When the first Global Symposium on Health Systems Research, held under the theme "Science to Accelerate Universal Health Coverage" ended a week ago, after hearing the concluding statement (included in this newsletter), many people went back to heavily fragmented health systems with very different experiences of access and service for different social groups. The two editorials in this newsletter take the issue of universal coverage to the real time of the policies and interests being negotiated at country level in South Africa. The discussion by Di McIntyre on national health insurance in South Africa points to the importance of perspective and clarity on the long term implications of choices being made in the current debates on national health insurance; while the report by Jacky Thomas of SANGOCO points to the measures civil society are taking to move from issue specific to common platforms, to challenge unhealthy divisions in systems and in society. Together they raise the challenge of twinning perspective with knowledge, and knowledge with organisation, to build universal, integrated health systems.
1. Editorial
There has been considerable media debate about the proposal to implement a National Health Insurance (NHI) in South Africa. This editorial attempts to unpack the options that face South Africa by painting scenarios of where we could head. These scenarios focus on two key elements of current debates: firstly whether this major health system reform will be ‘affordable’ and ‘sustainable’; and secondly, whether we are able to achieve an integrated health system or are destined to continue to have a highly fragmented health system.
It appears that we have essentially four scenarios for the South African health system:
1: the ‘no go’ option
2: the unsustainable, ‘divided forever’ option
3: the sustainable, ‘second rate’ health system with fragmentation option, and
4: the integrated, ‘healthy nation’ option.
The starting point for considering what health system changes would be helpful is to be clear about the path on which we are currently set. Our health system is heavily fragmented. A key division is between those that are medical scheme (private insurance) members (16% of South Africans) and those that are not (the remaining 84%). Health service access is very different for these two groups.
Our current health system is ‘second rate’ in many ways. For increasing numbers of families, medical scheme cover is just not affordable. In the early 1980s, medical scheme contributions for a family took about 7% of average formal sector wages and salaries. This had increased to a staggering 30% by 2007. The challenges facing the under-resourced public health sector are well known. There is no question that change is needed, and needed soon.
If this is not the direction in which we want to head, where do we want to go? Some argue that we need to pursue ‘social health insurance’ (SHI) – the ‘divided forever’ scenario. It is proposed that everyone who is formally employed and who earns more than the income tax threshold should be required to have medical scheme membership. The problem is that this scenario is a very expensive option. R1 in every R10 spent in South Africa would have to be spent on medical schemes alone, for the benefit of less than 40% of South Africans.
This scenario is called ‘divided forever’ because it will entrench a fragmented two-tier system between the haves (those that have insurance cover and access to any health service they desire) and the have nots. Proponents of this path argue that SHI is a logical step towards universal coverage. But experience in other middle-income countries, notably many Latin American countries, shows that it is very difficult to overcome the divisions created by SHI once they have been entrenched.
Many believe that, instead, an integrated system is needed. What is so prized about such a system? The global call for progress to universal health systems is based on the following two principles:
That no one should have their livelihood threatened because they have to pay for health care, i.e. that all citizens should be provided with financial protection from health care costs; and
That all citizens should be able to access the health care they need.
In order for these principles to be realised, an integrated health system is needed. It simply doesn’t work to have all the richer, healthier people contributing to and benefiting from one funding pool (or worse, a number of fragmented pools) and all the poorer, sicker people in a completely separate funding pool. You end up having a lot or most of the money for health care going to serve a relatively healthy minority and very little money available to provide health care for those who bear most of the burden of ill-health.
One way of pursuing an integrated system is to attempt to cover everyone using the current medical scheme model. However, this would result in more than R2 in every R10 that is spent in South Africa going to cover the entire population via medical schemes. For this reason, this scenario has been called a ‘no go’ – no country in the world has such a system and it is not something worth even considering for South Africa.
I believe that it is possible to achieve an affordable or sustainable and integrated system. Everyone agrees that the first step is to substantially improve services in the public health sector. There is much to be done, both in terms of improved management and resourcing. Some say: “why not just focus on improving the public sector”. The most valuable and scarce resource in the health sector is that of health professionals. We could be utilising the human resources we have far more efficiently and equitably than at present. However, this is only possible if we have a large integrated pool of public funds that can be used to purchase health services from public and private providers for the benefit of all South Africans. It is not simply a matter of focusing on improving the public sector. We need to change the way in which health services are funded if we are to effectively use the health professional resources in South Africa so that everyone can access health services on the basis of their need for care and not on the basis of their ability to pay.
Ensuring affordability in a universal health system requires other changes. Two things are particularly important. First, it is critical to have high quality primary level services and for primary care providers to determine access to specialist and hospital inpatient care. Second, we need to change the incentive structure for health care providers. At the moment, we pay private doctors and hospitals a fee for every service delivered; the incentive is to provide as many services as possible. International experience clearly demonstrates that changing the way of paying providers is necessary to secure greater value for money.
The ‘healthy nation’ scenario is what I believe public debate should focus on. Surely we can all agree that we do not want to continue on the current path (the ‘second rate system’)? Instead of saying that health system change is unaffordable, let’s focus on how we can achieve a sustainable, integrated health system that benefits all. A health system that brings our nation together rather than dividing us further.
This editorial has been modified by the author from a longer version published in the South African Independent Online media – the Mercury, the Star and the Argus. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the Health Economics Unit website at http://heu-uct.org.za/ and the EQUINET website at www.equinetafrica.org.
While individual organisations in civil society in South Africa are known for their struggles to ensure access to medicines, access to water, land shelter and other rights, September 2010 provided an opportunity for civil society across platforms and constituencies to build wider solidarity around poverty and inequality.
Since 1997, civil society in South Africa has gathered every two years to learn from each other, dialogue and debate, propose input into government policies and programmes and strengthen civil society’s role in challenging poverty and inequality. In 2010, this ‘NGO Week’ was on 20th-25th September in Cape Town under the banner of “Building Solidarity to Fight Poverty and Inequality” starting on Monday, 20th September 2010, ending with a Heritage Day Festival on Friday, 24th September 2010.
The week brought together a range of existing civil society campaigns, such as The Right to Health Campaign, The Peoples’ Budget Campaign, 16 Days of Activism for No Violence against Women and Children, Amplifying Feminist Voices and Building a Popular Education Movement. amongst others. The organisations that came together involve and work with a range of constituencies, including women, organised workers, health workers, people living with HIV and religious groups. The organisations included those that advanced issue based campaigns, like the Treatment Action Campaign, Feminist Forum, Women on Farms and the Learning Network, broad sectoral movements like Popular Education Movement and People’s Health Movement and membership based umbrella organisations like the South African Council of Churches (SACC), or the Congress of South African Trade Unions (COSATU). The gathering provided an opportunity for dialogue, self-organized workshops and sharing of case studies across the different groups, to build shared understanding on challenges and approaches to dealing with socio-economic rights. For example the campaign for the right to health, that includes the right to healthy living and social conditions and to access health care, was adopted by all groups as a common cause for all.
Over five hundred and fifty participants from civil society used the discussions and interaction to build and strengthen the kind of cross-cutting civil society platforms needed to tackle the multidimensional nature of poverty and inequality. Resolutions were made on actions that would benefit individual platforms but also have wider and more general impact, such as ensuring an enabling environment for the non-profit sector, or strengthening community action and participation around rights to health. These wider platforms call for strong networking across sectors, with strong leadership and accountable, transparent, democratic governance. Civil society organisations (CSOs) agreed that this calls for partnerships to build knowledge and learning between civil society and other institutions. Hence civil society was encouraged to partner with the twelve Higher Education and Research Institutions in the country, particularly the five in the Western Cape Province.
As a result of the deliberations of the week, the CSOs involved developed a number of resolutions on joint action (see http://www.sangocowc.org for the full resolutions). For example, as one outcome, CSOs are now interrogating and making input to the African Peer Review Mechanism (APRM) Report from South Africa. These reports have been adopted at African Union level to report on developments in governance on the continent. The CSO contribution in South Africa will feed into the draft of the Second Report on the Implementation of South Africa’s APRM Programme of Action, and through this into the wider continental discussion. Civil society resolved on a range of platforms to strengthen their role as a watchdog, to widen networks, to include champions from key stakeholder groups and to support and monitor our own programmes of action. The week ended with a cultural festival on the final day to commemorate ‘Community House’, which has a rich history as a hub of radical civil society organisations and trade unions.
