Grace was born in a family of 9 children. She was still in school when her mother became ill, so she dropped out to care for her. She married when she was young. “God blessed us with 2 children, both girls. Then my two children and my husband died of AIDS. I too have HIV and will never marry again”, she says. When her husband died she had no support for her life as their property was taken by her late husband’s relatives. She was left with nothing and helpless. She did not want to do commercial sex work, but she couldn’t see another option, and it gave her a means to earn enough to live a poor, risky and insecure daily life in Lilongwe.
This is not an unusual story. For some even younger than Grace, the AIDS epidemic has increased the risk of sexual, physical and emotional harm and neglect. Young women and children who have been deprived of care and support are particularly susceptible to working in the commercial sex industry. They face risk environments for HIV transmission for themselves and their clients, as well as of violence and other forms of abuse.
Today the story, at least for Grace, is different. She describes the changes she has brought in her own life and in her community. She herself has a more secure and healthy life. She also talks about commercial sex workers that have now accessed loans and are moving out of bars and running small businesses. Others have gone back to school. A meeting of women involved in commercial sex work raises rights and decisions, where to get counselling, testing and treatment for HIV, how to get greater control over their sexual activities and fertility, and how to build skills for other forms of work.
Grace points to the lever for this health affirming change - theatre.
“In 2007 some of us in commercial sex work trained on legislative theatre. Theatre for a Change contributed to the transformation of my life.”
Theatre for Change in Malawi equips socially and economically marginalised communities with the communications skills, knowledge and awareness to transform their lives and the lives of others personally, socially and professionally. In Malawi, it works with groups including commercial sex workers to reduce the risk of HIV. It involves women from the core group of former commercial sex workers who work as peer facilitators among younger people getting involved in sex work. Through the theatre and by performing their stories to a variety of audiences, the women access a voice and a platform to raise concerns and open debate. The process known as Legislative Theatre. The performances involve the audiences in coming up with solutions to the issues these women face, in the process changing attitudes and catalysing change in both the women themselves, their communities and even in policy makers when they are involved. The theatre work is supported by other programmes to provide access to female and male condoms, to HIV testing and counselling, and to relevant health services, including antiretroviral treatment. These services are available, but their uptake has been blocked by barriers like stigma. This process provides a vehicle for raising the health, gender and sexual rights and responsibilities of sex workers and their clients.
As Grace comments: “Now I know my rights and no one can violate my rights. I have self esteem and I am able to make decisions about my own body.”
It is already known that it is more effective to send former commercial sex workers to mobilise and reach out to others, as much as positive peer pressure from men has influenced other men to go for testing and counselling. For the women who have been involved in commercial sex work, the theatre work has helped to reach other commercial sex workers, especially adolescents. It has led to greater openness on health problems and changed attitudes towards commercial sex workers, including amongst the health workers who used to stigmatise commercial sex workers.
Those involved learn while they teach. They are trained in psychosocial issues and counselling to support their interactions with people of different ages, gender, place and occupation. They also build a more affirmative view of themselves, from being victims of economic insecurity and social stigma to people who plan and set goals for their own and their family lives.
Grace sums it up: “Everyday of my life brings an opportunity for a new beginning…I waste not a moment mourning yesterday’s misfortunes, defeats and challenges. These have been my stepping stones."
While antiretrovirals provide a therapy for the physical effects of HIV and AIDS, it seems that theatre can also be a powerful and equally necessary therapy for its social effects.
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, a film and further information on the Theatre for a Change programme visit www.tfacafrica.com/What-we-do/TfaC-in-Malawi/Sex-worker-programme
1. Editorial
2. Latest Equinet Updates
The course brought 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 participants discussed an assessment of institutional capacities and needs, information resources and sources at regional and country level support for Global Health Diplomacy; and shared 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), with support from Graduate Institute of International and Development Studies Geneva
3. Equity in Health
In this paper, three categories of social inclusion policies are reviewed – cash-transfers, free social services and specific institutional arrangements for programme integration – in six selected countries, including Botswana, Mozambique, South Africa and Zimbabwe. The authors highlight the impact of these policies on health inequities. They identify crosscutting benefits, such as poverty alleviation, notably among vulnerable children and youths, improved economic opportunities for disadvantaged households, reduction in access barriers to social services, and improved nutrition intake. However, they caution that the impact of these benefits, and hence the policies, on health status can only be inferred. A major weakness of most policies was the lack of a monitoring and evaluation system. The authors call on governments of sub-Saharan African countries to conduct research to measure health inequities and design social policies that address the constraints identified in the research. They also call for support for a strong movement by civil society to address health inequities and to hold governments accountable for improving health and reducing inequities.
According to this paper, Zambia’s Millennium Development Goal (MDG) progress reports of 2003 and 2005 show that it is unlikely that Zambia will achieve even half of its MDG goals, despite laudable political commitment and some advances made towards achieving universal primary education, gender equality, improvement of child health and management of the HIV and AIDS epidemic. The authors of this paper argue that Zambia’s health systems have been weakened by a high disease burden and high mortality rates, natural and man-made environmental threats and some negative effects of globalisation such as major external debt, low world prices for commodities and the human resource ‘brain drain’. They urge for the government to put its political promises into action, and offer some tried-and-tested strategies and ‘quick wins’ that have been proven to produce high positive impact in the short term.
This report card on South African children and youth shows that there has been little or no improvement in the areas of tobacco use, nutrition, physical activity and obesity over the last three years. It draws on more than 95 published, peer-reviewed studies or reports, which cumulatively show a decline in physical activity levels, with only 42% of youth having participated in sufficient vigorous physical activity to be considered health-enhancing. Less than one-third of youth surveyed participated in moderate activity and nearly 42% did little or no physical activity. There was an increase in overweight and obese children to 20% and 5% respectively. Nearly 30% of teens consumed fast food two to three times a week, while researchers found that healthy foods in rural settings cost almost twice as much as the unhealthy equivalent, further fuelling unhealthy eating habits. Almost 30% of adolescents say they have ever smoked, while 21% admit to being smokers currently (which is double that of global prevalence estimates). Most smokers start before the age of 19, with 6.8% starting under the age of 10. These trends may give rise to serious non-communicable and preventable diseases such as heart disease, diabetes, lung disease and certain cancers, which are responsible for over half of adult deaths worldwide, according to the report.
In June 2010, the Lesotho health department, in partnership with the World Health Organisation and the United Nations (UN) Children's Fund, launched a programme targeting the four worst-performing Millennium Development Goals (MDGs), namely those relating to the eradication of poverty and hunger, to reducing child and maternal mortality and to combating HIV. The programme has been implemented in the four worst-performing of Lesotho's 10 districts. Interventions are focused on helping mothers, and the programme also tries to address the lack of coordination and wasted resources that have plagued aid delivery in the past. The health department aims to identify pregnant, breast-feeding and HIV-positive mothers and their infants who are in need of food rations from the World Food Programme. They will be supplied with seeds, tools and advice on how to grow vegetables and raise chickens, in the hope of making them less reliant on food assistance, and will later receive training on how to start small businesses. By 2012, the programme should have yielded enough results and best practices for government to decide whether to take over and replicate it in other districts. The UN resident coordinator in Lesotho has called for funding for the programme to become part of the national budget, otherwise it runs the risk of failing.
In this study, the authors examine the importance of national female literacy on women’s maternal health care use in sub-Saharan Africa, using data from the 2002-2003 World Health Survey. They found that, within the various countries, individual age, education, urban residence and household income were associated with lack of maternal health care. National female literacy modified the association of household income with lack of maternal health care use. The strength of the association between income and lack of maternal health care was weaker in countries with higher female literacy. The study concludes with the observation that higher national levels of female literacy may reduce income-related inequalities through a range of possible mechanisms, including women’s increased labour participation and higher status in society. National policies that are able to address female literacy and women’s status in sub-Saharan Africa may help reduce income-related inequalities in maternal health care use.
In this study, researchers investigated whether depression, psychological distress and alcohol use are associated with sexual risk behaviours in young Ugandan adults. They sampled households in two Ugandan districts, recruiting 646 men and women aged 18-30 years. Participants were assessed for depression and psychological distress, as well as alcohol use and sexual behaviour risk. Researchers found that depression was associated with a greater number of lifetime partners and, among women, with having concurrent partners. Psychological distress was associated with a greater number of lifetime partners in both men and women but was only marginally associated with having concurrent partners among women. Psychological distress was associated with inconsistent condom use among men. Alcohol use was associated with a greater number of lifetime partners and with having concurrent partners in both men and women, with particularly strong associations for both outcome measures found among women. The researchers conclude that poor mental health is associated with sexual risk behaviours in a low-income sub-Saharan African setting. They argue that HIV preventive interventions should consider including mental health and alcohol use reduction components into their intervention packages, especially in settings where depression, psychological distress and alcohol use are common.
