In a landmark moment on May 21 2010, the World Health Assembly adopted the Code of Practice on the International Recruitment of Health Personnel. It marks the culmination of a decade of advocacy on the recruitment and flow of skilled health workers, particularly from Africa to high income countries. In 2001 Southern African Development Community (SADC) health ministers called recruiting health workers from their understaffed, overburdened health systems ‘looting’ and observed that the outmigration of skilled people ‘further entrenches inequitable wealth and resources’. In 2009, despite having 25% of the global disease burden and 60% of people living with HIV, Africa had only 1% of global health spending and only 2% of the global health work force. It is clearly inequitable to lose health workers from low income countries with high health need to the richest countries in the world with significantly lower disease burdens.
Migration is not the sole factor leading to understaffing. In 2000, WHO estimated that African-born doctors and nurses working in high income OECD countries represented no more than 12% of the total shortage in the region. Inadequate production, limits to health worker training, employment and conditions imposed by resource shortages and fiscal thresholds, the disincentive of falling real wages in the health sector and other factors have been cited for shortfalls. Neither are the drivers for migration solely due to pull factors from high income countries. Economic, political, social and health system conditions in Africa are significant push factors driving migration.
In 2004, motivated by African countries, the World Health Assembly (WHA) requested the Director-General to develop a code of practice on the international recruitment of health personnel and to give consideration to the establishment of mechanisms to mitigate the adverse impact on developing countries of migration. Notably African countries sought to address both ethical recruitment and compensation for the losses they were experiencing through migration, including lost public investments in training, weakened capacities in health systems, loss of expertise and social disruption. Estimates set this at $60 000 in training costs alone for each doctor. In 2001 WHO estimated that South Africa lost US$37 million annually in direct financial losses in training costs, against OECD report of a combined (multilateral and bilateral) total education assistance received by the country in 2000 of US$35.5 million. Further, having experienced continued and rising outflows and foreign employment of health workers even in the face of codes such as the 2001/4 UK Code of Practice, African countries were concerned about how to ensure compliance with any instrument for managing recruitment. Within the SADC region, more binding measures were being used, such as the 2006 South African policy on recruitment and employment of foreign health professionals, which forbade individual applications from identified developing countries, in particular from SADC countries.
After six years of advocacy and work on the issue, the 2010 WHA adopted the global Code of Practice on the International Recruitment of Health Personnel. Its development has included multi-stakeholder consultation and review, including civil society through the Global Health Workforce Alliance, and the WHO regional forums. EQUINET was one of the more than 75 organisations making submissions on the draft. Country submissions on the draft submitted to the Assembly through the WHO Executive Board continued to reflect polarised positions on certain issues (see A63/INF.DOC/2 at http://apps.who.int/gb/e/e_wha63.html). The consensus outcome on the code was thus cause for specific recognition of role of the USA and African delegations in reaching agreement. The new Code of Practice is now the fourth WHO global legal instrument. The Framework Convention on Tobacco Control (FCTC) and the International Health Regulations are legally binding international treaties, while the Code of Practice on the International Recruitment of Health Personnel and the International Code of Marketing of Breast-Milk Substitutes are both voluntary instruments.
The new Code includes ten articles advising both source and destination countries on how to regulate the recruitment of health personnel, as a core component of national to global responses to health systems strengthening. The text makes clear that it is voluntary, and serves as a reference for countries in establishing or improving more binding national laws, policies, bilateral agreements and other international legal instruments on health worker recruitment. It links “properly managed” recruitment to health systems strengthening, especially in developing countries, and to safeguarding the rights of health workers, including their labour and social rights. It raises that countries should mitigate the negative effects and maximise the positive effects of migration on the health systems of the source countries, should plan workforces to reduce dependency on migration and should facilitate circular migration. It provides for gathering and sharing of data and information on international recruitment of health personnel.
Will it address the equity concerns that African countries have raised?
The commitment to developing countries, to health systems strengthening, to fair treatment of migrant workers and to ethical recruitment all signal that the code is a major step towards just outcomes.
Equity is less explicitly addressed within the code than in the debates that led to it. There is no reference to compensation. This was resisted by countries such as Canada, UK and Australia, who did not sign the earlier 2003 Commonwealth Code of Practice in part for its reference to this. Even reference to “mutuality of benefits” or “balancing” of gains and losses included in earlier drafts has been removed in the final draft. The code does make reference to the obligations of governments to protect population health and to equitable health systems. It recognises the “negative effects of health personnel migration on the health systems of developing countries” (Article 3.2), and the greater need of developing countries to health systems strengthening. In its remedies, while Article 5.1 seeks to ensure that both source and destination countries derive benefits from international migration, it does not include any reference to balancing or fairly distributing these benefits. Measures of technical assistance, training and other areas of support are thus included as means to “promote international co-ordination and co-operation on international recruitment of personnel” (Article 5.2), and not as measures of redress for negative effects of migration.
Perhaps this outcome reflects the balance of resources, political forces, power and formal evidence. The resource flows between source and receiving countries are neither simple to collect nor manage. The costs and returns accrue at different levels to individuals, households, communities, private and public sectors. Many of the flows and the measures to manage them lie outside the health sector, in economic, tax, immigration, employment, social security and other areas.
Nevertheless, these constraints and the goodwill around the code should not make it a smokescreen for the continuing research, innovation and dialogue needed to build on the code to further improve fairness and equity in managing these flows. The code has not limited itself to health sector measures, as some measures proposed such as “circular migration” will have implications for immigration, citizenship and labour market laws. Further, an explicit commitment to equity in Article 5.7 provides that “member states should consider adopting measures to address the geographical maldistribution of health workers” could be read to call for measures and resources at national, regional and international level. The code should thus be taken as a platform from which to further explore, develop and raise through its future review at WHA the options for measuring and fairly managing the resource flows between countries, including through tax and funding measures.
Taking the voluntary code to binding agreements and practice is the next front of action, as is monitoring and raising evidence to inform implementation for the next formal global review of the code at the 2012 WHA. Both areas raise challenges if countries in the region are to keep the push for equitable outcomes: to overcome information and evidence gaps, to inform and negotiate fair bilateral agreements, and to ensure that bilateral agreements reinforce and do not disrupt agreements that encourage skills production, circulation and retention within the region, such as the SADC protocols and strategies on education and training, on the movement of persons and on attracting and retaining health professionals.
Experience on prior codes suggests that civil society can play an important role in advancing implementation if effectively engaged. In particular, health workers, and especially female health workers, should not become commodified ‘objects’ to be traded in negotiations, but actively informed and involved through their associations.
Philemon Ngomu of the Southern African Network of Nurses and Midwives (SANNAM) reminds us, further, that the code is only one of a number of measures to address the conditions affecting recruitment and migration: “The very negative implications of political unrest and socio-economic crisis are major driving factors, and the code should not be taken in isolation of peace keeping and socio-economic and welfare initiatives. We cannot stop brain drain without addressing these issues”. When countries report back to the next United Nations General Assembly on the code, as feedback on Resolution 64/108 on Global Health and Foreign Policy, hopefully they will raise this, and make the point that the code is a significant milestone, but not a finishing line, in the path towards the fairer outcomes for health that African Health Ministers sought in 2001.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org. The next newsletter will provide the text of the code and all final resolutions from the World Health Assembly. Interim documents can be found at http://apps.who.int/gb/e/e_wha63.html
1. Editorial
2. Latest Equinet Updates
The countries in eastern and southern Africa and the East African Community are at various stages of enacting laws to address counterfeiting. Substandard and fasified medicines are a problem for public health if they lack the active ingredients that make them effective, or if they are harmful. Yet making quality, safety and efficacy an intellectuual property issue, and defining counterfeiting so widely as to include generic medicines have even greater potential public harm, as they may make these essential medicines available as branded versions, at significantly higher cost. This policy brief draws policy makers attention to the need to ensure that counterfeit laws do not include generic medicines and that falsified medicines are dealt with under public health and not ntellectual propoperty law. It discusses the key issues in these laws and draft laws and how they are likely to affect public health and access to essential medicines in the region.
Leaflet on EQUINET: A Rede Regional para a Equidade em saúde na África oriental e austral (EQUINET) é uma rede de profi ssionais, membros da sociedade civil, formuladores de diretrizes políticos, ofi ciais do estado e outros dentro desta região que se juntaram como catalisadores de equidade, para poder promover e realizar os valores compartilhadas da equidade e justice social na saúde.
