In this issue of the newsletter one author claims that this may be a year of a ‘perfect storm’ in health, where increased knowledge, widening health priorities, new institutional coalitions, economic challenges and innovations coalesce to create new ways of doing things. Some of these new approaches could advance health equity. For example in this newsletter there are contributions that call for a shift in focus from intellectual property as a stimulus for innovation in health technology to innovative policies for equity in research and development; from aid effectiveness to development effectiveness; or from downstream medical interventions to more upstream measures addressing the population-level determinants of ill health. Debates at the recent WHO Executive Board on reform of the organisation raised issues of equity in its leadership, organisation and funding. At the recently held World Social Forum, an ‘African Consensus’ presented alternative thinking about the continent and its economic and social development to the rapid liberalization and privatization policies of the ‘Washington Consensus’. Bona Chitah's editorial suggests that translating new thinking into health equity outcomes calls for feasible technical options, but more deeply demands an ethical foundation that is clear, shared and strong enough to navigate and sustain implementation, whatever the tide.
1. Editorial
Much attention has recently been given to raising an adequate level of resources for health, especially to achieve goals of universal coverage. But if these resources are to reach those who need them, we also need to allocate resources fairly. This is particularly important given the very different access different social groups have to health care. In spite of the recognition by many countries for needs based resource allocation, including my own country, Zambia, our experience suggests that we still face many obstacles to put this intention into practice.
Data in Zambia shows, for instance, that although the allocation formula was radically revised with policy support in 2004/5 to incorporate deprivation and population weights, the new formula has still not been fully implemented. We realize that applying a formula to redistribute resources on the basis of need is not just a technical issue, but has significant political implications. We found in our research in 2007 and 2010 that applying a formula that takes deprivation into account in Zambia implies a loss of over 30% of revenue for the wealthiest districts, if immediately implemented. This raised considerable resistance towards an immediate implementation of the revised formula from key stakeholders such as district health management teams, as well as from the political leadership in the affected districts.
Allocating a fair share of health care resources to those with greatest health need is not only an ethical issue. It also makes public health sense to reduce the burden of disease, improve the uptake of health care and reduce avoidable inequalities in health. It makes economic sense in terms of poverty reduction and improved productivity, Needs based allocation of resources combines with other elements of priority setting in health, including the setting of basic entitlements and ensuring the effectiveness of health interventions. So why have we faltered in achieving this goal?
A common explanation is that the available resources are too limited to allocate equitably. How do you distribute an unfair total amount fairly? Prior work in EQUINET has shown that it is easier to reallocate new resources equitably when budgets are increasing than to redistribute static or shrinking budgets. In 1995 to 2006 in Zambia, according to the Ministry of Health, the total health expenditure per capita ranged from $17.50 in 1999 to $58.00 in 2006, but the government share was only between 8 – 14 per cent of this. The resource allocation formula was applied only to the recurrent budget, and between 2004 and 2009, the per capita recurrent budgets to districts ranged between only US$1.50 and US$ 4.14. How much impact can be achieved on inequalities in access and coverage health when such limited resources are being reallocated? So even though fair resource allocation is a demand that arises from the scarcity of health care resources, it is itself limited by that scarcity. Breaking this vicious cycle would be important for equity.
It is thus a problem that the significant resources that come from external funders are not themselves subject to a needs based resource allocation formula. National Health Accounts data in Zambia show that 44% of health finances are spent on district health services comprising the district health management offices, district hospitals and health centres, and 20% on provincial and tertiary facilities. Of these expenditures, the share of external funding was 42%, and funding earmarked for HIV/AIDS made up almost 25% of this. These funds are disbursed as vertical funding for specific targeted programmes and purposes. The funds are distributed primarily to achieve geographical coverage, with less concern for equity, as has been the case for Prevention of Mother to Child Transmission and general ante-retroviral treatment programmes that command significant resources.
While the adequacy of funds available for reallocation and the segmentation of external funds may weaken resource allocation, there is a deeper issue: Priority setting - and thus allocation- has not been strongly grounded in ethical values or social norms. It makes a difference whether financing decisions, including those related to the allocation of resources, are based on the pursuit of equity and social justice, on utilitarian issues of efficiency, including economic efficiency, or on an egalitarian liberalism that aims for steadily improving coverage, complemented by individual actions to enhance uptake.
The lack of a shared ethical premise supporting resource allocation may be the most significant constraint to advancing the fair allocation of resources. Experiences of resource allocation in Zambia suggest that reforms aimed at enhancing fairness in resource allocation falter more easily when they are not protected, or demanded, by a strong expression of social norms and values. It could thus be the key factor leading to uncertainty, and sometimes failure to implement resource allocation in a consistent and committed way for the effective strengthening of the health system in low resource settings. So while we build the technical measures and institutional capacities to more fairly allocate the resources for health, we also need to ensure that the ethical foundation it is based on is clear, shared and strong enough to sustain implementation on the face of the other blocks we face.
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, and reports on equity in resource allocation please visit the EQUINET website at www.equinetafrica.org.
2. Latest Equinet Updates
This study was undertaken by University of Zambia within the Health Financing theme work of the Regional Network for Equity in Health in East and Southern Africa (EQUINET) within a regional programme that is exploring progress in integrating equity into resource allocation. The study was undertaken to update the experiences and progress on the design, review and implementation of an equity-based resource allocation formula in the Zambian health sector. The author found that the formula has only been implemented in partial form, and that second and third generation formulae have not been adjusted in the implementation process. A severe lack of funding for the public health system, whose funding is smaller than the financing for specific health programmes like HIV and AIDS, remains a significant concern. The study makes a number of recommendations. The author calls for more research evaluating the changes in health outcomes, outputs or processes as a consequence of implementing resource allocation formulae. He calls for integration of financing and expansion of the pooled funding for the health sector to raise possibilities for a realistic implementation of the resource allocation formula. Richer districts should not have to risk a revenue reduction. The way to achieve the formula should rather use limited revenue growth in these districts relative to accelerated revenue growth for the poorer districts. A clear time line should be established with regard to the transformation of resource allocation and this should be updated based on emerging evidence. A monitoring and evaluation process should track performance of both resource allocation and health and health care outcomes. Finally, the Ministry of Health should evaluate the effect of structural changes with regard to resource management and performance so as to ensure optimum implementation.
The 52nd Health Ministers Conference of the East, Central and Southern African Health Community that took place from 25-29 October 2010 in Harare, Zimbabwe, under the theme: Moving from Knowledge to Action: Harnessing Evidence to Transform Healthcare. The meeting recognised the limited production and use of locally generated evidence to influence policy within the region, and resolved to promote use of evidence in decision making and policy formulation within the region and make more effective links with existing resources and institutions within the region for this. This report provides information to support the connections particularly between regional institutions and regional policy forums. It provides summary information from desk review, internet sites and email follow up on the 25 institutions and networks in East and Southern Africa (ESA) identified that are local to the region and that undertake health policy, strategy, and health systems work at regional level. The report further presents the perceptions from key informant interview of six regional policy institution personnel of the current links with technical institutions in the region, and how they can be improved. The evidence gathered is used to suggest implications for strengthening links between regional technical institutions and regional policy forums. The recommendations identify actions that can be taken with current resources, and those that call for additional investment or re-orientation of resources. The authors welcome feedback and comment on the issues raised, as well as information on other institutions from within the region working at regional level on health policy issues to add to the database compiled.
The course will bring together senior officers from the health and related sectors in the East, Central and Sothern Africa-Health Community region (ECSA-HC). The need to build capacity and create strategic leadership in global health diplomacy is clearly manifest in the performance of the regional delegations in regional and global fora. The purpose of the course is to introduce, provide an overview and share information on Global Health Diplomacy, discuss key issues and challenges for GHD for the region and hear inputs about other regions on their response to these challenges. The participant will discuss an assessment of institutional capacities and needs, information resources and sources at regional and country level support for Global Health Diplomacy. The facilitation at the course will also enable the participants to share and enhance their negotiation GDH negotiation skills. This course has been developed in close cooperation between the School of Public Health-University of Nairobi, the Ministry of Public Health and Sanitation Kenya, ECSA-Health Community Secretariat, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), and the Global Health Programme with support from Graduate Institute of International and Development Studies Geneva.
3. Equity in Health
The author predicts significant adjustments in the global health status quo in the coming year and identifies seven forces that are converging towards what appears to be an inevitable tipping point. Some changes will be gradual, others may appear as sudden shifts. Each of these forces has the potential to make a significant difference in its own right, but as they begin to interact and influence one another, business as usual is an unlikely outcome. Within the health sector the forces include a shift in public health priorities towards maternal and child health, non-communicable diseases, urban health promotion and primary health care renewal, as well as a shift in national health programmes and global public health initiatives from delivering the downstream interventions that constitute traditional health care services towards addressing the social determinants of health. Also included is the increased focus on health system strengthening, and continued growth in domestic health funding, particularly in the middle-income countries that are experiencing economic growth. The author also points to a change in the locus of global health governance, as countries with emerging economies, like Brazil, China, India and South Africa, exert an increasing influence on global health policies and agendas, linking them increasingly to foreign policy priorities. The author predicts other major forces affecting the global health status quo will be the new global financial reality, where international assistance for health will continue to grow, but the new fiscal prudence will bring stringent accountability and demand for aid effectiveness.
