The world has become a very small place for some. Globalisation and the movement of people and goods mean that it’s possible on the same day to wake up in Asia and go to sleep in America. Farm products grown in an Africa can be on shelves in Europe within days. Yet it can take the same time or longer for a woman from that African country to get to a hospital with a midwife to access maternal health services. Clearly, the benefits of the increasingly rapid movement of goods, services and information across countries are not obtained by all. How have women in low-income rural and urban communities in Africa experienced the impact of globalisation?
A workshop held in Nairobi in May 2011 reviewed this experience and the implications for research on globalisation and health in Africa. The workshop was convened as part of a research programme on globalization and women’s health in east and southern Africa co-ordinated by Karolinska Institute and TARSC. The research programme found, through analysis of the Millennium Development Goals (MDG) database, that African countries are becoming more integrated with world markets and that women’s occupational roles are changing, but with inadequate disaggregation of global databases like the MDG data to assess the impact of these changes on women’s health and nutrition. A review of literature on existing studies suggested however that while globalisation related economic and trade policies have provided urban employment and social opportunities for women, they have also been associated with time and resource burdens for them that have had negative consequences for their own and their families’ health and nutrition.
Examples of research presented at the workshop similarly suggested that women’s involvement in export oriented coffee production in Uganda and in urban export processing zone (EPZ) factories in Tanzania had brought improved incomes for the women workers, but with longer working hours and weaker social protection. Improved incomes in both groups had not translated to better nutrition or dietary outcomes compared to women working in non EPZ factories or in farms producing food for local markets. For countries seeking to make a link between economic activity and improved health outcomes, this lack of improvement from globalisation related changes is a problem, especially given the context of Sub-Saharan Africa having the highest level of maternal mortality globally, with 900 maternal deaths per 100,000 live births, a level well above the targets aimed for in the MDG commitments. While globalisation has been associated with information, research and technological advancements and a wider demand for equity and rights for women, delegates also heard evidence that it has been associated with commercialised health care and reduced public funding, creating barriers to use of health services by poor women. Further, recent features of global markets - the 2008 financial crisis and the increased price of food and fuel – were raised by delegates as likely to intensify food insecurity, particularly for those already vulnerable to nutritional stress. Poor women in urban areas are likely to suffer more due to reliance on food purchases. A new trend of purchases or long-term leases for agricultural land by foreign investors for food exports and bio-could further threaten the local agricultural systems that commonly involve small scale women farmers, widening inequities in nutrition, health and access to livelihoods.
In discussing this evidence, delegates to the meeting identified that research on globalisation and women’s health in Africa needs to address three broad gaps, if the interests of low-income African women are to be better reflected in economic policies associated with globalisation:
i. to bring local evidence and voice into global policy processes;
ii. to highlight gaps between global policy commitments and local realities; and
iii. to ask the “what if?” questions, to explore and inform alternatives that would be more health promoting for African women and their livelihoods, and countries.
There are many specific areas of research that emanate from these three areas. For example, in the first, evidence on the experience and effect of global processes - whether IMF conditionalities, land grabs, commercialisation of services or other areas - needs to reach and be made accessible to national level and to those negotiating in global forums. Delegates noted that there is already evidence at local and regional level that could be useful for this, if reviewed and appropriately organised. This includes bringing together evidence from evaluations of global programmes and transnational activities in the different countries of the region.
However delegates also called for a shift in agenda formulation, with locally driven evidence and perspectives having greater influence on international agendas. Examples were given of research that explores such alternatives. For example, IDRCs Ecosystem and Human Health Programmes has supported work in Malawi to assess the effects of local production of nitrogen containing legumes. This was found to have not only improved soil fertility and reduced reliance on imported chemicals, but to also have improved the quality of diets and nutritional outcomes. Delegates concurred that this type of work had the potential of building partnership across actors, disciplines and countries, including with affected communities, that would better connect local level initiatives and evidence with global level processes and policies. While globalisation has raised attention to the injustice of the huge inequalities in women’s health globally, responding to these injustices calls for responses that strengthen the organisation of ideas, evidence and practice from the community level and their influence at national level, as a basis for the engagement in global processes.