Health research consists of multiple disciplines that conceptualise and operationalise health in different ways, making integration of knowledge difficult, according to the authors of this paper. They argue that, to help researchers and practitioners study and intervene on complex health processes, comprehensive integrative frameworks linking multiple disciplines and bodies of knowledge must be developed. To this end, they propose a conceptual framework of health that integrates multiple elements from biomedical, psychosocial, behavioural, and spiritual research, using a ‘transdisciplinary’ approach. The framework includes discipline-specific constructs and domains, outlines their interactions, and links them to a global or holistic concept of health. In this context, health is seen as an emergent individual experience, transcending objective and subjective classifications of health and disease.
According to this editorial from the Bulletin of the World Health Organisation, most of the literature on gender differences in smoking has focused on differences in traditional sex roles. These roles have translated historically into social norms, such as disapproval of female smoking, and gender-specific personal characteristics, such as greater rebelliousness among men, which is linked to higher smoking rates. However, countries can vary widely in their actual experience with the smoking epidemic. For example, smoking levels among Chinese women have always been low and even dropped during the 20th century. In the 21st century, the situation is changing, the author argues, noting that social norms that slowed the diffusion of smoking among women are diminishing in most parts of the developing world, an unintended consequence of gender empowerment and economic growth, which allow women to freely make choices and furnish them with the economic resources to pursue those choices. A clue to the changing demographics of smokers is found in the narrowing gender gap in the rates of smoking experimentation and adoption among teenagers around the world. The author call for more research on how women view triggers that could lead to smoking adoption, such as peer pressure and role models, how addiction develops in female smokers, and how they weigh the costs and benefits of smoking.
On World Health Day, 7 April 2011, the focus will be on antimicrobials. According to the World Health Organisation (WHO), the use and misuse of antimicrobials in human medicine and animal husbandry over the past 70 years have increased the number and types of micro organisms resistant to these medicines, causing deaths, greater suffering and disability, and higher health-care costs. If this phenomenon continues unchecked, WHO warns, many infectious diseases risk becoming uncontrollable and could derail progress made towards reaching the health-related United Nations Millennium Development Goals for 2015. Furthermore, the growth of global trade and travel allows resistant organisms to spread worldwide within hours. WHO calls on governments and stakeholders to implement the policies and practices needed to prevent and counter the emergence of highly resistant micro-organisms.
4. Values, Policies and Rights
A Ugandan health lobby group, the Centre for Health Human Rights and Development, has petitioned the Constitutional Court over the alarming number of maternal deaths in government health facilities - currently, Uganda has one of the highest maternal mortality rates in the world. The group is arguing that government neglect is responsible, manifested in the ‘careless manner’ in which government hospital staff handle expectant mothers before, during and after birth. They are hoping the Constitutional Court will declare that it is a violation of the right to health when health workers and government fail to take required essential care during pre- and post-natal stages. The petitioners also want financial compensation from government for the affected families.
In this study, the authors set out to determine whether countries with high gender empowerment have a higher female-to-male smoking prevalence ratio. They explored the relationship between the United Nations Development Programme’s gender empowerment measure (GEM) and the female-to-male smoking prevalence ratio (calculated from the World Health Organisation’s 2008 Global Tobacco Control Report). Because a country’s progression through the various stages of the tobacco epidemic and its gender smoking ratio are thought to be influenced by its level of development, they explored this correlation as well, with economic development defined in terms of gross national income (GNI) per capita and income inequality (Gini coefficient). In their findings, the authors note that gender smoking ratio was significantly and positively correlated with the GEM. In addition, the GEM was the strongest predictor of the gender smoking ratio after controlling for GNI per capita and for Gini coefficient. Whether progress towards gender empowerment can take place without a corresponding increase in smoking among women remains to be seen, the authors conclude. They argue for stronger tobacco control measures in countries where women are being increasingly empowered.
In this paper, the authors examine the growing convergence between human rights and development thinking, particularly with regard to social and economic rights. They ask how the dialogue between human rights and development can contribute to furthering progress on the Millennium Development Goals (MDGs). They argue that developing countries need to secure relatively good rates of economic growth to make progress, but may be hampered by the fact that they remain far behind the developed world in terms of technology. Given a good enabling environment, most developing economies would be able to raise productivity fairly rapidly by absorbing existing knowledge from abroad, rather than inventing it for themselves. The rapid growth of South-South trade and investment flows among developing countries would be another supportive factor, but the authors caution that economic growth alone will not guarantee reaching MDG outcomes: governments need to ensure that the economic benefits of growth are equitably distributed.
This paper examines parental control and monitoring and the implications of this on young people's sexual decision making in a rural setting in North-Western Tanzania. Data collection involved 17 focus group discussions and 46 in-depth interviews conducted with young people aged 14-24 years and parents/carers of young people within this age-group. The researchers found that parents were motivated to control and monitor their children's behaviour for reasons such as social respectability and protecting them from unwanted pregnancies and sexually transmitted diseases. Children from single-parent families reported that they received less control and researchers noted that a father's presence in the family seemed important in controlling the activities of young people, while a mother's did not appear to. Girls received more supervision compared to boys. Despite parents making efforts to control and monitor their young people's sexual behaviour, the researchers conclude that parents are faced with major challenges, such as too little time available to spend with their children, which make it difficult for them to monitor them effectively. The researchers argue that there is a need for interventions, such as parenting skills-building, that might enable parents to improve their relationships with their children and help guide their sexual behaviour.
The primary objective of this study was to explore risk factors for sexual violence in childhood in a nationally representative sample of females aged 13 to 24 years in Swaziland. During a household survey respondents were asked to report any experiences of sexual violence before the age of 18 years. A total of 1,244 respondents were included in the study. Using the survey data, the researchers then analysed the association between childhood sexual violence and several potential demographic and social risk factors. They found that, compared with respondents who had been close to their biological mothers as children, those who had not been close to her had higher odds of having experienced sexual violence, likewise with those who had had no relationship with her at all. In addition, greater odds of childhood sexual violence were noted among respondents who were not attending school at the time of the survey, who were emotionally abused as children, and who knew of another child who had been sexually assaulted or was having sex with a teacher. Childhood sexual violence was positively associated with the number of people the respondent had lived with at any one time. Inadequate supervision or guidance and an unstable environment put girls at risk of sexual violence, the authors conclude, calling for greater educational opportunities and improved mother-daughter relationships.
A HIV-positive South African man has won a case of discrimination and unfair dismissal against his former employers in the Labour Court, and he says he hopes the ruling will encourage other HIV-positive people who are being discriminated against by their employers to come forward. The court ruling stated that he was unfairly dismissed by his employer because of his HIV status. The man was dismissed two years ago immediately after his former employer discovered that he was HIV-positive. Human rights organisation Section 27 has hailed the ruling, saying it sends a clear message that HIV-positive people cannot be discriminated against. According to Section 27, people with HIV should come forward and seek the protection of the law because if they go to court and their case is clear, they will win in court and the employer will be forced to pay compensation or legal costs. Advocates identified two major barriers to seeking legal redress in cases of discrimination against HIV-positive people – most people are not aware of their rights, and lawyers are inaccessible because the cost of their services is beyond the means of ordinary South Africans. Without proper legal services, they warn, it’s unlikely that claims will succeed.
Despite a growing body of research into risk factors for intimate partner violence (IPV), methodological differences limit the extent to which comparisons can be made between studies. The authors of this study used data from ten countries (including Namibia and Tanzania) from the World Health Organisation’s Multi-country Study on Women's Health and Domestic Violence to identify factors that are consistently associated with abuse across sites. Standardised population-based household surveys were conducted between 2000 and 2003, with one woman aged 15-49 years randomly selected from each sampled household. Those who had ever had a male partner were asked about their experiences of physically and sexually violent acts. The researchers found that, despite wide variations in the prevalence of IPV, many factors affected risk similarly across sites. Secondary education, high socio-economic status and formal marriage offered protection, while the risk of IPV increased with alcohol abuse, cohabitation, young age, attitudes supportive of wife beating, having outside sexual partners, experiencing childhood abuse, growing up with domestic violence, and experiencing or perpetrating other forms of violence in adulthood. The strength of the association was greatest when both the woman and her partner had the risk factor. The authors conclude that current IPV prevention programmes should pay greater attention to transforming gender norms and attitudes, addressing childhood abuse and reducing harmful drinking. Development initiatives to improve access to education for girls and boys may also have an important role in violence prevention.
