This month's editorial draws our attention to the shift the profile on universal coverage has brought in the international debate on global health. Much of this dialogue on universal coverage has been focused on financing issues. However universal policies cannot be only technical, or financial. A December 2010 World Conference on Universal Social Security Systems in Brazil put it simply - universal policies are the means to deliver on rights based guarantees that citizens are entitled to and that states have a duty to ensure, including access to health care. At national and global level there is a huge gap in how this is delivered on. Researchers from Africa, Asia and the Americas observed in a statement at the final plenary of the first Global Symposium on health systems research: “Equity is the central goal. Universal health coverage is the means of achieving equity”. As experience has taught in many places, closing this gap, nationally and globally, calls, beyond technical options, on political leadership and social power and action. What we say and do within and across all our different constituencies will be pivotal in realising universal policies in health. We wish you a safe, healthy and peaceful new year and look forward to our interaction towards equity in 2011.
1. Editorial
Today, over 100 million people are cast into poverty each year because they have to pay for health care services “out of pocket”. The lack of adequate social protection in health and the lack of health care coverage in case of ill health, plays a decisive role in the scandalous inequity in access to proper health care - challenging all countries, not least those in Africa.
On November 22-23, 2010, on the occasion of the presentation of the World Health Report (WHO) Report for 2010 on ‘Health Systems Financing – the path to Universal Coverage’, the German Federal Government, together with the WHO, convened an International Conference in Berlin. The gathering was attended by almost thirty Ministers of Health from all over the world together with government officials, politicians, some researchers and a few non government organisations.
Everyone agreed on the aim to achieve universal coverage. Remarkably the model that was presented by WHO concerning this doesn’t speak about just going for “some coverage” or essential minimum packages for the poor, but demands from all countries to do their utmost to set up pooled funds that cover three dimensions: expanding the number of people covered, expanding the scope of services and reducing cost sharing (direct payment such as user fees).
WHO General Director Dr Margaret Chan who addressed the audience at the beginning raised the demand to get rid of user fees, because "user fees punish the poor". All countries have people who are too poor to contribute financially to health care. They need to be subsidised from pooled funds, generally tax-based health systems. Out of pocket payments have to be reduced by promoting prepayment and pooling systems (tax-based or mandatory social heath insurance). All agreed that there is no ‘silver bullet’ that serves as a solution for all countries. There is no global scheme that has to be "adopted" by all countries, but the need is to “adapt” a way to move forward in the three dimensions (population covered, the scope of services expanded and cost sharing reduced) at national level. Universal coverage cannot be achieved by connecting access to health care with individual purchasing power, but only by solidarity. This means that people who are richer also contribute to the health needs of those who are poorer. By articulating these principles, WHO has opened space for national adaptations. This provides civil society organizations with the opportunity to continuously engage and challenge their governments on their delivery on these principles, such as what they are doing to expand the scope of services.
With exception of few participants nobody mentioned private companies as relevant actors. Achieving universal coverage requires the strengthening of health systems. Ensuring affordable access to health was ultimately seen to be a public responsibility and not to be relegated to private insurance companies. Participants from Africa reiterated the 2001 Abuja Declaration to allocate at least 15% of annual government domestic spending to the improvement of the health sector.
To ultimately realize the right to health, governments have to create the needed fiscal space. In this regard, the 2010 World Health Report mentions as possible new sources of revenue: a special levy on large and profitable companies, a currency transaction levy, a financial transaction tax, and the so-called sin-taxes (alcohol, tobacco). No reference was made to ‘for profit Public-Private-Partnerships’.
In the context of global responsibilities, the report states that countries providing overseas development aid should do more to meet their international commitments, by providing a more predictable and long-term flow of aid.
We should not be surprised to find that a ministerial conference also produces nice and bubbly words. Some of the presenters mixed up risk-sharing with solidarity-actions. And when it came to actions many preferred to be vague in their statements. Nevertheless, there is an interesting shift in the international debate on global health. Thirty two years after its first use, the concept of ‘Health for all’ is back on the agenda.
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 see the 2010 World Health Report, www.who.int/whr/2010/en/index.html , the EQUINET website at www.equinetafrica.org. or the MEDICO website at http://www.medico.de/en/
2. Latest Equinet Updates
On 20-22 September 2010, world leaders gathered in New York to examine what needs to be done to meet the Millennium Development Goals (MDGs). The United Nations called for accelerated progress to meet the MDGs, citing unpredictable and insufficient international financing as the main obstacle. New mechanisms proposed for health financing included a currency transaction tax, in addition to overseas development aid. Mechanisms already launched have been projected to raise a further approximately US$$1billion annually. The transaction tax will raise an estimated US$30 billion per year. Multilateral tax funding has been blocked in the past by concerns over democratic oversight and how the revenues will be spent. The Summit recognised in its draft resolution that ‘innovative financing mechanisms can make a positive contribution’ and called for such financing to scale up and supplement, but not substitute, traditional sources. This article argues that it is likely that attention will grow around effective means to levy global economic activity to pay for global public goods, raising new resources for health and new challenges for African health diplomacy and systems to encourage, orient and effectively apply these resources. (Authors from TARSC and SEATINI in EQUINET contribute to the Global Health Diplomacy Monitor).
This radio series was developed from a participatory communications process undertaken in Monkey Bay, Malawi. The participatory communication process was a follow up to previous PRA research, and sought to identify a key message, the audience participants wanted the message to reach and the medium appropriate for doing so. In the participatory process, it was decided to communicate a positive message about how girl orphans and vulnerable children could avoid sex work to local stakeholders such as community-based organisations, families and local government officials. The participants chose to create a radio drama, for broadcast in Chichewa on Dzimwe Community Radio station. The script was developed by participants in the workshop, including orphans and vulnerable children and reformed sex workers; the children then acted in the show, and the show was later broadcast in several parts. The radio drama focuses on the ordeals of one character, Irene, who is an orphan staying with an abusive aunt. Despite the ordeals she goes through she finally succeeds, while the promiscuous children around her who turn to sex work, loose. The show encourages listeners to love and understand the needs of orphans and encourages orphans to seek positive ways out of their difficulties, not sex work. The file size for the programme is too large to upload but can be sent by direct email on request to admin@equinetafrica.org
The Learning Network for Health & Human Rights (South Africa) through University of Cape Town and HEPS-Uganda co-convened this regional meeting in Kampala Uganda on 8 October 2010 within the Regional Network for Equity in Heath in East and Southern Africa (EQUINET). The primary intention of the meeting was to enable the regional sharing of best practice around the right to health and community participation, as well as to explore the development of a toolkit/training manual on the Right to Health for Civil Society groups in the region. Discussions for the way forward included plans for future action on the toolkit, a human rights curriculum for health workers, and for community governance structures for health.
African countries are currently negotiating economic partnership agreements (EPAs) with the European Union to replace existing preferential trade agreements. The proposed EPAs cover a wide range of issues and are likely to impact on health, this article notes. The impacts include effecfts on public revenues for health and health care, access to medicines and determinants of health like food security. Without careful analysis during the negotiations, the author of this article warns EPAs could have negative impacts on the health systems and population health in Africa. Market liberalisation under structural adjustment programmes (SAPs) have so far weakened public health systems in Africa, the article argues, resulting in increased commercialisation of public services, falling public budgets for public health care, a shift in government away from direct health service provision to outsourcing contractors and the liberalisation of health insurance rather than tax-based financing. There have been concerns trade commitments in the EPA would translate into more market-based reforms and the negative effects they have been associated with. As negotiations are still underway, the author urges for government and other stakeholders to ensure clauses are included that explicitly protect health and do not mitigate national health objectives and commitments. (Authors from SEATINI and TARSC in EQUINET are contributing to the Global Health Diplomacy Monitor).
3. Equity in Health
The Global Tuberculosis Control Report is compiled annually by the World Health Organization, and this edition documents the success and challenges in tuberculosis (TB) treatment worldwide during 2009/2010. Some successes are highlighted, such as a 35% drop in the TB death rate since 1990, with a slow decline in TB incidence. It indicates that the world is on track to reach the Millennium Development Goal for TB incidence, and the Stop TB Partnership 2015 target for TB mortality. There has also been major progress in improving access to diagnosis and treatment, and also in the scale up of TB/HIV intervention and strengthening of laboratory services. However, major challenges still exist. In 2009, 1.7 million died from TB, and although incidence levels are falling, they are falling too slowly, the report has revealed. It predicts that, under the current rate of decline, TB will not be eliminated within the next generation. Also, the response to multi-drug resistant TB is still insufficient and more efforts are needed to scale up and strengthen programmes, especially with 440,000 new cases emerging each year. Less than 5% of those cases are being properly treated, the report notes.
According to this article, women's health is closely linked to a nation's level of development, with the leading causes of death in women in resource-poor nations attributable to preventable causes. Unlike many health problems in rich nations, the cure relies not only on the discovery of new medications or technology but also getting basic services to the people who need them most and addressing underlying injustice. In order to do this, the article argues that political will and financial resources must be dedicated to developing and evaluating a scaleable approach to strengthen health systems, support community-based programmes, and promote widespread campaigns to address gender inequality, including promoting girls' education. The Millennium Development Goals (MDGs) have highlighted the importance of addressing maternal health and promoting gender equality for the overall development strategy of a nation. The authors of this article urge stakeholders to capitalise on the momentum created by this and other international campaigns and continue to advocate for comprehensive strategies to improve global women's health.
