EQUINET NEWSLETTER 110 : 01 April 2010

1. Editorial

Keeping an eye on equity: Community visions of equity in health
EQUINET Eye on equity team: R Loewenson, T Loewenson, B Kaim, M Chigama, S Juma, J Musingye, D Baatjies, A Zulu Lishandu, M Ulola, S Ally Joe, D Masuku, J Ongala, A Muhinda, M Masaigana, A Ryklief, C Mbwili, A Baba, W Nelson, S Mbuyita

“I feel free- I am liberated by this new skill- I am now able to communicate my world.”
Meso Ulola, a community member from Bunia, eastern Democratic Republic of Congo pointed to his camera as the instrument of his liberation. Behind him a sequence of photographs from his community told a story: a pregnant woman blocked by a river from the road to health services; community members discussing issues around chalk images on a board; young men heaving logs across a river and images of a motorbike crossing a newly constructed bridge.

In the last five years EQUINET has through Training and Research Support Centre and Ifakara Health Institute been supporting institutions that work at community level to carry out participatory action research studies in east and southern Africa. In each of the nine country sites, in both rural and urban settings, these studies have explored how communities are interacting with health systems. The issues they addressed ranged from how to overcome the barriers people who consume harmful levels of alcohol face in adhering to ante-retroviral treatment, to how to improve communication between people and health workers in local health planning. The reports of these studies can be found on the EQUINET website (www.equinetafrica.org). However, we struggled with how the communities involved could themselves communicate the realities of their lives, actions and insights, and be useful to community discussion on how to address the determinants of health.

We proposed to use photography as one tool for this. Facilitators and community members from the participatory work in seven sites coming from DRC, Kenya, South Africa, Tanzania, Uganda, Zimbabwe and Zambia were trained in photography skills and we embedded photography within the participatory work. We wanted the photos to express the lives of the people involved, to show the diversity of views, to allow both painful and hopeful images to surface, to pose questions, probe, give visions of solutions and actions. The photos were as much a means to encourage local community discussion as to raise wider awareness and community voice on issues. This was not an academic exercise, or about outsiders documenting people as victims, but about community members documenting their own situation and actions to improve social justice in health. We called it “Keeping an eye on equity: Community visions of equity in health”.

It wasn’t straightforward. How to recharge batteries of cameras in communities that had no electricity? How to share photographs so all could comment when internet access is limited and slow? However even from remote areas in Western Kenya or a border town in Zimbabwe, the photos were uploaded to a shared website, we sent comments to each other, and the stories began to emerge through the images. After several months, the photographers chose those images that best communicated their reality and stories. These were compiled, have been shown locally in each setting in different ways, and will be used in ongoing work. They were also compiled by TARSC into an exhibit from all the countries at EQUINETs regional conference on equity in health in September 2009, and used to stimulate discussion on the issues raised, and on the power of different kinds of evidence in catalyzing action on health equity. As one participant at the conference commented: “From other sources of evidence I imagined reality. From the photos I saw reality”.

Some of this work is now produced as a book newly available on the EQUINET website at www.equinetafrica.org/bibl/docs/Eye%20on%20Equity%20book2010.pdf. The book introduces and communicates the work underway, and opens discussion on community photography as a tool for change.

Did we achieve our goal, of raising reality and issues as communities see them, and giving communities more direct voice in advancing equity in health?

When we brought the work of all the countries together, new patterns emerged. For example children and women featured strongly across the images. Its clear that we feel injustice strongly when we see children in unfair and harmful situations. It motivates us to act. Women constantly appeared in the images as active not passive. The images showed how women, often invisibly, are using the resources available to take diverse actions for health. The photographs provided a new lens to discuss what was going on in communities, often raising issues that had become invisible or hidden. Discussing the experience, the community photographers observed that “the camera allowed is to connect with people in unexpected ways, and to hear people’s opinions of their health and health care. The camera seemed to open new channels of communication, raising issues that may otherwise have been buried”. Others observed, “our photographs made us look afresh at unhealthy situations. They have also encouraged us by showing what we have achieved”.

This is important given that our participatory research showed that our health systems have high legitimacy, but weak capabilities for social roles. They weakly address barriers and facilitators to uptake of services and there are many communication gaps between health workers and communities. These issues are well within our grasp to change, but communication is vital for this. The most vulnerable in communities often face an imbalance in power, skills and common language in communicating with health workers, and may deal with this by dropping out of services. Our experience suggests that community photography, embedded within participatory, collective processes, may be one way of offering new power to communities to collectively show their realities, without feeling limited by language.

The way we use and respond to photography has as much to with reclaiming the resources for health as the way we implement research or use evidence. We are bombarded by visual images every day of our lives – pictures on billboards, on many of the consumer products we buy, in leaflets, posters, books, on television or media. Every day we unconsciously interpret and respond to these images, influencing our attitudes, beliefs, values and life style. As Susan Sontag said in 1973, photographs invite us to think or feel in particular ways and “… are inexhaustible invitations to deduction, speculation and fantasy.” In our work as health facilitators and activists, we see that photography in the hands of communities has the potential not only to give communities the power to present reality as they see it, but to use these images to move people from a point of feeling to questioning, to thinking about what change is needed. This is the power of the visual in the right context – to play a part in this process.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read the PRA reports on the EQUINET website and the Eye on Equity Book.

2. Latest Equinet Updates

Discussion paper 80: Implementation of the TRIPS flexibilities by east and southern African countries: Status of patent law reforms by 2010
Munyuki E and Machemedze R: January 2010

Least developed countries have until 2016 to reform their IP regimes and enact new patent laws in line with Trade-related Aspects of Intellectual Property Rights (TRIPS) Agreement of the World Trade Organisation (WTO). A number of amendments to the TRIPS agreement were made – TRIPS 'flexibilities' – to take care of the health-related concerns of developing countries. Member states have the authority to use these flexibilities when this is necessary to protect public health and to promote access to medicines. The Southern and Eastern African Trade, Information and Negotiations Institute (SEATINI), under the umbrella of the Regional Network for Equity in Health in East and Southern Africa (EQUINET), carried out an assessment of LDCs in East and Southern Africa with regard to their progress towards the new intellectual property (IP) regimes. The study reviewed the situation in sixteen east and southern African countries through a desk review of published and grey literature. The study found that most of the IP regimes currently in ESA countries were in existence before the TRIPS agreement was adopted. These included laws that provide some flexibilities, which were in most cases not being implemented. Only Mauritius and Zambia have formally adopted the protocol amending the TRIPS agreement at the WTO. The December 2009 deadline has been further extended to the end of December 2011 and it is important for all ESA countries to formally adopt the proposal by then to avoid unnecessary renegotiations of the TRIPS amendments. This paper presents a number of recommendations on how ESA countries should apply and implement the TRIPS flexibilities.

EQUINET: Regional network for Equity in Health in east and southern Africa
TARSC and EQUINET: March 2010

The Regional Network on Equity in Health in east and southern Africa (EQUINET) is a network of professionals, civil society members, policy makers, state officials and others within the region who have come together as an equity catalyst, to promote and realise shared values of equity and social justice in health. This brief outlines EQUINET's mission, organisation, areas of work and resources.

Keeping an eye on equity: Community visions of equity in health
Loewenson R, Loewenson T, Kaim B, Chigama M, Juma S, Musingye J, Baatjies D, Zulu Lishandu A, Ulola M, Ally Joe S, Masuku D, Ongala J, Muhinda A, Masaigana M, Ryklief A, Mbwili C, Baba A, Nelson W and Mbuyita S: EQUINET, March 2010

Photographs speak louder than words. This book presents photographs taken by community photographers in seven east and southern African countries: the Democratic Republic of Congo, Tanzania, Zimbabwe, Kenya, Uganda, South Africa and Zambia. We called our photographers the ‘Eye on equity’ team because the work was part of EQUINET’s participatory action research work. Implemented through institutions in east and southern Africa, this work investigated, documented and implemented actions to understand and promote equity in health. We added photography as another tool to build and strengthen people-centred health systems and people’s empowerment in health. The book presents images of equity in health and of actions to improve health. These are the stories of insiders: of members, health workers and health activists in the communities that are shown in the photographs. The photographs are being used to stimulate discussion of health issues and actions. The book thus introduces both the realities and the work underway. It opens discussion on community photography as a means of keeping an eye on equity and as a tool for change. The web version is for onscreen viewing. For a hard copy of the book please contact us at the email address given.

3. Equity in Health

An overview of the food security situation in eastern Africa
Mukhebi A, Mbogoh S and Matungulu K: United Nations Economic Commission for Africa (UNECA), 2010

This report presents the preliminary findings of a study undertaken in six pilot countries – Uganda, Rwanda, Kenya, Tanzania, Burundi and DR Congo. The objectives of the study were to provide a detailed assessment of food security-related initiatives, plans and strategies and also to describe the status of food security in the six countries. Based on the experiences and lessons learnt thereof, the study proposed ways of enhancing synergies and coherence between the identified food security initiatives of the regional economic communities (RECs), inter-governmental organisations (IGOs) and individual member states within Eastern Africa, to strengthen regional and country-specific partnerships in the development of a regional food security programme for Eastern Africa.

