Archbishop Ndungane, president of the African Monitor, commented after the United Nations (UN) Summit on the Millennium Development Goals (MDGs) in September 2010 on the gap between the concrete commitments made and clear plans for how they will be implemented. A bottom line for this is money.
Even before the Summit the UN Secretary-General in his March 2010 report had observed that unpredictable and insufficient international financing was blocking progress on the MDGs. Health needs alone at global level have been estimated to cost up to US$76 billion annually by 2015. The UN Non government Liaison Service reported this year that the financial deficit on resources to meet the MDGs could reach between US$324 - $336 million in 2012-2017, including a shortfall of about US$168-$180 million in official development assistance (ODA).
Which country and community you live in and what income group you are borne into affects your chances for health and for accessing the resources for health. This leads to an unacceptable global inequity. African countries, with the highest rates of mortality and ill health globally, are also most disadvantaged by widening gaps between rich and poor countries, by diminishing commodity prices and by outflows of key resources, such as skilled personnel. The financial crisis triggered by the US and European banking crisis has exacerbated this shortfall, creating a budget revenue hole of $65 billion in low and middle income countries. According to Development Finance International, aid has filled only one-third of this hole in revenue.
So African countries and people have a significant interest in debates on how global commitments will be financed.
ODA has been one way of releasing immediate resources for global priorities. Almost all low income countries could absorb much more aid without negative economic consequences, whereas they have much less space to borrow or to raise taxes. Attention has thus grown on how far the international community has fulfilled long-standing aid promises and improved aid effectiveness. A 2009 Mutual Review by the UN Economic Commission for Africa and OECD noted the welcome increase in commitments made at G8 and other summits. These include commitments to 0.7% of Gross national income to ODA in 2002; to an increase of $25 billion annually in aid to Africa in 2005; to an additional US$60bn to fight infectious diseases and strengthen health systems in 2006; to US$22bn to raise productivity of smallholder farming and $30bn for climate change mitigation in 2009; and to support for Universal access to HIV prevention and treatment. At the 2010 UN Summit an additional $40bn was pledged for the Global Strategy on Women’s and Children’s Health. The UN ECA and OECD report also noted that while progress was being made to the target of 0.7% ODA, it was still at 0.43% of combined GNI, with improved ODA largely related to debt relief flows in 2005/6. OECD reports indicate that less than half the $25bn promised in 2005 has been delivered and shortfalls exist on other pledges made.
The UNECA / OECD report points out that the most significant source of development finance in Africa is domestic revenue, making up 75% of its development financing. It indicates therefore that for African countries to raise the domestic revenue to deliver on development commitments, multilateral trade negotiations need to yield more substantial and faster improvements in market access and returns, and progress needs to be made in investment in areas such as energy access, technology transfer, infrastructure and climate adaptation. A further response to the resource gap is to reverse the net transfer of financial resources out of Africa. For example, Global Financial Integrity (2010) estimated that between 1970 and 2008 the outflows from Africa due to trade mispricing alone were as great as ODA inflows.
Unpredictable, inadequate aid flows and the slow progress in improved returns from the global economy have raised doubt whether business as usual will be enough to raise the funds needed to meet global goals. President Nicolas Sarkozy of France and Prime Minister Jose Luis Rodriguez Zapatero of Spain both raised in their addresses to the 2010 UN Summit the need for new approaches to financing global commitments, especially through a new tax on international currency transactions. President Sarkozy stated in his address to the Summit: “We can decide here to implement innovative financing, the taxation of financial transactions. Why wait? Finance has been globalized. Why shouldn’t we demand that finance contribute to stabilizing the world through a minuscule tax on each financial transaction?”
When a similar call was made by Nobel prize-winning U.S. economist James Tobin in 1972, and by UN panel chair Ernest Zedillo in 2000, it met strong opposition. However since then, a range of innovative development financing options based on levies have been established: UNITAID, an international facility for the purchase of drugs to combat HIV/AIDS, malaria and tuberculosis launched by Brazil, Chile, France, Norway and the United Kingdom in 2007, has raised US$1.5 billion in three years, 65% of which came from a micro-tax scheme on air tickets. In 2009, as a result of a Task force in Innovative Financing, a number of new facilities were introduced, including a US$1 billion expansion of the International Finance Facility for Immunisation (IFFIm); a new mechanism for making voluntary contributions when buying airline tickets, expected to raise up to US$3.2 billion by 2015; US$360 million worth of debt conversions in the Global Fund's Debt2Health Initiative; a VAT tax credit pilot scheme called De-Tax, expected to raise up to US$220 million a year in VAT resources; and a commitment to explore a second Advance Market Commitment for life-saving vaccines. In March 2010, the UN with country partners and the American Society of Travel Agents, launched ‘MASSIVEGOOD’ an offshoot of UNITAID, that provides travellers in the United States the option of making a voluntary contribution of up to $50 when purchasing tickets, booking a hotel room or renting a car online. This is expected to bring in up to US$1 billion in four years to support treatment for children with HIV, for tuberculosis and insecticide treated bed nets. Such funds bring significant new resources, and raise challenges for how they support the financing of systems and improve the production of domestic revenue.
These financial innovations, the impending deadlines for action on global commitments and a funding gap that is not being met through current approaches has brought new demand for the introduction of an international multi-currency transaction tax. Sixty countries in the Leading Group on Innovative Financing for Development (LGIFD) support it, and the potential financial contribution is significant. Financial flows have increased sevenfold since 2000, with a volume of transactions worldwide of about $3.6 trillion daily for foreign exchange, of $210 billion daily for bonds and $800 billion for stocks. At a session on 21 September at the Summit, Bernard Kouchner, foreign minister of France, held up a five-cent coin saying: ‘This will be the tax on a 1000-dollar transaction. It is impossible not to accept that. Especially when you have in mind that the result of such a tax would be 40 billion dollars a year..'.
An approaching deadline to account for global goals and an economic crisis may be a challenging situation for global social commitments, but it may also be an opportunity to implement the possible - to advance sustainable and equitable ways of financing them.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Further information on this issue and the UN 2010 Summit can also be found in the Health Diplomacy Monitor www.ghd-net.org.
1. Editorial
2. Latest Equinet Updates
Members of the EQUINET steering committee will be presenting work at the First Global Symposium on Health Systems Research, November 16-19 2010. EQUINET (through TARSC), with CGESS Guatemala and SATHI India is holding a session reviewing experiences with participatory action research (PAR) on health systems in Latin America, Africa, Asia and North America. In a roundtable, the case studies from the four regions will be presented and discussed to examine and reflect on the shared learning on health systems derived from PAR, the methods used and their application in health systems research and policy change. EQUINET will also have a marketplace stand at the Symposium and welcome visitors to the stand to see publications and hear more about the work of the network.
An Equity Watch is a means of monitoring progress on health equity by gathering, organizing, analysing, reporting and reviewing evidence on equity in health. Equity Watch work is being implemented in countries in East and Southern Africa in line with national and regional policy commitments. This report presents the Equity Watch in Mozambique. It explores the dimensions of inequality that need to be addressed for the improvements in economic performance to translate into the eradication of poverty and sustained and widest improvements in human development. It focuses on the social determinants of health and the features of the health system that have been shown to make a difference in reducing social inequalities, including in health, and asks the question: what progress are we making? The report examines the positive results achieved so far in health equity in Mozambique, the current levels and the prevailing constraints, in the context of the overall national response to equity. It presents recommendations based on an analysis of information available.
This document is published in Portuguese. ‘Observatório de Equidade’ é um meio de monitoria do progresso da equidade na saúde através da recolha, organização, análise de dados e elaboração de relatórios sobre a equidade na saúde. Este relatório explora as dimensões da inequidade que precisam de ser resolvidas para garantir melhorias no desempenho económico para conduzir à erradicação da pobreza e ao alcance de melhorias sustentáveis no desenvolvimento humano. Dá enfoque às determinantes sociais da saúde e às características do sistema de saúde que provaram fazer a diferença na redução das inequidades sociais, incluindo na saúde, e faz a seguinte pergunta: Que progresso estamos a fazer? O relatório analiza os resultados positivos alcançados até agora, os níveis actuais e os constrangimentos prevalecentes, no contexto da resposta nacional em relação à inequidade. Apresenta recomendações baseadas numa análise da informação disponível.
3. Equity in Health
In this presentation, the author argues that investing in family planning is the single most strategic, low cost, high impact and quick win strategy to achieving economic, social and political transformation. The author reviews several instruments for investing in family planning in Uganga, such as the National Development Plan (2010–2014), which has clear targets for family planning and focuses on investing in ‘demographic window’ (when the proportion of population of working age group is particularly prominent in a country), and the Medium Term Expenditure Framework, to which the government should link National Development Programme targets and in which the appropriate sectors should be prioritised to bring about investment. The Annual Health Sector budget allocation is reported to have been relatively stagnant for FP over the years and must be increased. In addition, government needs to monitor whether or not the allocated funds are actually spent on FP.
According to this presentation, over the long run, the importance of within-country inequalities has decreased and the importance of between-country inequalities has increased, while the global division between countries is actually greater than that between social classes. The presentation refers to two factors affecting an individual’s levels of wealth: citizenship premium and parental premium. According to citizenship premium, if the mean income of country where you live increases by 10%, your income goes up by about 10% too (called ‘unitary elasticity’). The parental premium states that, if your parents are one income class higher, your income increases by about 10.5% on average. In terms of global inequality of opportunity, country of citizenship explains 60% of variability in global income, while citizenship and parental income class combined explain more than 80%. In conclusion, if most of one’s income is determined by citizenship, then there is little equality of opportunity globally and citizenship may be regarded as a rent (unrelated to individual effort or whether or not the individual deserves it or not).
Using social tables, the author estimates global inequality (inequality among world citizens) from the early 19th century until the 21st century. The analysis shows that the level and composition of global inequality have changed over the past two centuries. The level has increased, reaching a high plateau around the 1950s, and the main determinants of global inequality have become differences in mean country incomes rather than inequalities within nations. The inequality extraction ratio (the percentage of total inequality that was extracted by global elites) has remained surprisingly stable, at around 70% of the maximum global Gini co-efficient, during the past 100 years.