The primary objective of this paper was to review progress towards adoption of contraception among married or cohabiting women in western and eastern Africa between 1991 and 2004 by examining subjective need, approval, access and use. Indicators of attitudes towards and use of contraception were derived from Demographic and Health Surveys and trends were examined for 24 countries that had conducted at least two surveys between 1986 and 2007. In western Africa, the subjective need for contraception remained unchanged; about 46% of married or cohabiting women reported a desire to stop and/or postpone childbearing for at least two years. The percentage of women who approved of contraception rose from 32 to 39 and the percentage with access to contraceptive methods rose from 8 to 29. The proportion of women who were using a modern method when interviewed increased from 7 to 15% (equivalent to an average annual increase of 0.6 percentage points). In eastern African countries, trends were much more favourable, with contraceptive use showing an average annual increase of 1.4 percentage points (from 16% in 1986 to 33% in 2007).
This paper reports on the prevalence of latent tuberculosis infection (LTBI) and risk factors for a positive tuberculin skin test (TST) among gold miners in South African gold mines. Among 429 participants, the estimated prevalence of LTBI was 89%; 45.5% of HIV-positive participants had a zero TST response compared to respectively 13% and 13.5% in the HIV-negative and status unknown participants. In participants with TST > 0, there was no significant difference between size of response by HIV status. Factors independently associated with a TST < 10 mm were positive HIV status and not working underground. The authors conclude that the prevalence of LTBI is very high in gold miners in South Africa. HIV-infected individuals are more likely to have a negative TST, but HIV infection does not affect the size of TST response.
With four years to go, Tanzania still lags behind other East African countries towards the realisation of the Millennium Development Goals (MDGs), according to this article, only surpassing war-torn Burundi. The minister for Health and Social Welfare, Dr Haji Mponda, admitted that he was aware of the problem and expressed the government’s willingness to ensure that some of the targets are fully realised by 2015. He highlighted the achievements made by the government, specifically in 2007, when the rate of HIV prevalence dropped from 7% to 5% and that of 2004 to 2005, when the number of maternal deaths went down from 98 to 51 out of every 1,000 deaths. The report comes exactly 10 years since the UN's adoption of the goals and twenty years since the recording of most baseline data surface. Despite an extraordinary public campaign to mobilize support for the MDGs, there has been surprisingly little effort to track, record, and disseminate information regarding progress toward the goals at the country level, the authors of the report argued. Reacting to Tanzania’s poor performance, the head of Twaweza, an information advocacy organization, expressed concern that Tanzania still lagged behind its peer East African neighbours. He challenged the government to review each of the eight MDGs by involving stakeholders in health, poverty reduction, environment and other sectors that are related to the MDGs. He also called for independent evaluation bodies of these strategies, with stakeholders involved and not just the government officials and added reports ought to be made available in the public domain, so that citizens know where the country is headed.
The United Nations predicts that the world's urban population will almost double from 3.3 billion in 2007 to 6.3 billion in 2050. Most of this increase will be in developing countries. Exponential urban growth is having a profound effect on global health. Because of international travel and migration, cities are becoming important hubs for the transmission of infectious diseases, as shown by recent pandemics. Physicians in urban environments in developing and developed countries need to be aware of the changes in infectious diseases associated with urbanization, the authors of this review argue. Furthermore, health should be a major consideration in town planning to ensure urbanisation works to reduce the burden of infectious diseases in the future.
Whether or not health inequalities are unjust, as well as how to address them, depends on how they are caused, the author of this paper argues. He reviews a range of health inequalities in different countries and internationally, between genders, class, income and racial groups and between countries, tentatively identifying pathways of causality in each case, and making judgments about whether or not each inequality is unjust. He asserts that health inequalities that arise due to medical innovation are among the most benign, while those that arise due to inequalities in early life are more significant, pointing to the importance of parental and child circumstances. Society judges racial inequalities in health as unjust, adding to injustices in other domains. While the inequalities in health between rich and poor countries are wide, the author asserts that they are not perceived as just nor unjust, nor are they easily addressed.
4. Values, Policies and Rights
Kenyan AIDS activists are demanding a full apology from a Kenyan cabinet minister who recently suggested that isolating HIV-positive people may be the way to eradicate the pandemic. At a 28 January 2011 meeting with members of parliament on HIV and AIDS, Esther Murugi, Minister for Special Programmes, put forward the option of permanently ‘locking up’ positive people to keep them out of general society. Kenya's National AIDS Control Council falls under the Ministry of Special Programmes. Nelson Otwoma, coordinator of the Network of People living with HIV/AIDS in Kenya, said her comments were highly irresponsible and only contributed to stigma surrounding the disease. She believed that the minister’s comments could prompt a wave of hatred against HIV positive people among ‘people who might hold a view like hers and who were simply waiting for a trigger’. Jacqueline Sewe, a member of local NGO, Women Fighting AIDS in Kenya (WOFAK), has called on the minister to either publicly apologise to people living with HIV or resign, highlighting the fact that HIV is not a contagious disease.
This report is the fourth in a series of annual reports published by Plan examining the rights of girls around the world throughout their childhood, adolescence and as young women. The short section regarding the health of girls is based on Plan’s cohort studies in Togo, Benin and Uganda. Their research find that nutritional deficiencies in early childhood are linked to learning difficulties and lower educational attainment. Girls not only faced a daily challenge of poor nutrition, but were more vulnerable to illness and disease. Despite immunisation coverage rates of above 90% of girls, many still face persistent illness. Malaria, for example, continues to affect many girls in Uganda, with the children treated at various times over the year either at the local health centre or the nearest hospital. Plan calls for governments to increase their investment in prevention and treatment of the range ofillnesses that affect girls, like malaria.
As part of the 11th edition of the World Social Forum (WSF) in Dakar, African civil society presented the draft of an African Consensus, to spur endogenous development of the continent. The WSF is an initiative of civil society and a democratic meeting place that aims to stimulate debate and deepen the collective thinking. This is a space where all types of social movements come to discuss world problems in a democratic way. Members of the International Committee of the Forum discussed the prospects for social movements to make proposals and alternatives to "a neoliberal system that is currently going through deep crisis". Inspired by that of the Himalayas, an innovative approach to development, the "African Consensus" refers to the implementation of economic platforms and autonomous enterprises programmes based on local realities, through skills transfer that give a sense of responsibility. Unlike the "Washington Consensus", which enhances the immediate liberalization of markets, privatization of enterprises, the elimination of subsidies, the "African Consensus" is based on the fact that Africa is not poor, but that it enjoys great wealth and the mosaic of cultures and ethnicity.
This paper deals specifically with the gender issues that arise in the role of faith-based organisations (FBOs) in service delivery. The author analysed secondary sources on FBOs affiliated to organised religion and other faith movements. The FBO services reviewed were in Africa, Asia, Europe, Latin America, the Middle East and the United States. The author presents no generic conclusions about this diverse group of actors but raises questions about the implications of FBOs as service providers for the advancement of gender equality. She raises questions on the nature of an FBO’s gender agenda, especially because a single organisation often takes different standpoints on various gender issues. Secondly, she questions the way the spiritual and social activities often provided relate to the way FBOs often delineate how women are expected to exercise their agency. She observes that while many FBOs work successfully at grassroots level, this does not necessarily mean that they all emerge from within the community or that they are necessarily ‘indigenous’. She notes the dilemma women face when the extension of services and assistance is conditional on their conforming to the FBOs’ interpretation of religiously appropriate gender roles and behaviour. Referring to ethnographic studies, she suggests that services may sometimes be used overtly or more subtly to inculcate religious values and ideologies. The complexity and variation in FBOs means that one needs to be cautious about drawing policy conclusions that re applicable to all faith-based actors engaged in service delivery. She rather argues for measures to engage with faith leaders on their gender agendas and the manner in which services take into account embedded partriarchal and other power relations.
Human Rights Watch has urged the Uganda Police Force to urgently investigate the murder of David Kato, a prominent gay activist who opposed the Anti-Homosexuality Bill submitted to parliament in 2009. ‘The government should ensure that members of Uganda's LGBT [lesbian, gay, bisexual and transgender] community have adequate protection from violence and take prompt action against all threats or hate speech likely to incite violence, discrimination, or hostility toward them,’ the group said in its statement. Police are investigating the matter and called for gay people who are being harassed to come forward and report these incidents - otherwise the police are not in a position to protect them. However, homosexuality is a criminal offence in Uganda, and reporting harassment to the police is a risk few are willing to take. Only a handful of gay Ugandans are ‘out of the closet’, with most preferring to live anonymously in a society where homosexuality is taboo. The criminalisation of homosexuality is predicted to have a negative effect on the transmission of HIV in the country, as gay men are unlikely to use health facilities for fear of discrimination and possible legal prosecution.
