In the last weeks of 2009, the UN held a meeting in Copenhagen to thrash out a comprehensive global agreement that could be converted into an internationally legally binding treaty to prevent dangerous global warming. By the end of the Copenhagen conference, the outcome was far from this: The conference accord preserved the Kyoto protocol, and while it recognised that global warming be limited to an increase of less than two degrees centigrade, it did not set targets for greenhouse gas cuts. While it set an aim to provide $30bn a year for poor countries to adapt to climate change rising to $100bn a year by 2020, it did not detail the source of these funds. It set no deadline for the conclusion of the climate talks.
The failure at Copenhagen has deep implications for people’s health, particularly in Africa, where the Intergovernmental Panel on Climate Change warn that consequences of global warming, such as loss of wetlands, will lead to increased frequency and severity of drought, further jeopardising food security (http://www.ipcc.ch/ipccreports/tar/wg2/index.php?idp=667). But what role do health activists play in this struggle? What are the special interests of health activists in relation to climate change and what special leverage might people’s health networks contribute in controlling the drivers of global warming? With the prevailing global inequities and the heavy disease burden and high barriers to health care in low income countries, such as in Africa, we need to understand the North- South dimensions of the Copenhagen fiasco.
It appears that the high income countries approached Copenhagen with low ambitions and high conditions, including conditions that tied their own action to comparable commitments from the big developing countries like South Africa, downplaying the role that emissions from high income countries have played in the historical accumulation of greenhouse gases. It appears that the big developing countries, led by China and India, were unwilling to accept the kind of restrictions on their economic development that were being canvassed and were unwilling to slow down what they described as the liberation of millions of desperately poor people from poverty. With pathways to less harmful economic development dependant on access to the necessary non-polluting technologies, the developing countries were not happy with the offers from the rich countries on this front.
Control of global warming and opportunities for economic development are both framed by the wider regime of global economic governance. The inequities, imbalances and instabilities of the global economy, manifest in the global food crisis and the global financial crisis, are direct reflections of this regime. Neoliberal globalisation is built upon a consumerism (with concomitant carbon pollution) that marginalises a billion humans, who are required neither for their labour power nor their buying power. In Copenhagen these inequities were again unmasked, in relation to the crisis of global warming.
It is untenable that these global policy challenges should be allowed to force a choice in low income and developing countries between economic development OR a mitigation of global warming. Rather we need to work towards a regime of global economic governance which reconciles the need for sustainable economic development for countries in Africa and other parts of the global south, and the need to contain global CO2 levels to 350ppm. Such a regime is technically and economically possible. The main challenge is political.
What does this mean for health activists? It raises four imperatives:
Firstly, we need to get our facts straight and build a robust analysis. We need to understand clearly the positions that were advanced by the various groups of countries at Copenhagen, put them in the context of the political economy of energy and global economic governance, and explore their health implications.
Secondly, we need to put sustainable economic development at the forefront of a shared struggle for health and for tackling global warming. This is not the high consumption, low employment, neoliberal globalised production model of development, but a more sustainable autonomous development, based to a large degree on local production and supply.
Thirdly, we need to build pressure on all governments, north and south, to accelerate the reform of domestic energy production and energy use, while continuing to work for binding international agreements.
Fourthly, in addition to energy efficiency and the move to renewables, we need to profile energy equity, or the fair distribution of energy resources across countries, social groups and generations. This has implications for high income countries, where the profligate use of carbon based energy is embedded in culture, economy and infrastructure. It also has implications for the elites and middle classes of low income countries. It calls for an alternative culture of global solidarity.
These four imperatives have implications for the work of health activists.
Comprehensive primary health care is fundamental for improving access to health care and action on the social determinants of health. It is also a strategy of social change through community mobilisation based on partnerships between PHC practitioners and the communities they are serving. It follows that energy reform must be included in the discourse on ‘the social determinants of health’ and community mobilisation for health. It must also be clearly contextualised in relation to the same problems of current economic globalisation that drive inequity in health, raising the challenge of global economic reform.
Global solidarity is central to taking forward comprehensive PHC. This calls for health activists to build communication channels and opportunities for collaboration across various axes of difference (nation, race, gender, religion as well as class) so that the forces for progressive global change can be more coherent and effective. Energy reform (including energy equity as well as efficiency and the use of renewables) must be included in this communication, in the context of economic globalisation.
Intersectoral collaboration is a core principle of all public health work. This calls on health social movements, like Peoples Health Movement, to build relationships with social movements who share common perspectives and values within other sectors, including with those engaging on global warming, environmental justice and energy reform.
Under the banner of the ‘right to health’, health as a basic human right de-normalises the status quo and inspires communities in their struggle for access and for decent living conditions. This is a political struggle as much as it is a moral claim. The political analysis which guides this practice must take us beyond the noise of Copenhagen to explain the workings of neo-liberal globalisation in relation to health, economic development and global warming. Opportunities like the Third People’s Health Assembly, planned for Cape Town in July 2011, are thus important for us to deepen our understanding of these relationships and what this means for our work as health activists in Africa, and globally.
Editor's comment: This issue EQUINET includes a focus on what the climate change discussions mean for health in east and southern Africa. We welcome materials, comments and editorial input from others working in this area, to further develop our work and understanding in the region. Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please also visit the websites of the People’s Health Movement http://www.phmovement.org/ and International People’s Health University http://www.phmovement.org/iphu/
1. Editorial
2. Latest Equinet Updates
In the last five years EQUINET has through Training and Research Support Centre and Ifakara Health Institute supported participatory action research work in nine countries in east and southern Africa exploring different aspects of community interactions with health systems. We did this to better understand these social dimensions of health, and, more importantly to support the empowerment of groups affected by health issues to analyse, act on and change the conditions that undermine their health. In 2008, working with seven institutions, we developed capacities to use photography as a tool for visual literacy, to support reflection and action in sites in seven countries in east and southern Africa. This book presents the work carried out in 2009, embedded within our work on strengthening people’s power in health. It presents through photography the lives of the people involved, the diversity of views on the determinants of health in these communities, the visions of solutions and the actions taken to act on the problems identified. The book is currently available as a hardcopy from the EQUINET secretariat.
The AIDS epidemic has resulted in over 1 million orphans and many other vulnerable children in Zimbabwe. Most of these children remain in their communities, either in child-headed households or looked after by their extended family or members of the community. While there has been a massive response from local organisations to the plight of these children, many programmes have been designed in a top-down manner, without taking into consideration the views of the children themselves. The study used a mix of quantitative assessment and participatory action research methods (PRA) to explore and strengthen the participation of orphans and vulnerable children in primary health care (PHC) in Victoria Falls, a town in the north-western part of Zimbabwe. Children, community representatives and health workers identified three priority health problems faced by these children, ie: poor access to ART; child abuse; and poor housing. Structural constraints, such as poverty and weakened health and community services, were seen as the primary underlying causes of these problems. Those involved identified actions they could take to address these problems, and based on this community organisations strengthened psychosocial support activities, undertook a number of awareness campaigns, initiated and participated in child protection committees and started to meet monthly to strengthen coordination. A participatory review of the interventions suggested that child involvement is an important component in a primary health care approach to designing ways of meeting children's needs, through structured platforms for the exchange of information and experiences, provision of child friendly services, and promotion of effective communication between health workers, community members and children.
3. Equity in Health
Improving maternal health and reducing newborn deaths is a complex undertaking because, among other things, it involves strengthening health systems, scaling up programmes to reach remote rural areas and marginalised populations, and ensuring that appropriate resources are committed to what some consider a ‘woman’s issue.’ WHO, UNFPA, UNICEF and the World Bank, known as the ‘Health 4’ or ‘H4’, are supporting countries with the highest maternal mortality, starting with six countries that include the Democratic Republic of Congo. In these countries they are supporting strengthening health systems to reduce maternal mortality by 75% and achieve universal access to reproductive health. The four agencies are seeking to enhance collaboration to not only get more money for health, but also more health for the money, by harmonising and working jointly.