Briefing leaflet on EQUINET. Le Réseau Régional sur l’Equité en matière de santé en Afrique orientale et australe (EQUINET) est un réseau de professionnels, membres de la société civile, décideurs, employés gouvernementaux et autres personnalités de la région qui se sont réunis pour mettre en oeuvre une politique en matière d’équité, ce afi n de promouvoir et défi nir des valeurs communes en matière d’équité et de justice sociale au niveau de la santé.
EQUINET September 2009 Conference Resolutions translated into French: Plus de 200 employés gouvernementaux, parlementaires, membres de la société civile, professionnels de santé, chercheurs, universitaires et décideurs, mais aussi les membres des Nations Unies, d’organisations internationales et non-gouvernementales d’Afrique orientale et Australe se sont rassemblés à la troisième Conférence Régionale de EQUINET sur l’Équité en Matière de Santé en Afrique Orientale et Australe, qui s’est tenue du 23 au 25 septembre 2009 au complexe hôtelier de Munyonyo à Kampala. Les délégués ont reconnu des inégalités significatives, grandissantes, évitables et injustes en matière de santé et de ressources de santé dans nos pays, notre région et notre monde. Comme la Commission de l’Organisation Mondiale de la Santé sur les Déterminants Sociaux de la Santé, nous sommes conscients que cette injustice sociale est en train de décimer certaines populations à une grande échelle. Bien que nous ayons dans notre région les ressources de santé nécessaires, nous notons que beaucoup d’entre elles, dont les professionnels de santé, quittent l’Afrique. Nos ressources restantes atteignent par conséquent rarement les personnes les plus démunies. Ceux qui en ont le plus besoin n’y accèdent pas suite aux contraintes économiques, causée par cette inégalité.
This is a report of a workshop for a project that TARSC and Country Minders for People’s Development (CMPD), under the auspices of EQUINET, undertook as a pilot to explore options for participatory communications with the community-based organisations and some of the orphans and vulnerable children in Monkey Bay, Tanzania.
EQUINET September 2009 Conference Resolutions translated into Portuguese: Mais de 200 oficiais de governo, membros de parlamento, membros de sociedade civil, trabalhadores de saúde, pesquisadores, acadêmicos, e executores de política assim como pessoal das Nações Unidas, e organizações internacionais bem como não governamentais de Africa Oriental e Austral, encontraram na terceira conferência regional da EQUINET sobre Equidade em Saúde em África, realizado entre 23-25 setembro 2009, em Munyonyo, Kampala.
3. Equity in Health
In her address at the 2010 World Health Assembly, Margaret Chan charted the successes and failures of public health over the past year. She underlined the importance of equity and social justice, which are central to the Millennium Declaration and its goals, as well as the primary health care approach. Principles such as universal access to services, multisectoral action and community participation form a solid basis for strengthening health systems. However, efforts to reduce maternal and newborn deaths have shown the slowest progress of all the Millennium Development Goals (MDGs) in all regions, largely, as she pointed out, because reducing these deaths depends absolutely on a well-functioning health system. She informed participants that, in preparation for the September United Nations Summit on the Millennium Development Goals, the Secretary-General’s office is finalising a joint action plan to accelerate progress in reaching the health-related MDGs, with a special focus on maternal and child health. She urges all participants to maintain a focus on building strong health systems and improving regulatory capacity. Acknowledging that WHO has not met its goals in the past, she re-iterated the organisation's commitment to improving fundamental capacities to help reach international commitments, increase efficiency and fairness, improve health outcomes in sustainable ways and move countries towards greater self-reliance.
Honorary Chair and Patron of the Africa Public Health Alliance and 15% Plus Campaign, Desmond Tutu, has called on African Heads of State and Ministers of Health and Finance to work urgently towards meeting their Abuja commitments before the 2011 High Level Progressive Review of Africa's commitment to health financing. He pointed out that, in the past nine years, only six out of 53 African Union member states have met their 2001 Abuja commitment to pledge 15% of their budgets to health. He attributed shortfalls on meeting health Millennium Development Goals (MDGs)to a combination of low per-capita investment in health and low investment in social determinants of health, such as clean water, improved sanitation, poor nutrition and gender equity in health, as well as a lack of pharmaceutical capacity and access to medicines. He urged the education and labour sectors to train and retain the necessary numbers of health workers, and double per capita investment in health.
This statement was made after a meeting of Commonwealth Health Ministers (CHMM), which was held on 16 May 2010 in Geneva, Switzerland. The theme of the meeting was 'The Commonwealth and the Health MDGs by 2015'. The Meeting noted that only 5% of Commonwealth developing countries have met Millennium Development Goal (MDG) 4 targets or are on track to do so. At least 19 countries have high maternal mortality rates, and only 36% of developing Commonwealth countries have achieved or are on track to achieve the targets for births attended by skilled staff. The Meeting also noted the major challenges facing the world, and Commonwealth countries in particular, if the MDGs are to be met. Ministers were optimistic that many of the 2015 MDG targets could be met by Commonwealth countries. They, however, noted that this would require greater technical co-operation; attention to enabling environments, including legal frameworks, and where appropriate free healthcare to mothers and children; and an integration of preventative and curative services in the context of strengthening health systems through primary healthcare. Ministers called on the global community, especially the G8 and G20, to support maternal and newborn health programmes, and to meet MDGs 4 and 5. While acknowledging the tremendous achievements in access to anti-retroviral treatment, the Ministers noted that two thirds of those needing treatment did not receive it. Ministers pledged support for the greater alignment of non-communicable disease issues with the MDGs.
The International Conference on Dynamics of Rural Transformation in Emerging Economies was held from 14 to 16 April 2010 in New Delhi, India. Up to 300 participants with over 70% from emerging economy countries and 30% from other developing countries, including those in the Organization for Economic Co-operation and Development, joined the discussions. Debates during the conference suggested that food security policies could be further explored as an important field for South-South knowledge sharing. The Conference offered an opportunity for stakeholders to discuss concepts and policies concerning rural development . The discussions raised areas that participants agreed would be explored in further dialogue, such as the increase in urban-rural disparities, the expansion of rural non-farm income-generation options, migration and environmental concerns, as well as persisting issues of food insecurity, land tenure and rural poverty.
This report provides an overview of progress in implementing the action plan for the global strategy for the prevention and control of non-communicable diseases since its endorsement by the Sixty-first World Health Assembly in May 2008. The action plan aims to: map the emerging epidemics of non-communicable diseases and analyse their social, economic, behavioural and political determinants; reduce the level of exposure of individuals and populations to the common modifiable risk factors; and strengthen health care for people with non-communicable diseases by developing evidence-based norms, standards and guidelines for cost-effective interventions and by orienting health systems to respond to the need for effective management of diseases of a chronic nature. The plan covers six objectives, each with two sets of proposed actions, for member states and international partners, and one set of actions for the WHO Secretariat. Its implementation is to be reviewed at the end of the first biennium.
The 63rd World Health Assembly, which brought together Health Ministers and senior health officials from the World Health Organization's (WHO) Member States, concluded on 21 May 2010. The delegates adopted resolutions on a variety of global health issues including: a global strategy and plan of action for public health, innovation and intellectual property; convening an intergovernmental working group to deal with counterfeit medical products; developing a comprehensive approach to the prevention and control of viral hepatitis; monitoring the achievement of the health-related Millennium Development Goals; enforcing the global code of practice for the international recruitment of health personnel; ensuring food safety; implementing the global strategy for the prevention and control of non-communicable diseases; implementing strategies to reduce the harmful use of alcohol; global eradication of measles by 2015; increasing availability, safety and quality of blood products; new guidelines on human organ and tissue transplantation; intensifying efforts to improve treatment and prevention of pneumonia; increased political commitment and a global strategy for better infant and young child nutrition; redressing the limited focus to date on preventing and managing birth defects; sharing of influenza viruses and access to vaccines and other benefits with regard to pandemic influenza preparedness; and implementing the International Health Regulations of 2005.
The World Health Organization (WHO) has launched a campaign to highlight urban planning as a crucial link to building a healthy 21st century. In particular, WHO calls on municipal authorities, concerned residents, advocates for healthy living and others to take a close look at health inequities in cities and take action. Rapid urbanisation has resulted in significant changes in our living standards, lifestyles, social behaviour and health. This article notes that many cities face a triple threat: infectious diseases, which thrive when people are crowded together; chronic, non-communicable diseases including diabetes, cancers and heart disease, which are on the rise with unhealthy lifestyles; and urban health is often further burdened by road traffic accidents, injuries, violence and crime. WHO outlines five actions that could significantly increase the chance people will be able to enjoy better urban living conditions: promote urban planning for healthy behaviours and safety; improve urban living conditions; ensure participatory governance; build inclusive cities that are accessible and age-friendly; and make cities resilient to disasters and emergencies.
