A quarter of the population in Sub-Saharan Africa are young people between the ages of 10 and 19 years. These young people carry the hopes and dreams of their families, their communities and their nation. They are the future leaders and, perhaps as important, the future parents of the next generation.
They live in a world where to be an adolescent is increasingly risky. Adolescents typically take risks, but with the AIDS epidemic, risk-taking can be fatal. When adolescents have unplanned and unprotected sex, sexually transmitted infections can cause infertility or cervical cancer, and pregnancy in adolescents is more risky, with higher rates of death in both adolescent mothers and their babies than in adults. Unsafe abortions amongst adolescents are unacceptably high, and early sexual activity may limit educational attainment and deprive young people of the opportunity to form mature, loving relationships. So it’s a tragic and unacceptable sign that most new HIV infections in sub-Saharan Africa occur among adolescents and young adults.
Adolescents grow up today in a different world. High rates of urbanization, extended periods of schooling and growing poverty contribute to a challenging social context for young people.
Traditional ways of preparing young people for adulthood, which relied on extended family members, are less practiced and might not be adequate to address the pressures that adolescents face. In the past, sexual maturity was closely followed by marriage. Today, young people reach puberty at younger ages and wait longer to marry. Because the aunt or uncle may not be available, or may not be considered relevant, many adolescents turn to other sources. Today, many young people learn from peers or the media. Much of this information is inadequate and sometimes it is just plain wrong.
Schools are an ideal setting in which to reach large numbers of young people with the information they need, including reproductive knowledge and life skills. Yet, wherever it has been introduced, the teaching of reproductive health in schools has generated controversy. Debate exists around what information should be given and how much, especially regarding sexual intercourse, pregnancy and disease prevention. Some adults are resistant to even acknowledging that teenage sex is taking place. Others are concerned that sex education will lead to sexual activity. These viewpoints are often based more on values and beliefs than on facts. Hence the same arguments are repeated again and again, year after year, despite contrary evidence. Its very likely these same views will continue to be expressed into the future.
Nevertheless, facts do help. Studies have shown, both regionally and internationally, that comprehensive sex education is effective in improving knowledge and reducing sexual risk behaviours, and that it does not increase sexual activity. In 1997, a UNAIDS study reviewing 53 sex education programmes globally found that 22 had a positive effect of safer adolescent sexual behaviour, and 27 had no impact. In the 3 studies where there was an increase in sexual activity, there were concerns about the design of the assessment and the validity of conclusions.
Such studies suggest that rather than sex education causing young people to have sex, the opposite is more likely to be the case: Giving young people more complete and accurate information, and more opportunities to discuss issues in an open and non-judgemental environment enables them to make more responsible choices.
Clearly the design and quality of the programme matters. Strengthening sex education programmes can be difficult in resource-strained countries. However some aspects of effective programmes that have been identified from reviews can be applied across different settings, including those where resources are scarce. These include:
• adopting school curricula that provide comprehensive, accurate sexual and reproductive health information;
• supporting teacher training;
• reaching young adolescents with information early, before they leave school and before they begin sexual activity;
• strengthening health and other community services for young people and ensuring that these services are youth-friendly, and
• helping adolescents stay in school. Even if they do not receive sex education, young people who stay in school are less likely then their peers to have sex.
Successful reproductive health programmes are not simply a matter of education. They involve youth issues, gender issues, human rights issues, and health issues. They involve and give a central role to youth themselves. They encourage young people to articulate and discuss issues, to talk about their lives, to understand their options, and to get the skills and support they need for healthy choices. And of course, for young people, they must also be fun.
Our efforts towards reducing maternal mortality or new HIV infection cannot be said to be successful as long as we have not made significantly more progress in reducing the risk for adolescents. Achieving this and reaching young people can’t be left to teachers alone. Parents, civic leaders, health providers, other government ministries all have a role to play. Support of youth is a multi-sectoral effort. As adults planning for a better future for our young people, we are all their parents.
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 or see as an example of resources for adolescent reproductive health the Auntie Stella materials on the TARSC website at http://www.auntiestella.org/
1. Editorial
2. Latest Equinet Updates
This paper outlines the flows of private capital that lie behind the growth of the for-profit pharmaceutical sector in Tanzania. It reports an analysis of the policy, access and equity challenges posed by the shift to increasing private sector participation in the sector. The study was implemented within EQUINET by the Institute of Development Studies, University of Dar es Salaam, in a regional programme co-ordinated by the Institute for Social and Economic Research, South Africa. Strengthening the pharmaceutical sector to produce an adequate supply of medicines in Tanzania, for Tanzanians, is hindered by numerous constraints, including: non inclusion of TRIPS flexibilities in Tanzanian law; lack of skilled staff; financial constraints; poor industrial infrastructure and services; weak local and international pharmaceutical industry links; and counterfeit medicines entering the market. The report recommends that the health ministry step up its own monitoring systems to ensure effective distribution of medicines to health facilities. New legislation is also needed to improve quality standards, implement TRIPS flexibilities in Tanzanian law, and tackle substandard medicines entering the market.
The private health sector in South Africa is substantial. This paper explores the private sector involvement in funding and providing health services in South Africa and the implications for equity and access to health care. Serious challenges face the private health care sector in South Africa, not least of all the very rapid increases in expenditure and, hence, contribution rates in medical schemes. A range of factors underlie these trends; but in recent years, schemes’ spending increases have been driven largely by private for-profit hospitals and specialists, with the number of private hospital beds increasing rapidly and considerable consolidation of beds within three large private hospital groups. The 2007 policy conference of the ruling African National Congress (ANC) resolved to introduce a National Health Insurance (NHI). If successfully implemented, the substantial reforms envisaged will promote health system equity, affordability and sustainability within South Africa. However, there are growing concerns that the introduction of these reforms will contribute to increased activities by South African private for-profit health care companies in other African countries. Private health care firms in South Africa not only have an interest in expanding into other African countries, they will also have access to substantial investment resources. In particular, the World Bank’s International Finance Corporation (IFC) is actively seeking to invest in the private health sector in African countries. The experience of the private health sector in South Africa should be taken into account by policy-makers in other African countries when considering what role they envisage for the private health sector within their country context.
In most East and Southern African (ESA) countries, total health expenditure from all sources, including external resources, is still less than the US$ 45 per capita per year needed to provide basic health services. This limits their ability to achieve universal coverage of basic health services. This policy brief draws policy makers’ attention to the demands and challenges in health financing in meeting universal coverage, the demand for improved domestic public financing for health, and suggests options for doing this.
3. Equity in Health
This paper reviews the Millennium Development Goals (MDGs) process, drawing some recommendations to feed into the debate concerning what will take their place in 2015 when the process comes to an end. The authors note that creating the MDGs was a process that was led by rich countries, with comparatively little involvement of the lower- and middle-income countries. Likewise, the merging of the international development goals (IDGs) and MDGs was undertaken mainly between rich countries and the United Nations. In this sense, the author indicates that rich countries needed ambitious goals for their image and legitimacy, while developing countries were more interested in national goals. The paper found some clear progress in meeting the MDGs, notably the reduction of extreme poverty and also an improvement in primary school enrolments, and similarly, the paper predicts that the target of halting and reversing the spread of HIV is likely to be met. However, several areas have shown only weak improvements and even the successes are qualified. Progress has been highly geographically uneven, with global progress masking regional slippage, and regional progress masking deterioration in individual countries. The paper concludes that the opportunity created by the Millennium Movement to mobilise countries and people against poverty has been lost. The MDGs have made a difference but they have not transformed the process of international co-operation in the ways that their proponents had initially hoped.