The South African Non-Governmental Organisation Coalition (SANGOCO) was tasked to co-ordinate and monitor the implementation of the resolutions. SANGOCO is a coalition of civil society networks and organisations. It originated in 1997 to re-build civil society and the society at large within the context of a world where social justice and civil liberties are under attack. It aims to establish a strong and vibrant civil society that has capabilities and policy influence in the interests of people, especially poor people. SANGOCO seeks to hold government programmes and policies accountable for the extent to which they effectively serve the needs and interests of poor people. SANGOCO was mandated by the CSOs to coordinate sectoral and cross-sectoral working groups to take forward the resolutions over the next two years 2012.
It was important for us that civil society representatives from other countries in east and southern Africa participated in the events of the week, including groups from Namibia, Mozambique, and Malawi, as well as people from civil society centres as far afield as Denmark, USA and India. The lunchtime cultural events provided an interactive marketplace where people from civil society from across different countries discussed and exchanged experiences on common struggles. The South African organisations urged their counterparts in other countries in the region to also strengthen their umbrella bodies and networking on common platforms.
Poverty has many dimensions and inequality exists across a range of social and economic factors. South African civil society has recognized that while issue specific platforms help to raise profile and draw attention to specific areas of deprivation, we need to bring civil society together around common agendas to address the many dimensions of poverty and causes of inequality. Even more so do we need to bring together civil society across East and Southern Africa to tackle the much deeper levels of poverty and inequality in the region, given the degree to which our economies, societies, labour markets and trade are interlinked. The policy dialogues and debates that were held during NGO Week 2010 in South Africa have helped strengthen these cross cutting coalitions in South Africa. We hope that they spread throughout the region.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For further information on SANGOCO or the NGO Week please contact sangocowesterncape@telkomsa.net or visit www.sangocowc.org
2. Latest Equinet Updates
Labour Voices of the Airwaves is broadcast in five languages on 39 community radio stations in South Africa. This 7-minute long show broadcast earlier this year looks at the South African government's progress towards the World Health Assembly resolution on universal coverage, defined as adequate access for all at an affordable price. The spokesperson from the Ministerial Advisory Committee on the National Health Insurance (NHI), Fidel Radebe explained that the NHI is intended to be a financing system to provide universal coverage to all South Africans. Prof Di McIntyre from EQUINET -Health Economics Unit at the University of Cape Town, argued that universal coverage can only be achieved through fair financing mechanisms, and these would either be tax funding or a national health insurance scheme that integrates all funds into one pool for the benefit of all. Nehawu spokesperson Sizwe Mpamla explained why the union is in favour of NHI, saying that an universal health system would mean increased funding for the public health sector, which would lead to improved facilities and this would positively impact on health workers working conditions. Asanda Fonqa of Denosa was similarly positive about the move towards NHI. Prof David Sanders of the School of Public Health at the University of the Western Cape said that NHI would only contribute to achieving universal coverage if it chose a viable model for delivery; he said that if the bulk of NHI funds were used to cover private health services, universal coverage would not be achieved. Activists like Sipho Magodella of the Anti-Privatisation Forum remained skeptical that the government was really committed to delivering an equitable, universal health system and therefore skeptical of the planned NHI. Only when the full NHI proposal is made public will South Africans be able to assess to what extent it is likely to bring about universal coverage. This file is too large to load to the website so those interested are asked to contact admin@equinetafrica.org
On September 27 2010, the Ministry of Health of Mozambique, in co-operation with partners, launched the Mozambique Equity Watch report. The launch was held during a one-week World Health Organisation AFRO training course building capacities in health equity and the social determinants of health. The launch was held in co-operation with EQUINET, represented through Training and Research Support Centre (TARSC). The report was launched by the Minister of Health and attended by officials of the Ministry and other sectors of government, the National Institute of Health, various technical institutions, and partners of the Mozambique Sector Wide Programme (SWAP) in health, including the focal point for the donor community, WHO and UNICEF. The Minister noted in the launch the need to now make effective use of the evidence in various forums and that the Ministry would want to repeat the Equity Watch in 2012 to see what progress has been made, and to include the inputs from other sectors of government and from civil society. After the presentations and comments participants were organized in three groups to discuss and propose measures for the follow up action on the Equity Watch: 1. On the actions to be taken by the Ministry of Health 2. On taking forward the dialogue with other stakeholders and partners on the report 3. On areas of follow up investigation and research.
3. Equity in Health
The Global strategy for women’s and children’s health sets out the key areas where action is urgently required to enhance health financing, strengthen policy and improve service delivery. It argues that investing in women’s and children’s health reduces poverty, stimulates economic productivity and growth, is cost-effective and helps women and children realise their human rights. The report makes a number of recommendations. First, it urges governments and the global community to support country-led health plans, emphasising life-saving interventions and ensuring that women and their children can access prevention, treatment and care when and where they need it. The report also advocates for stronger health systems, with sufficient skilled health workers at their core and innovative approaches to financing, product development and the efficient delivery of health services. The over-reaching aim of the report is to help reach the goal of saving the lives of 16 million women and children by 2015.
The HLSP Institute’s Global Update is a reference guide to the key events and activities of six months – April to September 2010 – in the health and development arena, with particular focus on aid effectiveness, health systems and public health. It reports on the United Nations (UN) Children’s Fund’s proposal to take a more equity-based approach to child health. The intended strategies are: upgrading selected facilities, particularly for maternal and newborn care, and expanding maternity services at the primary level, including maternity ‘waiting homes’; tackling the multiple barriers to access by the poorest – from massively expanding outreach services, and eliminating user charges, to extending cash transfers to cover indirect costs (e.g. transport); and task shifting, with more community outreach and involvement, and making greater use of community health workers to deliver basic health care services outside facilities. In terms of the global AIDS response, the update notes that the global AIDS response is at a crossroads, with a shortfall on achieving universal access targets, together with signs of funding declines and shortfalls. There has been growing attention to maternal health and commitments made in the US Global Health Initiative, the G8, the African Union Summit in Kampala in July 2010 and the MDG Summit in September 2010, with significant resources allocated to this area. The authors argue that assessing progress on delivery on these commitments and the impact of the resources is limited by lack of reliable and accurate maternal mortality data.
At the end of the Global Symposium on Health Systems Research, held from 16-29 November 2010 in Montreux, Switzerland, the Steering Committee made a number of resolutions. They proposed to electronically preserve and disseminate the knowledge from the symposium, using innovative communication channels. They also committed to creating an International society for health systems research, knowledge and innovation, with the goal of advancing ‘science to accelerate universal health coverage’, to take build greater constituency, credibility and capacity for health systems research globally. The Committee will give visibility and support to regional and national efforts to strengthen health systems research, promoting strengthened health systems within priority UN agendas and accelerating universal health coverage. Contributions will be solicited from the global scientific community to establish norms, standards and practices to strengthen the foundations for health systems research. The Committee will also identify joint opportunities for collaborative research and knowledge production across different disciplines, sectors, stakeholders and geographies. Finally, the Committee agreed to gather for a Second Global Symposium on Health Systems Research in 2012 or 2013 to evaluate progress, share insights and recalibrate the agenda of science to accelerate universal health coverage. China has offered to host the Symposium.
This study assessed changes in infant mortality patterns from 1992 to 2007, as well as factors associated with infant mortality risk in the Agincourt sub-district, rural northeast South Africa. Period, sex, refugee status, maternal and fertility-related factors, household mortality experience, distance to nearest primary health care facility and socio-economic status were examined as possible risk factors. The survey found that infant mortality increased significantly over the study period, largely due to the impact of the HIV epidemic. There was a high burden of neonatal mortality, with several ‘hot spots’ close to health facilities. Significant risk factors for all-cause infant mortality were mother's death in first year (most commonly due to HIV), death of previous sibling and increasing number of household deaths. Being born to a Mozambican mother posed a significant risk for infectious and parasitic deaths, particularly acute diarrhoea and malnutrition. The study concludes that prevention of vertical transmission of HIV and survival of mothers during the infants' first year in high-prevalence villages needs to be urgently addressed, including through expanded antenatal testing, prevention of mother-to-child transmission, and improved access to antiretroviral therapy. Persisting risk factors, including inadequate provision of clean water and sanitation, are yet to be fully addressed.