4. Values, Policies and Rights
The AIDS Law Project, one of South Africa's leading HIV and AIDS rights campaigners, has ceased to exist in its present form. Instead it has become part of Section27, a non-profit organisation that will focus on all 'the socio-economic conditions that undermine human dignity and development, prevent poor people from reaching their full potential and lead to the spread of diseases that have a disproportionate impact on the vulnerable and marginalised'. Section27 gets its name from the section in the country’s Constitution that states everyone has the right to access to health care services, enough food and water and social security. The organisation faces a potential legal battle over the right to use the name, Section27, as the Companies and Intellectual Properties Registration Organisation (CIPRO) claims that this name is the preserve of government only. Director Mark Heywood explained the change: 'To sustain the response to HIV, reduce new infections and ensure sustained access to treatment, it is necessary to campaign for equity, equality and quality in the health system.' Head of litigation services Adila Hassan said the new organisation will still focus on HIV/AIDS but also on the 'underlying determinants of health, and to do this we will be focusing on education and sufficient food as two such determinants'. Section27 will also defend the Constitution and its foundational values.
According to this article, World Health Organization (WHO) member states are responsible for directing and enabling WHO to undertake its normative and standard-setting functions effectively in facing the increasingly transnational nature of health threats, to be a trusted repository for knowledge and information, and to act as an effective convener of multiple players and stakeholders that can drive appropriate convergence, innovation, and effective decision making for health in a diverse landscape. In support of effective health governance, it states that better evidence and best practices are needed on how foreign policy can improve policy coordination at all levels and create an improved global policy environment for health. Foreign policy practitioners need to become more aware of positive and negative impact of policy options and decisions on health outcomes. This is how foreign policy can make a difference to health.
Children under 18 are legal minors who, in South African law, are not fully capable of acting independently without assistance from parents/legal guardians. However, in recognition of the evolving capacity of children, there are exceptional circumstances where the law has granted minors the capacity to act independently. This paper describes legal norms for child consent to health-related interventions in South Africa, and argues that the South African parliament has taken an inconsistent approach to: the capacity of children to consent; the persons able to consent when children do not have capacity; and restrictions on the autonomy of children or their proxies to consent. In addition, the rationale for the differing age limitations, capacity requirements and public policy restrictions has not been specified. The paper argues that these inconsistencies make it difficult for stakeholders interacting with children to ensure that they act lawfully.
The Secretariat has drafted this strategy to deal with alcohol abuse through an inclusive and broad collaborative process with member states. In doing so, it took into consideration the outcomes of consultations with other stakeholders on ways in which they can contribute to reducing the harmful use of alcohol. The draft strategy is based on existing best practices and available evidence of effectiveness and cost-effectiveness of strategies and interventions to reduce the harmful use of alcohol. This document first outlines the history of the consultative process to determine what approaches to take for combating alcohol abuse before it describes the strategy, which consists of a number of areas: increasing global action and international cooperation; ensuring intersectoral action; according appropriate attention; balancing different interests; focusing on equity; considering context in recommending actions; and strengthening information systems.
This document presents ten reasons why exposing or transmitting HIV to someone else should not be criminalised. It argues that criminalising HIV transmission is justified only when individuals purposely or maliciously transmit HIV with the intent to harm others. In these rare cases, existing criminal laws can and should be used, rather than passing HIV-specific laws. Furthermore, applying criminal law to HIV exposure or transmission does not reduce the spread of HIV, undermines HIV prevention efforts and promotes fear and stigma. Instead of providing justice to women, applying criminal law to HIV exposure or transmission endangers and further oppresses them. It points out that laws criminalising HIV exposure and transmission are drafted and applied too broadly, and often punish behavior that is not blameworthy. They are often applied unfairly, selectively and ineffectively, and ignore the real challenges of HIV prevention. Rather than introducing laws criminalising HIV exposure and transmission, legislators must reform laws that stand in the way of HIV prevention and treatment, and instead take a human-rights position in response to the problem.
The United Nations Development Programme (UNDP) has unveiled its new agenda for action to combat the spread of HIV among women and girls, which underscores the need to understand and respond to the particular effects of the HIV epidemic on women and girls and translate political commitments into scaled-up action. It calls on the United Nations to support governments, civil society and development partners in reinforcing country actions to put women and girls at the centre of the AIDS response, ensuring that their rights are protected. The UNDP will support leadership development for HIV positive women and girls in 30 countries, support positive women’s networks being fully involved and reporting on the Millennium Development Goals, encourage countries to put HIV reporting into their reporting under the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and initiate 'know your rights' campaigns focusing on the rights of women and girls in a number of countries.
5. Health equity in economic and trade policies
In this open letter to Margaret Chan, Director-General of the World Health Organization (WHO), Health Action International (HAI) urges WHO to dissociate itself from the work of IMPACT, a global intellectual property (IP) enforcement body that seeks to impose an IP agenda to deal with broader problems of medical products with compromised quality, safety and efficacy. It further demands that WHO no longer involve itself in IP enforcement with regard to pharmaceuticals and other medical products. It argues that, not only is the IP enforcement agenda ineffective in terms of addressing the wider public health threats from spurious and sub-standard medical products, but it has also been shown to impede access to medicines by undermining competition from generic medicines. WHO should continue to prioritise public health issues over issues of trade, which HAI points out has always been WHO's proper mandate.
India and Brazil have taken the first step towards raising a dispute at the World Trade Organization (WTO) against the European Union (EU) and the Netherlands over the seizure by EU customs of generic medicines in transit to developing countries. Their request for consultations under the WTO Dispute Settlement Mechanism is the first step in the possible establishment of a panel at the Dispute Settlement Body (DSB), if the consultations fail. Indian ambassador, Ujal Singh Bhatia, said that both India and Brazil were concerned primarily over two considerations. Firstly, the seizures seemed to emanate from complaints made by patent holders in Europe, even though the generic drugs were perfectly legitimate under WTO rules in the source countries, as well as in the destination countries. He noted that the intellectual property issues raised were unmerited and international transit guarantees were being violated. Secondly, he noted that the seizures confused intellectual property rights with substandard or spurious medicines. He believed there was a concerted effort to put together a TRIPS-plus enforcement agenda that does away with the flexibilities that are guaranteed to developing countries under the TRIPS regime.
While the Anti-Counterfeiting Trade Agreement (ACTA) is getting a lot of attention with its draft consolidated version just published, there is another convention dealing with one major aspect it was always said ACTA would tackle. The Medicrime Convention of the Council of Europe sets the first international standard for criminalising the manufacturing and distribution of counterfeited medicine risking public health. Governments that will sign the convention later this year commit to establish as offences 'the intentional manufacturing of counterfeit medical products, active substances, excipients, parts, materials and accessories' (Article 5), 'the supplying or the offering to supply, including brokering, the trafficking, including keeping in stock, importing and exporting of counterfeit medical products, active substances, excipients, parts, materials and accessories' (Article 6) and also the 'falsification of documents' (Article 7). Medicrime also covers falsified medical devices and aims to see 'aiding, abetting and attempt' of the described acts criminalised. According to Medicrime, falsification of generic drugs also would be covered and so would the distribution of legal drugs on the black market like hormones sold without prescription to people who want to build up their muscles or enhance their performance. Also drugs brought to the market without undergoing existing controls will be covered.
More than 45 non-governmental organisations (NGOs), from countries as diverse as Switzerland, India, the United States and Uganda, have voiced concern over the involvement of the World Health Organization (WHO) in the issue of 'counterfeit' medical products. In an open letter to WHO, the NGOs criticised WHO's involvement in the International Medical Product Anti-Counterfeit Taskforce (IMPACT), including its links to entities that are engaged in matters pertaining to intellectual property (IP) enforcement, the central role played by the International Federation of Pharmaceutical Manufacturers' Associations (IFPMA) in IMPACT's activities, the lack of transparency surrounding IMPACT's activities and the lack of accountability, as IMPACT has operated outside the purview of WHO member states. The open letter said that equating 'counterfeit' with spurious and falsely labelled pharmaceutical products not only undermines confidence in much-needed affordable quality generic products but also results in public health problems being addressed through an IP enforcement lens. It noted that spurious and falsely labelled pharmaceuticals will arise irrespective of whether or not there is an IP violation.
This publication affirms the World Health Organization's commitment to continue to work with member states and relevant regional economic integration organisations on the Pandemic Influenza Preparedness Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits. It guarantees to convene the Open-Ended Working Group before the 128th session of the Executive Board and to undertake any necessary technical consultations and studies to support the work of the Open-Ended Working Group in reaching a final agreement.