Keeping the promise: A forward-looking review to promote an agreed action agenda to achieve the Millennium Development Goals by 2015
Ki-Moon B, United Nations Secretary-General: 12 February 2010

This report, which is issued pursuant to General Assembly resolution 64/184, presents information on progress made in achieving the Millennium Development Goals through a comprehensive review of successes, best practices and lessons learned, obstacles and gaps, and challenges and opportunities, leading to concrete strategies for action. It consists of four main sections. The introduction examines the importance of the Millennium Declaration and how it drives the United Nations development agenda. The second section reviews progress on achieving the Millennium Development Goals, presenting both shortfalls and successes in the global effort and outlines emerging issues. The third section sums up lessons learned to shape new efforts for accelerating progress to meet the Goals and identifies key success factors. The fourth and final section lists specific recommendations for action. The report calls for a new pact to accelerate progress in achieving the Goals in the coming years among all stakeholders, in a commitment towards equitable and sustainable development for all.

Multidrug and extensively drug-resistant tuberculosis: 2010 global report on surveillance and response
World Health Organization: 2010

This report includes data on testing for extensively drug-resistant tuberculosis (XDR-TB) from 46 countries that have reported continuous surveillance or representative surveys of second-line drug resistance among multidrug-resistant tuberculosis (MDR-TB) cases. Combining data from these countries, 5.4% of MDR-TB cases were found to have XDR-TB. Eight countries reported XDR-TB in more than 10% of MDR-TB cases. To date, a cumulative total of 58 countries have confirmed at least one case of XDR-TB. According to the Stop TB Partnership’s Global Plan to Stop TB, 2006–2015, 1.3 million MDR-TB cases will need to be treated in the 27 high-burden countries between 2010 and 2015 at an estimated total cost of US$ 16.2 billion. The current level of funding in 2010 – including grants and other loans – in these countries is US$ 0.4 billion. Mobilisation of both national and international resources is urgently required to meet the current and future need. The funding required in 2015 is predicted to be 16 times higher than the funding that is available in 2010.

The shifting demographic landscape of pandemic influenza
Bansal S, Pourbohloul B, Hupert N, Grenfell B and Meyers LA: Public Library of Science ONE 5(2), 26 February 2010

As pandemic (H1N1) influenza spreads around the globe, it strikes school-age children more often than adults. Although there is some evidence of pre-existing immunity among older adults, this alone may not explain the significant gap in age-specific infection rates. Based on a retrospective analysis of pandemic strains of influenza from the last century, this study shows that school-age children typically experience the highest attack rates in primarily naive populations, with the burden shifting to adults during the subsequent season. Using a parsimonious network-based mathematical model, which incorporates the changing distribution of contacts in the susceptible population, it demonstrates that new pandemic strains of influenza are expected to shift the epidemiological landscape in exactly this way. The analysis here provides a simple demographic explanation for the age bias observed for H1N1/09 attack rates, and suggests that this bias may shift in the future. These results have significant implications for the allocation of public health resources for H1N1/09 and future influenza pandemics.

Trends in human development
Rodríguez FR: United Nations Development Programme, 15 March 2010

According to this report, the past four decades have, by and large, been a time of substantial progress in human development for the world as a whole. The world’s average Human Development Index (HDI) grew by 29% in this period. Only one of the 111 countries in the dataset saw a decline in its HDI since 1970 – Zambia. Strikingly, the improvements in the HDI come from improvements in education and health. But the author warns that one cannot assume that free-market globalisation has brought these benefits to people in the developing world. Instead, he points to current evidence that shows that the massive increases in education and health achieved over the past 40 years had little if anything to do with globalisation but rather with the decision by states to expand their educational and health systems, coupled by initiatives of the international community to enable access to vaccines and antibiotics. He refers to research that shows that the correlation between economic growth and changes in the non-income components of human development is nearly zero. These results, he suggests, indicate that the oft-repeated dictum that economic growth is a necessary condition for increasing human development is simply not true.

4. Values, Policies and Rights

Online protest fails to halt Uganda’s anti-gay bill
Plus News: 2 March 2010

More than 450,000 people have signed an online petition urging Uganda's parliament to drop a bill that would impose the death sentence when a positive person has sex with someone of the same sex who is disabled or under the age of 18. On 1 March, the petition was presented to the speaker of Uganda's Parliament, Hon Edward Ssekandi, by the country’s AIDS activists, including founder of the national non-governmental organisation, The AIDS Support Organization, Noerine Kaleeba, and Canon Gideon Byamugisha, the first religious leader to publicly declare that he was living with HIV. Responding to the petition, Hon Ssekandi said it could not be withdrawn at this stage, not even by the MP who tabled it; but he assured the activists that their concerns would be passed on to the legislature. The legislature would debate passing the bill, amending it or not passing it. Homosexuality is illegal in Uganda, but the new law would impose more stringent punishments for homosexual activity, while compelling people in authority with knowledge of such activity to report it or face criminal charges.

Policy development in malaria vector management in Mozambique, South Africa and Zimbabwe
Cliff J, Lewin S, Woelk G, Fernandes B, Mariano A, Sevene E, Daniels K, Matinhure S, Oxman A and Lavis J: Health Policy and Planning (Advance Access), 21 February 2010

Indoor residual spraying (IRS) and insecticide-treated nets (ITNs), two principal malaria control strategies, are similar in cost and efficacy. This study aimed to describe recent policy development regarding their use in Mozambique, South Africa and Zimbabwe. Using a qualitative case study methodology, semi-structured interviews of key informants were undertaken from May 2004 to March 2005, and a document review was carried out. Most respondents in the study strongly favoured one strategy over the other – IRS versus ITNs. In all three countries, national policy makers favoured IRS, and only in Mozambique did national researchers support ITNs. Outside interests also played a significant role in influencing policy. Research evidence, local conditions, logistic feasibility, past experience, reaction to outside ideas, community acceptability, the role of government and non-governmental organisations, and harm from insecticides used in spraying influenced the choice of strategy. In conclusion, it may be time for policy makers to consider changing from their favoured IRS strategy, while those intending to promote new policies such as ITNs should examine the interests and ideas motivating key stakeholders and their own institutions, and identify where shifts in thinking or coalitions among the like-minded may be possible.

Tuberculosis and air travel: A systematic review and analysis of policy
Abubakar I: The Lancet Infectious Diseases 10: 176–83, 2010

WHO international guidelines for the control of tuberculosis (TB) in relation to air travel require – after a risk assessment – tracing of passengers who sat for longer than eight hours in rows adjacent to people with pulmonary TB who are smear positive or smear negative. A further recommendation is that people with active TB should not carry out commercial air travel until the person has two consecutive negative sputum smears for drug-susceptible TB or two consecutive cultures for multidrug-resistant TB. This review examines the evidence put forward to support these recommendations and assesses whether such an approach is justifiable. A systematic review identified 39 studies of which 13 were included. The majority of studies found no evidence of transmission. Only two studies reported reliable evidence of transmission. Various factors made the screening process highly inefficient, including time and money spent on tracing and investigating passengers who tested positive and contacting different national authorities in the course of investigations. The analysis suggests that there is reason to doubt the value of actively screening air passengers for infection with TB and that the resources used might be better spent addressing other priorities for the control of the disease.

Women’s empowerment lifts obstacles to achieving development goals, Ban says
United Nations News Centre: 3 March 2010

More than a decade after world leaders agreed to eliminate all forms of discrimination against women, their empowerment remains a necessary element in attaining development targets, said United Nations (UN) Secretary-General Ban Ki-moon, addressing the Commission on the Status of Women in the run-up to International Women’s Day, which is observed annually on 8 March. ‘Until women and girls are liberated from poverty and injustice, all our goals – peace, security, sustainable development – stand in jeopardy,’ Ban said. This year is the 15th anniversary of the adoption of the Beijing Declaration and Platform for Action – the outcome of the Fourth World Conference on Women in Beijing in 1995 – which remains the most comprehensive global policy framework to achieve the goals of gender equality, development and peace. In September 2009, it was announced that four UN agencies and offices – including the UN Development Fund for Women (UNIFEM) – will be amalgamated to create a new single entity within the world body to promote the rights and well-being of women worldwide and to work towards gender equality. Mr Ban urged the General Assembly to adopt a resolution ‘without delay’ to set up this new entity.

