged by the nurse.
Kenya has launched an ambitious strategy to fight HIV and AIDS that aims to reduce new infections by at least 50% over the next four years and focus more on most at-risk populations (MARPs). The third Kenya National AIDS Strategic Plan, which runs from 2009/2010 till 2012/2013 and was launched in the capital, Nairobi, on 12 January, also aims to reduce AIDS-related mortality by 25%. 'We cannot achieve our target unless we close new taps of HIV infections – this involves putting most at-risk populations at the centre of our HIV programmes and prevention strategies,' said Alloys Orago, director of the National AIDS Control Council. In Kenya, female and male sex workers, injecting/intravenous drug users, and men who have sex with men (MSM) are considered primary MARPs. Speaking at the launch, UNAIDS executive director Michél Sidibé highlighted the paradox of the intention to increase HIV programming among MARPS while at the same time criminalising the activities that put them at an elevated risk of contracting and transmitting HIV. 'Criminalisation puts most at-risk populations, like commercial sex workers, injecting drug users and men who have sex with men, in the shadows,' he said. 'It is difficult to reach groups whose actions are deemed to be at odds with the law.' Sex work, homosexual acts and the use of illicit drugs are all outlawed in Kenya and are punishable by long terms in prison.
By the end of September 2009, there were 236 static ART clinics in Malawi in the public and private health sector; 22 of these static clinics provided ART at a total of 103 outreach or mobile sites, bringing the total to 339 ART service delivery points in Malawi in Q3 2009. In the third quarter of 2009 (July to September) a total of 18,292 new patients initiated ART and 3,030 ART patients transferred between clinics, resulting in a total of 21,322 ART clinic registrations (39% male, 61% female; 91% adults and 9% children). Improved integration of the supervision system for the public and private sector has led to a revision of previous M&E data in the private sector and patient outcomes in the private sector are similar to those in the public sector. The National programme has been affected by serious ARV drug supply shortage during Q3 due to the delayed release of funding and the ensuing logistical complications resulting in widespread drug re-allocations between sites. However a targeted survey revealed that patients were affected only in isolated cases, requiring regimen changes or short-term treatment interruption.
An ambitious, door-to-door voluntary counselling and testing (VCT) exercise launched in November 2009 has resulted in more than 1.5 million Kenyans being tested for HIV, according to a senior government official. 'Our preliminary data show that during the [first] three weeks… [] … we tested 1.5 million people and, as we continue putting our records together, we could go way above this number,' said Nicholas Muraguri, director of the National AIDS and Sexually transmitted infections Control Programme (NASCOP). 'Normally men do not come forward to be tested but this time round we are impressed... Our results show they formed 40% of the total number tested,' he added. 'Those above 50 also turned out in large numbers. Government research shows they are at risk because they too are sexually active.' He noted that the campaign reached out to most at-risk populations such as commercial sex workers through 'moonlight' VCT centres that opened out of regular business hours. The campaign was part of the government's initiative to have at least 80% of Kenyans tested for HIV by the end of 2010.
Adherence to antiretroviral medication in the treatment of HIV is critical, both to maximise efficacy and to minimise the emergence of drug resistance. The aim of this prospective study in three public hospitals in KwaZulu-Natal, South Africa, is to assess the use of traditional complementary and alternative medicine (TCAM) by HIV patients and its effect on antiretroviral (ARV) adherence 6 months after initiating ARVs. 735 (29.8% male and 70.2% female) patients who consecutively attended three HIV clinics completed assessments prior to ARV initiation and 519 after six months on antiretroviral therapy (ART) Results indicate that the use of herbal therapies for HIV declined significantly from 36.6% prior to antiretroviral treatment (ART) initiation to 7.9% after being on ARVs for six months. Faith healing methods, including spiritual practices and prayer for HIV declined from 35.8% to 22.1% and physical/body-mind therapy (exercise and massage) declined from 5.0% to 1.9%. In contrast, the use of micronutrients (vitamins, etc.) significantly increased from 42.6% to 87.4%. In multivariate regression analyses, ARV non-adherence (dose, schedule and food) was associated with the use of herbal treatment, not taking micronutrients and the use of over-the-counter drugs. The use of TCAM declined after initiating ARVs. As herbal treatment for HIV was associated with reduced ARV adherence, patients’ use of TCAM should be considered in ARV adherence management.
12. Governance and participation in health
Preventing malaria by controlling mosquitoes in their larval stages requires regular sensitive monitoring of vector populations and intervention coverage. The study assessed the effectiveness of operational, community-based larval habitat surveillance systems within the Urban Malaria Control Programme (UMCP) in urban Dar es Salaam, Tanzania. Cross-sectional surveys were carried out to assess the ability of community-owned resource persons (CORPs) to detect mosquito breeding sites and larvae in areas with and without larviciding. CORPs reported the presence of 66.2% of all aquatic habitats, but only detected Anopheles larvae in 12.6% of habitats that contained them. Detection sensitivity was particularly low for late-stage Anopheles, the most direct programmatic indicator of malaria vector productivity. Whether a CORP found a wet habitat or not was associated with their unfamiliarity with the area. Accessibility of habitats in urban settings presents a major challenge because the majority of compounds are fenced for security reasons. Furthermore, CORPs under-reported larvae especially where larvicides were applied. This UMCP system for larval surveillance in cities must be urgently revised to improve access to enclosed compounds and the sensitivity with which habitats are searched for larvae.