In this interview with Archbishop Ndungane, president and founder of African Monitor, he assesses the outcomes of the United Nations Summit on the Millennium Development Goals (MDGs). On the positive side, he welcomes the fact that the outcome document is comprehensive, touching on almost everything that needs to be addressed if MDGs are to be met, with commitments that are measurable and therefore can be tracked. The specific amounts committed by specific stakeholders is also a step in the right direction, according to him. Clause 23 (c) makes specific reference to the promotion of national food security strategies that strengthen support for smallholder farmers and contribute to poverty eradication. This is key to poverty eradication, particularly where without exception, 70% of the population in rural areas depend on agriculture for their livelihood. According to the Archbishop also commendable are the specific focus on maternal and child health, the references to lessons learnt, particularly the issue of supporting community-led strategies; and the commitment to strengthening the statistical capacity to produce reliable and disaggregated data. He also pointed out a number of concerns about the Summit, in the lack of any guarantee that the concrete commitments will go beyond mere ‘lip service’; the lack of clear mechanisms for enforcement; and the repetition of principles that have proved difficult to operationalise without new angles on how they are going to be implemented in reality. Finally, although there are specific commitments, world leaders need to find mechanisms to reinvigorate and stimulate the local energies, initiatives and actions which are people-driven. They should look beyond 2015 and work for sustainable solutions.
The General Assembly adopted this outcome document at the sixty-fifth session of the General Assembly on the Millennium Development Goals, held in September 2010. It reaffirms the United Nations’ commitment to achieving the Millennium Development Goals (MDGs) and calls on all stakeholders, including civil society, to enhance their role in national development efforts as well as their contribution to achieving the MDGs. The resolution indicates that there has been a mix of successes and failures in achieving the MDGs, with uneven progress and many remaining challenges and opportunities. It recognises that developing countries have made significant efforts towards achieving the MDGs and have had major successes in realising some of the targets of the MDGs, such as combating extreme poverty, improving school enrolment and child health, reducing child deaths, expanding access to clean water, improving prevention of mother-to-child transmission of HIV, expanding access to HIV prevention, treatment and care, and controlling malaria, tuberculosis and neglected tropical diseases. However, much more needs to be done to reach the MDGs, as progress has been uneven among regions and between and within countries. Hunger and malnutrition rose again from 2007 through 2009, partially reversing prior gains. There has been slow progress in reaching full and productive employment and decent work for all, advancing gender equality and the empowerment of women, achieving environmental sustainability and providing basic sanitation. New HIV infections still outpace the number of people starting treatment. In particular, the Assembly criticised the slow progress that has been made in improving maternal and reproductive health.
In this presentation, the author argues that meeting unmet need for family planning services in Kenya could help the country ‘significantly’ generate resources and save costs to achieve universal primary education, reduce child mortality, improve maternal health, ensure environmental sustainability, and help combat HIV and AIDS, malaria and other diseases. It draws on research to show that greater access to FP information and services in Kenya could contribute directly to the country’s attainment of Millennium Development Goals 4 and 5 (to reduce child mortality and improve maternal health).
In this interview, Patrick Bond discusses the failings of South Africa’s drive towards meeting the Millennium Development Goals (MDGs) and the extent to which the country’s government continues to operate against the interests of its poor majority. According to Bond, South African urban poverty increased from 1993–2008 and rural poverty declined only because more poor people moved to the cities and the welfare grant system was extended. The South African economy is structured so as to generate poverty-expanding 'growth' of GDP (gross domestic product) so, as accumulation of capital occurs in much of South Africa, the rich grow richer and the poor grow poorer. That structuring happens in ways concordant with the speculative, financial-driven and profit-exporting character of capitalism, interrupted only briefly by the great crash of 2008. Most of Pretoria's economic policies amplify this trend because of their neoliberal (pro-business) character, he argues. South Africa cannot be confident of making progress on any MDGs, given the coming austerity associated with a failing global and national 'Keynesian' (deficit-based) macroeconomic strategy that was largely based on white-elephant infrastructure investments. Such spending – especially for now-empty World Cup soccer stadiums costing R22 billion – plus declining state revenues (as profits and taxes fell) moved the national budget from a surplus of around 1% of GDP to more than 7%. What is therefore likely, within five years, is a similar turn by the Treasury to the kind of austerity now being felt in many other countries which ratcheted up their deficits to deal with the crisis. As shown in the recent civil servants' strike, the state is willing to put services mainly utilised by the poor majority – public schools, clinics and hospitals – at risk to maintain some semblance of fiscal discipline, which does not bode well for future state expenditure on MDG-related needs.
Compared with some countries in sub-Saharan Africa, infant mortality rate is relatively high in Tanzania, at 68 per 1000 live births (2004-2005). Studies of factors affecting infant mortality have rarely considered the role of birth order. This study aims to contribute to fill this research gap by determining the risk factors associated with infant mortality in Ifakara in rural Tanzania from January 2005 to December 2007. Data for 8,916 live births born from 1 January 2005 to 31 December 2007 was extracted for analysis. The study found that first and higher birth orders had highest levels of infant death, while mothers younger than 20 years old had the highest infant mortality. From 2005–2007, malaria remained the leading cause of infant death. Giving birth at the hospital was perceived by women to be associated with severe delivery complications. The study recommends that Tanzania’s health systems urgently need strengthening, and efforts should be made to communicate the benefits of health facility deliveries more effectively. Voluntary and community health workers also need to be trained adequately to recognise factors that put infants at risk.
This review uses Millennium Development Goal 5 (reducing the maternal mortality ratio by three quarters and achieving universal access to reproductive health by 2015) to assess global progress in improving maternal health. The main study limitation was a lack of reliable and accurate data on maternal mortality, particularly in developing-country settings where maternal mortality is high. An estimated 358,000 maternal deaths occurred worldwide in 2008, a 34% decline from the levels of 1990. Despite this decline, developing countries continued to account for 99% (355,000) of the deaths, with sub-Saharan Africa and South Asia accounting for 87% (313,000). Overall, it was estimated that there were 42,000 deaths due to AIDS among pregnant women in 2008. About half of those were assumed to be maternal. The contribution of AIDS was highest in sub-Saharan Africa where 9% of all maternal deaths were due to AIDS. These estimates provide an up-to-date indication of the extent of the maternal mortality problem globally. They reflect the efforts by countries, which have increasingly been engaged in studies to measure maternal mortality and strengthen systems to obtain better information about maternal deaths. The modest and encouraging progress in reducing maternal mortality, the review argues, is likely due to increased attention to developing and implementing policies and strategies targeting increased access to effective interventions. Such efforts need to be expanded and intensified, to accelerate progress towards reducing the still very wide disparities between developing and developed worlds.
4. Values, Policies and Rights
On the basis of an analysis of popular and medical texts which address a debate over the ethics of clinical drug trials designed mainly for sub-Saharan Africa, this paper argues that the international public health discourse about infant HIV infection in Africa reflects and legitimates a anti-reproductive justice ideology. The author argues that the texts most commonly advance the view that biomedicine, funded from outside Africa with medicines from outside the continent, is the magic bullet that addresses mother and child HIV, avoiding issues of domestic advance in reproductive and sexual rights. This dominant focus is argued to give greater control over HIV to biomedical perspectives and to strengthen right-wing movements against advances in reproductive rights.
The goal of this methodology is to assist in the creation of valid, useful and ultimately meaningful human rights impact assessments. This followed the United Nation’s Special Representative on Human Rights and Business Professor John Ruggie's presentation to the Human Rights Council with a framework for delegating human rights and responsibilities between governments and companies. The process of creating and using HRIA is still in its early phases. Their relevance will depend on a continuing improvement of method, capacity and result which can only be accomplished through the sharing of experience and information between companies and assessors. The methodology looks at HRIA assessment sources, goals, and types. It covers basic concepts and looks provides five steps for implementation: gather project contexts and company information; drawing up a preliminary list of impacted rights; drawing up a preliminary list of impacted right holders; special topics; and inquiry guided by topic catalogue. The methodology offers recommendations for policies, procedures, structures and action. It also provides an appendix of other tools and selected best practices.
Data presented at the United Nations Summit in September in New York has revealed that many countries are unlikely to achieve all the health targets of the Millennium Development Goals (MDGs) by 2015. The simultaneous and interrelated challenges of poverty, health, food security, energy, the global economic crisis and climate change should be viewed by the global community as a unique opportunity to develop innovative approaches to achieve sustainable growth without compromising health equity. One such innovative approach is the concept of working across many sectors to improve governance for health and well-being. The 2010 Adelaide Statement on Health draws on the increasing body of knowledge on “joined-up” government to propose a new way for governments to engage multiple sectors in the joint goal of improving health and well-being. The article calls for an accountability mechanism between governments and their citizens, to ensure that global commitments on health are honoured. The shortfalls in progress towards the MDGs have occurred not because they are unreachable, it argues, but rather due to unmet commitments, inadequate resources, lack of focus and insufficient interest in sustainable development.
For the empowerment of women to make a real difference in the promotion of peace, the discussion needs to shift from one of competing forces to one of cooperation and collaboration, according to this article. Feminist scholars argue that both men and women possess characteristics that are considered, for lack of more refined language, masculine as well as feminine. The difference lies in the way we are socialised. We grow up being taught to behave in a particular way due to what society perceives gender differences to mean and to require. Social norms compel us to reinforce these perceptions and expectations, and then to undermine them when we use those very perceptions and expectations to blame one gender for being collaborative rather than competitive, accommodating rather than uncompromising, submissive rather than aggressive, gentle rather than violent. This article argues that it is in peace education and peace studies that a more meaningful perspective on gender equality has been developed. Such a perspective might enable leaders to promote uMunthu (belief that all humans are connected and therefore deserve respect), peace and social justice at the local and global level, making them much more relevant to the majority of people around the world.