Although HIV and tuberculosis (TB) prevalence are high in prisons throughout sub-Saharan Africa, little research has been conducted on factors related to prevention, testing and treatment services. To better understand the relationship between prison conditions, the criminal justice system, and HIV and TB in Zambian prisons, the authors of this study conducted facility assessments and in-depth interviews with 246 prisoners and 30 prison officers at six Zambian prisons, as well as 46 key informant interviews with government and non-governmental organisation officials and representatives of international agencies and external funders. A review of Zambian legislation and policy governing prisons and the criminal justice system was also conducted. The findings indicated serious barriers to HIV and TB prevention and treatment, and extended pre-trial detention that contributed to overcrowded conditions. Disparities both between prisons and among different categories of prisoners within prisons were noted, with juveniles, women, pre-trial detainees and immigration detainees significantly less likely to access health services. The authors call on the government to make immediate improvements to the situation and they recommend that external funders to co-operate with the Zambian government to ensure that funding in such areas as health services respect human rights standards.
Maternity protection for women workers is essential for ensuring women's access to equality of opportunity and treatment in the workplace, the International Labour Organization (ILO) argues in this review. Maternity protection also contributes to the health and well-being of mothers and their babies, and may thereby be linked to the achievement of Millennium Development Goal 3 (promoting gender equality and women's empowerment) and Goals 4 and 5 on the reduction of child mortality and improvement of the health of mothers. This updated review of national legislative provisions for maternity protection in 167 ILO member states assesses how well countries’ provisions conform to the ILO Maternity Protection Convention of 2000 and its accompanying recommendation no. 191. The review shows that, over the last 15 years, there have been noticeable improvements in maternity protection legislation around the world, with a shift towards longer rest periods at the time of childbirth, and movement away from employer liability systems of financing maternity leaves. The report focuses on the key aspects of maternity leave provisions: the duration, the benefit paid and the source of the funding, as well as other kinds of leave provision, safeguards on employment, health and safety, and breastfeeding. There are also annexes containing information on maternity provisions by region and country.
This article reports the findings of research conducted with a randomly selected sample of men aged 18–49 years from the general population of the Eastern Cape and KwaZulu-Natal, who were asked in an anonymously conducted survey about their rape perpetration practices, motivations, and consequences thereof. Overall 27.6% of men had forced a woman to have sex with them against her will, whether an intimate partner, stranger or acquaintance. Some perpetrated alone, others with accomplices. Most men who had raped had done so more than once, started as teenagers, and often had different types of victims. Asked about motivations, men indicated that rape most commonly stemmed from a sense of sexual entitlement, and it was often an act of bored men (alone or in groups) seeking entertainment. Rape was often also a punishment directed against girlfriends and other women, and alcohol was often part of the context. A third of men had experienced no consequences from their acts, not even feelings of guilt. More commonly there was remorse and worry about consequences, and in a third of cases there had been action against them from their family, that of the victims, or respected community members, and about one in five had been arrested for rape. This research confirms that rape is prevalent in South Africa, with only a small proportion of incidents reported to the police. Many of the roots of the problem lie in an accentuated gender hierarchy. This highlights the importance of interventions and policies that start in childhood and seek to change the way in which boys are socialised into men, building ideas of gender equity and respect for women.
5. Health equity in economic and trade policies
The international debate around patents has been largely framed in terms of ‘protection for’ versus ‘access to’ intellectual property (IP), according to this article. If the framing of the debate shifts to a focus on research and development, this is likely to strengthen the leverage of developing countries to change the dynamics of IP negotiations in trade agreements, the authors argue. In fact, shifting the entire debate from IP rights to the research and development (R&D) gap may help tackle the fundamental problem of a monopoly-based innovation and access system. One example is nonexclusive licensing practices, such as those used by the not-for-profit Drugs for Neglected Diseases Initiative. The initiative finances R&D up front and offers the outcome of its research on a nonexclusive basis to generic producers, allowing for technology transfer and competition among multiple producers. Furthermore, universities currently hold important patents on many life-saving drugs, which prompted Universities Allied for Essential Medicines to propose that when a university licenses a promising new drug candidate to a pharmaceutical company, it should require that the company allow the drug to be made available in low income countries at the lowest possible cost. Another alternative to overcoming current patent barriers is the use of patent pools, as proposed by the World Health Organization, Médecins Sans Frontières, and UNITAID. Here, a number of patents held by different entities, such as companies, universities, or research institutes, are pooled and made available to others for production or further development. The patent holders receive royalties that are paid by those who use the patents. The pool manages the licences, the negotiations with patent holders, and the receipt and payment of royalties, in a manner that facilitates access to medicines in low income countries. The author proposes that other innovative policy proposals, such as the Heath Impact Fund (a strategy to create a publicly funded ‘pot of gold’ that would attract the private sector to create R&D innovations that effectively address priority global heath needs), be implemented. However the author argues that using patents as the financial incentive to encourage the pharmaceutical industry to develop drugs for the world's poor is of limited use, given that the market is nonexistent as neither governments nor patients can afford the end product.
According to this report by Oxfam, poor-quality, or ‘substandard’, medicines threaten patients and public health in developing countries. Prioritisation of medicines regulation by developing-country governments, with the technical and financial support of rich countries, is badly needed. However, under the guise of helping to address dangerous and ineffective medicines, rich countries are pushing for new intellectual-property rules and reliance on police – rather than health regulatory – action. This approach will not ensure that medicines consistently meet quality standards. Worse, new intellectual property rules can undermine access to affordable generic medicines and damage public health. Oxfam argues. Developing countries must improve medicines regulation – not expand intellectual-property enforcement – in order to ensure medicine quality. Oxfam recommends that developed-country governments should expand funding and support for national and regional initiatives that increase the ability of drug-regulatory authorities in developing countries to protect their populations from harmful products, and stop pursuing TRIPS-plus enforcement measures (intellectual property rules that exceed minimum obligations under global trade rules) through internal regulations, multilateral trade initiatives, bilateral trade agreements, or through technical assistance. Developing-country governments should prioritise the expansion of public health-care infrastructure and invest in drug-regulatory authorities' capacity together with the provision of free essential medicines, as well as promote generic competition in national medicines policies, including implementation of TRIPS flexibilities in national laws, and reject initiatives modeled on ACTA, and any other TRIPS-plus enforcement initiatives. Oxfam calls on the World Health Organisation (WHO) to prioritise its comprehensive programme of work, which underpins access to affordable, quality medicines for its Member States, and disband IMPACT, the controversial task force that inappropriately uses an intellectual property framework to evaluate the public-health problem of unsafe medicines. Oxfam also calls on pharmaceutical companies to adhere consistently to WHO quality standards and to recognise the damage inflicted on public health as a result of the confusion of quality with intellectual-property issues in initiatives such as IMPACT, and correct this fundamental error in their public statements and documents.
This report is an update of Global Financial Integrity’s 2008 report, which found that developing countries lost between US$859 billion and US$1.06 trillion in illicit financial outflows in 2006. On the same basis, this report finds that illicit outflows increased to between US$1.26 and US$1.44 trillion in 2008 and that, on average, developing countries lost from US$725 billion to US$810 billion per year over the nine-year period, 2000-2008. Globally, illicit flows increased by 18% per annum from US$369.3 billion at the start of the decade to US$1.26 trillion in 2008. When adjusted for inflation, the real growth of such outflows was 12.7%. Illicit flows from Africa grew by 21.9% over the nine years, representing 4.5% of total illicit flows. Trade mispricing accounts for 54.7% of cumulative illicit flows from developing countries, according to the report, which identifies bribery, theft, kickbacks and corporate tax evasion as other significant sources of illicit flows.
The United Nations (UN) has been enjoined in a case that claims that enforcement of the Anti-Counterfeit Act 2008 would endanger lives due to limits to access to affordable and essential drugs. The Special Rapporteur from the UN, Mr Anand Grover, intervened in the suit as an interested party to support the constitutional principles of access to essential medicines. The court allowed the importation of generic anti-retrovirals (ARVs), pending the hearing and determination of this case. The interim order issued in April 2010 was aimed at saving the lives of those living with the virus by stopping implementation of three sections of the new Anti-Counterfeit Act, which was enacted by Parliament in 2008. While the objective of the Act was to prohibit trade in counterfeit goods, advocate Omwanza told the court if implemented the clauses would deny people using ARVs access to affordable and essential medication necessary for their fulfillment of the right to life, as enshrined in the Constitution. Although generic drugs for the treatment of HIV and AIDS are available and affordable, the advocate argued that if implemented the clauses would force government to buy more expensive branded medicines.
The Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits Arising, adopted on 29 October 2010 and the Convention of Biological Diversity (CBD), both have implications for the WHO intergovernmental dialogue on influenza preparedness and virus sharing. Article 8 requires countries to ‘pay due regard’ to ‘cases of present or imminent emergencies that threaten or damage human, animal or plan health’. Article 4 calls for ‘due regard’ to be paid to ongoing work or practices, provided such work or practices are supportive of and do not run counter to the objectives of the Convention of Biological Diversity (CBD) and the Protocol. The CBD and protocol are important as they have a legally binding status as they are treaties. Notably the United States is not party to the CBD.
South Africa is set to launch its own development aid agency in 2011. The South African Development Partnership Agency is expected to become operational before mid-2011 and will work with other external funding agencies to coordinate development programmes, mainly on the African continent. Although the government is hoping for contributions from the private sector, most of the funding will come from public money, according to Ayanda Ntsaluba, Director-General of the Department of International Relations and Cooperation. Since 2001, the South African government has channelled its aid contributions through the African Renaissance Fund (ARF), which is administered by the department. Much of the assistance provided by the ARF has focused on conflict resolution and peacekeeping in various countries, including Mali, Zimbabwe, Burundi and the Democratic Republic of Congo. However, transparency and accountability was problematic and Ntsaluba conceded that the tracking of ARF funds had not been optimal. Although the mandate for the new agency was still in draft form, he said South Africa would continue providing assistance to countries recovering from conflict. He assured critics that the new agency would be set up as a separate institution, with the administrative capacity to track and oversee all the programmes it funded.