5. Health equity in economic and trade policies
A decade ago, the anti-malaria drug artemisin – available only from the sweet wormwood plant, Artemisia annua – was scarce and expensive. But by 2007, the market was wallowing in a surfeit of the drug as farmers flocked to grow the crop. Now, as a US$343-million initiative starts to battle malaria through hugely subsidised medicines, suppliers are again worried that there will not be enough artemisinin to go around, while farmers, plant breeders and synthetic biologists are hoping that they can snap the drug out of its roller-coaster supply cycle. Farmers and scientists are struggling to keep up with needs of ambitious medicine-subsidy programme, the article notes. The authors observe that artemisin yields could be improved by planting new Artemisia strains. On average, one kilogram of its dried leaves yields some 8 grams of artemisinin. Researchers have used selective breeding to create hybrid plants that produce up to 24 grams, according to a British Artemisia breeding consortium. These plants are now being grown and harvested commercially in Madagascar, and trialled in South Africa, Uganda, Zimbabwe and the United States, as well as in Britain.
The author of this paper argues for public-private partnerships to help deliver locally produced generics in Africa, and against protectionism in favour of open market access. He points to promising developments, such as experienced Indian and Western pharmaceutical firms undertaking original research and development and partnering with firms in African countries. He believes this investment by reputable companies should help ensure quality drugs are produced by furnishing the technical expertise that overcomes capacity constraints. Local production enterprises in Africa will allow international companies to diversify their supply sources, the author argues, guarding against potentially disastrous shocks such as a natural disaster that would destroy an Artemisia crop and send the price of artemisinin-based malaria drugs skyrocketing. Local production partnerships could encourage trade, especially because the bulk active ingredients needed to produce them still come most efficiently from abroad. Partnerships between foreign pharmaceutical firms and African companies may also help train a pool of skilled workers, improving a country’s long-term development prospects.
In February 2011, experts gathered at the World Intellectual Property Organisation (WIPO) to rewrite the negotiating document on intellectual property rights and traditional knowledge. The new document caused disagreements over common language in most articles, in particular, Article 1 on the subject matter of protection of traditional knowledge, which includes the definition of traditional knowledge (TK), the criteria for eligibility and on secret TK. To accommodate different opinions, several options were listed in the draft document. In Article 1, one of the options mentions the fact that, among eligibility criteria, protection should extend to TK not widely known outside that community, which could imply that some TK already in the public domain would not be considered as eligible. A representative of the Indigenous Peoples Council on Biocolonialism argued that the language in Article 1 might be misconstrued as intellectual property language and it was important that Article 1 really reflect the integrity of TK in its cultural context as a dynamic form of knowledge transmitted from generation to generation to serve the interest of the community. Article 2 only contains two brackets signifying lack of agreement, one of which is around the word ‘nations’ as beneficiaries of protection. Some countries would like the protection to include indigenous peoples, local communities and nations. The representative of the Indigenous Peoples Council on Biocolonialism said beneficiaries should be TK holders themselves, and not nations. A developed country source agreed, noting that indigenous peoples and local communities are holders of TK and should be beneficiaries and managers of their rights, but that nations could not be beneficiaries of the instrument being elaborated as this would confuse intellectual property rights with public heritage protection.
The proposed intervention by The Global Fund to drastically reduce prices of Artemisinin Combined Therapies (ACTs) through its Affordable Medicines for Malaria programme (AMFm) will see ACTs from six foreign companies sell ACTs at a reduced, monitored price regime of between US$0.40 and 0.47. However, controversy has arisen over two competing development goals - making high quality medicines available to those in need at affordable prices vs strengthening local industrial capacity. The paper argues from the Nigeria situation, that manufacturers in Nigeria have practically no access to bank credit and provide their own infrastructural requirements, compared to foreign counterparts who may have access to cheap credit, enjoy tax reliefs and export incentives. This makes it difficult for Nigerian manufacturers to compete with their foreign counterparts. It is not clear whether there are actual foreign assistance efforts aimed at building the capacity of malaria endemic countries in Africa to produce their own pharmaceutical products. The author suggests that if such a longer term project were started in parallel with efforts like AMFm, there may be more acceptance for temporary set backs in the local market, given that the international community is trying to strengthen countries’ abilities to fight malaria into the future. The author calls for an aid programme that can address the infrastructural problems facing Nigerian manufacturers and provide a legal framework that protects intellectual property and gives the local companies a fair chance to compete.
In this study, the authors argue that an optimal drug registration approach for Africa should reliably evaluate safety, efficacy, and quality of drugs for African use. It should include African expertise, contribute to building African regulatory capacity, and, ultimately, expedite African access by reducing duplicative and sequential reviews by different regulators. However they present an overview of the current situation that shows the present system of drug approval to be far from achieving these goals, with inefficiencies in the use of regulatory resources and in the uptake of capacity-building opportunities for African regulators. As a result regulatory processes and decisions may not meet current needs. The authors recommend that countries institute formal twinned regulatory reviews, fund Centres of Regulatory Excellence in each of Africa’s main regions and conduct a strategic review of WHO drug pre-qualification disease and product priorities.
South-South trade is growing fast, but barriers among developing countries are still up to seven times higher than those imposed by the developed world, according to this article. The Organisation for Economic Cooperation and Development (OECD) has announced that exports from developing countries have grown to 37% of global trade, of which about 50% related to South-South trade. Historically, developing countries focused on preferential access to developed markets, but an OECD spokesperson said that the global economy had dramatically changed over the last two decades with wealth shifting from the developed world to developing countries, necessitating a change in thinking and attitude when it came to trade. The OECD anticipates that the growth trend would continue, predicting an increased contribution by developing countries. However, OECD pointed out that accelerated growth had resulted in greater inequalities in society, which could lead to political unrest, like the recent civil demonstrations in North Africa. The OECD called for good policy and governance in developing countries to build the correct developmental infrastructure, improve education and health, and increase human capital, while continuously diversifying their economies with a strong focus on productivity and innovation. One way to achieve this is through peer-to-peer learning, where policymakers can come together and share their successes and failures with each other, OECD argues.
According to this article, a drugs producer in Uganda has become the first in a least-developed country (LDC) to achieve a world-class seal of quality for its manufacturing standards. The Quality Chemicals plant, in the Ugandan capital Kampala, is the first to get this far along the World Health Organisation (WHO) pre-qualification process, a stringent quality check imposed on manufacturers of drugs. The next step is to gain approval, or pre-qualification, for each malaria and HIV/AIDS drug the firm produces, before international agencies, such as UNICEF, are allowed to buy from the company. It is an important milestone because of scepticism over domestic, or local manufacturing, in such countries, the author notes. There are around 37 manufacturers in sub-Saharan Africa. Pharmaceutical companies from Democratic Republic of the Congo to Ethiopia are being helped to reach international standards too. German development agency GTZ is even sending individual inspectors from the German regulator to Africa to do personal plant assessments. Although no substitute for a full WHO pre-qualification, the process helps identify improvements necessary to reach international standards.
The technical symposium on ‘Access to Medicines, Patent Information and Freedom to Operate’, held on 18 February 2011 in Switzerland, was hosted by the World Health Organisation (WHO) and co-organised by the World Intellectual Property Organisation (WIPO), and the World Trade Organisation (WTO). According to Margaret Chan, WHO’s Director-General, countries could save about 60% of their pharmaceutical expenditures by shifting from originator medicines to generic medicines, but a lack of essential procurement and regulatory capacities are preventing this shift in many developing countries. This is especially so in relation to non-communicable diseases, which is a growing problem in low and middle income countries. She called for more transparent and accessible data on patents to help with decisions on the ‘freedom to operate’, such as a user-friendly database that contains public information on the administrative status of health-related patents. Pascal Lamy, WTO Director-General, said the main aim of the symposium was not to enter policy discussions or legal debates but rather to evaluate the area where the three agencies could collaborate to provide an information base for policy debates. He argued for a move from raw data to accessible, trusted, neutral and relevant information that directs policymaking processes, practical innovation and procurement strategies. However, some participants at the symposium called for greater involvement of the generic industry to provide affordably priced medicines, and questioned the legitimacy of WIPO involvement in public health.
6. Poverty and health
This report explores how States can and must achieve a reorientation of their agricultural systems towards modes of production that are highly productive, highly sustainable and that contribute to the progressive realisation of the human right to adequate food. Drawing on an extensive review of the scientific literature published in the last five years, de Schutter identifies agro-ecology as a mode of agricultural development with strong conceptual connections with the right to food. Moreover, agro-ecology delivers advantages that are complementary to better known conventional approaches such as breeding high-yielding varieties. In the report, de Schutter argues that the scaling up of these experiences is the main challenge today. Appropriate public policies can create an enabling environment for such sustainable modes of production, such as: prioritising the procurement of public goods in public spending rather than solely providing input subsidies; investing in knowledge by reinvesting in agricultural research and extension services; investing in forms of social organisation that encourage partnerships, including farmer field schools and farmers’ movements innovation networks; investing in agricultural research and extension systems; empowering women; and creating a macro-economic enabling environment, including connecting sustainable farms to fair markets.