For further information on this issue please read the background papers at http://sjp.sagepub.com/content/38/4_suppl and the report of the meeting available in the annotated bibliography at http://tinyurl.com/6zeeod5 at www.equinetafrica.org. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
The training held in Kiboga district Uganda was aimed at building capacities of Health workers and communities jointly to work together to strengthen their interactions through health literacy and participatory approaches. It is anticipated that the training will go a long way in strengthening communication between health workers (employed in the health system in the community or the primary care level services) and community members at primary care level towards specific, measurable improvements of the health system for both with local coordination by Health Literacy facilitators. Specifically the training aimed to: Introduce the health literacy programme and Participatory Reflection and Action (PRA) approaches to community members and Health Workers in Kybwanzi District (Former Kiboga District); Provide core skills and information to HEPS Uganda health literacy facilitators to implement joint action to improve and strengthen Community-Health worker interactions; Reflect on the current facilitators and blocks to communication between health workers and communities, and how to improve this; Provide training materials and orient HEPS Uganda facilitators to jointly identify and prioritize health needs and ill health problems, identify actions on shared priorities, identify gaps or barriers to uptake of primary health care (PHC) responses to prioritized problems, and set a shared (HW-Community) action plan and orient HEPS Facilitators in Kybwanzi District on administering the baseline and the programme post survey instruments.
3. Equity in Health
In this study, monthly pediatric admission data from five Ugandan hospitals and their catchments were gathered retrospectively across 11 years from January 1999 to December 2009. The researchers found that in four out of the five sites under study there was a significant increase in malaria admission rates. At all hospitals, malaria admissions had increased by 47% from 1999. Observed changes in intervention coverage within the catchments of each hospital showed a change in insecticide-treated net coverage from less than 1% in 2000 to 33% by 2009, but this was accompanied by increases in access to nationally recommended drugs at only two of the five hospital areas studied. The authors conclude that their findings show that the reported decline in malaria in Africa is not a universal phenomenon across the continent. More data is needed from a wider range of malaria settings to provide accurate data on progress of the impact of malaria interventions.
Despite widespread implementation of effective multidrug therapy, leprosy has not been eliminated. The authors of this paper report that a third of newly diagnosed patients have nerve damage and might develop disabilities, although the proportion varies according to several factors, including level of self-care. Women who develop leprosy continue to be especially disadvantaged, with rates of late diagnosis and disability remaining high in this subgroup. Leprosy was not a specified disease in the Millennium Development Goals, but improvements in the other areas they cover, such as education and levels of poverty, will help leprosy patients and services, the authors argue. Recommendations for research on diagnosis, treatment, and prevention include further use of molecular analysis of theMycobacterium leprae genome, implementation of BCG vaccination and administration of chemoprophylaxis to household contacts. The authors also suggest development of tools for early diagnosis and detection of infection and nerve damage, and formulation of strategies to manage the chronic complications of leprosy, such as immune-mediated reactions and neuropathy.
A pilot study was conducted in one district of Zambia, in which maternal deaths occurring over a period of twelve months were identified and investigated. Data was collected through in-depth interviews with family, focus group discussions and hospital records. A total of 56 maternal deaths were investigated. Poor communication, existing risk factors, a lack of resources and case management issues were the broad categories under which contributing factors were assigned. Potential high impact actions were related to management of AIDS and pregnancy, human resources, referral mechanisms, birth planning at household level and availability of safe blood. In resource-constrained settings, authors note that the Investigate Maternal Deaths and Act (IMDA) approach promotes the use of existing systems to reduce maternal mortality, thereby strengthening the capacity of local health officers to use data to determine, plan and implement relevant interventions that address local factors contributing to maternal deaths. Monitoring actions taken against the defined recommendations within the routine performance assessment should help ensure sustainability.
In this study, researchers investigated which alcohol indicator can most effectively detect associations between alcohol use and unsafe sexual behaviour among male sex workers - single-item measures of frequency and patterns of drinking (>=6 drinks on 1 occasion), or the Alcohol Use Disorders Identification Test (AUDIT). A cross-sectional survey in 2008 recruited male sex workers who sell sex to men from 65 venues in Mombasa district, Kenya, similar to a 2006 survey. Information was collected on socio-demographics, substance use, sexual behaviour, violence and STI symptoms. The 442 participants reported a median 2 clients/week, with half using condoms consistently in the last 30 days. Of the approximately 70% of men who drink alcohol, half drink two or more times a week. Binge drinking was common (38.9%). In conclusion, male sex workers have high levels of hazardous and harmful drinking, and require alcohol-reduction interventions, the authors argue. Compared with indicators of drinking frequency or pattern, the AUDIT measure has stronger associations with inconsistent condom use, STI symptoms and sexual violence. Increased use of the AUDIT tool in future studies may assist in delineating with greater precision the explanatory mechanisms which link alcohol use, drinking contexts, sexual behaviours and HIV transmission.
