In this issue we bring news of cause to celebrate, but also a call for action on an expanding IP enforcement agenda that challenges our rights to health. In the section on 'Resource allocation and health financing' we welcome the heads of state restatement of their 2001 Abuja commitment to allocate at least 15% of annual budgets to health. EQUINET was part of this campaign (have a look at Newsletter #113) and while we recognise that 15% of government's own spending may not be sufficient resources for health, it does signal a prioritisation of the domestic and public sector role in health. This newsletter editorial draws our attention to an issue that needs attention, and more than that, action. In the competition between social rights to health, and private rights to intellectual property, our dependence on medicines purchased from outside Africa makes us weak defenders of rights to health.
1. Editorial
The 18 to 23 July International AIDS Conference held in Vienna this year, subtitled “Rights Here, Right Now” was a platform to raise, yet again, the values based universal and indivisible human rights and the political commitments that inform our response, globally, to the unacceptable level of new HIV infection and mortality from AIDS. At the same time the shrinking provision of aid to low income countries and persistence of avoidable inequities globally in the progressive realisation of these rights starkly raises the reality of the competition between social rights to health, and private rights to intellectual property.
International aid to developing countries has declined in the past two years, with a fall of $1.1 billion in high income country support for developing country AIDS programmes between 2008 and 2009, according to UNAIDS and Kaiser Foundation. At the same time rich countries continue to pursue with vigour stronger protections for intellectual property rights (IPR) – in what is now known as the ‘IP Enforcement Agenda”. The effects of strong IPR protection may have been abated in earlier years by aid support for purchase of patented medicines, but low income countries seeking to meet needs in the current financial squeeze by procuring cheaper options or initiating their own local production of medicines, including of anti-retrovirals, face an unabated challenge to their implementing even those measures that are legal under the World Trade Organisation's (WTO's) Trade-Related Intellectual Property Rights (TRIPs) agreement.
The fall in funding to AIDS has itself been challenged by many, including the President of the International AIDS Society, Dr. Julio Montaner, and Stephen Lewis (former UN special envoy for HIV/Aids in Africa). As Dr Montaner said: “International governments say we face a crisis of resources, but that is simply not true: The challenge is not finding money, but changing priorities. When there is a Wall Street emergency or an energy crisis, billions upon billions of dollars are quickly mobilized. People’s health deserves a similar financial response and much higher priority.”
At the same time the fall in funding has made very clear the need to implement long-standing calls by progressive civil society to put in place more predictable means of global financing, and for African countries to maximise use of TRIPS flexibilities and to advance local production of pharmaceuticals. Yet is it precisely in this arena that measures are being taken to strengthen and enforce intellectual property rights and reduce the flexibilities needed by developing countries. There have been numerous examples of this, included those reported in prior issues of the EQUINET newsletter.
Measures to reinforce IPRs include in regional and bilateral agreements provisions that exceed TRIPs requirements and reduce the flexibilities provided by TRIPS (TRIPS plus); and also pressures on African countries not to exercise rights to compulsory licensing or parallel importation. The EU, which stated its commitment to access to medicines, has pursued measures that exceed TRIPs obligations in its trade agreements with developing countries including with India, in spite of an EU Parliamentary resolution on 12 July 2007 (P6_TA(2007)0353) urging it not to do so. There have been seizures in the EU of generic medicines in transit, not destined for Europe, performed at the insistence of EU pharmaceutical companies for allegedly being counterfeit. The EU has contributed to work on anti-counterfeiting legislation in East African countries that has raised new IPR restrictions on legitimate generic medicines, defining them within the scope of counterfeits (see EQUINET Newsletter 111). Similar seizure laws are being supported through a global initiative called IMPACT.
Significantly at the July AIDS conference, attention was also drawn to the use by the USA of its ‘Special 301’ law which it uses to list and “shame” countries for violating US commercial interests by not providing sufficient protection to IPRs. Health Gap, the Foundation for AIDS Rights and the Thai Network of People Living with HIV/AIDS with others have filed a complaint with the UN's Special Rapporteur on the Right to Health, Anand Grover, alleging that use of this law reduces access to medicines in low and middle income nations and violates international human rights obligations.
Global institutions appear to be offering weak protection to developing countries in their efforts to assert their rights, and the rights and flexibilities provided for in global treaties. In the 2006/7, during the WHO's negotiations on Public Health, Innovation and Intellectual Property (for so-called “neglected diseases”) efforts were made to contain the challenge to IPRs from neglected diseases by including a proposal to limit the scope of the discussion to only 14 diseases, a due process violation as no country proposed this for inclusion in the negotiating text. The IMPACT programme referred to earlier has had an association with WHO that was heavily criticised at the 2010 World Health Assembly. The WTO Dispute Settlement Body (DSB), instead of the defending the flexibilities provided in its own instruments through multilateral measures, has allowed the US room for unilateralism on its Special 301 law in a January 1999 dispute raised by the European Community. This was a decision that Chakravarthi Raghavan of the South-North Development Monitor termed as blatantly based on politics, rather than legal interpretation.
Almost a decade since the 2001 Doha Declaration on TRIPS and Public Health made the important step of asserting more clearly the rights countries already enjoyed to promote access to medicines, few countries have been able to use the rights enshrined in it. The Declaration was needed then because poor countries were precluded from using these rights by the rich countries. The cases cited in this editorial suggest that the last decade has been one of countless efforts to restrict and reverse those rights.
This is in a context where the latest WHO treatment guidelines recommend that people with HIV should start treatment earlier, bringing treatment for people in developing countries in line with treatment in wealthy nations, to help prevent transmission of HIV. Of the 14 million people needing treatment, only 4 million currently receive it. While private rights to IPRs are being vigorously enforced, who is vigorously enforcing the rights to life and health of these 10 million people, or the millions more who need medicines for other common diseases, including chronic conditions like diabetes and hypertension?
And where will we be ten years from now, with an unabated and expanding IP enforcement agenda?. The evidence from recent years outlined here suggests that basing future access to medicines on a benevolent global market, or even one that prioritises human rights in one region over commercial rights in another may be wishful thinking. There seems to be no alternative but for African countries to set a vision, and to develop, negotiate, build space for and implement strategies for their own local production of medicines, to meet their own market and population needs, while simultaneously fending off an IP enforcement agenda that does not meet their interests, in all its guises.
2. Latest Equinet Updates
The national review meeting on the role of the medical aid societies in Zimbabwe was convened by TARSC, SEATINI with collaboration from the Ministry of Health and Child Welfare, and support from the Southern African Health Trust through ISER, Rhodes University, in EQUINET. The activity was one of a series in a regional programme on capital flows in the health sector in southern Africa co-ordinated by ISER. The workshop brought together researchers, policy makers, health sector regulators and the medical aid societies to discuss issues around the flow and impact of capital flows through medical aid societies in the health sector in Zimbabwe. The review workshop guided by the research work that was implemented in Zimbabwe by TARSC and SEATINI on capital flows in the health sector, separately reported in EQUINET discussion paper 82. The meeting raised issues in relation to the functioning of medical aid societies and made recommendations to address them.
The ECSA Secretariat organised the first Regional Monitoring and Evaluation Expert Core Group meeting in Harare Zimbabwe from 12th to 16th July 2010. The participants came from Member States of Tanzania, Kenya, Lesotho, Zimbabwe, Zambia, Uganda, Malawi, Mozambique and Mauritius and international partners, namely EQUINET, UNICEF, ESARO, WHOIST/ESA and USAID-EA. The meeting deliberated and agreed on the Terms of Reference for the regional M&E Expert Group. The meeting also updated the HMC Monitoring tool, adopted with amendments the Regional Core set of indicators that will be used to monitor progress towards the Millennium Development Goals (MDGs), finalised the M & E Framework, developed indicators to monitor the implementation of the HMC resolutions and included indicators to monitor health equity in order to address inequalities in health in the region. In addition, the meeting resolved that it was necessary to monitor other codes, protocols and conventions such as the WHO Global Code of Practice on the International recruitment of health personnel. The indicators and the monitoring tools agreed upon by the expert core group will not only make it easier to compare member states in progress towards achieving the MDGs, addressing equity issues in health and implementation of the HMC resolutions, but also will be valuable in evaluation of in country changes from the baseline. The meeting also discussed, reviewed and adopted the Equity watch work in east and southern African countries.