4. Values, Policies and Rights
According to this article, one aspect of the efforts of global capital to shape health policy in developing countries is the practice of so-called ‘independent’ think tanks, which seek to put into the public domain seemingly dispassionate opinion pieces on public policy, but which are openly oriented to promoting free market policy at the expense of public benefit. These think tanks propose that only free market liberalisation can solve problems related to food security, housing and health, but offer limited empirical evidence for this. The role of large corporate funding in their work is obscured. The article presents one example, the London-based International Policy Network, which is argued to promote private healthcare by arguing that human rights are not indivisible and inalienable, and by dismissing the validity of social and economic rights, particularly the right to health.
The 52nd East, Central and Southern African (ECSA) Health Ministers Conference was held in Zimbabwe from 25-29 October 2010, with the theme ‘Moving from Knowledge to Action: Harnessing Evidence to Transform Healthcare’. A number of resolutions were passed, calling for governments to promote evidence-based policy making, engage with the international community/global movement towards achieving universal health coverage, develop training programmes and monitoring mechanisms for improved maternal child health and reproductive health/family planning, establish and/or strengthen a national gender commission for dealing with gender-based violence and child sexual abuse, develop and monitor strategies for retaining health workers in the region and support strategic leadership in global health diplomacy. Further resolutions call for ECSA countries to prioritise nutrition interventions, strengthen monitoring and evaluation systems, strengthen the response to multi-drug resistant and extremely drug resistant tuberculosis, and strengthen partnerships for health by ensure that partner involvement in health programmes is aligned and harmonised with national health policies, plans and priorities. The countries should develop mechanisms for tracking health care investment and evaluating the outcomes of partnerships.
According to this report, forcing 'development' or 'progress' on indigenous people does not make them happier or healthier. The authors argue that indigenous peoples' well-being is primarily affected by whether their land rights are respected. Where this is not the case, and where indigenous people are not given a role in guiding development actions, they suffer poorer health outcomes, with increased rates of obesity and malnutrition, drug addiction, alcoholism, and with a change to Western diets, diabetes. The report links identity, freedom and mental health and argues that mental health problems, notably suicide, increase dramatically when a group’s identity and freedom is taken away.
In response to criticism of ethical review of a South African clinical trial, this study contrasts aspects of the United States (US) Common Rule with South African research ethics requirements. In the US the Common Rule does not apply to all health research and allows many exemptions from ethics review and waivers of informed consent. The study found that, at a structural level, research ethics review in South Africa is in many cases equivalent to the US institutional review board (IRB) and Office for Human Research Protections (OHRP) oversight system, is wider reaching, and has no exclusions.
This statement was released by the People’s Health Movement (PHM) in response to the Global Symposium on Health Systems Research, held from 16-29 November 2010 in Montreux, Switzerland. It raises a number of issues and suggestions for the future. It identifies some areas of relative neglect that may be rectified in the next Symposium, such as: the role of the health system in promoting primary health care, including the involvement of communities and intersectoral action; the place of people and participatory research in the field of health systems research; the challenge of balancing equity with universal coverage; and the roles of and interrelationship between public financing and insurance. PHM detects a tacit approval for the expansion of private financing and insurance models, which they consider problematic. While the importance of political and ideological factors were mentioned several times, PHM believes that more discussion could be had to discuss and determine the political, normative and ideological views of the community of health systems researchers. Health systems policy should be informed by research, but it needs to be shaped by normative principles and values first. At the Symposium, PHM notes that there was inadequate discussion about the way the HSR is shaped by university/academic context and the publishing industry and no discussion about the political economy of HSR and the biases in the research agenda that exist. Finally, PHM urges leaders and civil society not to tolerate the ‘myth of scarce resources’, and instead insist on equal focus and emphasis on the structural and macro-economic context of health systems.
5. Health equity in economic and trade policies
European governments have promised to fix laws that caused generic medicine seizures in the Netherlands, the Indian Minister of Commerce and Industry announced. He added that seizures were illegal under the Trade-Related Aspects of Intellectual Property Rights agreement. Minister Anand Sharma pointed to significant savings in buying Indian-made generics for developing countries, for example by reducing the price of treatment for one patient for one year of antiretroviral medicines from US$12,000 to $400. He cautioned against confusing generic medicines with counterfeits, arguing that India was fully TRIPS compliant. India has had meetings with the Directorate-General for Trade at the European Commission, and European Union (EU) Trade Commissioner Karel De Gucht and his predecessor Catherine Ashton in this regard. Some were expecting India to call for formation of a panel in the dispute case after several months of consultations, but the Minister said that he has received ‘clear assurance [from] the EU trade commissioner that the notification under which actions were taken was misinterpreted and will be amended to plug all loopholes’.
According to the authors of this article, the exchange of South-South knowledge and experience has an enormous potential role in the emerging global development architecture. Many current answers to development challenges come from developing countries. For example, developing countries have designed and implemented solutions that have no precedent in the developed world, such as microfinance models in countries like Bangladesh and Indonesia, or the use of mobile technologies for all kinds of services in Africa and elsewhere, including health. Those same developing countries are building strong and reputable academic institutions and development think tanks, with implications for the diversity, sources, and availability of development knowledge and experience. The article proposes greater investment in a more demand-driven model of co-operation that promotes horizontal relationships, invests in local capacity and moves away from a one-size-fits-all solution. For this new approach to work, regional and global multilaterals should mainstream South-South approaches in their business lines and develop funding and brokering mechanisms for low-and middle-income countries, as well as for short-term and long-term projects. Traditional external funders need to be made aware of the win-win opportunity that lies in developing capacity in one country to promote sustainable change in another, and they need to adapt their co-operation strategies accordingly. Parliamentarians and civil society organisations can ensure that governmental peer learning fosters democratic ownership and human rights. Academia and the private sector can help enrich the agenda and engage more with governments and other stakeholders.
This report summarises the main themes, ideas and discussion points from the G20 Conference, held on 30 June 2010. The purpose of this conference was to explore options for the future for the G20 in advancing key issues in global health and development, set against a background of a G8 legacy of contributions to global health aid and the G20’s current focus on the economic crisis. Several themes emerged. First, the Global Fund noted it cannot meet its funding promises and is looking for contributors for the next three years. The Fund needs US$10 billion to sustain current levels, and $17 billion to continue to make gains in fighting HIV and AIDS, tuberculosis and malaria. The conference heard that there is a real possibility of eradicating polio in the next ten years, as just four countries still suffer from the disease, but this requires a concerted effort and political will. While it could be expensive, the long-term savings may be huge as people will no longer need to be immunised against the disease.
6. Poverty and health
This report seeks to explain why people are poor and why inequalities exist, as well as what can be done to rectify these injustices. It explores the causes, dynamics and persistence of poverty; examines what works and what has gone wrong in international policy thinking and practice; and lays out a range of policies and institutional measures that countries can adopt to alleviate poverty. It notes that 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 most 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 (whether in the agricultural, industrial or service sectors) that generate and sustain adequately paid jobs; comprehensive social policies that are grounded in universal rights and that support structural change, social cohesion and democratic politics; and protection of civic rights, activism and political arrangements that ensure that States are responsive to the needs of citizens and that the poor have some influence in how policies are made.
This report notes that, despite the important role education plays in shaping indicators of progress, we understand little about the causal relationships and pathways between educational interventions and social outcomes. The report provides a synthesis of the existing evidence, data analyses and policy discussions. It finds that education has the potential to promote health directly and through supporting civic and social engagement. Education may reduce inequalities by fostering cognitive, social and emotional skills and promoting healthy lifestyles, participatory practices and norms. These efforts are most likely to be successful when family and community environments are aligned with the efforts made within educational institutions. This calls for policy coherence across sectors and across the stages of education.