This paper assessed the extent to which the Kenyan health financing system meets the key requirements for universal coverage, including income and risk cross-subsidisation. Recommendations on how to address existing equity challenges and progress towards universal coverage are made. An extensive review of published and gray literature was conducted to identify the sources of health care funds in Kenya. In cases where data were not available at the country level, they were sought from the World Health Organisation website. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing. The Kenyan health sector relies heavily on out-of-pocket payments. Government funds are mainly allocated through historical incremental approach. The sector is largely underfunded and health care contributions are regressive (i.e. the poor contribute a larger proportion of their income to health care than the rich). Health financing in Kenya is fragmented and there is very limited risk and income cross-subsidisation. The country has made little progress towards achieving international benchmarks including the Abuja target of allocating 15% of government's budget to the health sector. The Kenyan health system is highly inequitable and policies aimed at promoting equity and addressing the needs of the poor and vulnerable have not been successful. Some progress has been made towards addressing equity challenges, but universal coverage will not be achieved unless the country adopts a systemic approach to health financing reforms. Such an approach should be informed by the wider health system goals of equity and efficiency.
4. Values, Policies and Rights
This paper reports the results of an assessment of the mental health policies of Ghana, South Africa, Uganda and Zambia. The WHO Mental Health Policy Checklist was used to evaluate the most current mental health policy in each country. All four national policies addressed community-based services, the integration of mental health into general health care, promotion of mental health and rehabilitation. Only the Zambian policy presented a clear vision, with the other three countries spelling out values and principles, the need to establish a coordinating body for mental health, and to protect the human rights of people with mental health problems. None included all the basic elements of a policy, nor specified sources and levels of funding for implementation. Only Uganda sufficiently outlined a mental health information system, research and evaluation, while only Ghana comprehensively addressed human resources and training requirements. No country had an accompanying strategic mental health plan to allow the development and implementation of concrete strategies and activities. The authors recommend strengthening capacity of key stakeholders in public (mental) health and policy development, the creation of a culture of inclusive and dynamic policy development, and coordinated action to optimise use of available resources.
In this article, Horace Campbell charts Africa’s exploitative history of ‘aid’ and the struggle to establish a new global system rooted in dignity, equality and genuine social justice. Throughout Africa, Asia and Latin America the author argues that international capitalism has plundered the resources of the planet. Today, ‘international plunderers’ work with local African allies and sometimes their governments in extracting resources. The author argues that some African leaders have been compromised by their “development partners” and have remained silent in the face of intensified exploitation of Africa. The continued plunder of resources by oil companies and others has grown in this period, and observers have pointed to the constant interconnections between wars, violence and economics. Similarly, as Africans move into the twenty-first century there is increased interest in the genetic resources and fresh water of Africa, especially the water resources of the Congo River and its tributaries. Thus far there is not enough work on how this century will impact the lives of Africans.
This strategy is a detailed and comprehensive guide to how health sectors can most effectively tackle the HIV and AIDS epidemic. Data shows that the epidemic has been halted and that the spread of HIV is beginning to be reversed. New infections have fallen by almost 20% in the last ten years and between 2003 and 2009 there was a 13-fold increase in treatment coverage. However, in 2009 only a third of people in need of treatment received it and the demand for resources is still outstripping supply. The Strategy is intended to optimise progress towards universal access and the attainment of the Millennium Development Goals. It aims to promote tailored responses to national and regional epidemics and analyses the underlying socio-economic and cultural determinants contributing to the spread of the virus. The strategy seeks to reduce vulnerability and structural barriers to accessing good quality services. It also demonstrates how HIV programmes can play a role in broader health outcomes and recognises the importance of strong health and community systems to guarantee a sustainable response. WHO will make five key contributions to the Global Health Sector Strategy: scale up innovation in prevention; optimise treatment and care; support health for women and children; promote strategic health-sector information and planning; and provide leadership in addressing health equity and HIV (examining inequities in access to HIV services).