3. Equity in Health
This article identifies two ‘gaps’ in maternal, newborn, and child health (MNCH): a ‘science to policy and practice’ gap, where, despite mounting research on MNCH, it has failed to achieve importance on the domestic policy agendas of African countries; and a ‘policy to practice’ gap, where, despite clear policy commitments to MNCH, substantial challenges prevent these policies from being implemented effectively. The article focuses on the ‘science to policy and practice’ gap, in the belief that action to address the second gap is already mobilised, although clearly not yet fully effective. In contrast, the first gap remains neglected. It first addresses what is already known about how scientific evidence has influenced MNCH policy and practice, then it considers some of the key challenges in closing the science to policy and practice gap, and concludes by identifying promising paths for future action: developing MNCH policy networks, mainstreaming the use of MNCH science and investing in innovative approaches to develop and apply MNCH evidence.
In this statement, Commonwealth Health Ministers acknowledged the progress made globally towards the attainment of the health-related Millennium Development Goals (MDGs), including the steady reduction in under-five deaths from 12.6 million in 1990 to 9 million in 2007. They note that at least 16 developing Commonwealth countries have achieved or are on track to achieve MDG 5. 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. They particularly called for support to meet the target of 90% of births being attended by skilled health workers by 2015.
The analysis in this paper illustrates that the child survival picture – in terms of rate and inequality – varies in the developing world, highlighting the importance of differentiated child survival strategies between middle- and low-income countries. In many countries, reductions in child mortality among poorer households have been smaller than for the higher income groups. Once child mortality is concentrated among lower income groups – as is the case in many middle-income countries – major efforts to reduce child mortality should be equalising, but these require a focus on systematic interventions rather than ‘quick win’ strategies. On the other hand, under-five mortality in low-income countries is usually high not only among the poorest quintile, but in the bottom 40–60% of the population, suggesting the need for more comprehensive strategies to reduce under-five mortality across a broader spectrum of the population.
The paper argues that neonatal mortality tends to fall more slowly than under-five mortality, since reducing it needs longer-term and relatively more expensive interventions associated with functioning health systems. This indicates that while there are quick wins that can help improve child survival, middle-income countries (and low-income ones that have relatively low child mortality rates) need to focus more on reducing neonatal deaths.
This article focuses on a number of countries in Africa that have made improvements in their health outcomes and that are on their way to meeting their health Millennium Development Goal (MDG) targets, including Tanzania, Kenya and Rwanda. Infant mortality fell by over 40% in Tanzania, from 99 deaths per 1,000 live births in 1999 to 58 in 2007-08, which suggests that the country can reach its Millennium Development Goal (MDG) target by 2015. Under-five mortality has also declined, from 146 deaths per 1,000 live births to 91. After a period of stagnation during which infant and child mortality rates deteriorated and life expectancy dropped, Kenya has recently made very significant progress, reversing its negative health trends between 2003 and 2007. The 2008 Kenya Demographic and Health Survey (DHS) reveals remarkable declines in infant and under-five mortality rates in this period (from 77 to 52, and from 115 to 74, per 1000 live births, respectively). After the 1994 conflict, which took a great toll on the health sector, Rwanda entered the 21st century with one of the weakest health systems in the world. Yet today it shows some very strong health results. Assisted childbirths rose from 39% in 2005 to 52 percent in 2008; while under-5 mortality fell by a third, from 152 deaths per 1,000 live births in 2005 to 103 in 2008. And the use of modern contraception has increased from 10% to 27% in just three years.
According to this paper, the world is off track in meeting the Millennium Development Health Goals. It urges world leaders and other stakeholders to accelerate progress to reach the goals set to improve maternal and child health. It calls for rapid expansion of antiretroviral coverage for women with HIV in order to reduce maternal mortality, rapid expansion of antiretroviral treatment for all men and women with HIV, the integration of services to prevent HIV transmission to infants and to achieve rapid paediatric HIV diagnosis across all sexual and reproductive health services and all services for newborns. Governments are urged to provide support to implement the most effective antiretroviral regimens to prevent HIV transmission to infants and scale up efforts to diagnose HIV in children, expand ART for children and the paper argues that expanded funding for the Global Fund is required to bring it in line with its most ambitious scenario of USD$20 billion for the next three years.
According to this report, in 2008, an estimated 390 000–510 000 cases of multi-drug resistant tuberculosis (MDR-TB) emerged globally (best estimate, 440 000 cases). Among all incident TB cases globally, 3.6% are estimated to have MDR-TB. The report notes that more data on drug resistance has become available and estimates of the global MDR-TB burden have been improved. Even in settings gravely affected by drug resistance, it is possible to control MDR-TB, although new findings presented in this report give reason to be cautiously optimistic that drug-resistant TB can be controlled. While information available is growing and more and more countries are taking measures to combat MDRTB, urgent investments in infrastructure, diagnostics, and provision of care are essential if the target established for 2015 – the diagnosis and treatment of 80% of the estimated MDR-TB and extensively drug-resistant TB cases – is to be reached.
Drawing on evidence of what has worked in 50 countries, this report provides an eight-point MDG action agenda to accelerate and sustain development progress over the next five years. The eight points focus on supporting nationally-owned and participatory development; pro-poor, job-rich inclusive growth including the private sector; government investments in social services like health and education; expanding opportunities for women and girls; access to low carbon energy; domestic resource mobilisation; and delivery on Official Development Assistance commitments. From the abolition of primary school fees leading to a surge in enrolment in Ethiopia to innovative health servicing options in Afghanistan reducing under-five child mortality, the report brings forward concrete examples that have worked and can be replicated, even in the poorest countries, to make real progress across the Millennium Development Goals. Rapid improvements in both education and health, the report illustrates, have occurred in countries where there were adequate public expenditures and strong new partnerships, where economic growth is job-rich and boosts agricultural production, where robust social protection and employment programmes are in place, and where development is country led, with an effective government in place.
The pandemic threat of the H1N1 or ‘swine flu’ virus has now passed, according to World Health Organization (WHO) Director-General, Margaret Chan. The virus has largely run its course, said Chan, though she added that WHO continues to recommend the use of remaining pandemic vaccines as their efficacy has not decreased. The announced closing of the pandemic period means that the names of the WHO’s Emergency Committee, which decided when to declare the pandemic and when it could be considered ended, are now public. This new information should help answer some of the more critical questions being asked about WHO’s influenza response, such as whether conflicts of interest within the body’s expert advisory group led to an exaggeration of the risks of the H1N1 virus.
4. Values, Policies and Rights
The African Union (AU) Summit in Kampala August 2010 adopted an action plan for the improvement of maternal, infant and child health and development and made a commitment to spending 15% of national budgets in an effort to reach the Millennium Development Goals in this area. An AU task force will track progress to ensure implementation. On the partnership for the eradication of mother-child transmission of HIV (PMTCT), the Assembly invited all Member States to intensify efforts relating to antiretroviral treatment and PMTCT and to extend such efforts to primary health centres. The Assembly underscored the need for programmes for the total eradication of PMTCT and called for all African actors concerned to act immediately to make eradication a realisable outcome. An initiative on agriculture and food security was also launched. Economic growth, job creation and investment are the preferred focus for the Africa-Europe Summit in November and the next AU Summit in 2011 will focus on the Pan-African Governance Architecture.