This article looks at the main challenges to European Union-Africa relations in light of the EU-Africa summit held in Tripoli, Libya from 29-30 November 2010. The Tripoli meeting marked the third Africa-EU Summit since 2000. In 2007, both parties to the JAES pledged to work together to implement the Africa Health Strategy, the EU Project on Human Resources for Health, the Abuja commitment to dedicate 15% of government financing for health, and the European Programme for Action to Tackle the Shortage of Health Workers in Developing Countries. President Jacob Zuma of South Africa openly expressed his concern that after ten years of the partnership, there was still too little to show in terms of tangible implementation of the undertakings made in previous summits. He cautioned the summit against committing to another action plan when commitments made in the past have not been implemented. The author noted that for example the ongoing Economic Partnership Agreement (EPA) negotiations, have become a contentious issue in EU-Africa relations, with clauses for example that may negatively impact on the production of affordable generic medicines for developing countries by rigorously protecting patent holders in developed countries.
At the World Health Organization (WHO) Executive Board meeting, held from 17-25 January 2011, members raised strong concerns that a working group they mandated last May to address problems with WHO policy on counterfeit and substandard medicines has yet to be formed – with only four months remaining before it must report back to members. The Indian delegation called for a halt to WHO activities on anti-counterfeiting until the outcome of the working group is accepted by member states. Members agreed falsified medicines were a threat for global public health but some delegates argued the solution cannot be dominated by intellectual property rights enforcement concerns. The Indian delegate said that the working group was supposed to investigate the International Medical Products Anti-Counterfeiting Taskforce (IMPACT). IMPACT is a project with international police agency Interpol and other agencies, housed within WHO, and is meant to ‘halt the production, trading and selling of fake medicines around the globe’. It has been criticised in the past by some countries who claim IMPACT has not helped clarify the confusion between substandard, falsified or unsafe drugs and legal, reliable generic medicines.
6. Poverty and health
The transnational influence in South Africa's economy is argued in this paper to be linked with ecological and economic problems that reflect in increasing hunger and health problems, higher food prices and polluting agro-processing. The Democratic Left Front proposes an Anti-Hunger and Food Sovereignty Campaign to challenge the current reality and politicise the food question in a people-centred way. They propose a campaign that is advanced from the grassroots through participatory processes, to mobilise mass forces against hunger and the way the current agro-processing industry shifts the value away from producers and raises costs for poor communities. They propose an alternative food economy as part of a wider socio-economic change, guided by the principles of solidarity, collective ownership, self-management, democratic control of capital, an eco-centric emphasis, direct community benefit and participatory democracy.
Using panel data from Mozambique collected in 2007 and 2008, the authors explore the impact of the food crisis on welfare of households with people living with HIV and AIDS. The analysis finds that there has been a real deterioration of welfare in terms of income, food consumption, and nutritional status in Mozambique between 2007 and 2008, among both sets of households. Households with people living with HIV have not suffered more from the crisis than others. Results on the evolution of labour-force participation suggests that initiation of treatment and better services in health facilities have counterbalanced the effect of the crisis by improving the health of patients and their labour-force participation. The authors look at the effect of the change in welfare on the frequency of visits to health facilities and on treatment outcomes. Both variables can proxy for adherence to treatment. This is a particularly crucial issue as it affects both the health of the patient and public health because sub-optimal adherence leads to the development of resistant forms of the virus. The authors find no effect of the change in welfare on the frequency of visits, but they do find that people who experienced a negative income shock also experienced a reduction or a slower progress in treatment outcomes.
The authors have two main policy messages from this study for food security and trade for low and middle income countries. First, as evidence shows that poverty and hunger materialise at household and individual levels, the special and differential treatment for developing countries in trade negotiations at the national and/or crop levels may not be sufficient to reach the households and individuals at risk. Secondly, they argue for a balance between protections that help small producers with protections for poor consumers. They propose increased investments in physical capital and human development, land tenure, water access, technology, infrastructure and general services (such as health and education), especially focusing on poor and female headed households. They call for state support to non-agricultural rural enterprises and also well-designed safety nets, including conditional cash transfers (CCT), school lunches, women and infant nutrition and food-for-work. They propose strengthening of organisations of small farmers and women and supporting their participation in policy and political processes. This is argued to demand financial, human and institutional capacity support.
This study uses updated global poverty estimates to infer that nearly half a billion people escaped extreme poverty in the five years from 2005 to 2010. However the gains have not been equally distributed, globally. Between 2005 and 2015, Asia’s share of global poverty is expected to fall from two-thirds to one-third, while Africa’s share will more than double from 28% to 60%. Although sub-Saharan Africa’s poverty rate had by 2010 fallen to below 50% for the first time and is projected to fall below 40% by 2015, at global level the authors argue that the share of the world’s poor people living in fragile states is rising sharply and will exceed 50% by 2014.
The United Nations World Food Programme (WFP) and the United Nations Children’s Fund (UNICEF) have signed an agreement to work together to reduce child stunting in Eastern and Southern Africa in an effort to reach the UN Millennium Development Goals by 2015. UNICEF and WFP acknowledged the progress that had been made to address the nutritional factors hampering children’s health. UNICEF said that the prevalence of stunting in the developing world declined from 40% to 29% between 1990 and 2008. Stunting in Africa only fell from 38% to 34% in the same period. Of the 24 countries that make up 80% of the world’s stunting burden, at least seven are in Eastern and Southern Africa. UNICEF argues that investing in child nutrition pays high dividends for a country’s social and national development. National nutrition strategies need to tackle not only the root causes of stunting, but also to target the most vulnerable children and their families, including those in remote areas, or from the poorest and most marginalised communities. Only 11 African countries are on track to reaching the Millennium Development Goals to halve hunger by 2015, four of which are from the eastern and southern African (ESA) region: Mozambique, Botswana, Swaziland and Angola.
7. Equitable health services
The Angolan government is preparing to renew efforts to eradicate polio with support from global partners, including the Bill and Melinda Gates Foundation, which has made polio eradication its top priority. Angola succeeded in stamping out polio for three consecutive years at the beginning of the century, but a strain of the virus prevalent in India reappeared in 2005 and has since spread to the neighbouring countries of Namibia, the Democratic Republic of Congo and the Republic of Congo. In 2010, 32 people in Angola contracted the highly infectious and incurable disease. Angola's health system, still recovering from years of war, only managed to fully vaccinate 35% of infants in 2009. According to UNICEF, supplementary immunisation campaigns have been beset by a lack of manpower, technical capacity and planning, particularly in Luanda where most of the polio cases in recent years have been concentrated. Since the war, Luanda's population has boomed, and many of the rural migrants live in cramped conditions with little access to safe water and sanitation. Such conditions are ideal for spreading polio, which is transmitted through faecal-oral contact. During a meeting on 24 January 2011 with Anthony Lake, UNICEF Executive Director, and Tachi Yamada, president of The Gates Foundation's global health programme, José Eduardo dos Santos, Angola’s president, reaffirmed the government's commitment to eradicating polio. The government's strategy consists of better surveillance of new polio cases, accelerated routine immunisation of children, better-quality vaccination campaigns and a campaign to promote household water treatment and hygiene.
The world risks losing its most potent treatment for malaria unless steps are quickly taken to prevent the development and spread of drug-resistant parasites, according to this action plan by the World Health Organization (WHO) and Roll Back Malaria partnership (RBM). The plan outlines the necessary actions to contain and prevent resistance to artemisinins, which are the critical component of artemisinin-based combination therapies (ACTs), the most potent weapon in treating falciparum malaria, the deadliest form of the disease. Resistance to artemisinins has already emerged in areas on the Cambodia-Thailand border. Although ACTs are currently more than 90% efficacious around the world, quick action is essential, WHO and RBM argue. If these treatments fail, many countries will have nothing to fall back on. The global plan aims to contain and prevent artemisinin resistance through a five-step action plan. 1. Stop the spread of resistant parasites through a fully funded and implemented malaria control agenda. 2. Increase monitoring and surveillance for artemisinin resistance. 3. Improve access to malaria diagnostic testing and rational treatment with ACTs and reduce unnecessary use of ACTs – WHO recommends diagnostic testing of all suspected malaria cases prior to treatment. 4. Invest in artemisinin resistance-related research, especially with regard to developing more rapid techniques for detecting resistant parasites, and to developing new classes of antimalarial medicines to eventually replace the ACTs. 5. Motivate action and mobilise resources.