In 2007, world attention was focused on the World Health Organization (WHO) when claims emerged that WHO’s Global Influenza Surveillance Network (GISN) was unfair to the interests and needs of developing countries. According to this book, GISN has failed to deliver fair and equitable benefit-sharing with regard to vaccines, anti-virals and other technologies by not ensuring these products were available at affordable prices to developing countries that were most affected by the influenza outbreak. At the same time, developed countries profited from the virus sharing system by, for example, having timely access to vaccines and making intellectual property (IP) rights claims over shared biological materials and products developed using such materials. Developing countries thus potentially face astronomical bills for the purchase of vaccines and other medical supplies, as well as difficulties in accessing such supplies, due to their limited availability. Latest technologies were also protected by IP rights, creating more obstacles for developing countries that might seek to build their own production capacity. This book provides an in-depth understanding of the background to, and rationale for, the current WHO negotiations on influenza virus and benefit sharing, as well as a front-line view of the negotiations.
Pharmaceutical and medical device manufacturers argue that the current patent system is crucial for stimulating research and development (R&D), leading to new products that improve medical care. The financial return on their investments that is afforded by patent protection, they claim, is an incentive toward innovation and reinvestment into further R&D. But this view has been challenged in recent years. Many commentators argue that patents are stifling biomedical research, for example by preventing researchers from accessing patented materials or methods they need for their studies. Patents have also been blamed for impeding medical care by raising prices of essential medicines, such as antiretroviral drugs, in poor countries. This debate examines whether and how patents are impeding health care and innovation.
This book explores the history of and current collision between two of the major global phenomena that have characterised the last 30 years: the spread of HIV and other diseases of poverty and the ascendancy of neoliberal economic ideas. The book explains not only how International Monetary Fund policies of restrictive spending have exacerbated public health problems in developing countries, in particular the HIV and AIDS crisis, but also how such issues cannot be resolved under these economic policies. It also suggests how mounting global frustration about this inability to adequately address HIV and AIDS will ultimately lead to challenges to the dominant neoliberal ideas, as other more effective economic ideas for increasing public spending are sought. Rowden offers a unique and in-depth critique of development economics, the political economy dynamics of global foreign aid and health institutions, and how these seemingly abstract factors play out in the real world - from the highest levels of global institutions to African finance and health ministries to rural health outposts in the countryside of developing nations, and back again.
6. Poverty and health
With 87% of the world’s population or approximately 5.9 billion people using safe drinking water sources, the world is on track to meet or even exceed the drinking water target of the Millennium Development Goals (MDGs), according to this new report. The report confirms that advances continue to be made towards greater access to safe drinking water. In contrast, progress in relation to access to basic sanitation is 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 United Nations Food and Agriculture Organization (FAO) has launched a major online drive to spur action to eliminate hunger and highlight the fact that one in six people worldwide go hungry everyday. Through its '1 billionhungry project' people can voice their opinions about world hunger by adding their names to an online petition. The campaign uses a yellow whistle as an icon encouraging people to blow the whistle against this global scourge. Events in support of the petition launch are organised through FAO offices around the world. International athletes, football players and recording artists will add their voices to the campaign. Civil society organisations, including the World Association of Girl Guides and Girl Scouts, will also promote the campaign through their own networks.
7. Equitable health services
In this paper, a simple method based on the end-user as the denominator was employed to classify individuals into one of four insecticide-treated net (ITN) use categories: living in households not owning an ITN; living in households owning, but not hanging an ITN; living in households owning and hanging an ITN, but who are not sleeping under one; and sleeping under an ITN. This framework was applied to survey data designed to evaluate distribution of long-lasting insecticidal nets (LLINs) following integrated campaigns in five African countries, including Madagascar and Kenya. The study found that the percentage of children <5 years of age sleeping under an ITN ranged from 51.5% in Kenya to 81.1% in Madagascar. Among the three categories of non-use, children living in households without an ITN make up largest group, despite the efforts of the integrated child health campaigns. The percentage of children who live in households that own but do not hang an ITN ranged from 5.1% to 16.1%. The percentage of children living in households where an ITN was suspended, but who were not sleeping under it ranged from 4.3% to 16.4%. Use by all household members in Madagascar (60.4%) indicate that integrated campaigns reach beyond their desired target populations. The framework outlined in this paper may provide a helpful tool to examine the deficiencies in ITN use. Monitoring and evaluation strategies designed to assess ITN ownership and use can easily incorporate this approach using existing data collection instruments that measure the standard indicators.
The Perinatal Mental Health Project in Cape Town, which offers counselling to mothers throughout their pregnancy, is playing a role by tackling depression in the initial stages of the pregnancy. While most programmes only tackle cases of depression among pregnant women after the birth of the baby, the Perinatal Mental Health Project (PMHP) at the University of Cape Town intervenes during the early stages of pregnancy. Simone Honikman, director of the project said severe cases of depression could be treated more successfully if detected early. According to PMHP, South Africa’s postnatal depression (PND) prevalence is three times that in developed countries. For over eight years the PMHP has screened about 8,000 pregnant women for mental health conditions, while up to 1 234 women have been counselled as part of this free service. The PMHP model is one of integration. Mental health care is provided on site together with antenatal care services. This means that the mothers needing help can access this service at the same service point where they receive other health care related to the pregnancy.
Global efforts focusing on eliminating malaria are counterproductive to the fight against the disease in Africa, experts have warned. They emphasise the importance of maintaining, and building on, control strategies rather than aiming for a target that may not be met. Buoyed by a reduction in malaria mortality in Africa, health leaders in 2007 switched their primary goal from control to elimination. But researchers from the Kenya Medical Research Institute-Wellcome Trust Research Programme in Nairobi now say that the emphasis on elimination or eradication in strategic plans for the next 10 to 20 years in Africa is 'at best irrelevant and at worst counterproductive', raising expectations that cannot be met. Increased use of insecticide-treated bed nets, improved rapid diagnostic tests and the replacement of failing drugs with artemisinin-based combination therapy are among the interventions that have helped to reduce malaria transmission and incidence substantially across the continent. On the coast of Kenya, for example, the incidence of severe malaria has fallen by more than 90% in the last five years. However, the researchers warn that positive results are not universal throughout Africa. A substantial funding gap remains to meet the estimated US$4 per head needed to treat malaria, which currently stands at less than US$1 per head.
In this study, an initial assessment of hospital management systems demonstrated weak functioning in several management areas. In response, the authors developed a novel Master of Hospital Administration (MHA) programme, a collaborative effort of the Ethiopian Ministry of Health (MoH), the Clinton HIV/AIDS Initiative, Jimma University and Yale University. The MHA is a two-year executive style educational programme to develop a new cadre of hospital leaders, consisting of 5% classroom learning and 85% executive practice. It has been implemented with 55 hospital leaders in the position of chief executive officer within the MoH, with courses taught in collaboration by faculty of the North and the South universities. The programme has enrolled two cohorts of hospital leaders and is working in more than half of the government hospitals in Ethiopia. Lessons learned include the need to: balance education in applied technical skills with more abstract thinking and problem solving; recognise the interplay between management education and policy reform; remain flexible as policy changes have direct impact on the project; be realistic about resource constraints in low-income settings, particularly information technology limitations; and manage the transfer of knowledge for long-term sustainability. The authors hope that this programme will set a precedent for other sub-Saharan countries wishing to improve their health sector management.
According to this study, clinically protective malaria vaccines consistently fail to protect adults and children in endemic settings, and at best only partially protect infants. It identified and evaluated 1,916 immunisation studies between 1965 and 2010, and excluded partially or nonprotective results to find 177 completely protective immunisation experiments. Detailed re-examination revealed an unexpectedly mundane basis for selective vaccine failure: live malaria parasites in the skin inhibit vaccine function. It show how published molecular and cellular data support a testable, novel model where parasite-host interactions in the skin induce malaria-specific regulatory T cells, and subvert early antigen-specific immunity to parasite-specific immunotolerance. This ensures infection and tolerance to re-infection. The paper concludes that skinstage-initiated immunosuppression, unassociated with bloodstage parasites, systematically blocks vaccine function in the field. The model it uses exposes novel molecular and procedural strategies to significantly and quickly increase protective efficacy in both pipeline and currently ineffective malaria vaccines, and forces fundamental reassessment of central precepts determining vaccine development. This has major implications for accelerated local eliminations of malaria, and significantly increases potential for eradication.