This brief is based on the Human Sciences Research Council’s (HSRC) 2006 Social Attitudes Survey and aims to explore the existence of a so-called ‘dependency’ culture among the unemployed and social grants recipients. It seeks to inform the policy context around social security in South Africa. By providing evidence to show that poor people demonstrate a greater attachment to the labour market than the non-poor, it challenges the notion that the provision of social grants will rear a ‘dependency culture’ among the unemployed and recipients of social grants. It suggests that both groups of people are interested in and are motivated to find work. It also provides the evidence to show that, among the poor, having a job is perceived to be better than claiming grants and work is valued for its social integration role and helps to overcome feelings of isolation. The brief’s findings indicate that the Child Support Grant does not discourage people from seeking work. It appears the main cause of people remaining unemployed is the structural conditions of the labour market, as opposed to a reluctance to find work and choosing, instead, to rely on State support.
7. Equitable health services
Malnutrition in Congo-Brazzaville causes more than a quarter of deaths among children under five, according to United Nations Children's Fund (UNICEF). In response, on 20 October 2010, the Act Now, No Woman Should Die Giving Life campaign was launched across the country. It aims to reduce maternal and child mortality, and involves the government, three United Nations (UN) agencies, civil society and private partners. It aims to reduce the maternal mortality rate of 781 per 100,000 live births, as well as child mortality. UNICEF also pointed out health inequities, as the rich have access to faster essential interventions than the poor and stressed that reducing this inequality is essential to achieve the Millennium Development Goals related to health. The Congolese Minister for Health and Population assured that adoption of the new national roadmap will accelerate reduction in mortality rates. He said that since 2008 pregnant women and children aged 5-15 have been able to access free malaria treatment, and from January 2011 pregnant women will be able to get free Caesarean sections.
The objective of the East Africa Public Health Laboratory Networking Project for Africa is to establish a network of efficient, high quality, accessible public health laboratories for the diagnosis and surveillance of tuberculosis and other communicable diseases. There are three components to the project, the first component being regional diagnostic and surveillance capacity. This component will provide targeted support to create and render functional the regional laboratory network. Uganda, working in close collaboration with the East, Central and Southern African Health Community (ECSA-HC), will lead the establishment of the network. The second component is joint training and capacity building. The project will support training in a range of institutions in the four countries and across the region. Tanzania will provide leadership in this area and establish a regional training hub. It will provide practical training at its state-of-the-art national health laboratory quality assurance and training centre and in-service training and post-graduate mentorships at the Muhimbili University of Health and Allied Sciences. Finally, the third component includes joint operational research, knowledge sharing and regional co-ordination, and programme management.
The authors of this article challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment in poor countries. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deploying primary and secondary caregivers, using off-patent drugs, and applying regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage, with a focus on people living in poverty. These strategies can reduce costs, increase access to health services and strengthen health systems to meet the challenge of cancer and other diseases, the authors argue. To promote cancer treatment in poor countries, the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries was formed in 2009. It is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation and evaluation of strategies to advance this agenda.
Eclampsia is the commonest direct cause of maternal death in South Africa. The latest Saving Mothers Report (2005-2007) indicates that there were 622 maternal deaths due to hypertensive disorders of pregnancy. Of these, 334 (55.3%) were due to eclampsia; of the eclamptic deaths, 50 were over the age of 35 years and 83 were under 20 years old. Avoidable factors involved patient related factors (mainly delay in seeking help), administrative factors (mainly delay in transport) and health personnel issues (mainly due to delay in referring patients). The major causes of death were cerebrovascular accidents and cardiac failure. The majority of deaths due to cardiac failure were due to pulmonary oedema. To reduce deaths from eclampsia, this study argues that more attention must be given to the detection of pre-eclampsia; the provision of information on the advantages of antenatal care to the population at large and training of health professions in the management of obstetric emergencies.
The United Nations Economic Commission for Africa (UNECA) and the World Health Organization (WHO) are joining forces to establish an African-owned and -governed initiative to promote innovation for the research and development of pharmaceuticals and other products to meet the health needs of the continent. The African Network for Drugs and Diagnostics Innovation (ANDI) will be based in Ethiopia and will help build research capacity on the continent and link biomedical innovation to development and public health. Overall, ANDI aims to mobilise Africa health research capability, uncapping African health innovation potential and expanding global partnerships and regional collaborations to accelerate the delivery of quality health care in Africa. Specific goals include increasing research and development collaboration among African institutions and countries, and fostering public-private partnerships within Africa to support the development and manufacture of new drugs and health products. It also aims to generate and manage intellectual property, explore innovative mechanisms to encourage and reward local innovation – including research drawing on traditional medicine – and promote long-term economic sustainability by supporting research and development.
Despite lack of resources, activities undertaken to mitigate the impact of neglected tropical diseases are so far producing unprecedented results, according to this report. It points to a number of successes: treatment with preventive chemotherapy reached 670 million people in 2008, while dracunculiasis, also called guinea worm disease, is on course to becoming first disease eradicated not by a vaccine, but by health education and behaviour change. Reported cases of sleeping sickness have also dropped to their lowest level in 50 years. The report notes opportunities for strengthening delivery systems, such as by targeting primary schools to treat millions of children for schistosomiasis and helminthiasis in Africa. In addition, better co-ordination is argued to be needed, such as with veterinary public health and to respond to changing disease patterns resulting from climate change and environmental factors.
8. Human Resources
In response to its critical health worker shortages, the Ministry of Health (MoH) in Zambia plans to double the annual number of health training graduates in the next five years to increase the supply of health workers. This study sought to determine the feasibility and costs of doubling training institution output through an individual school assessment framework. Assessment teams consulted faculty, managers and staff in all of Zambia's 39 public and private health training institutions in 2008. The individual school assessments affirmed the MoH's ability to double the graduate output of Zambia's public health training institutions. Lack of infrastructure was determined as a key bottleneck in achieving this increase while meeting national training quality standards. The authors argue that an investment of US$ 58.8 million is required to meet infrastructure needs, and the number of teaching staff must increase by 111% over the next five years.
Insecure access to food is increasingly recognized as a major contributor to cycles of poverty and HIV and AIDS in sub-Saharan Africa, according to this article. In this context, volunteers espouse desires for economic ‘progress’ amid a mix of pro-social and self-interested motivations to be volunteer AIDS caregivers. For these volunteers, food insecurity was particularly demotivating. Food crisis on top of chronic food insecurity pushed them to reconsider what they deemed as appropriate compensation for their efforts. Ironically, volunteers in such contexts may often be poorer than their clients. Ideally, effective and resilient community health workers should derive mental satisfaction and fair remuneration from their labour. The question for policy-makers is how to generate the spiritual benefits of altruistic, compassionate care as well as a level of remuneration that allows for secure livelihoods among volunteers who are often socioeconomically marginalized. WHO’s recent recommendation challenges various public and private entities to adapt to a system in which funding and other measures are used to create fairly-paid and secure health-care jobs in low-income countries facing pervasive food insecurity and high burdens of chronic and infectious disease. In sub-Saharan Africa, hiring, training and paying community health workers may be a win-win situation: people receive secure jobs that provide food security for their families and communities, and their participation strengthens health-care systems and people in need of care. The article emphasises that health programmers need to listen to what volunteers themselves – and the people whom they serve – say about the benefits and costs of volunteering.
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% (227/441) and 50% in 2007/08 (484/968). 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. In conclusion, there is a high level of commitment to public sector service. However, students, as future doctors, have very high salary expectations that will not be met by current public sector salary scales. This is reflected in an increasing degree of orientation to double sector employment after graduation.