5. Health equity in economic and trade policies

Aid for trade: An opportunity for re-thinking aid for economic growth
Brüntrup M and Voionmaa P: Trade Negotiation Insights 9(2), March 2010

In this article discussing aid for trade (AfT) initiatives between European and African states, the author points out that AfT may be misused, as it aims to integrate developing countries into global markets, which serves the interests of the Western world as they view these African states as (future) trading partners and as drivers of the global trade policy agenda they serve. Another risk of AfT is that it tends to underestimate the potential of domestic markets. For instance, the rapidly growing population and urbanisation in many African countries creates great opportunities for domestic farmers and food industries. The AfT agenda also adds to the increasing number of ‘vertical’ initiatives, such as the fund for HIV and AIDS or infrastructure. This leads to a segmentation of development cooperation, while efforts instead should seek to make aid more flexible by aligning it to developing countries’ priorities without earmarking it in advance for certain thematic issues. For all these reasons, the authors recommend a very careful, transparent and participatory use of the AfT initiative. Trade and AfT are not ends in themselves, but means to achieve the ultimate goal of reducing poverty. Hence, AfT must be embedded in overarching national growth and poverty strategies which balance inward and outward orientation of national economies and ultimately aim to generate resources for social development and poverty reduction.

EU’s win in tough trade deal may set precedent for developing nations
Cronin D: Intellectual Property Watch, 25 February 2010

This piece sends a warning signal on the issue of patenting on trade agreements. Far-reaching provisions on the patenting of medicine have been inserted into a controversial free trade agreement (FTA) between the European Union (EU) and Colombia and Peru. While less ambitious on patenting and with shorter durations of exclusivity than proposals earlier put forward by EU, in the agreement makers of branded drugs will enjoy ‘test data exclusivity’ over the scientific formulae they have used and will be able to delay generic versions of their products from appearing on the market. This data exclusivity will apply for five years, increasing the amount countries spend on medicines in the period, despite high poverty levels. The concern for Africa is that this agreement sets an unfortunate precedent for countries concluding trade agreements with the EU, notably the African, Caribbean and Pacific (ACP) group, to avoid such clauses which undermine their efforts to meet the health care needs of their citizens.

6. Poverty and health

Is Africa heading for another food crisis?
IRIN News: 2 March 2010

Long, dry spells in parts of Africa have cast an uncertain cloud over crop yields for 2010 in some African countries. Food prices are lower than 2008 levels, but higher than in 2007. Abdolreza Abbassian, economist and secretary of the Intergovernmental Group on Grains at the United Nations Food and Agriculture Organization (FAO) observed that it would take ‘two consecutive bad years’ for the 2008 food crisis to be repeated. Global cereal stocks were reported to be at comfortable levels, although reduction in producer subsidies in the Organization for Economic Cooperation and Development (OECD) countries has meant smaller surpluses in these regions, affecting overall available supplies.

Meals per gallon: The impact of industrial biofuels on people and global hunger
ActionAid: 2010

In their new report, ActionAid estimates that, if all global biofuel targets are met, global food prices could rise by up to an additional 76% by 2020, causing an estimated 600 million extra people to go hungry. The report indicates that industrial biofuels are having disastrous local impacts on food security and land rights in many of the communities where they are grown. The scale of the current land grab has escalated in Africa – in just five African countries, 1.1 million hectares have been given over to industrial biofuels – an area the size of Belgium. Also, many industrial biofuels do not have lower greenhouse gas emissions compared to fossil fuels. The report puts forward a number of recommendations: placing a moratorium on the further expansion of industrial biofuel production and investment; ensuring that member states do not lock-in industrial biofuels to their 2010 national action plans; ending targets and financial incentives for industrial biofuels; and supporting small-scale sustainable biofuels in the European Union and abroad.

Progress on sanitation and drinking water: 2010 update report
WHO/UNICEF Joint Monitoring Programme (JMP): March 2010

Unsafe water, sanitation and hygiene claim the lives of an estimated 1.5 million children under the age of five each year. Almost 884 million people are living without access to safe drinking water and approximately three times that number lacking basic sanitation. This report confirms that advances continue to be made towards greater access to safe drinking water. Progress in relation to access to basic sanitation is, however, insufficient to achieve the Millennium Development Goal (MDG) target to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The vast majority of people without access to water and sanitation live in rural areas (eight out of ten and seven out ten people respectively). A similar disparity is found between poor and non-poor people. A comparison between the richest and poorest 20% of the population in sub-Saharan Africa reveals that the richest are more than twice as likely to use an improved drinking-water source and almost five times more likely to use improved sanitation facilities. Although there is insufficient data at present, country data available confirms similar disparities elsewhere.

The social and economic impacts of South Africa’s child support grant
Williams MJ: Economic Policy Research Institute Working Paper 40, November 2007

Evidence from this South African study indicates that cash transfers achieve positive education, health and nutrition outcomes. South Africa's child support grant (CSG) is the country's largest social cash transfer programme and is regarded as one of the government's most successful social protection interventions. This study analysed panel data constructed from general household surveys (2002 to 2004), and compared eligible children who received the CSG in 2003 and 2004 with those who did not receive it. It found robust evidence that the CSG is improving nutrition and education outcomes for children. Hunger, as defined by the lack of food in a household, fell among both CSG recipients and non-recipients over the study period, but the reduction was found to be two to three times larger for children receiving the grant. Children under seven years of age who were eligible for the CSG were significantly less likely to be attending school in 2002 than those not receiving the CSG, but after receiving the CSG for two years there was a 6% increase in their pre-school and early grades enrolment by 2004. The study concludes that these effects are likely to be sustained over time among households receiving the CSG, with cumulative improvements in children’s nutrition and educational attainment in the future.

The story of bottled water
The Story of Stuff: March 2010

This short video about the story and challenges to local communities of production of bottled water was launched as part of World Water Day on 22 March 2010.

7. Equitable health services

Aid workers battle to help ‘forgotten’ refugees
IRIN News: 10 March 2010

With at least 67,000 refugees in southwest Uganda, the government and aid workers are still battling inadequate resources in what a United Nations (UN) official described as a ‘silent emergency’. ‘We can hardly meet international standards of indicators such as water, health and food,’ reported Nemia Temporal, deputy representative of the UN Refugee Agency (UNHCR) in Uganda. ‘For instance, we are delivering fifteen litres [of water] per person per day instead of the standard twenty litres.’ After years of protracted conflict in eastern Democratic Republic of Congo (DRC), with large influxes to neighbouring countries, the situation of the majority Congolese refugees is no longer considered that urgent by the wider aid community, Temporal said. At least 45,000 Congolese live in the 217sqkm Nakivale settlement in Isingiro District and Kyaka II in Kyegegwa District, where, thanks to the Ugandan government's refugee-friendly policy, they cultivate small pieces of land. Among the aid delivery gaps were the provision of shelter (plastic sheeting), water, health and sanitation, infrastructure and refugee protection. She urged a shift in humanitarian assistance so that relief aid goes hand-in-hand with livelihood support ‘right from day one'.

Benefits of global partnerships to facilitate access to medicines in developing countries: A multi-country analysis of patients and patient outcomes in GIPAP
Kanavos P, Vandoros S and Garcia-Gonzalez P: Globalization and Health 5(19), 31 December 2009

Chronic Myeloid Leukemia (CML), a rare disease, can be treated effectively, but the pharmaceutical treatment available (imatinib) is costly and unaffordable by most patients. 'GIPAP' is a programme set up between a manufacturer and a non-governmental organisation to provide free treatment to eligible CML patients in 80 countries worldwide. This study discusses the socio-economic and demographic characteristics of patients participating in GIPAP. It researches the impact GIPAP is having on health outcomes (survival) of assistance-eligible CML patients and discusses the determinants of such outcomes and whether there are any variations according to socio-economic, demographic, or geographical criteria. Data for 13,568 patients across 15 countries, available quarterly, was analysed over the 2005-2007 period. GIPAP was found to have a significant positive effect on patient access to medicines for CML and on survival rates.

Malawi plans to scale up antiretroviral therapy for 2010
Plus News: 19 March 2010

Malawi's government has set itself a major challenge this year, announcing plans to more than double the number of people receiving antiretroviral (ARV) drugs to half a million by the end of 2010. The country recently adopted new World Health Organization (WHO) guidelines that raise the threshold for ARV therapy from a CD4 count (a measure of immune system strength) of less than 200, to a CD4 count of 350, regardless of whether the patient is displaying symptoms. Some experts argue that starting patients on ARVs earlier could save the government money in the long term by reducing opportunistic infections such as tuberculosis. UNAIDS Country Coordinator, Patrick Brenny, said the targets were reachable, provided the country could mobilise the resources, including money, drugs and manpower. He noted that the Global Fund to Fight AIDS, Tuberculosis and Malaria had expressed willingness to fund implementation of new WHO treatment guidelines. Malawi has just had its funding extended by the Fund for a further six years and is now looking at how to make best use of the money in relation to the new guidelines. Brenny said Malawi was also researching ways to reduce its high dependence on foreign aid, including the possibility of building a local ARV manufacturing plant in partnership with Indian drug companies.