The World Health Organization is establishing the Joint Learning Initiative (JLI) on National and Global Responsibilities for Health to articulate an overarching, coherent framework for sharing the responsibility for health that goes further than the United Nations Millennium Development Goals. The Initiative forges an international consensus around solutions to four critical challenges: defining essential health services and goods; clarifying governments’ obligations to their own country’s inhabitants; exploring the responsibilities of all governments towards the world’s poor; and proposing a global architecture to improve health as a matter of social justice. The first challenge for the JLI is to determine essential health services and goods that every person has a right to expect. The JLI aims to launch a wide participatory process involving all major stakeholders, including international organizations, governments, industry, philanthropists and civil society, and emphasises a bottom-up approach to decision making.
New sections of the Children’s Act and the Children’s Amendment Act in South Africa came into effect on 1 April 2010. The Children’s Act dealing with the capacity of children to consent to HIV testing and to access contraceptives have been in effect since 1 July 2007 and the new sections now allow children of 12 years of age to consent to medical treatment, and to surgical operations with the assistance of their parent or guardian. The provisions allowing consent to termination of pregnancy by girls of any age in the Choice on Termination of Pregnancy Act are not affected by this Act.
Navi Pillay, the United Nations High Commissioner for Human Rights, has described as ‘a very significant advance’ the outcome document of the UN’s Millennium Development Goals (MDGs) summit, but noted a number of gaps in some aspects of the global plan of action to eradicate poverty and end social-economic inequality. During the summit, she emphasised that States should take a human rights-based approach to the MDGs, which would mean that development and aid policies should explicitly prioritise the needs of the poorest and most excluded people. But she stressed that, with their emphasis on global average targets, the MDGs often neglect large segments of the world’s population, and may unwittingly exacerbate existing inequalities. The principle of participation, for example, is reflected strongly in relation to the empowerment of women, but there is no explicit recognition of participation as a right, and no specific commitments to guarantee freedom of expression and association or other human rights guarantees necessary for active, free and meaningful participation. Issues of accountability, good governance and the rule of law are referred to in a number of contexts, she said, but in relation to MDG 8, which mandates a global partnership for development, there is still a critical accountability defect because it lacks time-bound targets.
5. Health equity in economic and trade policies
Substantive progress eluded the United Nations Convention on Biodiversity (CBD) Interregional Negotiating Group on Access and Benefit Sharing (ABS), which met from 18-21 September in Montreal, Canada. This third attempt at finding consensus on key aspects of the text was unsuccessful and negotiations were postponed to October 2010. At stake is a binding instrument aimed at protecting against extraction of biological resources without proper access to or benefits from products arising from them. Outstanding issues include what genetic resources may be excluded from the text, such as human genetic resources, or human pathogens, and the benefits to indigenous peoples and local communities who are often the most affected by biopiracy.
The United States National Institutes of Health has become the first patent holder to join the newly created Medicines Patent Pool, a project of the drug-purchasing mechanism, UNITAID. Public health organisations, such as Medicins sans Frontiers, hailed the move as key step in the right direction but said there is still much work to do. The pool is intended to be a ‘one-stop shop’ for licensing on generic versions of patented HIV medicines. The hope is that by cutting down on the complexity and cost that often surrounds the licensing process – particularly when one drug can carry several patents from several different places –the pool will reduce the cost and increase the speed at which generic medicines can be made available. It is also hoped that the ease of licensing will help ease also the development of affordable formulations specific to children and to conditions in poorer countries where they are often needed. According to Guy Willis of the International Federation of Pharmaceutical Manufacturers and Authorities (IFPMA), the UNITAID Patent Pool is part of an increasing trend towards open innovation in research and development to create new medicines.
This article argues that Africa today is trailing the rest of the world because, in part, the African leadership has failed to mobilise its people along the lines of a Pan-African agenda that informed the earlier phases of our political development. This is due to its weak ideological base, which, instead of drawing from such a heritage, is wedded to Western ways of knowing and doing things which we have derived from their educational institutions without questioning, including Christian and Muslim religious influences. While these external interventions have added to Africa’s modern culture, the article argues, they have also left a negative impact on African intellectual capacity to think independently unlike, say, the Asian intellectuals and political leaders who have links to their religions and cultures. This is due to the fact that Asia, unlike Africa, was less destabilised by way of religious intrusions, resulting in its intellectual and political leadership remaining more anchored to their religions, languages and cultures.
This paper points to the failure of the ‘post-Washington Consensus’ in the 1990s to reduce poverty, due to macroeconomic policies that promoted fixed investment, neglect of productivity growth and employment creation, a focus on price stabilisation, the absence of accelerated structural change and insufficient capital accumulation. Consequently, the development gap has widened over the past 20 years in South America and Africa. In most developing countries there is a pressing need to increase public sector provision of essential social services, especially those concerned with nutrition, sanitation, health and education. This is important not only for the obvious direct effects in terms of improved material and social conditions, the paper notes, but also for macroeconomic reasons. The public provision of such services tends to be labour intensive, and therefore also has considerable direct effects on employment. Government revenues from the extractive industries could be used not only for public investments in infrastructure, health and education, but also for the provision of fiscal incentives and improved public services under industrial policies aimed at diversification of economic activities. This would reduce countries’ dependence on natural resources. Growth in the modern sector is associated with higher private and public investment in fixed capital as well as greater government spending for the provision of education and health services and social protection.
6. Poverty and health
Poverty reduction is a central feature of the international development agenda and contemporary poverty reduction strategies increasingly focus on ‘targeting the poor’, yet poverty and inequality remain intractable foes. This paper argues that this problem exists because many current approaches to reducing poverty and inequality fail to consider key institutional, policy and political dimensions that may be both causes of poverty and inequality, and obstacles to their reduction. Moreover, when a substantial proportion of a country’s population is poor, it makes little sense to detach poverty from the dynamics of development. For countries that have been successful in increasing the well-being of the majority of their populations over relatively short periods of time, the report shows, progress has occurred principally through state-directed strategies that combine economic development objectives with active social policies and forms of politics that elevate the interests of the poor in public policy. The report is structured around three main issues, which, it argues, are the critical elements of a sustainable and inclusive development strategy: patterns of growth and structural change that generate and sustain jobs that are adequately remunerated and accessible to all, regardless of income or class status, gender, ethnicity or location; comprehensive social policies that are grounded in universal rights and that are supportive of structural change, social cohesion and democratic politics; and protection of civic rights, activism and political arrangements that ensure states are responsive to the needs of citizens and the poor have influence in how policies are made.
This paper argues that poverty and social analysis should inform the monitoring and evaluation frameworks of policies and programmes in order to demonstrate the distributional impact of initiatives. Indicators need to be identified and progress should be monitored in a disaggregated way – that is, not just how much more trade, income or employment was generated as a result of an initiative, but also for whom the initiative generated trade, income or employment. Policymakers should design policies or programmes in a way that caters to differentiated needs. For example, they should ensure that trade-related infrastructure (e.g. roads, telecommunications and electrification) reaches and benefits typically poorer trading groups, such as female traders, informal traders and those in remote rural areas. They should also support complementary policies that help tackle identified binding constraints to trade and which enhance people’s abilities to engage with and benefit from trade (e.g. access to land, access to credit and financial services, access to business education and marketing support). They should support mitigating measures that manage the adverse impacts that may stem from trade policy changes and consider activities that cushion or manage these impacts, such as vocational training to enable laid-off workers to diversify their income streams and shift into sectors with export potential.
This special report found that national burdens of disease, undernutrition, ill health, illiteracy and many protection abuses are concentrated in the most impoverished child populations. It argues that providing these children with essential services through an equity-focused approach to child survival and development has great potential to accelerate progress towards the Millennium Development Goals and other international commitments to children. An equity-focused approach could bring vastly improved returns on investment by averting far more child and maternal deaths and episodes of undernutrition and markedly expanding effective coverage of key primary health and nutrition interventions. Nearly 1.8 billion people have gained access to improved drinking water in the past two decades. HIV prevalence appears to have stabilized in most regions, and deaths from AIDS have fallen since 2004. And despite the global economic crisis, progress is still being made in reducing income poverty.
In response to food price riots in early September, the Mozambican government has laid on a range of price cuts and subsidies to make life easier for the poor, and has promised to do some belt tightening of its own. On 21 September 2010, two weeks after the first riots, it was reported that registered bakers would receive a subsidy for wheat flour and other relief measures included halving water connection fees for low-consumption households, considerably reducing the cost of piped water to the poor, and giving free electricity to low-consumption households consuming 100 kwh or less. Food prices for some basic items were also reduced and customs duties lowered on vegetable imports from South Africa. Analysts argue that a better long-term strategy to fight poverty and the rising cost of living would be for Mozambique to grow its own food, instead of relying on imports from South Africa. An increase in agricultural output would shelter the country’s food supply from volatile international markets.
7. Equitable health services
This report provides highlights of the findings of the phase 1 Researching Equity in Access to Health Care (REACH) project, completed in 2009. REACH aims to document levels of and inequities in access, according to socio-economic status, gender, and urban/rural status, within the public health system for three services: maternal health (focusing on emergency and specialised needs at the time of delivery), tuberculosis (TB) care, and antiretroviral therapy. Detailed case studies were undertaken in various parts of South Africa. During 2008 and 2009, the REACH project undertook exit interviews with approximately 4,000 adult (+18 years) users of TB, HIV and maternal health services, carried out quality of care assessments in fifty health facilities, and analysed secondary data from a variety of sources to establish the socio-economic profile of facility catchment populations. The project found that considerably greater access barriers are experienced by rural compared to urban communities, with respect to distance, time, costs and staff attitudes. Rural women experience large health cost burdens during their pregnancy and at the time of delivery, and coverage by a minimum package of antenatal care is still inadequate. TB services were found to be more accessible than anti-retroviral therapy services in all dimensions of availability, affordability and acceptability. The report also notes there was considerable local variation in nature of services (e.g. home visits) and policies (e.g. birth companions).