Canada has announced that it will make maternal and child health a priority when it hosts the G8 summit in June 2010. Canadian Prime Minister, Stephen Harper, said in a statement that his country would champion a major initiative to improve the health of women and children in the world’s poorest regions. He said that members of the G8 could make a difference in maternal and child health and that Canada would be making this the top priority in June. The Prime Minister suggested that the solutions are within reach for the international community and include better nutrition, clean water, inoculations and training of health workers. With only five years left to achieve the internationally agreed Millennium Development Goals (MDGs), successes have been achieved but much more needs to be done, particularly with MDG 5, which targets maternal health and lags furthest behind of all the eight MDG targets.
A group of senior officials from China, Africa and from international organisations involved in health assistance in Africa met in Beijing on 4-5 December 2009 to review China’s health assistance to Africa and to discuss opportunities for international cooperation in achieving the health-related Millennium Development Goals in Africa. The International Roundtable on China-Africa Health Collaboration was part of an ongoing effort by Government of China to develop a new strategy for health assistance to Africa as part of its overall South-South collaboration. A key message, emphasised by representatives of international organisations, African officials, and Chinese officials alike, is the importance of strong country ownership, on the one hand, and benefits of working through partnership, on the other. Dr. Tedros Adhanom Ghebreyesus, Ethiopian Minister of Health and Chair of the Global Fund to Fight AID Tuberculosis and Malaria, described his country’s experience in working under the framework of the International Health Partnership, with its reliance on supporting Ethiopia’s national health development plan. He noted that ‘it is through ownership that you can generate commitment, and with commitment begin to see results’. He also noted an African proverb, which was quoted by Chinese Premier Wen Jiaobao in his speech at the recent Forum on China Africa Cooperation, and which says ‘If you want to go quickly, go alone. If you want to go far, go together’.
According to South Centre, the Copenhagen Accord has five important implications and effects. First, it lays the foundation for weakening the Kyoto Protocol as the multilateral treaty instrument for developed countries’ binding emission reduction commitments. Second, it creates the potential for changing the balance of obligations under the United Nations Framework Convention on Climate Change (UNFCCC) by laying the basis for a new set of obligations for developing countries. Third, it re-interprets the commitments of developed countries to provide or mobilise climate financing to support developing countries’ climate change-related mitigation and adaptation actions in ways that are conditional and highly ambiguous. Fourth, it creates a parallel framework of climate change-related ‘commitments’ and actions, thereby laying the foundation for a shift away from the UNFCCC per se as the primary multilateral treaty instrument for global long-term cooperative action on climate change. Fifth, it recognises the science relating to a two degree centrigrade global temperature increase but does not elaborate on how this would be achieved. It also talks about equity but does not define clearly how equity considerations are to be addressed, what it means, and the modalities for achieving equity.
The Copenhagen Accord presented after the climate summit is only three pages in length. According to the author of this article, what is left out is probably more important than what it contains. The Accord does not mention any figures of the emission reduction that the developed countries are to undertake after 2012, either as an aggregate target or as individual country targets. The author believes this failure at attaining reduction commitments is the biggest failure of the document and of the whole Conference. It marks the failure of leadership of the developed countries, which are responsible for most of the greenhouse gases retained in the atmosphere, to commit to an ambitious emissions target. While developing countries have demanded that the aggregate target should be over 40% reduction by 2020 compared to 1990 levels, the national pledges to date by developed countries amount to only 13–19% in aggregate. Perhaps this very low ambition level is the reason that the Accord remains silent on this issue, except to state a deadline of 31 January 2010 for countries to provide their targets. The author doubts this deadline will be met given the reluctance to be explicit on this in the last four years.
Effects of climate change on health will impact on most populations in the coming decades and put the lives and well-being of billions of people at increased risk, according to this report. The Intergovernmental Panel on Climate Change (IPCC) states that ‘climate change is projected to increase threats to human health’. Climate change can affect human health directly (such as impacts of thermal stress, death/injury in floods and storms) and indirectly through changes in the ranges of disease vectors (such as mosquitoes), water-borne pathogens, water quality, air quality, and food availability and quality. The report also states that social impacts will vary dependent on age, socioeconomic class, occupations and gender, and the world’s poorest people will be most affected. The risks to health from climate change arise from: direct stresses (such as heatwaves, weather disasters and workplace dehydration); ecological disturbance (such as altered infectious disease patterns); disruptions of ecosystems on which humanity depends (for example, health consequences of reduced food yields); and population displacement and conflict over depleted resources (for example, water, fertile land, fisheries).
In this interview, Dr Brawley discusses the challenges particular to Africa in relation to cancer and debunks some of the myths around cancer. He believes Africa is addressing the cancer pandemic, but more focus is needed to bring politicians and non-government organisations into the fold to address cancer in Africa. Cervical cancer is highly treatable in many areas of the world and abilities to prevent, detect and treat it need to reach African more widely. Smoking, which is not very common in Africa but is growing, needs to be stopped to prevent an epidemic of lung cancer. With regard to the role tobacco control plays in cancer control in Africa, he noted that the Africa Tobacco Control Regional Initiative, the Africa Tobacco Control Alliance, and the Framework Convention Alliance have already been instrumental in helping to establish an agenda for cancer control in Africa. With tobacco companies looking at Africa as an area of market growth there is need to combat what could be an epidemic of lung cancer, cardiac and other diseases.
All populations will be affected by a changing climate but, according to this article, the initial health risks vary greatly, depending on where and how people live. People living in small island developing states and other coastal regions, megacities, and mountainous and polar regions are all particularly vulnerable in different ways. Health effects are expected to be more severe for elderly people and people with infirmities or pre-existing medical conditions. The groups who are likely to bear most of the resulting disease burden are children and the poor, especially women. The major diseases that are most sensitive to climate change – diarrhoea, vector-borne diseases like malaria, and infections associated with undernutrition – are most serious in children living in poverty. Strengthening of public health services needs to be a central component of adaptation to climate change. The international health community already has a wealth of experience in protecting people from climate-sensitive hazards, and proven, cost-effective health interventions are already available to counter the most urgent of these. Broadening the coverage of available interventions would greatly improve health now. Coupled with forward planning, it would also reduce vulnerability to climate changes as they unfold in the future.
According to this study, three circumstances make the present moment unique for global health. First, health has been increasingly recognised as a key element of sustainable economic development, global security, effective governance and human rights promotion. Second, due to the growing perceived importance of health, unprecedented – albeit still insufficient – sums of funds are flowing into this sector. Third, there is a burst of new initiatives coming forth to strengthen national health systems as the core of the global health system and a fundamental strategy to achieve the health-related Millennium Development Goals. In order to realise the opportunities offered by the conjunction of these unique circumstances, it is essential to have a clear conception of national health systems that may guide further progress in global health. To that effect, the first part of this document examines some common misconceptions about health systems. Part two explains a framework to better understand this complex field. Finally, a list of suggestions is offered on how to improve national health system performance and what role global actors can play.
4. Values, Policies and Rights
AIDS activists in Zimbabwe have launched a major drive to ensure that the rights of people living with HIV are enshrined in the new constitution. The Global Political Agreement signed in September 2008 between Zimbabwe's various political rivals, which gave rise to the coalition government in February 2009, includes writing the new constitution expected to be introduced in 2010. ‘We are not calling for a token participation, but significant and meaningful involvement that will go a long way in promoting our welfare and rights when the constitution is adopted,’ Tonderai Chiduku, advocacy coordinator of Zimbabwe National Network of People Living with HIV and AIDS (ZNNP+) said. The Southern Africa AIDS Information Dissemination Service (SAFAIDS) and ZNNP+ are calling for a bill of rights that would promote better access to health services. An estimated two million people are living with HIV and AIDS in Zimbabwe, one of the countries hardest hit by HIV and AIDS, but have never before been actively involved in such legislation and do not have representation in parliament, Chiduku said. The activists have also urged policy-makers to include a clause that would commit the government to spending a minimum of 10–15% of the national budget on healthcare.
This paper reports on an interview with Professor Savitri Goonesekere, an international expert on the rights of women and children and a member of the United Nations Committee on the Elimination of Discrimination against Women between 1999 and 2002. In the interview she notes ‘a cynicism about rights and what they can do, especially in developing countries. This just encourages states not to implement the treaties they have signed'. She notes that human rights laws create a culture of support for implementing health policies by helping the community to monitor the state’s actions and programmes. She notes that some argue that if health policies are in place, health rights do not need to be put in the constitution and other laws. However she suggests that political systems are very fragile and a change in a health minister can bring in someone with a different attitude, leading everything to change. 'If a right is not in place in a law or constitution, it’s very easy to pull it back.’