The Joint Meeting of SADC Ministers responsible for Youth and Ministers Responsible for Vulnerable Children was held in Windhoek, Namibia, from 1-3 June 2011. The meeting was attended by delegates from all SADC Member States, except Seychelles. It was convened to discuss common ways of addressing the increasing problems and concerns of vulnerable children and youth in the SADC Region which include diseases such as HIV and AIDS, malaria, and tuberculosis; poverty; hunger and malnutrition; social and political conflicts; disability among children and youth; and the growing problems of pregnancy among teenagers and unemployment among the youth. Ministers adopted common plans and actions for the region that will help to accelerate the delivery of basic services and needs for vulnerable children and youth such as the provision of safe drinking water, health care, education and skills that enable youth to earn income and to create jobs for themselves, protection from abuse, and the provision of housing and family care. Other basic services include those relating to improving the capacity of children and youth to cope with the stresses of life, and to be able to live in harmony with others in society. Ministers agreed to set up the necessary structures required to fully implement their decisions and improve the lives of children and youth in the region. In order to address issues more effectively, they agreed that in future they would meet separately as Ministers responsible for children, and those responsible for youths. Before ending their meeting, Ministers agreed to meet again in 2012 to follow up progress on the implementation of their decisions.
According to this paper, the gap between practice and policy - those providing health services to migrants versus those making policies about migrants' entitlements - is increasingly evident. At the same time that clinicians are treating more diverse migrant groups, policy-makers are attempting to implement restrictive or exclusive immigration-related health policies that contradict public health needs and undermine medical ethics that operate on the ground. Policies that respond to the diversity of migrant groups and their differential health risks and service access must be developed and implemented, the authors of this paper argue. Moreover, to make real advances in the protection of both individual and public health, interventions must target each stage of the migration process and reach across borders. Services should be based on human rights principles that foster available and accessible care for individual migrants.
According to this article, the International Monetary Fund is deepening poverty in developing countries, especially for women who make up 70% of the world’s poor. By means of ‘structural adjustment programmes’ (SAPs), it pushes for lower tariffs and cuts in government programmes such as welfare and education. IMF-mandated government austerity measures may require cutting public sector jobs, which disproportionately impact women, as women hold most of the lower-skilled public sector jobs, so are often the first to be cut. As social programmes like caregiving are slashed, women are expected to take on additional domestic responsibilities that further limit their access to education or other jobs. In exchange for borrowing US$5.8 billion from the IMF and World Bank, Tanzania agreed to impose fees for health services, which led to fewer women seeking hospital deliveries or post-natal care and naturally, higher rates of maternal death. In Zambia, the imposition of SAPs led to a significant drop in girls’ enrollment in schools and a spike in ‘subsistence sex’ as a way for young women to continue their educations, the authors note.
In this paper, the authors evaluate the effectiveness of the World Starts With Me (WSWM), a comprehensive sex education programme in secondary schools in Uganda, focusing on socio-cognitive determinants of safe sex behaviour, namely delay, condom use and non-coercive sex. A survey of 1,864 students was conducted, which showed significant positive effects of WSMW on beliefs regarding what could or could not prevent pregnancy, the perceived social norm towards delaying sexual intercourse, and the intention to delay sexual intercourse. Furthermore, significant positive effects of WSWM were found on attitudes, self-efficacy and intention towards condom use and on self-efficacy in dealing with sexual violence (pressure and force for unwanted sex). However, all significant positive effects disappeared for those schools that only implemented up to 7 out of 14 lessons in the programme. The authors conclude that the effectiveness of WSWM could be improved by giving more systematic attention to the context in which such a programme is to be implemented.
At the High-level Meeting on AIDS, held 8–10 June 2011 in New York, 3,000 participants gathered to chart a path for the future of the AIDS response, including 30 heads of State and government, along with senior officials, representatives of international organisations, civil society and people living with HIV. The declaration adopted by Member States of the General Assembly contains clear, measurable targets, including targets to halve sexual transmission of HIV by 2015, to reduce HIV transmission among people who inject drugs by 50% by 2015, to ensure that by 2015 no child will be born with HIV, to increase universal access to antiretroviral therapy, to get 15 million people onto life-saving treatment by 2015, and to halve tuberculosis deaths in people living with HIV by 50% by 2015. Member States also pledged to close the global resource gap for AIDS and work towards increasing funding to between $22 and $24 billion per year by 2015. Paul De Lay, Deputy Executive Director of the Joint UN Programme on HIV/AIDS (UNAIDS) noted that the declaration clearly outlines the urgent need to increase access to HIV services for people most at risk of infection, including men who have sex with men, people who inject drugs and sex workers. The pledge to eliminate gender inequality, gender-based abuse and violence and to empower women and girls must be fulfilled without delay, he added.