Although recent survey data make it possible to examine inequalities in maternal and newborn health care in developing countries, analyses have not tended to take into consideration the special nature of urban poverty. Using improved methods to measure urban poverty in 30 countries, this study found substantial inequalities in maternal and newborn health, and in access to health care. The ‘urban advantage’ is, for some, non-existent. The urban poor do not necessarily have better access to services than the rural poor, despite their proximity to services. There are two main patterns of urban inequality in developing countries: massive exclusion, in which most of the population do not have access to services, and urban marginalisation, in which only the poor are excluded. At a country level, these two types of inequality can be further subdivided on the basis of rural access levels. Inequity is not mandatory. Patterns of health inequality differ with context, and there are examples of countries with relatively small degrees of urban inequity. Women and their babies need to have access to care, especially around the time of birth. Different strategies to achieve universal coverage in urban areas are needed according to urban inequality typology, but the evidence for what works is restricted to a few case studies.
Despite the Zambian Government’s effort to expand services to district level, this study reports that it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages. The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital. The study found that mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases ‘lost to follow-up’. This might be due to the closer involvement of the community and the better support offered by these services to rural clients. These services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.
The South African Mental Health Care Act (the Act) No. 17 of 2002 stipulated that regional and district hospitals be designated to admit, observe and treat mental health care users (MHCUs) for 72 hours before they are transferred to a psychiatric hospital. This study surveyed medical managers in 49 ‘designated’ hospitals in KwaZulu-Natal (KZN) on infrastructure, staffing, administrative requirements and mental health care user case load pertaining to the Act for the month of July 2009. Thirty-six (73.4%) hospitals responded to the survey: 83.3% stated that the Act improved mental health care for MHCUs through the protection of their rights, provision of least restrictive care, and reduction of discrimination; 27.8% had a psychiatric unit and, of the remaining 26 hospitals, 30.6% had general ward beds dedicated for psychiatric admissions; 44.4% had some form of seclusion facility; and 66.7% provided an outpatient psychiatric service. Seventy-six per cent of admissions were involuntary or assisted. Thirteen of the 32 state psychiatrists in KZN were employed at eight of these hospitals. Designated hospitals expressed dissatisfaction with the substantial administrative load required by the Act. The Review Board had not visited 29 (80.6 %) hospitals in the preceding 6 months. Although ‘designated’ hospitals admit and treat assisted and involuntary MHCUs, they do so against a backdrop of inadequate infrastructure and staff, a high administrative load, and a low level of contact with Review Boards.
As a signatory to the UN Convention on the Rights of Persons with Disabilities, South Africa has committed itself to transformation aimed at ending the inequities that characterise mental health service provision and ‘closing the gap’. To measure South Africa’s progress, this study compared budget allocations over a five-year period to six psychiatric and six general hospitals in KwaZulu-Natal (KZN) and contrasted current numbers of psychiatric beds and psychiatric personnel in that province with the numbers required to comply with national norms. It found that the mean increase in budget allocations to public psychiatric hospitals was 3.8% per annum, while that to general hospitals over the same period was 10.2% per annum. The median cumulative budget increase for psychiatric hospitals was significantly lower than that of general hospitals. No psychiatric hospitals received specific funding for tertiary services development. KZN has 25% of the acute psychiatric beds and 25% of the psychiatrists required to comply with national norms, with the most serious shortages experienced in northern KZN. There are 0.38 psychiatrists per 100 000 population in KZN. In conclusion, the author argues that inequitable funding, inadequate facilities and significant shortages of mental health professionals pervade the mental health and psychiatric services in KZN; and that there is little evidence of government abiding by its public commitments to redress the inequities that characterise mental health services.
This presentation investigates the barriers to access that couples face when deciding to use family planning. It identifies a number of key barriers in Africa, including limited method choice, prohibitive financial costs, psychosocial factors relating to the status of women, medical and legal restrictions, provider bias and misinformation. The author of the presentation has two recommendations. Firstly, Governments should prioritise family planning and have line items in their budgets for family planning training and services, and for commodities. Secondly, they should make available the fullest possible range of contraceptive choices, including voluntary sterilisation, through the widest range of distribution channels, backed up by access to safe abortion.
This research asks whether a cervical cancer prevention programme in South Africa that includes an HPV vaccine is more cost-effective than the current strategy of screening alone. It found that, while a combination of vaccination and screening at the current vaccine price is more costly than screening alone, it is a cost-effective strategy for preventing cervical cancer. The main cost driver is the vaccine cost. If the vaccine price is reduced, vaccination followed by screening might be a very affordable policy option. The vaccine has the potential to reduce the incidence of HPV-related diseases, and to reduce the cost of treating cervical cancer. This requires a well-functioning screening programme aimed at secondary prevention of cervical cancer as the HPV vaccine does not eliminate, but rather reduces the risk of cervical cancer. In South Africa, screening coverage is very low (well below 50%) and adherence to treatment of pre-cancerous and cancerous lesions is also less than 100%, thus having another preventative measure could be desirable. Approaches for reducing the cost of introducing the vaccine (which should be publicly funded) include accessing international funding mechanisms, such as the United Nations Children’s Fund (UNICEF), using public-private partnerships and getting commitment from pharmaceutical companies to reduce prices.
Microbicides Development Programme 301 was a phase 3, randomised, double-blind, parallel-group trial, undertaken at thirteen clinics in South Africa, Tanzania, Uganda, and Zambia. The study enrolled 9,385 of the initial 15,818 women who were screened. Mean reported gel use at last sex act was 89%. HIV-1 incidence was much the same between groups at study end, for placebo, for hazard ratio 1.05, and at discontinuation. Incidence of the primary safety endpoint at study end was 4.6 per 100 woman-years in the 0.5% PRO2000 group and 3.9 in the placebo group; and was 4.5 in the 2% PRO2000 group at discontinuation. The study concludes that, although they are safe, 0.5% PRO2000 and 2% PRO2000 gels are not efficacious against vaginal HIV-1 transmission and are not indicated for this use.
An estimated 55,000 people die of rabies in Africa and Asia every year, a viral disease passed from an infected animal to a human through biting or scratching. In both humans and animals it is deemed fatal once it enters the central nervous system, with only a handful of survivors. Already nine human cases that resulted in death have been confirmed in South Africa this year; three in the Eastern Cape, two in Kwa Zulu-Natal, one in Mpumalanga and three in Limpopo. Experts in the medical fraternity have described this as worrying, saying people need to be aware of rabies. Professor Lucille Blumberg of the National Institute for Communicable Diseases, says her institution deals with up to 20 cases of human rabies per year. She says that if a person is bitten by a stray animal, they should immediately wash the wound very well, to physically remove the virus, then visit a clinic immediately to get an injection to prevent infection and to go on a course of injections to develop antibodies to the disease.
The Global Plan to Stop TB 2011-2015 is a new roadmap for curbing the global epidemic of tuberculosis, and it aims to save five million lives between 2011 and 2015 and eliminate TB as a public health problem by 2050 but comes with a price tag of US$47 billion, nearly half of which must still be found. The Plan builds on progress towards goals laid out in 2006 to halve TB prevalence and death rates by 2015 and scale up TB diagnosis, treatment and care, but adds essential research targets including the development of faster methods to test and treat TB and to prevent it through an effective vaccine. Specifically, the plan provides countries with guidance on how to improve TB control through scaling up existing interventions for its diagnosis and treatment and by making use of new diagnostic tests and drugs that will become available over the next five years. A new test that uses molecular line probe assays to detect multi-drug resistant (MDR) TB in a few days instead of the weeks needed using older testing methods has already been introduced in some countries. Other tests that will soon be available can detect TB in a matter of hours. The pipeline of new TB drugs promises shorter treatment times. Meanwhile, nine TB vaccine candidates are in clinical trials and a new generation of TB vaccines is expected to be available by 2020. Other major elements of the plan focus on efforts to combat drug-resistant TB and TB in people living with HIV. It calls for a scale-up in access to tests that can detect resistance to first- and second-line TB drugs, identifying limited laboratory capacity as the main reason why only 5% of the estimated 440,000 people who had MDR-TB in 2008 were diagnosed. It also recommends testing all TB patients for HIV and providing antiretroviral treatment to all those who test positive.
8. Human Resources
Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: a rural background; positive clinical and educational experiences in rural settings as part of undergraduate medical education; and targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. It gives examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. It demonstrates how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.
This paper compares the socioeconomic profile of medical students registered at the Faculty of Medicine of Universidade Eduardo Mondlane (FM-UEM), Maputo, for the years 1998/99 and 2007/08. Its objective is to describe the medical students' social and geographical origins, expectations and perceived difficulties regarding their education and professional future. Data was collected through questionnaires administered to all medical students. The response rate in 1998/99 was 51% and 50% in 2007/08. The main results reflect a doubling of the number of students enrolled for medical studies at the FM-UEM, associated with improved student performance (as reflected by failure rates). Nevertheless, satisfaction with the training received remains low and, now as before, students still identify lack of access to books or learning technology and inadequate teacher preparedness as major problems. Despite a high level of commitment to public sector service, students, as future doctors, have very high salary expectations that will not be met by current public sector salary scales, as reflected in an increasing degree of orientation to double sector employment after graduation.
This presentation is based on a literature review that was carried out as part of a research collaboration between the School of Public Health Wits University and the African Population Health Research Centre, Nairobi, Kenya, with feedback from colleagues in Kenya, Uganda, Nigeria and South Africa. The review found that mid-level workers (MLWs) were active in 25 of the 47 sub-Saharan African countries reviewed: 18 countries had non-nurse based programmes for training secondary school leavers, which avoided depleting scarce ranks of nurses. MLWs were treated as second-best or a temporary stop gap until enough physicians were trained, instead of being recognised as key front line health workers responsible for care of their communities. Problems affecting MLWs were identified as: poor work environment; perceptions of resource inadequacy, with staff members indicating that they had neither sufficient staff nor time to do their work; poor pay and low status; inadequate management support and a sense of not being valued by their managers; and burnout, emotional exhaustion and low personal accomplishment. The presentation cautions that increasing numbers of MLWs is not a solution on its own. Accompanying investment is needed in supervision, district team strengthening, morale building and training. Recognition, career and skills development are strong motivators for MLWs, while positive feedback from patients is valued and seen as indicator of professional conduct. The need for professionalisation of MLWs is also underscored.