The authors of this study set out to estimate the reduction in child mortality as a result of interventions related to the environmental and nutritional Millennium Development Goals (MDGs) and to estimate how the magnitude and distribution of the effects of interventions vary based on the economic status of intervention recipients. They modelled the mortality effects of interventions on child nutrition and environmental risk factors, using data on economic status, child underweight, water and sanitation, and household fuels. The authors found that providing these interventions to all children younger than five years old would result in an estimated annual reduction in child deaths of 49,700 (14%) in Latin America and the Caribbean, 0.8 million (24%) in South Asia, and 1.47 million (31%) in sub-Saharan Africa. These benefits are equivalent to 30% to 48% of the current regional gaps toward the MDG target on reducing child mortality, the authors point out. Fifty percent coverage of the same environmental and nutritional interventions, as envisioned by the MDGs, would reduce child mortality by 26,900, 0.51 million, and 1.02 million in the three regions, respectively, but only if the interventions are implemented among the poor first.
At the International Conference on Leveraging Agriculture for Improving Nutrition and Health, held from 10 to 12 February 2011 in India, participants reached consensus that the way forward for improving agriculture, nutrition and health was to think and act multi-sectorally and inter-sectorally, and break down the silos among the three disciplines. Symptoms of the breakdown surfaced in 2007/2008, during the global food price crisis, said David Nabarro, the UN Special Representative on Food Security and Nutrition, when increased prices contributed to a rise in poverty and hunger around the world. Women's health was a central feature in most of the conference debates. Various speakers pointed out that a woman's well-being shaped the future of her children, especially her daughters, the mothers of the next generation. The future prosperity of a country often also rested on the shoulders of women, as agriculture not only created economic growth, they argued, but children who ate well often went on to earn better incomes. Experts said it was time to re-establish the links between agriculture, nutrition and health, and perhaps educate each sector about the objectives of the others.
From 2007 to 2009, HarvestPlus (a global NGO aimed at reducing world hunger) and its partners disseminated orange-fleshed sweet potato (OFSP) to 24,000 farming households in Uganda and Mozambique with the goal of reducing vitamin A deficiency. OFSP has higher vitamin A levels than white or yellow sweet potato. An evaluation of the intervention found a 68% and 61% increase in adoption of OFSP in Mozambique and Uganda respectively. The share of OFSP in the total area dedicated to sweet potato increased sharply as households substituted white or yellow sweet potato with OFSP. There was also a significant net increase in vitamin A intakes in young and older children and women in these countries. In some instances, this increased intake resulted in children reaching the recommended intakes for their age group. The author of the study discusses how to reduce costs of promoting and scale up of the intervention through greater diffusion of OFSP between farming communities.
Many outside South Africa imagine that after Mandela was freed and the ANC won free elections all was well. But for many the struggle against apartheid, poverty and inequality continues, according to this book. Early in 2007 hundreds of families living in shacks in Cape Town were moved into houses they had been waiting for since the end of apartheid. But soon they were told the move was illegal and they were evicted. They built shacks alongside the road opposite and organised themselves into the Symphony Way Anti-Eviction Campaign. In this book they tell their own stories, in words and photographs, of the struggle for justice.
In this review of the book, ‘The bottom billion: Why the poorest countries are failing and what can be done about it’, by Paul Collier (Oxford University Press, 2008), Reinert identifies Collier’s core argument: four ‘traps’ lock Africa into poverty, namely the conflict trap, the natural resource trap, the trap of being landlocked with bad neighbours, and the trap of bad governance in a small country. Collier’s analysis, Reinert argues, represents a departure from traditional development economics to ‘development aid strategy’, and comes at a time when the world has long been dominated by Washington Consensus policies pushing for market liberalisation. Compared to the first decades after the Second World War, the growth record of this neo-liberal period has been dismal, he notes, especially in Africa. However, the reviewer expresses some concern that the book appears to defend the past policies of the World Bank, with the most salient misinterpretation of history being Collier’s presentation of the successes of China and India as a result of the policies of the Washington Institutions, when in fact their success was the result of actually not following the policies and rather opening their markets gradually. Collier tends to reverse the directions of the arrows of causality and even to disregard co-evolution of economic structure and institutions. As a former employee of the Washington Institutions responsible for enforcing neo-liberalism, the reviewer concludes that he attempts to cover up the past rather than present new constructive insights, and the book contains more descriptions of symptoms of poverty than of its root causes.
According to this report, the agriculture sector is underperforming in many developing countries, in part because women do not have equal access to the resources and opportunities they need to be more productive. The gender gap imposes real costs on society in terms of lost agricultural output, food security and economic growth, the Food and Agriculture Organisation (FAO) argues. Promoting gender equality is not only good for women – it is also good for agricultural development. Women make essential contributions to the rural economy of all developing country regions as farmers, labourers and entrepreneurs. Their roles are diverse and changing rapidly, so generalisations should be made carefully, the FAO warns. Yet one finding is strikingly consistent across countries and contexts: women have less access than men to agricultural assets, inputs and services and to rural employment opportunities.
7. Equitable health services
On 14 February 2011, the GAVI Alliance rolled out its plan for a new pneumococcal vaccine for children, which it aims to administer in 19 countries by 2012 and in more than 40 countries by 2015. GAVI’s plan is part of the global drive to reach the Millennium Development Goals for Maternal and Child Health. The Kenya Medical Research Institute in Kilifi has welcomed the vaccine's rollout in the fight against penicillin-resistant and multi-drug resistant pneumococcal strains of the disease that are emerging in Africa. The Institute noted that the disease also causes severe financial difficulties and emotional burdens for families and communities, most of whom never have sufficient funding to treat their affected children. At US$3.50 per dose, the vaccine being issued in developing countries is about 90% cheaper than in the developed world. GAVI and its partner countries will co-finance the rollout, with governments in the poorest income bracket paying US$0.15 per dose. GAVI warned that participating countries would need to step up their health system capacity to achieve this. In addition, the Alliance’s plans to roll out this and other vaccines for major killer diseases are threatened by a funding gap of US$3.7 billion over the next five years.
Antimicrobial resistance is a global problem that affects all countries. This year’s World Health Day on 7 April aims to make governments more aware of the problem and to encourage them to take measures to combat this global threat. According to this article, clinicians agree that one of the biggest challenges is finding out the true size of the problem of resistant infections in each country. Data is lacking, they say. The problem of microbial resistance is significant in middle- and low-income countries: for example, poor children in Africa, Asia and Latin America suffering from pneumonia, meningitis or blood stream infections are often given old drugs rendered ineffective by resistance since they are the only available treatment options. For some, simply restricting over-the-counter sales of antimicrobials does not go far enough, and they suggest that more is needed to curb the use of second-line antibiotics, which should be used to treat infections when first-line antibiotics fail and may be the last resort. They argue that the beneficial effect of restriction of first-line antibiotics sold over the counter will be evident in the long term, but what is needed most is restriction of higher-end antibiotics used in hospitals.
In Zanzibar, the Ministry of Health and its partners accelerated malaria control from September 2003 onwards by scaling up provision of insecticide-treated nets, indoor-residual spraying and artemisinin-combination therapy. The authors of this study assessed the impact of the scale up on malaria burden at six out of seven in-patient health facilities in Zanzibar by comparing numbers of out-patient and in-patient cases and deaths between 2008 and the pre-intervention period 1999-2003. They found that, in 2008, for all age groups combined, malaria deaths had fallen by an estimated 90%, malaria in-patient cases by 78% and parasitologically confirmed malaria out-patient cases by 99.5%. Anaemia in-patient cases decreased by 87%, but declines in anaemia deaths and out-patient cases were statistically insignificant due to small numbers. Reductions were similar for children under-five and older ages. The authors conclude that the government’s scaling up effective malaria interventions reduced malaria-related burden at health facilities by over 75% over a period of five years. They argue that, in high-malaria settings, intensified malaria control can substantially contribute to reaching the Millennium Development Goal 4 target of reducing under-five mortality by two-thirds between 1990 and 2015.