The Kenyan government is drafting new regulations to stop fraudulent herbalists claiming to be able to treat diseases, including HIV, from practising. Anybody found selling untested herbal products will face legal action for ‘endangering people's lives,’ said Jayesh Pandit, head of pharmacovigilance at the Pharmacy and Poisons Board. The Pharmacy and Poisons Board has registered 300 legitimate herbalists, but thousands more are practising outside the law, often selling useless or even harmful products to desperate patients. According to the World Health Organization, up to 80% of Africans use traditional medicine. The government is planning to introduce a ‘Traditional Medicines Practitioners Bill’, which will regulate the use of herbal medicines and define the punishment to be handed down to herbalists practising illegally.
In his address to the Eighteenth International AIDS Conference in Vienna, Mark Heywood of the Treatment Action Campaign (TAC) has warned that South Africa’s campaign to test 15 million people for HIV in one year risks being implemented in a way that undermines people’s human rights. Incidents of coercive testing have been recorded but the lack of effective monitoring procedures means that it’s impossible to know whether those incidents are widespread or not. The testing campaign is a means to an end, and not of value in itself, he said. Unless the campaign delivers on its promise to link newly diagnosed people into treatment services, then the means to achieve this end will be unjustifiable. He noted human rights concerns about a lack of monitoring of ‘adverse events’, such as whether a person who is diagnosed with HIV then suffers discrimination, suffers violence or gains access to treatment. Incidents of refusing HIV-positive patients access to health services have been recorded by the TAC in South Africa. Heywood said it was unclear whether such incidents were rare or widespread, but that any violations of basic principles should be taken seriously.
The AIDS 2010 conference theme emphasises the central importance of protecting and promoting human rights as a prerequisite to a successful response to HIV. The right to dignity and self-determination for key affected populations, to equal access to health care and life-saving prevention and treatment programmes, and the right to evidence-based interventions based on evidence rather than ideology are all incorporated in this urgent demand for action. Rights Here, Rights Now, a campaign launched by the International Lesbian, Gay, Bisexual, Trans and Intersex Association, emphasises that concrete human rights measures need to be in place to protect those most vulnerable to and affected by HIV, especially women and girls, people who use drugs, migrants, prisoners, sex workers, men who have sex with men and transgender persons.
This book is a collection of 16 critical essays by leading scholars and practitioners in the field of sexual and reproductive health and rights. Each author analyses the legacy of the International Conference on Population and Development (ICPD) from a different perspective or focuses on a particular topic. They examine strengths, weaknesses and whether and how the ICPD mandate can still be used to improve sexual and reproductive health. Given the complexities and challenges of implementing and continuing to take forward the ICPD agenda after more than fifteen years, the undertaking in this volume is laudable. The essays all contain some dimension that should be of interest to a variety of readers. Some provide historical background which might otherwise be forgotten. Several other authors point out that the absence of reproductive health in the initial targets for the Millennium Development Goals was a serious setback. While the target of ‘universal access to reproductive health’ has since been added, one of the essays, ‘Mobilising resources for reproductive health’, points out that a strong evidence base is needed to demonstrate that poor reproductive health outcomes do, in fact, undermine the chances of the poor to escape poverty.
The aim of this paper is to examine young women's motivations to exchange sex for gifts or money, the way in which they negotiate transactional sex throughout their relationships, and the implications of these negotiations for the HIV epidemic. An ethnographic research design was used, with information collected primarily using participant observation and in-depth interviews in a rural community in North Western Tanzania. The qualitative approach was complemented by an assisted self-completion questionnaire. The study found that transactional sex underlay most non-marital relationships and was not, per se, perceived as immoral. However, women's motivations varied, for instance: escaping intense poverty, seeking beauty products or accumulating business capital. There was also strong pressure from peers to engage in transactional sex, in particular to consume like others and avoid ridicule for inadequate remuneration. Young women actively used their sexuality as an economic resource, often entering into relationships primarily for economic gain. In conclusion, transactional sex is likely to increase the risk of HIV by providing a dynamic for partner change, making more affluent, higher-risk men more desirable, and creating further barriers to condom use. Behavioural interventions should directly address how embedded transactional sex is in sexual culture.
The United Nations (UN) General Assembly has declared access to safe, clean drinking water and sanitation to be a ‘'human right' in this resolution, which more than 40 countries (including the United States) didn't support. The text is non-binding. The resolution expresses deep concern that, despite the fact that the Millennium Development Goal (MDGs) adopted by world leaders in 2000 call for the proportion of people without access to safe drinking water and basic sanitation to be cut in half by 2015, an estimated 884 million people still lack access to safe drinking water and more than 2.6 billion people do not have access to basic sanitation. In the resolution, the Assembly calls on UN ‘member states and international organisations to offer funding, technology and other resources to help poorer countries scale up their efforts to provide clean, accessible and affordable drinking water and sanitation for everyone’. Additionally, the resolution backs the UN Human Rights Council recommendation that the UN independent expert on the issue of human rights obligations related to access to safe drinking water and sanitation must report annually to the General Assembly. This annual report will focus predominantly on the principle challenges of achieving the right to safe and clean drinking water and sanitation, as well as progress towards the relevant MDGs.
5. Health equity in economic and trade policies
Act-Up Paris made this speech via the European Commission's (EC) satellite to the International AIDS Conference, held from 18 – 23 July in Vienna, Austria. It denounces the EC’s actions, such as its decision to take a trade-based and not a health-based approach to access to medicines, and accuses the body of duplicity in its Free Trade Agreement negotiations with India, its negotiations regarding the proposed All Censorship Trade Agreement (ACTA), which aims to govern global intellectual property rights, and seizures of allegedly counterfeit generics being transported from India to South America and Africa. Act-Up Paris asserts that the EC is working to make medicines more expensive, while at the same time freezing its contributions to the Global Fund. It urges the EC to respect the Doha Declaration and to embark on a global rights-based approach to dealing with HIV and AIDS.
Are counterfeit products first and foremost a threat to human health and safety or is provoking anxiety just a clever way for wealthy nations to create sympathy for increased protection of their intellectual property rights? This article indicates that coverage of this issue in the world’s news media varies greatly. Some argue that attempts to fight fake drugs are as much a risk to access to the real medicines as the fakes themselves. Legitimate, low-cost generics – often the only medicines the poor can afford – can get caught in the crossfire of anticounterfeiting enforcement measures. In addition, they say, there is need to combat not only medicines that violate trademarks (as counterfeit is often defined) but also medicines of general low quality (harder to spot and often, some say, a greater problem). The article examines a variety of news items that have recently appeared in the international media. Sources in American media have focused on organised crime in drug counterfeiting without considering the problems of access to medicines in developing countries. On the other hand, India’s newspapers are concerned with the impact of new legislation on the production of generics and the United Kingdom’s BBC has acknowledged the problems of access to medicine.
The Bill and Melinda Gates Foundation, known for concentrating on vaccines and AIDS in its charitable work, has added Ecolab and Monsanto to its portfolio. Monsanto is the world largest biotechnology company dealing in genetically modified organisms.
Most of the estimated 5.2 million people worldwide on antiretroviral (ARV) treatment are taking generic versions manufactured primarily in India, but tighter global intellectual property rights and trade rules could shut down this trade. While the patents on many older, first-line ARVs have expired, leaving generic manufacturers free to produce them, newer, less toxic and more effective drugs are patented and priced out of reach of less developed nations. The main way generics manufacturers can produce newer drugs is to obtain a ‘voluntary licence’ from the patent holder. This usually sets quality requirements and defines the markets in which the licensee can sell the product. For example, pharmaceutical giant Gilead has allowed the South African firm, Aspen Pharmacare, to manufacture and distribute branded and generic versions of tenofovir, one of the newer first-line ARV drugs. However, civil society activists say voluntary licences skew the balance of power too far in favour of patent-holders and present a way to control generic competition by creating dependency on the innovator companies, according to this article. The United States and the European Union have been accused of pressuring developing countries by using trade threats to coerce these countries into adopting intellectual property laws that will increase the cost of medicines. By jeopardising generics, especially those from India, this article argues that they are effectively putting millions of lives at risk.