9. Public-Private Mix
This reference guide on public-private partnerships (PPP) theory and practice is intended for senior policy-makers and other public sector officials in developing countries. The guide, available on order from the Commonwealth Secretariat, focuses on the key lessons learned and emerging best practice from successful and failed PPP transactions over the past thirty years. The guide provides a background to PPPs: concepts and key trends; the infrastructure PPP project development process; constraints to infrastructure PPPs and measures to alleviate them; donor initiatives to support infrastructure PPPs; recent PPP experience in Commonwealth developing countries and lessons learned and emerging best practices on PPPs.
10. Resource allocation and health financing
The deputy speaker of Uganda’s Parliament, Rebecca Kadaga, has accused finance ministers in Africa of being insensitive by failing to prioritise the health sector during allocation of funds. She accused finance ministers of being unaware of the realities of everyday health care. She recommended that the ministers should be invited to conferences like the regional meeting of the Southern and Eastern Africa Parliamentary Alliance of Committees on Health near Kampala, where she was speaking. Kadaga said Uganda had registered progress in various sectors of development, including education, women’s empowerment and HIV and AIDS, but women and infant health had lagged behind. She attributed this to the country’s ‘weak health system, as well as inadequate human resources for health, especially reproductive health’. The reproductive health and family planning services, Kadaga said, remain mainly urban-based yet most women live in rural areas. Kadaga also decried the high population growth rate in Africa, saying it was a major challenge to the Governments' efforts to reduce poverty.
Direct facility funding (DFF) links facility funding levels to general indicators of facility size and workload rather than specific output targets. To reduce user fees, DFF was piloted in Coast Province, Kenya, with health facility committees (HFCs) responsible for managing the funds. This study evaluated the implementation and perceived impact 2.5 years after DFF introduction. Quantitative data collection at 30 public health centres and dispensaries included a structured interview with the staff member in-charge, record reviews and exit interviews. In-depth interviews were also conducted with the in-charge and HFC members at 12 facilities, and with district staff and other stakeholders. DFF procedures were well established and it made an important contribution to facility cash income, accounting for 47% in health centres and 62% in dispensaries. DFF was perceived to have a highly positive impact through funding support staff such as cleaners and patient attendants, outreach activities, renovations, patient referrals and increasing HFC activity. A number of problems were identified, such as inadequate HFC training, and lack of DFF documentation at facility level. Charging user fees above those specified in the national policy remained common, and understanding of DFF among the broader community was very limited. The study concludes that relatively small increases in funding may significantly affect facility performance when the funds are managed at the periphery. Kenya plans to scale up DFF nationwide and the authors indicate this is warranted, but should include improved training and documentation, greater emphasis on community engagement, and insistence on user fee adherence.
Overall, this paper found that health care in South Africa is very ‘pro-rich’, with the richest 20% of the population receiving 36% of total benefits (despite having a ‘health need share’ of less than 10%) while the poorest 20% receive only 12.5% of the benefits (despite having a ‘health need share’ of more than 25%). The findings indicate that there is a lack of cross-subsidies in the overall health system in South Africa. Although health care financing is ‘progressive’, this is largely due to the richest groups bearing the burden of medical scheme funding. However, the richest groups are the exclusive beneficiaries of these funds. The study shows that benefit incidence in South Africa is inequitable and notes that, in terms of a solution, the only component of the current South African health system that could contribute to overall income and risk cross-subsidies is tax funding. However, the strongly progressive component of personal income tax is to some extent offset by the regressivity of excise taxes and fuel levies and the proportional impact of VAT. In the context of the degree of income inequalities that exist in South Africa, the paper calls for a move to a health system where South Africans contribute according to ability-to-pay and benefit according to need for health care.
This paper considers the minimum resources that would be required to achieve South Africa’s proposed National Health Insurance (NHI) system and contrasts these with the costs of scaled up access to antiretroviral treatment (ART) between 2010 and 2020. The costs of ART and universal coverage (UC) were assessed through multiplying unit costs, utilisation and estimates of the population in need during each year of the planning cycle. Costs are from the provider’s perspective reflected in real 2007 prices. The study found that the annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real gross domestic product (GDP) growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget.
Many of the Millennium Development Goals (MDGs)are not being achieved in the world’s poorest countries, yet only five years remain until the target date. The financing of these Goals is not merely insufficient; current evidence indicates that the temporary nature of the financing, as well as challenges to coordinating its delivery and directing it to the most needy recipients, hinder achievement of the Goals in countries that may benefit most. Traditional approaches to providing development assistance for health have not been able to address both prevalent and emergent public health challenges captured in the Goals; these challenges demand sustained forms of financial redistribution through a coordinated mechanism. This paper proposes a global social health protection fund to address recurring failures in the modern aid distribution mechanism. Such a Fund could use established and effective strategies for aid delivery to mitigate many financial problems currently undermining the MDG initiative.
At the conclusion of the meeting to replenish the Global Fund to Fight AIDS, Tuberculosis and Malaria on 5 October 2010 in New York, donors fell far short of investing the US$20 billion needed to fully fund the fight against the three pandemics. Instead of the doubling of funding commitments needed to accelerate HIV, TB and malaria programme scale up, countries announced initial increases averaging approximately 25% or, in the case of some donors such as the United Kingdom, Ireland and Spain, did not pledge at all. This shortfall, unless corrected, will mean that the Global Fund will have to reject high-quality country proposals, and dramatically slow down the pace of scale up. The pledges and projections add up to $11.687 billion. Unless more commitments are made, the $8.3 billion funding shortfall will result in millions of deaths: at least 3.1 million people will die of AIDS and more than 2.9 million in need of TB treatment will not have access. On the positive side, one outcome of the meeting was the first ever multi-year commitment to the Fund from the United States, which intends to seek $4 billion for the Fund for 2011 through 2013, amounting to a 38% increase over the preceding three-year period.
This report is part of the SHIELD (Strategies for Health Insurance for Equity in Less Developed Countries) project, which aims to critically evaluate existing inequities in health care in Ghana, South Africa and Tanzania and the extent to which changes in health care financing mechanisms could address equity challenges. The first phase of SHIELD involved undertaking detailed financing incidence analyses (i.e. an evaluation of the distribution of the current health care financing burden between socio-economic groups relative to each group’s ability-to-pay) and benefit incidence analyses (i.e. an evaluation of the distribution of the benefits of using health services across socio-economic groups relative to each group’s need for health care) as a means of identifying existing health system inequities and the factors contributing to these inequities in each of the three countries. The second phase of SHIELD relates to identifying and critically evaluating options for the future development of health care financing mechanisms in relation to their potential equity impact and their feasibility and sustainability given attitudes of key stakeholders. This report focuses on aspects of this phase of work in South Africa, namely the feasibility and sustainability of alternative health financing reforms in relation to their respective resource requirements.
South Africa intends implementing major reforms in the financing of healthcare. Free market reforms in private health insurance in the late 1980s have been reversed by the new democratic government since 1994 with the re-introduction of open enrolment, community rating and minimum benefits. A system of national health insurance with income cross-subsidies, risk-adjusted payments and mandatory membership has been envisaged in policy papers since 1994. Subsequent work has seen the design of a Risk Equalisation Fund intended to operate between competing private health insurance funds. This paper outlines the South African health system and describes the risk equalisation formula that has been developed. The risk factors are age, gender, maternity events, numbers with certain chronic diseases and numbers with multiple chronic diseases. The Risk Equalisation Fund has been operating in shadow mode since 2005 with data being collected but no money changing hands. The South African experience of risk equalisation is of wider interest as it demonstrates an attempt to introduce more solidarity into a small but highly competitive private insurance market. The measures taken to combat over-reporting of chronic disease should be useful for countries or funders considering adding chronic disease to their risk equalisation formulae.
This brief is part of the SHIELD (Strategies for Health Insurance for Equity in Less Developed Countries) project. The brief calculates that the total resource requirements for the ‘mandatory extension of medical scheme coverage’ option (or SHI) will be considerable. Only one country in the world has spending levels as high as 13% of GDP – the USA. The brief dismisses this option as unaffordable in the South African context, based on the fact that the burden on households that are required to join a medical scheme will be very high, with scheme contribution rates per person being twice as high as they currently are in real terms (i.e. before the effect of inflation is added). The major decision facing policy makers is therefore whether we should retain the status quo or whether the country should pursue a universal health system. The ‘universal coverage’ option would see health spending levels increasing in line with expected growth in gross domestic product (GDP), so that when fully implemented, total health care spending as a percentage of GDP would be comparable to what it currently is. The author points out that the key challenge with pursuing universal coverage is the need to allocate more public funds to the health sector, partly through increased taxes.
This brief outlines the role that social transfers have to play in providing an inclusive framework to reduce intergenerational and chronic poverty. The authors argue that the Millennium Development Goals (MDGs), in common with many development, policies and programmes, focus effort on children, young people and the ‘working-age’ poor. However, they fail to recognise and support the social, economic and caring needs and contributions of older people. The paper highlights HelpAge's call on the international community to invest in government-led social transfer schemes in order to accelerate progress to achieve the MDGs. HelpAge calls for multilateral and bilateral development agencies to commit to working in partnership with national governments and invest in the development or scaling up of long-term, sustainable social transfer schemes, disaggregated monitoring of aid budgets and national government budgets to track the impact of social transfers, and recognition by the United Nations’ MDG database of the need for age-disaggregated data to ensure the effective monitoring and evaluation of the MDGs for all age groups.