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4. Values, Policies and Rights
This joint statement from a range of international development organisations argues that regular, predictable social transfers (cash or in kind) from governments to communities can reduce child poverty and vulnerability by helping to ensure children get access to basic social services. Social insurance offers access to health care for children, as well as services to support communities to reach all households and individuals, including children. The statement propose steps that governments and international development partners can take to further social protection in the interests of children, such as ensuring that existing social protection policies and programmes are child-sensitive and setting priorities and sequence policy development and implementation to progressively realise a basic social protection package that is accessible to all those in need. The statement calls for governments and donors to seek to improve fiscal space and increase available resources for child-sensitive social protection programmes, while making broader efforts to build awareness, political will, capacity and intersectoral coordination. Adequate investment is required, and links should be built between transfers and social services to ensure the reach, effectiveness and impact of social protection. At the same time, ongoing research, monitoring and evaluation are needed to better understand effective programme design and implementation, as well as how child-sensitive approaches can benefit the wider community and national development.
For years, there has been silence at the global level about the disproportionate impact that HIV and AIDS have on men who have sex with men (MSM). This silence has led to unabated epidemics and especially weak HIV prevention programming at national levels for MSM across the globe. This policy brief aims to provide universal guidelines for HIV and AIDS services that target MSM. It also discusses the legal context in Africa, where sex between members of the same sex is illegal in most countries, explaining how criminalising homosexuality heightens the risk for HIV transmission and drives those most at need away from prevention, care, treatment, and support services. The brief points to consensus among HIV behavioral researchers and practitioners that combination approaches to prevention, sustained over time and tailored to the specific local needs of MSM, should be adopted to effectively address HIV prevalence and incidence among MSM. These approaches should combine and integrate biomedical and behavioral strategies with community-level and structural approaches. The brief provides some important core principles of practice that can serve as broad guidelines in the design, implementation, and evaluation of targeted HIV prevention programmes and paradigms within MSM communities worldwide.
The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa focuses on nine major priority areas: leadership and governance for health, health services delivery, human resources for health, health financing, health information systems, health technologies, community ownership and participation, partnerships for health development and research for health. This paper describes a framework constructed for implementing the necessary activities in each of these priority areas, and proposes recommendations for consideration by World Health Organization Member States in the development of their own country frameworks. In conclusion, countries are expected to use this Framework, adapted to their own specific situations, by taking into account the progress made and the efforts needed for better and more equitable health outcomes. The Regional Committee is requested to endorse the Framework and urges Member States to put in place monitoring frameworks that feed into the national and regional observatories. Partners are expected to support countries in a harmonised and predictable manner that reduces fragmentation during the implementation of the Ouagadougou Declaration. It is expected that the implementation of the Ouagadougou Declaration by countries will contribute in accelerating progress towards the achievement of the Millennium Development Goals, and reduce the inequities and social injustices that lead to large segments of the population remaining without access to essential health services.
This paper describes the development of a tool that uses human rights concepts and methods to improve relevant laws, regulations and policies related to sexual and reproductive health. This tool aims to improve awareness and understanding of States’ human rights obligations. It includes a method for systematically examining the status of vulnerable groups, involving non-health sectors, fostering a genuine process of civil society participation and developing recommendations to address regulatory and policy barriers to sexual and reproductive health with a clear assignment of responsibility. Strong leadership from the ministry of health, with support from the World Health Organization or other international partners, and the serious engagement of all involved in this process can strengthen the links between human rights and sexual and reproductive health, and contribute to national achievement of the highest attainable standard of health.
Three leading scientific and health policy organisations have launched a global drive for signatories to the Vienna Declaration, a statement seeking to improve community health and safety by calling for the incorporation of scientific evidence into illicit drug policies. Misguided drug policies that criminalise drug abuse are claimed to fuel the AIDS epidemic and result in violence, increased crime rates and destabilisation of entire states, without evidence they have reduced rates of drug use or drug supply. Scientists are calling for evidence-based approaches to illicit drug policy that start by recognising that addiction is a medical condition, not a crime. The Vienna Declaration describes the known harms of conventional ‘war on drugs’ approaches and calls for governments to implement evidence-based approaches that respect, protect and fulfil human rights, as well as reduce harms deriving from current policies. This would allow for the redirection of the vast financial resources towards where they are needed most: implementing and evaluating evidence-based prevention, regulatory, treatment and harm reduction interventions. Legal barriers to scientifically proven prevention services such as needle programmes and opioid substitution therapy (OST) mean hundreds of thousands of people become infected with HIV and Hepatitis C (HCV) every year.
5. Health equity in economic and trade policies
The Economic Development in Africa Report 2010 examines recent trends in the economic relationships of Africa with other developing countries and the new forms of partnership that are animating those relationships. It discusses the variety of institutional arrangements that are guiding and encouraging these new economic relationships, provides up-to-date information on African trade with other developing countries outside Africa, describes official financial flows and foreign direct investment into Africa from those countries and assesses important policy issues that arise from the new relationships in each of these areas. The report argues that South–South cooperation opens new opportunities for Africa, and the main challenge facing African countries is how to harness these new relationships more effectively to further their long-term development goals. It also stresses the need to broaden the country and sectoral focus of cooperation with the South to ensure that the gains are better distributed across countries. It argues that South–South cooperation should be seen as a complement rather than a substitute for relations with traditional partners, and that the latter can make South–South cooperation work for Africa by strengthening support for triangular co-operation as well as through better dialogue with developing country partners.
This paper discusses how regional integration processes may contribute to state building and reduce economic and social insecurity. After presenting a simple conceptual framework to discuss the effects of external and regional integration in weak states, it analyses the policy trade-offs that may arise in such contexts. The paper then reviews the specific regional experiences of sub-Saharan countries. Finally, it discusses policy implications for the European Union (EU) in the context of its regional trade and development policies with African countries. The author concludes that a two-tier approach to regional integration, which combines both top-down and bottom-up processes, is necessary; the EU approach to regional integration in Africa should promote ‘building blocks’ and not ‘stumbling blocks’; and specific considerations should be given to make the strategy for trade integration responsive to the needs of fragile states.
The African, Caribbean and Pacific (ACP) Council and the ACP-EU (European Union) Council of Ministers met from 17-22 June to sign the revised ACP-EU Partnership Agreement. Aimed at eradicating poverty and supporting sustainable development and the gradual integration of the ACP states into the world economy, the agreement was finalised in 2000 and is reviewed every five years. The 2010 amendments seek to improve EU policy coherence for development, the promotion of domestic resource mobilisation, an d the role of non-state actors in cooperation. Cooperation and political dialogue is also enhanced to address the Millennium Development Goals, climate change, food security, state fragility, HIV and AIDs, organised crime and aid for trade. The revision further contains enhanced regional integration provisions and makes the African Union a partner to the agreement. The parties also adopted joint statements on the Millennium Development Goals and on climate change which should strengthen their position in the upcoming international negotiations on these issues. The ACP Council adopted unilateral declarations asking the EU to revisit its position on contentious issues in the Economic Partnership Agreement negotiations and on trade arrangements in bananas, sugar and cotton.