In this interview with Dr Lucica Ditiu, newly appointed executive secretary of the Stop TB Partnership, she reports that global tuberculosis (TB) control is reaching a plateau, especially in case detection, due to the fact that the most vulnerable, marginalised, high-risk populations are still not being reached. She argues that TB cannot be tackled without looking at the bigger picture, as it is a disease of poverty and is directly linked to poor nutrition and living conditions, as well as other social determinants of health, like education. These factors, combined with a lack of awareness and the stigma of TB, mean people often delay seeking care. Countries still face problems in planning, forecasting their needs, with supply shortages throughout the developing world, and Ditiu calls on civil society organisations and activists to continue to help flag these shortages. She praised current collaboration and integration efforts for HIV and TB health services, which were already showing results, but pointed to the need to scale up services and funding.
This report released by the World Health Organisation (WHO) reveals that a third of 306 anti-malarial medicines collected and tested from six African countries failed to meet international quality standards. Reasons for this failure include insufficient active pharmaceutical ingredient (API), an excess of degradation substances, and poor dissolution. In fact in two samples one of the APIs was totally absent. The countries surveyed were Cameroon, Ethiopia, Ghana, Kenya, Nigeria and Tanzania. The quality of anti-malarial medicines varied across countries, from Ethiopia – where no samples failed quality testing – to Nigeria, where the highest incidence of failure occurred (64%). This result implies that a patient in Nigeria is more likely to be treated with a substandard anti-malarial than a patient in a country that complies with international quality standards. Failure rates were noticeably low for WHO-prequalified medicines available in these countries (less than 4%) as well as for imported products manufactured by well-established manufacturers. The report concludes that WHO prequalification is a highly effective mechanism for verifying the quality of medicines.
8. Human Resources
Developed countries' gains in health human resources (HHR) from developing countries with significantly lower ratios of health workers have raised questions about the ethics or fairness of recruitment from such countries. Little is known, however, about actual recruitment practices. In this study, the researchers focus on Canada (a country with a long reliance on internationally trained HHR) and recruiters working for Canadian health authorities. They conducted interviews with health human resources recruiters employed by Canadian health authorities to describe their recruitment practices and perspectives and to determine whether and how they reflect ethical considerations. HHR recruiters' reflections on the global flow of health workers from poorer to richer countries mirror much of the content of global-level discourse with regard to HHR recruitment. A predominant market discourse related to shortages of HHR outweighed discussions of human rights and ethical approaches to recruitment policy and action that consider global health impacts. The researchers conclude by suggesting that the concept of corporate social responsibility may provide a useful approach at the local organisational level for developing policies on ethical recruitment. Such local policies and subsequent practices may inform public debate on the health equity implications of the HHR flows from poorer to richer countries inherent in the global health worker labour market, which in turn could influence political choices at all government and health system levels.
The objective of this study was to estimate the shortage of mental health professionals in low- and middle-income countries (LMICs). The researchers used data from the World Health Organisation’s Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, as well as country-specific information on the burden of various mental disorders, focusing on eight mental health issues: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders. The researchers found that all low-income countries and 59% of the middle-income countries in the sample had far fewer professionals than needed to deliver a core set of mental health interventions. According to their calculations, the 58 LMICs sampled would need to increase their total mental health workforce by 239,000 full-time equivalent professionals to address the current shortage. The authors of the study call for country-specific policies to overcome the large shortage of mental health-care staff and services in LMICs.
The purpose of this article is twofold. First, the authors describe Uganda's transition from a paper filing system to an electronic HRIS capable of providing information about country-specific health workforce questions. They then examine the ongoing five-step HRIS strengthening process used to implement an HRIS that tracks health worker data at the Uganda Nurses and Midwives Council (UNMC). Secondly, 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 indicate that, for the 25 482 nurses and midwives who entered training before 2006, 72% graduated, 66% obtained a council registration, and 28% obtained a license 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 per cent 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 conclude that the UNMC database is valuable in monitoring and reviewing information about nurses and midwives. However, information obtained from this system is also important in improving strategic planning for the greater 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. 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, this issue of the International Labour Review presents a collection of essays that pay particular attention to developing country contexts where issues of worker insecurity and exploitation are most intransigent, and where research has been sparse and data gaps are often significant. The special issue 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.
The purpose of this article is to explore the responses of nurses to a point-of-care e-health system that was implemented in a large private hospital in South Africa, to find out why the nursing staff rejected the implementation of the system. The authors of the study examined user responses with reference to a model designed to account for the use and adoption of mobile handheld devices, having adapted the model for an e-health context. In addition to the input features of technological characteristics and individual differences identified in the model, the added features of nursing culture and group differences were found to be influential factors in fuelling the nurses' resistance to the point-of-care system. Nurses perceived a lack of cultural fit between the system and their work. Their commitment to their nursing culture meant that they were not prepared to adapt their processes to integrate the system into their work, believing it might reduce quality of care. The study shows that the model is useful for understanding adoption in an organisational context and also that the additional elements of nursing culture and group differences are important in an e-health context.
9. Public-Private Mix
In this study, the authors examined how economic reforms, like structural adjustment programmes that were developed and implemented in the 1990s, have affected the health sector. They report that these policies facilitated reforms in the health sector that facilitated the entry of multinational financial (insurance) and pharmaceutical capital. This redefined both the health-ill-care model and converted patients into consumers being pressured to buy products, largely via the media and the advertising industry.
In Kenya’s Home Management of Malaria Strategy, the government seeks to improve prompt and effective anti-malarial drug availability through the informal sector, with a potential channel being the private medicine retailers (PMRs). This paper examines the implementation processes of three PMR programmes in Kenya, in the Kwale, Kisii Central and Bungoma districts. The research methods included 24 focus group discussions with clients and PMRs, 19 in-depth interviews with implementing actors, document review and a diary of events. The researchers found that the Kisii programme was successfully implemented, thanks to good relationships between district health managers and the ‘resource team’, and supported by a memorandum of understanding. It had flexible budgetary and decision making processes which were responsive to local contexts, and took account of local socio-economic activities. In contrast, the Kwale programme, which had implementation challenges, was characterised by a complex funding process, with lengthy timelines tied to the government financial management system. Although there was a flexible funding system in Bungoma, a perceived lack of transparency in fund management, inadequate management of inter-organisational relationships, and inability to adapt and respond to changing circumstances led to implementation difficulties. The researchers conclude that an active strategy to manage relationships between implementing actors through effective communication mechanisms is essential for the PMR approach to work, in conjunction with a strong and transparent management system.
The purpose of this report is to identify and summarise lessons learned, opportunities and challenges in relation to the role of the private sector in the context of aid effectiveness. The authors conducted 47 qualitative interviews with different stakeholders, including external funders, private sector representatives (for-profit and private foundations), partner countries, civil society organisations and independent experts. Some respondents emphasised that the profit-driven incentives of the private sector seldom converge with development objectives, which poses challenges for the aid effectiveness agenda. In contrast, others noted that business incentives can converge with those of donors and partner countries, and private sector companies can contribute to development in three main ways, namely by integrating their core business operations and value chains, by making social investments and undertaking philanthropic ventures, and by promoting public advocacy, policy dialogue and institution strengthening. External funders in particular emphasised that for-profit private sector contributions to the development process are more sustainable if they are embedded in the core business strategy of a company. The authors propose new types of inclusive business models, with increased commitments to include people living in poverty as part of core business strategy, and where the private sector contributes best to aid objectives by running responsible businesses but also plays diverse roles and engages directly in aid processes.
10. Resource allocation and health financing
According to this report by Oxfam, coverage of the National Health Insurance Scheme (NHIS) in Ghana could be as low as 18%. Every Ghanaian citizen pays for the NHIS through Value added Tax (VAT), but as many as 82% remain excluded. They report that 64$ of people in the highest wealth quintile are signed up to the NHIS, compared with 29% of the lowest wealth quintile. Those excluded from the NHIS still pay user fees. They report that the administration of health insurance costs US$83 million each year, enough to pay for 23,000 more nurses. They propose that improved progressive taxation of Ghana’s own resources, especially oil, could increase spending to US$54 per capita, by 2015.
With United States (US) President Barack Obama's release of his 2012 foreign affairs budget and a Senate proposal to cut US international spending, the fight to sustain US aid abroad is intensifying, according to this article. Development and foreign policy analysts largely praised the administration's funding appeal for maximising returns by focusing spending on strategic areas such as global health, food security and climate change. Major funding hikes include an US$850 million (10.8%) raise for global health and child survival programmes, and a US$400 million (16%) raise for development assistance – which includes a US$1.1 billion boost to the Feed the Future Initiative and a US$651 million contribution to the Global Climate Change Initiative. But a proposal has been put forward to cut total spending for 2011 by US$100 billion, and conservative lawmakers are moving to lump the international budget with non-security accounts in a bid to make massive reductions possible. Their efforts emerge in the wake of Obama’s State of the Union speech in January 2011, where he pledged to freeze non-security funding for the next five years.