This book identifies four types of dynamics impact on reforms at the sector-level: sector-specific dynamics, cross-sectoral dynamics, the dynamics of the political process and country-wide dynamics. It divides approaches into two groups: sector-level political economy approaches; and country-level and politics-centred political economy approaches. Based on this analysis, the book found that sector-level political economy approaches can be characterised by a series of strengths, weaknesses and gaps. Strengths tended to be their focus on core development challenges, methodological diversity and dynamic evolution. Weaknesses, on the other hand, tended to be around having a very small number of empirical, comparable and publicly accessible sector studies; too few policy management-oriented action frameworks and an insufficient theoretical guidance on using some approaches, frameworks and matrices. Gaps were identified in the assessment of political viability of sector reforms; in the analysis of domestic decision making and subsequent implementation; and in the consideration of concrete operational implications. One of the sectors covered in this book is the health sector.
This study's aim was to explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone. Cross-sectional data were derived from three randomly selected matched clusters in rural South Africa. Adjusted risk ratios (aRRs) employing village-level summaries compared associations between groups in relation to indicators of economic well-being, empowerment, intimate partner violence (IPV) and HIV risk behaviour. The magnitude and consistency of aRRs allowed for an estimate of incremental effects. A total of 1,409 participants were enrolled, all female, with a median age of 45. After two years, both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group. However, only the IMAGE group demonstrated consistent associations across all domains with regard to women's empowerment, intimate partner violence and HIV risk behaviour. In conclusion, the addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits. Donor agencies should encourage intersectoral partnerships that can foster synergy and broaden the health and social effects of economic interventions such as microfinance.
The objective of this project was to achieve high, sustainable levels of net coverage in a village in rural Tanzania by combining free distribution of long-lasting insecticide-impregnated nets (LLINs) with community-tailored education. Community leaders held an educational session for two members of every household addressing these practice and attitudes, demonstrating proper LLIN use, and emphasizing behaviour modification. Attendees received one or two LLINs per household. Baseline interviews and surveys revealed incorrect practices and attitudes regarding: use of nets in dry season, need to retreat LLINs, children napping under nets, need to repair nets and net procurement as a priority, with 53- 88.6% incorrect responses. A three-week follow-up demonstrated 83-95% correct responses. Results suggest that addressing community-specific practices and attitudes prior to LLIN distribution promotes consistent and correct use, and helps change attitudes towards bed nets as a preventative health measure. Future LLIN distributions can learn from the paradigm established in this project.
This book builds on eight case studies, all loosely involving financial networks such as the G20, several written by network insiders, to try and sort out whether networks are a blessing or a curse for developing countries. The contributors ask a number of questions: Are networks exciting new avenues for poor country governments and civil society to influence the big decisions, or sneaky ways to get round accountability and exclude the population through a 21st century version of invitation-only gentleman’s clubs? Will they replace or strengthen formal international institutions like the United Nations or the International Monetary Fund? Are North-South networks different from South-South ones? (both are proliferating). The book sets out five functions of networks: agenda setting; consensus building; policy coordination; knowledge exchange and production and norm-setting and diffusion. It identifies two categories of network. Advocacy networks aim to mobilise support for a cause and concentrate on the agenda-setting, norm-setting and consensus-building functions, while ‘self-help’ or ‘problem-sharing’ networks focus on improving members’ capacities through knowledge production and exchange and policy coordination.
13. Monitoring equity and research policy
This report presents a historical reflection on research evaluation studies, their recurrent themes and challenges, and their implications. It critically examines studies of how scientific research drives innovation and socioeconomic benefits. First, it provides a predominantly descriptive historical overview of some landmark studies in the research evaluation field, from the late 1950s until the present day, and highlights some of their key contributions. Then, it reflects on the historical overview analytically, in order to discuss some of the methodological developments and recurrent themes in research evaluation studies. The report concludes by discussing the enduring challenges in research evaluation studies and their implications. The authors emphasise that this report does not address all of the key studies in the research evaluation field. The evaluation literature today is so extensive that a selective approach is necessary to focus on those studies that they feel provide the most valuable insights in the context of biomedical and health research evaluation.
Researchers should protect the welfare of research participants by providing methods to reduce their risk of acquiring HIV. This is especially important given that late-phase HIV vaccine trials enrol HIV-uninfected trial volunteers from high-risk populations. This study recommends that current normative guidance be systematically reviewed and actual practice at vaccine sites be documented. Adding new tools to the current package of prevention services will involve complex decision making with few set standards, and regulatory and scientific challenges. The paper recommends that stakeholders (including regulators) should convene to consider standards of evidence for new tools, and that decision-making processes be explicitly documented and researched. A further critical ethical task is exploring the threshold at which adding new tools will compromise the validity of trial results.