Reproductive health problems among teenagers are the focus of a new European Union-funded project, which will investigate the effectiveness of existing programmes and identifying the structural drivers that restrict access to adolescent reproductive health (ARH) services in Niger and Tanzania. The INTHEC ('Health, education and community integration: evidence based strategies to increase equity, integration and effectiveness of reproductive health services for poor communities in sub-Saharan Africa') project has received EUR 2.75 million in funding under the European Union's Seventh Framework Programme. The project, launched in March 2010 and scheduled to end in February 2014, will also address the cultural barriers that currently limit access to or curb the effectiveness of ARH services in the two countries. Led by the Liverpool School of Tropical Medicine in the United Kingdom, the INTHEC consortium consists of experts from the fields of reproductive health research and interventional implementation, as well as leaders in governance and policymaking in Belgium, Niger and Tanzania. The government ministries responsible for ARH in Tanzania and Niger are partners in the programme, meaning that the outcome of the research will be genuinely owned by the key policymakers, helping ensure the impact of this research beyond the life of the project.
Primary health care in rural South Africa is predominantly provided by remote clinics and health centres. In 1994, health centres were upgraded and new health centres developed to serve as a health care filter between community clinics and district hospitals. This study set out to describe the spectrum of clinical problems encountered at a new health centre in an area of high economic deprivation and compare this with an adjacent community clinic and district hospital. The International Classification of Primary Care-2 (ICPC-2) was used to code data collected over a 13-week period from patients presenting at a community clinic, health centre and district hospital. Altogether, 4,383 patient encounters were recorded across all three sites in 2001. Most contacts at the clinic (97%) and the health centre (80%) were with a nurse. Females over 15 years of age comprised over half of all contacts at health facilities (53%). The most common diagnosis category was respiratory (23%). Cough was the most common symptom. Thirty per cent of children up to 5 years of age were seen for immunisations. Most childhood immunisations (79%) were carried out at the health centre. The study concluded that, of all the health care facilities surveyed, the health centre had the highest throughput of patients, indicating that the health centre is an efficient filter between the community and hospital. In this light, the ICPC-2 system can be successfully used to monitor encounters at similar African health care facilities.
This study aimed to describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. It conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. It identified 1,701 malaria cases, of which 1,548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals, while 1,149 (68%) patients were male. Most (84%) infections were acquired in Mozambique. While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. The study recommends that providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.
Oral polio vaccine (OPV) is recommended to be given at birth together with BCG vaccine. This study investigated the effect of OPV given simultaneously with BCG at birth on the immune response to BCG vaccine. It compared the in vitro and the in vivo response to PPD in the infants who received OPV and BCG with that of infants who received BCG only. The study is the first to address the consequences for the immune response to BCG of simultaneous administration with OPV. The authors expressed concern that the results indicate that the common practice in low-income countries of administering OPV together with BCG at birth may down-regulate the response to BCG vaccine.
8. Human Resources
This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. A comprehensive search of the English literature was conducted using the National Library of Medicine’s (PubMed) database and a total of 110 articles were included. The available evidence was classified into five intervention categories: selection, education, coercion, incentives and support. The main definitions used to define ‘rural and/or remote’ in the articles reviewed were summarised before the evidence in support of each of the five intervention categories was presented. The review argues for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. The review concludes that the impact of untested interventions needs to be evaluated in a scientifically rigorous fashion to identify winning strategies for guiding future practice and policy.
Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include 'obligatory', 'mandatory', 'required' and 'requisite.' All these different programme names refer to a country’s law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.
The lack of health workers in remote and rural areas is a worldwide concern. Many countries have proposed and implemented interventions to address this issue, but very little is known about the effectiveness of such interventions and their sustainability in the long run. This paper provides an analysis of the effectiveness of interventions to attract and retain health workers in remote and rural areas from an impact evaluation perspective. It reports on a literature review of studies that have conducted evaluations of such interventions. It presents a synthesis of the indicators and methods used to measure the effects of rural retention interventions against several policy dimensions such as: attractiveness of rural or remote areas, deployment/recruitment, retention, and health workforce and health systems performance. It also discusses the quality of the current evidence on evaluation studies and emphasises the need for more thorough evaluations to support policy-makers in developing, implementing and evaluating effective interventions to increase availability of health workers in underserved areas and ultimately contribute to reaching the United Nations' Millennium Development Goals.
Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multi-method and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective.
This policy brief notes that a significant share of health worker migration is occurring between Organization for Economic Co-operation and Development (OECD) countries, even though the bulk of migration flows is originating from developing and emerging countries. Countries with expatriation rates of doctors above 50% (which means that there are as many doctors born in these countries working in the OECD countries as there are working in their home country) include five African countries: Mozambique, Angola, Sierra Leone, Tanzania and Liberia. The brief found that the needs for health workers in developing countries, as estimated by the World Health Organization (WHO), largely outstrip the numbers of immigrant health workers from those countries working in OECD countries. In 2000, all African-born doctors and nurses working in the OECD represented no more than 12% of the total shortage for the region, as estimated by WHO. The brief argues that international migration is neither the main cause of healthcare shortages in developing countries, nor would its reduction be enough to address to the worldwide health human resources crisis. It recommends that receiving countries should expand education and training capacity to reduce dependency on foreign health personnel to fill domestic needs.
The authors of this paper undertook a systematic review to consolidate existing evidence on the impact of financial and non-financial incentives on health worker motivation and retention. They searched four literature databases, as well as Google Scholar and the journal, Human Resources for Health. Grey literature studies and informational papers were also captured. Twenty articles met the inclusion criteria, consisting of a mix of qualitative and quantitative studies. Seven major motivational themes were identified: financial rewards, career development, continuing education, hospital infrastructure, resource availability, hospital management and recognition/appreciation. There was some evidence to suggest that the use of initiatives to improve motivation had been effective in helping retention, but less clear evidence on the differential response of different cadres. While motivational factors are undoubtedly country specific, the authors identified financial incentives, career development and management issues as core factors. The authors concluded that financial incentives alone are not enough to motivate health workers, that recognition is highly influential in health worker motivation and that adequate resources and appropriate infrastructure can improve morale significantly.
The National Institutes of Health has announced a new initiative to strengthen medical education in sub-Saharan Africa, in collaboration with the President’s Emergency Plan for AIDS Relief (PEPFAR). The programme, called the Medical Education Partnership Initiative, is a joint effort of the Office of the United States Global AIDS Coordinator, the Health Resources and Services Administration, the Centres for Disease Control and Prevention, the United States Department of Defense and 19 components of NIH. This programme is in support of PEPFAR's goal to increase the number of new health care workers by 140,000, and will also serve the related objectives of strengthening host-country medical education systems and enhancing clinical and research capacity in Africa. Foreign institutions and their partners in PEPFAR-supported Sub-Saharan African countries are invited to submit proposals to develop or expand models of medical education. These models are intended to contribute to the sustainability of country HIV and AIDS responses by expanding the pool of well-trained clinicians. The awards will also build the capacity of local scientists and health care workers to conduct multidisciplinary research, so that discoveries can more effectively be adapted and implemented in their communities and countries. Nine programmatic awards are available.
This study aimed to evaluate the relative effectiveness of different policies in attracting nurses to rural areas in Kenya, South Africa and Thailand using data from a discrete choice experiment (DCE). A labelled DCE was designed to model the relative effectiveness of both financial and non-financial strategies designed to attract nurses to rural areas. Data were collected from over 300 graduating nursing students in each country. Mixed logit models were used for analysis and to predict the uptake of rural posts under different incentive combinations. The study found that nurses’ preferences for different human resource policy interventions varied significantly between the three countries. In Kenya and South Africa, better educational opportunities or rural allowances would be most effective in increasing the uptake of rural posts, while in Thailand better health insurance coverage would have the greatest impact. In conclusion, it recommends that DCEs can be designed to help policy-makers choose more effective interventions to address staff shortages in rural areas. Intervention packages tailored to local conditions are more likely to be effective than standardised global approaches.
9. Public-Private Mix
This research project aimed to assess current attitudes of major global and national stakeholders on the role of the private sector in low- and lower-middle-income countries in health service provision and financing. The research team used qualitative and quantitative methods to gather data on attitudes toward the private sector. The research found that there was no agreement about what the 'private sector' or a 'public-private partnership' was. Most respondents gave qualified responses in their views of the private sector, although their perceptions varied depending on their personal ideology and history, type of intervention, area of focus, and country context. Negative views were deeply rooted. The public sector viewed the private sector as a means to an end. At the national level, the private sector feared government interference, while the public sector feared a loss of control. There was significant experience with many different forms and models of public-private interaction.