5. Health equity in economic and trade policies
Across Africa, China has become known as the agent of mass construction, bartering infrastructural development – chiefly mining-specific – for long-term access to strategic resources. Through this mechanism, Ghanaian cocoa, Gabonese iron and Congolese oil have been swapped for construction of dams (Bui, Poubara, and River Dam), allowing Chinese corporations such as Sinohydro to capture Africa's hydropower market. The 'barter system' enables China to export goods and labour and to 'import' recycled project capital and African resources. In the process, the author of this article argues that China has activated the same 'Western' capitalist vehicles of engagement but with one noticeable difference: prior to Beijing's entrance, just 4% of foreign direct investment (FDI) was earmarked for infrastructure. China has constructed stadiums across the continent, as well as buildings and special economic zones. Though Zambia was pegged as the third largest recipient of Chinese investment in Africa, Zambian labour unions appear apprehensive about Chinese FDI as the means of national development, stating that Chinese FDI has had modest impact on national development, with overall negative impacts on the labour market. In Zambian mines, the bulk of the work is reported to be subcontracted to Chinese workers and companies, leading to complaint of displacement of local workers.
British firms are reported to have acquired more land in Africa for controversial biofuel plantations than companies from any other country, a Guardian investigation has revealed. Half of the 3.2m hectares (ha) of biofuel land identified in countries from Mozambique to Senegal is linked to 11 British companies, more than any other country. There are no central records of land acquisitions in Africa, but research by the Guardian revealed 100 biofuel projects in sub-Saharan Africa by 50 companies in more than 20 countries. The authors note that the revelation of the central role of UK companies in biofuels coincides with a report from Oxfam forecasting that the price of staple foods will more than double in the next 20 years. The report identifies biofuels as a factor and demands that western governments end biofuel policies that divert food to fuel for cars.
A large group of developing countries has submitted a proposal to amend the World Trade Organisation's Trade-related Aspects of Intellectual Property Rights (TRIPS) Agreement to require the disclosure of origin of genetic resources and associated traditional knowledge in patent applications. The proponents stressed that the change would help ensure that the utilisation of genetic resources and associated traditional knowledge would comply with the access and benefit-sharing legislation of the country providing genetic resources and traditional knowledge, that is, the country of origin. They call for acknowledgement that a legal obligation establishing such a mandatory disclosure requirement in patent applications will help prevent both misappropriation of genetic resources and the granting of erroneous patents and also enhance transparency about the utilisation of genetic resources and associated traditional knowledge.
While China's relationship to Africa is much examined, knowledge and analysis of India's role in Africa has until now been limited but, as a significant global player, India's growing interactions with various African countries call for detailed analysis of the Asian giant's influence and its relations with the African continent. In this book, which enables readers to compare India to China and other 'rising powers' in Africa, expert African, Indian and western commentators draw on a collection of accessibly written case studies to explore inter-related areas including trade, investment, development aid, civil society relations, security and geopolitics.
As world market prices for crops such as grain and soybeans have risen, governments in countries that import food have realised they can no longer depend on the market for supplies. At the same time, predictions that food and water shortages are being exacerbated by climate change and expanding populations have convinced countries such as China, South Korea, Saudi Arabia and others to buy large amounts of land in poor countries in Africa, according to this paper. Agribusinesses, government agencies, and investment funds alike have been acquiring long-term leases for more than 50 million hectares of land in countries such as the Democratic Republic of Congo, Madagascar and Mozambique. But in many cases the contracts are just a few pages long, and the land is sold for less than US$1 per hectare. These so-called “land grabs” are water acquisitions as well; some contacts include turning over water rights without a fee. And since most of the leases are for up to 100 years, the local population often loses the rights to its land and water for generations. Why are the governments in these African countries signing such fragile deals? Poor African nations hope to gain jobs and infrastructure development, the author concedes. Yet many local farmers living on land sold to foreign entities stand to lose much as most of the contacts to acquire the land were completed without local participation or notification.