In the context of South Africa's intense preparation for hosting the 2010 FIFA World Cup, anxiety over HIV transmission in the context of sex work has sparked debate on the most appropriate legal response to this industry. Drawing on existing literature, the authors highlight the increased vulnerability of sex workers in the context of the HIV pandemic in southern Africa. They argue that laws that criminalise sex work not only compound sex workers' individual risk for HIV, but also compromise broader public health goals. International sporting events are thought to increase demand for paid sex and, particularly in countries with hyper-endemic HIV such as South Africa, likely to foster increased HIV transmission through unprotected sex. The 2010 FIFA World Cup presents a strategic opportunity for South Africa to respond to the challenges that the sex industry poses in a strategic and rights-based manner. Public health goals and growing evidence on HIV prevention suggest that sex work is best approached in a context where it is decriminalised and where sex workers are empowered. In short, the authors argue for a moratorium on the enforcement of laws that persecute and victimise sex workers during the World Cup period.
In late 2009 the South African government announced that it had approved a new HIV and AIDS policy in the South African National Defence Force (SANDF). This was widely welcomed by AIDS and human rights lobbyists. A November 2009 statement by the SANDF noted that the new policy made provision for the recruitment and selective deployment of HIV-positive members of the military. The new policy complies with a High Court ruling in May 2008, which found that the previous policy of excluding HIV-positive people from recruitment and foreign deployment was unconstitutional. The new policy draws on a system of classifying soldiers according to their health status and needs. An HIV-positive soldier who is stable and asymptomatic can now be classified as a ‘G2K1’, meaning they have a chronic but treatable disease and can be deployed ‘anywhere at any time’. An HIV-positive recruit is required to be on ante-retrovirals for three to six months before being considered for deployment, and failure to adhere to treatment is grounds for being declared ‘temporarily unfit for deployment and military courses’.
This 20th annual World Report summarises human rights conditions in more than 90 countries and territories worldwide, based on investigative work in 2009 by Human Rights Watch (HRW) staff in partnership with human rights activists in the country in question. HRW notes that attacking human rights defenders, organisations, and institutions aims to silence the messenger, to deflect pressure and to lessen the cost of committing human rights violations. In the report, HRW calls on government supporters of human rights to defend the defenders by identifying and countering these attacks. The report also points out that defense of human rights, including health rights, depends on the vitality of the human rights movement.
5. Health equity in economic and trade policies
This article argues that climate change and aid for trade financing initiatives can be used in a complementary manner to overcome their weaknesses and promote synergies in affected countries. Most less developed countries (LDCs) are more concerned with day-to-day survival than with climate change. A number of these countries have received Aid for Trade (AFT) to help them invest in trade-related economic infrastructure and to build supply-side capacity. Climate change and aid for trade financing initiatives are argued to need greater coherence and complemetarity. One step, it is argued in this paper, is for aid-for-trade initiatives operating largely at the bilateral level in what is argued to be a rather uncoordinated manner to be more formalised and multilateral.
The author of this article believes that trade in services will play a more prominent role in the economic development of the Eastern and Southern Africa (ESA) countries in the coming years. He calls for special attention to be given to strengthening capacity and improving competitiveness in African countries and to providing appropriate flexibility in the sequencing of liberalisation commitments. Services account for between 30% and 60% of the GDP in African countries. Countries with a more developed services sector have tended to adopt an offensive stance in trade negotiations on services, such as with the EU, while the majority of states have favoured a defensive posture. This latter group argues that liberalisation of services trade should be preceded by capacity building to develop the necessary regulatory framework, given that this is lacking in many African countries. Trade liberalisation should not, in their view, be viewed as a magic wand that will inevitably lead to the development of their nascent services sector.
The degree and pace of liberalisation necessary for a free-trade agreement (FTA) to comply with World Trade Organization (WTO) rules (especially Article XXIV of GATT) remains an important discussion point in EPA (economic partnership agreement) negotiations. This article helps clarify the different interpretations of Article XXIV by analysing some 40 free-trade agreements notified to the WTO, including interim EPAs. Developing countries can make proposals for flexibilities in the FTAs they negotiate with developed countries. The concept of asymmetry justifies this approach, and these flexibilities are an important means for adjusting to liberalisation that goes beyond WTO requirements. Two WTO legal texts can be used as a basis: on the one hand, the enabling clause which states that ‘contracting parties may accord differential and more favourable treatment to developing countries, without according such treatment to other contracting parties’, and, on the other hand, the General Agreement on Trade in Services (GATS), which allows some flexibility to developing countries depending on their global and sectorial and subsectorial development level. At a time when the West Africa and Central Africa EPA negotiations have stalled over provisions that would provide more flexibility, the analysis of the FTAs notified to the WTO reveals that there is room to manoeuvre. Indeed, the precedent set in some FTAs is a basis for understanding and accepting the ACP’s request to liberalise 60% – and not 80% – of their market or to benefit from a 25-year transition period.
In this report, the authors allege relief for Indian generic drug manufacturers, as five East African countries – Uganda, Tanzania, Rwanda, Burundi and Sudan – refused in a health meeting to endorse a proposal by the East African Community (EAC) to introduce an anti-counterfeit products law. The law, which could have potentially blocked exports of generic drugs from India because of a lack of clarity on what is counterfeit, had worried the Indian drug industry ever since the 2007 draft proposal by the EAC. East African countries together contribute almost one-fifth of India's Rs40,000 core drug exports. Kenya passed a similar law in 2008 that Uganda had used as a model for its own draft Bill last year, and which was due for implementation this year. The Ugandan Bill has been sent back for review. The members of the East African states present at this regional health meeting refused to endorse the draft proposal and demanded that the definition of generics be what WHO [the World Health Organization] stipulates. The views of trade ministers are, however, not made clear in the report.
This fact sheet contains vital information on counterfeit medicines, especially regarding identification of these medicines. Counterfeit medicines are medicines that are deliberately and fraudulently mislabelled with respect to identity and/or source. Use of counterfeit medicines can result in treatment failure or even death. Public confidence in health-delivery systems may be eroded following use and/or detection of counterfeit medicines. Both branded and generic products are subject to counterfeiting. All kinds of medicines have been counterfeited, from medicines for the treatment of life-threatening conditions to inexpensive generic versions of painkillers and antihistamines. Counterfeit medicines may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient or too much active ingredient, or with fake packaging.
A member of the European Parliament is reported to have argued that trade agreements must not contain clauses on intellectual property rights that could imperil poor people's access to affordable medicines. A veteran member of the European Parliament (MEP), David Martin, is reported to have expressed concern about ‘data exclusivity’ requirements, whereby major pharmaceutical companies would be able to block India’s generic medicines industry from using the formulae with which new drugs are developed for a period of several years. This is because India is a leading exporter of low-priced generic medicines to other developing countries, and such provisions have repercussions for those countries to which generic medicines from India are provided, including African countries.
In this article, the author states that affordability through reduced pricing is only one part of enhancing access to treatment in public health emergencies: supply security and the guarantee of supply consistency is the other. To the extent that patent pooling is able to create regional African manufacturing capability, Africans will support the concept. However, if it further decentralises manufacture away from the continent and increases Africa’s dependence on imports, it can potentially weaken supply security and will continue to relegate Africa a continent of dependency, rather than one that invests in its own capability. The author cautions that patent pooling should be viewed guardedly on the African continent and only be embraced if it is consistent with the AU Heads of State’s call for an African manufacturing plan. Africa must aspire to move from ‘converting charity dollars into sustainable, long term investment dollars’.