The Municipal Services Project and Focus on the Global South held a one-day workshop on building alternatives to the privatisation of basic services on 31 March 2010 in New Delhi, India. This presentation on health in Africa was given at the workshop. The presenter discussed some alternatives to privatisation, such as community-based health insurance and mutual health organisations. Functional national health insurance schemes are already in operation in Ghana and Nigeria, while South Africa is busy putting together its own scheme and a similar scheme is in its initial stages in Uganda. Community-based alternatives to the privatisation of health services were considered but measures are needed to promote equity through cross-subsidisation provisions for democratic participation and improved quality of health services. However, the presenter pointed out that administrative efficiency and the cost effectiveness of collecting the premiums in community-based approaches were often problematic and sustainability was also a challenge, and faced dwindling membership due to low income. Benefits, including improved accountability through greater member involvement, were more likely if these approaches were integrated with national health systems, as shown in Rwanda, Tanzania and Ghana.
This report points out that the private health sector is growing rapidly in low- and middle-income countries, while the debate about the purported advantages and drawbacks of the reliance on public, private not-for- profit and private for-profit providers has suffered from a distinct lack of factual documentation and evidence. It indicates a need for better empirical information, over a range of contexts, on the characteristics, extent, growth and consequences of unregulated commercial care provision. Such information should cover short- and long-term impact on safety, access, quality of care, health outcomes, health equity and social outcomes, as well as the level of trust in health systems and health authorities. An improved evidence base would also allow for a more productive exchange of experience between countries on best practices regarding constructive engagement with and regulation of different types of health-care providers. In many low- and middle-income countries reduced institutional capacity constrains constructive engagement with the wide range of actors involved in health-care provision. The World Health Organization aims to consolidate experience, document best practice and facilitate exchange and joint learning about ways to strengthen government capacity for constructive engagement and effective oversight of the full range of health-care providers.
10. Resource allocation and health financing
This paper was presented at the African Union's (AU) Continental Conference on Maternal, Infant and Child Health in Africa from 19 to 21 April 2010. It outlines the basis for a required paradigm shift in ‘health financing’ in Africa, given the limited gains from isolated health financing and the rising health burden and mortality in 2010 since 2000. In April 2001, African Heads of State met in Abuja, Nigeria to make the continent's main financial commitment towards meeting the health Millennium Goals by pledging to allocate at least 15% of domestic national budgets to health. Yet nine years later, the pledge remains largely unmet. Broad-based social development investment is required in addition to the 15% pledge and the paper calls for investment in integrated and needs-based health, population and social development, moving from just 15% to 15%+.
This occasional paper focuses on China’s and the EU’s aid policies towards Africa by examining their different approaches to aid and the internal logic behind these differences in order to facilitate mutual understanding. It points out that, due to their different development stages, different development models and different aid co-operation experiences in Africa, China and the EU have developed different aid principles, priorities and modalities with different logics. China advocates more ‘co-operation’ than ‘aid’ itself, so the country’s main principles guiding the way in which it manages aid are no political conditions attached to aid provisions, two-way co-operation and a win-win formula. The EU considers aid as a one-way instrument to promote Africa’s good governance and sustainable development, so the key principles that it applies are conditionality, one-way benevolence and co-responsibility. However, the paper highlights that these different logics behind the EU’s and China’s policy approaches are not necessarily contradictory. It proposes that both sides should shift perspective, putting aside the perception of ‘competing models’, to study the points of overlap and thus open a new window for co-operation. Considering the wide perception gap that exists between the two sides, the author recommends that a practical and pragmatic way to advance co-operation may be through focusing initially on second track approaches.
Members of the Organization for Economic Co-operation and Development's (OECD) Development Assistance Committee (DAC) gave US$121.5 billion in bilateral aid in 2009, reaching a historic high, but the gap between commitments and promises made in 2005 is widening, according to this report. In 2005 DAC external funders collectively promised to commit 0.56% of gross national income to aid by 2010, but reached just 0.31% in 2009. Though aid commitments have continued to increase, the rate of increase has dropped off in the past few years, making external funders increasingly off-track. DAC external funders gave US$27 billion to Africa in 2009, an increase of 3% on 2008, but this is still less than half of the extra aid they promised at Gleneagles in 2005. Norway, France, the UK, Korea, Finland, Belgium and Switzerland all increased their aid commitments, while Japan, Greece, Ireland, Spain and Portugal, among others, reduced theirs. The largest external funders by volume were the USA, France, Germany, the UK and Japan, but just five countries met or exceeded the UN overseas development aid target of 0.7% of national income: Denmark, Luxembourg, the Netherlands, Norway and Sweden. External funders pledged to increase aid to US$130 billion by 2010; but the report predicts they will fall short by US$78 billion (both figures in 2004 US dollars).
This paper looks first at the relevance of sector approaches and their overall effectiveness, then on the systemic challenges that they entail. This is followed by a closer look of the links between sector approaches and global agendas, and of sector approaches in fragile situations. Operational aspects, the particular challenges related to policy/political dialogue, accountability, monitoring and quality assurance are presented, and the issue of modalities – budget support, pooled funding and/or projects – is touched upon. Finally, the changing roles played by embassy staff are discussed. Although external funders are expected to respect sovereignty and not to interfere in internal affairs, this paper argues that in reality they do interfere, no matter what they do – the money they bring to the table will, no matter what, modify power structures and strengthen some actors while weakening others. The challenge is therefore to intervene in a way that does not enter into big (party) politics, but aims at strengthening the domestic sector system of politics, policies, knowledge and institutions that can bring the sector forward in a direction that fits both donor objectives and the objectives of domestic stakeholders.
The focus of this report is on sub-Saharan Africa because this region appears to be particularly lagging behind in the sphere of the provision of social protection, being at the same time more vulnerable than other developing areas. More people live below the poverty line, more people die of HIV or malaria, income distribution is very unequal, more people depend on volatile agriculture, the climate changes threaten to bring about more dramatic natural disasters, state institutions are often unrecognised or illegitimate, economies are less diversified and violent conflict is rife. In the aftermath of the three crises (food, fuel and financial), which in a short time span have hit the world economy, sub-Saharan Africa has little resources to react. The European Union, together with other external funders, this paper argues, should pursue a development policy that reinforces social protection and, in particular, can help sub-Saharan African countries to build resilience through social protection, and break out of vicious circles and poverty traps. However, the paper cautions that any action can interfere with ownership; furthermore, overseas development assistance can itself become a source of vulnerability if the initial commitments in terms of amounts, targets and time horizon are not fulfilled.
Is the sector approach still relevant to development assistance and aid given the track record and the rapidly changing global context? Or is it time – again – to look for something new that might work better? This paper argues that the sector approach continues to be relevant, but that it needs to become a 'sector approach version 2.0'. This requires significant – and difficult - changes in how external funders work. The new approach has to make where connectivity, collaboration, communication and horizontal knowledge acquisition central to its aims. This entails addressing five closely linked challenges: accepting the complexity of the task; working proactively with the new global interconnectedness; paying more attention to knowledge, dialogue, quality and results; adapting the sector approach to the specific context and sector, particularly in fragile situations; and gaining leverage as 'brokers' of knowledge and agendas.
This report examines the evidence for and against foreign aid, and finds that, while there is much room for improvement, good quality 21st century aid not only saves lives, but is indispensable in unlocking poor countries’ and people’s ability to work their own way out of poverty. It makes a number of recommendations. Countries and stakeholders should ensure aid is channelled to help support active citizens, build effective states as a pathway to reducing poverty and inequality, and support diverse forms of financing to contribute to development. They should deliver aid through a mix of models, including increasing budget support wherever possible, and ensure that a percentage of aid flows are channelled to civil society organisations, to enable people to better hold their governments to account. Also, there is a need to dramatically improve the predictability of aid, by increasing the proportion of aid that is general budget support where possible and by sector support where general budget support is not an option, and limit conditions attached to aid to mutually agreed poverty indicators. Rich countries should give at least 0.7% of their national income in aid, and set out how this target will be reached, with legally binding timetables. Furthermore, the global community should reject a culture of corruption, uphold human rights standards, and act in ways which are transparent and open to scrutiny. It should also provide legal environments in which civil society organisations monitoring government activities can flourish and respect the independence of non-government bodies like audit offices and the judiciary.
11. Equity and HIV/AIDS
Community home-based care is the Botswana Government's preferred means of providing care for people living with HIV (PLHIV). However, primary (family members) or volunteer (community members) caregivers experience poverty, are socially isolated, endure stigma and psychological distress, and lack basic care-giving education. This study estimated the cost incurred in providing care for PLHIV through a stratified sample of 169 primary and volunteer caregivers drawn from eight community home-based care groups in four health districts in Botswana. The results show that the mean of the total monthly cost (explicit and indirect costs) incurred by the caregivers was US$90.45, while the mean explicit cost of care giving was US$65.22. This mean of the total monthly cost is about one and a half times the caregivers' mean monthly income of US$66 and more than six times the Government of Botswana's financial support to the caregivers. The study, therefore, concludes that as the cost of providing care services to PLHIV is very high, the Government of Botswana should substantially increase the allowances paid to caregivers and the support it provides for the families of the clients. The overall costs for such a programme would be quite low compared with the huge sum of money budgeted each year for health care and for HIV and AIDS.