This article reviews the debates at the United Nation’s Millennium Development Goal Summit, held from 20-22 September 2010. Rather than bringing a convincing message about a turning point for the future, the article argues that the Summit highlights missed opportunities in acting on what has already been agreed to. Barriers to moving forward are hardly mentioned and strategies to overcome them remain largely vague. The outcome of the High Level Meeting can therefore be seen as mixed and fragile as the uneven successes and progress documented in the UN Secretary General’s report to the meeting. On the positive side, the negotiated outcome document combines a return to basics. In promoting public health for all, it brings back the integrated primary health care approach, the social justice and rights imperatives, and participation of civil society as in the Alma Ata Declaration, together with conditional cash transfer, new technology and innovative finance.
4. Values, Policies and Rights
In 2008 WHO analysed 186 national constitutions and found that 135 (73%) include provisions on health or the right to health. Of these, 95 (51%) constitutions mention the right to access health facilities, goods and services, which includes medicines. Only four national constitutions (2%) specifically mention universal access to medicines. There are at least three different routes, the study argues, through which the right to health – and essential medicines – can be recognised in national legal frameworks. The strongest government commitment is created by including the right to essential goods and services in the national constitution. The second approach is constitutional recognition that international treaties ratified by the State override or acquire the status of national law. The third option, inclusion of health rights in other national legislation, is easier to create but also easier to change or cancel. The full range of strategies should be used to promote universal access to essential medicines through rational selection, affordable prices, sustainable financing and reliable health systems, the article argues. Constitutional recognition of the right to access essential medicines is an important sign of national values and commitment, but is neither a guarantee nor an essential step – as shown by those countries that have failing health systems despite good constitutional language, and those that have good access without it. Yet constitutional recognition creates an important supportive environment, especially in middle-income countries where health insurance systems are being created and patients are becoming more aware of their rights and are more vocal in demanding them.
In light of the World Health Organization's declaration that non-dependent drinking contributes more to the global burden of alcohol-related disease than does drinking by those who meet diagnostic criteria for dependence, this article argues that clinicians, researchers and decision-makers need to consider microsocial and macrosocial impacts of alcohol use, not just addiction and clinical effects on individuals meeting diagnostic criteria at the extreme high end of the alcohol-use spectrum. It suggests some qualitative dimensions to further define social or low-risk drinking and proposes that all drinking beyond that be described as harmful, because of its impacts on personal, community and population health.
Gay Kenyans will be driven further underground and away from HIV prevention, treatment and care services following a recent call by Prime Minister Raila Odinga for a nationwide crackdown on homosexuals, activists say. Addressing a rally in Nairobi on 28 November, Odinga ordered the police to arrest and bring criminal charges against anyone found engaging in sex with someone of the same gender. He added that the country's constitution made it clear that homosexual activity was not tolerated. David Kuria, chair of the Gay and Lesbian Coalition of Kenya, said the prime minister's remarks will negatively impact the government's efforts to include the country's gay population in HIV prevention programmes. For example, activists warned that few would be willing to participate in a government survey - due to start in December - that aims to draw on responses from the country's gay population to inform HIV programming for men who have sex with men (MSM). Activists said potential respondents would be too fearful of being targeted by the authorities. Homophobia is widespread in Kenya, but this is the first time such a senior political figure has openly called for legal action against homosexuals. In October, a cabinet minister who called for tolerance towards gays was urged to resign for promoting ‘un-African’ culture.
This article proposes six action strategies to guide global health researchers to synergistically target women's health outcomes in the context of improving their right to freedom, equity, and equality of opportunities. Its main purpose is to offer a feasible approach to health researchers who, conceptually, may link women's health to social and cultural conditions but are looking for practical implementation strategies to examine a women's health issue through the lens of their human rights. The proposed strategies include becoming fully informed of women's human rights directives to integrate them into research, mainstreaming gender in the research, using the expertise of grass-roots women's organisations in the setting, showcasing women's equity and equality in the organisational infrastructure, disseminating research findings to policymakers in the study locale to influence health priorities, and publicising the social conditions that are linked to women's diseases. The article explores conceptual and logistical dilemmas in transforming a study using these principles and also provides a case study to illustrate how these strategies can be operationalised.
This paper identifies South Africa as a country with much internal and cross-border migration within a region of high population mobility, and argues that the country urgently needs to develop, implement and monitor an evidence-based, coordinated, multilevel national response to migration and health. This includes acknowledging the developmental benefits of migration, ensuring ‘healthy migration’ and engaging with a ‘place-based’ approach to addressing the diverse health needs and health impacts of the multiple migrant groups present within South Africa. The paper recommends that South Africa develop a co-ordinated regional response to migration and health. It should support the implementation of a regional framework for communicable diseases and population mobility. Four priority areas were identified: monitoring migrant health, developing partnerships and networks, developing migrant-sensitive health systems and putting in place policy and legal frameworks for migrants’ health. Migrants and migrant communities should be involved in health and migration responses, the paper argues.
This article reviews formal and informal mechanisms through which the World Health Organization (WHO) is promoting policies for the advancement of women's health, such as Countdown to 2015 and the Partnership for Maternal, Newborn, and Child Health. Specific attention is given to examples of innovative strategies WHO has adopted in recent years to increase political commitment to women's and children's health and influence the development of policies supportive of country efforts to achieve Millennium Development Goals 4 (MDG4) and MDG 5 (to reduce child mortality and improve maternal health, respectively). It is expected that WHO’s commitment to women’s health and efforts to translate its political agenda of improving the lives of women and girls through influencing policy development at the country level will progressively increase under the leadership of Dr Margaret Chan, the current WHO Director General. The Director-General has indicated that improvements in the health of the people of Africa and the health of women are considered the key indicators of WHO’s performance in the coming year.
The United Nations Global Strategy for Women's and Children's Health, together with the African Union’s commitment to deliver a coordinated campaign to improving maternal, child and newborn health and the G8’s commitment of US$5 billion, form part of a global strategy to save 16 million mothers and children by 2015. The strategy, according to this article, aims to integrate service delivery and funding platforms, involving a wide range of stakeholders, research and innovation, and track progress through an accountability framework. Planned outcomes include: 43 million new users having access to comprehensive family planning and 19 million more women giving birth attended by a skilled health worker with access to necessary infrastructure, drugs, equipment and regulations. The strategy is designed to ensure that 2.2 million additional neonatal infections are treated, 21.9 million additional infants are breastfed, 15.2 million more children are fully immunised in the first year of life and that 117 million more children aged less than five years receive vitamin A supplements. To deliver these interventions, 85,000 more health facilities and up to 3.5 million additional health workers are needed.
5. Health equity in economic and trade policies
African countries have stalled on signing economic partnership agreements (EPAs) with the European Commission because they fear negative consequences for their smaller economies, this article reports. To avoid the pitfalls of signing the EPAs in their current form, the article suggests African countries should negotiate trade preferences. The author notes that the 33 least-developed countries (LDCs) in the African Union do not have to sign the EPAs since their trade preferences will continue under the ‘Everything But Arms’ scheme. They should not have to sign EPAs in order to maintain the common external tariffs they have or would like to have with the non-LDCs in their regional economic groupings. Instead, the 14 non-LDCs can request that the EU provide them also with the ‘Everything But Arms’ scheme, without their having to give preferences to the EU in return. He argues that there is a good case for this, as these 14 countries are also poor and vulnerable, and have similar characteristics as the LDCs. Moreover, they belong to regional economic groupings in which LDCs are the majority of the membership, and there is thus also a good case that they be given a similar status as the LDCs so that these groupings can continue with their common tariffs, without the LDCs having to be sacrificed. There are a number of cases in the WTO in which waivers have been given for non-reciprocal agreements between a developed country member and a developing country or region. The article concludes that the best option to resolve the EPA impasse is for Europe to give a non-reciprocal preferential package for Africa as a region, or for the 14 African non-LDCs, in a treatment similar to ‘Everything But Arms’.
This article is concerned with the Anti-Counterfeiting Trade Agreement (ACTA), an international agreement that seeks to strengthen the power of enforcement agencies, such as customs, to seize products that are fakes and infringe intellectual property rights (IPRs). It would allow customs officials to seize products – including generic medicines - if they believe these are counterfeit. The problem with this, the author argues, is the presumption that customs officials are competent to make such technical judgments, when they are not. These agencies could thus be used by rights holders to launch action against exporters from the developing world in a move that could destroy their business. Initiating proceedings places exporters in a tough financial position even if the goods turn out to be bona fide, as they would have to pay exorbitant legal fees to fight in court. Although ACTA is being presented as an anti-counterfeiting measure, it really has very little to do with controlling the international trade in counterfeit goods, the author argues, whose value has been exaggerated by its proponents. Rather, the effort is to bring about a fundamental shift in the rules governing international trade in a wide variety of knowledge goods - counterfeit or not. For India and the developing world, a primary concern is generic drugs. The article points to the fact that ACTA does not include any due processes, and encourages award of significant damages based on the suggested retail price, which makes valuations and lost profit presumptions in favour of the rights holders. It also extends injunctions to third parties not directly accused as infringers of IPRs.