German Marshall Fund of the United States: 19 November 2009
This document is a collection of seventeen essays on economic partnership agreements (EPAs) authored by recognised trade experts and senior policy-makers. Their responses constitute a mix of positive and negative elements, reflecting the complexity of the EPA processes. The negative message here is that EPAs are not useful or, at least, that these agreements are not necessarily relevant in light of the challenges faced by poor and vulnerable states, such as the African, Caribbean and Pacific (ACP) countries. The positive message is that all stakeholders continue to strongly believe that the EPAs should and can make a positive difference and that it is therefore possible to shape them for a truly positive outcome. The views expressed here reflect great convergence over the fact that there continues to be a huge trust gap in the negotiations. Whether perceived or observed, there is a persistent impression among ACP negotiators that EPAs are about European interests. Without trust among negotiating parties, chances are scant that negotiations will actually lead to genuine partnerships, as implied by the term ‘economic partnership agreement’.
A waiver to World Trade Organization (WTO) rules intended to aid people in poor countries in gaining access to medicines is reported to have remained essentially unused in the over six-and-a-half years since it was put in place. Member states of the WTO will be holding an informal meeting to discuss this situation and see what, if anything, needs be done. The 2003 waiver was made an amendment in 2005 within the WTO Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement to allow for increased export of medicines made under compulsory licences. This was intended to give a helping hand to nations without a domestic pharmaceutical industry, who might have public health needs for a patented and unaffordable medicine they are unable to produce themselves.
Under TRIPS, compulsory licences are meant to primarily serve a national market, but the TRIPS public health amendment (often referred to as the ‘paragraph 6’ solution referring to the Doha Declaration on TRIPS and Public Health) allows countries with pharmaceutical industries to manufacture and export more medicines under a compulsory licence to countries without them, provided certain conditions are met.
6. Poverty and health
According to this film, global poverty did not just happen. It began with military conquest, slavery and colonisation that resulted in the seizure of land, minerals and forced labour. Today, the problem persists because of unfair debt, trade and tax policies – in other words, wealthy countries taking advantage of poor, developing countries. Actor and activist, Martin Sheen, narrates the film, a feature-length documentary directed by award-winning director, Philippe Diaz, which explains how today's financial crisis is a direct consequence of these unchallenged policies that have lasted centuries. It considers that 20% of the planet's population uses 80% of its resources and consumes 30% more than the planet can regenerate. At this rate, to maintain our lifestyle means more and more people will sink below the poverty line. Filmed in the slums of Africa and the barrios of Latin America, ‘The end of poverty?’ features expert insights from: Nobel prize winners in Economics, Amartya Sen and Joseph Stiglitz; authors Susan George, Eric Toussaint, John Perkins, Chalmers Johnson; university professors William Easterly and Michael Watts; government ministers such as Bolivia's Vice President Alvaro Garcia Linera and the leaders of social movements in Brazil, Venezuela, Kenya and Tanzania.
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.
World Food Programme (WFP) Executive Director Josette Sheeran has urged doctors and medical experts to put their knowledge to work to support the battle against malnutrition, a factor in 10,000 child deaths every day. Speaking at the Royal Society of Medicine in London, Sheeran said that the world already had the ability and knowledge to tackle the challenge of malnutrition. What was lacking was the coordinated focus and political will, she said. 'We need to harness what we know – take the knowledge that we have right now and put it into action. We cannot wait,' she said in remarks to a breakfast meeting with a group of eminent doctors and medical experts. If a child under two is deprived of the nutrition needed for mental and physical growth, the damage is irreversible, Sheeran noted. 'For the world's bottom billion, can we take the technology and what we know, and ensure that there is access to nutrition? And can we stand with those under two year olds and at least make sure they are getting a shot at life?' The costs of undernutrition are high. Without adequate nutrition children cannot learn in school, HIV and AIDS drugs don’t work, populations are more vulnerable to disease and economic growth is undermined, she added.
7. Equitable health services
Cervical cancer is a leading killer among women living with HIV, but a low-cost screening programme developed in Zambia is proving that simple techniques can go a long way in saving lives. New research presented at the 17th Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco has shown that cervical cancer screening among HIV-positive women prevented one death for every 32 women screened. The research originated from a pilot study of about 6,600 HIV-positive women examined as part of the Cervical Cancer Prevention Programme in Zambia (CCPPZ), an ongoing low-cost screening project. More than half the women had abnormal results, and about 20% were diagnosed as having lesions at varying stages from pre-cancerous to advanced cancer. Screening by the programme's service costs about US$1 as compared to pap smears that cost about $15 and remain prohibitively expensive even in richer countries like South Africa. To keep costs this low, the programme enables health workers and nurses to carry out screening and treatment, allowing doctors - already in short supply - to perform other tasks. The screening programme has also drawn interest from other countries, including Botswana, Tanzania and Cameroon, which have sent delegations for training.
This study took the form of a randomised, placebo-controlled, multicenter trial in South Africa and Malawi to evaluate the efficacy of a live, oral rotavirus vaccine in preventing severe rotavirus gastroenteritis. A total of 4,939 infants were enrolled and randomly assigned to one of the three groups: 1,647 infants received two doses of the vaccine, 1,651 infants received three doses of the vaccine, and 1,641 received placebo. Of the 4,417 infants included in the per-protocol efficacy analysis, severe rotavirus gastroenteritis occurred in 4.9% of the infants in the placebo group and in 1.9% of those in the pooled vaccine group. Vaccine efficacy was lower in Malawi than in South Africa (49.4% vs. 76.9%); however, the number of episodes of severe rotavirus gastroenteritis that were prevented was greater in Malawi than in South Africa (6.7 vs. 4.2 cases prevented per 100 infants vaccinated per year). Efficacy against all-cause severe gastroenteritis was 30.2%. In conclusion, human rotavirus vaccine significantly reduced the incidence of severe rotavirus gastroenteritis among African infants during the first year of life.
The expiry of medicines in the supply chain is a serious threat to the already constrained access to medicines in developing countries. This study investigated the extent of, and the main contributing factors to, expiry of medicines in medicine supply outlets in Kampala and Entebbe, Uganda. A cross-sectional survey of six public and 32 private medicine outlets was done using semi-structured questionnaires. The study area has 19 public medicine outlets (three non-profit wholesalers, 16 hospital stores/pharmacies), 123 private wholesale pharmacies and 173 retail pharmacies, equivalent to about 70% of the country’s pharmaceutical businesses. The findings indicate that medicines prone to expiry include those used for vertical programmes, donated medicines and those with a slow turnover. Sound coordination is needed between public medicine wholesalers and their clients to harmonise procurement and consumption as well as with vertical programmes to prevent duplicate procurement. Additionally, national medicine regulatory authorities should enforce existing international guidelines to prevent dumping of donated medicine. Medicine selection and quantification should be matched with consumer tastes and prescribing habits. Lean supply and stock rotation should be considered.
This report is a short update to the WHO report on global tuberculosis (TB) control that was published in March 2009, based on data collected from July to September 2009. It is designed to fill an 18-month gap between the full reports of 2009 (in March) and 2010 (in October), following changes to the production cycle of the report in 2009 that have been made to ensure that future reports in the series contain more up-to-date data. In 2008, there were an estimated 8.9–9.9 million incident cases of TB, 9.6–13.3 million prevalent cases of TB, 1.1–1.7 million deaths from TB among HIV-negative people and an additional 0.45–0.62 million TB deaths among HIV-positive people (classified as HIV deaths in the International Statistical Classification of Diseases), with best estimates of 9.4 million, 11.1 million, 1.3 million and 0.52 million, respectively. The number of notified cases of TB in 2008 was 5.7 million, equivalent to 55–67% of all incident cases, with a best estimate of 61% (10% less than the Global Plan milestone of a case detection rate of 71% in 2008). Among patients in the 2007 cohort, 87% were successfully treated; this is the first time that the target of 85% (first set in 1991) has been exceeded at global level. Funding for TB control has increased since 2002, and is expected to reach US$ 4.1 billion in 2010. Funding gaps remain, however; compared with the Global Plan, funding gaps amount to at least US$ 2.1 billion in 2010.
This report offers a fresh and practical approach to strengthening health systems through ‘systems thinking’. It first decodes the complexity of a health system, and then applies that understanding to design better interventions to strengthen health systems, increase coverage, and improve health. The report suggests ways to more realistically forecast how health systems might respond to strengthening interventions, while also exploring potential synergies and dangers among those interventions. Additionally, it shows how better evaluations of health system strengthening initiatives can yield valuable lessons about what works, how it works and for whom. It is hoped that this report will deepen understanding and stimulate fresh thinking among stewards of health systems, health systems researchers, and development partners.