Natural ventilation for infection control in health-care settings
Atkinson J, Chartier Y, Pessoa-Silva CL, Jensen P, Li Y and Seto W: World Health Organization, 2009

Adequate ventilation can reduce the transmission of infection in health-care settings. Natural ventilation can be one of the effective environmental measures to reduce the risk of spread of infections in health care. This guideline first defines ventilation and then natural ventilation. It explores the design requirements for natural ventilation in the context of infection control, describing the basic principles of design, construction, operation and maintenance for an effective natural ventilation system to control infection in health-care settings.

Packages of care for alcohol use disorders in low- and middle-income countries
Benegal V, Chand PK and Obot IS: Public Library of Science Medicine 6(10), 27 October 2009

Alcohol use disorders (AUDs) – conditions that range from hazardous and harmful alcohol use to alcohol dependence – are a low priority in low- and middle-income countries (LMICs), despite causing a large health burden. Most alcohol-related harm is attributable to hazardous/harmful drinkers who make disproportionate use of primary health care systems, but often go undetected and untreated for long periods, even though brief, easily delivered interventions are effective in this group of people. Health care systems in LMICs currently focus on providing tertiary care services for the treatment of dependence (where there is often a poor outcome). This study indicates that the focus needs to shift towards the cost-effective strategy of providing brief interventions for early AUDs. Effective evidence-based combinations of psychosocial and pharmacological treatments for AUDs are available in LMICs but are costly to implement. Policy makers need to ensure that people with AUDs are offered the most appropriate services using stepped-care solutions that start with simple, structured advice for risky drinkers and progress to specialist treatment services for more serious AUDs. LMICs also need to improve their implementation of proven population-level preventive measures to reduce the health burden due to AUDs. An international Framework Convention on Alcohol Control may help them do this.

Packages of care for dementia in low- and middle-income countries
Prince MJ, Acosta D, Castro-Costa E, Jackson J and Shaji KS: Public Library of Science Medicine 6(11), 3 November 2009

Two-thirds of people with dementia live in low- and middle-income countries (LMICs), where there are few services available and levels of awareness and help-seeking are low. After early diagnosis, the principal goals for management of dementia are optimising physical health, cognition, activity, and wellbeing; detecting and treating behavioural and psychological symptoms (BPSD); and providing information and long-term support to carers. This study recommends that routine packages of continuing care should comprise diagnosis coupled with information, regular needs assessments, physical health checks, and carer support, and where necessary carer training, respite care, and assessment and treatment of BPSD. Care can be delivered by trained primary care teams working in a collaborative care framework. Continuing care with practice-based care coordination, and community outreach are essential components of this model. Efficient care delivery in LMICs involves integrating dementia care with that of other chronic diseases and community-support programmes for the elderly and disabled.

Packages of care for depression in low- and middle-income countries
Patel V, Simon G, Chowdhary N, Kaaya S and Araya R: Public Library of Science Medicine 6(10), 6 October 2009

Depression is clearly a global health priority. Improving the recognition of this disorder in clinical populations in LMICs is aided by the successful adaption of depression-screening instruments from HIC settings into settings with few resources and weaker health systems. This review suggests that evidence-based treatments such as antidepressants and psychotherapy are effective in managing depression; it is important, however, that such treatments are adapted when used in LMICs to increase their acceptability, accessibility, and manage their costs. The review proposes two packages of care on the basis of the availability of mental health specialist resources. The delivery of these treatments should ideally be carried out through an integration of depression programmes into existing health services or community settings with task-shifting to non-specialist health workers to deliver front-line care and a supervisory framework of appropriately skilled mental health workers.

Packages of care for schizophrenia in low- and middle-income countries
Mari JJ, Razzouk D, Thara R, Eaton J and Thornicroft G: Public Library of Science Medicine 6(10), 20 October 2009

It is estimated that about 41.7 million people need treatment for schizophrenia and related disorders in low- and middle-income countries (LMICs). The majority of these cases are concentrated in Asia (70%) and Africa (16%). In countries with low resources, general physicians and primary health care workers can be trained to recognise and treat people with psychotic disorders in the community. This study found that health systems can scale up such interventions across all routine-care settings by training general physicians and primary health care workers to recognise and treat clients with schizophrenia with effective, evidence-based interventions. In addition, first- and second-generation antipsychotics (FGAs and SGAs) are similarly effective in the acute treatment of psychotic symptoms. In addition, a number of trials have shown the efficacy of psycho-educational strategies to improve adherence to antipsychotics, to decrease relapse and readmission rates, and to have a positive impact in social functioning of family members and patients. The study recommends a package of care combining low doses of conventional antipsychotics along with brief and simple psycho-educational interventions as an important strategy to decrease the treatment gap for schizophrenia in LMICs. The combination of FGAs and psycho-educational interventions are more cost-effective than the use of drugs alone.

Preventive health services are the future, says South African health minister
Thom A: Health-e News, 10 March 2010

South Africa’s health minister, Dr Aaron Motsoaledi, is reported as having called for South Africa’s health system to make a 180 turn away from the dominant curative health system, which is unsustainable and unaffordable, to a health system where prevention is the cornerstone. This and the primary health care approach is argued by the Minister to make the national health insurance system an affordable option and to improve equity and universal coverage.

TB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis
Cramm JM, Finkenflügel HJM, Møller V and Nieboer AP: BMC Public Health 10(72), 17 February 2010

This study investigated knowledge of, perceptions of and access to tuberculosis (TB) treatment and adherence to treatment among an Eastern Cape population in South Africa. An area-stratified sampling design was applied. A total of 1,020 households were selected randomly in proportion to the total number of households in each neighbourhood. It found TB knowledge was fairly good among this community. A full 95% of those interviewed believe people with TB tend to hide their TB status out of fear of what others may say and therefore may not seek treatment. Regression analyses revealed that in this population young and old, men and women and the lower and higher educated share the same attitudes and perceptions, suggesting that the findings are likely to reflect the actual situation of TB patients in the population. Future interventions should be directed at improving attitudes and perceptions to potentially reduce stigma. This requires a patient-centred approach to empower TB patients and their active involvement in the development and implementation of stigma reduction programmes.

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8. Human Resources

'Danger pay’ for TB staff?
Cullinan K: Health-e News, 23 March 2010

Durban health workers who treat patients with drug-resistant TB are noted to face increase risk of drug resistant TB. According to Dr Iqbal Master, head of clinical services at King George V Hospital in Durban, the province’s specialist hospital for drug-resistant TB, they should be given special incentives to recognise this. King George V Hospital has been trying to get itself declared 'inhospitable', which would mean that staff would get additional incentives for this. Workers at the facility are reported to be six times more likely to get drug-resistant TB than ordinary members of the public. In the last decade, 14 staff members are reported to have died of the TB and one staff member was being treated for drug-resistant (XDR) TB.

Task shifting routine inpatient pediatric HIV testing improves program outcomes in urban Malawi: A retrospective observational study
McCollum ED, Preidis GA, Kabue MM, Singogo EBM and Mwansambo C et al: Public Library of Science ONE 5(3), 10 March 2010

This study evaluated two models of routine HIV testing of hospitalised children in a high HIV-prevalence resource-constrained African setting. Both models incorporated task shifting, namely the allocation of tasks to the least-costly, capable health worker. Two models were piloted for three months each within the paediatric department of a referral hospital in Lilongwe, Malawi between January 1 and June 30, 2008. Model 1 utilised lay counsellors for HIV testing instead of nurses and clinicians, while Model 2 further shifted programme flow and advocacy responsibilities from counsellors to volunteer parents of HIV-infected children, called 'patient escorts'. The strategy presented here in the two models, namely task shifting from lay counsellors alone to lay counsellors and patient escorts, was found to improve programme outcomes greatly, while only marginally increasing operational costs. The wider implementation of this strategy could accelerate paediatric HIV care access in high-prevalence settings.

Wrong schools or wrong students? The potential role of medical education in regional imbalances of the health workforce in the United Republic of Tanzania
Leon BK and Kolstad JR: Human Resources for Health 8(3), 26 February 2010

This paper is based on the premise that medical schools can play an important role in solving the problem of geographical imbalance of doctors in the United Republic of Tanzania. It reviews available research evidence that links medical students' characteristics with human resource imbalances and the contribution of medical schools in perpetuating an inequitable distribution of the health workforce. Structured questionnaires were also administered to 130 fifth-year medical students at the medical faculties of MUCHS (University of Dar es Salaam), HKMU (Dar es Salaam) and KCMC (Tumaini University, Moshi campus) in Tanzania. The study found a lack of a primary interest in medicine among medical school entrants, biases in recruitment, the absence of rural-related clinical curricula in medical schools, and a preference for specialisation not available in rural areas. These were considered the main obstacles for building a motivated health workforce to help correct the inequitable distribution of doctors in the Tanzania. The study suggests that there is a need to re-examine medical school admission policies and practices.