According to this article, the developing countries of the South should seek to establish trade and financial arrangements between themselves. Instead of seeking alliances with the United States or China, they could construct regional arrangements independently from the rules governing the global system. In this way, the economies of emerging countries will not have to be contingent on the problems experienced by the economies of these superpowers. A regional currency basket is also proposed, to build local capacity and independence. These various arrangements in different parts of the South could eventually be inter-related at the level of a global South. The article points to the failure of the G20 to reach consensus on a number of issues, including trading in health services, as indication that there is no possible global consensus. The author suggests that the way forward for countries of the South is to take independent initiatives among themselves.
Based on the outcome of a meeting that took place from 22-26 November in Switzerland, the World Intellectual Property Organization (WIPO) has initiated an intellectual property (IP) project aimed at developing countries. The New Platform for Technology Transfer and IP Collaboration addresses WIPO Development Agenda recommendations 19, 25, 26 and 28 regarding developing countries. These recommendations require WIPO to facilitate access to knowledge and technology for developing countries and least-developed countries, to promote the transfer and dissemination of technology to benefit developing countries, and to foster research co-operation between developed and developing countries. The project consists of five phases: the organisation of five regional technology transfer consultation meetings, the commissioning of peer-reviewed analytic studies, the organisation of a High-Level International Expert Forum, the creation of a web forum on technology transfer and IP, and ‘the incorporation of any adopted set of recommendations resulting from the above activities into the WIPO programmes’.
This report includes the draft version of the Joint Africa-Europe Strategy (JAES) Action Plan 2011-2013 for the Partnership on the Millennium Development Goals (MDG), which commits the European Community and African Union (AU) partnership to several health actions and goals, focused on implementing the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA), increasing human resources for health in Africa and ensuring that governments meet their Abuja commitment to allocate 15% of spending on health. Certain goals are provided. By 2013, CARMMA must have been launched in all 53 AU Members States and its strategy implemented in at least 25 Members States. By 2013, more AU Member States should have improved access to HIV and AIDS, tuberculosis and malaria services by implementing the ‘Abuja Call’ with its new set indicators aligned with those of MDG 6. Finally, by 2013, more Member States must have strengthened their health systems through improved human resources for health strategies.
This resolution was adopted by the African Caribbean and Pacific (ACP) Council of Ministers during their meeting in Brussels on 8-10 November 2010. It makes no explicit references to health, but the inclusion of health may be inferred by references to the Millennium Development Goals (MDGs), food insecurity and development aid. The Council re-affirmed the need to develop objective criteria that will be used to determine the parameters to enable the conclusion and implementation of the economic partnership agreements (EPAs). These criteria may be linked to a number of areas, including the Millennium Development Goals (MDGs), agricultural production, and the level of official development aid. The Council calls on the European Union to demonstrate maximum flexibility on all the outstanding contentious issues, with a view to resolving them and thereby affording the ACP States and regions the opportunity to grow economically, particularly in the context of south-south trade, and allow for maximum use of policy space for development purposes. The Council requests that the EU include a specific safeguard clause for agriculture in the framework of the EPAs while maintaining the possibility of resorting to the Special Safeguard Mechanism during WTO negotiations, to help protect small farmers and maintain food security in the ACP regions.
This report calls for the creation of a new international development architecture (NIDA) for least-developed countries (LDCs) that will reverse their marginalisation in the global economy and help them catch up, while supporting a pattern of accelerated economic growth and diversification that will improve the general health and well-being of all their people. It argues that these objectives can be achieved if there is a paradigm shift that supports new, more inclusive development paths in LDCs and outlines alternative policy scenarios to accelerate growth and reduce poverty. The NIDA will consist of formal and informal institutions, rules and norms, including incentives, standards and processes, which would shape international economic relations in a way that is conducive to sustained and inclusive development. It will be supported by reforms of the global economic regimes that directly affect development and poverty reduction in LDCs, as well as the design of a new generation of special international support mechanisms (ISMs) for LDCs aimed at addressing their specific structural constraints and vulnerabilities. Increasing South-South cooperation could also play an important role.
Health is not mentioned much in this report, with its focus on trade and development, but a few links are made. The report argues that, in developing countries, as in developed countries, the ability to achieve sustained growth of income and employment on the basis of productivity growth depends critically on how the resulting gains are distributed within the economy, how much additional wage income is spent for the consumption of domestically produced goods and services, and whether higher profits are used for investment in activities that simultaneously create more employment, including in some service sectors, such as the delivery of health and education. In most developing countries there is a pressing need to increase public sector provision of essential social services, especially those concerned with nutrition, sanitation, health and education, according to the report. This is important not only for the obvious direct effects in terms of improved material and social conditions, but also for macroeconomic reasons. The public provision of such services tends to be labour-intensive, and therefore also has considerable direct effects on employment.
Medical tourism involves patients intentionally leaving their home country to access non-emergency health care services abroad. This article reviewed academic articles, grey literature, and media sources extracted from 18 databases to examine what is known about the effects of medical tourism in destination and departure countries. It found that most of the 203 sources accepted into the review offer a perspective of medical tourism from the Global North only, focusing on the flow of patients from high-income nations to lower- and middle-income countries, biasing the findings. Five interrelated themes emerged: medical tourism was promoted as a solution to health system problems and a revenue-generating industry offering patients higher standard of care, but some studies criticised it for using scarce public resources and causing health inequity. The study concluded that what is currently known about the effects of medical tourism is minimal, unreliable, geographically restricted and mostly based on speculation. Additional primary research on the effects of medical tourism is needed if the industry is to develop in a manner that is beneficial to citizens of both departure and destination countries.
6. Poverty and health
The 2010 edition of the European Report on Development (ERD) deals with the issues of poverty, inequality and social protection, notably in sub-Saharan Africa. It examines the external shocks that African countries experiencing chronic poverty are undergoing, such as climate change, food and fuel price volatility, or the recent financial crisis. These shocks are undermining progress towards the Millennium Development Goals, and the report highlights increasing demand for new and more substantive social protection programmes in many African countries. It focuses on the role of formal and informal mechanisms of social protection as a means to enhance the resilience of sub-Saharan countries when faced with shocks (short-term) and structural vulnerabilities such as poverty traps (long-term). Specific interventions targeting the most vulnerable sectors of the population should go hand in hand with more traditional pro-growth policies, the report argues, especially when dealing with emerging unstable global socio-economic scenarios.
In this article, International Integrated Regional Information Networks (IRIN) offers five strategies to reduce the psychological trauma experienced by African AIDS orphans. In Africa, most orphans remain with their extended families, being cared for by either the remaining parent, or by grandparents or other relatives, and this approach has been shown to minimise trauma for the children. Institutional care should only be a temporary solution or last resort, the article argues. Also, keeping brothers and sisters together also enhances their emotional wellbeing. Other strategies include meeting the basic needs of orphans, for example by instituting school feeding schemes and providing social grants, as well as providing psycho-social care in the form of grief counseling and peer support groups. Governments should also ensure that orphans remain at school. So far, free primary education has gone some way to improving overall school attendance, but other factors, such as living with a non-relative, appear to continue to hamper orphans' education. Finally, the article agues for more support for the carers of orphans, especially custodial grandparents. It recommends that health workers and home-based caregivers be trained to support orphans' caregivers.
If wheat and maize production do not rise substantially in 2011, global food security could be uncertain for the next two years, the United Nations Food and Agriculture Organization (FAO) has warned in its latest Food Outlook report. Wheat and maize prices have passed their 2009 highs, with FAO adding that international food import bills could surpass one trillion US dollars in 2010. Food imports last topped the trillion dollar mark during the 2007/2008 food price crisis. The FAO anticipates that world cereals stocks will shrink by 7%, with barley declining by 35%, maize by 12% and wheat by 10%. Six percent more maize will have to be produced in 2011 than in 2010, while wheat stocks need to rise by more 3.5% to ensure the world has enough reserves to tide it over 2011. The FAO has cautioned that its calculations have not taken into account the possibility of unfavourable weather conditions in 2011.
This brief notes some developments in the provision of water to poor Kenyans since the enactment of the 2002 Water Act. These include increased government spending for further water provision and policy reforms that separated asset ownership from service provision, regulation and policy formulation. Yet it found that at least 16 million Kenyans do not receive clean, piped water and remain at risk for water-borne diseases. It also noted that urban water kiosks provide an inadequate service, with many users forced to use minimal quantities of water as distance, waiting times and cost make water inaccessible. Poor people in urban areas appear to pay much more for water than those with piped water, while urban coverage of the piped system is declining. Large inequities exist in access to water as the struggle for water by the excluded sections of Kenya’s population contrasts sharply with the privileged, who benefit from water delivered to their homes, often at very low prices. At the current pace of expansion, the author argues that it will take unacceptably long to cover populations that urgently need water. It estimates that it will take at least 30 years for rural areas to have acceptable water supplies. The government’s budgets allocated to water provision, the author argues, do not reflect need. To address existing inequalities, the government should urgently develop and implement a needs-based budget allocation formula.