This paper sought to investigate the feasibility, the ease of implementation, and the extent to which community health workers with little experience of data collection could be trained and successfully supervised to collect data using mobile phones in a large baseline survey. A web-based system was developed to allow electronic surveys or questionnaires to be designed (on a word processor), sent to, and conducted on standard entry level mobile phones. The web-based interface permitted comprehensive daily real-time supervision of CHW performance, with no data loss. The system permitted the early detection of data errors in combination with real-time quality control and data collector supervision. In conclusion, the benefits of mobile technology, combined with the improvement that mobile phones offer over personal digital assistants (PDAs) – or palmtop computers – in terms of data loss and uploading difficulties, make mobile phones a feasible method of data collection that needs to be further explored.
This paper studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomised control trials. It used a qualitative case-study methodology to explore the policy-making process. It carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Prior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries. The paper concluded that translating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.
14. Useful Resources
According to this paper, health impact assessment (HIA) provides an important decision-making tool through which health issues can be addressed upstream in development planning and design. HIA proposes a systematic process to screen, scope, assess, appraise and formulate management plans to address key issues in development project implementation. While most African countries have a framework for environmental impact assessment (EIA), few have adequate capacity for HIA, which is still at a relatively early stage of development compared to other types of impact assessment globally. Partly because the importance of HIA is not yet well understood by policy makers in Africa, the tool has not been used to support development processes, including large-scale infrastructure projects. In addition to the lack of awareness of HIA, low technical competencies and inadequate institutional arrangements hinder the application of the process in Africa. The development of national HIA capacity building is the main means through which to respond to these challenges. This paper explains how to implement the HIA process.
The official launch of the pre-decision and information kit on migration and women health workers was held on the 9th of December, 2009, at the Parktonian Hotel in Johannesburg. The launch was attended by representatives from the National Department of Health (NDH), the International Labour Organization (ILO), Treatment Action Campaign (TAC), Public Service Coordinating Bargaining Council (PSCBC) and affiliates of the Public Services International (PSI) in South Africa, including a number of trade unions. The pre-decision and information kit was prepared by the National Working Group (NWG), composed of representatives of PSI affiliates in South Africa. The objective of the pre-decision information kit was to provide as much information as possible to professional women health workers intending to leave or enter South Africa for work. It provides a wide range of information from cost of living comparisons, terms and conditions of employment, cultural and language dynamics, workers’ rights and referral organisations to assist and guide health workers to make informed decisions or help them in cases of possible abuse. The launch of the toolkit came at an opportune time a few days before International Migrants Day, which is commemorated on the 18th of December each year.
In this paper, the authors argue that the successful application of technologies for the management of environmental risks to human health relies on a country’s capacity to assess risks and potential health impacts, as well as develop and implement appropriate policies, monitor and evaluate the effectiveness of these policies, and engage and communicate with stakeholders. The authors identify the main challenges to most African countries as lack of access to relevant tools and reduced the capacity to deliver vital evidence-based knowledge on the links between the environment and health. The translation of evidence into policies and programmes is often a complex issue, and legal and regulatory frameworks in Africa remain largely limited or ineffective. This paper describes useful tools for policy making and proposes that governments integrate health and environmental impact considerations into economic development processes, identify knowledge gaps, support local applied research to build technical capacity and strengthen cooperation among key actors to answer practical policy questions.
15. Jobs and Announcements
Three leading paediatric associations are uniting to host the 26th IPA Congress of Pediatrics in Johannesburg, South Africa from 4–9 August 2010. More than 5,000 participants are expected to attend this landmark event, the first IPA congress to be held in sub-Saharan Africa. It will unite paediatricians and health professionals working towards the target set by Millennium Development Goals (MDGs) to reduce child mortality by two thirds before 2015. The scientific programme is designed to meet the needs of general paediatricians from both the developed and the developing world. Plenary sessions will include: the MDGs and the current state of health of children in the world, and progress towards the MDGs; the state of the world’s newborns, including major issues determining maternal and newborn health in developing and developed countries; the determinants of health, such as genetics, nutrition and the environment; disasters and trauma affecting child health, such as disasters, crises and the worldwide epidemic of trauma; and the global burden of infectious diseases affecting children and the challenge of emerging infections.
The World Health Organization (WHO) is expanding its activities on environmental impact assessment in the health sector. WHO seeks an independent consultant to develop tools, guidance, and monitoring and reporting frameworks for use in assessing and managing environmental issues affected by health sector projects and activities. The scope of work for this consultancy consists of three tasks: design and implementation of customised environmental screening and impact assessment tools; development of environmental monitoring and reporting framework and related information management systems; and contribute to training materials to build capacity for the use of the above. The consultancy will be for six months and will start at the end of February 2010 (or as soon as reasonably possible). The consultant will be remunerated at a monthly rate that is commensurate with their experience and based on the United Nations common salary scale. Expression of interest must be emailed to Michaela Pfeiffer, Technical Officer, WHO, at the email address given, before the closing date.
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