The ‘brain drain’ has long been a common concern for migrant-sending countries, particularly for small countries where high-skilled emigration rates are highest. However, while economic theory suggests a number of possible benefits, in addition to costs, from skilled emigration, the evidence base on many of these is very limited, according to this review. Moreover, the lessons from case studies of benefits from skilled emigration may not be relevant to much smaller countries. This paper presents the results of innovative surveys which tracked academic high-achievers to wherever they moved in the world in order to directly measure at the micro level the channels through which high-skilled emigration affects the sending country. The results show that there are very high levels of emigration and of return migration among the very highly skilled. The income gains to the best and brightest from migrating are very large, and an order of magnitude or more greater than any other effect. There are large benefits from migration in terms of postgraduate education. Most high-skilled migrants from poorer countries send remittances; but involvement in trade and foreign direct investment is a rare occurrence. There is considerable knowledge flow from both current and return migrants about job and study opportunities abroad, but little net knowledge sharing from current migrants to home country governments or businesses. Finally, the fiscal costs vary considerably across countries, and depend on the extent to which governments rely on progressive income taxation – the greater the reliance on progressive taxation, the higher the fiscal cost of losing health professionals to the economy.
This study’s objective was to assess the effect of food taxes and subsidies on diet, body weight and health through a systematic review of the literature. Researchers searched the English-language published and grey literature for empirical and modelling studies on the effects of monetary subsidies or taxes levied on specific food products on consumption habits, body weight and chronic conditions. Twenty-four studies met the inclusion criteria. The study found that, in general, taxes and subsidies influenced consumption in the desired direction, with larger taxes being associated with more significant changes in consumption, body weight and disease incidence. However, studies that focused on a single target food or nutrient may have overestimated the impact of taxes by failing to take into account shifts in consumption to other foods. The quality of the evidence was generally low. The study concludes that food taxes and subsidies have the potential to contribute to healthy consumption patterns at the population level. However, the empirical evaluation of existing taxes should become a research priority, along with research into the effectiveness and differential impact of food taxes in developing countries.
This discussion paper underlines a major risk in the Joint Africa-EU Strategy (JAES) implementation process so far: the perceived gradual dilution of the political substance of the new policy framework. This risk lies in contrast to the original negotiations for the JAES, where there was a much stronger commitment to negotiating political differences. It is reflected in the fact that the JAES finds it difficult (so far) to politically uplift the partnership ‘beyond Africa’, ‘beyond cooperation’ and ‘beyond institutions’. According to this paper, the dilution should be a matter of concern considering that the added value of the JAES, compared to existing policy frameworks such as the Cotonou Agreement or bilateral relations, precisely lies in its ambitious political agenda to renew and transform Africa- EU relations. Little tangible progress has been achieved in establishing the JAES as the overarching political framework for Africa-EU relations. Levels of ownership tend to be low beyond the inner circle of those concerned with the JAES. The paper argues that that the current difficulties experienced by the JAES are linked to fundamental political choices in the implementation strategies followed so far rather than to the validity of the overall vision underlying the search for a renewed Africa-EU partnership.
6. Poverty and health
This study’s objective was to evaluate mortality and morbidity among internally displaced persons (IDPs) who relocated in a demographic surveillance system (DSS) area in western Kenya following post-election violence. In 2007, 204 000 individuals lived in the DSS area, where field workers visited households every four months to record migrations, births and deaths. Between December 2007 and May 2008, 16,428 IDPs migrated into the DSS, and over half of them stayed six months or longer. In 2008, IDPs aged 15–49 years died at higher rates than regular residents of the DSS. A greater percentage of deaths from HIV infection occurred among IDPs aged ≥ 5 years (53%) than among regular DSS residents (25–29%). Internally displaced children < 5 years of age did not die at higher rates than resident children but were hospitalised at higher rates. In conclusion, HIV-infected internally displaced adults in conflict-ridden parts of Africa were found to be at increased risk of HIV-related death. Relief efforts should extend to IDPs who have relocated outside IDP camps, particularly if afflicted with HIV infection or other chronic conditions.
New data on the nutritional status of Zimbabwe’s children reveals that more than one third of Zimbabwe’s children under the age of five are chronically malnourished and consequently stunted. Zimbabwe’s current food production remains too low to meet national requirements. Years of persistent droughts and the downturn of the Zimbabwean economy over the past decade have adversely affected food availability in many homes in Zimbabwe. The report calls for accelerated action to reverse chronic malnutrition and maintain the low levels of acute malnutrition highlighted by the report. Chronic malnutrition poses long-term survival and development challenges for Zimbabwe. The survey also shows plummeting exclusive breastfeeding rates. However, the low and stable rates of severe acute malnutrition that were found are a sign that the food security programmes supported by the international community are reaping benefits. The report also acknowledges the tremendous coping mechanisms of the Zimbabwean people at a time of great difficulty.
7. Equitable health services
The objective of the Health Systems Strengthening Project, which is funded by the world Bank, is to deliver the Uganda National Minimum Health Care Package (UNMHCP) to Ugandans, with a focus on maternal health, newborn care and family planning. This will be achieved through improving human resources for health; physical health infrastructure; and management, leadership and accountability for health service delivery. There are four components to the project, the first component being improved health workforce development and management. The objective of this component is to improve development and management of the health workforce. The second component is the improved infrastructure of existing health facilities. The objective of this component is to improve infrastructure of existing health facilities. Emphasis will be placed on providing minimum quality standards of health care services, especially in the areas of maternal and child health, through: renovation of selected health facilities; provision of medical equipment; improved capacity for operations and maintenance; and strengthening the referral system. The third component is the improved leadership, management, and accountability for health service delivery. The objective of this component is to strengthen management, leadership, and accountability for health service delivery. Finally, the fourth component is the improved maternal, newborn and family planning services. The objective of this component is to improve access to, and quality of, maternal health, newborn care, and family planning services.
UNICEF and the World Health Organisation (WHO) have appealed for the participation of all sectors of the Angolan society to ensure the vaccination of about 5.6 million children under five years against polio from 10–12 September 2010. The two United Nations agencies said the exercise was aimed at protecting children in the country against the crippling disease, and a forerunner to Angola's plans to carry out a national vaccination campaign in 2011. It is also part of the Emergency Plan of the Angolan government to eradicate poliomyelitis. According to Angola's Ministry of Health, the country has recorded 17 cases of poliomyelitis in 2010 in the provinces of Luanda, Bengo, Huambo, Bié, Lunda Norte and Lunda Sul. The Ministry warned that the disease is spreading and affecting children who live in the border regions of the Democratic Republic of Congo. The Angolan government has so far committed to releasing US$9.3 million to support vaccination in the 32 main districts in order to increase the coverage to at least 90%.
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8. Human Resources
Physician anaesthetists are scarce in many developing countries and not available at first referral level health facilities. According to this article, the shortage exists because there is not enough recognition of the need for surgical and anaesthesia services at all levels of the health system and their potential to reduce mortality and morbidity. As a result, there is a serious lack of equitable services in developing countries, especially in rural and remote areas. Creating awareness through better documentation of the burden of disease, in terms of death and disability that can be prevented by availability of surgical and anaesthesia services, would be an important step to generate political commitment and local investments in education, training and retention of the health workforce. This needs to be followed up by appropriate policies, legislation, and the establishment of innovative and effective anaesthesia training programmes that address both the immediate need as well as the long-term needs of the health system.
There is currently limited published evidence of health-related training programmes in Africa that have produced graduates, who remain and work in their countries after graduation. However, anecdotal evidence suggests that the majority of graduates of field epidemiology training programmes (FETPs) in Africa stay on to work in their home countries, many as valuable resources to overstretched health systems. In this study, alumni data from African FETPs were reviewed in order to establish graduate retention. Retention was defined as a graduate staying and working in their home country for at least three years after graduation. African FETPs are located in a number of African countries – this paper only includes the Uganda and Zimbabwe FETPs, as all the others are recent programmes. The review shows that enrolment increased over the years, and that there is high graduate retention, with 85.1% of graduates working within country of training, mostly for Ministries of Health and non-governmental organisations. Retention of graduates with a medical undergraduate degree was slightly higher than for those with other undergraduate qualifications. The paper concludes that African FETPs have unique features which may explain their high retention of graduates, including: programme ownership by ministries of health and local universities; well defined career paths; competence-based training coupled with a focus on field practice during training; awarding degrees upon completion; extensive training and research opportunities made available to graduates; and the social capital acquired during training.