The intensity of trade among countries belonging to the same region depends not only on the existence and effectiveness of a regional integration agreement, but also on other factors, which include the overall trade policy orientation and the relative level of geo-graphic and economic barriers affecting intra- and extra-regional trade. The paper presents a set of indicators aimed at measuring the intensity of bi-lateral trade preferences. These indicators suggest that most African countries trade more intensely with coumtries in the same region than with the rest of the world.
The global financial crisis has also exposed serious weaknesses in global economic governance, according to this report. The report proposes fundamental revisions of the existing institutions for global economic governance. But for an effective more sustainable rebalancing of the global economy much closer coordination is needed across the trading system, the new regime for international financial regulation, the global reserve system and the mechanisms for mobilising and channelling development finance and climate funding. At present, the Group of 20 (G20) is taking on some areas of coordination, but as an informal platform responding to the crisis it has mostly focused on financial reforms. The report notes that sustainable rebalancing of the world economy will take years, if not decades, and can only be successful if there is greater policy coherence. To this end, it proposes that the international community consider institutionalising a global economic coordination mechanism within the more representative multilateral system.
6. Poverty and health
The different explanations given for Africa’s current food crisis seem to miss the real causes of the problem, according to this article. The crisis is not of an economic nature. Rather, it is the endpoint of the dismantling of Africa’s agricultural sector and its linking to the international market and brutal liberalism. The article cautions that there are huge risks associated with linking African agriculture to global markets dominated by subsidised produce from the United States and the European Union. There is also the threat of genetically modified organisms and other industrial hybrids that could wipe out tradition systems. Radical measures are necessary to safeguard local production and producers, who make up close to 80% of the population in some countries. Based on an analysis of the political choices that have contributed to the current situation, notably the structural adjustment programmes of the 1980s, the article proposes solutions and decisions that need to be taken to achieve food sovereignty in Africa, such as re-nationalising agri-food industries that are strategic to agricultural development and setting in place agricultural policies that are based on food sovereignty and that make all issues related to food human rights issues.
Though global progress in sanitation has been poor, some low income countries have achieved a reduction of up to 60% in the proportion of people without improved sanitation. This article argues that it is likely that this progress was not simply due to installing infrastructure, but also due to political support, modest financing cleverly applied and a focus on changing behaviour and social norms. Building demand for toilets, especially among those people who have practiced open defecation all their lives, helps trigger household investments. Evidence that these approaches are effective suggests that accelerated progress is possible. Barriers in providing drinking-water can also be overcome using innovations like low-cost drilling techniques and cheaper hand pumps, the use of locally-managed, small-scale systems and civil society intermediation between poor communities and service providers. Providing water, sanitation and hygiene in schools is increasingly a priority for ministries of education in developing countries. Emerging designs for toilets that incorporate privacy and facilities for menstrual hygiene provide a multitude of benefits. Water, sanitation and hygiene also enable women to play roles in their community’s development, including decision-making and management of water and sanitation systems.
The objective of this paper was to investigate the relationships between the prevalence of HIV infection and underlying structural factors of poverty and wealth in several African countries. A retrospective ecological comparison and trend analysis was conducted by reviewing data from demographic and health surveys, AIDS indicator surveys and national sero-behavioural surveys in twelve sub-Saharan African countries with different estimated national incomes. The relationship between the prevalence of HIV infection and household wealth quintile did not show consistent trends in all countries. In particular, rates of HIV infection in higher-income countries did not increase with wealth. The Tanzanian data illustrated that the relationship between wealth and HIV infection can change over time in a given setting, with declining prevalence in wealthy groups occurring simultaneously with increasing prevalence in poorer women. In conclusion, both wealth and poverty can lead to potentially risky or protective behaviours. To develop better-targeted HIV prevention interventions, the paper urges the HIV community to recognise the multiple ways in which underlying structural factors can manifest themselves as risk in different settings and at different times. Context-specific risks should be the targets of HIV prevention initiatives tailored to local factors.
This paper examines the South African government’s mandate to halve unemployment and poverty by 2014, noting the growing evidence of the unlikelihood of this happening. The paper found that disagreements among academics on the severity of poverty can be traced to the failure by Statistics South Africa to conduct adequate surveys on poverty, while unemployment rates have undermined the progress of poverty-elevation made since 2006. It estimates that, in 2014, there will still be between three and five million unemployed lacking any kind of income protection. The impact of AIDS on mortality also means that the number of poor has been significantly reducing, also impacting on unemployment rates. The paper attempts to explain the reasons behind the offhand rejection of the 'Basic Income Grant' (BIG) by government, concluding that the political bargains were behind scrapping the proposal of BIG.
7. Equitable health services
According to this report, 4.4 million children and 265,000 mothers die in sub-Saharan Africa every year, which amounts to half of the world's maternal, newborn and child deaths. It identifies the five biggest challenges for maternal, newborn and child health in sub-Saharan Africa as pregnancy and childbirth complications, newborn illness, childhood infections, malnutrition, and HIV and AIDS. Many scientifically proven health interventions are available for maternal, newborn, and child health such as medicines, immunisations, insecticide-treated bed nets, and equipment for emergency obstetric care. Yet many African governments are currently underutilising existing scientific knowledge to save women's and children's lives. The report recommends a scientific approach based on local epidemiological and coverage data that will prioritise the highest impact and most appropriate interventions in a given context. Although most countries in sub-Saharan Africa are behind in achieving the Millennium Development Goals (MDGs) for maternal and child health by 2015, progress in several low-income countries demonstrates that the MDGs could still be attained through immediate strategic investments in selected evidence-based interventions and targeted health systems strengthening.
A targeted mass distribution of free LLINs to children under five and pregnant women was implemented in Zanzibar between August 2005 and January 2006. The outcomes of this distribution among children under five are evaluated in this study, four to nine months after implementation. Two cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island. Household interviews were conducted with 509 caretakers of under-five children, who were surveyed for socio-economic status, the net distribution process, perceptions and use of bed nets. The overall proportion of children under five sleeping under any type of treated net was 83.7% in MI and 91.8% in NA. The LLIN usage was 56.8% in MI and 86.9% in NA. Overall system effectiveness was 49% in MI and 87% in NA, and equity was found in the distribution scale-up in NA. In both districts, the predicting factor of a child sleeping under an LLIN was because caretakers had received a LLIN or considered LLINs to be better than conventional nets. In conclusion, targeted free mass distribution of LLINs can result in high and equitable bed net coverage among children under five. However, in order to sustain high effective coverage, there is need for complimentary distribution strategies between mass distribution campaigns. Considering the community's preferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage.
The Algiers Declaration on Narrowing the Knowledge Gap to Improve Africa’s Health was adopted during a Conference held in Algiers, Algeria, in June 2008. The Conference, which brought Ministers from the African Region together with researchers, non-governmental organisations, donors and the private sector, renewed commitments to narrow the knowledge gap in order to improve health development and health equity in the Region. This paper describes the background to the Algiers Declaration and the Framework for its implementation and their significance in assisting efforts by countries in the Region to strengthen their health systems. The paper argues that countries should implement the series of steps in the Algiers Framework to strengthen their health systems. These steps will help them to develop the content, processes and use of technology aimed at improving: the availability of relevant and timely health information; the management of health information through better analysis and interpretation of data; the availability of relevant, ethical and timely research evidence; the use of evidence by policy-makers and decision-makers; improving dissemination and sharing of information, evidence and knowledge; access to global health information; and the use of information and communication technologies.