This paper conducted four phase III and one phase IIb trials of women-initiated HIV prevention options in KwaZulu-Natal between 2003 and 2009. A total of 7,046 women participated, with HIV prevalence between 25% and 45% and HIV incidence ranging from 4.5-9.1% per year. Community benefits from the trial included education on HIV prevention, treatment and care and provision of ancillary care (such as pap smears, reproductive health care and referral for chronic illnesses). Social benefits included training of home-based caregivers and sustainable ongoing HIV prevention education through peer educator programmes. Several challenges were encountered, including manipulation by participants of their eligibility criteria in order to enrol in the trial. Women attempted to co-enrol in multiple trials to benefit from financial reimbursements and individualised care. The trials became ethically challenging when participants refused to take up referrals for care due to stigma, denial of their HIV status and inadequate health infrastructure. Lack of disclosure of HIV status to partners and family members was particularly challenging. The researchers concluded that conducting these five trials in a period of six years provided them with invaluable insights into trial implementation, community participation, recruitment and retention, provision of care and dissemination of trial results.
In collaboration with local stakeholders, this study designed and assessed a referral system to link persons diagnosed at a voluntary counselling and testing (VCT) clinic in a rural district in northern Tanzania with a government-run HIV treatment clinic in a nearby city. Two-part referral forms, with unique matching numbers on each side were implemented to facilitate access to the HIV clinic, and were subsequently reconciled to monitor the proportion of diagnosed clients who registered for these services, stratified by sex and referral period. Delays between referral and registration at the HIV clinic were calculated, and lists of non-attendees were generated to facilitate tracing among those who had given prior consent for follow up. The study found that referral uptake at the HIV clinic averaged 72% among men and 66% among women during the first three years of the national antiretroviral therapy (ART) programme, and gradually increased following the introduction of the transportation allowances and community escorts, but declined following a national VCT campaign. It concluded that the referral system reduced delays in seeking care, and enabled the monitoring of access to HIV treatment among diagnosed persons. Similar systems to monitor referral uptake and linkages between HIV services could be readily implemented in other settings.
South Africa has launched an extensive programme of HIV testing, treatment and prevention that United Nations officials say is the largest and fastest expansion of AIDS services ever attempted by any nation. In the past month alone the government has enabled 519 hospitals and clinics to dispense AIDS medicines, more than it had in all the years combined since South Africa began providing antiretroviral drugs to its people in 2004, according to this article. The government has trained the hundreds of nurses now prescribing the drugs — formerly the province of doctors — and will train thousands more so that each of the country’s 4,333 public clinics can dispense AIDS medicines. President Jacob Zuma has inaugurated a campaign to test 15 million of the country’s 49 million people for HIV by June 2011.
African church leaders met in Johannesburg in May 2010 to find common ground in response to HIV and AIDS. At the meeting, the church acknowledged that it has failed to react timeously and effectively to the challenge of AIDS. At the meeting, church leaders spoke out about the silence and judgmental stance that characterised their response to the HIV and AIDS epidemic. The church resolved to amend its ways.
While health outcomes of HIV and AIDS treatments in terms of increased longevity has been the subject of much research, there appears to be very limited research on the improved health-related quality of life (HRQL) that can be applied in cost-utility analyses in Africa south of the Sahara. In this study, a systematic review of the literature on HRQL weights for people living with HIV and AIDS in Africa was performed, and the study also used focus group discussions in panels of clinical AIDS experts to test the preference based on a generic descriptive system EQ-5D. It contrasted quality of life with and without antiretroviral therapy (ART), and with and without treatment failure. It found that only four papers estimated the HRQL weights for HIV and AIDS in sub-Saharan Africa with generic preference based methodologies that can be directly applied in economic evaluation. A total of eight studies were based on generic health profiles. The focus group discussions revealed that HRQL weights are strongly correlated to disease stage. Furthermore, clinical experts consistently report that ART has a strong positive impact on the HRQL of patients, although this effect appears to rebound in cases of drug resistance. The study concluded that EQ-5D appears to be an appropriate tool for measuring and valuing HRQL of HIV and AIDS in Africa. More empirical research is needed on various methodological aspects in order to obtain valid and reliable HRQL weights in economic evaluations of HIV and AIDS prevention and treatment interventions.
12. Governance and participation in health
This report assesses the progress made in some of the major countries that have begun to implement the African Peer Review Mechanism (APRM) and address their governance problems, including two countries from east and southern Africa – South Africa and Kenya. The overall picture is generally positive, with dialogue between stakeholders occurring and changes being introduced in the ways policies are developed and implemented. There is peer learning, with experiences from a given country being introduced to others. But the report notes that the pace of learning and the pace of change are slow. It argues that the APRM itself has to be changed to make it more straightforward and more efficient. Human and financial resources must be increased at the national level to help countries carry out their evaluations successfully and, more importantly, implement the priority actions that are agreed on. The report argues that civil society is a key player in the APRM, but this is often forgotten by governments, by the continental APRM authorities and by external funders, and the inclusion of civil society representatives in the APRM process is often just an afterthought.
This paper argues that it is necessary to conduct a participatory, cross-national assessment and action-planning programme on civil society in all developing and developed countries. It acknowledges the scarcity of sound empirical studies on civil society and identifies some of the causes for this situation, including the elusive and highly disputed nature of the concept of civil society and a lack of valid data in many regions of the world, as well as the trend of confusing the tasks of advancing the normative ideal of civil society with honestly assessing its current reality. CIVICUS believes that reflections on the current reality of civil society are necessary to strengthen civil society. In other words, only by knowing the current state of civil society, can one work to successfully improve it. The paper argues that cross-national research, covering a wide range of different contexts, is a conceptual, methodological, cultural and logistical minefield. But by designing an assessment tool based on context, and by designing it in a way which, in principle, should make it applicable in every country, the Civil Society Index aims to push the boundaries of existing comparative work on the topic.
This study aimed to determine noise exposure levels of spectators at a FIFA 2010 designated training stadium during a premier soccer league match and changes in auditory functioning after the match. This was a one-group pretest–post-test design of football spectators attending a premier soccer league match at a designated FIFA 2010 training stadium in Gauteng, South Africa. Individual spectator noise exposure for the duration of the football match and post-match changes in hearing thresholds were measured with pure-tone audiometry, and cochlear functioning was measured with distortion product oto-acoustic emissions (DPOAEs). The study found that average sound exposure level during the match was 100.5 LAeq (dBA), with peak intensities averaging 140.4 dB(C). A significant deterioration of post-match hearing thresholds was evident at 2,000 Hz, and post-match DPOAE amplitudes were significantly reduced at 1,266, 3,163 and 5,063 Hz. In conclusion, exposure levels exceeded limits of permissible average and peak sound levels. Significant changes in post-match hearing thresholds and cochlear responsiveness highlighted the possible risk for noise-induced hearing loss. Public awareness and personal hearing protection should be prioritised as preventive measures.
At a meeting in Addis Ababa in February 2010, African Heads of States reviewed the framework guiding the relationship between the two continents, namely, the Joint Africa-EU Strategy (JAES) and its associated Action Plan. The meeting noted that the JAES aims to upgrade European Union-Africa relations to a strategic political partnership based on joint interests and a common vision. It is meant to enable continent-continent cooperation, especially with a view to addressing global challenges such as climate change, terrorism etc., while fostering integration on both sides. It serves as an over-arching and inclusive framework for EU-Africa relations. However, three major challenges facing the JAES have been identified: lack of engagement of all stakeholders, lack of results from cooperation and dialogue in this framework so far, and the fact that political dialogue is not driving partnerships. According to this report, a genuine change in mentality has not yet taken place, and the JAES is currently not being used as a true partnership between the two players to address important global challenges. It further argues that most of the current cooperation could be done through other already existing frameworks. It concludes that there is a risk that the framework will lose credibility if its added value is not clarified.