This study contributes to the debate on aid effectiveness by exploring challenges to DAC and non-DAC development partner (DP) coordination at country level, with Rwanda serving as the country case. (DAC countries are those listed by the Organisation for Economic Co-operation and Development as eligible for European overseas development assistance.) The researchers took Germany as an example of a DAC development partner, with China as an example of a non-DAC partner. Their results showed that Rwanda’s government, despite its aid dependency, demonstrates strong ownership of its development agenda. However, the government has not yet been successful in integrating China into its aid co-ordination architecture. The authors argue that the lack of integration of non-DAC DPs may pose a threat to maintaining Rwanda’s leverage over its DAC partners.
The purpose of this chapter in the South African Health Review is to describe the proposed national health insurance (NHI) in South Africa. The author explains the objective of the proposed reform, evaluates how South Africa currently fares relative to this objective and explores the implications of lessons from international experience for the South African health system. She argues that the term ‘NHI’ has itself contributed to the confusion about the intended reform and that the focus should instead be placed on its core objective – a universal health system that ensures that everyone is able to use health services when needed and that provides financial protection against the costs of health care for everyone. Another key area of contention has been whether NHI is affordable or not. The author argues that universal health care is affordable and, instead, the debate around affordability should rather be focused on the appropriateness and effectiveness of system design. The author calls for constructive and evidence-informed debate from all stakeholders on how best to achieve improved health for all South Africans through health system reform.
Bad governance and the persistence of tax avoidance allow billions of dollars of profit to be siphoned out of Africa, untaxed, every year, according to this report. For the past 25 years, tax revenues in most African countries have missed even the low target of 15% of gross domestic product, far less than rich countries’ average of 35%. Tax Justice Network (TJN) notes that 80% of Africa’s exports consist of primary commodities and, while African governments depend heavily on the resource rents from these commodities, many commodities are exempt from taxation. Multinational companies operating in African economies, including those of least-developed countries, are granted massive tax exemptions by under-resourced, inept or corrupt tax officials, according to TJN, and they enjoy tax holidays and deferments, extremely low royalty payments and cheap access to natural resources. For example, estimates in the report indicate that Kenya’s government only manages to collect 35% of the corporate income tax required by national law. The cumulative stock of illicit financial flows from Africa is estimated at US$854 billion between 1970 and 2008, or more than US$30 billion each year. Because borders are one of the few effective tax collection points, tariffs are rigorously enforced, which holds back regional economic integration, TJN argues. TJN argues further that some African countries have become tax havens for corporations exporting resources, including mineral resources, from the region.
How has the Paris Declaration has been translated into action in Mozambique, Tanzania and Zambia? The authors of this study found that, despite some positive developments, the dialogue between donor and recipient governments is breaking down. External funders are becoming increasingly concerned with governance issues in recipient countries, so the dialogue has become more political in nature. At some point in the past, all three countries have had their general budget support temporarily suspended or permanently stopped due to corruption disputes. The authors argue that the dialogue structure developed so far by external funders has become too complex for the three recipient countries, which have insufficient capacity and lack funds for higher-than-expected transaction costs. In conclusion, the authors recommend that stakeholders must try to deal with the inherent contradictions between aid partners: on the external funders’ side there is increasing concentration on short term quantifiable results, a continuous tendency for micro-management and over-optimistic expectations on the speed of agreed reforms, while on the recipients’ side, a lack of visible improvements in governance has undermined the necessary trust needed for increased alignment and programme-based forms of aid.
According to this brief, health insurance cover is gradually increasing among the Tanzanian population since its introduction over a decade ago. However, wealthier groups working in the formal sector are more likely to benefit from this development than poorer groups. The diversity of schemes, in terms of contribution rates and benefits offered, means that the effectiveness of insurance is inconsistent, both in terms of the amount and nature of services received by members. What is clear is that insurance is generally increasing the intensity of outpatient care use and also influencing where people go for such care, diverting people from informal drug shops to formal care. Members with insurance are more likely to use public primary care than their non‐insured rural counterparts, consistent with their benefit package. Despite equal contributions, health insurance members in urban areas use a much wider range of outpatient care than those in rural areas.
11. Equity and HIV/AIDS
In this article, the authors consider a neglected aspect of AIDS and HIV treatment – pain management. With enormous progress in preventing and treating HIV, more people than ever before now live with HIV as a chronic disease, especially in countries like Kenya, where, over the past year, the number of people receiving anti-retroviral (ARV) therapy has risen by 25%. But HIV patients can suffer from various types of chronic pain – and this includes those on ARVs who are living otherwise healthy, active lives – and pain management is usually overlooked, the authors note. They argue that palliative care, which requires caregivers to improve a patient's quality of life by treating pain and other symptoms, should become an essential element of comprehensive HIV care. It can also help patients to keep taking their antiretroviral drugs. Curative and palliative treatment should work side by side for any patient with a life-threatening disease, the authors state. A major barrier is unavailability of essential pain drugs in Kenya's health facilities. Oral morphine, the mainstay medication for moderate-to-severe chronic pain, is available in just seven of Kenya's 250 public hospitals, and even these facilities sometimes run out, even though oral morphine is inexpensive. However, because of a lack of training, healthcare workers often fear giving an overdose or causing addiction, which can be avoided with proper medical practice. The authors argue for greater, monitored use of morphine for pain management in children.
This Letter to Partners coincides with the 10th anniversary of the 2001 Declaration of Commitment on HIV/AIDS and five years since the world committed to achieve universal access to HIV prevention, treatment, care and support. In the letter, Michel Sidibé outlines a set of six new frontiers to move the global AIDS response forward. He calls for the democratisation of the response: political promises must be realised in the form of improved resources and services, and the communities that are served must be included in decision-making. Also, he notes that the law must work for not against AIDS: for example, national laws must stop discrimination against people living with HIV, men who have sex with men, lesbians, people who inject drugs, sex workers and transgender people. Sidibé calls on stakeholders to reduce the upward trajectory of programme costs, and make funding for AIDS a shared responsibility, as well as help build the AIDS movement as a bridge to development and foster scientific innovation for HIV prevention and treatment. According to Sidibé, each of the six new frontiers supports the other, and he cautions that a singular advancement in only one will not be sufficient to move the entire global AIDS response forward.
The authors of this study assessed retention in HIV care for individuals not yet eligible for antiretroviral therapy (ART) and explored factors associated with retention in a rural, public health HIV programme in South Africa. During the period January 2007 to December 2007, HIV-infected adults (≥16 years) who were not yet eligible for ART, with a CD4 count of >200, were included in the analysis. Retention was defined by repeat CD4 count within 13 months. A total of 4,223 participants were included in the analysis, of whom 83.9% were female. Overall retention was 44.9%, with 201 days as median time to return to the clinic. Males were independently associated with lower odds of retention, and older participants with higher odds of retention. The authors conclude that retention in HIV care before eligibility for ART is poor, particularly for younger individuals and those at an early stage of infection. Further work to optimise and evaluate care and monitoring strategies is required to realise the full benefits of the rapid expansion of HIV programmes in sub-Saharan Africa.
The South African government has announced that it will soon launch a controversial step in its national campaign to test 15 million people for HIV by June 2011. Under the plans, children and adolescents will be offered voluntary HIV testing and counselling in high schools. This editorial addresses some of the major obstacles it predicts the campaign will face. Under South African law, children aged 12 years and older can give consent to a HIV test. But some issues remain problematic, such as how a health worker should determine whether consent provided by a 12-year-old or adolescent is sufficiently informed or not, and how to ensure confidentiality of test results. It is also not clear whether children who test positive will receive anti-retroviral therapy, or if parental or peer pressure might be applied on children to divulge their test results. The Lancet editors call on the task team that is planning the intervention to consider whether schools are the best place for children to learn their HIV status. Problems in the national HIV testing and counselling campaign, launched in April 2010, heed a cautionary warning, the editors note. Monitoring and evaluation of the campaign has so far been poor and there have been reports of HIV-positive people not being referred for treatment, clinics not complying with national testing and counselling protocols, and anecdotal reports of coercive testing.
The authors of this study reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). They identified 19 articles published in nine journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings, as measured against accepted international benchmarks. The authors conclude that interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses should focus on local assessment of rapidly evolving HIV MTCT options, strategies to improve coverage and reach underserved populations, evaluation of a more comprehensive set of MTCT approaches, and the integration of HIV MTCT and other sexual and reproductive health services.