This study looks at successful examples of health-focused online communities, like the Capacity Project’s Global Alliance for Pre-Service Education (GAPS), which provides an online forum to discuss issues related to teaching and acquiring competence in family planning in developing countries, and the Global Alliance for Nursing and Midwifery's ongoing web-based community of practice (CoP), which reaches many participants in a range of settings. In the survey, GAPS members suggested that, instead of focusing solely on family planning competencies, GAPS should include professional competencies (e.g. communication, leadership, cultural sensitivity, teamwork and problem solving) that would enhance the resulting health care graduate's ability to operate in a complex health environment. Resources to support competency-based education in the academic setting must be sufficient and appropriately distributed. The study concludes that online CoPs are a useful interface for connecting developing country experiences. To sustain an online CoP, funds must come from an international organisation (e.g. the World Health Organization) or a university that can carry the long-term costs. Eventually, the long-term effectiveness and sustainability of GAPS rests on its transfer to the members themselves.
In 2007, the Mozambican Ministry of Health (MoH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasising antiretroviral therapy (ART). Forty-four randomly selected TMs were directly observed by expert clinicians as they cared for HIV-infected patients in their usual worksites. Observed clinical performance was compared to national norms as taught in the course. In 127 directly observed patient encounters, TMs assigned the correct WHO clinical stage in 37.6%, and correctly managed co-trimoxazole prophylaxis in 71.6% and ART in 75.5%. Correct management of all five main aspects of patient care (staging, co-trimoxazole, ART, opportunistic infections, and adverse drug reactions) was observed in 10.6% of encounters. The observed clinical errors were heterogeneous. Common errors included assignment of clinical stage before completing the relevant patient evaluation, and initiation or continuation of co-trimoxazole or ART without indications or when contraindicated. In Mozambique, the in-service ART training was suspended. The MoH subsequently revised the TMs' scope of work in HIV/AIDS care, defined new clinical guidelines, and initiated a nationwide re-training and clinical mentoring program for these health professionals. Further research is required to define clinically effective methods of health-worker training to support HIV and AIDS care in Mozambique and similarly resource-constrained environments.
This study analysed the effect of Kenya’s Emergency Hiring Plan for nurses on their inequitable distribution in rural and underserved areas. It used data from the Kenya Health Workforce Informatics System on the nursing workforce to determine the effect of the Emergency Hiring Plan on nurse shortages and maldistribution. Of the 18,181 nurses employed in Kenya’s public sector in 2009, 1,836 (10%) had been recruited since 2005 through the Emergency Hiring Plan. Nursing staff increased by 7% in hospitals, 13% in health centres and 15% in dispensaries. North Eastern province, which includes some of the most remote areas, benefited most: the number of nurses per 100 000 population increased by 37%. The next greatest increase was in Nyanza province, which has the highest prevalence of HIV infection in Kenya. Emergency Hiring Plan nurses enabled the number of functioning public health facilities to increase by 29%. By February 2010, 94% of the nurses hired under pre-recruitment absorption agreements had entered the civil service. Preliminary indicators of sustainability are promising, as most nurses hired are now civil servants. However, continued monitoring will be necessary over the long term to evaluate future nurse retention.
The United States (US) Department of Health and Human Services is partnering with the US President’s Emergency Plan for AIDS Relief (PEPFAR) with a plan to invest US$130 million over five years in African medical education to increase the number of health care workers. Through the Medical Education Partnership Initiative (MEPI), grants are being awarded directly to African institutions in a dozen countries, working in partnership with US medical schools and universities. The initiative will form a network including about 30 regional partners, country health and education ministries, and more than 20 US collaborators.
9. Public-Private Mix
Each year, diarrhoeal diseases claim the lives of nearly two million people – 90% of them children under the age of five. The problem is especially critical in Africa, a continent that contains 10% of the world's population, but accounts for 40% of the deaths of children under age five. This paper uses panel data on the sub-national regions of 26 African countries over 1985-2006, a period of expanded private sector participation in water supplies to explore the impact on child health. Using a fixed effects analysis the author suggests that an expansion in piped water after PSP was associated with a 5% decrease in diarrhoea in children under-five. The author notes, however, that PSP In Africa was often pursued as a remedy to a severely distressed water sector with government under-investment for years.
10. Resource allocation and health financing
What is the relevance of the aid commitments embodied in the Paris Declaration on Aid Effectiveness (2005) and the Accra Agenda for Action (2008) to development actors in South-South co-operation? While research on South-South co-operation is increasing, this article notes that it appears to be largely focused on financial flows or on a limited number of emerging economies, but not on the experiences of practitioners of South-South (SS) co-operation themselves. The article offers two reasons why aid matters for SS partners. First, aid effectiveness is important for partner countries. The effectiveness commitments embodied in the Paris Declaration and the Accra Agenda for Action have failed to promote behavior change, for example, in increasing the use of country systems and in making aid more predictable. One possible solution is the internationally recognised Survey on Monitoring the Paris Declaration, which tracks the implementation of the Paris commitments. Second, development actors need to go beyond the conventional ‘donor-recipient’ relationship, especially as the development co-operation architecture is becoming more diversified and complex. The Accra Agenda for Action in 2008 opened the door to encourage an inclusive and effective development partnership with civil society, parliamentarians, private sector, providers of South-South co-operation, foundations and global programmes. More actors are taking ownership of the aid effectiveness agenda by shaping it with their own views and experiences. One such example is the Dili Declaration (April 2010), in which a group of fragile states, including the Democratic Republic of Congo, have adapted aid effectiveness principles to their situations of national conflict and fragility.
This report aims to call health leaders’ attention to the importance and feasibility of establishing the systems and institutions needed to pursue universal health coverage (UHC). It also seeks to quantify the transition costs associated with reforming a health system away from one that relies on out-of-pocket payments and towards one in which health expenditures are more evenly distributed and that can supply UHC. Although models for UHC vary by country, governments are re-organising national health systems to share health costs more equitably across the population and its life cycle, instead of concentrating the burden on the few who face catastrophic illness in any given year. Using examples from four countries that have made tremendous strides toward achieving universal coverage, including Rwanda, the report puts an approximate price tag on these investments. It concludes that relatively small early investments can set countries on the path toward UHC.
Many of the 68 priority countries in the Countdown to 2015 Initiative are dependent on official development assistance (ODA). This study analysed aid flows for maternal, newborn, and child health for 2007 and 2008 and updated previous estimates for 2003—06. It found that, in 2007 and 2008, US$4.7 billion and $5.4 billion, respectively, were disbursed in support of maternal, newborn and child health activities in all developing countries, reflecting a 105% increase between 2003 and 2008, but no change relative to overall ODA for health. Targeting of ODA to countries with high rates of maternal and child mortality improved over the six-year period, although some of these countries persistently received far less ODA per head than did countries with much lower mortality rates and higher income levels. Funding from the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria exceeded core funding from multilateral institutions, and bilateral funding also increased substantially between 2003 and 2008, especially from the United States and the United Kingdom. However, the authors caution that these increases do not reflect increased prioritisation relative to other health areas.
This study found that international financing for malaria control has increased by 166% (from $0.73 billion to $1.94 billion) since 2007 and is broadly consistent with biological needs. African countries have become major recipients of external assistance, but countries where malaria continues to pose threats to control ambitions are not as well funded. Twenty-one countries have reached adequate assistance to provide a comprehensive suite of interventions by 2009, including twelve countries in Africa. However, this assistance was inadequate for 50 countries, representing 61% of the worldwide population at risk of malaria - including ten countries in Africa and five in Asia that co-incidentally are some of the world’s poorest countries. Approval of external funding for malaria control does not correlate with gross domestic product, the study found. In conclusion, funding for malaria control worldwide is 60% lower than the US$4.9 billion needed for comprehensive control in 2010. This includes funding shortfalls for a wide range of countries with different numbers of people at risk and different levels of domestic income. More efficient targeting of financial resources against biological need and national income should create a more equitable investment portfolio that with increased commitments will guarantee sustained financing of control in countries most at risk and least able to support themselves.
In this report, the World Health Organization maps out what countries can do to modify their financing systems so they can move more quickly towards the goal of universal health coverage and sustain the gains that have been achieved. The report builds on new research and lessons learnt from country experience. It provides an action agenda for countries at all stages of development and proposes ways that the international community can better support efforts in low income countries to achieve universal coverage and improve health outcomes. To ensure universal coverage, countries must raise sufficient funds, reduce the reliance on direct payments to finance services, and improve efficiency and equity. The report proposes three ways for governments to raise money: increase the efficiency of revenue collection, re-prioritise government budgets and put innovative financing mechanisms in place.