13. Monitoring equity and research policy
This report presents findings of a European-Africa consultation on the research agenda for non-communicable diseases. The workshop found that research in Africa can draw from different environmental and genetic characteristics to understand the causes of non-communicable diseases, while economic and social factors are important in developing relevant strategies for prevention and treatment. The suggested research needs include better methods for description and recording, clinical studies, understanding cultural impacts, prevention strategies, and the integrated organisation of care. Specific fields proposed for research are listed in the report. Although the European Union Seventh Framework Research Programme prioritises biomedical and clinical research, it recommends that research for Africa should also address broader social and cultural research and intervention research for greatest impact. Research policy leaders in Africa must engage national governments and international agencies as well as service providers and research communities. None can act effectively alone.
The Bill & Melinda Gates Foundation has announced 78 grants of US$100,000 each in the latest round of Grand Challenges Explorations. Grants have been awarded for the development of a low-cost cell phone microscope to diagnose malaria, the study of the strategic placement of insect-eating plants to reduce insect-borne diseases, and the investigation of nanoparticles to release vaccines when they come in contact with human sweat. The grants support research across 18 countries and six continents. This year’s European grantees are based at universities, research institutes and non-profit organisations. The winners represent groups in Germany, Sweden, Norway and the United Kingdom. Some examples of the projects funded in this round include more effective vaccines, a 'seek-and-destroy' laser vaccine, treating worm infections to improve vaccine effectiveness and new strategies to fight malaria, such as insecticide-treated traditional scarves, using carnivorous plants to control mosquitoes and using cell phone microscope to diagnose malaria. Solutions to promote family health include using ultrasound as a reversible male contraceptive and the use of vitamin A probiotics to combat diarrhoea.
In some areas of the world, one in four people with tuberculosis (TB) becomes ill with a form of the disease that can no longer be treated with standard drugs regimens, according to this report. It estimates that, worldwide, 440,000 people had multi-drug resistant tuberculosis (MDR-TB) worldwide in 2008 and that a third of them died. Of those patients receiving treatment, 60% were reported as cured, yet only an estimated 7% of all MDR-TB patients are diagnosed. These figures point to the urgent need for improvements in laboratory facilities, access to rapid diagnosis and treatment with more effective drugs and regimens shorter than the current two years. In Africa, there is a low percentage of MDR-TB reported among new TB cases, compared with regions such as Eastern Europe and Central Asia, due in part to the limited laboratory capacity to conduct drug resistance surveys. Latest estimates of WHO put the number of MDR-TB cases emerging in 2008 in Africa at 69,000. Previous reports found high levels of mortality among Africans living with HIV and infected with MDR-TB and extensively drug-resistant TB (XDR-TB).
Since 1990, the World Health Organization has used the disability-adjusted life year (DALY) statistic to quantify the burden of diseases. This indicator quantifies both morbidity and mortality due to diseases. This article notes that estimating DALYs is intrinsically problematic since, for some conditions, only limited data is available. For several tropical diseases, especially those affecting people in the poorest countries, it has been argued that DALYs are systematically underestimated. Because it is considered economically unprofitable, virtually no new drugs are being developed for this group of conditions. Being underestimated and lacking targeted drug development programmes, these conditions have been termed neglected tropical diseases (NTDs). Although there may be room for improvement in the calculation of DALYs related to NTDs, the article acknowledges that governments and policy makers use them to determine priorities in prevention and health care and therefore they cannot be ignored. It argues that research efforts targeted at a disease should ideally be in proportion to its global health impact. It considers that NTDs may be neglected twice: once by being attributed an underestimated DALY and again by limited scientific attention.
This article critiques the limitations of gross domestic product (GDP) as a measurement of a nation's success – do individuals living in countries with a high GDP really have a better life than those who don't? It discusses the work of the Stiglitz-Sen-Fitoussi Commission in attempting to find a set of indicators that better represent individuals’ circumstances today, recommending that every country should also apply other indicators to capture what is happening economically, socially and environmentally. Most criticisms of GDP fall into two distinct camps: some maintain that GDP itself needs to be fixed, while others seek to recast the criticism of GDP from an accounting debate to a philosophical one, as our reliance on such a measure suggests that we may still be equating economic growth with progress on a planet that is already overburdened by human consumption and pollution. One measure has succeeded in challenging the hegemony of growth-centric thinking – the Human Development Index (HDI), which turns 20 this year and is still used by the United Nations. The HDI incorporates a nation’s GDP and two other modifying factors: its citizens’ education, based on adult literacy and school-enrolment data, and its citizens’ health, based on life-expectancy statistics. But the HDI has plenty of critics. For example, a slight drop in literacy rates can have a disproportionate effect on a nation's HDI ranking. As a result, researchers are continuing their search for a set of indicators that will reliably measure progress for all nations.
This strategy document acknowledges that research is central to economic development and global health security and recognises that, in order to be effective, research has to be multidisciplinary and intersectoral in nature. In the face of current and emerging health threats – such as those posed by pandemics, chronic diseases, food insecurity, the impact on health of climate change, and fragile health systems – the document affirms that the Secretariat, member states and World Health Organization (WHO) partners have a joint responsibility to ensure that research and evidence help to achieve health-related development goals and improve health outcomes. It recommends an approach that involves all government departments so that health is reflected in all government policies. It identifies five interrelated goals that will help realise the draft strategy’s vision: the strengthening of research culture across WHO; the reinforcement of research that responds to priority health needs; improving capacity to strengthen national health research systems; the promotion of good practice in research, drawing on WHO’s core function of setting norms and standards; and strengthening of links between the policy, practice and products of research.
The World Health Statistics series is the World Health Organization's annual compilation of health-related data for its 193 member states, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets. As with previous versions, World Health Statistics 2010 has been compiled using publications and databases produced and maintained by the technical programmes and regional offices of WHO. Indicators have been included on the basis of their relevance to global public health; the availability and quality of the data; and the reliability and comparability of the resulting estimates. Taken together, these indicators provide a comprehensive summary of the current status of national health and health systems in the following nine areas: mortality and burden of disease; cause-specific mortality and morbidity; selected infectious diseases; health service coverage; risk factors; health workforce, infrastructure and essential medicines; health expenditure; health inequities; and demographic and socioeconomic statistics. With only five years remaining to 2015, the report notes that there are signs of progress in many countries in achieving the health-related MDGs. In other countries, progress has been limited because of conflict, poor governance, economic or humanitarian crises, and lack of resources. The effects of the global food, energy, financial and economic crises on health are still unfolding, and action is needed to protect the health spending of governments and external funders alike.
14. Useful Resources
Funds for NGOs.org is an online initiative working for the sustainability of non-governmental organizations (NGOs) by increasing their access to external funders, resources and skills. It uses online technologies to spread knowledge about organisational sustainability, promote creative ideas for long-term generation of institutional funds for development interventions, improve professional efforts in resource mobilisation and advocate for increased allocation of donor resources for building the skills and capacities of NGOs.
The objective of this paper was to develop and publish a guideline for doctors managing acute viral bronchiolitis because this condition is extremely common in South Africa. Acute viral bronchiolitis is responsible for significant morbidity in the population, and subsequently a great deal of patient and parental distress, and the disease is costly, since many children are unnecessarily subjected to investigations and treatment strategies that are of no proven benefit. The main aims of the guideline are to promote an improved standard of treatment based on understanding of the disease and its management, and to encourage cost-effective and appropriate management. A detailed literature review was conducted and summarised into this document by a selected working group of paediatricians from around the country. Recommendations include the appropriate diagnostic and management strategies for acute viral bronchiolitis.
SURE is a collaborative project that builds on and supports the Evidence-Informed Policy Network (EVIPNet) in Africa and the Region of East Africa Community Health (REACH) Policy Initiative. These educational video and audio documentaries let people describe in their own words how the SURE project, a collaboration of EVIPNet Africa and REACH, is working to improve health systems in Africa by making better use of research evidence to inform decisions. The audience can hear this and see the context in which people are working. The documentaries can be downloaded and used in meetings or broadcasts to introduce concepts, raise awareness and generate discussion about evidence-informed health policymaking. They are targeted at a broad audience, including policymakers, researchers, stakeholders and the general public.
15. Jobs and Announcements
The University of the Western Cape Spring School is offering one-week courses over four weeks in September 2010 in parallel sessions by experts in their fields. Courses offer health workers exposure to the latest thinking in public health and opportunities to extend their own knowledge and skills in the field. Bookings are taken on a first-come first-served basis, as the courses are often over-subscribed. Courses are open to students registered in the SOPH Postgraduate Programme, health workers from the health and social services and the general public. Over the years, at least 6,000 participants, mainly nurses and middle level managers from all over South Africa and from many other African countries, have attended these professional development courses. Many participants have been sent by a health authority, an important indication that the services place value on our training courses. At the school, health and welfare professionals will be able to exchange ideas relevant to health services.
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