11. Equity and HIV/AIDS
Home-based voluntary counseling and testing (HCT) presents a novel approach to early diagnosis. This study sought to describe uptake of pediatric HIV testing, associated factors, and HIV prevalence among children offered HCT in Kenya. HCT was offered to 2,289 children (18 months to 13 years) and accepted for 1,294 (57%). Children were more likely to be tested if more information was available about a suspected or confirmed maternal HIV infection, if parents were not in household, if they were grandchildren of head of household, or if their father was not in household. Of the eligible children tested, 60 (4.6%) were HIV infected. The paper concludes that HCT provides an opportunity to identify HIV among high-risk children, but acceptance of HCT for children was limited. Further investigation is needed to identify and overcome barriers to testing uptake.
This 2010 update of the original 2006 publication by the World Health Organization (WHO) outlines a public health approach to the delivery of anti-retroviral therapy (ART) for adults and adolescents in settings with limited health systems capacity and resources. The recommendations encourage earlier HIV diagnosis and earlier antiretroviral treatment, and promote the use of less toxic regimens and more strategic laboratory monitoring. The guidelines identify the most potent, effective and feasible first-line, second-line and subsequent treatment regimens, applicable to the majority of populations, the optimal timing of ART initiation and improved criteria for ART switching, and introduce the concept of third-line antiretroviral regimens. The primary audiences are national treatment advisory boards, partners implementing HIV care and treatment, and organisations providing technical and financial support to HIV care and treatment programmes in resource-limited settings. WHO notes that it is critical that national ART programme and public health leaders consider these recommendations in the context of countries’ HIV epidemics, the strengths and weaknesses of health systems, and the availability of financial, human and other essential resources and adapt the guidelines carefully. It is similarly important to ensure that the adaptation of these guidelines do not stifle ongoing or planned research, since the new recommendations reflect the current state of knowledge and new information for sustainability and future modifications of existing guidelines will be needed.
This study compares effectiveness of antiretroviral therapy (ART) services between primary healthcare (PHC) facilities and hospitals in low-income settings. A retrospective cohort study was conducted including ART-naïve adults from 59 facilities in four provinces in South Africa, enrolled between 2004 and 2007. A total of 29,203 adults from 47 PHC facilities, nine district hospitals and three regional hospitals were included. Patients at PHC facilities had more advanced WHO stage disease when starting ART. Retention in care was 80.1%, 71.5% and 68.7% at PHC, district and regional hospitals respectively, after 24 months of treatment. The study concludes that ART outcomes were superior at PHC facilities, despite PHC patients having more advanced clinical stage disease when starting ART, suggesting that ART can be adequately provided at this level and supporting the South African government's call for rapid up-scaling of ART at the primary level of care. Further prospective research is required to determine the degree to which outcome differences are attributable to either facility level characteristics or patient co-morbidity at hospital level.
The aims of this study were to determine the relative incidence of tuberculosis (TB) by HIV or anti-retroviral therapy (ART) status and the effect of the ART roll-out on TB incidence trends in Karonga District, Malawi. Data from the Karonga Prevention Study was analysed, including TB epidemiological studies done since 1985 and data on ART services available since 2005. The study found that relative incidence of TB was high early after initiation on ART and decreases with time, but still remains elevated. Recommendations include starting ART earlier, further collaboration between and greater integration of TB and ART programmes, and intensified case finding for TB in high-risk populations of patients receiving ART.
Recent preliminary results of Caprisa's study of the microbicide gel, Tenofovir, which showed that it can protect women from HIV infection by about 39%, have sparked concern that people might be less cautious about the use of condoms. Communities activists say condoms are already being used sparingly, with some suggesting that use of the gel might worsen the rate of condom use. Vusi Msiza, a South African community activist from Kwa-Tema, on Gauteng’s East Rand, said that the results have brought hope, but cautioned that they could also create a misperception. He urged that the message needs to be clear: there is a need to advocate use of the gel, but he also urged men to take initiative by using condoms. But other members of his community have hailed the results of the Caprisa study, saying it will give women some power as there are perceived stereotypes in using condoms. Charles Hlatshwayo who is part of a community advisory board on clinical trials in Soweto, said that the results spell good news. However, he cautioned that there might be resistance towards using the gel.
This paper’s objective was to assess the age and gender differences of clients accessing mobile HIV counselling and testing (HCT) compared with clients accessing facility-based testing, and to determine the difference in HIV prevalence and baseline CD4 counts. A prospective observational cross-sectional study was conducted of three different HIV testing services in Cape Town. The researchers compared data on age, sex, HIV status and CD4 counts collected between August and December 2008 from a mobile testing service (known as the Tutu Tester), a primary health care clinic, and a district hospital. A total of 3,820 individuals were tested. Of the HIV-infected individuals from the mobile service, 75% had a CD4 count higher than 350 cells/µl compared with 48% and 32% respectively at the clinic and hospital. Age- and sex-adjusted risk for HIV positivity was 3.5 and 4.9 times higher in the clinic-based and hospital-based services compared with the mobile service. The authors conclude that mobile services are accessed by a different population compared with facility-based services. Mobile service clients were more likely to be male and less likely to be HIV-positive, and those infected presented with earlier disease.
Kaposi's sarcoma (KS), an HIV-related cancer, is neglected in HIV and AIDS services in Africa, according to Medicines Sans Frontiers (MSF). How to administer chemotherapy at a small rural clinic is just one of the many difficulties faced by health workers treating patients with KS at 10 health facilities run by Medicines Sans Frontiers (MSF) in the Chiradzulu district of southern Malawi. Other challenges are the lack of infrastructure and safety equipment for injection-driven chemotherapy, poor case management and problematic drug supplies. MSF research, which was presented at the meeting of the Rural Doctors Association of Southern Africa (RuDASA) in Swaziland in August, found that about 7% of 11,100 ARV patients surveyed in Thyolo district had KS. Dr Francois Venter, head of the Southern African HIV Clinicians Society, said that the incidence rate in Africa is still lower than developed countries, but because of the sheer number of patients and because they present so late for treatment, KS remains an ever-present danger. He noted that the cancer was difficult to manage even in better-resourced healthcare settings like academic hospitals. MSF is now planning to train palliative care teams to handle difficult cases, and to develop a protocol to guide health workers regarding the special needs of KS patients, including how to dress lesions.
Self-tests for HIV in South Africa are currently unregulated. Gaps in law and policy have created a legal loophole where such tests could effectively be sold in supermarkets, but not in pharmacies. At the same time, South Africa lacks an effective regulating mechanism for diagnostic tests, which brings the quality and reliability of all self- tests into question. The authors argue for greater access to, and availability of, quality HIV self-tests, despite drawbacks like increased risk of unmanaged anxiety with potential for suicide if a positive result is given, lack of counselling and possible family coercion into testing. They argue that self-testing will lead to earlier diagnosis of HIV status and earlier enrolment into treatment, and decrease the costs associated with traditional voluntary counselling and testing, and allay fears about stigma and confidentiality when testing in public facilities.
This study investigated the factors associated with uptake of antiretroviral therapy (ART) through a primary healthcare system in rural South Africa. Detailed demographic, HIV surveillance and geographic information system (GIS) data was used to estimate the proportion of HIV positive adults accessing antiretroviral treatment within northern KwaZulu-Natal, South Africa in the period from initiation of antiretroviral roll-out until the end of 2008. Demographic, spatial and socioeconomic factors influencing the likelihood of individuals accessing antiretroviral treatment were explored using multivariable analysis. Mean uptake of ART among HIV positive resident adults was found to be 21.0%. Uptake among HIV positive men (19.2%) was slightly lower than women (21.8%). An individual's likelihood of accessing ART was not associated with level of education, household assets or urban/rural locale. ART uptake was strongly negatively associated with distance from the nearest primary healthcare facility. Despite concerns about the equitable nature of antiretroviral treatment rollout, the study identified very few differences in ART uptake across a range of socio-demographic variables in a rural South African population. However, even when socio-demographic factors were taken into account, individuals living further away from primary healthcare clinics were still significantly less likely to be accessing ART.
Recent guidelines recommend that all HIV-infected women should receive highly active antiretroviral therapy throughout pregnancy and lactation, irrespective of whether or not they need it for their own health. This strategy for prevention of mother-to-child transmission (PMTCT) of HIV is more effective than the well-established use of single-dose nevirapine, but it is also a more costly alternative. In this economic evaluation, the researchers used a decision model to combine the best available clinical evidence with cost, epidemiological and behavioural data from Northern Tanzania. It found that a highly active antiretroviral therapy-based PMTCT Plus regimen is more cost effective than the current Tanzanian standard of care with single-dose nevirapine. Although PMTCT Plus is roughly 40% more expensive per pregnant woman than single-dose nevirapine, the expected health benefits are 5.2 times greater. The incremental cost effectiveness ratio of the PMTCT Plus intervention is calculated to be US$4,062 per child infection averted and $162 per disability-adjusted life year.
Pages
12. Governance and participation in health
According to this review, the achievements of African governments on political and economic governance, and peace and security have been an important factor in helping the continent weather the impact of the crisis over 2009–2010. Improvements to macroeconomic frameworks have created the fiscal space for counter-cyclical policies, which have helped partly to cushion the impact of the crisis and provide a foundation for recovery. Improvements in political governance have helped to maintain political stability in the face of economic shocks. External financial support has held up in the face of fiscal pressures, even if at a level below earlier commitments. And trade is recovering dramatically, enabled in part by success in resisting protectionism during the crisis, even though discussions on further trade liberalisation on a global basis remain stalled. At the same time, the impact of the crisis has still been severe. Although the picture varies significantly by sub-region, growth rates for the continent as a whole fell from an average of about 6% in 2006–2008 to 2.2% in 2009, meaning that the growth of per capita gross domestic product came to a near standstill. Although forecasts for 2010 and 2011 are more positive, the loss of growth in 2009 and its impact over the next two to three years have set back the impressive progress that Africa had started to make towards the Millennium Development Goals, and has left the legacy of significantly greater challenges over the five-year period remaining, to 2015. The review makes nine recommendations. Recommendations for Africa itself include improved political and economic governance, working towards peace and security, increased regional integration, and domestic revenue mobilisation and allocation. For Africa’s partners, the paper recommends improvements in economic governance, and greater trade and official development assistance. Global recommendations include addressing climate change and climate change finance, as well as enhanced participation in global governance for Africa.