This report was launched during the Third African Water Week in Addis Ababa on 23 November 2010. About 350 million Africans still do not have access to water, according to the report. The author investigates whether poor governance has been a major contributory factor in the lack of sustainability in the African water sector. The report identifies numerous but common governance risks, and shows that these are easily identifiable and preventable. The main challenges and issues in the water sector are identified as sustainability, capacity and finance. The report also finds that substantial gains would be made if government assessments became standard procedure and if governance criteria were introduced in donor project approval procedures. While local and national institutions have the most visible role to play in governing the water sector, the report notes that it is the sector’s underlying policies, legislation and regulations that provide the foundation for overall governance. To meet the Millennium Development Goals by 2015, an enormous annual investment is required, probably more than four to five times current investment rate in the water sector.
7. Equitable health services
This study aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy (ART) in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. Between May 2007 and October 2008, a total of 538 randomly assigned HIV-infected adults who initiated ART in three clinics in Kenya were selected. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 hours. Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group. Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group. The number needed to treat (NNT) to achieve greater than 95% adherence was nine and the NNT to achieve viral load suppression was 11. The study concludes that patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcomes in resource-limited settings.
Sub-Saharan Africa is undergoing health transition as increased globalisation and accompanying urbanisation are causing a double burden of communicable and non-communicable diseases. This study indicates that rates of communicable diseases such as HIV and AIDS, tuberculosis and malaria in Africa are the highest in the world and the impact of non-communicable diseases is also increasing. For example, age-standardized mortality from cardiovascular disease may be up to three times higher in some African than in some European countries. As the entry point into the health service for most people, primary care plays a key role in delivering communicable disease prevention and care interventions. This role could be extended to focus on non-communicable diseases as well, within the context of efforts to strengthen health systems by improving primary-care delivery. The study puts forward several policy proposals to improve the primary-care response to the problems posed by health transition. Governments should improve data on communicable and non-communicable diseases and implement a structured approach to the improved delivery of primary care. They should also focus on quality of clinical care, align the response to health transition with health system strengthening and capitalise on a favourable global policy environment.
This study aimed to synthesise recent evidence on how to scale up the delivery of malaria interventions in endemic regions through a systematic review of the available literature. A total of 39 papers were selected, which related to delivery at scale of intermittent preventive treatment in pregnancy, artemisinin combination therapy (ACT) or insecticide treated nets (ITNs). In terms of coverage and equity, the review found that the evidence to link changes in coverage to any specific strategy is weak: only 3 of 24 studies reporting coverage had a concurrent comparison group, and only one was classified as high-level evidence using the GRADE criteria. For ACT, an associated increase in treatment among children (73% to 88%) was reported with delivery through accredited drug dispensing outlets and health facilities in Tanzania. For ITN programmes, instances where household ownership or use of nets reached targets of 80% were associated with free delivery of nets through campaigns. The study identifies barriers and facilitators to interventions, notably cost as a barrier. The study cautions that, to prioritise strengthening of health system elements for scale up, systematic reviews alone are not sufficient and additional research methods are needed.
Examining vulnerabilities within the world’s current public healthcare systems, the authors of this study propose borrowing two tools from the fields of engineering and design: A systems approach, as advocated by Reason in 1990, and a user-centered design, as advocated by Norman and Draper. Both approaches are human-centered in that they consider common patterns of human behaviour when analysing systems to identify problems and generate solutions. This paper examines these two human-centered approaches in relation to health care systems. It argues that maintaining a human-centered orientation in clinical care, research, training and governance is critical to the evolution of an effective and sustainable health care system.
This paper was commissioned as a background paper for discussion at the First Global Symposium on Health Systems Research, held 16-19 November, 2010, in Montreux, Switzerland. It argues that, to advance towards universal coverage, decision-makers have to determine ways to incentivise providers and patients alike to increase access to good quality health services and promote efficient modes of delivery that can be sustainable. It found little rigorous evidence to guide policymakers on how the theoretical incentives created by different payment mechanisms for individual providers or facilities operate in practice. Available data indicates that fee-for-service systems (for individuals or facilities) result in higher rates of utilisation and resource use. Limited evidence on reimbursement mechanisms for facilities suggests that case-based payments are efficiency enhancing, but important questions remain about their impact on quality of care and the possibility of implementing them in systems or facilities where capacity is low. The evidence in support of pay-for-performance (P4P) mechanisms was found to be mixed and the paper advises policymakers seeking to implement P4P schemes to proceed with caution. Conditional cash transfers (CCT) were found to have been effective in increasing uptake of health services, but continued success is likely to be dependent on adequate infrastructure, reliable funding and technical capacity. Key questions remain about the desirability and cost-effectiveness of CCTs, in particular in low-income settings.
The objective of this study was to assess the quality of child health services provided at primary health care (PHC) facilities in Johannesburg, South Africa. Sixteen PHC clinics were surveyed, using a researcher-developed structured checklist based on national guidelines and protocols. Most facilities were found to be adequately equipped and well stocked with drugs. A total of 141 sick child and 149 well child visits were observed. Caregivers experienced long waiting times (mean length of 135 minutes). Many routine examination procedures were poorly performed, with an adequate diagnosis established in 108 of 141 consultations (77%), even though health professionals were experienced and well trained. Triage and attention to danger signs were poor. An antibiotic was prescribed in almost half of the consultations, but antibiotic use was unwarranted in one-third of these cases. Health promotion activities (such as growth monitoring) were consistently ignored during sick child visits. HIV status was seldom asked about or investigated, for the mother or for the child. Growth monitoring and nutritional counselling at well child visits was generally inadequate, with not one of 11 children who qualified for food supplementation receiving it. In conclusion, the findings indicate that PHC offered to children in Johannesburg is seriously inadequate. The study urges for a deliberate and radical restructuring of PHC for children, with clearly defined and monitored standard clinical practice routines and norms.
In this report, research findings from a population-based household survey are presented on the general health status of infants, children, and adolescents in South Africa including morbidity, utilisation of health facilities, immunisation coverage, HIV status and associated risk factors. It also investigates the exposure of children and adolescents to HIV communication programmes. Close to 90% of children visited a public or private outpatient clinic the last time they were sick, indicating a high rate of utilisation for health services in South Africa. However, more than 20% of children were hospitalised for an average duration of 6.9 days. This demonstrates both the failure of the primary health care system to prevent and adequately manage diseases and the low quality of care provided in these services. This report is intended to play a vital role in assisting policy makers and stakeholders in targeting and prioritising key issues in planning and programming efforts focusing on the broad health issues of South African children.
8. Human Resources
This summary of a report by the Portfolio Committee on Health and Child Welfare in Zimbabwe notes that the shortage of doctors in Zimbabwe has reached crisis levels with the country having only 21% of the required medical practitioners. The report by the Portfolio Committee on Health and Child Welfare provided statistics showing that vacancy levels stand at 80% for midwives, 62% for nursing tutors, 63% for medical school lecturers and over 50% for pharmacy, radiology and laboratory personnel. Poor working conditions were cited as among the reasons for the high vacancy rates. The report added that these shortages and disruption of transport and telecommunications have compromised patient transfers, malaria indoor residual spraying, drug distribution and supervision of districts and rural health centres.
This study sought to analyse the effect of Kenya’s Emergency Hiring Plan for nurses on their inequitable distribution in rural and underserved areas, using data from the Kenya Health Workforce Informatics System. It found that, 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, with nurses increasing by 37%. By February 2010, 94% of the nurses hired under pre-recruitment absorption agreements had entered the civil service. The study cautions that, despite promising preliminary indicators of sustainability, continued monitoring will be necessary over the long term to evaluate future nurse retention.
A total of 1,000 doctors are to be hired to improve the delivery of health services, according to Uganda’s Health Service Commission. The Commission's chairman said an advert will be placed in the newspapers in December and the interviews will follow thereafter. He said the recruitment of health workers will be a continuous and consistent process every year. Makerere, the most prestigious medical school in the country, produces about 100 doctors a year. In total, the country produces about 250 doctors per year, including other universities. In Uganda, the doctor to patient ratio is 1:24,725, falling short of the 1:600 standard set by the World Health Organisation. The recruitment is part of the five-year new health sector strategic and investment plan. Plans are also in advanced stages to increase salaries for all health personnel, according the directorate of health services. The health service commission has also proposed to the Cabinet to have doctors availed vehicle and housing soft loans. The Government offers newly recruited medical officers a gross monthly salary of Ugandan sh626,181, while the highest medical officer at the level of a consultant takes home sh1.6 million per month. Despite a recent 30% increase in salaries for Ugandan health workers, they still earn three times less than workers in neighbouring Rwanda and Kenya.
Despite scale up of anti-retroviral therapy (ART) in Africa, this study draws attention to the shortage of quality data to assess the impact of task-shifting and the loss of doctors from other parts of the health system to HIV and AIDS programmes. It calls for greater documentation and further studies how past increases in ART coverage have been achieved, for instance, by assessing health worker performance using surveys of ART facilities. However, the paper argues that such research alone is not enough. Some of the most important factors determining the long-term progress towards universal coverage – such as ‘victim of our own success’ mechanisms – may only become apparent with time and as ART coverage increases. The challenge of predicting future need through the study of past outcomes is exacerbated by uncertainties around the definition of ART need (such as increases in the CD4 count threshold for treatment eligibility) and ART-related health problems (such as widespread viral resistance). Health policy-makers need to anticipate these factors with the aid of models, allow for significant uncertainty in their ART strategies, and set realistic expectations for the magnitude of resources required for universal ART coverage.