The objective of this study was to establish the feasibility and reliability of a questionnaire for healthcare service satisfaction and a questionnaire for satisfaction with information received about TB medicines among adult TB patients attending public and private programme clinics in Kampala, Uganda. Researchers recruited 133 patients of known HIV status and confirmed pulmonary TB who were receiving care at public and private hospitals in Kampala, Uganda. A translated and standardised 13-item patient healthcare service satisfaction questionnaire (PS-13) and the Satisfaction with Information about Medicines Scale (SIMS) tool were administered by trained interviewers. Of the 133 participants, 35% were starting, 33% had completed two months, and 32% had completed eight months of TB therapy. The male to female and public to private hospital ratios in the study population were 1:1. The PS-13 and the SIMS tools were highly acceptable and easily administered. Patients that were enrolled at the public hospital had relatively lower PS-13 satisfaction scores for technical quality of care and responsiveness to patient preferences when compared to patients that were enrolled at the private hospital. The authors conclude that their study provides preliminary evidence that the PS-13 service satisfaction and the SIMS tools are reliable measures of patient satisfaction in TB programmes. Satisfaction score findings suggest differences in patient satisfaction levels between public and private hospitals, as well as between patients starting and those completing TB therapy.
Households in malaria endemic countries experience considerable costs in accessing formal health facilities because of childhood malaria. The Ministry of Health in Malawi has defined certain villages as hard-to-reach (HTR) on the basis of either their distance from health facilities or inaccessibility. Some of these villages have been assigned a community health worker, responsible for referring febrile children to a health facility. In this study, researchers compared health facility utilisation and household costs of attending a health facility between individuals living near the district hospital and those in HTR villages. Two cross-sectional household surveys were conducted in the Chikhwawa district of Malawi; one during each of the wet and dry seasons. Half the participating villages were located near the hospital, the others were in HTR areas. The researchers found that those people living in HTR villages were less likely to attend a formal health facility compared to those living near the hospital. Analyses including community health workers (CHWs) as a source of formal health-care decreased the strength of this relationship, and suggested that consulting a CHW may reduce attendance at health facilities, even if indicated. Household costs for those who attended a health facility were greater for those in HTR villages than for those living near the district hospital. The researchers call on health service planners to consider geographic and financial barriers to accessing public health facilities in designing appropriate interventions.
The authors of this study set out to explore the relationship between homestead distance to hospital and access to care and to estimate the sensitivity of hospital-based surveillance in Kilifi district, Kenya. In 2002–2006, clinical information was obtained from all children admitted to Kilifi District Hospital and linked to demographic surveillance data. Travel times to the hospital were calculated and the relationships between travel time, cause-specific hospitalization rates and probability of death in hospital were examined. The analysis included 7,200 admissions (64 per 1,000 child-years). Median pedestrian and vehicular travel times to hospital were 237 and 61 minutes, respectively. Hospitalisation rates decreased by 21% per hour of travel by foot and 28% per half hour of travel by vehicle. Distance was positively associated with the probability of dying in hospital. In this setting, hospital utilisation rates decreased and the severity of cases admitted to hospital increased as distance between homestead and hospital increased. Access to hospital care for children living in remote areas was low, particularly for those with less severe conditions. Distance decay was attenuated by increased levels of maternal education. Hospital-based surveillance underestimated pneumonia and meningitis incidence by more than 45% and 30%, respectively, the researchers found.
Despite more than half a century of advocacy for safe water, sanitation and hygiene, approximately 100,000 cholera cases and 5,000 deaths were reported in Zimbabwe between August 2008 and by July 2009. Safe and effective oral cholera vaccines have been licensed and used by affluent tourists for more than a decade to prevent cholera. The authors of this study investigated whether oral cholera vaccines could be used to protect high risk populations at a time of cholera. They calculated how many cholera cases could have been prevented if mass cholera vaccinations would have been implemented in reaction to past cholera outbreaks, estimating that determined, well-organised mass vaccination campaigns could have prevented 34,900 (40%) cholera cases and 1,695 deaths (40%) in Zimbabwe. They identify barriers to implementation of mass vaccinations, particularly the cost of the vaccine.
This study examined 'stigmatising' ideas and the view that TB patients should queue with other chronically ill patients at health facilities. Data was gathered through a survey administered to respondents from 1,020 households in Grahamstown, South Africa. The survey measured stigmatisation surrounding TB and HIV and AIDS, and determined perceptions of respondents whether TB patients should queue with other chronically ill patients. Results showed that respondents with TB-stigmatising ideas held positive attitudes toward volunteer support, special TB queues, and treatment at clinics, but held negative attitudes toward temporary disability grants, provision of information at work or school, and treatment at the TB hospital. Respondents who felt it beneficial for TB patients to queue with other chronically ill patients conversely held positive attitudes toward provision of porridge and disability grants, and treatment at the TB hospital, while they held negative attitudes toward volunteer support, special TB queues, information provision at work or school, and treatment at clinics. The authors conclude that TB stigma and the view that TB patients should queue with other chronically ill patients are associated with opposing attitudes and preferences towards TB treatment. These opposing attitudes complicate treatment outcomes, and the authors suggest that complex behaviours must be taken into account when designing health policy.
This report, compiled annually by Human Rights Watch (HRW), is focused on human rights, but it makes a number of observations about the state of health services in several east, central and southern African countries. It notes that, partly due to health care system failures, tens of thousands of Kenyan women and girls die each year in childbirth and pregnancy, while more suffer preventable injuries, serious infections, and disabilities. Maternal deaths represent 15% of all deaths for women of reproductive age, while an estimated 300,000 women and girls are living with untreated fistula. Kenya’s restrictive abortion laws, which criminalise abortion generally, are argued to contribute to maternal death and disability, as unsafe abortions account for 30% of maternal deaths. HRW also alleges that the Kenyan government fails to provide adequate pain treatment and palliative care for hundreds of thousands of children with diseases such as cancer or HIV and AIDS. Oral morphine, an essential medicine for pain treatment, is currently out of stock. Kenya’s few palliative care services, which provide pain treatment but also counselling and support to families of chronically ill patients, lack programmes for children. In South Africa, millions of suffer from inadequate access to shelter, water, education, and health care, according to the report. South Africa is unlikely to meet the health-related Millennium Development Goals, and is one of only eight countries in the region where the rate of maternal deaths seems to be increasing. The South African government estimates that the maternal mortality ratio was 625 deaths per 100,000 live births in 2007, up from 150 deaths per 100,000 live births in 1998. In Uganda, women face numerous obstacles to reproductive health products and services such as contraception, voluntary sterilisation procedures, and abortion after rape. The most common barriers are long delays in obtaining services, unnecessary referrals to other clinics, demands for spousal permission contrary to law, financial barriers, and, in some cases, arbitrary denials. As a direct result of these barriers, women and girls may face unwanted or unhealthy pregnancies. Unsafe abortions have been a leading cause of maternal mortality for decades. HRW argues that government oversight of reproductive health care and accountability practices is seriously deficient.
This survey was conducted in October 2010 in Zimbabwe. Afrobarometer found that access to modern medical care and medicine improved in 2009 and 2010, although 39% of respondents often or always went without modern medical care and medicine in 2010. One in five had access to traditional medicines, while more than half of respondents (55%) experienced difficulty when seeking treatment at a clinic. A third and a quarter of respondents always or often went without food and water respectively in 2010, increasing potential for malnutrition and cholera. Seven out of ten (71%) regularly had no cash, curtailing their ability to pay for treatment or even transport to a health facility. One in five Zimbabweans (20%) made illegal payments to public health facilities. The high cost of medical care was identified as the most important health problem in the country, followed by shortages of supplies, poor infrastructure and insufficient staff. One in three was not satisfied with maternal and child health care services, and the same number was dissatisfied with nurses and midwives, while one in four was dissatisfied with the village health workers network. Reports of dirty facilities and illegal payments increased since 2005. There was some improvement with the availability of medical supplies and doctors in public clinics since 2005 and widespread satisfaction with government performance on HIV and AIDS, but most respondents (58%) did not want government to prioritise HIV and AIDS above other health problems.
8. Human Resources
Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address health worker shortages in low-income countries. This study uses an economics perspective to review the skill mix literature to determine the evidence in favour of task shifting, identify gaps in the evidence and propose a research agenda. Thirty-one studies, primarily from low-income countries and published between 2006 and September 2010, were included. First, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. Second, although task shifting is promising, it can present its own challenges, the authors argue, such as quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadre's results to the results from the care that would have been provided - if any care at all - had task shifting not occurred. The authors conclude that task shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.
The author of this study assessed the situation of nurses and home-based care givers in Tanzania and found a number of challenges. Most non-household care services for PLWHAs were found to be carried out by a few civil society organisations, which are heavily reliant on external funding and the labour of volunteers, mostly women. This dependency on external funding and volunteer labour is argued to threaten the sustainability of the HBC programme. Volunteers include retired nurses, PLWHAs and poor women, who subsidise the cost of care out of their pockets by helping PLWHAs, such as with transport to clinics. Within the health workforce, the nursing cadre (the majority of whom are women) carry a disproportionate burden of care without adequate compensation, with gaps in provision of proper protective gear and allowances for HBC nurses not adequately covering transport costs and other hidden expenses. The authors note that this gap could be addressed, but many district councils do not have capacity to utilise the AIDS money allocated to them. They conclude that the HBC programme appears to have created unexpected financial burdens for households, and for paid HBC employees and volunteers.
With increased global attention on health worker retention, this analysis of the current situation finds a diversity of country contexts and situations that affect health worker retention and proposes that policy-makers develop a tailored bundle of interventions to attract health workers to rural service and encourage them to stay that are most appropriate for their own context and situation.