The objective of the study was to determine the prevalence of musculoskeletal conditions (MSC) and the functional implications in a sample of people attending community health centres in Cape Town, South Africa. It was conducted in clinics in two resource poor communities. A total of 1,005 people were screened. Of these, 362 (36%) reported MSC not due to injury in the past three months. Those with MSC had higher rates of co-morbidities in every category than those without. The mean Disability Index for those with MSC was mild to moderate, and moderate to severe in those aged over 55 years. In conclusion, although the sample may not be representative of the general community, the prevalence is considerably greater than those reported elsewhere, even when the population of the catchment area is used as a denominator. The common presentation of MSC with co-morbid diabetes and hypertension requires holistic management by appropriately trained health care practitioners. Any new determination of burden of disease due to MSC should recognise that these disorders may be more prevalent in developing countries than previously estimated.
South Africa remains the country with the greatest burden of HIV-infected individuals and the second highest estimated tuberculosis (TB) incidence per capita worldwide. This study reviewed records of consecutive HIV-infected people initiated onto ART between 1 January 2005 and 31 March 2006. Patients were screened for TB at initiation and incident episodes recorded. CD4 counts, viral loads and follow-up status were recorded; data was censored on 5 August 2008. Geographic cluster analysis was performed using spatial scanning. Eight hundred and one patients were initiated. TB prevalence was 25.3%, associated with lower CD4 and prior TB. Prevalent and incident TB were significantly associated with mortality. Incident TB was associated with a non-significant trend towards viral load >25copies/ml. A low-risk cluster for incident TB was identified for patients living near the local hospital in the geospatial analysis. The study concluded that there is a large burden of TB in the population. Rate of incident TB stabilises at a rate higher than that of the overall population. This data highlights the need for greater research on strategies for active case finding in rural settings and the need to focus on strengthening primary health care.
8. Human Resources
This dossier offers practical up to date information about how to address human resource problems and issues, drawing upon evidence about what works, and identifying innovations in approaches, policy and practice. Developing countries have committed to achieving the Millennium Development Goals (MDGs). They will need to make the most effective use of all available resources to achieve the MDGs - this includes human resources. Many countries are improving their short and medium term financial planning and budgetary processes but in the past, few, if any, have given human resource management a similar focus. Now, however, human resources are being seen to be as crucial as money in improving services for poor people. Sections include: planning for human resources; strengthening capacity; migration; management issues; international initiatives; and a section focusing on Africa.
This paper highlights and discusses changing patterns of outward migration of Zambian nurses 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 was attributed to a policy of active recruitment by the United Kingdom's National Health Service and Zambia's policy of offering Voluntary Separation Packages: early retirement lump-sum payments promoted by the government, which nurses used towards migration costs. The dramatic decline in migration to the United Kingdom since 2004 was reported to be most likely due to increased difficulties in obtaining United Kingdom registration and work permits. Despite smaller numbers, enrolled nurses were also noted now to be leaving Zambia for other destination countries. This paper 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.
This paper presents and discusses a variety of experiences of faith-based organisations (FBOs) working in rural and remote areas of Anglophone Africa in dealing with human resources for health (HRH). The paper is intended to be used in discussions among people working in the field of HRH or who have tasks related to the management of health staff. It covers a number of case studies, including those in sub-Saharan Africa. It can be used for HRH discussions at different levels - at the level of umbrella organizations of FBOs, at district level, or at health facility level - and in different settings such as decentralised or centralised settings.
9. Public-Private Mix
The Bill & Melinda Gates Foundation has given a grant of US$7 million over five years to the American Cancer Society to lead and coordinate the African Tobacco Control Consortium, a global coalition of public health-oriented organisations focusing on using evidence-based approaches to stem the tobacco epidemic in Africa. According to the International Agency for Research on Cancer, much of the rise in cancer in Africa can be attributed to widespread tobacco use and exposure to secondhand smoke. Tobacco is the leading cause of preventable death in the world, and according to the World Health Organization, if current trends continue, tobacco use will cause one billion deaths worldwide during this century. As the managing organisation, the Society will collaborate with consortium partners to implement an ambitious tobacco control program across the 46 countries of sub-Saharan Africa. The overall goal will be to reduce tobacco use in these countries by implementing proven strategies at the national and local level.
The South African Government Treasury is reported to have set aside an extra R8,4bn for HIV and AIDS over the next three years, reflecting its commitment to improving the quality of services for people affected by the disease and to doubling the number of patients getting life-saving antiretroviral therapy. An increase in funds flowing to provinces through conditional grants for HIV and AIDS and increased budget allocations to to wage increases for doctors, dentists, pharmacists and emergency services personnel, and for therapeutic practitioners such as physiotherapists intend to retain vital skills in the public sector, while a hospital revitalisation grant covers costs of refurbishing public hospitals. Citing Finance Minister Pravin Gordhan, the report notes that these investments seek to improve the public health care sector as part of building a closer partnership between the public and private healthcare systems.
10. Resource allocation and health financing
The WRR Council notes that it is significant that three quarters of Dutch development aid is spent on healthcare and education, and less than a quarter on infrastructure, agriculture and economic activity. Although it is important to provide social care from a humanitarian perspective, the Council adds that it does not automatically lead to the fundamental changes which promote growth and development, and which gradually make countries and peoples self-sufficient. It is important to start approaching development from a far broader perspective. Stability and security, trade conditions that facilitate development, combating tax evasion, a fair tax system which does not entice companies to pay taxes in the Netherlands instead of in developing countries, less stringent intellectual property rights for poor countries, a more productive policy on knowledge exchange, and a more properly thought-out migration policy can all be of greater significance to the development of countries than classical aid provided in situ. The development perspective will have to be better incorporated into policy in these areas, and that calls for more policy coherence for development. Furthermore, attention to global public goods such as financial stability, climate policy and the eradication of contagious diseases will become increasingly important.
This document outlines Greenpeace’s assessment of the decisions taken at the Copenhagen Summit on Climate Change held in Denmark in December 2009. In this, Greenpeace calls for a financial mechanism for dealing with climate change that is transparent and inclusive. At Copenhagen, Governments agreed to establish a Copenhagen Climate Fund, which Greenpeace believes is one step to ensuring that investments take place where they are most needed, noting that developing country action on climate change must have technological and financial support from industrialised countries.
South Africa is reported to be facing large cuts in external funding, such as in falling US funding, for its HIV and AIDS programme over the next five years, despite needing an extra R2-billion a year to reach all those who need antiretroviral treatment. Almost a million South Africans will soon be on lifelong antiretroviral treatment and this number will triple in the next decade if government keeps to its implementation plan. Scenario planning by Treasury indicates that the demand for treatment and care will peak in 2021, when the country would need close to South African Rands 30-billion (about 4.3 billion US dollars).
This information sheet presents evidence on the distribution of benefit of health services in South Africa. Within the public sector, the poor benefit relatively more than the rich from outpatient services at lower levels of care. The rich benefit considerably more than the poor from regional and central hospital services (both outpatient and inpatient services) and also benefit more from public sector inpatient services overall. The rich benefit far more from private sector services than the poor; the richest 40% of the population receive about 70% of the benefits of private outpatient services (from general practitioners, specialists, dentists and retail pharmacies) and nearly 80% of the benefits of inpatient care in private hospitals. Overall, health care benefits in South Africa are very ‘pro-rich’, with the richest 20% of the population receiving more than a third of total benefits while the poorest 20% receive less than 13% of the benefits, despite poor people bearing a much greater share of the burden of ill-health than rich people.
The South African Budget and Expenditure Monitoring Forum meeting in February 2010 was reported to raise a number of issues relevant to antiretroviral (ARV) tenders to ensure adequate supplies of appropriate medicines at the lowest possible prices. The meeting noted the need for co-operation between treasury and health departments to achieve a scale of procurement to use the leverage of the world’s largest ARV treatment programme to get the best possible deals from drug companies.