9. Public-Private Mix
According to this article, South African government spending on health care comprises less than half of total health expenditure even though the public system serves more than 80% of the population (i.e. around 40 million South Africans) without private health insurance. Around 70% of all doctors and most specialists only work in the private sector, the remaining 30% serve the public sector. Sixteen per cent of the population use private doctors and hospitals which are covered by their health insurance, often with a monthly contribution from their employers. It is this stark public–private divide that the South African Government hopes its proposed National Health Insurance (NHI) scheme will deal with by providing universal access to health care based on need rather than ability to pay. Despite some reservations about whether government can afford to pay for the proposed national health insurance scheme, an integrated pool of funds has been offered as one way to ensure that all the public sector’s available human resources are used more effectively and efficiently.
10. Resource allocation and health financing
Economic collapse in Swaziland, exacerbated by a major decline in revenue from the Southern African Customs Union (SACU), has cast uncertainty over financing the national HIV and AIDS response. According to the Ministry of Economic Planning and Development, revenue from SACU contributed 76% of the Swazi government's income in 2009 but dropped in 2010 and is expected to continue declining over the next decade. The decline in SACU tariffs and revenue collection has been identified as part of a policy shift towards freer trade within the southern African region and it is likely to continue. The National Emergency Response Council on HIV/AIDS (NERCHA) has blamed the situation on years of government overspending and the International Monetary Fund has urged the government to downsize the civil service by almost a third. Swaziland is heavily dependent on foreign donors to finance its HIV and AIDS programmes and doubts have been expressed that external funders might fill the gap left by an increasingly insolvent government. Meanwhile, the government assures that health services will not be cut, although long-term financing remains uncertain and there are concerns that no funds will remain to expand HIV and AIDS services.
Global Fund spokesman Jon Liden said it is not exceptional for proposals to be rejected, adding that Zimbabwe has enough funds coming from the organization to keep its programs going. Health experts said Monday that Zimbabwe’s gains in the fight against HIV/AIDS could be eroded if the Global Fund to fight AIDS, Tuberculosis and Malaria adopts a decision by its technical review panel not to fund Zimbabwe’s Round 10 proposal.A spokesperson for the Global Fund confirmed the technical panel had not recommended funding of the country’s latest HIV and TB grant requests. But Jon Liden said it is not unusual for proposals to be rejected, adding that Zimbabwe has enough funds coming from the organization to keep its programs going. Coordinator Gilles Van Cutsen of the medical relief group Doctors Without Borders said the Global Fund should reconsider its decision. Cutsen told VOA Studio 7 reporter Sandra Nyaira that the failure to recommend funding of the proposal is a disaster for Zimbabwe, noting that other countries in the region such as Lesotho and Mozambique have also seen their latest bids rejected. Programs manager Raymond Yekeye of the National Aids Council said Zimbabwe must look to other sources for funding to ensure gains are not rolled back.
The Global Fund to Fight HIV, Tuberculosis (TB) and Malaria has rejected Zimbabwe’s application for US$220 million to finance HIV and TB programmes for 2011, threatening to derail progress achieved so far towards efforts containing the two diseases. The Global Fund did not give reasons for the rejection. Zimbabwe had applied for US$170 million for HIV and US$50 million for TB. National Aids Council chief executive, Dr Tapiwa Magure, described the development as devastating, and doubted that Zimbabwe would be able to attain the Millennium Development Goal of universal access to treatment. Zimbabwe’s adult HIV prevalence has been on a downward trend, dropping from 18.1% in 2006 to 13.7% in 2009. Yet, according to the government, about 343,600 adults and 35,200 children under 15 years urgently need anti-retroviral (ARV) treatment out of a total of 1.2 million Zimbabweans living with HIV and AIDS. The government’s anti-retroviral programme only caters for about 200,000 infected people, while an estimated 3,000 people die of AIDS-related illnesses every week.
Microfinance among people living with HIV and AIDS (PLWHAs) faces some opposition and remains understudied. This literature review examines microfinance’s evolution and impact on a variety of social and health indicators and its emerging implementation as a primary prevention tool for HIV and economic intervention for PLWHAs. There is an abundance of literature supporting the apparent utility of microfinance. However the author argues that understanding of the subject remains clouded by the heterogeneity and methodological limitations of existing impact studies, the still limited access to microfinance in this population and inadequate understanding of the specific challenges posed by the socioeconomic and health issues of PLWHA. The author concludes that carefully designed studies are needed to assess the role of microfinance for PLWHA.
In its annual World Health Report, the World Health Organization (WHO) shows how all countries, rich and poor, can adjust their health financing mechanisms so more people get the health care they need. It highlights three key areas where change can happen – raising more funds for health, raising money more fairly, and spending it more efficiently. WHO says that in many cases, governments can allocate more money for health. In 2000, African heads of State committed to spend 15% of government funds on health, a goal that three countries – Liberia, Rwanda and Tanzania – have already achieved. If the governments of the world’s 49 poorest countries each allocated 15% of state spending to health, they could raise an additional $15 billion per year – almost doubling the funds available, notes the report. Countries can also generate more money for health through more efficient tax collection, and find new sources of tax revenue, such as sales taxes and currency transactions. A review of 22 low-income countries shows that they could between them raise $1.42 billion through a 50% increase in tobacco tax. The report also cites the role of the international community, noting that most donors still need to allocate 0.7% gross domestic product (GDP) to official development assistance. Smarter spending could also boost global health coverage anywhere between 20-40%, the report points out, highlighting 10 areas where greater efficiencies are possible, including the use of generic drugs wherever possible – a strategy that saved almost US$2 billion in 2008.
11. Equity and HIV/AIDS
Botswana has said it is prioritising the prevention of new HIV infections as its number one HIV and AIDS strategy, since the cost of keeping people alive on treatment is no longer sustainable. National AIDS Council spokesperson, Lorato Mongatane, said there is need for a comprehensive public awareness campaign to ensure the nation is made aware of the cost of the national response to HIV and AIDS and its impact on economic growth. Mongatane said with over 150,000 people on treatment and HIV and AIDS budget for 2010/2011 exceeding US$500 million, the Botswana government is prioritising the prevention of new infections to ensure that the number of people living with HIV and AIDS stabilises to help contain the cost over time. She pointed out that HIV prevention knowledge has not translated into major behaviour changes that could ultimately reduce the number of new infections.
This study, conducted between May 2009 and January 2010, undertook to explore the social, economic and cultural factors related to engagement in multiple concurrent sexual partnerships in Zambia. In-depth interviews were conducted at seven geographically diverse sites across Zambia. Interviews were conducted with 301 men and women who perceived themselves to be in stable relationships. Researchers used structured interviews and careful probing to elicit detailed information on all sexual partnerships during the previous 12 months. They found that overlapping concurrency was frequent among both men (71%) and women (46%) who identified themselves as being in stable relationships. Men who reported overlapping concurrency averaged three partners compared with women who had approximately two partners over the 12-month recall period. Quantitative data indicated that a high degree of mobility, with more than three-quarters of the entire sample indicating some degree of travel in their daily lives. The study calls for more research into the role of mobility in HIV transmission, as well as more national surveillance (biological and behavioural) data on mobile and migrant populations in Zambia. Currently, there is no systematic framework for collecting behavioral or biomedical data from migrant/mobile populations, and numerous gaps exist in data with regard to these groups. In addition, HIV prevention efforts must reflect a better understanding of the social and cultural nuances of mobility and migration that affect decisions to engage in sexual concurrency.
Based on field experience in environments with limited resources, this paper aims to illustrate the various strategies developed by Medicins sans Frontiers (MSF) to simplify patient screening and follow-up in order to increase access to anti-retroviral treatment. These include decentralising and streamlining treatment protocols, transferring skills, beginning treatment earlier, using new biological monitoring tools, gaining access to new drugs with fewer side effects, and not leaving out patients with complicated cases. The new strategies tend to place more responsibility on patients and simplify their treatment. Medical teams can then focus on treating the most complicated cases. Decentralising medical care and delegating responsibilities to less-qualified personnel (task shifting) are crucial, the paper argues. By giving patients more autonomy and making them responsible for their health, this paper argues, health facilities can spread out their medical consultations to every six months and thus reduce their workload. Simplifying medical follow-up may be achieved by decentralising and streamlining patient care and ensuring that two essential blood tests are available to patients - measuring the CD4 cell count, and the viral load.
This study found that farm workers in South Africa's Limpopo and Mpumalanga provinces have the highest HIV prevalence among any working population in Southern Africa. Conducted from March to May 2010 on 23 commercial farms, the survey included 2,810 farm workers, who anonymously gave blood specimens for HIV testing. The survey found that an average of 39.5% of farm workers who tested were HIV positive, which is more than twice the UNAIDS estimated national prevalence for South Africa of 18.1%. HIV prevalence was significantly higher among female employees, with almost half of the women (46.7%) testing positive compared to just under a third (30.9%) of the male workforce. The study could not pin-point a single factor causing this high rate of HIV infection on these farms, but cites a combination of factors such as multiple and concurrent partnerships, transactional sex, irregular condom use, presence of sexually transmitted infections (STIs) and tuberculosis, and high levels of sexual violence. The authors of the study note that a major research gap exists with regard to HIV among farm workers in southern Africa and they call for more research. The report makes several recommendations including increasing farm worker access to healthcare and implementing prevention programmes that are goal driven and monitored. The programmes should address gender norms that increase risky behaviour and vulnerability to HIV, such as the belief that a man has to have multiple partners. Both permanent and seasonal farm workers should be included in workplace health and safety policies.