At the Regional Meeting of Parliamentary Committees on Health in Eastern and Southern Africa, held in Kampala, Uganda, on 28-29 September 2010, the Southern and East African Parliamentary Alliance of Committees On Health (SEAPACOH) committed themselves to the realisation of the Millennium Development Goals (MDGs), the Maputo Plan of Action and the Accra Agenda for Aid Effectiveness. SEAPACOH underscored its role in offering leadership to ensure good governance in all matters of health, as well as to continue providing stewardship on policy, legislation and budgetary oversight, and ensure that family planning and population issues are integrated into national development strategies, including the poverty reduction strategies and action plans. It also championed advocacy strategies to promote family planning as essential to the achievement of all MDGs, especially MDG4 and MDG5, in partnership with civil society organizations and the media, and promote gender equity. In terms of financing, SEAPACOH will advocate for increased government resources to health to realise the Abuja target of 15%, ensure accountability in public expenditures and continue support for strengthening health systems. It also aims to enhance partnerships with civil society organisations and learn from the best practices in countries in the region through South-South cooperation.
This document reports efforts that were made across Africa to gather grassroots opinions to reflect the views and aspirations of ordinary Africans in shaping the policy agenda for the forthcoming decade. It found that Africa is endowed with natural and human resources whose development is in the interest of world security due to its global strategic importance. Meanwhile, the increasing return of the diasporas is raising the demand for accountable governance and economic development. The current so-called development is exclusionary and does not reach the intended beneficiaries - hence their minimal access to basic services such as health, education, water and sanitation. The report makes a number of recommendations, like replacing the current unjust and exclusionary development ideal with one that is values-based and sustainable, spelling out the Millennium Development Goals need to be spelt out properly for the African and Western public with the emphasis on detailing the public good, ensuring that African governments operate with financial transparency especially in the extractive sector, and making civil society, professional associations, social movements and business entrepreneurs catalysts for engendering accountability from governments, NGOs, donors and big businesses. Agriculture, food security and the informal sector should be prioritised by African governments and those who support Africa’s development, and the skills and remittances of the returning African Diaspora must be harnessed and used to ensure good governance on the continent.
The updated version of the Worldwide Governance Indicators, covering 213 countries over the 1996-2009 period, has found that the world continues to underperform on governance. Over the past decade, dozens of countries have improved significantly on such dimensions of governance such as rule of law and voice and accountability. But a similar number of countries have experienced marked deteriorations, while others have seen short-lived improvements that are later reversed, and scores of countries have not seen significant trends one way or the other. A number of key messages emerged. The most powerful economies are not always the best governed – likewise, good governance is also found in countries that are not wealthy. Governance can significantly improve over a relatively short period of time yet, on average, the world has not significantly improved in the quality of governance over the past dozen years. Sustained commitment to governance reforms is needed to avoid reversals. The authors warn that measuring governance is difficult, and all measures of governance are necessarily imprecise, requiring interpretative caution.
This article reports findings about the impact of the Poverty Reduction Strategy Paper (PRSP) process on Malawi’s National HIV/AIDS Strategic Framework (NSF). In 2007, researchers conducted a survey to measure perceptions of NSF resource levels, participation, inclusion, and governance before, during, and after Malawi’s PRSP process (2000–2004). They also assessed principle health sector and economic indicators and budget allocations for HIV and AIDS. These indicators are part of a new conceptual framework called shared health governance (SHG), which seeks congruence among the values and goals of different groups and actors to reflect a common purpose. Under this framework, global health policy should encompass: consensus among global, national, and sub-national actors on goals and measurable outcomes; mutual collective accountability; and enhancement of individual and group health agency. Indicators to assess these elements included: goal alignment; adequate resource levels; agreement on key outcomes and indicators for evaluating those outcomes; meaningful inclusion and participation of groups and institutions; special efforts to ensure participation of vulnerable groups; and effectiveness and efficiency measures. Results suggested that the PRSP process supported accountability for NSF resources. However, the process may have marginalised key stakeholders, potentially undercutting the implementation of HIV and AIDS Action Plans.
Indoor residual spraying (IRS) and insecticide-treated nets (ITNs), two principal malaria control strategies, are similar in cost and efficacy. This study aimed to describe recent policy development regarding their use in Mozambique, South Africa and Zimbabwe. Using a qualitative case study methodology, researchers undertook semi-structured interviews of key informants from May 2004 to March 2005, carried out document reviews and developed timelines of key events. They found that a disparate mix of interests and ideas slowed the uptake of ITNs in Mozambique and Zimbabwe and prevented uptake in South Africa. Most respondents strongly favoured one strategy over the other. In all three countries, national policy makers favoured IRS, and only in Mozambique did national researchers support ITNs. Outside interests in favour of IRS included manufacturers who supplied the insecticides and groups opposing environmental regulation. International research networks, multilateral organisations, bilateral donors and international non-governmental organisations (NGOs) supported ITNs. Research evidence, local conditions, logistic feasibility, past experience, reaction to outside ideas, community acceptability, the role of government and NGOs, and harm from insecticides used in spraying influenced the choice of strategy. The end of apartheid permitted a strongly pro-IRS South Africa to influence the region, and in Mozambique and Zimbabwe, floods provided conditions conducive to ITN distribution. The study concludes that both IRS and ITNs have a place in integrated malaria vector management, but pro-IRS interests and ideas have slowed or prevented the uptake of ITNs. Those intending to promote new policies such as ITNs should examine the interests and ideas motivating key stakeholders and their own institutions, and identify where shifts in thinking or coalitions among the like-minded may be possible.
The Big Push Back, which took place on 22 September 2010, was convened by the Participation and Social Change team at the United Kingdom’s Institute of Development Studies. With over 70 attendees, the theme of the meeting was to reflect on and develop strategies for ’pushing back’ against the increasingly dominant bureaucratisation of the development agenda and the pressure to design projects/programmes and report on performance in a manner that assumes all problems are bounded/simple. This is reported to result in research that is linear (cause-effect) based, at the expense of research that is emergent, i.e. a complex, only partially controllable process in which local actors may have conflicting views on what is happening, why and what can be done about it, where complexity is recognised and accountability promoted to those people international funds are supposed to serve. The meeting also called for collaboration with people inside funding and development agencies who are equally dissatisfied with the prevailing ‘audit culture’, and communication to build public understanding that some aspects of development work that cannot be reduced to numbers are also valuable.
The Governance Cluster of the Regional Coordination Mechanism of United Nations Agencies and Partner Organisations held its annual retreat in Johannesburg South Africa on 14-15 September 2010, at which a number of resolutions were adopted. The Cluster resolved that UN agencies’ support to the African Union Commission (AUC), the NEPAD Planning and Coordinating Agency (NPCA) and the Regional Economic Communities (RECs) should be premised on the strategic orientation and priorities of these institutions as articulated in their strategic plans and other relevant documents. Horizontal interaction/links should be developed among the RECs for purposes of joint planning, programming, and sharing of information and experience. Also, AU member states should be encouraged to make efforts to sign, ratify, domesticate and apply existing charters, treaties, protocols, conventions and declarations on governance, democracy and human rights. They should also accelerate the ratification of the African Charter on Democracy, Elections and Governance, 2007. To date, about 38 AU member states have signed this historic democracy charter. Eight more signatories are required to ratify the charter. AU member states that have already signed and ratified the Charter must set in motion steps for its domestication and application, and a comprehensive mechanism should be established to monitor and evaluate implementation of existing African charters, protocols and treaties relating to governance. More AU member states should accede to the African Peer Review Mechanism, as well.
13. Monitoring equity and research policy
This study aimed to determine whether routine surveys, such as the Demographic and Health Surveys (DHS), have underestimated child mortality in Malawi. Rates and causes of child mortality were obtained from a continuous-registration demographic surveillance system (DSS) in Malawi for a population of 32,000. Between August 2002 and February 2006, 38,617 person-years of observation were recorded for 20,388 children aged < 15 years. There were 342 deaths. Re-census data, follow-up visits at 12 months of age and the ratio of stillbirths to neonatal deaths suggested that death registration by the DSS was nearly complete. Infant mortality was 52.7 per 1000 live births, under-5 mortality was 84.8 per 1000 and under-15 mortality was 99.1 per 1000. One-fifth of deaths by age 15 were attributable to HIV infection. Child mortality rates estimated with the DSS were approximately 30% lower than those from national estimates as determined by routine surveys. The fact that child mortality rates based on the DSS were relatively low in the study population is encouraging and suggests that the low mortality rates estimated nationally are an accurate reflection of decreasing rates.
In countries with generalized epidemics of human immunodeficiency virus (HIV) infection, standard statistics based on fertility history may misrepresent progress towards this target owing to the correlation between deaths among mothers and early childhood deaths from acquired immunodeficiency syndrome. To empirically estimate this bias, this study collected child mortality data and fertility history, including births to deceased women, through prospective household surveys in eastern Zimbabwe during 1998–2005. According to the empirical data, standard cross-sectional survey statistics underestimated true infant and under-5 mortality by 6.7% and 9.8%, respectively. These estimates were in agreement with the output from the model, in which the bias varied according to the magnitude and stage of the epidemic of HIV infection and background mortality rates. The bias was greater the longer the period elapsed before the survey and in later stages of the epidemic. Bias could substantially distort the measured effect of interventions to reduce non-HIV-related mortality and of programmes to prevent mother-to-child transmission, especially when trends are based on data from a single survey. A mathematical model with a user-friendly interface is available to correct for this bias when measuring progress towards Millennium Development Goal 4 in countries with generalised epidemics of HIV infection.