Results from the AIDS Treatment for Life International Survey (ATLIS 2010), a multi-country survey of more than 2,000 people living with HIV/AIDS (PLWHA), were presented at the International AIDS Conference in Vienna, held from 19–23 July 2010. The results revealed a significant gap in patient-physician dialogue about critical health-related conditions that may negatively impact patients’ overall long-term health, quality of life, and treatment outcomes. While the ATLIS 2010 findings showed a high degree of patient satisfaction with HCPs globally (97%), and the majority of patients believe they are being treated according to their individual needs (84%), some respondents claim to have never engaged in important discussions related to their long-term wellness, such as health history, present medical conditions, treatment side effects, new treatment options, or how all of these factors may impact their overall health and treatment outcomes. The report calls for more in-depth discussions to reinforce the importance of adherence to HIV medicines and avoidance of HIV drug resistance. The main findings were that co-morbid conditions are increasingly affecting PLWHAs, there is a critical need for patient literacy in treatment adherence and drug resistance, and that side effects caused by anti-retrovirals need to be monitored closely.
This paper reports and analyses health workforce responses in Malawi and Zambia during a period of large increases in global health initiative (GHI) funds. Health facility record reviews were conducted in 52 facilities in Malawi and 39 facilities in Zambia in 2006/07 and 2008, as well as interviews with staff. Facility data confirmed significant scale-up in HIV and AIDS service delivery in both countries. In Malawi, this was supported by a large increase in lower trained cadres and only a modest increase in clinical staff numbers. In Zambia, total staff and clinical staff numbers stagnated between 2004 and 2007. Key informants described the effects of increased workloads in both countries and attributed staff migration from public health facilities to non-government facilities in Zambia to PEPFAR. Malawi, which received large levels of GHI funding from only the Global Fund, managed to increase facility staff across all levels of the health system: urban, district and rural health facilities, supported by task-shifting to lower trained staff. The more complex GHI arena in Zambia, where both Global Fund and PEPFAR provided large levels of support, may have undermined a coordinated national workforce response to addressing health worker shortages, leading to a less effective response in rural areas.
The World Health Organization’s (WHO) recommendations focus on education, regulatory mechanisms, financial incentives, and personal and professional support. In terms of education, WHO recommends that countries use targeted admission policies to enrol students with a rural background in education programmes to increase the likelihood of graduates choosing to practise in rural areas. Undergraduate students should be exposed to rural community experiences and clinical rotations and study curricula should be revised to include rural health topics. Regulatory recommendations include introducing and regulating enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction. Compulsory service requirements in rural and remote areas should be accompanied with appropriate support and incentives to increase recruitment and subsequent retention of health professionals in these areas. Governments should use a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation and paid vacations, to improve rural retention. Personal and professional support should also be offered by improving living conditions for health workers and their families and investing in infrastructure and services. A good and safe working environment should be provided, with sufficient equipment and supplies.
9. Public-Private Mix
Global health problems require global solutions, and public-private partnerships are increasingly being called upon to provide these solutions. These partnerships involve private corporations in collaboration with governments, international agencies and non-governmental organisations. According to this book, they can be very productive, but they also bring their own problems. The book examines the organisational and ethical challenges of partnerships and suggests ways to address them. It considers issues such as creating shared objectives and shared values in a partnership, and fostering and sustaining trust among partners in times of conflict and uncertainty. It focuses on public-private partnerships that seek to expand the use of specific products to improve health conditions in poor countries and includes case studies of partnerships involving specific diseases such as trachoma and river blindness, international organisations such as the World Health Organization, multinational pharmaceutical companies, and products such as medicines and vaccines. Individual chapters draw lessons from successful partnerships, as well as troubled ones, to help guide efforts to reduce global health disparities.
10. Resource allocation and health financing
The Africa Public Health Alliance & 15% Plus Campaign has welcomed the laudable decisions by the July 2010 African Union Heads of State Summit on various health policies and budget commitments, especially the restatement of the 2001 Abuja commitment to allocate at least 15% of annual budgets to health. The Alliance has identified six key areas requiring improvement. 1. More investment is needed in immunisation, in social determinants of health, in integrated health services and population and social development as this is crucial to reducing child mortality and improving healthy life expectancy. 2. The absolute level of per capita investment in health is as important as percentage allocation and should be increased to above at least $38 per capita. 3. Integrated health, education and labour policies are crucial to resolving health workforce shortages – and meeting all health Millennium Development Goals. 4. Ensuring gender equity in health budgeting is crucial, especially regarding adolescent and youth health. 5. The capacity for production, purchase and distribution of pharmaceuticals, essential medicines and commodities must be improved to prevent stock outs. 6. There should be at least one well-staffed and properly equipped primary health care clinic per community.
At the close of the African Union (AU) Heads of State Summit, health experts and activists from across Africa expressed grave concern that leaders are not delivering on fundamental commitments to expand investments in maternal and child health and other life-saving health services, including treatment and prevention for HIV, tuberculosis and malaria. Although the AU Summit asserted that universal access to quality healthcare is a human right, the advocates expressed disappointment at the overall outcome – particularly regarding mobilising additional resources needed to save lives and advance maternal and child health. For example, the Declaration on Maternal and Child Health has committed AU Members to ‘enhancing domestic resources’ but not to a concrete, time bound increase in domestic investment in health. Activists also challenged donor governments to keep their health funding promises, including the commitment to scale up investments in order to reach universal access to HIV treatment and prevention.
At the end of their meeting on 27 July 2010 in Kampala, Uganda, members of the African Union (AU) reaffirmed that they would strive to spend 15% of their national budgets on health, but health experts like Chikezie Anyanwu, Africa Advocacy Advisor to Save the Children, which works to promote children's rights, were unsure of how effectively the money would be spent. According to him, countries could spend more than 15% and still show no real reduction in the deaths of children younger than five, or among women during or after childbirth, as specified in the Millennium Development Goals (MDGs) set by the United Nations. Rwanda, Liberia and Tanzania are the only three African countries devoting more than 15% of their national spending on health, said Anyanwu, citing a 2010 World Health Organization (WHO) report, based on data from 2007. But they have made insufficient progress in meeting MDGs 4 and 5, which aim to reduce maternal and child mortality. In South Africa, one of the most developed and richest countries in the continent, the infant mortality rate has escalated and the country will probably not achieve the MDG target by the deadline of 2015.
Despite the enormous progress that has been made over the past decade, there are still huge gaps and deficiencies in national plans, budgets, and expenditure tracking systems, according to this paper. Few countries have developed detailed cost estimates of their national strategic plans. All too often, they do not specify how limited resources will be allocated, nor how priorities will be set if they are unable to achieve their goals. The paper argues that, even if AIDS costs are almost certain to rise between now and 2031, the cost trajectory can be significantly influenced by our actions today. Policy choices have different price tags – ranging from $397 billion to $722 billion over the 22-year period. Reducing costs will demand stronger political will and AIDS financing capacity, but the potential payoff in making the right choices is great, leading to fewer infections and more lives saved. Governments and development partners could be much more effective in the AIDS activities they back, and more financially efficient, if they focused resources on prevention programmes that are more closely aligned with specific epidemics. The paper also argues that showing that money for AIDS can be used more efficiently and to achieve greater benefits will also help to maintain political support and enthusiasm for the large-scale efforts that will need to be sustained for decades to come. These steps will require global creativity, national and international leadership, and improved policies and programmes.