The European Commission has issued a new draft customs regulation that it says addresses past concerns over wrongful seizures of generic drug shipments transiting through European ports. But the new regulation does not substantively change existing rules, it said, and civil society groups say it does not go far enough. The proposal does not explain that the customs regulation is of a procedural nature, and it does not change or add to the rules defining what an intellectual property rights (IPR) infringement is. In 2008, shipments of legitimate generic medicines transiting through Europe were detained by customs authorities on allegation of IPR rights infringement. This triggered the filing of disputes at the World trade Organisation (WTO). On 11 May 2010, India requested consultations at the WTO with the European Union and the Netherlands about seizures of generic drugs coming from India and travelling via the Netherlands to developing countries in Africa and elsewhere. India said those seizures were inconsistent with the obligations of the European Union and the Netherlands of various provisions of the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). The dispute is ongoing and remains at the consultation phase.
According to the author of this article, secrecy jurisdictions – or tax havens - act as financial sinkholes: places where vast sums of money flow between the legitimate world economy and the illicit underworld economy. The costs of financial sinkholes are borne by ordinary citizens throughout the world, not only by taxpayers in industrialised countries but also by many of the world’s poorest people. The author points to the flight of US$735 billion (in constant 2008 dollars) from sub-Saharan Africa from 1970 to 2008. Most of this disappeared into secrecy jurisdictions, with recorded African deposits in Western banks amounting to less than 6% of this amount. To put Africa’s capital haemorrhage into perspective, the total foreign debt of the same countries stood at US$177 billion at the end of 2008. In this sense Africa is a net creditor to the rest of the world because its external assets far exceed its external liabilities. However the assets are private and hidden, whereas the liabilities are public, owed by the people of Africa through their governments. The author points to advocacy from groups like the Tax Justice Network, Global Financial Integrity and Global Witness, who have raised public awareness of these issues.
6. Poverty and health
Contrary to popular perception, the current high food prices will not see more money flowing into agriculture in the long term, according to this forecast. Input costs, including that of fuel and fertiliser, have risen significantly and the Food and Agriculture Organisation (FAO) anticipates global agriculture production to slow down in the next decade. The Outlook has forecast in its last three editions that food prices will remain high for the next few decades. Global agricultural production is projected to grow at 1.7% annually until 2020, compared to 2.6% during the previous decade. Slower growth is expected for most crops, especially oilseeds and coarse grains, which face higher production costs and slowing productivity. The FAO estimates that to meet projected demand over the next 40 years, farmers in developing countries need to double production.
Despite increased research interest on the social and economic determinants of health (SEDH), the vast majority of studies on this issue are from developed countries. The authors of this study set out to determine whether there are specific social determinants of health in the world's poorest countries, and if so, how they could be better identified and researched in Africa in order to promote and support universal health coverage. They conducted a literature review of existing papers on the social and economic determinants of health, finding that most of the existing studies on the SEDH studies did not provide adequate explanation on the historical and contemporary realities of SEDHs in the world's poorest countries. As these factors vary from one country to another, the authors argue that it is necessary for researchers and policy makers to understand country-specific conditions and design appropriate policies that take due cognisance of these country-specific circumstances. They call for further research in the world's poorest countries, especially in Africa.
Since April 2011, the humanitarian community has been gearing up to deploy a new mechanism aimed at combining expertise on food aid and agricultural assistance to boost food security and make food insecure communities hit by a disaster more resilient. The tool, which is deployed by aid workers in emergency responses, is the "cluster approach", first implemented in 2005. A "cluster" consists of groupings of UN agencies, NGOs and other international organisations around a sector or service provided during a humanitarian crisis. The cluster approach currently encompasses 11 clusters or sectors such as logistics, water and sanitation, early recovery and nutrition. Agriculture as a separate cluster will cease to exist under the new scheme. The new cluster is led jointly by the UN Food and Agriculture Organization (FAO) and the World Food Programme (WFP). The tool is aimed at implementing a proper `early recovery' approach by introducing recovery and development aspects into relief work as early as possible and strengthening transition.