The Millennium Declaration, adopted by the United Nations in 2000, set a series of Millennium Development Goals (MDGs) as priorities for UN member countries, committing governments to realising eight major MDGs and 18 associated targets by 2015. Progress towards these goals is being assessed by tracking a series of 48 technical indicators that have since been unanimously adopted by experts. This concept paper outlines the role member Health and Demographic Surveillance Systems (HDSSs) of the INDEPTH Network could play in monitoring progress towards achieving the MDGs. The unique qualities of the data generated by HDSSs lie in the fact that they provide an opportunity to measure or evaluate interventions longitudinally, through the long-term follow-up of defined populations.
Couples should be included in HIV prevention research, but their recruitment in southern Africa is challenging given high levels of migration and non-cohabitation, according to the authors of this pilot study. The study describes the recruitment strategies and experiences in rural South Africa when conducting HIV research. With the aim of recruiting 20 couples at mobile voluntary counselling and testing (VCT) caravans and community venues, 75 index partners were screened with an average of four additional contacts required to schedule interviews. The study found that, despite the care taken to maximise recruitment, recruiting just 20 couples required a substantial investment of time and resources, so recruiting and interviewing couples is a feasible option, but requires substantial resources. Given the need to identify effective HIV behavioural interventions in South Africa, the authors believe that couples-focused studies and interventions can be one possible component in efforts to promote testing and reduce HIV transmission.
This annual collection of key economic and statistical data on states with fewer than five million inhabitants is designed as a reference for economists, planners and policy-makers. The book contains fifty-four tables covering selected economic, social, demographic and Millennium Development Goal indicators culled from international and national sources and presents information unavailable elsewhere. A detailed parallel commentary on trends in Commonwealth small states, looking at growth, employment, inflation, human development, and economic policy, permits a deeper understanding of developments behind the figures. The book also includes three articles focusing on trade in services.
South Africa is one of only 12 countries that has failed to reduce child mortality since 1990, according to the South African Child Gauge 2009/2010, an annual review of the situation of children in the country. The review contains essays by child health experts from across the country. 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. South Africa has also failed to submit its reports on progress in relation to implementing the United Nations 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. Improving child health outcomes requires concerted action from both within and outside the formal health care system. To reduce child mortality, governments should alleviate poverty and eliminate inequality, as well as improve the performance of its health services, and medical interventions should focus on prevention and encourage the participation of children.
14. Useful Resources
The INDEPTH Network has conducted two INDEPTH Health Equity studies. Study Phase 1, which is leading to a monograph, demonstrated that large disparities exist in terms of health outcomes among different socio-economic subgroups among populations in INDEPTH sites that cover small geographically defined populations. These sites include two countries in southern Africa - Tanzania and South Africa. With this evidence, the Network decided to move to the next stage, Study Phase 2, to develop intervention studies or manipulate existing interventions to have a pro-poor focus in order to inform policy. The Network has also developed a tool for measuring socio-economic status, which is available on their website.
The Canadian Institute of Health Research Institute of Gender and Health (IGH) Cochrane Corner is a new online resource that highlights reviews pertinent to gender, sex, and health questions. It aims to introduce those working in gender, sex, and health to the methods of the Cochrane Collaboration and, reciprocally, to bring awareness of sex- and gender-based analyses to the Cochrane community. The Corner will provide a range of knowledge users with a gender- and sex-focused entrée into the collection of research evidence provided through the Cochrane Library. By creating a focused collection of systematic reviews relevant to gender, sex, and health, the IGH Cochrane Corner will be a valuable tool for knowledge translation in the field. The Corner also features an original series of columns, which highlight methodological, substantive, or newsworthy issues related to sex, gender, health, and systematic reviews. The columns reflect current knowledge and activities in the field.
This paper discusses the need for specific pro-poor measures to ensure water service provision to poor urban populations. Given the proven importance of pro-poor measures for urban water service delivery and viability, the question arises as to why such measures are not undertaken by utilities as normal practice. Although financial constraints matter, they do not constitute the only barrier. The report argues that the missing ingredient needed in order to reach poor people is accountability to the people, which necessitates the meaningful involvement of users in the planning, delivery and monitoring of water services. This increases the chances of delivering reliable, sustainable and affordable water services to more urban inhabitants. The engagement of users in utility reforms and ongoing service improvement processes is crucial, since reforms to improve efficiency (inevitably the main driver for reforms) do not necessarily translate into geographical equity or a commitment to serve the poor. Without incentives, a clear mandate to serve the poor or a ‘champion’, companies chase markets that are ‘easy’, offer the highest returns and do not require subsidies. However, user engagement is far from simple and its outcomes far from predictable. The paper draws on a variety of literature, as well as a series of key-informant interviews.
The One World Trust, with support from the International Development and Research Centre, has created an interactive, online database of tools to help organisations conducting policy relevant research become more accountable. The database provides an inventory of over two hundred tools, standards and processes within a broad, overarching accountability framework. With a dynamic interface and several search functions, it allows users to identify aspects of accountability that interests them, and provides ideas to improve their accountability in this context. Each tool is supported by sources and further reading. The site also encourages engagement with and discussion on the database content, through allowing users to comment on individual tools, or to submit their own tools, processes and standards for inclusion. The database is an output of a three-year project, titled ‘Accountability Principles for Research Organisations’. Working with partners across the globe, the project has generated an accountability framework which is sufficiently flexible to apply to many contexts and different organisations.
The Rural Health Advocacy Project (RHAP) was launched in August 2009 in response to the specific health challenges in rural areas. The RHAP believes that a focus on rural health is key to improving national health outcomes and achieving progress towards the millennium development goals. This is because rural communities have poorer health status, less access to health care facilities, fewer resources, less information and fewer health care professionals than their counterparts in urban areas. The RHAP believes that for South Africa to improve its health outcomes, the problems faced by rural communities need specific attention. The RHAP is a partnership between the Wits Centre for Rural Health (CRH), the Rural Doctors Association of Southern Africa (RuDASA) and SECTION27, incorporating the AIDS Law Project. The website contains news items and papers by researchers on various topics regarding rural health, such as health worker retention, health services and health financing.
15. Jobs and Announcements
The African Women's Development Fund (AWDF) funds local, national, sub-regional, and regional organisations in Africa working towards women’s empowerment. The AWDF is an institutional capacity-building and programme development fund, which aims to help build a culture of learning and partnership within the African women's movement. In addition to awarding grants, the AWDF attempts to strengthen the organisational capacities of its grantees. The AWDF funds work in six thematic areas: women's human rights; political participation; peace building; health, reproductive rights; economic empowerment; and HIV and AIDS. Applicants are expected to build relevant and reasonable running/core costs into their project proposals. Grants are made to national and regional organisations for aspects of organisational growth and development such as strategic planning, developing fundraising strategies, communications systems, retreats, governance systems etc. Grants cover capital costs such as purchase of computers, printers, and photocopiers. The AWDF makes grants in three cycles each year. Applications can be sent in at any time. Organisations can apply for grants ranging from US$1,000 - US$40,000. Grants over US$20,000 are only made to organisations which operate on a regional basis.
The fifth African Programme on Rethinking Development Economics (APORDE) will be held in Johannesburg (South Africa) from the 5th to the 19th of May 2011. APORDE is a high-level training programme in development economics which aims to build capacity in economics and economic policy-making. The course will run for two weeks and consist of lectures and seminars taught by leading international and African economists. This call is directed at talented African, Asian and Latin American economists, policy makers and civil society activists who, if selected, will be fully funded. APORDE will cover essential topics in development economics, including industrial policy, inequality, poverty, financial crises and social policy. Lectures will equip participants with key information pertaining to both mainstream and critical approaches. Day lectures will last for three and a half hours, while a number of shorter lectures will also be organised.
In partnership with Computer Aid International, BioMed Central will be hosting a two-day conference on open access publishing at Kenyatta University in Nairobi, Kenya, from 11-12 November 2010. Open access to the results of scientific and medical research has potential to play an important role in international development, and this conference will discuss the benefits of open access publishing in an African context, from the perspective of both readers seeking access to information, and researchers seeking to globally communicate the results of their work. Attendance at the conference is free and is open to researchers, librarians, vice-chancellors and funders for discussions on access to scientific research. However, space is limited so, to reserve your place, please send an email to the address given here.
The WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, housed at the Centre for Global Health at the University of Ottawa, is currently in the process of updating and expanding its Equity-Oriented Toolkit for Health Technology Assessment (HTA). The Equity-Oriented Toolkit is based on a needs-based model of HTA. It provides tools that explicitly consider health equity at each of the four steps of health technology assessment: burden of Illness, community effectiveness, economic evaluation, and knowledge translation and implementation. It also incorporates concepts of health impact assessment within the HTA process. The centre is seeking suggestions on validated and widely disseminated HTA tools that explicitly consider health equity and that are relevant to the toolkit. These tools may be specific analytical methods such as the Disability-Adjusted Life Years, checklists such as the Health Impact Screening Checklist, software programmes such as the Harvard Policy Maker, and databases such as the Cochrane Library.
Medicins sans Frontieres has launched its campaign ‘Europe! Hands off our medicine’ to fight against legislative changes that could see the supply of generic drugs from India and other countries shut down or significantly reduced. This is an appeal to you to sign the petition and distribute it as widely as possible in your country and networks. Millions of people in developing countries rely on affordable generic medicines to stay alive. More than 80% of the medicines used by MSF to treat AIDS across the developing world are produced in India. But the European Commission (EC) is now launching an attack on affordable medicines by pushing for unfair legislation to govern the production, registration, transportation and exportation of generic medicines. This legislation makes no clear distinction between fake drugs and genuine generics. People who need generics could face shortages and may die if they need are life-saving drugs. Negotiations are ongoing between the European Union and India, and MSF wants to use this petition to draw the attention to this problematic issue and send a message to the EC Trade Commissioner, Karel De Gucht, and European Union governments, calling on him to put a halt to Europe’s destructive trade policies and to commit to an agenda that will offer access to medicines for all. To sign on, click on the link given here.
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.
Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to info@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact editor@equinetafrica.org immediately regarding any issues arising.