11. Equity and HIV/AIDS
According to new data presented in this update, new HIV infections have been reduced by 17% over the past eight years. Since 2001, when the United Nations Declaration of Commitment on HIV/AIDS was signed, the number of new infections in sub-Saharan Africa is approximately 15% lower, which is about 400,000 fewer infections in 2008. In East Asia new HIV infections declined by nearly 25% and in South and South East Asia by 10% in the same time period. In Eastern Europe, after a dramatic increase in new infections among injecting drug users, the epidemic has leveled off considerably. However, in some countries there are signs that new HIV infections are rising again. The report highlights that, beyond the peak and natural course of the epidemic, HIV prevention programmes are making a difference. ‘The good news is that we have evidence that the declines we are seeing are due, at least in part, to HIV prevention,’ said Michel Sidibé, Executive Director of UNAIDS. ‘However, the findings also show that prevention programming is often off the mark and that if we do a better job of getting resources and programmes to where they will make most impact, quicker progress can be made and more lives saved.’
Adolescents (aged 10–18) were systematically recruited from acute admissions to the two public hospitals in Harare, Zimbabwe, to answer a questionnaire and undergo standard investigations including HIV testing, with consent. Pre-set case-definitions defined cause of admission and underlying chronic conditions. Participation was 94%. In total, 139 (46%) of 301 participants were HIV-positive, but only four were herpes simplex virus-2 (HSV-2) positive. Age and sex did not differ by HIV status, but HIV-infected participants were significantly more likely to be stunted, have pubertal delay, and be maternal orphans or have an HIV-infected mother. In conclusion, HIV is the commonest cause of adolescent hospitalisation in Harare, mainly due to adult-spectrum opportunistic infections plus a high burden of chronic complications of paediatric HIV and AIDS. Low HSV-2 prevalence and high maternal orphanhood rates provide further evidence of long-term survival following mother-to-child transmission. Better recognition of this growing phenomenon is needed to promote earlier HIV diagnosis and care.
New national treatment guidelines are set to make the world's largest antiretroviral (ARV) programme even bigger as South Africa extends treatment to more HIV-positive infants, pregnant women and people battling HIV-tuberculosis (TB) co-infection. Dr Nono Simelela, CEO of the South African National AIDS Council (SANAC), confirmed that the revised guidelines were in the final stages of editing and would go to print in March, while implementation is scheduled to begin on 1 April 2010. Major changes to the guidelines include providing ARVs to all HIV-positive infants less than one year old regardless of their CD4 count – which measures immune system strength – without having an expensive polymerase chain reaction (PCR) test that is not widely available at clinics to confirm their HIV status. Pregnant HIV-positive women will be able to start treatment at a new, higher CD4 count of 350, as will all TB/HIV co-infected patients, rather than having to wait until their CD4 counts fell to 200 or below as was previously the case. TB remains the leading cause of death among people living with HIV. The shifts in treatment could significantly reduce infant and maternal mortality due to HIV, and lower the rate of new infections.
In 2006, the World Health Organization (WHO) recommended that all patients start anti-retroviral therapy (ART) when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms. WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives. The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.
World Health Organization (WHO) recommendations on infant feeding and HIV were last revised in 2006. Significant programmatic experience and research evidence regarding HIV and infant feeding have accumulated since then. In particular, evidence has been reported that antiretroviral (ARV) interventions to either the HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding. This has major implications for how women living with HIV might choose to feed their infants, and how health workers should counsel mothers when making these choices. The potential of ARVs to reduce HIV transmission throughout the period of breastfeeding also highlights the need for guidance on how child health services should commu¬nicate information about ARVs to prevent transmission through breastfeeding, and the implications for feeding of HIV exposed infants through the first two years of life.
In 2006, the World Health Organization (WHO) recommended that ARVs be provided to HIV-positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother-to-child transmission of HIV. At the time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period. WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs during that period. This will reduce the risk of HIV transmission and improve the infant's chance of survival. ‘In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs,’ said Daisy Mafubelu, WHO's Assistant Director General for Family and Community Health. National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.
The need for empirical evidence on the state of HIV and AIDS in prisons in Kenya which can influence prison specific policy formulation nationally prompted this study. Its objectives included describing the level of knowledge of HIV among male inmates; describing the sexual health knowledge and practices among male inmates before and during imprisonment; determining the prevalence and predictors of HIV infection among male inmates; and examining policy, practice and legal frameworks around prevention of HIV infection in prisons. A cross sectional study design was utilised. Data was collected from inmates and stakeholders involved in HIV and AIDS policy formulation using quantitative and qualitative approaches respectively. Both the inmates and the key informants agreed that consensual and non-consensual sex occurs between inmates. Although not many inmates were found to be abusing drugs, those who were doing so were likely to be first timers in prison. Without underestimating the role played by condoms in HIV prevention, their provision in prisons is not a panacea to the consequences of sexual practice among inmates. There is therefore a need for a comprehensive approach in programming which will be fundamental in alleviating the HIV/AIDS scourge in prisons.
In this study, national antiretroviral therapy (ART) policy is examined over the period of 1999 to 2008, which coincided with the government of President Thabo Mbeki and his Minister of Health, Dr Manto Tshabalala-Msimang. The movement towards a national ART programme in South Africa was an ambitious undertaking, the likes of which had not been contemplated before in public health in Africa. One million AIDS-ill individuals were targeted to be enrolled in the ART programme by 2007/08. Fewer than 50% of eligible individuals were enrolled. This failure resulted from lack of political commitment and inadequate public health system capacity. The human and economic costs of this failure are large and sobering. The total lost benefits of ART not reaching the people who need it are estimated at 3.8 million life years for the period, 2000 to 2005. The economic cost of those lost life years over this period has been estimated at more than US$15 billion.
The Zimbabwe Minister of Health and Child Welfare, Dr Henry Madzorera is reported to have announced plans to increase the number of people on anteretrovirals from the current 180,000 to 300,000 (or 60% of the 500,000 adults estimated to need treatment) using resouces from the Global Fund, the United States President's Emergency Plan for AIDS Relief (PEPFAR), and a basket funding mechanism to which donors contribute for various HIV and AIDS interventions, known as the Expanded Support Programme on HIV/AIDS (ESP).
12. Governance and participation in health
The European Parliament in considering the second review of the Cotonou Agreement between European and African and Caribbean states, deplored the fact that the Parliament, the ACP-EU Joint Parliamentary Assembly (JPA), national parliaments of the ACP (African, Caribbean and Pacific) States and civil society organisations and non-state actors were not involved in the decision-making process that led to the identification of areas and articles of the Cotonou Agreement for revision and to the establishment of the negotiating mandates adopted by the Council of the European Union (EU) and the ACP Council of Ministers. This omission was argued to affect the transparency and credibility of the revision process and to alienate EU and ACP populations from their governments and institutions. The Parliament stressed the need to consolidate the political dimension of the Cotonou Agreement, particularly in respect of the commitment of the parties to implement the obligations stemming from the Rome Statute of the International Criminal Court. The European Parliament called on the Commission, the EU and the ACP Council to take into account the principles and results of the International Aid Transparency Initiative, and to launch a debate, involving also non state actors, on the future of ACP-EU relations post-2020.
Distinguishing between ‘(good) governance’ as a process and an outcome, this paper examines both the processes and outcomes of governance in the context of the European Union’s (EU) relationship with African, Caribbean and Pacific (ACP) States within the period of the Cotonou Agreement (CA). It discusses and assesses a variety of governance mechanisms, including the European Commission’s use of the governance concept, economic partnership agreements (EPAs), manifestations of partner preferences, the revision of the CA, and Fisheries Partnership Agreements. Specific examples of the wielding of each mechanism are assessed based upon two criteria: the extent to which the wielding of the mechanism by the EU is a manifestation of ‘good governance’, and the extent to which the EU’s wielding of the mechanism has resulted, or is likely to result, in the sustainable development of and reduction of poverty in ACP countries. The examples are chosen to illustrate contradictions between rhetoric and practice and the consequential negative (actual and potential) impact upon development in ACP States. The final section offers suggestions for improving the EU’s governance processes and their outcomes for development.