Community home-based care is the Botswana Government's preferred means of providing care for people living with HIV. However, according to this study, primary (family members) or volunteer (community members) caregivers experience poverty, are socially isolated, endure stigma and psychological distress, and lack basic care-giving education. Community home-based care also imposes considerable costs on patients, their caregivers and families in terms of time, effort and commitment. The study estimated the cost incurred in providing care for people living with HIV through a stratified sample of 169 primary and volunteer caregivers drawn from eight community home-based care groups in four health districts in Botswana. The results show that the mean of the total monthly cost (explicit and indirect costs) incurred by the caregivers was US$ 90.45, while the mean explicit cost of care giving was $65.22. This mean of the total monthly cost is about one and a half times the caregivers' mean monthly income of $66.00 and more than six times the Government of Botswana's financial support to the caregivers. In addition, the cost incurred per visit by the caregivers was $15.26, while the total expenditure incurred per client or family in a month was $184.17. The study concludes that, as the cost of providing care services to people living with HIV 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 report provides the latest data available on donor funding based on data provided by governments. The year 2009’s totals reflect a substantial increase in funding provided by the United States (rising from US$3.95 billion in 2008 to $4.4 billion in 2009), which helped to offset reductions in support from Canada, France, Germany, Ireland, Italy, and the Netherlands. According to the report, the United States remains the largest donor nation in the world, accounting for more than half (58%) of 2009 disbursements, followed by United Kingdom (10.2%), Germany (5.2%), the Netherlands (5%) and France (4.4%). UNAIDS estimates that $23.6 billion was needed to address the epidemic in low- and middle- income countries in 2009, which suggests a growing gap of $7.7 billion between available resources and need. In 2009, donor governments disbursed $5.9 billion bilaterally and earmarked funds for HIV through multilateral organisations, as well as an additional US$1.6 billion to combat HIV through the Global Fund to Fight AIDS, Tuberculosis and Malaria and US$123 million to UNITAID.
This report starts with a brief overview of the Paris/Accra approach to aid effectiveness and a definition of global funds and partnerships and their role in the overall aid architecture. It summarises strategies for allocating funds across countries, including challenge funds and results-based aid, as well as specific model examples used by selected global funds and partnerships. It found that global funds, like external funders in general, seek to maximise the impact of their assistance and use a variety of allocation mechanisms to ration their funds. Overall, country sub-sectoral support can vary in modality (including sectoral budget support) and may make use of indicative country allocations based on need and performance. The difference between the approaches of global funds and of Paris/Accra ‘horizontal’ aid is not whether they seek to achieve results. Instead, the differences lie in how the fund allocation strategies are designed and implemented to achieve these results. A key issue for all approaches to linking finance to results is the relative emphasis between short- and medium- to longer-term results and between results per se and intermediate steps that bring them about. In this context, this report also emphasises three issues related to achieving medium- to long-term results: predictability, sustainability and capacity.
South African Health Minister, Aaron Motsoaledi cautioned those attending the International AIDS conference, held in Vienna, Austria, from 19–27 July 2010, that backtracking on funding for HIV could threaten treatment success rates. In his speech to the Conference, he outlined success stories in the fight against HIV and AIDS in South Africa, such as integrating HIV and tuberculosis services and committing an additional US$400 million to expand anti-retroviral therapy. He noted that African civil society organisations have a key role to play in holding all stakeholders accountable. He also called for increased funding, full replenishment of the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis and long-term term partnerships between international funders and recipient countries.
According to this fact sheet, health care services overall in Tanzania benefit the rich more than the poor. In particular, the poorest 20% receive less benefit than they need. Benefits from outpatient and inpatient care in public hospitals, and private facilities are pro-rich, while benefits from faith-based facilities are generally evenly distributed with benefits being shared equally among people of all socio-economic groups, especially for inpatient care. Distance to referral facilities and cost are two factors that limit access to inpatient care for poorer groups, especially in rural areas. Poor quality of care in public facilities leads to a preference for private facilities among those who have the ability to pay. The greater availability of faith-based providers in rural areas and their flexible pricing policies leads to a more even share of benefits between rich and poor.
This fact sheet notes that donor funding and general tax revenue are the main sources of health financing in Tanzania. Funding for health care may be progressive or regressive. Tax revenue in Tanzania is relatively progressive. Income tax is the most progressive, but Value Added Tax (VAT), import and excise tax are also marginally progressive. VAT contributes the most to tax revenue. About 10% of tax revenue goes to health care. Regressive payments include out-of-pocket payments, or direct payments to health care providers, represent a significant share of total health care financing and over half of household contributions to health care. Health insurance contributions are still a relatively small share of total health financing due to the limited coverage of insurance (less than 10% of the population). Contributions to the National Health Insurance Fund are progressive as members are concentrated among higher income groups and contributions are proportional to income. The Community Health Fund is regressive as membership is concentrated among lower income groups and the contribution is a flat rate irrespective of income.
11. Equity and HIV/AIDS
This study’s aim was to assess the evidence for a differential effect of positive prevention interventions among individuals infected and not infected with human immunodeficiency virus (HIV) in developing countries, and to assess the effectiveness of interventions targeted specifically at people living with HIV. The researchers conducted a systematic review and meta-analysis of papers on positive prevention behavioural interventions in developing countries published between January 1990 and December 2006. Nineteen studies met the inclusion criteria. The meta-analysis showed that behavioural interventions had a stronger impact on condom use among HIV-positive (HIV+) individuals than among HIV-negative individuals. Interventions specifically targeting HIV+ individuals also showed a positive effect on condom use. However, interventions included in this review were limited both in scope (most were HIV counselling and testing interventions) and in target populations (most were conducted among heterosexual adults or HIV-serodiscordant couples). Current evidence suggests that interventions targeting people living with HIV in developing countries increase condom use, especially among HIV-serodiscordant couples. Comprehensive positive prevention interventions targeting diverse populations and covering a range of intervention modalities are needed to keep HIV+ individuals physically and mentally healthy, prevent transmission of HIV infection and increase the agency and involvement of people living with HIV.
This Environmental Scan covers three broad research areas: clinical research (prevention of mother to child transmission, or PMTCT, and paediatric treatment), clinical research (women and antiretroviral therapy) and operations research (delivering treatment to women). A parallel consultative process, led by UNICEF, addressed operations research/implementation science questions related to PMTCT, including paediatric care, treatment and support. The report found that there has been substantial progress in improving access to anti-retroviral therapy (ART) in low- and middle-income countries in recent years. The need to better understand the potential role of sex differences in HIV disease progression and treatment response is being increasingly recognised by the research community as an understudied area of inquiry. To date, there is no evidence to support differential treatment strategies for men and women. Clinical trials addressing this question are still too few and too small to provide definitive answers. Women face greater threats to personal safety and financial security than men do and as a result, they experience HIV stigma more forcefully. Some studies have identified failure to successfully integrate HIV treatment programmes with other women’s health services as a particular barrier to accessing ART.
Recent data from antenatal clinic surveillance and general population surveys suggest substantial declines in human immunodeficiency virus (HIV) prevalence in Zimbabwe. The authors assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence. Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985-2007 was conducted. HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000. Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15-24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007. These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis level.
You Can Count on Me is a Pepfar-funded programme in South Africa that aims to change men’s behaviour and to educate them about the prevention of HIV transmission from mother to child (PMTCT). The programme trains men to understand what HIV is, how it’s transmitted, how to prevent it in the general population, to protect babies from getting it and to help their partners along the journey of pregnancy. Model students in these workshops are then selected to train other men across the nine provinces. Approximately 10,000 men have been reached through face-to-face community meetings. The programme provides support for men to become involved in the pregnancy of their partners, as it regards men’s sexual behaviour as one of the main drivers of the HIV and AIDS epidemic in southern Africa.