In this study, limited autopsies were conducted on young adults dying in a single public hospital in the province of KwaZulu-Natal between October 2008 and August 2009 in order to estimate the magnitude of deaths attributable to tuberculosis. A representative sample was taken of 240 adult inpatients (aged 20–45 years) who died after admission to Edendale Hospital. Ninety-four% of the study cohort was HIV seropositive and 50% of decedents had culture-positive tuberculosis at the time of death. Fifty percent of the participants were on treatment for tuberculosis at the time of death and 58% of these treated individuals remained culture positive at the time of death. Of the 50% not receiving tuberculosis treatment, 42% were culture positive. Seventeen percent of all positive cultures were multidrug resistant and 16% of patients dying during the initiation phase of their first ever course of tuberculosis treatment were infected with multidrug-resistant bacilli. The findings reveal the immense toll of tuberculosis among HIV-positive individuals in KwaZulu-Natal, as well as suggesting that the diagnosis of tuberculosis was made too late to alter the fatal course of the infection for many of the individuals. The study also revealed a significant burden of undetected multidrug-resistant tuberculosis among HIV-co-infected individuals dying in this setting. It recommends new public health approaches that improve early diagnosis of tuberculosis and accelerate the initiation of treatment.
According to this article, placing essential medicines at the centre of global health priorities is not without its risks. The geography of access is closely linked to other structural determinants of inequality, few of which can be fixed merely by providing a pipeline of medicines. Access to essential medicines is therefore a necessary condition but is not sufficient on its own for the amelioration of broad health disparities in global health. On the other hand, to truly engage the social factors that determine the development, production, regulation, distribution, utilisation and consumption of essential medicines is to engage with the project of understanding health disparities and the challenges of strengthening health systems at the most detailed level. As essential medicines programmes continue to expand, this article argues that it is crucial that they have the resources and leadership to realise this vision in the broadest sense possible.
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8. Human Resources
Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. 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.
This paper reports on two separate experiences of costing for Human Resources Development Plans (HRDP) costing in Mozambique and Guinea Bissau, with the objective of providing an insight into the practice of costing exercises in information-poor settings, as well as to contribute to the existing debate on human resources costing methodologies. The study adopts a case-study approach to analyse the methodologies developed in the two countries, their contexts, policy processes and actors involved. From the analysis of the two cases, it emerged that the costing exercises represented an important driver of the HRDP elaboration, which lent credibility to the process, and provided a financial framework within which HRH policies could be discussed. In both cases, bottom-up and country-specific methods were designed to overcome the countries' lack of cost and financing data, as well as to interpret their financial systems. Such an approach also allowed the costing exercises to feed directly into the national planning and budgeting process. The authors conclude that bottom-up and country-specific costing methodologies have the potential to serve adequately the multi-faceted purpose of the exercise. However, adopting pre-defined and insufficiently flexible tools may undermine the credibility of the costing exercise, and reduce the space for policy negotiation opportunities within the HRDP elaboration process.
This review of human resources in the health sector indicates that the African Region is faced with severe shortages of doctors and nurses, with only 590,198 health workers against an estimated requirement of 1,408,190 health workers. This situation is compounded by inappropriate skill mixes and gaps in service coverage. The estimated critical shortages of doctors, nurses and midwives is over 800,000. The problem is more severe in rural and remote areas where most people typically live in the countries in the African Region. This review provides information about the efforts and commitments by World Health Organization Member States and the various opportunities created by regional and global partners, including the progress made. The paper also explores issues and challenges related to the underlying factors of the health worker crisis, such as chronic underinvestment in health systems development in general, and specifically in human resources for health development, migration of skilled health personnel as a result of poor working conditions and remuneration, lack of evidence-based strategic planning, insufficient production of health workers and poor management systems.
According to this paper, about 59 million people make up the health workforce of paid full-time health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual performance, and there are far too many inequities in the distribution of health workers between countries and within countries. Sub-Saharan Africa, with about 11% of the world’s population, bears over 24% of the global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world’s financial resources on health. In most developing countries, the health workforce is concentrated in the major towns and cities, while rural areas can only boast of about 23% and 38% of the country’s doctors and nurses respectively. The imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. Countries in sub-Saharan Africa would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions to make a positive difference in the health and life expectancy of their populations. The paper argues that the global health workforce crisis can be tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development and the faintest hope of attaining the Millennium Development Goals in the sub-continent.
The authors of this study developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels.
According to this review, researchers and policymakers in the past have paid little attention to the role of health workers in developing countries but a new generation of studies are providing a fuller understanding of these issues using more sophisticated data and research tools. The review refers to recent research that views health workers as active agents in dynamic labour markets who are faced with many competing incentives and constraints. Studies using this approach appear to provide greater insights into human resource requirements in health, the motivations and behaviours of health workers and health worker migration. The review urges for more high-quality research on the role of health workers in developing countries.
The objective of this paper was to understand the factors influencing health workers’ choice to work in rural areas as a basis for designing policies to redress geographic imbalances in health worker distribution. Data from a cohort survey of 412 nursing and medical students in Rwanda was used to examine the determinants of future health workers’ willingness to work in rural areas as measured by rural reservation wages. The data was combined with data from an identical survey in Ethiopia to enable a two-country analysis. The research found that health workers with higher intrinsic motivation – measured as the importance attached to helping the poor – as well as those who had grown up in a rural area and Adventists who had participated in a local bonding scheme were all significantly more willing to work in a rural area. The main result for intrinsic motivation in Rwanda was strikingly similar to the result obtained for Ethiopia and Rwanda combined. In conclusion, intrinsic motivation and rural origin play an important role in health workers’ decisions to work in a rural area, in addition to economic incentives, while faith-based institutions can also influence the decision.
This paper reviews available research evidence that links medical students’ characteristics with human resource imbalances and the contribution of medical schools in perpetuating an inequitable distribution of the health workforce. Existing literature on the determinants of the geographical imbalance of clinicians, with a special focus on the role of medical schools, is reviewed. Structured questionnaires collecting data on demographics, rural experience, working preferences and motivational aspects were administered to 130 fifth-year medical students at the medical faculties of MUCHS (University of Dar es Salaam), HKMU (Dar es Salaam) and KCMC (Tumaini University, Moshi campus) in the United Republic of Tanzania. The 130 students represented 95.6% of the Tanzanian finalists in 2005. The paper found that the lack of a primary interest in medicine among medical school entrants, biases in recruitment, the absence of rural related clinical curricula in medical schools, and a preference for specialisation not available in rural areas are among the main obstacles for building a motivated health workforce that could help correct the inequitable distribution of doctors in the United Republic of Tanzania. The paper suggests that there is a need to re-examine medical school admission policies and practices.
9. Public-Private Mix
This study reviewed peer-reviewed and grey literature on examples of innovation in pruvate sector health care. From 46 studies, 10 case studies were selected spanning different countries and health service delivery models. The cases included social marketing, cross-subsidy, high-volume, low cost models. They tended to have a narrow clinical focus, facilitating standardised care models but allowing experimentation with delivery models. Information on the social impact of these innivations was variable, with more data on availability and affordability and less on quality of care. More rigorous evaluations are needed to investigate the impact and quality of private health service innovations and to determine the effectiveness of the strategies used.