11. Equity and HIV/AIDS
In light of increasing access to antiretroviral therapy in sub-Saharan Africa, the authors conducted a longitudinal study to assess the impact of antiretroviral therapy on sexual risk behaviours among HIV-infected South Africans in urban and rural primary care clinics. This prospective observational cohort was conducted at rural and urban primary care HIV clinics, consisting of 1,544 men and 4,719 women enrolled from 2003 to 2010, and representing 19,703 clinic visits. The primary outcomes were being sexually active, unprotected sex and more than one sex partner and were evaluated at six-monthly intervals. Generalised estimated equations assessed the impact of antiretroviral therapy on sexual risk behaviours. Among 6,263 HIV-infected men and women, over a third (37.2%) initiated antiretroviral therapy (ART) during study follow-up. In comparison to pre-ART follow-up, visits while receiving antiretroviral therapy were associated with a decrease in those reporting being sexually active. Unprotected sex and having more than one sex partner were reduced at visits following ART initiation compared to pre-ART visits. Sexual risk behaviour significantly decreased following antiretroviral therapy initiation among HIV-infected South African men and women in primary care programmes. The study concludes that further expansion of ART programmes could enhance HIV prevention efforts in Africa.
This short film argues that many more people living with HIV in sub-Saharan Africa could be treated if laboratory tests were used in a targeted rather than routine way. Trial participants, practitioners and investigators explain how maintaining and scaling up access to antiretroviral therapy (ART) in low- and middle-income countries could be possible on current funding levels, even in the midst of a global economic crisis. The principal message from Developing Antiretroviral Therapy in Africa (DART) is that ART saves lives, and that it can be delivered safely and successfully without the use of routine laboratory testing for drug toxicity and side effects. Use of routine CD4 testing for monitoring disease progression is argued to offer only a small benefit to patients after the second year of therapy. Trial investigators believe that priority should be given to widening access to first- and second-line drugs to treat HIV, with resources focused on strengthening healthcare systems and training well-supervised healthcare workers to deliver quality care in rural areas.
This study assessed differences in access to antiretroviral treatment (ART) and patient outcomes across public sector treatment facilities in the Free State province, South Africa. It took the form of a prospective cohort study with retrospective database links. Data on patients enrolled in the treatment programme was analysed across 36 facilities between May 2004 and December 2007. Of 44,866 patients enrolled, 15,219 initiated treatment within one year, 8,778 died within one year (7,286 before accessing ART). Outcomes at one year varied greatly across facilities and more variability was explained by facility-level factors than by patient-level factors. The odds of starting treatment within one year improved over calendar time. Patients were less likely to start treatment if they were male, severely immunosuppressed, or underweight. Men were also more likely to die in the first year after enrolment. Although increasing numbers of patients started ART between 2004 and 2007, many patients died before accessing ART. Patient outcomes could be improved by decentralisation of treatment services, fast-tracking the most immunodeficient patients and improving access, especially for men.
The authors of this study assessed symptom prevalence, general health, ability to perform normal activities, and employment status among adult antiretroviral therapy (ART) patients in South Africa over three full years following ART initiation. A cohort of 855 adult pre-ART patients and patients on ATY for <6 months was enrolled and interviewed an average of 4.4 times each during routine clinic visits for up to three years after treatment initiation using an instrument designed for the study. The probability of pain in the previous week fell from 74% before ART initiation to 32% after three years on ART, fatigue from 66% to 12%, nausea from 28% to 4%, and skin problems from 55% to 10%. The probability of not feeling well physically yesterday fell from 46% to 23%. Before starting ART, 39% of subjects reported not being able to perform their normal activities sometime during the previous week; after three years, this proportion fell to 10%. Employment rose from 27% to 42% of the cohort. Improvement in all outcomes was sustained over three years and, for some outcomes, increased in the second and third year. Improvements in adult ART patients' symptom prevalence, general health, ability to perform normal activities and employment status were large and were sustained through the first three years on treatment. These results suggest that some of the positive economic and social externalities anticipated as a result of large-scale treatment provision, such as increases in workforce participation and productivity and the ability of patients to carry on normal lives, may indeed be accruing.
This study sought to quantify the number of cases and prevalence of human immunodeficiency virus (HIV) infection among older adults in sub-Saharan Africa. It reviewed data from Demographic and Health Surveys (DHS), of which 8 surveys contained data on HIV infection among men aged ≥ 50 years. Data was also extrapolated from the Joint United Nations Programme on HIV/AIDS on the estimated number of people living with HIV and on HIV infection prevalence among adults aged 15–49 years. The study found that, in 2007, approximately 3 million people aged ≥ 50 years were living with HIV in sub-Saharan Africa. The prevalence of HIV infection in this group was 4.0%, compared with 5.0% among those aged 15–49 years. Of the approximately 21 million people in sub-Saharan Africa aged ≥ 15 years that were HIV+, 14.3% were ≥ 50 years old. The study concludes that to better reflect the longer survival of people living with HIV and the ageing of the HIV+ population, indicators of the prevalence of HIV infection should be expanded to include people > 49 years of age. Little is known about comorbidity and sexual behaviour among HIV+ older adults or about the biological and cultural factors that increase the risk of transmission. HIV services need to be better targeted to respond to the growing needs of older adults living with HIV.
Much of the debate as to whether or not the scaling up of HIV service delivery in Africa benefits non-HIV priority services has focused on the use of nationally aggregated data. This paper analyses and presents routine health facility record data to show trend correlations across priority services. The authors conducted a review of district office and health facility client records for 39 health facilities in three districts of Zambia, covering four consecutive years (2004-2007). Intra-facility analyses were conducted, service and coverage trends assessed and rank correlations between services measured to compare service trends within facilities. Voluntary counselling and testing, antiretroviral therapy and prevention of mother-to-child transmission client numbers and coverage levels were found to have increased rapidly during the period. There were some strong positive correlations in trends within facilities between reproductive health services (family planning and antenatal care) and antiretroviral therapy and prevention of mother-to-child transmission. Childhood immunisation coverage also increased. Stock-outs of important drugs for non-HIV priority services were significantly more frequent than were stock-outs of antiretroviral drugs. The analysis shows scale-up in reproductive health service numbers in the same facilities where HIV services were scaling up. While district childhood immunisations increased overall, this did not necessarily occur in facility catchment areas where HIV service scale-up occurred. The paper demonstrates an approach for comparing correlation trends across different services, using routine health facility information. Larger samples and explanatory studies are needed to understand the client, facility and health systems factors that contribute to positive and negative synergies between priority services.
Delayed test results often mean HIV patients in Mozambique fail to get timely treatment, but new technology is reducing the need to send tests to far away laboratories, and speeding up test results and HIV treatment. After a successful 2009 pilot, the country has nationally rolled out SMS or text message printers, which transmit the results of infant HIV tests electronically from two central reference laboratories in Maputo and the northern provincial capital, Nampula, to more than 275 health centres. Previously, test samples and results would have taken on average three weeks and up to several months to be transported to and from clinics via car, plane and even kayak in remote parts of the country. According to research conducted by the Ministry of Health and the Clinton Health Access Initiative (CHAI), who developed the technology, the time it took for clinics to receive test results dropped from an average of about three weeks to about three days after the printers were introduced. This, in turn, reduced the time it took to start infants on antiretroviral (ARV) treatment as part of national prevention of mother-to-child (PMTCT) HIV transmission services by about four months. The number of infants starting treatment also increased by 60%.
This study is based on a one-week integrated multi-disease prevention campaign in Lurambi, Western Kenya. The aim was to offer services to at least 80% of those aged 15-49. Thirty-one temporary sites in strategically dispersed locations offered: HIV counselling and testing, 60 male condoms, an insecticide-treated bed net, a household water filter for women or an individual filter for men, and, for those testing HIV+, a three-month supply of cotrimoxazole and referral for follow-up care and treatment. Over seven days, 47,311 people attended the campaign with a 96% uptake of the multi-disease preventive package. Of these, 99.7% were tested for HIV (80% had previously never tested), of whom 4% tested positive. Three-hundred and eighty-six certified counsellors attended to an average of 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age and tended to correlate with an ended marriage and unemployment. Always using condoms with a non-steady partner was more common among HIV-infected women participants who knew their status compared to those who did not. The study concludes that integrated campaigns can efficiently cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services to help achieve various national and international health development goals.