This study aimed to describe the scale-up of a decentralised HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population. A total of 5,719 adults who initiated ART between October 2004 and September 2008 were included and stratified into six-month groups. There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84%, while 10.9% died and 3.7% were lost to follow-up. Mortality was highest in the first three months after ART initiation, with 30.1 deaths per 100 person–years. At twelve months, 23% had a detectable viral load. The study concluded that outcomes were not affected by rapid expansion of this decentralised HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.
IRIN/PlusNews has put together a list of seven ways in which HIV service providers could cut costs and improve their efficiency. Task-shifting has already seen positive results in Ethiopia, Malawi and Mozambique, but insufficiently trained medical staff can be harmful to national antiretroviral (ARV) programmes. Community support also plays a significant role in HIV education and care in many poor countries where relatives and neighbours often help to monitor patients and raise awareness about HIV. The cost of combination ARV therapy has come down significantly from about US$10,000 per person per year in 2000 to about $88 a year. However, second- and third-line anti-retrovirals are still prohibitively expensive for low-income countries. Simpler drug delivery systems will help reduce the amount of money spent on non-drug-related costs, especially as between two-thirds and 80% of money spent on HIV is related to service delivery, patient monitoring and laboratory costs. Using technology, such as SMS-based check-ups, may help save patients the costs of travelling to a clinic every month. Country ownership and health system integration are also crucial for success in fighting HIV in developing countries.
12. Governance and participation in health
Sex Workers Outreach Programme (SWOP) is a project run by the University of Nairobi and Canada's University of Manitoba, which trains sex workers to be peer educators for other sex workers and inform them about sexual health and rights. Through the SWOP programme, educators have enabled more than 3,000 of their Nairobi peers to get tested for HIV and other sexually transmitted infections. They have also taught them skills to negotiate condom use with their clients. Since 2008, the SWOP clinic in Nairobi, which is open 24 hours a day, has provided HIV prevention services to more than 7,000 commercial sex workers, 150 of them male. The HIV prevalence among those tested is 33 percent. The prevention package includes condom demonstration and provision, sexually transmitted infection screening and treatment, family planning and post-exposure prophylaxis.
In this statement, the Public Service Accountability Monitor (PSAM)points out that, by the end of the 2009/10 financial year, the Eastern Cape Department of Health had accrued debt of approximately US$ 245 million. PSAM argues that this overspending was largely as a result of underfunded and unbudgeted mandates relating to human resources, as well as higher than expected costs for pharmaceuticals and laboratory services. It notes that the debt has already resulted in stock-outs of basic medicines, but cautions that the issue is not only one of inadequate funding. Over the last ten years the Eastern Cape Department of Health has consistently received poor audit opinions from the Auditor General. These opinions have revealed that chronic financial mismanagement continues to result in the misuse and misappropriation of public funds. This means that even those resources which are available have not been used appropriately. The PSAM calls on the National Department of Health and the National Treasury to make public details of the Eastern Cape Department of Health’s financial status, and to publicly guarantee that no patients in the province will be refused basic treatments because of a shortage of medicines and medical supplies.
This report synthesises the results of the first evaluation of the early implementation of the Paris Declaration, from March 2005 to late 2007. It comprises extensive assessments in eight countries, together with ‘lighter’ studies on eleven development partner agencies, focusing at the headquarters level. It found that the principle of ownership has gained much greater prominence since 2005, although the evaluations show that the practical meaning and boundaries of country ownership and leadership often remain difficult to define. The evaluations do not suggest any backsliding on harmonisation, but neither do they indicate any overall trend toward progress. All the evaluations convey a sense that the joint processes for tracking progress and resolving problems fall short in terms of mutual accountability. Development agency and partner country evaluations reveal that, despite clear commitments to alignment, implementation of the various components of alignment set out in the Paris Declaration has been highly uneven.
This compilation includes peer reviews on government accountability from Kenya and South Africa. The Kenyan review concluded that, while the reviewing process yielded a lot of data it was not as empowering and inclusive as it should have been and did not foster significant dialogue between Kenya’s government and its people. This was in part due to the way the self-assessment was carried out and also because it was focused on the efficiency and effectiveness of government, and not democratic decision-making and human rights. The South African review concluded that, while the reviewing process had many strengths, it had too great a level of government control, an overly ambitious timetable, and lacked meaningful civil society input.
13. Monitoring equity and research policy
The Access to Medicine Index independently assesses how individual pharmaceutical companies perform in promoting universal access to essential medicines, and may be used as a tool in improving performance. The 2010 ranking reveals important progress, if only because companies have shown far greater willingness to open up. The Index unveils improvements research and development, and pricing, but also shows that the industry as a whole still has a long way to go, according to Wim Leereveld, the Index's founder. The Access to Medicine Index ranks 20 of the world's largest pharmaceutical companies on their efforts to make sure that medicines are made for, and reach, people in developing countries. The Index encourages drug companies to compete and offers investors and others a way to compare their social responsibility records.
This article discuss the work of the Global Forum, a global body of health decision-makers that focuses on questions of equity, advocating for more research to address the health problems of those most in need – essentially the poor and marginalised –and providing evidence to support greater investments in neglected areas. Since the Forum’s previous conference in 2009, the article notes that a paradigm shift has taken place from ‘health research’ to ‘research for health’. This new approach promotes greater understanding among all stakeholders of the impact on health of policies, programmes, processes, actions or events originating from other sectors. It also is intended to assist in developing interventions that will help prevent or mitigate any adverse impact on health and contribute to the achievement of health equity. While the number of resources, actors and efforts to address the health problems of the poor have grown signifi cantly in recent years, the range of health challenges faced by low- and middle-income countries has expanded considerably, demanding a more extensive research portfolio. Challenges include countries that are not on track to reaching the Millennium Development Goals, rising rates of chronic non-communicable diseases in low- and middle-income countries, urbanisation, demographic shifts, climate change, food security, the threat of pandemics, and the global financial crisis.
In preparation for the Science Online London 2010 Conference, which will be held from 3-4 September 2010 in London, United Kingdom, this video provides information on how the web is changing the way researchers conduct, communicate, share, and evaluate their work. The video is a panel discussion with Jimmy Watson, Stephen Friend and John Wilbanks, which is moderated by Tim O’Reilly. Some of the topics they talk about will also be discussed at Science Online London, such as new platforms for collaboration, networking and sharing research.
This paper examines the recommendations of the World Health Organization's Commission on the Social Determinants of Health regarding the need for improved research on determinants of health inequity and discusses the following barriers to implementation of those recommendations: the power of the biomedical imagination in health and medical research; emphasis on vertical health programming; ideological biases outweighing evidence in policy decisions; and academic reward systems, including the inherent conservatism of peer review. The paper concludes with suggestions for changing research funding and assessment systems to overcome these barriers, for example by setting the agenda for social determinants research in consultation with researchers, policy actors and, wherever possible, relevant affected communities.
In 1990, a report from the Commission on Health Research for Development pointed to the gross imbalance between the magnitude of diseases affecting the world’s poor majority and the meager funds spent on research to fight them. Responding to growing momentum, in 1997 the Global Forum for Health Research was founded to address this skewed research agenda. In the editorial, the editors of MEDICC Review reviews progress made since 1997 in terms of the Global Forum’s agenda. They refer to the contributions of Cuba and other developing nations to the evidence suggesting that only through simultaneous development of technologies and public health strategies can disease be effectively tackled and prevented. In turn, this requires the political will to consciously develop health research capacities and a health research system with lines of investigation well-matched to disease burden and national public health priorities. Since 1997, when lack of financing for biomedical research on diseases of the poor was the main health equity concern, over time the health equity lens has revealed other, more complex dimensions of the factors influencing research priorities and the eventual application of their findings. The editors argue that this requires an approach that moves the debate from issues of biomedical and technological research to introduce tough questions about implementation, bringing in discussion of health systems, social innovation, and ways for equity-guided research to become more influential in policy decisions.