10. Resource allocation and health financing
This report provides details on the performance, results and prospects in cooperation led by the European Commission (EC) with 140 countries and regions and in areas such as the Millennium Development Goals, aid effectiveness and policy coherence for development. The report also examines sectors of cooperation ranging from democracy and human rights to stability and macro-financial assistance. Specific aid instruments and delivery modalities such as the European Union (EU) Food Facility and ‘Vulnerability FLEX’ instrument, technical cooperation and budget support are also examined. Coordination with EU Member States is also assessed. Overall, EC external aid results show that project performance improved compared to the previous year. 94% of the projects are now rated positively. The report asserts that the EC has acted to ensure that the impact of its resources are maximised, that the EU has shown the capacity to innovate and adapt its aid instruments to meet new challenges and that the dynamics of this process have created new synergies and more effective results.
This paper explores the links between aid and budgets in two ways. First, it documents similarities among 14 aid-recipient country budgets, comparing them with the Creditor Reporting System of the Development Assistance Committee (DAC/CRS) and the UN Classification of the Functions of Government (COFOG) system. It assesses the fit of the latter for practical use by donor agencies. The main aim is to contribute to the development of more comprehensive sub-sector classifications, which may also be movable among top-level sectors, so as to fit around decisions made at country level on sector definitions. Second, the paper constructs a generic functional classification, designed specifically for the purpose of examining budget administrative classifications. This set of functions is grouped at sector level for ease of analysis and use, but is anchored on the lowest level of the classification. The aim was to review the commonalities between budget administrative classifications and develop a draft set of generic functional definitions that best align with the administrative structures of the countries in the sample. Those definitions may then be tested at donor headquarters level. The paper also makes recommendations on how to facilitate the transfer of aid information, particularly aid that is not spent through recipient country budget systems.
This paper challenges current practices within the research and funding community. It notes that social protection is an extremely important policy agenda for Africa, and that remarkable progress has been made in a very short time. In recent years, external funders and other external actors have invested heavily in financing social protection projects, strengthening capacity among implementing agencies, and building the evidence base to demonstrate the powerful positive impacts of social protection programmes. Nonetheless, many governments remain resistant to social protection, as advocated by external funders and international non-government organisations. Also, where governments express a preference for different funding models, these are often neglected or dismissed, while 'beneficiaries' themselves are hardly ever consulted. This paper notes that a fundamental rethinking is required that takes domestic political priorities and policy processes into account. It concludes by proposing ten principles for future engagement by development partners with social protection policy processes in Africa, including support for national policy priorities and minimise policy intrusion; limits on pilot project 'experiments'; and the involvement of programme participants at all stages, starting with vulnerability assessments and project selection.
This paper argues that weaknesses in health systems have contributed to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programmes, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programmes that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.
11. Equity and HIV/AIDS
This book is an in-depth evaluation of a new approach to create behavioural change that could affect the course of the global health crisis of HIV and AIDS. Taking a close look at the South African HIV and AIDS epidemic, it demonstrates that regular workers serving as peer educators can be as – or even more – effective agents of behavioural change than experts who lecture about the facts and so-called appropriate health care behaviour. After spending six years researching the response of large South African companies to the AIDS epidemic, Dickinson describes the promise of this grassroots intervention and the limitations of traditional top-down strategies. His case studies directly examine the South African workplace to tackle sexual, gender, religious, ethnic, and broader social and political taboos that make behaviour change so difficult, particularly when that behaviour involves sex and sexuality. Dickinson's findings show that people who are not officially health care experts or even health care workers can be skilled and effective educators. This book demonstrates how peer education can be used as a tool for societies grappling with the HIV and AIDS epidemic and why those interested in changing behaviours to ameliorate other health problems like obesity, alcoholism, and substance abuse have so much to learn from the South African context.
According to this article, the evidence that concurrency is driving the African AIDS epidemics is limited. There is as yet no conclusive evidence that concurrency is associated with HIV prevalence, nor that it increases the size of an HIV epidemic, the speed of HIV transmission and the persistence of HIV in a population. The article admits that concurrency could theoretically play a dominant role in transmission of HIV through networks, but it argues that this should not be taken to mean that it is or it has played that role. Little evidence supports the hypothesis that sexual behavior differs dramatically in Africa compared to the rest of the world, nor that sexual behavior in Africa is different in countries with high versus low HIV prevalence. Without strong data showing that people have more concurrent partnerships in Africa than elsewhere and that places with high levels of concurrency also have high levels of HIV, the authors conclude that only under certain conditions may concurrency be a significant driver of the HIV epidemics in sub-Saharan Africa. To definitively answer this question, additional studies are needed. Improved methods for measuring sexual behavior and particularly partnership duration and overlap are also required, with better study designs. Designing prevention interventions around concurrency without a better understanding of the intricacies of the relationship between concurrency and HIV transmission may well not produce the intended result of preventing new HIV infections.
In this statement, the South African Department of Health has given the go-ahead for patients on antiretroviral treatment (ART) to be given three months supply of medicines instead of one month. It will be more convenient for patients because they will have to make fewer trips to their health facility. It will also reduce patient-load on the health system, particularly on health facility pharmacies given the shortage of pharmacists in the public health system. The Department of Health states: ‘There is no indication of any legislation prohibiting the supply of medicines for three months to any one patient. This practice should only be implemented once the patient has proved stable on the regimen.’
This review aimed to identify the current modes of transmission of HIV in Uganda, as well as where and among whom incident HIV infections are occurring. It indicates that the previously heralded decline in prevalence from a peak of 18% in 1992 to 6.1% in 2002 may have ended. There is stabilisation of prevalence between 6.1 and 6.5% in some antenatal care sites and even a rise in others. This is accompanied by deterioration in behavioural indicators especially an increase in multiple concurrent partnerships. There has also been a shift in the epidemic from spreading mainly in casual relationships to also seeing a large proportion of new infections in people in long-term stable relationships. The main risk factors for transmission were identified as having, multiple partners, discordance and non-disclosure, lack of condom use, transactional sex, cross-generational sex, presence of herpes simplex and sexually transmitted infections, alcohol and drug use, and behavioural disinhibition due to anti-retroviral therapy.
This article argues that a population-wide interruption of risk behaviour for a set period of time could reduce HIV incidence and make a significant contribution to prevention efforts. If everyone in a population abstained from high-risk sex for a given period of time, in theory the viral loads of all recent seroconverters should pass through the acute infection period. When risk behaviour resumed there would be almost no individuals in the high-viraemic phase, thereby reducing infectivity, and HIV incidence would fall. The article calls for mathematical modelling of periodic risk behaviour interruptions, as well as encouragement of policy interventions to develop campaigns of this nature. A policy response, such as a ‘safe sex/no sex’ campaign in a cohesive population, deserves serious consideration as an HIV prevention intervention. In some contexts, periods of abstinence from risky behaviour could also be linked to existing religious practices to provide policy options, for example sexual abstinence practiced during the Muslim holy month of Ramadaan.