Global Call to Action Against Poverty (GCAP) has proposed seven major issues that must be tackled by the G8 if it is serious about alleviating poverty. Public accountability, just governance and human rights should be enshrined in programmes financed by G8, with reporting that takes into account real prices (after inflation) and is based on consistent year-on-year calculations. The G8 must also place gender equality and empowerment at the heart of its development policies. It should reaffirm the Gleneagles, L’Aquila and Muskoka commitments in the G8 communiqué and set out an emergency plan to deliver the US$19 billion shortfall against commitments by 2012. In terms of debt cancellation, the G8 should endorse the formation of an International Debt Court to ensure a fair and transparent process that is independent of borrowers and lenders, based on clear rules, legally enforceable, comprehensive and mandated to assess the validity and legitimacy of all debt cancellation claims. The G8-Africa Declaration and related agreements must be based on fairness to both Northern and Southern countries, ensuring equitable trade conditions. Justice in terms of climate change agreements should be secured for developing countries, and peace and security should also be taken into account by the G8, as democracy is currently being undermined in Africa by continual armed conflict.
Poverty is the state of having little or no money and few or no material possessions. Poverty can be caused by unemployment, low education, deprivation and homelessness. This study assessed the relationship between poverty and patient abandonment (PA) in hospitals, and the attitude of health care professionals (HCPs) towards the patient. The study targeted all patients who were abandoned at MNH and who voluntarily accepted to participate in this study under informed consent and strict confidentiality. This is the first study to be conducted in Dar es Salaam with respect to PA in hospital. Results revealed unnecessary overcrowding in wards and overwhelmingly heavy burden of patient care on the HCPs. The study also observed a correlation between poverty and PA, which was to a great extent related to the patient's level of education. The respondents strongly condemned PA immoral. The authors propose that government re-introduce subsidies on services to alleviate the burden of medical expenses incurred by the low income citizens, particularly the unemployed and farmers. The study also recommends that the government should improve services in regional hospitals to reduce travel and patients care expenses.
Adequate infant and young child nutrition demands high rates of breastfeeding and good access to nutrient rich complementary foods, requiring public sector action to promote breastfeeding and home based complementary feeding, and private sector action to refrain from undermining breastfeeding and to provide affordable, nutrient rich complementary foods. The authors argue, however, that public and private sectors do not work well together in improving infant and young child nutrition. The authors argue that there are lessons to learn in managing public and private interactions on nutrition from the actions taken around sweatshops. One example is the Ethical Trading Initiative, in which companies, trade unions, and civil society organisations work together to enhance implementation of labour standards and address alleged allegations of abuse.
7. Equitable health services
According to this paper, puerperal sepsis is an infection contracted during childbirth and one of the commonest causes of maternal mortality in developing countries, despite the discovery of antibiotics over eighty years ago. Some developing countries have recently experienced increased use of health facilities for labour and delivery care and there is a possibility that this trend could lead to rising rates of puerperal sepsis. Drug and technological developments need to be combined with effective health system interventions to reduce infections, including puerperal sepsis. The authors review health system infection control measures pertinent to labour and delivery units in developing country health facilities. Organisational improvements, training, surveillance and continuous quality improvement initiatives, used alone or in combination have been shown to decrease infection rates in some clinical settings. There is limited evidence available on effective infection control measures during labour and delivery and from low-resource settings. The authors argue that a health systems approach is necessary to reduce maternal mortality and the occurrence of infections resulting from childbirth. Organisational and behavioural change underpins the success of infection control interventions. A global, targeted initiative could raise awareness of the need for improved infection control measures during childbirth.
Insecticide-treated bed nets are the preeminent malaria control means, although there is no consensus as to a best practice for large-scale insecticide-treated bed net distribution. In order to determine the paramount distribution method, the author of this review assessed literature on recent insecticide treated bed net distribution programmes throughout sub-Saharan Eastern Africa. She included all studies that had taken place in sub-Saharan Eastern Africa, targeted malaria prevention and control, and occurred between 1996 and 2007. Forty-two studies were identified and reviewed. The results indicate that distribution frameworks varied greatly, and so did outcomes of insecticide-treated bed net use. Studies revealed consistent inequities between urban and rural populations, which were most effectively alleviated through a free insecticide-treated bed net delivery and distribution framework. Cost sharing through subsidies was shown to increase programme sustainability, which may lead to more long-term coverage. Thus, distribution should employ a catch up/keep up programme strategy, the author argues. The catch-up programme rapidly scales up coverage, while the keep-up programme maintains coverage levels.