This case study on Rwanda investigates the links between investments in the AIDS response (specifically, Millennium Development Goal 6) and progress towards other health-related Millennium Development Goals (MDGs). The methodology used for this study draws on a rapid assessment approach, with significant study limitations, and the authors caution that their study should only be seen as a step-wise contribution to a more rigorous, research-based analysis. They also emphasise that recent developments in the health sector have a bearing on this study, such as decentralisation of healthcare services with structural integration and establishment of a cadre of community health workers, as well as scaling up of performance-based financing and community-based health insurance. Overall, Rwanda has made good progress in addressing MDG 6. The multisectoral AIDS response, which is based on the principles of the ‘Three Ones’, has resulted in a decline in HIV prevalence to 3% (from 11% in 2000), with some 76,726 individuals receiving ART in 2009 (representing around 77% of those in need). In terms of the other health-related MDGs, investments in the scale-up of prevention of mother-to-child transmission and paediatric ART are likely to have contributed to the reduction of child mortality in Rwanda (MDG 4), while the country shows a 25% reduction in maternal mortality between 2000 and 2005 (MDG 5), and investments from the AIDS response are suggested to have contributed to the prevention and mitigation of violence against women (MDG 3).
12. Governance and participation in health
The 2010 Corruption Perceptions Index shows that nearly three quarters of the 178 countries in the index score below five, on a scale from 10 (highly clean) to 0 (highly corrupt). These results indicate a serious corruption problem. To address these challenges, Transparency International recommends that governments integrate anti-corruption measures in all spheres, from their responses to the financial crisis and climate change to commitments by the international community to eradicate poverty. It also advocates stricter implementation of the UN Convention against Corruption, the only global initiative that provides a framework for putting an end to corruption.
This paper argues that the World Health Organization (WHO) should act as the directing and co-ordinating authority on future international health work, and its global health leadership must be earned through strategic and selective engagement. The authors caution that the focus of the paper is not the co-ordination of external development funders for health – which they do not consider WHO’s role – but the challenge of how WHO’s accountability to the global health community can be increased in the context of other normative and strategic dimensions of global health governance. WHO needs to provide mechanisms and instruments that link the new global health actors to the system of multilateral intergovernmental institutions, and it should engage in new ways with the many non-health actors that can influence health both positively and negatively, as well as improve its co-ordination function in relation to the development of legal instruments for health. The authors consider the World Health Assembly (WHA) as an inclusive forum that allows poorer countries to have a voice in global health. Consequently, they propose the establishment of a Committee C of the WHA, which will be legitimately represented and will deal with coherence, partnerships and the co-ordination of global health governance.
This paper explores whether community participation through health committees can advance the right to health, and what constitutes best practice for community participation through South African health committees. It reports on a series of 32 in-depth interviews with members of three community health committees and health service providers in the Cape Metropolitan area. The interviews revealed that, even in resource-constrained settings, community participation through health committees can advance the right to health. This advance mainly occurs through reported improvements in the acceptability and accessibility of local health services. Still, progress is restricted by the amount of power held at different levels of decision-making. The most prominent barriers to participation mentioned by participants included underrepresentation of vulnerable and marginalised groups, and the absence of a formal mandate giving health committees clear objectives and the authority to achieve them, which undermined their ability to make any significant improvements.
This article raises the question of whether the Gates Foundation’s underwriting of journalism, for example by funding radio health programmes in the United States (US) and health journals like Global Health, creates a conflict of interest for journalists, especially when the Foundation does not disclose its funding upfront. Although the Foundation might not have advocated for specific programmes, it does have distinct policy preferences and policy-shaping efforts, potentially influencing the media. The Kaiser Family Foundation (KFF), which was given a five-year, US$9.9 million grant last year by the Gates Foundation, is supposed to provide independent analysis of US global health policies, which have direct bearing on the Gates Foundation’s programmes. Prominent among these programmes is KFF’s US Global Health Policy portal, which selects and summarises global health news from more than 200 worldwide sources spanning mainstream media outlets to blogs. KFF sends a daily email news digest to policy makers, opinion leaders and journalists. The author argues that, not only does KFF have the power to choose what constitutes global health news but, in summarising the stories it selects, it can give them a construction of its own choosing. In key instances, the KFF’s global health news coverage suggests bias both in story selection and preferential treatment of the Gates Foundation. The author calls for increased transparency of funding sources for health programmes and health journalism.
This study first briefly reviews the historical evolution of global environmental diplomacy and governance. It then examines its dominant ideas, instruments, and institutions, including the key environment-economy connection, comparing them with the experience in health at every stage. Its analysis reveals that both environmental and health diplomacy are better at solving yesterday’s specific, acute, concentrated, deadly problems than today and tomorrow’s diffuse, silent, chronic, cumulative but more dangerous and deadly ones. The authors therefore advise caution when sharing lessons, in light of the significant failures in each field. The environmental field is seen as more progressive than health, which has relied largely on the 1948 World Health Organization (WHO) Constitution’s principles, with little added to elaborate and modernise it since. The authors argue that environmental diplomacy and governance is better integrated with the economy and peoples’ livelihoods, which depend on natural resources, while the global health sector still struggles to promote a socio-economic approach, amid the many incentives to focus on single, high-profile diseases. The paper calls for more civil society participation in health, referring to lessons from a long tradition of environmental activism. Health could engage more with groups, such as the G8 and G20, so that health issues are recognised and integrated within economic policy dialogue.
This article reports efforts of Civil Society Organisations (CSOs) to make South-South (SS) co-operation a vehicle for knowledge exchange. The article argues that SS co-operation must be aligned to national development strategies developed through broad-based processes with the participation of parliaments, CSOs, academic institutions, and independent media. It calls for mutual accountability between Southern external funders, countries and their citizens, and increased inclusion of affected actors in assessing aid and development effectiveness.
This article considers new opportunities for South-South co-operation, and proposes that the G20 is a good platform for African countries to leverage South-South (SS) exchange practices. African organizations, like the African Union (AU) and the New Partnership for Africa’s Development (NEPAD), offer mutual learning opportunities to other South countries, like Brazil, and have supported both South-South and North-South knowledge exchanges. The development priorities identified by the AU and NEPAD have been guided by sectoral policy frameworks encouraging innovative exchanges in multistakeholder collaborations and partnerships. If Africa is to be globally competitive, greater investment in this kind of knowledge and learning will be required, the article argues. Knowledge-based approaches to resolving Africa’s development challenges should be strengthened, with research and innovation helping to expand the SS co-operation policy frontiers. Strategically designed institutional arrangements can facilitate the participation of multiple stakeholders, thus fostering the formation of social capital by enhancing SS networks for the exchange of knowledge. Existing regional frameworks are critical in guiding and framing the knowledge and learning architecture in Africa, but innovations must be grounded in the realities of the continent to achieve their desired results. The article concludes that the success of this new development paradigm depends on the establishment of new partnerships to foster more inclusive, equitable and sustainable forms of development co-operation.
13. Monitoring equity and research policy
A new platform for scaling up drugs and other health interventions to meet national and regional needs in developing countries was launched at the opening of the First Global Symposium on Health Systems Research, held from 16-19 November 2010 in Switzerland. The platform is a new collaboration of several organisations at the World Health Organization, with funding from the Norwegian Agency for Development Co-operation (NORAD) and the Swedish International Development Co-operation Agency (SIDA). The first seven projects were announced, which include projects in Kenya and Uganda. The platform is guided by an open, transparent selection of proposals and has been set up to help build evidence for the health-related Millennium Development Goals to improve child and maternal health and reduce HIV/AIDS, and to build capacity for health systems research and knowledge translation, particularly in low- and middle-income countries. The platform is intended to allow a greater degree of ‘inter-disciplinarity’ to strengthen the whole health system. It will examine the interface between scale-up and implementation of health services.