This review of the HIV and AIDS national strategic plan (NSP) since the NSP's inception in 2007, reports that condom use has almost doubled, treatment coverage among adults living with HIV has almost tripled, and prevention of mother-to-child HIV transmission (PMTCT) services among HIV-positive pregnant women has reached 76%. In contrast, the uptake of dual ARV therapy PMTCT has been problematic, and there are major shortcomings in monitoring and evaluation (M&E) that could leave decision-makers operating in a vacuum, the report warns. It notes that while provinces had adopted the dual therapy regimen and were training health workers to administer it, some districts were still using the outdated single dose of Nevirapine because funding to buy the ARVs for dual therapy was problematic. It also highlights a dearth of data on babies born HIV-positive, but quotes department of health estimates showing that almost 40% of infants exposed to HIV were put at risk of contracting the virus by incomplete provision of PMTCT services. Problems with monitoring and evaluation were also highlighted, with inadequate data on mothers, babies and HIV-positive patients awaiting treatment. The report suggests that measuring South Africa's success against numerous goals and objectives set by the NSP may be logistically and bureaucratically challenging. Despite a wealth of information on HIV and AIDS that is collected to fulfill government reporting requirements, the uneven quality, scope and availability of the data has presented considerable challenges to those trying to implement evidence-based HIV interventions.
According to this article, Swaziland has made remarkable progress in reducing HIV transmission from infected mothers to their babies, but health activists have raised concerns that this progress may be stalled or even reversed if lapses in basic health services are not addressed. Since prevention of mother-to-child transmission (PMTCT) services became available in 2003, HIV transmission has almost halved, from 40% of children becoming infected by their HIV-positive mothers to 21%. The number of teenage pregnancies has also fallen. As teen mothers are less likely to use antenatal care and PMTCT services, fewer teens giving birth means fewer HIV-positive babies. However, a significant proportion of pregnant women are giving birth at home, and so are not using PMTCT services. A rise in home deliveries appears to be a direct result of poor conditions at underfunded clinics and hospitals. Leaking roofs, unreliable water supplies and a lack of beds at clinics are contributing to the problem of ‘burnout’ among nurses. According to the latest World Health Organization (WHO) guidelines, a pregnant woman's HIV status should be determined in her first trimester so as to provide optimal PMTCT services, but Swazi tradition discourages women from talking about a pregnancy during the first 14 weeks and, as a result, women delay seeking treatment.
The International Labour Organization’s (ILO) Code of Practice on HIV and AIDS, which aims to strengthen the global response to HIV in the workplace, was adopted by governments, employers and workers at the annual conference of the ILO, held in Switzerland from 2–18 June 2010. As a new labour standard, it is intended to reinforce and extend anti-discrimination policies in the workplace. It reaffirms the right to continued employment regardless of HIV status and asserts that workers should not be screened for HIV for employment purposes. The standard also recognises the need for focused action to protect the rights of populations that may be more vulnerable to HIV infection, and is expected to provide support to the goal of universal access to HIV prevention, treatment, care and support. The labour costs of HIV are recognised in the standard, especially since HIV affects the most economically active age range in every population and the loss of most the 33.4 million people living with HIV would represent a major loss of skills and experience that might have a negative effect on economies and communities. The standard is the first internationally-sanctioned instrument that focuses specifically on HIV in the workplace. It is expected to significantly enhance the impact of HIV prevention and treatment programmes in the workforce globally.
In this report, research findings from a population-based household survey are presented on the general health status of infants, children, and adolescents in South Africa including morbidity, utilisation of health facilities, immunisation coverage, HIV status and associated risk factors. The study also investigates the exposure of children and adolescents to HIV communication programmes. Major recommendations were that the number and scope of community health workers be expanded to include high-impact but low-cost health and nutrition interventions. The report found very little exclusive breastfeeding, with 51.3% of babies on mixed feeding. The report highlighted the lack of HIV communication programmes in rural areas, and for English, Afrikaans, Tsonga and Venda speakers, recommending that future campaigns also focus more strongly on complementing school-based programmes and on children. It recommends implementing an accreditation system ‘as a matter of urgency’ to regularly monitor the quality of health facilities and to serve as a mechanism to hold managers accountable for the health outcomes of mothers and children. The report may be used by policy makers and stakeholders in targeting and prioritising key issues in planning and programming efforts focusing on the broad health issues of South African children.
The writer of this article argues that FIFA, as the world’s football authority, has an ethical responsibility for social action, especially with regard to HIV and AIDS and the World Cup. As the overwhelming percentage of professional footballers come from poverty or financially disadvantaged childhoods, world football owes a tremendous debt to these poorer communities who, by their resourcefulness, allowed world‐class footballers to develop. FIFA President, Sepp Blatter, claims that FIFA has been ‘committed to a wide range of humanitarian projects’ but the author argues these are largely insufficient. For example, the FIFA ‘Football for Hope’ project is costing only about US$17 million, while FIFA is expected to net revenues of US$3.3 billion and profits of US$1.7 billion from the Cup. The project costs amount to a mere 0.5% of the revenues and 1% of the earnings for South African charities. The author challenges FIFA to recognise that other sports have already done more per capita than world soccer for human development, specifically HIV and AIDS education and empowerment.
12. Governance and participation in health
This study assessed community acceptability of the use of rapid diagnostic tests (RDTs) by Ugandan CHWs, locally referred to as community medicine distributors (CMDs). The study was conducted in Iganga district using 10 focus group discussions (FGDs) with CMDs and caregivers of children under five years, and 10 key informant interviews (KIIs) with health workers and community leaders. The study found that CMDs are trusted by their communities because of their commitment to voluntary service, access, and the perceived effectiveness of anti-malarial drugs they provide. Some community members expressed fear that the blood collected could be used for HIV testing, the procedure could infect children with HIV, and the blood samples could be used for witchcraft. Education level of CMDs is important in their acceptability by the community, who welcome the use of RDTs given that the CMDs are trained and supported. Anticipated challenges for CMDs included transport for patient follow-up and picking supplies, adults demanding to be tested, and caregivers insisting their children be treated instead of being referred. Use of RDTs by CMDs is likely to be acceptable by community members given that CMDs are properly trained, and receive regular technical supervision and logistical support.
Local East African programmes are discovering the benefits of bringing HIV services closer to rural communities, with mobile drug distribution improving HIV-positive patients' adherence to antiretroviral treatment (ART). Health facilities in rural areas are normally remote, but by using mobile care and treatment centres, it is easy to reach populations who may not otherwise have access to services, according to the Support for International Change (SIC), a local HIV-focused non-governmental organisation in Tanzania. SIC reports using mobile drug distribution in northern Tanzania and witnessing a reduction of cases lost to follow up, compared to local health facilities that are recording higher levels of drop-out amongst patients. Patients must visit a hospital for their initial diagnosis and ART prescription, and are required to visit the health centre periodically, but in between visits, SIC uses community-based volunteers and trained medical workers to drive around villages refilling prescriptions as well as providing education on condom use and the prevention of opportunistic infections. SIC in Tanzania reaches nearly 2,500 people with mobile ART clinics and has so far trained around 200 health workers in Babati District in northern Tanzania.
The community-directed intervention (CDI) strategy is an approach in which communities themselves direct the planning and implementation of intervention delivery. This CDI study involved multi-disciplinary research teams from seven sites in three African countries, including Uganda. Integrated delivery of different interventions through the CDI strategy proved feasible and cost-effective where adequate supplies of drugs and other intervention materials were made available. Communities, health workers, policy-makers and other stakeholders were quite supportive and their buy-in to the CDI approach increased significantly over time. Since intervention coverage also increased as more interventions were gradually included in CDI delivery, the results of the study are promising in terms of the sustainability of the CDI approach. Based on its findings, the study recommends that CDI approaches be adopted for integrated, community-level delivery of appropriate health interventions in the 16 African countries with experience in community-directed treatment for onchocerciasis control. This may comprise the interventions tested in this study, especially for malaria, or other intervention packages chosen on the basis of the lessons learnt.