In South Africa, many health care workers managing HIV-infected patients - particularly those in rural areas and primary care health facilities - have minimal access to information resources and to advice and support from experienced clinicians. The Medicines Information Centre, based in the Division of Clinical Pharmacology at the University of Cape Town, has been running the National HIV Health Care Worker (HCW) Hotline since 2008, providing free information for HIV treatment-related queries via telephone, fax and e-mail. This questionnaire-based study showed that 224 (44%) of the 511 calls that were received by the hotline during the two-month study period were patient-specific. Ninety-four completed questionnaires were included in the analysis. Of these, 72 (77%) were from doctors, 13 (14%) from pharmacists and 9 (10%) from nurses. Ninety-six percent of the callers surveyed took an action based on the advice they received from the National HIV HCW Hotline. Most of the queries concerned the start, dose adaptation, change or discontinuation of medicines. Less frequent actions taken were adherence and lifestyle counselling, further investigations, referring or admission of patients. The authors of this study conclude that the information provided by the National HIV HCW Hotline on patient-specific requests has a direct positive impact on the management of patients.
The purpose of this article is twofold. First, the authors describe Uganda's transition from a paper filing system to an electronic Human Resource Information System (HRIS) capable of providing information about country-specific health workforce questions. They examine the ongoing five-step process to strengthen the HRIS to track health worker data at the Uganda Nurses and Midwives Council (UNMC). Second, they describe how HRIS data can be used to address workforce planning questions via an initial analysis of the UNMC training, licensure and registration records from 1970 through May 2009. The data indicated that, for the 25,482 nurses and midwives who entered training before 2006, 72% graduated, 66% obtained a council registration, and 28% obtained a licence to practice. Of the 17,405 nurses and midwives who obtained a council registration as of May 2009, 96% are of Ugandan nationality and just 3% received their training outside of the country. Thirteen percent obtained a registration for more than one type of training. Most (34%) trainings with a council registration are for the enrolled nurse training, followed by enrolled midwife (25%), registered (more advanced) nurse (21%), registered midwife (11%), and more specialised trainings (9%). The authors found the UNMC database was valuable in monitoring and reviewing information about nurses and midwives. However, they add that information obtained from this system is also important in improving strategic planning for the wider health care system in Uganda.
Over the past decades, changes in economic, social and demographic structures have spurred the growth of employment in care-related occupations, according to this special edition of the International Labour Review (ILR). As a result, care workers comprise a large and growing segment of the labour force in both North and South. One impetus for much of the research and policy work in this area is a concern about the labour market disadvantages of particular segments of the care workforce (such as migrant domestic workers, elderly carers, and nursing aides). Although the issue of care work and its vulnerability is a global phenomenon, the collection of papers in the ILR pays particular attention to developing country contexts where issues of worker insecurity and exploitation are most intransigent, and where research has been sparse and data challenges are often significant. The book raises questions about who the care workers are, whether they are recognised as workers, how their wages compare to those of other workers with similar levels of education and skill, the conditions under which they work, and how their interests could be better secured. This ILR contains two research papers relevant to the east, central and southern African region, one of which deals with nurses and home-based caregivers in Tanzania and the other which deals with nurses, social workers and home-based care workers in South Africa.
9. Public-Private Mix
During a World Economic Forum held from 26-29 January 2011 in Davos, Switzerland a panel discussion was held on children’s health, the first in the history of the Forum. The panel included World Health Organization Director-General, Margaret Chan, who called for universal access to vaccines for preventable diseases, insecticide-treated bed nets for all children living in malaria zones and proper and balanced nutrition for children. It also included Melinda Gates from the Gates Foundation, who called for greater investment in women and frontline health workers, such as community health workers, as well as universal vaccine access for all children. The panel included a number of speakers from the private sector, such as Muhtar A. Kent, Chairman of the Board and Chief Executive Officer, Coca-Cola Company, USA; Lars Rebien Sorensen, President and Chief Executive Officer, Novo Nordisk, Denmark who raised some examples of how product innovation can respond to health needs. While there was pressure for private sector involvement in improving child health globally, there was also critique of insufficient product innovation to make food and other products less harmful to child health; that industry voice and influence in political circles is stronger than that of people working with child health; that cuts to financing of social services are having a negative effect on child health; and the question was asked: "Can we have healthy children without healthy labour conditions and healthy wages?"
At the World Economic Forum, held from 26-29 January 2011 in Davos, Switzerland, the debate on health centred on combating chronic or non-communicable diseases (NCDs), such as diabetes, heart disease and obesity. A panel was held to discuss the issue, where speakers highlighted the need to redefine ‘global health’ to include not only infectious diseases such as HIV and AIDS, malaria and tuberculosis, but also NCDs. NCDs were noted to cause more than 60% of deaths around the world, of which 80% are in the developing world, yet only about 3% of developmental assistance goes specifically towards chronic disease. The panel discussed the potential of technologies to improve health, such as cellphone technology in monitoring patients’ health. The private sector was argued to have a role in implementing workplace policies to support employees’ health and well-being. The panel called for a diagonal approach blending disease specific programmes with health system strengthening, through specific priorities being used to drive general improvements and to build capacity of the public health sector to meet both current and future health challenges.
A compromise was struck at the World Health Organization (WHO) Executive Board meeting, held from 17-25 January 2011, allowing a Swiss pharmaceutical industry representative to sit on a committee selecting proposals for research and development (R&D) financing for neglected diseases, despite the fact that he is author of one of the proposals. In light of the fact that a predecessor working group fell prey to allegations of conflict of interest and lack of transparency, WHO added special safeguards to prevent undue influence, but questions remain for some about conflict of interest. The compromise was reached in the margins of the meeting after developed countries threatened to subject other committee appointees to scrutiny. Developing countries, including those with burgeoning generics industries also have candidates on the 21-member expert committee, though none is considered as directly positioned to benefit from the outcome. Critics say the Swiss private sector proposal could be worth billions of dollars to developed country brand-name pharmaceutical companies. Thailand raised concerns about the proposed expert and Brazil argued that equity in global health was at stake.
10. Resource allocation and health financing
At this meeting, held in Tokyo from 16-17 December 2010, participants took note of the significant positive impact of innovative financing in the health sector including IFFIm, advance market commitment (AMC), the air Ticket levy, and private sector initiatives. New ideas were also introduced like a tobacco tax and new public-private partnerships. The setting up of a dedicated Task force was put forward for consideration. Participants also reconfirmed the necessity of reducing the cost of migrants’ remittances, and the improvement of their impact on development in recipient countries, including through microcredit institutions. For the way forward, participants pledged support for scaling up of initiatives and concrete actions, promising to work within the United Nations (UN) to foster follow up of the UN Resolution on Innovative financing for Development, with special emphasis on least-developed countries. The Group called on the G20 group of nations to give due attention to the potential of innovative financing in its development agenda.
In November 2011, the international community will meet in South Korea for the Fourth High Level Forum on Aid Effectiveness. The aim of this paper is to inform and prompt debates on development effectiveness in the lead up to the Forum. The author observes that the concept of development effectiveness responds to many of the criticisms leveled at development efforts historically, such as: narrow focus on aid, rigid and often ineffective and irrelevant measurements of successes and failures, the need to address systemic inequality at the international level and improve partner-country ownership of development, and limited attention to and insufficient understanding of issues relating to power and the root causes of poverty. Development effectiveness could be an important ‘game changer’ for the international aid effectiveness agenda and have far-reaching implications for global development agendas and priorities, the author of this study argues. Development effectiveness is about more than aid effectiveness, she notes, both in design and substance. Aid effectiveness is still important in this context and will most certainly be a part of a development effectiveness agenda in the short and medium terms. Depending on how it is articulated and operationalised, development effectiveness could lay the foundation for different types of partnerships between external funders, partner-country governments and institutions, civil society organisations, philanthropists, private-sector actors, and citizens, with implications for accountability and implementation mechanisms. A shift to development effectiveness will require different evaluation and monitoring tools, especially if it involves something more than organisational effectiveness. Given these considerations, policymakers should avoid rushing into an international agreement on development effectiveness, the author cautions, to ensure that, when one emerges, it is based on international consensus and can be easily operationalised and communicated not only at the global level but also on the ground in partner countries.
The authors of this study, who represent France, Japan and Belgium, identify current measures of innovative financing as including taxes on airline tickets to finance access to essential medicines through UNITAID, an innovative financing fund hosted by the World Health Organisation (WHO), and bonds secured by government pledges to finance immunisation (GAVI). Such measures have made it possible to mobilise resources to fight against the three major infectious diseases (HIV/AIDS, Tuberculosis and Malaria) and to scale up immunisation programmes, the authors argue. They have produced remarkable results. Moreover, efforts to encourage voluntary contributions such as donations by citizens, consumers and companies have been made. The Doha Conference in November 2008 called on the world to expand the scope of innovative development financing. New instruments that are based on global activities are becoming available, as well as broad-based financing that could, through numerous miniscule contributions, change the public health financing landscape, if properly coordinated. Before the UN Summit on the Millennium Development Goals in September 2010, France, Japan and Belgium agreed to endeavour to make more countries understand the importance of innovative development financing, whose success has already generated more than US$3 billion since 2006. As a step towards achieving this aim, the countries established a Taskforce on International Financial Transactions for Development in October 2009 with two objectives: to come up with a shared analysis of what is feasible and to make concrete, realistic proposals. The authors caution that developing countries can no longer rely on traditional overseas development assistance. Instead, the challenge ahead is to design an innovative mechanism based on strict governance and allocation criteria.