Adolescents continue to be at high risk for HIV infection, with young men who have sex with men and youth with drug abuse and/or mental health problems at particularly high risk, according to this study. Multiple factors may interact to confer risk for these youth. Engaging vulnerable youth in HIV prevention research can present unique challenges in the areas of enrollment, retention, and trial adherence. Examples of successful engagement with vulnerable youth offer encouraging evidence for the feasibility of including these youth in clinical trials. Ethical challenges must be taken into consideration before embarking on biomedical HIV prevention studies with vulnerable youth, especially in the global context. Given the many individual and contextual factors that contribute to their high-risk status, the study urges that vulnerable youth populations be included in HIV prevention clinical research studies.
This report evaluates the work that Medicins sans Frontiers (MSF) has done in HIV and AIDS in Mozambique over the past ten years. MSF’s HIV and AIDS programmes offer HIV testing and counseling, treatment and prevention of opportunistic infections, paediatric diagnosis and treatment, prevention of mother-to-child transmission, and the provision of anti-retroviral therapy. At the end of August 2010, more than 33,000 people in Mozambique were being treated for HIV and AIDS through MSF’s projects. However, the report cautions that MSF’s model of care is not a prescriptive cure, and significant challenges remain. More than 350,000 people in Mozambique are in need of ARV treatment but do not have access to it, which equates to two-thirds of all HIV-positive Mozambicans. After years of political willingness and financial commitment to combat HIV and AIDS, external funders are now either flatlining, reducing or withdrawing their funding for HIV, thus abandoning those who are still in dire need of lifesaving treatment. HIV-infected people continue to face major barriers in their access to services, even in a context of free treatment. A shortage of qualified health workers is also considered a major barrier to access in Mozambique, with only 3 doctors and 143 nurses per 100,000 people, one of the lowest workforce per population ratios in the world.
Men who have sex with men (MSM) do not make headlines in South African media and HIV experts have warned that a lack of accurate coverage prevents targeted HIV prevention and care for these men. Human rights activists have spoken up about the South African media's tendency to divide men into two groups - heterosexual or homosexual - and caution against reinforcing stereotypes that deter them from accessing target HIV services for fear of being labelled. About 6% of lesbian, bisexual, transgender or intersex people and MSM surveyed have reported being turned away from government clinics, the government estimates. According to the national strategic plan (NSP), at least 70% of MSM should have been reached with a comprehensive, customised HIV prevention package by 2011. But the country is unlikely to meet this target. According to a recently released government review of NSP progress, nobody is systematically collecting data on HIV prevention among MSM.
The government of Rwanda, through the National AIDS Commission, is intensifying condom use campaigns with plans to install seven hundred condom vending machines countrywide in 2011, the executive secretary of the National Aids Commission, Anita Asiimwe, has said. The Commission plans to install the vending machines at places of hospitality like hotels, bars, and restaurants for easy access. The machines helped many people avoid the embarrassment of buying condoms in ordinary shops, she said. The condom use campaigns were launched in 2009 and had proved positive with people changing attitude towards the method. The campaign launched to mark 2009’s World Aids Day was meant to sensitise the public on condom use on top of abstinence and faithfulness – topics which were given much publicity but without quantified results. The seven hundred condom vending machines follow another one hundred and fifty machines that were installed in 2009.
Life-prolonging antiretroviral (ARV) medication is reaching more HIV-positive Ugandans than ever before, but health workers are concerned about how they will deal with the inevitable rise in drug resistance. An estimated 400 accredited facilities are providing about 218,000 Ugandans with ARVs, and more than 300,000 have enrolled on HIV treatment, but many patients have died and some have simply abandoned treatment. Although studies show that ARV adherence is generally high, frequent drug stock-outs as a result of funding shortages and supply-chain problems as well as food insecurity mean that patients have experienced interruptions in their treatment regimens, predisposing them to resistance. The Europe-Africa Research Network for Evaluation of Second-line Therapy (EARNEST) trial is trying to determine the best option for resource-limited settings at the Infectious Disease Institute (IDI), part of the Mulago Hospital Complex in the capital, Kampala. Currently, about 3% of adults and 4.6% of children on ARVs are taking second-line drugs. According to the previous World Health Organization's CD-4 count cut-off of 200, the Ministry of Health has estimated that 379,551 more people would require ARVs.
This report shows that the AIDS epidemic is beginning to change course as the number of people newly infected with HIV is declining and AIDS-related deaths are decreasing. Together, these are contributing to the stabilisation of the total number of people living with HIV in the world. Data from the report indicates that an estimated 2.6 million people became newly infected with HIV, nearly 20% fewer than the 3.1 million people infected in 1999. In 2009, 1.8 million people died from AIDS-related illnesses, nearly one-fifth lower than the 2.1 million people who died in 2004. At the end of 2009, 33.3 million people were estimated to be living with HIV, up slightly from 32.8 million in 2008. This is in large part due to more people living longer as access to antiretroviral therapy increases, the report argues. From 2001 to 2009, the rate of new HIV infections stabilised or decreased by more than 25% in at least 56 countries around the world, including 34 countries in sub-Saharan Africa. Of the five countries with the largest epidemics in the region, the report notes that four countries - Ethiopia, South Africa, Zambia and Zimbabwe - have reduced rates of new HIV infections by more than 25%, while Nigeria’s epidemic has stabilised. Sub-Saharan Africa continues to be the region most affected by the epidemic, with 69% of all new HIV infections.
12. Governance and participation in health
In this article, some of the factors that contribute to poor performance in achieving population health goals are examined, such as lack of shared responsibility for outcomes, lack of co-operation and collaboration, and limited understanding of what works. It also considers challenges to engaging stakeholders at multiple levels in building collaborative partnerships for population health. It outlines twelve key processes for effecting change and improvement, such as analysing information, establishing a vision and mission, using strategic and action plans, developing effective leadership, documenting progress and using feedback, and making outcomes matter. The article concludes with recommendations for strengthening collaborative partnerships for population health and health equity. These include establishing monitoring and evaluation systems, developing action plans that assign responsibility for changing communities and systems, facilitating natural reinforcement for people working together across sectors and ensuring adequate funding for collaborative efforts. Governments should also provide training and technical support for partnerships, establish participatory evaluation systems and arrange group contingencies to ensure accountability for progress and improvement.
This book articulates a vision of women and men in communities everywhere who are equipped with education, enjoy good health, have rights, dignity and a voice – and are in charge of their own destinies. What is required to achieve that is nothing less than a global new deal – a redistribution of power, opportunities, and assets. The report considers the alternative of a world of ever-deepening gulfs between the ‘haves’ and the ‘have-nots’ as unsustainable. Based on its experience in more than 100 countries around the world, Oxfam argues that the necessary redistribution can best be accomplished through a combination of active citizens and effective nation states. Markets alone cannot meet the challenges of poverty, inequality and environmental degradation. Effective states and active citizens must ensure the market delivers growth that benefits poor people. An economics for the twenty-first century is needed that provides tools to enable countries to achieve growth that is environmentally sustainable. This new economics will recognise the importance of unpaid work, predominantly by women and target poverty and inequality. It discusses case studies, including the Treatment Action Campaign in South Africa.
This report evaluates South Africa’s compliance with twelve selected African Union (AU) instruments to which it is a signatory. Eight of these twelve instruments are treaties while four are strategies, resolutions or plans of action. While treaties are legally binding on States Parties, resolutions are not. Seven of the treaties are already in force. Two await the required instruments of ratification to become effective and have not yet been signed or ratified by South Africa. Several health instruments are covered, including the Africa Health Strategy 2007-2015 (AHS), the Abuja Call for Accelerated Action towards Universal Access to HIV and AIDS, Tuberculosis and Malaria Services in Africa by 2010, and the Maputo Plan of Action for the Operationalisation of the Continental Sexual and Reproductive Health and Rights Policy Framework 2007-2010 (MPA). The audit of compliance indicates that South Africa has made significant strides to comply with the selected AU instruments, though much remains to be done. For example, in terms of the Abuja call, the country has a solid HIV and AIDS programme in place and is making progress towards treating tuberculosis and malaria, but the report points to lack of political will, lack of financial resources, and lack of public involvement and well-trained medical staff as factors impeding compliance with the AHS and the MPA. Many health workers are noted to not know about these health instruments because the government has failed to popularise them.
This paper argues that the case for global universal coverage is strong, yet it is not pursued actively enough. Although there may be a problem of ‘free riders’ (countries hoping that other countries will pay for a global public good), the main obstacle would be that global universal health coverage reduces country autonomy and embraces a paradigm of managing mutual dependence. Even if mutual dependence in health is a reality, the paper notes, countries nonetheless try to preserve their autonomy: richer countries require assurances regarding how the assistance they provide will be used (in a manner that serves their interests too), while poorer countries want to have the freedom to address their own health priorities. Recent paradigm shifts in the practice of international health financing can be seen as attempts to manage mutual dependence in health while trying to preserve country autonomy. Over the past decades, these attempts to better manage mutual dependence in health have led to increasingly sophisticated governance mechanisms. The authors suggest that a combination of the best elements of these mechanisms could help progress the world towards global universal health coverage.