9. Public-Private Mix

Private aid for state hospitals
Parker F: Mail and Guardian, 22 February 2010

In a move that has already sparked controversy, the South African treasury is to draw private business into the public health sector as a way of upgrading the services provided by state hospitals. In his budget speech, Finance Minister Pravin Gordhan referred to broadening the implementation of public-private partnerships (PPPs) in the health sector to improve hospitals system as a “prerequisite for the introduction of a national health insurance system”. A flagship PPP project is proposed as Chris Hani Baragwanath Hospital in Johannesburg, for which a feasibility study is now complete. However the Congress of South African Trade Unions (Cosatu), the largest union in the country, has opposed PPPs as a vehicle for privatisation, which is argued to lead to higher costs, poorer services and the loss of jobs.

The public-private health sector mix in South Africa
Health Economics Unit (HEU), University of Cape Town: HEU Health Care Financing Information Sheet, 2009

This sheet provides information on financing in the public and private health sectors in South Africa. It notes that medical schemes cover 16% of the population, on whom about R11,300 is spent per person (this includes both medical scheme spending and out-of-pocket payments), while the public sector covers most of the rest of the population, particularly the 68% who do not use any private care – government spends about R1,900 per person on this group. Sixteen percent of the population use the private sector on an out-of-pocket basis for primary care but are almost entirely dependent on the public sector for hospital care; for this group nearly R2,500 is spent per person. Medical scheme spending has been increasing, while public sector health spending has been largely stagnant until recently. Most health professionals (except enrolled nurses) work in the private health sector.

10. Resource allocation and health financing

Health care financing in South Africa: Moving towards universal coverage
Ataguba JE and Akazili J: Continuing Medical Education, 28(2): 74–78, February 2010

This article argues that South Africa’s proposed national health insurance (NHI) puts it on a trajectory of achieving universal access to quality health care for all its residents. It reports that current inequalities and inequities in access and utilisation of health care services place a greater burden on the poor and vulnerable. While it argues that the proposed NHI is not a magic bullet for all the problems of the health sector in South Africa, if it is well designed, planned, managed and effectively implemented, it is likely to improve the overall health outcomes of South Africans, as well as nudge the country towards achieving the Millennium Development Goals.

Interview with Global Fund director Michel Kazatchkine
Plus News: 12 March 2010

In this interview, the executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Michel Kazatchkine answers some questions about HIV and AIDS funding at the launch of the organisation's 2010 report. He said that he considered AIDS an exceptional threat, quoting the large numbers affected by the epidemic. He did not think that too much has been invested in HIV and AIDS to the detriment of other illnesses, pointing out that over a third of the overall funding of the Global Fund goes to strengthening health systems. The interview reports on the limited impact of the financial crisis on the Global Fund, the significant contribution of the Fund to anti-retroviral treatment in low-income countries and observations on the channels for the funds of the organisation.

National and subnational HIV/AIDS coordination: Are global health initiatives closing the gap between intent and practice?
Spicer N, Aleshkina J, Biesma R, Brugha R, Caceres C, Chilundo B, Chkhatarashvili K, Harmer A, Miege P, Murzalieva G, Ndubani P, Rukhadze N, Semigina T, Walsh A, Walt G and Zhang X: Globalization and Health 6(3), 2 March 2010

This study reviews primary data from seven country studies on the effects of three GHIs on coordination of HIV and AIDS programmes: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief (PEPFAR), and the World Bank's HIV and AIDS programmes, including the Multi-country AIDS Programme (MAP). In-depth interviews were conducted at national and sub-national levels (179 and 218 respectively) in seven countries in Europe, Asia, Africa and South America, between 2006 and 2008. Studies explored the development and functioning of national and sub-national HIV coordination structures, and the extent to which coordination efforts around HIV and AIDS are aligned with and strengthen country health systems. Positive effects of GHIs included the creation of opportunities for multi-sectoral participation, greater political commitment and increased transparency among most partners. However, the quality of participation was often limited, and some GHIs bypassed coordination mechanisms, especially at the sub-national level, weakening their effectiveness. The paper identifies residual national and sub-national obstacles to effective coordination and optimal use of funds by focal GHIs, which these GHIs, other donors and country partners need to collectively address.

OECD International Development Statistics 2010
Organization for Economic Co-operation and Development (OECD): 17 February 2010

Aid to developing countries in 2010 will reach record levels in United States dollar terms after increasing by 35% since 2004. But it will still be less than the world’s major aid donors promised five years ago at the Gleneagles and Millennium + 5 summits. Though a majority of countries will meet their commitments, the underperformance of several large donors means there will be a significant shortfall, according to this OECD review. Africa, in particular, is likely to get only about USD 12 billion of the USD 25 billion increase envisaged at Gleneagles, due in large part to the underperformance of some European donors who give large shares of official development assistance (ODA) to Africa. Other Development Assistance Committee (DAC) countries made varying ODA commitments for 2010, and most, but not all, will fulfill them. The United States pledged to double its aid to sub-Saharan Africa between 2004 and 2010. Canada aimed to double its 2001 International Assistance Envelope level by 2010 in nominal terms. Australia aimed to reach $A 4 billion. New Zealand plans to achieve an ODA level of $NZ 600 million by 2012-13. All four countries appear on track to meet these objectives. Norway will maintain its ODA level of 1% of its GNI, and Switzerland will likely reach 0.47% of its GNI, exceeding its previous commitment of 0.41%.

Public sector health care spending in South Africa
Health Economics Unit (HEU), University of Cape Town: HEU Health Care Financing Information Sheet, 2009

This sheet provides information on public sector health care spending in South Africa. I found that public sector health spending as a share of total government spending has remained relatively constant. However, it has been following a downward trend in that it did not keep pace with inflation or population growth through much of the 1990s, but there have been recent increases. Public sector health personnel employment also declined in the 1990s; there is an urgent need for additional clinical staff. The largest single share of funds is spent on primary care and district hospitals. It argues that meeting one of South Africa's major health challenges, namely HIV and AIDS treatment, will require resources that exceed those currently available.

Rich countries have no excuse for broken aid promises
Oxfam: 17 February 2010

Responding to the Organization for Economic Co-operation and Development’s (OECD) predictions that 2010 will see overseas aid stand at $21bn lower than promised, Head of Oxfam Campaign, Emma Seery observed that the missing $21 billion could pay for every child to go to school, and could save the lives of 2 million of the poorest mothers and children, "making this failure of the richest countries nothing short of a scandal". Oxfam estimates it would cost $16bn each year to ensure that every child gets the chance to go to school and $5bn would provide improved medical care that would save the lives of about 2 million mothers and children. ‘Rich countries have no excuse for failing to deliver the aid increases they promised’, she added. Collectively the EU-15 who are members of the OECD will miss their 0.51% aid target they committed to in 2005, with OECD projections putting them at just 0.48% average in 2010. Nine out of ten Europeans believe strongly that their leaders must meet their aid promises, despite the economic downturn, according to a recent Eurobarometer study.

Statement before the 2011 High Level Forum on aid effectiveness
Capacity4Dev: March 2010

Some 300 participants gathered in Bogota, Colombia, from the 24-26 March, for an intermediate international meeting to discuss and agree on policy recommendations ahead of a 2011 High Level Forum on aid effectiveness in South Korea. Capacity development (CD) is strongly embedded in the agenda of the South. This agenda aims to harness broad political leadership, get beyond fragmented and piecemeal approaches, address systemic issues related to state reform and incentives, and make increased use of South-South co-operation and regional/local resources.

The future of financing for WHO: Report of an informal consultation convened by the Director-General, Geneva, Switzerland, 12–13 January 2010
World Health Organization: March 2010

Several themes emerged from initial discussions in this consultation, which was convened by the World Health Organization (WHO): determining to what extent, and how, WHO should address the broader social and economic determinants of health; deciding what constitutes good partnership behaviour at global and country level; determining how WHO can match the support it provides more closely and flexibly to the needs of different countries; and improving WHO’s involvement in the field of technical collaboration. Participants agreed that improving performance is intimately linked to the way WHO is financed and this warrants further consideration. They indicated a need to seek the views of all member states on the wider issues raised at this meeting. Questions raised in this report will be used as the basis for a web-based consultation, to which all countries will be invited to contribute their views.

The Global Fund 2010: Innovation and impact
Global Fund: 2010

The Global Fund 2010 results report has projected that the virtual elimination of mother-to-child HIV transmission by 2015 is within reach, that malaria may be eliminated as a public health problem within a decade, and that the international target of halving tuberculosis prevalence could be met by 2015. According to the report, Fund-supported programmes saved at least 3,600 lives per day in 2009 and an estimated total of 4.9 million since the creation of the Fund in 2002. By the end of 2009, Fund-supported programmes provided antiretroviral treatment to 2.5 million people with HIV and AIDS, treatment to 6 million people who had active TB, and had distributed 104 million insecticide-treated nets to prevent malaria.