South Africa’s Sex Workers Education and Advocacy Taskforce (SWEAT) and Sisonke have launched a helpline for commercial sex workers. The line was initiated to give commercial sex workers a platform to voice the concerns and fears they face at work. SWEAT noted that it was not easy for commercial sex workers to get adequate information because they are often scared of revealing what they do to earn a living. The line could also be used by anyone who wanted to get information about the industry. The line opened at the beginning of June and provides assistance on sexual health, drug and alcohol problems as well as emotional and work related matters. Those with e-mail access can also send e-mails. Commercial sex workers needing assistance would be assisted by trained counsellors from 9 am to 5pm with plans to upgrade the line to a 24-hour facility.
Civil society activists and anti-poverty campaigners from around the world have personally delivered a letter containing recommendations for a breakthrough plan to end poverty and inequality to United Nations (UN) Secretary-General, Ban Ki-moon. The open letter was signed by more than 120 civil society organisations, including Global Call to Action Against Poverty (GCAP), the Feminist Task Force, CIVICUS, End Water Poverty and the International Trade Union Confederation. It contains nine key recommendations, including calls for greater accountability, measures to increase gender equality and reduce social exclusion and the provision of quality affordable public services. GCAP affirmed that signatories to the letter were determined to ensure that the breakthrough plan is developed further and implemented to meet the Millennium Development Goals (MDGs). The campaign is intended to be extended to all UN member states, as well as to the United Nations Summit, which will be held in September and is expected to produce additional pledges to achieve the MDGs.
This study aims to fill a research gap regarding the positive health and socio-economic outcomes and experiences of volunteers in the home-based care context in South Africa. It investigated the perception of rewards among volunteers working in home-based care settings. Qualitative interviews were conducted with a purposively selected sample of 55 volunteer caregivers using an interview schedule containing open-ended questions. The study found that volunteer caregivers derived intrinsic rewards, related to self-growth and personal development, which were a direct consequence of the experiences of caring for terminally ill patients with AIDS. Extrinsic rewards came from appreciation and recognition shown by patients and community members. The greatest sources of extrinsic rewards were identified as the skills and competencies acquired from training and experience while caring for their patients, and volunteers' ability to make a difference in the community. The insights revealed by this study may be useful to programme managers in recruiting and assisting volunteers by helping managers to identify and reflect on rewards in the caregiving situation as a means of reducing the burden of care and sustaining volunteer interest in caregiving.
The purpose of this study was to explore and describe the challenges faced by people who are living with HIV or AIDS (PLWHAs) and their caregivers in resource-poor, remote South African villages. In-depth interviews were conducted with nine PLWHAs and their direct informal caregivers. Interviews explored the themes of physical, emotional and social wellbeing. Two focus groups were also conducted. The results of the study underscored the needs of PLWHAs and the needs of their direct informal caregivers, which include physical/medical, social, material, financial, instrumental and physiological/emotional needs, as well as gender issues. In developing home-based care programmes, the study argues that it is vital to consider the perceived needs of PLWHAs and their caregivers. The results from this study may serve as a basis for the development of a home-based care programme in similar remote and resource-poor settings.
13. Monitoring equity and research policy
Health information systems (HIS) are increasingly being recognised as the ‘central nervous system’ of the health sector, with the information they generate being used for decision making to improve health system performance, accountability and health outcomes. To guide countries in developing and strengthening their HIS, Health Metrics Network (HMN) has developed a standard reference for health information systems development, the HMN Framework. This brief report demonstrates the widespread application of the Framework and the growing body of evidence that better health information improves health outcomes and contributes to saving lives. By 2010, HMN tracked a cumulative total of US$ 514 million from a limited number of domestic and donor sources that was invested in HIS strengthening globally. Although estimates show an upward trend in investment, the brief argues that further resources are needed to meet the increasing demand from countries for HIS investment. It argues that a strengthened HIS produces better quality information for use in decision making, and that information-driven decisions lead to cost savings, more efficient use of resources, better quality essential health services, improved coverage and more lives saved.
Africa's progress depends on her capacity to generate, adapt, and use scientific knowledge to meet regional health and development needs. Yet, according to this paper, Africa's higher education institutions that are mandated to foster this capacity lack adequate resources to generate and apply knowledge, raising the need for innovative approaches to enhance research capacity. The paper describes a newly developed programme to support PhD research in health and population sciences at African universities: the African Doctoral Dissertation Research Fellowship (ADDRF) Programme. It documents the authors’ experiences implementing the programme. As health research capacity-strengthening in Africa continues to attract attention and as the need for such programmes to be African-led is emphasised, the authors propose that their experiences in developing and implementing the ADDRF may offer invaluable lessons to other institutions undertaking similar initiatives.
According to this study, the availability, quality and use of health information, research evidence and knowledge is not adequate in the African Region. This has resulted in two major types of knowledge gaps: gaps in health knowledge, and the so-called ‘know-do gap’. Health knowledge gaps are where essential answers on how to improve the health of the people in the Region are missing. This is an issue related to the acquisition or generation of health information and research evidence. The ‘know-do gap’ is the failure to apply all existing knowledge to improve people’s health. This is related to the issue of sharing and translation of health information, research evidence, or knowledge. Although there are major structural constraints, the study argues that the key to narrowing the knowledge gap and sustaining health and development gains is a long-term commitment to strengthen national capability to ensure the availability of relevant and high quality health information and evidence and its use for policy and decision making. Close links and the co-ordination of fragmented disciplines such as information, health research and knowledge management are argued to be an essential step in this process.
Health impact assessment (HIA) has been proposed as one mechanism that can inform decision-making by public policy-makers, yet it has been criticised for a lack of rigour in its use of evidence. The aim of this study was to formulate, develop and test a practical guide to reviewing publicly available evidence for use in HIA. The formulation and development of the guide involved substantial background research, qualitative research with the target audience, substantial consultations with potential users and other stakeholders, a pilot study to explore content, format and usability, and peer review. Finally, the guide was tested in practice by invited volunteers who used it to appraise existing HIA evidence reviews. During development, a wealth of data was generated on how the guide might be applied in practice, on terminology, on ensuring clarity of the text and on additional resources needed. The final guide provides advice on reviewing quantitative and qualitative research in plain language and is suitable for those working in public health but who may not have experience in reviewing evidence. During testing, it enabled users to discriminate between satisfactory and unsatisfactory evidence reviews. By late 2009, 1,700 printed and 2,500 downloaded copies of the guide had been distributed. In conclusion, substantive and iterative consultation, though time-consuming, was pivotal to producing a simple, systematic and accessible guide to reviewing publicly available research evidence for use in HIA.