In this book the author cautions against promises of the market as a means to meeting the challenges of social change. The author proposes that real change will come when business acts more like civil society, not the other way around, as business by its very nature is not equipped to attack the root causes of poverty, inequality, violence, and discrimination. Achieving fundamental social transformation requires a different set of operating values – cooperation rather than competition, collective action more than individual effort, and patient, long-term support for systemic solutions over immediate results. He argues that people give their money and time to social change organisations to serve a cause, not a balanced quarterly spreadsheet. With a vested interest in the status quo, all business can promise are valuable but limited advances: small change, in comparison to the more sweeping transformation that can be brought about by social action.
This study proposes to sketch out an overview of the challenge of accountability within donor countries, and includes a few innovative initiatives set up by these countries to reinforce the demand for accountability, as well as to advance the production of ‘accountable’ information and diversify the tools for disseminating agencies’ action and for opening the debate. It aims to find the thread linking services provided by different agencies, to understand how they interface and what their limitations are. The study poses and attempts to answer the following questions: What is the ‘accountability demand’ currently levelled at development agencies? How can the tools for producing and disseminating information be ‘grown’ so as to meet the mounting accountability objective? How can the agencies’ accountability targets and tools be broadened to better answer the needs for information and dialogue of the stakeholders and the public at large?
13. Monitoring equity and research policy
Country teams from ten low- and middle-income countries (LMICs), including Tanzania, participated in the development and testing of a questionnaire to assist researchers, policymakers, and healthcare providers to describe and monitor changes in efforts to bridge the gaps among research, policy and practice. The study found that internal consistency (Cronbach's alpha) for sets of related items was very high, ranging from 0.89 to 0.96, suggesting some item redundancy. Both face and content validity were determined to be high. Assessments of construct validity using criterion-related measures showed statistically significant associations for related measures. Assessments using convergent measures also showed significant associations. In conclusion, while no direct comparison can be made to a comparable questionnaire, the findings do suggest a number of strengths of the questionnaire but also the need to reduce item redundancy and to test its capacity to monitor changes over time.
Country teams from ten low- and middle-income countries, including Tanzania, participated in the development, translation, pilot-testing and administration of a questionnaire designed to measure health-care providers' views and activities related to improving their clinical practice and their awareness of, access to and use of research evidence, as well as changes in their clinical practice that they attribute to particular sources of research evidence that they have used. The study found that the questionnaire had high internal consistency, with Cronbach's alphas between 0.7 and 0.9 for 16 of 20 domains and sub-domains (identified by factor analyses). Cronbach's alphas were greater than 0.9 for two domains, suggesting some item redundancy. In conclusion, the analysis points to a number of strengths of the questionnaire – high internal consistency (reliability) and good face and content validity – but also to areas where it can be shortened without losing important conceptual domains.
The act of telling a story is a deceptively simple and familiar process, a way to evoke powerful emotions and insights. By contrast, working with stories in organisational settings – to aid reflection, build communities, transfer practical learning or capitalise experiences – is more complicated. This guide is designed to create story-telling skills and confidence. It provides ideas about development cooperation contexts in which stories can be an effective communication tool. The authors argue that story telling is not suitable for every situation. Methodologies should be selected by practitioners with due care to the wider working context and intention. Some methods, for example the systemic introduction of story into core organisational processes such as evaluation, need patience and management backing over a long period, for the right approach to be developed through trial and error.
This article explores the use of multimedia to enhance development enquiry and analysis, and the design and implementation of process interventions aimed at poverty alleviation in sub-Saharan Africa. It discusses some important interventions in Africa: the Catalyzing Access to ICT in Africa (CATIA) programme; the LINK Centre (University of the Witwatersrand); the Acacia Initiative; the African Information Society Initiative (AISI); the APC (Association for Progressive Communications); and Research ICT Africa. Despite these interventions, Africa still faces problems of access and use of these interventions and services, especially among poor and vulnerable people. The areas of weakness include: poor performance in the telecommunications sector; little e-access and use in small and medium enterprises; and absence of an equitable system of intellectual property rights that is friendly to developing countries in sub-Saharan Africa. As a result the author observes barriers to access often expensive, modern technologies.
The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. According to this article, the target is critically off track. Despite difficulties inherent in measuring maternal mortality, it notes that interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV and AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. The article analyses historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa.
Only 5.4% of the world's population was covered by comprehensive smoke-free laws in 2008, up from 3.1% in 2007, according to the World Health Organization’s (WHO) second report on the global tobacco epidemic. The report also describes countries' efforts to implement the tobacco control package called MPOWER, which WHO introduced in 2008 to help countries implement some of the demand reduction measures in the WHO Framework Convention and its guidelines. These measures are: monitor tobacco use and the policies to prevent it; protect people from tobacco smoke; offer people help to quit tobacco use; warn about the dangers of tobacco; enforce bans on tobacco advertising, promotion and sponsorship; and raise taxes on tobacco. Less than 10% of the world's population is covered by any one measure, the report states. The report tracks the global tobacco epidemic, giving governments and other stakeholders a tool to see where evidence-based demand reduction interventions have been implemented and where more progress is needed. It gives country-by-country tobacco use prevalence figures as well as data about cigarette taxation, bans on tobacco advertising, promotion and sponsorship, support for treatment of tobacco dependence, enforcement of tobacco-free laws and monitoring of the epidemic.
14. Useful Resources
Fifteen years after the International Conference on Population Development, a large global family of development workers committed to universal access to sexual and reproductive health (SRH) continue to work on improving the lives and expanding the choices of individuals and couples. This guide considers reproductive health as a human right, while it notes that reproductive health conditions are the leading cause of death and illness in women of childbearing age worldwide. At least 200 million women who want to plan their families or space their births lack access to safe and effective contraception. Investments in reproductive health save and improve lives, slow the spread of HIV and encourage gender equality. These benefits extend from the individual to the family and from the family to the world. Yet resources allocated for improving SRH are scarce and needs are urgent. The guide aims to help practitioners to use limited resources in the most effective way. Contributors to the guide have developed and used many tools and methodologies to promote SRH – these are streamlined in the guide for the busy programme manager at national or district level.
The European Union (EU) established this projects database in December 2008. It ‘includes information about projects, conferences, and operating grants funded through calls for proposals in the years 2003 to 2008 under the previous EU Public Health Programme and the current EU Health Programme 2008-2013’.
This guide is an attempt to help humanitarian aid agencies look a generation into the future to begin making the necessary changes now to their thinking and organisation, to ensure that they continue to deliver the right assistance and protection to the right people in the right ways. It examines possible future scenarios and the consequences they may bring with them for humanitarian agencies. Three central themes emerge: the emergence of a ‘new humanitarianism’ that will be part of neither the humanitarian nor development systems; the continued growth of information, communication and technology tools; and strategic leadership that is central to humanitarian action in an increasingly uncertain world. Navigating these dynamics is noted to require leadership that is comfortable with ambiguity and risk, drawing on evidence and data, but not constrained by its absence. According to the guide, agencies need a leadership that encourages dissent and experimentation, in organisations that are flatter, able to implement functions of both ground delivery and global analysis.
The AIDS and Law Exchange (AIDSLEX) is a new website that may be used as an online resource tool for activists, community organisations, researchers, policy-makers, journalists, health workers and anyone who seeks quick and easy access to a wide range of resources about HIV, human rights and the law. It helps people around the world communicate and share information, materials and strategies, with the ultimate goal of contributing to a global effort to protect and promote the human rights of people living with or vulnerable to HIV and AIDS.
African Networks on Ethnomedicines, the publisher of African Journal of Traditional, Complementary and Alternative Medicines (AJTCAM) has launched an interactive forum for traditional medical practitioners. It is hoped that it will prove to be a useful resource for traditional medical practitioners and others in uplifting the standard of traditional medicines and alternatives medicines. In order to post on this forum, you may register with your username and password. If you have registration problems, enable cookies on your browser.