The rise of budget support in European development cooperation: A false panacea
Alvarez RC: FRIDE Policy Brief 31, January 2010

According to this policy brief, European aid donors are taking steps to meet promises to deliver a higher share of development aid directly to governments in the form of budget support. The brief points to positive and negative consequences of budget support. While budget support is argued to enhance local accountability, it may not succeed unless government recipients are accountable to their populations for how the funds are used. A more self-serving reason is argued for donors to turn to budget support – it enables the donor to increase aid delivery, thus meeting disbursement rates, without requiring an enlargement of their own administrative operations, thereby keeping costs down. This motivation has more to do with donors’ institutional dynamics than with poverty reduction. The brief calls for a more nuanced political analysis to ensure that budget support enhances rather than undermines democratic accountability in developing countries.

11. Equity and HIV/AIDS

'Side dishes' campaign in Uganda gets people talking
Plus News: 24 March 2010

A national campaign to encourage sexual fidelity in Uganda is reported to have got the country talking. The nine-month-long 'One Love' campaign is in the second of three phases, which uses television and radio ads that highlight AIDS-related deaths from 'eating a side dish' - a euphemism for having a sexual relationship outside marriage. The intention of the second phase is to bring home the effects of infidelity, not just on health, but on the lives of the people they care for most. The first phase - which ended in February - introduced the public to sexual networks, using forum theatre in rural communities and billboards, TV ads and radio spots in towns urging people to 'get off the sexual network'. Previous prevention campaigns have failed to directly address married and cohabiting Ugandans, the most likely group to become HIV infected. Beyond the traditional routes of advertising, the campaign has also employed mobile-phone technology and the social networking site Facebook to engage with younger people in a higher socio-economic group.

A cluster randomized trial of routine HIV-1 viral load monitoring in Zambia: Study design, implementation, and baseline cohort characteristics
Koethe JR, Westfall AO, Luhanga DK, Clark GM and Goldman JD et al: Public Library of Science ONE 5(3), 12 March 2010

This study took the form of a cluster randomised controlled trial to compare the use of routine viral load (VL) testing for antiretroviral therapy (ART) versus local standard of care (which uses immunological and clinical criteria to diagnose treatment failure, with discretionary VL testing when the two do not agree). Twelve ART clinics in Lusaka, Zambia were included. The study was powered to detect a 36% reduction in mortality at 18 months. From December 2006 to May 2008, the study completed enrolment of 1,973 participants. Measured baseline characteristics did not differ significantly between the study arms. Enrolment was staggered by clinic pair and truncated at two matched sites. A large clinical trial of routing VL monitoring was successfully implemented in a dynamic and rapidly growing national ART program. Close collaboration with local health authorities and adequate reserve staff were critical to success. Randomised controlled trials such as this will likely prove valuable in determining long-term outcomes in resource-constrained settings.

Adolescent HIV: Cause for concern in southern Africa
Gray GE: Public Library of Science Medicine 7(2): 2 February 2010

In 2006, the Society for Adolescent Medicine issued its second position paper on HIV/AIDS in adolescents. It noted that although great progress had been made in the scientific understanding, diagnosis and treatment of HIV, and the prevention of perinatal transmission, there was a growing HIV crisis in the developing world. At least half of all new infections in the developing world were amongst youth and young adults, and a substantial number of teenagers and young adults were already living with HIV and AIDS. As HIV epidemics mature, increasing numbers of children infected perinatally survive and will present with HIV-related symptoms in older childhood and adolescence. Whilst the epidemiology of sexually acquired HIV infection amongst 15–24 year olds is well described in southern Africa, few data on the prevalence and disease pattern of perinatally acquired HIV infection in older children and adolescence exist. Recent data from a household survey conducted in South Africa in 2008 estimated the prevalence of HIV in children aged 2–14 years to be 2.5%. The survey indicates the relatively high prevalence of HIV in children and adolescents in this region. Most of these infections are acquired early in life and are probably undiagnosed.

Causes of acute hospitalization in adolescence: Burden and spectrum of HIV-related morbidity in a country with an early-onset and severe HIV epidemic: A prospective survey
Ferrand RA, Bandason T, Musvaire P, Larke N, Nathoo K, Mujuru H, Ndhlovu CE, Munyati S, Cowan FM, Gibb DM and Corbett EL: Public Library of Science Medicine 7(2): 2 February 2010

Survival to older childhood with untreated, vertically acquired HIV infection, which was previously considered extremely unusual, is increasingly well described. However, the overall impact on adolescent health in settings with high HIV sero-prevalence has not previously been investigated. Adolescents (aged 10–18 y) systematically recruited from acute admissions to the two public hospitals in Harare, Zimbabwe, answered a questionnaire and underwent standard investigations including HIV testing, with consent. Pre-set case-definitions defined cause of admission and underlying chronic conditions. Participation was 94%. One hundred and thirty-nine (46%) of 301 participants were HIV-positive, but only four were positive for herpes simplex virus-2 (HSV-2). Case fatality rates were significantly higher for HIV-related admissions (22% versus 7%, p<0.001), and significantly associated with advanced HIV, pubertal immaturity, and chronic conditions. The paper concluded that 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/AIDS. Low HSV-2 prevalence and high rates of maternal orphanhood 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.

Gaps in HIV prevention for pregnant Kenyan women
Plus News: 22 March 2010

The Kenyan government is considering a policy of repeat HIV testing during pregnancy. 'Currently, the lack of it is a gap in our policies,' said Peter Cherutich, head of HIV prevention at the National AIDS and Sexually Transmitted Infections Control Programme. 'Testing should be done periodically, even after childbirth, because a mother can become infected even during the breastfeeding period.' At present, HIV-positive mothers and their babies in Kenya are given a combination of three antiretroviral drugs after a single test, usually carried in the early stages of the pregnancy. 'If a woman tests negative during her prenatal test, gets infected during the pregnancy, and is not given the necessary medication during labour to protect the child, she stands a chance of infecting her child at birth or even during breastfeeding and you go back to square one,' Cherutich said. Infants contracting HIV through their mothers account for about 20% of an estimated 166,000 annual HIV infections in Kenya.

High uptake of HIV testing for tuberculosis patients in an integrated primary health care HIV/TB programme in rural KwaZulu-Natal
Wallrauch C, Heller T, Lessells R, Kekana M, Barnighausen T, Newell M: South African Medical Journal 100(3): 146–147, March 2010

Tuberculosis (TB) is the leading cause of morbidity and mortality in the HIV-infected African population. The need for improved integration of HIV and TB services was highlighted by the World Health Organization (WHO) several years ago, but implementation of recommendations has been slow. HIV testing for TB patients is the gateway for combined HIV and TB treatment, care and prevention yet, in 2007, only 37% of TB patients in the WHO African region were tested for HIV. While some countries reported testing rates above 75%, a testing rate of only 39% was reported in South Africa, the country with the largest burden of HIV/TB co-infection. This study describes efforts to ensure high HIV testing rates in TB patients via an integrated programme at primary health care level in rural KwaZulu-Natal.

HIV prevention for South African youth: Which interventions work? A systematic review of current evidence
Harrison A, Newell M, Imrie J and Hoddinott G: BMC Public Health 10(102), 26 February 2010

In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest, which prompted this review to assess youth HIV-prevention interventions in the country since 2000. Eight interventions were included, all of which were similar in HIV prevention content and objectives, but varied in thematic focus, hypothesised causal pathways, theoretical basis, delivery method, intensity and duration. Interventions were school- or group-based, involving in- and out-of-school youth. Primary outcomes included HIV incidence, reported sexual risk behaviour alone, or with alcohol use. Interventions led to reductions in sexually transmitted infections and reported sexual or alcohol risk behaviours, although effect size varied. All but one targeted at least one structural factor associated with HIV infection: gender and sexual coercion, alcohol/substance use or economic factors. Delivery methods and formats varied, and included teachers, peer educators and older mentors. School-based interventions experienced frequent implementation challenges. Key recommendations include: address HIV social risk factors, such as gender, poverty and alcohol; target the structural and institutional context; work to change social norms; and engage schools in new ways, including participatory learning.

Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in sub-Saharan Africa: A cohort study
Myer L, Carter RJ, Katyal M, Toro P and El-Sadr WM et al: Public Library of Science Medicine 7(2), 9 February 2010

This study investigated whether or not antiretroviral therapy (ART) influences pregnancy rates. It analysed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multi-country HIV care and treatment programme for women, children and families. From eleven programmes in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals, while ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. The study found that ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioural or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services.

New model for HIV data takes into account new science
Odendal L: Health-e News, 23 March 2010

A new model for determining the demographic impact of HIV and AIDS in South Africa has been designed by two researchers, Leigh Johnson of the Centre for Infectious Disease Epidemiology and Research and Rob Dorrington of the Centre for Actuarial Research at the University of Cape Town. The new model is to replace the ASSA 2003 model for estimating HIV prevalence, HIV-related deaths, the numbers of those in need of ARVs and the impact of HIV interventions to integrate new data emerging from South Africa’s antenatal HIV-prevalence survey. The new model includes the ARV rollout data for up to the end of 2008. Because data shows that two-thirds of people starting ARVs are females, the model allows for different rates of ARV initiation in males and females, as well as for children and adults. It also recognises that the variable attrition rate across provinces.