A US$45 million five-year grant has been awarded to the Elizabeth Glaser Paediatric Foundation (EGPAF) to fund various child HIV interventions in Zimbabwe. Some of this funding is intended for the country’s prevention of mother-to-child transmission (PMTCT) programme, which, according to this article, is performing poorly, as more 150,000 children are estimated to be HIV positive and more than 90% of childhood HIV infections can be attributed to mother-to-child transmission. USAID blamed the high figure on the fact that most children were ‘getting lost in the system’ because their mothers did not return to clinics for additional maternal and child health services after the initial visit to the antenatal clinic. Financial constraints and lack of knowledge about the importance of registering for antenatal services were identified as major barriers, while long distances from health facilities prevented many women from accessing treatment for their infants. In the article, Plus News argues that the government should implement the 2010 World Health Organisation guidelines on PMTCT, which recommend that all HIV-positive pregnant women begin anti-retroviral treatment at 14 weeks of pregnancy and continue until they stop breastfeeding.
12. Governance and participation in health
In this interview, Lilian Celiberti of Feminist Dialogues reports that the World Social Forum (WSF), held in Dakar, Senegal from 6–11 February 2011, was an opportunity for a variety of activists and other civil society stakeholders to take part in discussions across varying perspectives and experiences. She highlights the strong and active participation of African women and youth, and the barriers of poor logistics and translation. She comments that the Declaration of the Women's Organisations was heavily focused on international conventions and UN-Resolutions, despite multiple tensions and conflicts amongst African groups and regions. She recognises that although interpersonal exchanges enable the deepening of debates, ‘colonisation continues in the divisions that we experience in different parts of the world’, and questions remain unanswered about how to develop collective thinking and solidarity in social movements.
In this assessment of the World Social Forum (WSF), which took place in Dakar, Senegal, from 6–11 February 2011, the author highlights an important trend in global activism: activists arrived already well prepared and networked among them and with local partners and with a key concern about further strengthening regional and global alliances on shared issues. Those convergences, at the heart of WSF’s mission, proved exceedingly successful, beyond activists’ expectations even, and for some seem to indicate a clear trend towards consolidation of struggles at the global level. The convergence of the Assembly of Social Movements, a regular event at the forums since the first edition, saw the participation of thousands of activists from all around the world. The success of the assemblies moved in the direction of addressing some of the long standing concerns of some WSF organisers and critics, namely the fragmentation of the programme and the atomisation of the different strands of global activism with the perceived outcome of weakening the resistance against neoliberalism and reducing the impact of imaginations and practices aimed at building a new, more equitable world.
Innovation in biomedicine is a global enterprise in which 'Rising Power' states (emerging states) figure prominently, and which undoubtedly will re-shape health systems and health economies globally, the authors of this paper argue. Against this background, they present an overview of a range of approaches that have potential for advancing understanding of governance of global life science and biomedical innovation, with special reference to the 'Rising Powers'. The authors’ analysis indicates significant convergences and complementarities between the approaches discussed, concluding that the role of the national state itself has become relatively neglected in much of the relevant literature. They call for a new approach that enables innovation and governance to be seen as 'co-producing' each other in a multi-level, global ecology of innovation, taking account of the particular, differing characteristics of different emerging scientific fields and technologies.
In this article, the author examines the potential role of health information technology (IT) in addressing healthcare disparities among racial and ethnic minority populations. The author’s overview of health IT utilisation among healthcare providers reveals that use of health IT among racial and ethnic minorities carries significant promise and potential. Yet realising the potential will not come without surmounting several significant technical, practical and human challenges. In order to measure success or failure, he argues for ongoing surveillance and monitoring of progress at a national level. However, because of the great diversity in the types of technologies, types of users, and settings in which health IT may be employed, obtaining accurate estimates of adoption and utilisation will be a significant challenge. In addition, the development of the ‘meaningful use’ criteria and the linking of meaningful use to provider reimbursement will help, the author adds. As patients become more involved in accessing, managing, and using their health information, a need to develop ‘meaningful patient use’ criteria may arise, he predicts, which will help refine systems.
13. Monitoring equity and research policy
This paper identifies some of the advantages and disadvantages of a global health research and development (R&D) tax credit and considers whether it would succeed in increasing the overall volume of global health R&D. In his analysis, the author remains uncertain whether the tax could increase pharmaceutical firms’ return on investments for global health products with small commercial markets or if it could bring down the costs of philanthropic research and help maintain private sector participation in global health. Since there are minimal profits to be reaped from charitable research and benefits, a tax credit is unlikely to appeal to many firms who are not already interested in supporting global health, the author argues. His findings suggest that a global health tax credit is unlikely to result in significantly more or better global health R&D, but he emphasises the limitations of his research, calling for more research into existing fiscal incentives for R&D to clarify the decision-making process that drives global health research in pharmaceutical firms.
In this study, the authors outline some of the challenges faced when carrying out a financing incidence analysis (FIA) in Ghana, Tanzania and South Africa and illustrate how innovative techniques were used to overcome data weaknesses in these settings. They conducted a FIA for tax, insurance and out-of-pocket payments, drawing data from the Living Standards Measurement Surveys (LSMSs) and household surveys conducted in each of the countries. They found that LSMSs are likely to underestimate financial contributions to health care by individuals. For tax incidence analysis, reported income tax payments from secondary sources were severely under-reported. Income tax payers and shareholders could not be reliably identified. The use of income or consumption expenditure to estimate income tax contributions was found to be a more reliable method of estimating income tax incidence. Assumptions regarding corporate tax incidence had a huge effect on the progressivity of corporate tax and on overall tax progressivity. In terms of policy development, the authors show how data constraints can be overcome for FIA in lower-income countries and provide recommendations for future studies.
The 20th anniversary of the report of the Commission on Health Research for Development inspired a Symposium to assess progress made in strengthening essential national health research capacity in developing countries and in global research partnerships. Significant aspects of the health gains achieved in the 20th century can be attributed to the advancement and translation of knowledge, the authors of this paper argue, and knowledge continues to occupy center stage amidst growing complexity that characterises the global health field. The authors propose a way forward that will entail the reinvigoration of research-generated knowledge as a crucial ingredient for global co-operation and global health advances. However, a number of divisions are identified that need to be addressed, such as the divide between domestic and global health, and the divide among the disciplines of research (biomedical, clinical, epidemiological, health systems), as well as divisions between clinical and public health approaches, between public and private investments, and between knowledge gained and action implemented. Overcoming these obstacles can accelerate progress towards research for equity in health and development.
In this paper, the authors discuss open source approaches for research and development (R&D) for neglected diseases, and their potential to lower costs and R&D time frames, increase collaboration and build a knowledge commons. They describe existing initiatives and debates, and suggest how readers and the global health community might better make use of open source approaches. While most of the open source initiatives examined in the review appear to demonstrate significant potential, the authors conclude that hard evidence of impact appears to be limited thus far. They make three short-term recommendations. Governments and other stakeholders should first develop detailed profiles of open source initiatives for R&D into neglected diseases, then they should prioritise gaining more substantial and long-term investments into the area. Finally, they should start a demand-driven website incorporating a group weblog, which will act as a focal point for disparate threads of discussion as well as seeding connections and a sense of community.
With growing interest in methods to accelerate the development of drugs, vaccines and diagnostics for neglected diseases, product development partnerships (PDPs), non-profit research institutes and private sector groups have come together to conduct R&D in these areas. However, some argue that their efforts are disjointed and that funding flows inefficiently to individual research projects resulting in insufficient resources, funding volatility, poor resource allocation and duplicated, as well as unnecessary, efforts. In this paper, the authors evaluate several pooled funding mechanisms that have been proposed to address these problems: the Industry R&D Facilitation Fund (IRFF) originally proposed by the George Institute; the Fund for Research in Neglected Diseases (FRIND) proposed by Novartis; and the Product Development Partnership Financing Facility (PDP-FF) proposed by the International AIDS Vaccine Initiative (IAVI). These proposals are measured against two criteria: their capacity to raise additional money for neglected disease R&D and their capacity to improve the efficient allocation of those funds. The authors conclude that all three proposals had potential, but the challenge with deciding which proposal to implement is the lack of clarity and agreement on what exactly the core problems facing R&D funding flows for neglected diseases are.
The Soul City Institute for Health and Development Communication, a non profit organisation, was started in 1992 in a bid to reduce child mortality caused by dehydration. "Children were dying unnecessarily and it was because people did not know what they were supposed to be doing," says Goldstein. Information was widely available on the process of rehydration but it did not seem to be having an impact on the desired audience. After studying the situation, Soul City decided to launch a television soap opera to capture their target audience. A radio show and newspaper series quickly followed. In trying to describe the relationship between research and mass media campaigns, Goldstein uses the phrase "simplification versus complexity." At one end stands the scientist who seeks in-depth knowledge and at the other the ordinary non-scientific individual who prefers a simple explanation. Melissa Meyer, Project Coordinator for the HIV/AIDS and the Media Project, says, "Research and entertainment need not be at odds with each other. With just a slight adjustment in perspective, they can be used very effectively to complement each other."