This report is part of initial findings from an ongoing review of development progress to generate comparative analysis that illustrates relative and absolute progress at national, sub-national and regional levels. The analysis is based on the Millennium Development Goal (MDG) database, household demographic and health surveys and multiple indicator cluster surveys. Two measures are used to evaluate progress: absolute and relative. Both measures are needed to tell the full story of progress, particularly in low-income countries. The report found that most countries are making progress on most of the key MDG indicators. For example, the number of people living in extreme poverty fell from an estimated 1.8 billion in 1990 to 1.4 billion in 2005. The share of children in primary school in low- and middle-income countries has risen from just over 70% to well over 80%. Ninety-five per cent of countries are making progress in reducing child mortality, which overall fell from 101 to 69 per 1000 live births between 1990 and 20071. And, despite wide variation in progress on maternal mortality, access to maternal health services has increased in about 80% of countries. The key message from many years of working towards the MDGs is that progress is possible. In every aspect of development – even in the least successful of the MDGs reviewed here, on maternal health (Goal 5) – a significant number of countries have made real achievements. Although these statistics are encouraging, the challenge for the remaining five years and beyond is to learn from, and build upon, progress made.
Field trials require extensive data preparation and complex logistics. The use of personal digital assistants (PDAs) can bypass many of the traditional steps that are necessary in a paper-based data entry system. In this study, the authors programmed, designed and supervised the use of PDAs for a large survey enumeration and mass vaccination campaign. The project was implemented in Zanzibar, Tanzania. Zanzibar is composed of two main islands, Unguja and Pemba, where outbreaks of cholera have been reported since the 1970s. PDAs allowed the researchers to digitise information at the initial point of contact with the respondents. Immediate response by the system in case of error helped ensure the quality and reliability of the data. PDAs provided quick data summaries that allowed subsequent research activities to be implemented in a timely fashion. Portability, immediate recording and linking of information was found to enhance structured data collection in the study. The study recommends PDAs as more useful than paper-based systems for data collection in the field, especially in impoverished settings in developing countries.
14. Useful Resources
The updated 2010 healthcare workers handbook on influenza provides detailed guidelines on the diagnosis and management of influenza, both seasonal and pandemic, for healthcare workers in South Africa. It gives historical background to the disease in southern Africa, symptoms, case descriptions, information on laboratory testing and clinical management guidelines. The guide concludes with a section on infection management and control.
Results for Development has launched its new Centre for Health Market Innovations (CHMI), a new initiative that works to improve health markets in developing countries to deliver better results for the poor. CHMI is a publicly accessible global knowledge platform that collects, analyses and disseminates information about health market innovations and facilitates the creation of strategic links among key stakeholders. It provides access to interactive, comparable and filterable information on health market programmes. You can use CHMI for research, to allow you to promote your ideas, publications and programmes, and enable you to make better connections with people in the field. The website contains a programmes database and funder database. It also contains information about health market innovations, which are programmes and policies that harness market incentives and mitigate the negative effects of unregulated markets to provide better health and financial protection for the poor. You can join the conversation on the blog, as well as provide feedback on the site.
This is the first Model Formulary for Children released by the World Health Organization (WHO), which provides information on how to use over 240 essential medicines for treating illness and disease in children from 0 to 12 years of age. A number of individual countries have developed their own formularies over the years, but until now there was no single comprehensive guide to using medicines in children for all countries. The Model Formulary is the first resource for medical practitioners worldwide that provides standardised information on the recommended use, dosage, adverse effects and contraindications of medicines for use in children. The new Formulary is based on the best global evidence available as to which medicines should be used to treat specific conditions, how they should be administered and in what dose. The Formulary also identifies a number of areas where more research is needed to provide better treatment for children, such as child appropriate antibiotics to treat pneumonia and specific medicines for neonatal care.
15. Jobs and Announcements
The Commonwealth Foundation’s Civil Society Responsive Grants are intended for organisations planning a regional or international workshop or an exchange visit to another non-governmental organisation (NGO) or project. The grants support strengthening of civil society for sustainable development, democracy and intercultural learning within the Commonwealth countries, and may cover short training courses, workshops, seminars, conferences, cultural festivals, exchanges and study visits in other Commonwealth countries. They are targeted at Commonwealth developing countries. Generally, the Foundation awards g around £5,000, but NGOs can request funding up to £10,000. In rare cases, Grants of up to £20,000 can also be made. The grants support activities in four main areas: culture; governance and democracy; human development; and communities and livelihoods.
Funded by the Netherlands Ministry of Foreign Affairs, the Netherlands Fellowship Programme (NFP) offers an opportunity for non-governmental organisations (NGOs) in developing countries to gain skills and build their capacities internationally through training and education. Mid-career staff working in organisations in developing countries can apply for this fellowship programme. Applicants must be nominated by their organisations. Applicant should have at least three years of work experience. Further refresher courses are offered to NFP alumni developed for the purpose of prolonging the effect of the previous fellowship given. NFP has dedicated half of the budget to be spent on fellowships for female candidates and candidates from sub-Saharan Africa. Please note that there are different deadlines and different durations for various programmes of the fellowship, depending on which country you come from.
The Senior Fellows Programme is looking for civil society leaders who are committed to collaborative action to bring sustainable, systemic improvements in the lives of the communities they serve. To qualify for the programme, these leaders must present a compelling vision for solving complex, systemic problems of poverty, inequity and social injustice, and show commitment to the participation of and accountability to the community they serve, as well as credibility and legitimacy from that community to speak authoritatively about its issues. The Fellowship lasts three years and the fellows are expected to take part in activities while performing their ongoing professional responsibilities. This includes attending Senior Fellows global and regional events, being available for peer consulting, exchange and field service opportunities, and contributing to the programme’s shared body of knowledge. Synergos covers the costs of the activities during the three years, and fellows are expected to remain part of the Fellows Network after completion of their three-year programme.
The 14th Annual Conference on Rural Health will be held from 26–28 August 2010 in Swaziland. Plenary sessions will focus on creative ways of funding health care and personal accounts of having made a difference. The Skills Training Programme includes treating Kaposi Sarcoma at a rural hospital, managing snakebites, new developments in mental health care and developing a decentralised drug-resistant tuberculosis programme. The Scientific Programme will provide a platform where delegates can present their achievements. Five oral presentations or posters grouped around a similar theme will be discussed during the sessions, with time for participation. The Medical Training Track will be relevant to student participants, as it includes in-depth discussions of medical training needs. A debate will be held on the issue of mid-level health workers, with experts from Mozambique, Botswana, Malawi and South Africa outlining advances made in these countries. The traditional Focus on Advocacy Track is expected to be vigorous, given the participation of the new Rural Health Advocacy Project. For the first time there will be a track dedicated entirely to debating policy issues and formulating resolutions. Health care professionals who are interested in rehabilitation will be able to attend multi-disciplinary sessions.
The main goal of the International Development and Research Centre (IDRC) Internship Awards is to provide exposure to research for international development through a programme of training in research management and grant administration under the guidance of IDRC programme staff. Internships are designed to provide hands-on learning experiences in research programme management and in the creation, dissemination and utilisation of knowledge from an international perspective. The interns will first undertake a programme of research on the topic submitted when competing for the internship award. Thereafter, they will be expected to provide support to management and programme staff in some of the following areas: synthesis of project outcomes; production of publications and dissemination materials or activities on research results; participation in team meetings; research tasks to locate, review and synthesise relevant material; preparation of state-of-the-art reviews; preparation of correspondence, reports and presentations; assistance with the organisation of meetings, workshops and seminars; preparation of minutes; updating and maintaining databases; and maintenance of the website; and exchange with other institutions working on a broad range of issues related to programming.
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