Critics of performance-based financing suggest that it may be a fad of external funders, with limited potential to improve service delivery. Most critics view it solely as a provider payment mechanism. The authors of this article argue that performance-based financing can catalyse comprehensive reforms and help address structural problems of public health services, such as low responsiveness, inefficiency and inequity. The emergence of performance-based financing in Africa may profoundly transform the public sectors of the low-income countries in the region. However, the authors caution on the limits to performance-based financing, particularly as some dimensions of performance are difficult to measure and, therefore, to remunerate. More classical support and mechanisms will remain crucial for strengthening health systems in low-income countries.
The authors of this paper reviewed aid to health and borrowing from the International Monetary Fund (IMF) between 1996 and 2006. They found that, on average, for each US$1 of development assistance for health, only about $0.37 is added to the health system. In their comparison of IMF-borrowing versus non-IMF-borrowing countries, non-borrowers add about $0.45 whereas borrowers add less than $0.01 to the health system. Health system spending grew at about half the speed when countries were exposed to the IMF than when they were not.
At the opening of the World Health Organization’s (WHO) Executive Board meeting, held from 17–25 January 2011, there were calls for reform amid concerns about WHO’s finances for the year ahead. WHO Director-General, Margaret Chan, said that the United Nations agency is stretched thin due to a high level of demand impacting its efficiency in some areas, and that far-reaching reform is needed. She also warned against big corporations’ influence on policies, in her response to dissension over a pharmaceutical industry representative named by the WHO secretariat to join a new research and development funding working group. In her opening remarks, Chan underlined the financial shortfall of the WHO, which some later said could range between US$200 and $600 million dollars in the biennium.
11. Equity and HIV/AIDS
In the context of growing recognition that primary prevention, including behavioural change, must be central in the fight against HIV and AIDS, the authors of this study conducted an extensive multi-disciplinary synthesis of the available data on the causes of the remarkable HIV decline that has occurred in Zimbabwe (29% estimated adult prevalence in 1997 to 16% in 2007) despite severe social, political, and economic disruption in the country. The behavioral changes associated with HIV reduction - mainly reductions in extramarital, commercial and casual sexual relations, and associated reductions in partner concurrency - appear to have been stimulated primarily by increased awareness of AIDS deaths and secondarily by the country's economic deterioration. These changes were probably aided by prevention programs utilising both mass media and church-based, workplace-based, and other inter-personal communication activities, the authors surmise. They conclude that focusing on partner reduction, in addition to promoting condom use for casual sex and other evidence-based approaches, is crucial for developing more effective prevention programmes, especially in regions with generalised HIV epidemics.
The authors of this paper studied how increased access to antiretroviral therapy affects sexual behaviour, using data collected in Mozambique in 2007 and 2008. They surveyed both HIV-positive individuals and households from the general population. The findings support the hypothesis of disinhibition behaviours, where individuals are more likely to engage in risky sexual behaviour when they believe that they will have greater access to better health care, such as antiretroviral therapy. The findings suggest that scaling up access to antiretroviral therapy without prevention programmes may lead to more risky sexual behaviour and ultimately more infections. The authors conclude that with increased antiretroviral availability, prevention programmes need to include educational messages so that individuals know that risky sexual behaviour is still dangerous.
Researchers in this study investigated reasons for clinical follow-up and treatment discontinuation among HIV-infected individuals receiving antiretroviral therapy (ART) in a public-sector clinic and in a workplace clinic in South Africa. Participants in a larger cohort study who had discontinued clinical care by the seventh month of treatment were traced using previously provided locator information. Those located were administered a semi-structured questionnaire regarding reasons for discontinuing clinical follow-up. Participants who had discontinued antiretroviral therapy were invited to participate in further in-depth qualitative interviews. Fifty-one of 144 (35.4%) in the workplace cohort had discontinued clinical follow-up by the seventh month of treatment. The median age of those who discontinued follow-up was 46 years and median educational level was five years. By contrast, only 16.5% (44/267) of the public-sector cohort had discontinued follow-up. Among them the median age was 37.5 years and median education was 11 years. Qualitative interviews were conducted with 17 workplace participants and 10 public-sector participants. The main reasons for attrition in the workplace were uncertainty about own HIV status and above the value of ART, poor patient–provider relationships and workplace discrimination. In the public sector, these were moving away and having no money for clinic transport. The authors argue that, in the workplace, efforts to minimise the time between testing and treatment initiation should be balanced with the need to provide adequate baseline counselling taking into account existing concepts about HIV and ART. In the public sector, earlier diagnosis and ART initiation may help to reduce early mortality, while links to government grants may reduce attrition.
This is the first study to report malaria as a risk factor of concurrent HIV infection at the population level. The authors examined the association between malaria and HIV prevalence in east sub-Saharan Africa. They used large nationally representative samples of 19,735 sexually active adults from the 2003–04 HIV and AIDS indicator surveys conducted in Kenya, Malawi and Tanzania, as well as the Atlas Malaria Project, and analysed the relationship between malaria and HIV prevalence, adjusting for important socio-economic and biological cofactors. They found that individuals who live in areas with a high malaria parasite rate are about twice as likely to be HIV positive compared with individuals who live in areas with a low parasite rate. The authors argue that these findings emphasise the need for field studies focused on quantifying the interaction among parasitic infections and risk of HIV infection, as well as studies to explore the impact of control interventions. Public health programmes in the region should be focused on reducing malaria transmission, especially in HIV-infected individuals.
An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. The authors of this study evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region. Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills. The authors conclude that MEMS-bottle use was readily accepted by patients, but patients need to be more explicitly instructed to continue MEMS-use when travelling. In addition, even if HIV clinics have sufficient staff and free medication, supplying an insufficient amount of pills may impose adherence barriers on patients.
12. Governance and participation in health
The authors of this study conducted a print media analysis in 44 countries in Africa, the Americas, Asia and the Eastern Mediterranean to find out whether and how policymakers, stakeholders, and researchers talk in the media about three topics: policy priorities in the health sector, health research evidence, and policy dialogues regarding health issues. In their literature review, the authors identified approximately five times more articles describing health research evidence compared to the number of articles describing policy priorities. Few articles describing health research evidence discussed systematic reviews (2%) or health systems research (2%), and few of the policy dialogue articles discussed researcher involvement (9%). News coverage of these concepts was highly concentrated in several countries like China and Uganda, while few articles were found for many other jurisdictions. The authors conclude that, in many countries of the countries reviewed, the print media (as captured in a global database) are largely silent about these three topics central to evidence-informed health systems. These findings suggest the need for proactive-media engagement strategies.
Developing countries have highlighted a number of concerns over the reform agenda of ‘The Future of Financing for WHO’, which was unveiled by the Director-General of the World Health Organization (WHO) at the 128th session of the organization's Executive Board held from 17-25 January. Several developing countries pointed out that health cannot be de-linked from socio-economic development, and voiced strong support for the WHO's role in development and its leadership on global health issues. There was also a call for a transparent process to discuss the reform. While the reform agenda was initially instigated by the need to ensure more predictable and sustainable financing for WHO, proposals for reform that are contained in Director-General Margaret Chan's report suggest a more far-reaching agenda that could lead to significant changes in the role of WHO on matters of public health at the global level. In depating the proposals representatives of several low and middle income countries pointed out that health cannot be de-linked from socio-economic development and WHO cannot be reduced to being a mere technical agency. They also expressed strong support for WHO's role in development and its leadership in global health issues. Civil society groups, including the People’s Health Movement cautioned that public health should not take a back seat to market-led initiatives. Mozambique, on behalf of the African group, stated that reform of the organisation should maintain WHO's leadership position in international health, adding that any debate on financial aspects deserves a wider discussion.
The African Peer Review Mechanism (APRM), a tool designed to promote good governance on the continent, is built on the belief that the continent does not lack ideas to advance its development, but that states have struggled to live up to their principles and implement their policies. The APRM rests on the fundamental belief that good governance is a precondition for taking Africa out of its spiral of conflict, underdevelopment, poverty and increasing marginalisation in a globalised world. Looking back almost a decade after the APRM was first conceived, Grappling with Governance explores how this complex process has evolved from theory to practice in a variety of contexts. In a combination of case studies and transversal analysis, multiple voices from different African civil society actors - mainly analysts, activists and journalists - examine the process from their specialised perspective. The chapters tease out what can be learned about governance in Africa from these experiences, and the extent to which the APRM has changed the way that governments and civil society groups engage. This book demonstrates that undergoing review through the APRM can be messy, haphazard and full of reversals. Like any tool, the APRM’s effectiveness depends on the suitability of its design for the task at hand, the situation in which it is used, and the skill of its user. The different authors reflect on these characteristics as users of this tool. While it is ill-advised to draw universal conclusions, this book nevertheless demonstrates that the APRM has added value, sometimes in unexpected ways.