The South African Child Gauge monitors the realisation of children’s rights and is published annually. Key features include: legislative developments affecting children; child-centred data tracking children’s access to social assistance, education, housing, health and other services; and a series of essays to inform, focus and sometimes direct national dialogue and debate. While South Africa is making progress towards meeting the Millennium Development Goal (MDG) target on sustainable access to safe drinking water, this has not trickled down to children – only 64% of children have access to safe drinking water on site. Progress has been slow for access to basic sanitation, education and gender equality. On the MDG targets for reducing child hunger, HIV, tuberculosis and child mortality, South Africa is not making any progress, according to the Gauge. South Africa has also failed to submit its reports on progress in relation to implementing the UN Convention of the Rights of the Child – the key accountability mechanism aimed at monitoring South Africa’s progress in promoting the maximum survival and development of children. The report further notes that South Africa is one of only twelve countries worldwide that has failed to reduce child mortality since 1990.
14. Useful Resources
The Initiative to Strengthen Health Research Capacity in Africa (ISHReCA) is an African-led initiative aimed at building a strong foundation for health research in Africa. ISHReCA was born out of consultative meetings between African researchers and research funders and aims to serve as a forum for African scientist to collate ideas about capacity building and to speak to funders collectively. It emphasises a comprehensive approach to capacity building that leads to sustained increase recruitment, training and retention of African scientists. This website serves three key purposes. First, it provides a forum for African health researchers to discuss capacity building needs and approaches. These discussions will be used to negotiate with funders' innovative initiatives for capacity building and to give feedback to funders on current capacity building initiatives. Second, it is a resource tool for providing up-to-date information on capacity building to African health researchers. Third, it is a tool for collecting information for an African health researchers’ database, which will hopefully be used to facilitate the development of collaboration networks.
The World Health Organization (WHO) has launched the Global Network of Age-friendly Cities as part of a broader response to the rapid ageing of populations. WHO notes that populations in almost every corner of the world are growing older. The greatest changes are occurring in less-developed countries. By 2050, it is estimated that 80% of the expected 2 billion people aged 60 years or over will live in low- or middle-income countries. The Network aims to help cities create urban environments that allow older people to remain active and healthy participants in society. While the response to population ageing has often focussed on the implications for governments of increasing demand for pensions and health care, WHO tries to place more emphasis on the positive contributions older people make to society. It underlines the importance for older people of access to public transport, outdoor spaces and buildings, as well as the need for appropriate housing, community support and health services. But it also highlights the need to foster the connections that allow older people to be active participants in society, to overcome ageism and to provide greater opportunities for civic participation and employment. Cities that are interested in joining the Network, should contact Dr John Beard at the email address given.
This new film, Youth Zones, Voices from Emergencies documents the lives of young people affected by conflict and natural disaster in five countries, including Uganda. It show how, in conflicts and natural disasters around the world, young people, at a crucial stage of their development, are faced with profound challenges. Emergencies often steal their adolescence and force them to undertake adult responsibilities. The structures and institutions that should guarantee their secure, peaceful development – schools, family, community and health centres – have often broken down, leaving them with little, if any, support. Access to basic sexual and reproductive health services, including information on sexually transmitted infections and HIV, is often impossible. Yet in the midst of hardship and deprivation, this film show how young people exhibit tremendous resilience. They raise their younger siblings, form youth groups and organisations, put food on the table for their families, conduct peer education activities, contribute to peace movements, galvanise their communities and contribute in numerous other ways to positive change. The film is available in English, Spanish, Arabic, and Luo with English subtitles.
15. Jobs and Announcements
The United Nations Permanent Forum on Indigenous Issues (UNFPII) is the advisory body to the United Nations Economic and Social Council for discussing indigenous issues related to economic and social development, culture, the environment, education, health and human rights. It has a trust fund on indigenous issues relating to the Second International Decade of the World’s Indigenous People. This Fund is now offering funding for non-governmental organisations for 2011. Projects can be proposed in the areas of culture, education, health, human rights, the environment and social and economic development. All projects should primarily be focused upon indigenous peoples and they should directly benefit them. The guidelines suggest that the project proposals should be developed by indigenous people, but in cases where non-indigenous organisations are submitting proposals, they should develop them with full participation, consultation and free, prior and informed consent of indigenous peoples, groups or committees receiving the benefits of the project.
The African Journal of Traditional, Complementary and Alternative Medicines (AJTCAM) will publish a special issue in 2011 entitled 'Reviews of modern tools in traditional medicines'. Experts in different fields may write on any of the following topics: specific case management studies in traditional medicines (malaria, diabetes, snake bites, cancer, infertility etc); traditional medical practice (general practice, psychiatry, traditional birth attendants etc) in different systems of traditional medicines; African traditional medicines; Chinese traditional medicines; Indian systems of medicines; complementary and alternative medicines; other systems of traditional medicines; evaluation of herbal products as potential medicines/drugs; clinical trials of herbal medicines; traditional medicines and HIV and AIDS – current research; chemical profiling of herbal medicines; cultivation of medicinal plants; safety evaluation of herbal products/medicines; standardisation of herbal medicines; packaging of herbal products; economics of herbal medicines; and biotechnology and traditional medicines.
The Operational Hospital Management Conference is aimed at improving performance and the quality of services at public hospitals. It offers a learning and sharing opportunity for all management levels within South Africa’s public hospitals and health care sector. It will assist healthcare management with practical solutions to meet the ever-increasing demands being placed on services, clinical and hospital resources. Determined by continuous research, the programme explores the key aspects and issues that healthcare management is faced with today. The programme provides a robust agenda of keynote and case study presentations and panel discussions. The Conference will focus on key industry issues presented in a combination of keynote presentations and panel discussions.
Community Toolbox, a global resource of free information on essential skills for building healthy communities is inviting applications for its Out of the Box Prize 2010. The Prize has been established to honour innovative approaches to promoting community health and development worldwide. Non-governmental organisations and other groups working in the areas of community health, education, urban or rural development, poverty, the environment, social justice or other related issues of importance to communities in any part of the world can apply for the Prize. The Prize is looking for innovative and promising approaches implemented in these areas. Innovative approaches may include ‘a unique or effective way of planning or implementing a change effort, creative use of existing community resources, original ways of generating participation and collaboration, implementing a best practice within a new context or group, or other innovative and promising approaches. The grand prize consists of a US$5,000 cash award and a customised WorkStation for your organisation to the value of $2,100.
The Third HIV and AIDS in the Workplace Research Conference, taking place in Johannesburg from 9-11 November, will reflect on the intersection of workplace HIV responses, academic research and surveillance, with a particular focus on strengthening prevention interventions in the fight against HIV and AIDS in Africa, linking prevention research to workplace practice. Prevention will be a key priority focus area, as success in preventing new infections is now widely accepted as the key to ultimately curbing the impact of HIV and AIDS on South Africa and its people. The Conference offers an opportunity for business to step back and reflect on HIV and AIDS programmes, using the lens of research and practice to consider what has worked and what lessons can be extracted. The Conference is also a platform to translate research into meaningful and sustainable responses that can be applied in the workplace.
The Women's Global Network for Reproductive Rights is calling on all people's rights, health rights, reproductive justice, and economic and social justice advocates to join them in writing to country representatives at the United Nations Headquarters to raise concerns about the upcoming High Level Summit on the Millennium Development Goals. With the ongoing lobbying by advocates working on sexual and reproductive rights with access to the halls of the UN, and community level mobilisations for social change, there is pressure mounting on state representatives to the summit to incorporate the Network’s suggestions into their position statements and negotiation points. The network is expressing concerns that grassroots people speaking up for basic rights are being systematically shut out of UN processes. The letter asks for the state delegation to the MDG Summit to include members of civil society groups, particularly those representing the concerns of marginalised communities, and calls for modification of the high level advisory panel in order to respect principles of gender parity, and to include women as advisors for MDG 5, and increase the number of representatives from the Global South, with an emphasis on those from civil society organisations. The network calls on civil society to add voice to the call by forwarding the letter provided on the website to the country’s ambassador.
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