13. Monitoring equity and research policy
The purpose of this article is twofold: to explore the entry process in community-based research when researching sensitive topics; and to suggest a framework for entry that utilises the values of participatory action research (PAR). The article draws on a collaborative community-university research study that took place in the Waterloo and Toronto regions of Ontario, Canada, from 2005–2010. The article emphasises that community entry is not only about recruitment strategies for research participants or research access to community but it is also concerned with the ongoing engagement with communities during various stages of the research study. The indicator of success is a well established and trusted community-researcher relationship. This article first examines this broader understanding of entry, then looks at how community research entry can be shaped by an illustrative framework, or guide, that uses a combination of participatory action research (PAR) values and engagement strategies.
This paper was commissioned as a background discussion paper for the Global Symposium on Health Systems Research, held in Switzerland from 16-19 November 2010. It explores experiences of and factors that influence how knowledge from health systems research (HSR) is translated into policy and practice, particularly at the national level, in low- and middle-income countries (LMICs). It found that whether the knowledge from health systems research (HSR) is used in policy and practice in low- and middle-income countries (LMICs) depends on the political economy context, the policy environment, institutional capacities and practice in the health system, and the research community. The study aims to link these four ‘streams’ and their impact on HSR. Although not always well documented, there is experience within LMIC on the strategic use of HSR. There are also some conditions that appear to be a greater challenge for LMICs, particularly low-income countries (LICs). International agencies have a more powerful influence on research agendas and resources in LICs, while resources for sustained research programmes and interaction are limited, as are the incentives, time, resources and authority for local personnel to gather and use evidence. Much LIC research is poorly published in accessible databases and a significant digital divide discourages HSR and its use. Local level personnel, especially in peripheral areas, face these constraints most sharply.
The burden of chronic, non-communicable diseases in low-income and middle-income countries is increasing. This study outlines a framework for monitoring of such diseases and reviews the mortality burden and the capacity of countries to respond to them. It draws on World Health Organization (WHO) data and published work for prevalence of tobacco use, overweight, and cause-specific mortality in 23 low-income and middle-income countries with a high burden of non-communicable disease. Although reliable data for cause-specific mortality was scarce, non-communicable diseases were estimated to be responsible for 23.4 million (or 64% of the total) deaths in the 23 countries that were analysed, with 47% occurring in people who were younger than 70 years. Tobacco use and overweight were found to be common in most of the countries and populations we examined, but coverage of cost-effective interventions to reduce these risk factors is low. Capacity for prevention and control of non-communicable diseases, including monitoring and surveillance operations nationally, is inadequate. A surveillance framework, including a minimum set of indicators covering exposures and outcomes, is essential for policy development and assessment and for monitoring of trends in disease, the study argues. However, technical, human and fiscal resource constraints are major impediments to the establishment of effective prevention and control programmes. Despite increasing awareness and commitment to address chronic disease, the study found that concrete actions by global partners to plan and implement cost-effective interventions were inadequate.
Following the five days of keynotes, plenaries, concurrent sessions, satellites and informal discussions and debates at the November 16-19 2010 First Global Symposium on Health Systems Research (HSR), Montreux, Switzerland, the final statement to the conference from the Steering Committee recognized “that there is an enormous energy to move forward with a further agenda of action reflecting the spirit and commitment that brought us to Montreux from Mexico and Mali”. The steering committee initiated a new alliance of actors globally with an agenda of work to:
o electronically archive and disseminate the papers and debates at the conference
o create an international society for health systems research, knowledge and innovation, to build greater constituency, credibility and capacity for improved and interdisciplinary HSR globally, and to provide visibility and support to regional, national and collaborative efforts on HSR;
o work with the priority agendas related to the recently agreed United Nations SG strategy on maternal, neo-natal and child health; and the upcoming UNGASS related to non communicable diseases to bring more effective health systems strengthening to accelerate universal health coverage.
A Second Global Symposium on Health Systems Research is planned for 2012 or 2013 to evaluate progress, share insights and recalibrate the agenda of science to accelerate universal health coverage, hosted by China.
This book captures developments in Participatory Action Research (PAR), exploring the justification, theorisation, practice and implications of PAR. It offers a critical introduction to understanding and working with PAR in different social, spatial and institutional contexts. The authors engage with PAR’s radical potential, while maintaining a critical awareness of its challenges and dangers. The book is divided into three parts. The first part explores the intellectual, ethical and pragmatic contexts of PAR; the development and diversity of approaches to PAR; recent poststructuralist perspectives on PAR as a form of power; the ethic of participation; and issues of safety and well-being. Part two is a critical exploration of the politics, places and practices of PAR. Contributors draw on diverse research experiences with differently situated groups and issues including environmentally sustainable practices, family livelihoods, sexual health, gendered experiences of employment, and specific communities such as people with disabilities, migrant groups, and young people. The principles, dilemmas and strategies associated with participatory approaches and methods including diagramming, cartographies, art, theatre, photovoice, video and geographical information systems are also discussed. Part three reflects on how effective PAR is, including the analysis of its products and processes, participatory learning, representation and dissemination, institutional benefits and challenges, and working between research, action, activism and change.
The 15 countries evaluated in this report card - including Angola, Democratic Republic of the Congo, Kenya, Tanzania and Uganda - account for nearly three-quarters of all pneumonia deaths worldwide. The card provides a total score for each country by evaluating data on seven key interventions identified by the Global Action Plan for the Prevention and Control of Pneumonia (GAPP), which indicated that up to two-thirds of child pneumonia deaths could be prevented if at least 90% of children had access to a few simple, effective pneumonia interventions. GAPP’s recommended 90% coverage on the interventions is based on the need to reach Millennium Development Goal targets for child survival by 2015. The interventions include prevention measures, protection measures and treatment. The card finds that country scores fall far short, ranging from 61 to 23% on these measures combined. While some pneumonia vaccines like measles and pertussis are already in widespread use, the card shows that new pneumonia vaccines against Hib and pneumococcal infections have not yet been adopted in all countries. With support from the GAVI Alliance, nearly all of these countries are expected to increase coverage of existing vaccines, as well as introduce Hib and pneumococcal vaccines, in the next five years.
This article argues that mobile phone connectivity in developing countries facilitates social and economic development through increased access to people, information and services such as health care, education, employment opportunities and market information. In developing countries, which lack the physical and technical infrastructure present in more developed nations, cell phone surveys provide an inexpensive and feasible way to conduct population-based data collection. However, the authors point out several issues that should be considered when conducting cell phone surveys in developing countries. Reception may not be available in rural zones, and it may be difficult to sample owners from cell phone registration lists if most users are unregistered. In addition, one needs to be aware of the cost that cell phone subscribers pay to receive a call and offer reimbursement for the time spent responding to the survey. Selection of one adult respondent from a sample household should always include consideration of the number of adults with cell phones in the household and whether people share cell phones. Text messages rather than voice calls may also be the primary means of cell phone communication in developing countries. The authors conclude that cell phone health surveys may come into wider use if the above issues can be addressed.
This paper was commissioned as a background discussion paper for the Global Symposium on Health Systems Research, held in Switzerland from 16-19 November 2010. It discusses 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. The review sought to identify and include all papers that described a capacity development initiative for health systems or health services research. Out of 73 articles identified, 24 papers were concerned with LMICs. The articles found in the review 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. This may be because many of the papers were from high-income countries, where the challenges faced are somewhat different in nature to LMICs. Given the very weak evidence found through the systematic review, the recommendations build upon the findings from the review, but also draw upon the experience of the authors, to identify promising avenues for capacity development in the future.
14. Useful Resources
This aide-memoire from the World Health Organization identifies the key universal precautions that health care workers (HCWs) should take to lessen their risk of contracting blood-borne diseases in the workplace, notably HIV and hepatitis B and C. It argues for hepatitis B immunisation for all HCWs, provision of necessary safety equipment, like gloves and goggles, and effective management of post-exposure treatment of HCWs who may have been accidentally exposed to blood. A number of procedures are proposed for healthcare facilities that wish to implement a strategy for dealing with accidental exposure, such as setting up and empowering an Infection Control Committee, using surveillance to identify risk situations and procedures and modify them wherever possible, and achieving compliance with universal precautions though ongoing commitment and training of all staff members. The strategy emphasises the important role of health managers in monitoring and supervising the programme, in co-ordination with the Infection Control Committee.
This article describes the 'Toolbox for the 21st Century Village' action research project and outline the critical research contexts that underpin its development as an online informatics and social engagement tool aimed at facilitating understanding, sharing and planning of integrated sustainability by individual communities. The article questions the assumption that rural livelihoods are necessarily ‘green’, arguing that rural behaviours are disproportionately dependent on natural resources and as a consequence are ‘less sustainable’, despite relative autonomy and community potential to make significant gains. The article also explores how the term ‘sustainability’ serves to divide and detract as a polemic and absolute term, whereas the term ‘self-sufficiency’ may be more appropriate to meaningful sustainable development.
CapacityPlus’s iHRIS software is open sourcesoftware that is designed to help organisations and governments to cost interventions to retain rural health workers. It is based on the World Health Organization’s global policy recommendations for rural retention. Using this software, health workforce leaders will be able to determine the costs of different retention interventions across cadres at the national, regional, district, or facility level. The software guides users through the costing process step by step. Based on data entered, it will determine the total costs and generate reports for each intervention. Stakeholders can use the results to determine the economic feasibility of different scenarios. This is the first iHRIS product that will be coded in-country and is currently being coded in Uganda. Capacity Plus aims to not only meet the specific goal of retaining rural health workers, but also to build in-country information technology (IT) capacity.