With the current World Health Organization (WHO) Director-General’s term of office ending in June 2012, WHO members have set up a drafting group to try to reconcile divergent views on the process leading to the election. At the WHO Executive Board meeting, which ran from 17-25 January 2011, some countries were in favour of geographical rotation, citing over 60 years of no representation from their regions, while others objected that rotation should not override more important selection criteria such as expertise and experience, as it could endanger the organisation’s future. A draft resolution on the rules of procedure for the appointment of the WHO Director-General (DG) was proposed by Burundi on behalf of the member states of the African region, asking for the Executive Board to approve the principle of geographical rotation of the post of DG among the six regions of WHO, namely Africa, the Americas, South-East Asia, Europe, the Eastern Mediterranean and the Western Pacific. In this draft resolution, Burundi stressed the need for further strengthening of guarantees of transparency and equity among the six geographical regions of the WHO in the process of nominating and appointing the DG. The proposed document stirred a debate that some countries said has been on the table since 2006.
Civil society activists say Uganda's presidential candidates have not placed sufficient emphasis on how they plan to tackle the HIV and AIDS epidemic should they come into office, despite rising HIV prevalence and major funding problems. Critics maintain there is not enough focus on HIV and AIDs in the election, with candidates’ manifestos mostly making general statements on health. Local civil society activists have lobbied all major political parties to commit to a ‘ten-point platform’ to fight HIV and AIDS, which includes commitments to fully fund the fight against HIV, increase the number of health workers and end corruption in the health sector.
13. Monitoring equity and research policy
The authors of this study aimed to illustrate the effects of failing to account for model uncertainty when modelling is used to estimate the global burden of disease, with specific application to childhood deaths from rotavirus infection. To estimate the global burden of rotavirus infection, different random-effects meta-analysis and meta-regression models were constructed by varying the stratification criteria and including different combinations of covariates. The models were then compared. The authors found that, in the models they examined, the estimated number of child deaths from rotavirus infection varied between 492,000 and 664,000. While averaging over the different models’ estimates resulted in a modest increase in the estimated number of deaths (541,000 as compared with the World Health Organization’s estimate of 527,000), the width of the 95% confidence interval increased from 105,000 to 198,000 deaths when model uncertainty was taken into account. The authors conclude that sampling variability explains only a portion of the overall uncertainty in a modelled estimate. The uncertainty owing to both the sampling variability and the choice of model(s) should be given when disease burden results are presented. Failure to properly account for uncertainty in disease burden estimates may lead to inappropriate uses of the estimates and inaccurate prioritisation of global health needs.
The current globally agreed definition of cumulative anti-retroviral therapy (ART) coverage is expressed as the number of individuals receiving ART at a point in time divided by the number of individuals who are eligible to receive treatment at the same point in time (including those who are already receiving ART). The authors of this paper acknowledge that so far it has proved an invaluable tool for promoting the systematic estimation of ART coverage at country level and for holding countries accountable through reporting requirements, such as those requested by the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). But, as programmes mature and funding for ART becomes more uncertain, the increasing number of patients on ART included in the definition render the measure increasingly insensitive to annual changes in ART enrolment, the authors argue. In response to the need to expand reporting of ART access to include measures of recent enrolment, they propose a new definition to complement the existing UNGASS definition of ART coverage. The ratio of ART initiation to HIV progression is not only a better reflection of recent programme performance, the authors argue, but also a more robust measure that is less sensitive to model assumptions and to changes in ART eligibility criteria.
The first Human Development Report was released in 1990 and the 2010 edition marked the 20th anniversary of these annual United Nations Development Programme reports. A panel discussion at the report’s launch in early November 2010 discussed the findings of the report. David Morrison, Executive Secretary of the United Nations Capital Development Fund, noted how approaches in development 20 ago equated with economic growth and how this has changed, as people have become aware that any measurement of well-being should include opportunities for education and health, and the ability to use knowledge to shape one’s destiny. The panellists highlighted the innovative ways the report continues to measure poverty, including this year’s addition of three new indices, which allow researchers more leeway to compare findings. One of the new measures is the Multidimensional Poverty Index (MPI), a tool which aims to give a more accurate picture of acute poverty than traditional ‘dollar-a-day’ measures by considering indicators of health, education, and standard of living, in addition to income. One advantage of the tool is it indicates the source of poverty, giving policy makers some insight about causes and manifestations of poverty.
With rapidly increasing globalisation, trends towards unhealthy diets, obesity, sedentary lifestyles and unhealthy habits are resulting in an increased worldwide burden of chronic non-communicable diseases (NCDs). In Africa this means that health systems face the challenge of an increasing burden of NCDs as well as continuing high morbidity and mortality from communicable diseases. This health transition represents an enormous challenge to Africa as the region with the least resources for an effective response, the authors of this paper argue. As previous epidemics, including HIV, have caught Africa unprepared, they urge the health community to plan ahead for health transition in Africa. Health research is identified as having a key role to play in meeting health and development goals, and must be responsive to changing disease patterns, such as health transition. Key areas for further research suggested in this paper include: epidemiological research so that a good understanding of the distribution in Africa of communicable and non-communicable diseases can inform health planning; research on the interactions between communicable and non-communicable diseases; health system research with a particular focus on new approaches to improve the primary care response to health transition; and policy research to evaluate the more upstream measures addressing the population-level determinants of NCDs. The authors call on government and public health stakeholders to capitalise on the global policy environment, which is becoming more favourable to action on health transition in Africa, and implement a research agenda for health transition. Alliances have a key role to play in Africa as well as in other regions in implementing the research agenda on health transition by building research capacity and mobilising the necessary investments.
14. Useful Resources
The One World Trust (OWT), with support from the International Development Research Centre, has created an interactive, online database of tools to help organisations conducting policy relevant research become more accountable. OWT believes policy-relevant research and innovation must continually take into account and balance the needs of a diverse set of stakeholders: from the intended research users, to their clients and donors, to the research community and the research participants. Responsiveness to all of these is crucial if they are to be legitimate and effective. In this, accountable processes are as important as high quality research products. OWT has built the online accountability database to support researchers, campaigners and research managers to think through the way they use evidence to influence policy in an accountable way. The database provides an inventory of over two hundred tools, standards and processes within a broad, overarching accountability framework. Each tool is supported by sources and further reading.
This online resource can help doctors select the most effective combination of anti-HIV drugs for patients with extensive experience of antiretroviral therapy. The HIV Resistance Response Database Initiative is a not-for-profit organisation with the mission of improving the clinical management of HIV infection through the application of bioinformatics to HIV drug resistance and treatment outcome data. The RDI has three specific goals: to be an independent repository of HIV resistance and treatment outcome data; to use bioinformatics to explore the relationships between resistance, other clinical and laboratory factors and HIV treatment outcome; and to develop and make freely available a system to predict treatment response, as an aid to optimising and individualising the clinical management of HIV infection. The HIV Treatment Response Prediction System is based on a computer model that includes information gathered from 65,000 HIV-positive patients across the world.
15. Jobs and Announcements
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 International Society for Equity in Health- ISEqH - will hold its 6th International Conference: Making Policy a Health Equity Building Process in Cartagena de Indias, Colombia - September 26-28, 2011. Equity is an important issue to champion for, however nobody disagrees with it because is too broad. The conferebce aims to provide more detail, to be more specific and, at the same time, offer a multi-disciplinary look. The organisers call for submissions for organised sessions by 4 March and individual abstracts by 15 April 2011. All participants are invited to submit an abstract for symposia and/or oral and/or poster presentations to abstracts@iseqh.org. It is not necessary to be a member of the International Society for Equity in Health to submit an abstract.
At the third annual HIV in Context Research Symposium, researchers, policy makers, activists and practitioners will share emerging and ongoing research at the intersections of gender, violence and HIV. Roundtables, panels and debates will address the following thematic areas: gender-based and sexual violence; gendered experiences of interpersonal, criminal, political and structural violence; gender(ed) inequalities in vulnerability; violence and HIV and barriers to effective access health, education, legal, economic interventions against gendered violence and HIV; intervention research, longitudinal research and capacity strengthening; primary health care and gender, violence and HIV; and theoretical and methodological developments in research against gendered and gender violence and HIV. The two-day Symposium will review and debate the state of the art in research, policy and practice to support ongoing and emerging research.
Is aid for trade working? This is the question that the Third Global Review of Aid for Trade will seek to address when it convenes in July 2011. The Review will evaluate progress in terms of the Aid-for-Trade Work Programme 2010-2011, which was issued on 27 November 2009. The work Programme’s aim is to keep an on-going focus on aid for trade, which will generate continued impetus to resource mobilisation, mainstreaming, operationalisation and implementation of aid for trade projects. The Work Programme is complemented by Aid-for-Trade meetings, culminating in the Third Global Review of Aid for Trade. The World Trade Organisation is hosting the event.
The World Health Organization (WHO) is inviting submissions of papers describing research that addresses violence against women. WHO is particularly interested in research with a strong intervention focus, including ways to get violence against women onto different policy agendas, lessons about how to address some of the challenges policy-makers face, and innovative approaches to prevention or service provision, including community-based programmes in both conflict- and crises-affected and more stable settings. Papers may address more neglected forms of violence against women or provide evidence on the costs and cost-effectiveness of intervention responses. Descriptive research that contributes to a better understanding of the global prevalence and costs of violence, or that provides evidence about the root causes of such violence, will also be considered.
Pages
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.