India and South Africa will launch a joint research project to find vaccines for HIV strains common to both countries. The project was formally approved by the governments of both countries last spring and is expected to be launched by the end of 2010. Virander Chauhan, director of the International Centre for Genetic Engineering and Biotechnology, New Delhi, said that the five-year, US$1 million dollar project will involve around five research groups from each country with core competence in basic and HIV vaccine research. A successful partnership could serve as a model for similar South–South collaborations and inspire other developing countries to go the same route.
Infectious diseases are bound by a complex interplay of factors related as much to the individual as to the physical, social, cultural, political and economic environments. Furthermore each of these factors is in a dynamic state of change, evolving over time as they interact with each other. Simple solutions to infectious diseases are therefore rarely sustainable solutions, this article argues. This calls for interdisciplinary approaches that address complexity. The article proposes that research and the largely biomedical interventions for neglected tropical diseases, largely neglect the social and ecological contexts that lead to the persistence of these diseases.
This background paper was prepared for the Global Symposium on Health Systems Research, held from 16-19 November 2010 in Switzerland, and it is concerned with how best to enhance capacity for health systems research (HSR), with a particular focus on low- and middle-income countries (LMICs). A systematic review was conducted of initiatives and interventions that have sought to enhance capacity for health systems research, and 73 research papers were included - 49 papers from high-income countries (HICs) and 24 from low- and middle-income countries. The review found that capacity building initiatives focused primarily on the individual and organisational levels and paid less attention to the broader environment, such as national research funding systems and their links to HSR. Governments, donors and non-governmental organisations are urged to invest in co-ordinated efforts to develop additional capacity for health systems research, partly by re-directing funding that currently goes to short-term technical assistance towards longer-term institutional support.
14. Useful Resources
The Equity-Oriented Toolkit is currently in the process of being updated and expanded. It is based on a needs-based model of health technology assessment (HTA). It provides tools that explicitly consider health equity at each of the four steps of HTA: burden of illness, community effectiveness, economic evaluation, knowledge translation and implementation. It also incorporates concepts of health impact assessment within the HTA process. The World Health Organization 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, databases such as The Cochrane Library. Visit the website to make your suggestions.
In 1970, the United Nations General Assembly passed Resolution 2626 (1), which pledged for the first time that developed nations would provide 0.7% of their wealth in foreign aid. Forty years later this pledge has yet to be realised and currently looks unlikely to be met. On the 40th anniversary of the Resolution, Action for Global Health has launched an ‘Action Tracker’, an online tool that tracks the contributions that European Union (EU) member states make to improve health in developing countries. It determines whether or not these states are actually providing 0.7% of their wealth for development aid, and calculates how much of this aid is devoted to health. So far the Action Tracker has data on about half the countries in the EU, but will develop over time to include all 27 EU member states. It will also assess to what extent they are implementing their commitments to make this aid more effective and ensuring their other policies support health in developing countries.
The Global Health Diplomacy Network (GHD.Net) brings together researchers and practitioners with the common goal of improving capacity for health diplomacy (GHD). GHD.Net defines ‘global health diplomacy’ as the policy-shaping processes through which States, intergovernmental organisations and non-State actors negotiate responses to health challenges or utilise health concepts or mechanisms in policy-shaping and negotiation strategies to achieve other political, economic or social objectives. GHD.Net’s mission is to increase knowledge about GHD, improve training and education for those who engage in GHD, and innovate in the provision of advice into GHD processes. Through its website, publications, and other activities, it aims to put in the public domain up-to-date information on research and training in this field. It will also track and report on current diplomatic negotiations that have direct or indirect impact on health policy and health. It has four functions: to act as a clearinghouse for GHD-related information; to enhance connectivity among network participants; to develop content for research, training and education; and to build capacity, especially in partnership with interested institutions and individuals in low-income countries. GHD.Net will also identify the characteristics of health as a foreign policy and diplomatic issue and provide research, training, and policy-relevant inputs to contribute to improving the protection and promotion of health through foreign policy and diplomatic means. It offers training and regularly calls for submission of research papers.
15. Jobs and Announcements
The Executive Board of the World Health Organization (WHO) has decided that its 128th session should be convened on 17 January 2011, at WHO headquarters, Geneva, and should close no later than 25 January 2011. The Board further decided that the thirteenth meeting of the Programme, Budget and Administration Committee of the Executive Board should be held on 13 and 14 January 2011, at WHO headquarters.
The Best Practices in Global Health Award is given annually by the Global Health Council to celebrate and highlight the efforts of a public health practitioner or organisation dedicated to improving the health of disadvantaged and disenfranchised populations, and to recognise the programmes that effectively demonstrate the links between health, poverty and development. The person or organisation selected for this award must be able to demonstrate the success of their programme(s) and measurable results in the field, as well as possess the ability and expertise to share, inspire and extend best practices for improving health. If you would like to nominate someone, visit the website address given.
The Canadian International Development Agency’s (CIDA) Partnerships with Canadians Branch (PWCB) is launching a C$75 million call for projects over $500,000 to take a comprehensive and integrated approach to address maternal, newborn, and child health, under its Partners for Development Programme. Projects must align with the elements and principles of Canada's contribution to the Muskoka Initiative, which will focus its efforts along three key paths: strengthening health systems to improve health service delivery at the district level by training more health workers and expanding access for mothers and children to needed health care facilities and interventions; improving nutrition by increasing access to healthy and nutritious food and needed nutritional supplements that help reduce mortality; and addressing the leading diseases and illnesses that are killing mothers and their children. Projects must be implemented in eligible countries with high rates of maternal and child mortality. Eligible countries in the East, Central and Southern African region are the Democratic Republic of Congo, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe. This call will fund projects from Canadian organisations in partnership with organisations in developing countries.
Funded by the Ministry of Foreign Affairs and managed by the Netherlands Organizations for International Co-operation in Higher Education (NUFFIC), the Netherlands Fellowship Programme is an opportunity for non-governmental organisations, governmental and private organisations in developing countries to build their capacity. The overall aim of the NFP is to help alleviate qualitative and quantitative shortages of skilled staff within a wide range of governmental, private and non-governmental organizations by offering fellowships to mid-career professionals to improve the capacity of the organizations they work for. The need for training has to be evident within the context of an organisation. Candidates from Sub-Saharan Africa, women and members of priority groups and marginalised regions are specifically invited to apply for an NFP fellowship. The NFP offers several sub-programmes. Each sub-programme has a separate section on the Fellowship Programme’s website, with information about eligibility criteria, application and selection and deadlines (if applicable). Sub-programmes include short courses, master’s degrees and PhD studies.
The threat from counterfeit and sub-standard medicines is growing, particularly in poorer countries with weak regulatory mechanisms and poorly monitored distribution networks. Counterfeiting can be very profitable, and counterfeiters are increasingly sophisticated, making patients in developing countries, who usually have to buy medicines from their own resources, particularly vulnerable. The Centre on Global Health Security is organising this roundtable meeting, the objective of which is to help refine definitions of counterfeit, falsified and substandard medicines and to consider possible ways forward for the international community in addressing the health hazards posed by these medicines. Participants will include senior representatives from concerned international organisations, governments, industry, academia and civil society.
In 2006, the United Nations General Assembly (GA) agreed to undertake a comprehensive review in 2011 of the progress achieved in realising the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS. Civil society involvement is being called for in the UN General Assembly 2011 Comprehensive AIDS Review, to be held in New York in June 2011 (still to be confirmed). A Civil Society Task Force (CSTF) is being set up as a mechanism to facilitate input of civil society and the private sector in the 2011 Review, including the preparatory process. The Task Force will include twelve individuals from a broad range of civil society groups and from geographically diverse countries. The Task Force will lead on: shaping and implementing the design for the Civil Society Dialogue in April 2011, including format, topics, messages and speakers; devising criteria and the call for nominations for civil society speakers; identifying, preparing and briefing civil society speakers for all formal sessions; and briefing civil society participants in the High Level Meeting. Those civil society advocates interested in participating in joint advocacy and mobilisation are invited to join the AIDS Review listserve.
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