This new blog is aimed at helping development practitioners to better understand and address the governance and corruption (GAC) impediments to development effectiveness, including how GAC may be dealt with by policy reforms and how effective community participation may be increased. It provides a forum for World Bank Group staff engaged in GAC mainstreaming and the wider development community for experience sharing, reflection and discussion regarding the implications of GAC mainstreaming for development work. The blog mandates a methodology for GAC work that works ‘with the grain’, in a way that takes institutions and politics into account calls for different approaches to engagement – and different ways of identifying which approaches make sense across different country contexts. A spectrum of approaches is discussed, ranging from incremental approaches, which adapt their design to the existing context, to transformational approaches, which seek to expand and accelerate change. Relevant stakeholders and policy makers are invited to discuss their experiences of the various approaches and share tools for better shaping and measuring governance and accountability.
The Joint Learning Network for Universal Health Coverage (JLN) is a new platform that aims to connect health financing practitioners from across the globe to share experiences and solve problems together. The JLN is a network of countries and partners implementing reforms to expand health coverage. Its activities include practitioner-to-practitioner based learning activities on various technical topics, dissemination of technical resources and documentation of country reform experiences. The JLN gathers and consolidates technical materials related to health financing reforms from many sources, including member countries and international technical and academic partners. It also offers financial assistance to support practitioner-to-practitioner learning, targeted technical assistance, and other priority areas.
Research Matters has launched a web resource for knowledge brokers and intermediaries, which includes those who are interested in knowledge translation and how research evidence can influence decision making. The forum is a shared space for knowledge brokers and intermediaries, people involved in knowledge translation and peers interested in the subject. It is designed as a space where they can access and share resources on the strategic, practical and technical aspects of knowledge brokering and intermediary work, learn from a global community of peers working in the field and share experiences with others. In addition to providing a space for discussions, requesting peer advice and posting knowledge translation-related blogs, the forum will be hosting regular themed discussions, including how evidence is used in the development of policy and practice and what this means for knowledge brokers and intermediaries, how to conduct knowledge brokering and intermediation on issues where opinion divides sharply, and how to measure the effectiveness of knowledge brokering and intermediation.
15. Jobs and Announcements
The 21st African Union Summit will take place in Addis Ababa, Ethiopia, at the African Union Headquarters and the Conference Centre of United Nations Economic Commission for Africa (UNCC-ECA) from 24-31 January 2011. The theme of the Summit is ‘Towards Greater Unity and Integration through Shared Values.’ The main events are : 24-25 January 2011: 21st Session of the Permanent Representatives Committee (PRC); 27-28 January 2011: 18th Session of the Executive Council; and 30-31 January 2011: 16th Ordinary Session of the Assembly of the African Union.
The International Association of HIV Social Scientists is calling for abstracts for the First International HIV Social Science and Humanities Conference. Abstracts should cover any of the following themes: treatment as prevention, HIV and the body, social epidemiology and social networks, global politics, responsibility and risk governance, and new directions for HIV and AIDS treatment. The abstracts should be original contributions to any of the themes listed above and demonstrate the contribution of the social sciences or humanities to any aspect of the HIV epidemic. The conference welcomes papers, session proposals and events that are innovative in their delivery, organization, range of topics and type of public or audience. As well as traditional research papers, proposals are open for sessions and papers using ‘new media’ or other new forms of presentation.
The University of California (UCLA) Sonke Health and Human Rights Fellowship will provide specialised training in the United States to top graduates from South African law schools for careers as impact-oriented public interest lawyers in the areas of health, human rights, HIV prevention, and gender equality. The Fellowship offers a full-tuition grant to enroll in UCLA Law’s Master of Law Program (LL.M.), assists fellows in securing living and travel expenses for their studies, and offers the opportunity to apply for a one-year fellowship placement with Sonke in Cape Town or Johannesburg. Courses include Problem Solving in the Public Interest, and Human Rights and Sexual Politics. Upon completion of the LL.M. degree, each fellow will have the opportunity to apply for a year-long fellowship placement with Sonke in South Africa. If awarded, the fellow will undertake cutting edge legal work to address the gender inequality dynamics driving the spread of HIV and examine how to engage men and boys as stakeholders in gender and health equity. The Fellowship is open to experienced lawyers and new law graduates holding LL.B. degrees classified second class (division one) or higher from South African law school programmes. Competitive applicants will also have a demonstrated commitment to health, human rights, or gender equality, and work or volunteer experience in this area.
The African Programme on Rethinking Development Economics (APORDE) is a high-level training programme in development economics that aims to build capacity in economics and economic policy-making. The course will run for two weeks and consist of lectures and seminars taught by leading international and African economists. This call is directed at African, Asian and Latin American economists, policy makers and civil society activists who, if selected, will be fully funded. Only 30 applicants will be selected.
The CUD (Cutting-edge International Trainings and Courses for Development) Scholarships Programme for the year 2011-2012 is available for applicants from developing countries. Courses include Masters in Public Health, Master in Development, Environment and Society, Master of Science and Supplementary Environmental Management in Developing Countries, Management Systems in Health Services, and Methodology in Support of Innovation in Family Planning. Some of these courses and trainings are in French and candidates should be familiar with the language before applying for them. Nevertheless, selected candidates also need to learn French while participating in the programme. Only candidates from specific countries may apply, including South Africa, Ethiopia, Kenya, Madagascar, Mozambique, Uganda, Democratic Republic of Congo, Rwanda, Tanzania, Zambia and Zimbabwe. Eligible candidates will be those holding a graduate degree comparable to a Belgian University graduate degree. After completion of the programme, selected candidates should return to their country and pursue work in the field in which they have undergone the course or training.
The Sustainable Livelihood Approach (SLA) is a people-centred approach used by non-governmental organisations and researchers to identify the main constraints and opportunities faced by poor people, as expressed by the people themselves. It consists of a framework and a set of guiding principles that aim to protect and foster the resources and livelihood assets of poor people, such as their natural resources, technologies, skills, knowledge, capacity, health, access to education, sources of credit and their networks of social support. The approach is intended to help stakeholders to navigate the complex reality of the development context and ensure people are at the centre of development. Some critiques of SLA point to its limitations in dealing adequately with some issues such as power, gender and governance, and many in the development sector incorrectly assume that SLA is only relevant at the micro level. At the sixth and final seminar on Sustainable Livelihoods Approaches (SLAs), taking place at the Institute of Development Studies on 26 January 2011, you can take part in the online debate. Some directions for debate include what the future holds for SLAs, how SLAs are relevant to current development challenges and how SLAs need to adapt, as well as research, policy and practical implications for the future. To register, please email the seminar administrator at the address provided.
This conference will consider the link between and contributions of the social sciences and humanities to HIV research and action. The International Association of HIV Social Scientists, which is organising the event, argues that social science emphasises a critical, reflexive stance and willingness to confront the social, ethical, and political dimensions of scientific investigations of the HIV epidemic, which has made it instrumental in successful HIV prevention efforts such as the normalisation of condom use against sexual transmission and the introduction of safe injecting equipment for injecting drug use. Social scientific research has also provided insights into issues related to the treatment and care of people living with HIV and AIDS, and has addressed the broader social and political barriers to effective responses to HIV. Yet there have been few forums in which scholars from different social science and humanities disciplines can come together to develop connections among the various phenomena we study, and between ourselves and our biomedical, policy and community based colleagues. This conference is a forum for those keen to extend the scope of the social sciences and its capacity to trace connections between all kinds of phenomenon, notably those that contribute to the complexity and changing nature of the epidemic. Themes include: treatment as prevention, HIV and the body, social epidemiology and social networks, global politics, and responsibility and risk governance, as well as new directions for HIV and AIDS treatment.
This symposium considers infectious diseases in Africa, including bacterial, viral, fungal and parasitic diseases, which comprise a major cause of death, disability, and social and economic disruption for millions of people in Africa’s developing countries. This conference will aim to look at the borderless effect of infection, its impact on children and the importance of intervention. International speakers will talk about how to help prevent the spread of infectious diseases and discuss new diagnostics vaccines and drug treatments.
The Second Conference of the African Health Economics and Policy Association (AfHEA) will be held in Saly Portudal (Palm Beach), Senegal from 15-17 March 2011. The overall theme of this conference is ‘Toward universal health coverage in Africa’. Universal coverage is understood to mean providing financial protection against health care costs for all, as well as ensuring access to quality health care for all when needed.
The Second Global Forum on Human Resources for Health is intended to build upon the successes achieved in the previous Global Forum, held in 2010 in Kampala, and will provide a platform to review progress made in fulfilling the commitments outlined in the Kampala Declaration and the Agenda for Global Action. It will be an opportunity to further galvanise and accelerate the global movement on human resources for health (HRH) towards achieving the Millennium Development Goals and Universal Health Coverage. Expected outcomes include sustaining the global movement on HRH and sharing of knowledge and experiences and measuring the progress made since Kampala through concrete examples of global and country actions. The Forum will also be expected to find strategies for coping with new and emerging issues and challenges in HRH.
Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to info@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact editor@equinetafrica.org immediately regarding any issues arising.