The 'ART' of linkage: Pre-treatment loss to care after HIV diagnosis at two PEPFAR sites in Durban, South Africa
Losina E, Bassett IV, Giddy J, Chetty S and Regan S et al: Public Library of Science ONE 5(3), 4 March 2010

Although loss to follow-up after antiretroviral therapy (ART) initiation is increasingly recognized, little is known about pre-treatment losses to care (PTLC) after an initial positive HIV test. The objective of this paper was to determine PTLC in newly identified HIV-infected individuals in South Africa. It examined records of patients presenting for HIV testing at two sites offering HIV and CD4 count testing and HIV care in Durban, South Africa. PTLC was defined as failure to have a test for CD4 count within eight weeks of HIV diagnosis. Infected patients were significantly more likely to have PTLC if they lived &#8805;10 kilometers from the testing centre, had a history of tuberculosis treatment or were referred for testing by a health care provider rather than self-referred. Patients with one, two or three of these risks for PTLC were 1.88, 2.50 and 3.84 times more likely to have PTLC compared to those with no risk factors. In conclusion, nearly half of HIV-infected persons at two high prevalence sites in Durban, South Africa, failed to have CD4 counts following HIV diagnosis. These high rates of pre-treatment loss to care highlight the urgent need to improve rates of linkage to HIV care after an initial positive HIV test.

12. Governance and participation in health

Cholera prevention programme in Malawi a beacon of success
Ngozo C: Inter Press Service News Agency, 23 February 2010

Mkanda, in central Malawi, is presented as a successful example of cholera control through the Community-Led Total Sanitation (CLTS) approach, with a fall from fourteen to zero cholera cases in a year. The article does not give adequate evidence to attribute the cause of the decline, but toilet availability and community awareness both improved in the year.

Conditional cash transfers: A ‘pathway to women’s empowerment’? Do cash transfers continue poor women’s second-class citizenship status?
Molyneux M: Pathways of Women's Empowerment RPC, 2008

Conditional cash transfers (CCTs) provide mothers of school-age children in extreme poverty with a cash subsidy conditional on their children's attendance at school and health clinics. This paper assesses the evidence for the claim that these programmes empower women. It finds that, although CCTs are designed to target the extremely poor and the particularly vulnerable, they operate under a highly selective definition of social need, and these programmes privilege and target some needs over others even at household level, reinforcing social/gender inequalities within the family itself. Highly unequal gender relations were found to be central in the functioning of such programmes. The paper argues that cash transfers should be part of a broader effort to improve and strengthen the social sector while attending to the urgent needs of the most deprived. If they signal a move in the direction of residualist welfare policies designed as compensation for exclusionary economic development, then they represent a more worrying trend. If cash transfers are to enhance the life chances of seriously disadvantaged populations, their design needs to take into account the household as a whole, so that the needs of all members are met.

Participatory Learning and Action 60: Community-based adaptation to climate change
International Institute for Environment and Development, 2009

The articles in this issue on participatory learning and action focus on the recent approaches to adaptation to climate change utilising the priorities, knowledge and capacities of local people. Community-based adaptation (CBA) draws on participatory approaches and methods developed in both disaster risk reduction and community development work and sectoral-specific approaches. The emphasis now leans to policy processes and institutionalisation, issues of difference and power, assessing the quality and understanding the impact of participation, rather than promoting participation. Participatory Learning and Action reflects these developments and recognises the importance of analysing and overcoming power differentials which work to exclude the marginalised. This issue is divided into three sections: reflections on participatory processes and practice in community-based adaptation to climate change; participatory tool-based case studies; and participatory tools, with step-by-step descriptions of how to use them. The report also presents two important tools: communication maps, which help participants to understand communication patterns and relationships, and a tool called Rivers of Life, where participants reflect on personal experiences that have motivated them in their personal lives.

Strong ministries for strong health systems
Omaswa F and Boufford JI: African Center for Global Health and Social Transformation (ACHEST) and the New York Academy of Medicine: January 2010

This study and report were commissioned by the Rockefeller Foundation to explore the feasibility of establishing a support mechanism for ministers and ministries of health especially in the poorest countries, as part of the Foundation’s Transforming Health Systems initiative. Based on data from minister and stakeholder interviews and supporting research and consultation activities, this report offers seven action items geared toward building a systematic and sustained program of support for health ministries. Recommendations and proposals provided address: capacity assessment tools; leveraging existing management development resources; mapping country networks of expertise; regional networks to support health systems stewardship and governance; knowledge networks to support ministers of health; executive leadership development; and advocacy for strengthening health ministries. Collective action on these proposals is needed to strengthen health ministries and enhance the leadership capabilities of ministers.

13. Monitoring equity and research policy

Are the investments in national HIV monitoring and evaluation systems paying off?
Peersman G, Rugg D, Erkkola T, Kiwango E and Yang JM: Journal of Acquired Immune Deficiency Syndromes 52(S2): S87-S96, December 2009

Globally, concerted efforts and substantial financial resources have gone toward strengthening national monitoring and evaluation (M&E) systems for HIV programmes. This paper explores whether those investments have made a difference in terms of data availability, quality and use for assessing whether national programmes are on track to achieve the 2015 Millennium Development Goal of halting and reversing the global HIV epidemic. It found a marked increase in the number of countries where the prerequisites for a national HIV M&E system are in place, as well as in human resources devoted to M&E at the national level. However, crucial gaps remain, such as available M&E data and data quality assurance. The extent to which data are used for programme improvement is difficult to ascertain. There is a potential threat to sustaining the current momentum in M&E, as governments have not committed long-term funding and current M&E-related expenditures are below the minimum needed to make M&E systems fully functional. Nonetheless, essential data gaps will need to be filled urgently to provide quality data to guide future decision making.

Implicit value judgments in the measurement of health inequalities
Harper S, King NB, Meersman SC, Reichman ME, Breen N and Lynch J: Milbank Quarterly Volume 88, Number 1, 2010

This study questions the assumption that the measurement of health inequalities is a value-neutral process that provides objective data that is then interpreted using normative judgments about whether a particular distribution of health is just, fair or socially acceptable. The study discusses five examples in which normative judgments play a role in the measurement process itself, through either the selection of one measurement strategy to the exclusion of others or the selection of the type, significance, or weight assigned to the variables being measured. Overall, it found that many commonly used measures of inequality are value laden and that the normative judgments implicit in these measures have important consequences for interpreting and responding to health inequalities. Because values implicit in the generation of health inequality measures may lead to radically different interpretations of the same underlying data, the study urges researchers to explicitly consider and transparently discuss the normative judgments underlying their measures. Policymakers and other consumers of health inequalities data should pay close attention to the measures on which they base their assessments of current and future health policies.

Systematic review of methods for evaluating healthcare research economic impact
Yazdizadeh B, Majdzadeh R and Salmasian H: Health Research Policy and Systems 8(6), 2 March 2010

The economic benefits of healthcare research require study so that appropriate resources can be allocated to this research, particularly in developing countries. This study took the form of a systematic review to identify the methods used to assess the economic impact of healthcare research, and the outcomes. The initial search yielded 8,416 articles, of which 18 articles were included in the analysis, as well as eleven other reports. It found that the outcomes assessed as healthcare research payback included direct cost-savings, cost reductions in healthcare delivery systems, benefits from commercial advancement, and outcomes associated with improved health status. The study found that different methods and outcomes can be used to assess the economic impacts of healthcare research. However, none of the research from low- and middle-income countries had evaluated the economic return of research. The authors recommend a consensus on practical guidelines at international level in order to build capacity, arrange for necessary informative infrastructures and promote necessary skills for economic evaluation studies in developing countries.

Tracking progress in advocacy: Why and how to monitor and evaluate advocacy projects and programmes
O’Flynn M: International NGO Training and Research Centre (INTRAC) M&E paper 4, October 2009

This paper begins by introducing the scope of and rationale for engaging in advocacy work as part of development interventions. It notes that effective advocacy can prove to be a very powerful and empowering strategy, and contrasts this with ineffective advocacy strategies, which can be hugely wasteful of time and resources and leave stakeholders feeling bewildered, disempowered or uninterested. It then focuses on the issue of monitoring and evaluating (M&E) these efforts – offering reasons why and when these processes should be planned and implemented, what’s involved, and who should be engaged in the process. The paper discusses organisational approaches to M&E of a number of agencies in the development sector, like Oxfam and the Institute of Development Research (IDR), and offers tools and methods for M&E of advocacy projects in international and national non-governmental organisations.

14. Useful Resources

2010 Mass Immunisation Campaign
Department of Health, South Africa: 2010

This website contains all the documentations relevant to the South African Department of Health’s national mass immunisation campaign of 2010. Documents cover immunisations against polio, measles and influenza, vitamin A supplementation and preventing worm infestation, together with evaluation guidelines. The website also provides emergency procedures to follow in case of anaphylaxis, information on the cold chain for vaccines, vaccine stock control and data, and worker-oriented information on the role of team leaders and supportive supervision. It also details the government’s social mobilisation campaign to promote immunisation and awareness of the procedure.