The South South North (SSN) network adopts a pragmatic approach to tackling climate change and sustainable development. This module incorporates the main approaches and provides a toolkit for practitioners wishing to implement mitigation and/or adaptation in communities in developing countries. These tools and methodologies are gleaned from a learning-by-doing approach from projects implemented in countries like South Africa, Tanzania and Mozambique. The SSN mitigation programme describes the SSN Matrix Tool of criteria and indicators for appraising sustainable development projects. The SSN adaptation programme details the community based approach to adaptation (CBA) and details the SSN Adaptation Project Protocol ‘SSNAPP’ methodology, including the selection of community-based projects, and ‘mapping’ of vulnerable areas. This is followed by a ‘bottom-up’ approach of identifying a beneficiary community, to confirm vulnerability ‘hotspots’ and learn about current coping mechanisms to incorporate into an adaptation strategy. The SSN capacity building approach deals with indicators of sustainability. The SSN technology receptivity programme describes the steps for identifying and contributing to the technical receptivity and capacity of the programme.
Developed in direct consultation with researchers, the newly launched open beta version of the UK PubMed Central (UKPMC) site offers a whole range of new search and data mining tools designed to unlock the scientific knowledge held by the repository. It will enable researchers to search and link information from literature and drill down into underlying datasets in new and innovative ways. The easy-to-use, intuitive interface developed by the British Library for the latest open beta version will enable researchers to: conduct a full-text search of 1.7 million articles; access abstracts for over 19 million articles; exploit the scientific literature with innovative features that enrich abstracts and full-text articles by linking scientific terms to other sources of quality-assured and useful information; and search content not included in traditional journal literature – including clinical guidelines, as well as other hard-to-find material such as PhD theses.
15. Jobs and Announcements
The International People's Health University (IPHU) of the People's Health Movement (PHM) and The Great Lakes University of Kisumu (GLUK) are holding a ten-day short course for health activists scheduled in Kisumu, Kenya 19-28 April, 2010. The course will be conducted in English. A limited number of scholarships for travel and accommodation will be available for qualified applicants from sub-Saharan Africa and Kenya. Younger health activists and practitioners working on the issues of health, gender and human rights and particularly including those involved in the People’s Health Movement (PHM). Applications are particularly welcomed from from women and from South Africa, Botswana, Congo, Tanzania, Namibia and Ghana. Applicants should be fluent in English. Priority, with respect to enrolment, will be given to younger people motivated to get involved in PHM, primary health care and public health practitioners, and people with a track record as health activists within the PHM, in particular those who have been actively involved in organisations that are part of the PHM.
The Symposium is the first of its kind targeting a multi-disciplinary field and audience and will gather researchers, policy-makers, funders and other stakeholders in a three-day conference. Researchers, policy-makers, funders, and other stakeholders representing diverse constituencies will meet from 16–19 November 2010 in Montreux, Switzerland, to share evidence, identify significant knowledge gaps, and set a research agenda that reflects the needs of low and middle-income countries. Themes include: political economy of universal health coverage; health system financing; scaling-up of health services; monitoring and evaluation; knowledge translation; terminology, taxonomies and frameworks; methods for health science research (HSR) and knowledge translation; measures used in HSR; capacity building for HSR; and multidisciplinary approaches.
In just two weeks, nearly half a million people have signed the global petition against Uganda's proposed law to sentence gay people to death and jail their friends. But more is needed. Extremists are escalating their rhetoric, with one pastor showing gay pornography in order to whip up rage. But very few Ugandans know the harsh details of this draconian bill. And no public opinion poll has asked whether the Ugandan people would support such mass execution. The Ugandan movement against the bill hasn't had the resources to inform their fellow citizens about the bill's deadly provisions. If enough people contribute, Avaaz can help launch radio spots, newspaper ads and billboard campaigns that reach millions of Ugandans with the truth and a call to protect human rights. Donate now to fuel the defence of rights in Uganda.
Diplomacy is undergoing profound changes in the 21st century - and global health is one of the areas where this is most apparent. As health moves beyond its purely technical realm to become an ever more critical element in foreign policy, security policy and trade agreements, new skills are needed to negotiate global regimes, international agreements and treaties, and to maintain relations with a wide range of actors.
The summer course will focus on health diplomacy as it relates to health issues that transcend national boundaries and are global in nature, discuss the challenges before it, and how they are being addressed by different groups and at different levels of governance. Deliberations include Intellectual Property Rights, the Framework Convention on Tobacco Control, the International Health Regulations, the creation of new finance mechanisms such as the Global Fund for Aids, Tuberculosis and Malaria or UNITAID, and the response to SARS and Avian Flu. The course director is Prof. Dr. Ilona Kickbusch. Tuition for attending the programme is 2,800 Swiss francs, excluding travel costs, accommodation or other living expenses in Geneva.
DL4D (Distance Learning for Development) offers postgraduate training to those working in the field of international development. This site has information on over 140 short courses available to study at a distance. They cover the range of skills and knowledge areas expected of the international development professional, including: essential skills for implementing and managing projects in developing countries; introductions to macro-level economic and policy-making practice; and advanced courses in health, sanitation, agriculture and environmental studies. All courses are available as stand-alone units of study. They may also contribute towards a broader programme of learning, leading to internationally recognised higher-level qualifications. Some courses are only available at certain times of year. Check the details of the courses you are interested in for more information.
The Susie Smith memorial prize of £3000 will be awarded to a single piece of already published writing on HIV and AIDS from sub-Saharan Africa. Any type of piece – (e.g. poetry, fiction, article, chapter of a book) – of up to 10,000 words, in English, and published since January 2006, will be eligible. The judges will focus on two key elements: Quality of the piece itself (writing, analysis, insights); and evidence of impact of the writing in the media and/or with people, governments or other institutions. All submissions must be received by 18th April 2010 and include a cover letter outlining what kind of impact the piece has had and/or what it has achieved sent to Susie Smith Memorial Prize Submission
Oxfam Great Britain Oxfam House John Smith Drive Oxford OX4 2JY.
The European Development Fund is offering grants for its ARIAL programme. The overall objective of the programme is to promote the political recognition and engagement of the local authorities (LAs) as important players and partners of development. The specific objective of the programme is to promote and strengthen the capacity of LAs in African, Caribbean and Pacific (ACP) countries. In particular it seeks to strengthen LA representative institutions from the national level up to the international level so that they will be able to take part in the implementation of development policies, in particular with the European Union, and play a political role as provided for by the Cotonou Agreement. The core target group will be existing national and regional local authority associations, which are still to be identified by the successful candidates. Applicants will explain the methodology with which they plan to select/or have already selected the associations who will receive their support. Any selection process should ensure the effective representation of all ACP regions, and, where possible, all ACP countries. The successful candidate will ensure that existing associations, who most effectively represent local authorities, will receive support.
The 2010 Humanitarian Fund is now accepting applications. The Fund, supported by donations from the BMA and Royal College of Nursing, offers grants of up to £3,000 for projects taking place in developing countries. Projects must offer clear health benefits to the local population, must involve at least one current National Health Service employee and should have a sustainable impact. The grants will cover incidental costs such as travel and accommodation only (not equipment or drugs). For more details on the Fund please contact the BMA’s International Dept at the email address given or complete and return the application form on their website.
World Health Day, 7 April 2010, will focus on urbanisation and health. The theme was selected in recognition of the effect urbanisation has on our collective health globally and for us all individually. Tell the world about what is happening in your city and exchange ideas with people from around the globe. Go to the campaign social media site to join the discussion, upload your videos and photos and nominate your urban health hero. With the campaign 1000 cities, 1000 lives, events will be organised worldwide during the week of 7 – 11 April 2010. The global goals of the campaign are: 1,000 cities – to open up public spaces to health, whether it be activities in parks, town hall meetings, clean-up campaigns, or closing off portions of streets to motorised vehicles – and 1,000 lives – to collect 1,000 stories of urban health champions who have taken action and had a significant impact on health in their cities.
This will be the first time MEDINFO is held in Africa. The Congress aims to boost exposure to grassroots healthcare delivery and the underpinning health information systems, as well as to open the door to new academic partnerships into the future and help to nurture a new breed of health informaticians. The theme for the Congress is ‘Partnerships for effective e-health solutions’, with a particular focus on how innovative collaborations can promote sustainable solutions to health challenges. Information and communication technologies may 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. To this end, the Congress brings together the health informatics community from across the globe who are seeking to work together and share experiences and knowledge to promote sustainable solutions to global health challenges.
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