14. Useful Resources
This collection is a groundbreaking volume that provides a critical mapping of the plurality of African sexualities while also challenging the reader to interrogate assumptions, thereby unmapping the intricate tapestry of the broad range of contemporary African sexualities. Incorporating original research and analysis, life stories and artistic expression, this accessible but scholarly book examines, from a distinctly African perspective, dominant and deviant sexualities, analyses the body as a site of political, cultural and social contestation and investigates the intersections between sex, power, masculinities and femininities. Using feminist approaches, African Sexualities analyses sexuality within patriarchal structures of oppression while also highlighting its emancipatory potential.
This webpage provides links to external funders that give small, unrestricted grants internationally to directly support community-based organisations and groups. The grants are intended to help small, local organisations firmly establish themselves as civil society institutions within their community. Grants amounts are less than US$20,000.
The TB Process-Based Performance Review (TB-PBPR) tool was developed to identify ‘missed opportunities’ for timely and accurate diagnosis of tuberculosis (TB). The tool enables performance assessment at the level of process and quality of care. It is a single-page structured flow-sheet that identifies 14 clinical actions (grouped into elicited symptoms, clinical examination and investigations). In this study, the tool is evaluated. Medical records from selected deceased patients were reviewed at two South African mine hospitals (A = 56 cases; B = 26 cases), a South African teaching hospital (C = 20 cases) and a UK teaching hospital (D = 13 cases). The researchers found that, in hospital A, where autopsy was routine, TB was missed in life in 52% of cases and was wrongly attributed as the cause of death in 16%. Clinical omissions were identified at each hospital and at every stage of clinical management. For example, recording of chest symptoms was omitted in up to 39% of cases, sputum smear examination in up to 85% and chest radiograph in up to 38% of cases respectively. In conclusion, the authors found that simple clinical actions were omitted in many cases and the tool was effective in detecting these errors. The tool, in conjunction with a manual describing best practice, is adaptable to a range of settings, is educational and enables detailed feedback within a TB programme.
This knowledge translation self-assessment tool for research institutes (SATORI) was designed to assess the status of knowledge translation in research institutes. It identifies the gaps in capacity and infrastructure of knowledge translation support within research organisations. Research institutes using SATORI have pointed out that strengthening knowledge translation is paramount and may be achieved through the provision of financial support for knowledge translation activities, creating supportive and facilitating infrastructures, and facilitating interactions between researchers and target audiences to exchange questions and research findings.
15. Jobs and Announcements
The first BIAS FREE TOT Workshop to be held in Ottawa, June 20-24, 2011, for people who have taken an Introductory BIAS FREE Workshop. The BIAS FREE TOT Workshop is designed to provide participants with an interactive experience to learn and practice together best practices in how to: Introduce participants of Introductory BIAS FREE Workshops to the BIAS FREE Framework, how it works, its purpose, and its cross-equity and cross-cultural applications; Engage participants of Introductory BIAS FREE Workshops in an interactive process to identify from their own experiences, examples of specific biases that derive from any social hierarchy – gender, ability, race, ethnic/ cultural/religious background, socio-economic status, sexuality, etc. – and their intersections and compounding effects; Empower participants of Introductory BIAS FREE Workshops to explore and test how to use the Framework in their work and daily lives. If you have not taken an Introductory Workshop already, there are two opportunities for you to do so before the TOT Workshop – one in Ottawa, 10-12 April and one in Toronto, 3-5 June. The workshop will be June 20-24, 9:00 – 17:00 Ottawa Canada. The cost is $1500 and a limited number of full and partial scholarships are available.
Registration and to obtain forms and information by email.
The SANNAM Biennial Conference and Annual General Meeting will take place from 16-18 November 2011 in Gaborone, Botswana. SANNAM is calling for abstracts for the conference, the main theme of which is ‘Engaging Communities for Accelerating the Achievement of the Millennium Development Goals in the SADC Region’. Sub-themes include: health care programmes for addressing the Millennium Development Goals (MDGs); transforming general educational education for MDGs; strengthening educational nursing and midwifery for improvement for MDGs; community participation and MDGs; capacity building, leadership and MDGs; monitoring and evaluation progress for achievement/milestones on MDGs; challenges/factors related to MDGS; enhancing the environment for achieving MDGs; the expansion of nursing services to meet MDGs; collaboration and partnerships for MDGs; and human resources for achieving MDGs.
The Faculty of Law at University of KwaZulu-Natal (UKZN), in conjunction with the Foundation Open Society Initiative, is offering a two-week certificate course in Intellectual Property and Access to Medicines. The aim of the course is to equip participants to understand barriers to access to life-saving medicines from innovation to end user, and, in particular, to understand international, regional and national intellectual property regimes, including flexibilities that can be used. The course is action-oriented, with three days spent developing campaign strategies, and thus builds participants' capacity to advocate effectively to enhance access to medicines. The programme is open to East and Southern African residents working in the area of health, access to medicines, trade and development and human rights, including non-governmental organizations and government agencies, as well as health professionals, legal practitioners and academics. The following topics will be covered: registration of medicines; the impact of intellectual property rights and their flexibilities; regional and bilateral trade agreements; global health ethics and their implications for access to medicines policy; the impact of these regimes on human rights, in particular, the right of access to health care; innovations in research and development in medicines and their impact on neglected diseases; case studies will focus on the past and current campaigns to increase access to medicines. The course will run from 27 June to 8 July 2011.
The African Programme on Rethinking Development Economics (APORDE) is a high-level training programme in development economics that aims to build capacity in economics and economic policy-making. The course will run for two weeks and consist of lectures and seminars taught by leading international and African economists. This call is directed at African, Asian and Latin American economists, policy makers and civil society activists who, if selected, will be fully funded. Only 30 applicants will be selected.
The World Health Organisation (WHO) and Public Library of Science (PloS) are calling for papers for a joint WHO/PLoS collection on the theme of the 2012 World Health Report on Research for Health. This flagship report from WHO will, for the first time in its history, focus on research for better health. The primary target audience of the report will be ministers of health in the WHO member states, and the goal of the report is to provide new ideas, innovative thinking, and pragmatic advice for member states on how to strengthen their own health research systems. In addition to primary research (both quantitative and qualitative) and well-developed case studies, WHO and PLoS also invite the submission of review and policy articles on how national health research systems contribute to the broader international research endeavour, especially in the context of the following areas: global health research governance; inequitable access to the benefits and products of research; global standards for responsible research conduct; and future research trends with implications for the developing world.
This conference will consider the link between and contributions of the social sciences and humanities to HIV research and action. The International Association of HIV Social Scientists, which is organising the event, argues that social science emphasises a critical, reflexive stance and willingness to confront the social, ethical, and political dimensions of scientific investigations of the HIV epidemic, which has made it instrumental in successful HIV prevention efforts such as the normalisation of condom use against sexual transmission and the introduction of safe injecting equipment for injecting drug use. Social scientific research has also provided insights into issues related to the treatment and care of people living with HIV and AIDS, and has addressed the broader social and political barriers to effective responses to HIV. Yet there have been few forums in which scholars from different social science and humanities disciplines can come together to develop connections among the various phenomena we study, and between ourselves and our biomedical, policy and community based colleagues. This conference is a forum for those keen to extend the scope of the social sciences and its capacity to trace connections between all kinds of phenomenon, notably those that contribute to the complexity and changing nature of the epidemic. Themes include: treatment as prevention, HIV and the body, social epidemiology and social networks, global politics, and responsibility and risk governance, as well as new directions for HIV and AIDS treatment.
This symposium will consider infectious diseases in Africa, including bacterial, viral, fungal and parasitic diseases, which comprise a major cause of death, disability, and social and economic disruption for millions of people in Africa’s developing countries. This conference will aim to look at the borderless effect of infection, its impact on children and the importance of intervention. International speakers will talk about how to help prevent the spread of infectious diseases and discuss new diagnostics vaccines and drug treatments.
This first Southern African Network of Nurses and Midwives (SANNAM) biennial conference will present evidence demonstrating how nurses, as key members of the health team, promote and contribute to quality and access to health care. It will also demonstrate the importance of connecting other health workers and the community at large in accelerating the achievement of the Millennium Development Goals (MDGs). The conference will feature plenary sessions, which will set the stage for discussion of critical issues that either facilitate or impede the achievement of the MDGs. Concurrent sessions, symposia, poster presentations, debates and panel discussions will address issues to demonstrate the intricate links between the MDGs SANNAM is calling on all professionals and communities to work collectively at the conference in addressing the links.
The International Society for Equity in Health- ISEqH - will hold its Sixth 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.
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.
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