Free journal access via HINARI Programme for Access to Health Research
World Health Organization: 2010

The Programme for Access to Health Research (HINARI) provides free or very low cost online access to the major journals in biomedical and related social sciences to local, not-for-profit institutions in developing countries. More than 150 publishers are offering more than 6,200 journals in HINARI and others will soon be joining the programme. HINARI was developed in the framework of the Health InterNetwork, introduced by the United Nations' Secretary General Kofi Annan at the UN Millennium Summit in 2000. Local, not-for-profit institutions in two groups of countries may register for access to the journals through HINARI. The country lists are based on GNI per capita (World Bank figures). Institutions in countries with GNI per capita below US$1,250 are eligible for free access. Institutions in countries with GNI per capita between $1,250-$3,500 pay a fee of $1,000 per year / institution. Eligible categories of institutions are: national universities, research institutes, professional schools (medicine, nursing, pharmacy, public health, dentistry), teaching hospitals, government offices and national medical libraries. All staff members and students are entitled to access to the journals.

Human rights and HIV advocacy tools
United Nations Development Programme: 1 January 2009

This set of advocacy tools was developed by the AIDS and Human Rights Research Unit, a joint programme of the Centre for Human Rights and the Centre for the Study of AIDS at the University of Pretoria, and the United Nations Development Programme. According to the developers, violations of human rights exacerbate the spread of the pandemic and the impact of HIV on individuals, communities, and countries is worsened by the inadequate realisation of human rights. The tools are a series of documents created to respond to an identified need for advocacy and information material on human rights-based responses to HIV. They are based on the premise that ensuring the implementation and respect of human rights norms and standards will contribute to reduce vulnerability to HIV transmission, challenge stigma and discrimination, and ensure access to HIV-related treatment, care and support services. They are designed to assist parliamentarians, government officials, members of the judiciary, lawyers, civil society organisations, people living with HIV, and all interested institutions and individuals in the implementation and advocacy of human rights norms in the context of the HIV pandemic. They are designed to enhance efforts at national, regional, and global levels.

Mental health website
Movement for Global Mental Health: 2008

This website aims to improve services for people with mental disorders worldwide. In so doing, two principles are fundamental: first, the action should be informed by the best available scientific evidence; and, second, it should be in accordance with principles of human rights. The Movement is a global network of individuals and institutions who support this mission. The Movement's goal is to support demands for the scaling up of treatments for mental disorders, for the human rights of those affected to be protected, and for more research in low- and middle-income countries.

New online civil society project
Civil Society Gateway: 2010

If you’re working in civil society and looking to sharpen your skills in communicating effectively with the media about your work against poverty, the environment and other issues – especially if you’re presenting research from the South – then this online resource may be most helpful. The Civil Society Gateway aims to reduce isolation of civil society organisations, experts and other individuals by bringing them together in one place, where they can communicate on a wide range of themes. Easily searchable by geography and theme, this tool helps journalists and the media find the sources they need from civil society to produce their stories. The Civil Society Gateway was made possible through a partnership between CIVICUS (World Alliance for Citizen Participation) and the Inter Press Service (IPS), with the support of Oxfam Novib.

15. Jobs and Announcements

Call for abstracts: First Global Symposium on Health Systems Research: Science to accelerate universal health coverage
Deadline: 30 April 2010

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.

Call for abstracts: Ninth Scientific Conference and Third Quadrennial Meeting: Revitalising primary health care and achieving the Millennium Development Goals: Lusaka, Zambia, 23–27 August 2010
Deadline: 15 April 2010

Applicants are invited to submit abstracts to this year’s conference on the theme ‘Revitalising primary health care and achieving the Millennium Development Goals’. There are six sub-themes: strengthening human resources for health management for effective health; fostering quality assurance in health care; enhancing equitable access to mental health care services through primary health care; improving maternal and child health; advocating for improved sexual and reproductive health services; strengthening primary health care for prevention and control of communicable and non-communicable diseases and lifestyle health problems.

Call for applications: Graca Machel Scholarships for postgraduate study in South Africa
Closing date: 10 August 2010

The key aim of the Graça Machel Scholarship Programme is to help provide the female human resources necessary for economic, social and cultural development in the southern African region and to develop an educated and skilled workforce that can benefit the wider community. Scholarships that target women have long been recognised as an effective approach in addressing gender equality and eradicating poverty. By providing opportunities to study at postgraduate level, these scholarships aim to empower women and to equip them to take up leadership positions in order to have a direct impact in the communities, nations and region in which they live. These female scholars must be positive role models for other women. The scholarships are for female students from Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, South Africa, Zambia and Zimbabwe studying in South Africa. They are valid for two years’ postgraduate study and include payment of a maintenance allowance, travel, health insurance and tuition fees. Applicants must have at least two years’ relevant work experience.

Call for applications: YouthActionNet 2010 Global Fellowship Programme
Closing date: 9 April 2010

A programme of the International Youth Foundation, YouthActionNet seeks to develop a new generation of socially conscious global citizens who create positive change in their communities, their countries, and the world. Each year, 20 young social entrepreneurs are selected as YouthActionNet Global Fellows following a competitive application process. The yearlong Global Fellowship includes: skill-building, networking and resources, and advocacy. It is open to all young people aged 18–29. Applicants must be the founder/co-founder of an existing organisation, or a project within an organisation, with a demonstrated one year track record of leading societal change. Proficiency in English is required, and applications must be submitted in English. Applicants must attend the full retreat, 1–8 October 2010 (all expenses paid).

CIVICUS World Assembly 2010: Montréal, Canada: 20-23 August 2010
Closing date for registration: 6 August 2010

Every year, the CIVICUS World Assembly offers about fifty activities grouped around the overall theme, an annual focus theme and sub-themes. The activities comprise plenary sessions, round tables, workshops, networking sessions and formal events. The 2010 World Assembly in Montreal will introduce the concept of interactive group discussions (or Parcours) for the first time. The overall theme of the CIVICUS World Assembly is 'Acting Together for a Just World'. Every year this is explored through a focus theme. In 2010 the focus theme will be 'Seeking Out Solutions'. This theme will address the issues of economy, development and climate. The Assembly has a number of aims. It offers: to provide first hand knowledge on the state of the art of civil society thinking; to establish cross-cutting relationships with civil society, business, media, government and donor organisation professionals from around the globe; in-depth exchange of expertise on how people from all sectors act together to (re)gain the power to enforce decisions; training and capacity building on a wide range of tangible skills e.g. fundraising, networking, mobilisation, volunteering, campaigning etc; and the opportunity to find partners and funding to realise and expand your projects.

Course on global health diplomacy, Geneva 21-25 June 2010
The Global Health Programme at the Graduate Institute of International and Development Studies (IHEID): Deadline for applications: 2 April 2010

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.

Entries to Susie Smith Memorial Prize now invited for 2010
Oxfam GB: Closing date: 18 April 2010

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 18 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.

MEDINFO 2010: Thirteenth International Congress on Medical Informatics
12–15 September 2010, Cape Town: Registration Period: 1 March to 30 June 2010

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.

Registration for the First Global Symposium on Health Systems Research November 2010
Registration is now open!

Researchers, policy-makers, representatives of donor and multinational organizations, and other stakeholders representing diverse constituencies will gather in Montreux, Switzerland to share evidence, identify significant knowledge gaps, and set a research agenda aimed at accelerating universal health coverage. Registration to the Symposium is limited, so register early to ensure your participation. For information on registration fees and conditions visit http://www.hsr-symposium.org/index.php/registration.
Application is now open for the following:
- Young Researcher Programme - http://www.hsrsymposium.org/index.php/young-researchers-call
- Scholarships - http://www.hsrsymposium.org/index.php/scholarships
- Satellite sessions - http://www.hsrsymposium.org/index.php/satellite-meetings
- Marketplace stalls - http://www.hsr-symposium.org/index.php/marketplace
The Call for Abstracts closes on April 30, 2010

Twenty-sixth International Paediatric Association (IPA) Congress of Paediatrics, 2010
Registration deadline: 22 July 2010

Three leading paediatric associations are uniting to host the 26th IPA Congress of Paediatrics in Johannesburg, South Africa from 4–9 August 2010. More than 5,000 participants are expected to attend this landmark event, the first IPA congress to be held in sub-Saharan Africa. It will unite paediatricians and health professionals working towards the target set by Millennium Development Goals (MDGs) to reduce child mortality by two thirds before 2015. The scientific programme is designed to meet the needs of general paediatricians from both the developed and the developing world. Plenary sessions will include: the MDGs and the current state of health of children in the world, and progress towards the MDGs; the state of the world’s newborns, including major issues determining maternal and newborn health in developing and developed countries; the determinants of health, such as genetics, nutrition and the environment; disasters and trauma affecting child health, such as disasters, crises and the worldwide epidemic of trauma; and the global burden of infectious diseases affecting children and the challenge of emerging infections.

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