Each year in Sub-Saharan Africa, South Central Asia and Southeast Asia, 49 million women have unintended pregnancies, leading to 21 million unplanned births, 21 million induced abortions (15 million of which are unsafe), 116,000 maternal deaths and the loss of 15 million healthy years of women’s lives. Seven in 10 women with unmet need for modern contraception in the three regions cite reasons for non-use that could be rectified with appropriate methods. In these three regions, the typical woman with reasons for unmet need that could be addressed with appropriate methods is married, is 25 or older, has at least one child and lives in a rural area. In the short term, women and couples need more information about pregnancy risk and contraceptive methods, as well as better access to high-quality contraceptive services and supplies. In the medium term, adaptations of current methods can make these contraceptives more acceptable and easier to use. Investment in longer-term work is needed to discover and develop new modes of contraceptive action that do not cause systemic side effects, that can be used on demand, and that do not require partner participation or knowledge. Overcoming method-related reasons for non-use of modern contraceptives is projected to reduce unintended pregnancy and its consequences by as much as 59% in these regions.
The authors of this study aimed to establish delivery practices and associated factors among mothers seeking child welfare services at selected health facilities in Nyandarua South district, Kenya, to determine whether mothers were receiving appropriate delivery care. A hospital-based cross-sectional survey was conducted among 409 mothers who had delivered while in the study area between August and October 2009. A total of 1,170 deliveries were reported, with 51.8% attended by unskilled birth attendants and 11.7% self administered. Mothers who had unskilled birth attendance were more likely to have less than three years of education and more than three deliveries in a lifetime. The authors conclude that, among the mothers interviewed, utilisation of skilled delivery attendant services was still low. They call for cost effective and sustainable measures to improve the quality of maternal health services.
The objective of this study was to investigate potential differences in the availability of medicines for chronic and acute conditions in low- and middle-income countries. Data on the availability of 30 commonly-surveyed medicines – 15 for acute and 15 for chronic conditions – were obtained from facility-based surveys conducted in 40 developing countries. The researchers found that availability of medicines for both acute and chronic conditions was suboptimal across countries, particularly in the public sector. Generic medicines for chronic conditions were significantly less available than generic medicines for acute conditions in both the public sector and the private sector. An inverse association was found between country income level and the availability gap between groups of medicines, particularly in the public sector. In low- and lower-middle income countries, drugs for acute conditions were 33.9% and 12.9% more available, respectively, in the public sector than medicines for chronic conditions. Differences in availability were smaller in the private sector than in the public sector in all country income groups. Current disease patterns do not explain the significant gaps observed in the availability of medicines for chronic and acute conditions. Measures are needed to better respond to the epidemiological transition towards chronic conditions in developing countries alongside current efforts to scale up treatment for communicable diseases.
The aim of this study was to assess factors associated with birth-preparedness and complication-readiness as well as the level of male participation in the birth plan among emergency obstetric referrals in rural Uganda. This was a cross-sectional study conducted at Kabale regional hospital maternity ward among 140 women admitted as emergency obstetric referrals in antenatal, labor or the postpartum period. Data was collected on socio-demographics and birth preparedness and what roles spouses were involved in during developing the birth plan. The authors observed that male involvement in birth preparedness and complication readiness for obstetric emergencies is still low. Individual women, their spouses, their families and their communities need to be empowered to contribute positively to making pregnancy safer by making and implementing a birth plan.
In this literature review, researchers investigated the systems and tools used by public health to generate public health emergency preparedness and response (PHEPR) communications to health care providers (HCPs), and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective PHEPR communications. After a systematic review of peer- and non-peer-reviewed literature, they identified 25 systems or tools for communicating PHEPR messages from public health agencies to HCPs. They found that detailed descriptions of PHEPR messaging from public health to HCPs are scarce in the literature and, even when available, are rarely evaluated in any systematic fashion. Only one study compared the effectiveness of the delivery format, device or message itself. To meet present-day and future information needs for emergency preparedness, the authors argue that more attention needs to be given to evaluating the effectiveness of these systems in a scientifically rigorous manner.
The authors of this article argue that surgery can and should be recognised as an important global health intervention. To achieve this goal, they emphasise that it is critical to improve the local surgical capacity in low- and middle-income countries. While the accomplishment of this goal will not be easy it is certainly possible, especially when doctors join forces with providers and policy-makers that set the direction of a public health movement that has seen a dramatic change and increase in its authority over the past decade. The authors call on the World Health Organisation to exercise its leadership in advancing the status of surgical care in global health by organising action plans to meet unmet surgical burdens.
Traditional medicines, including herbal medicines, have been, and continue to be, used in every country around the world in some way. In much of the developing world, a large share of the population rely on these traditional medicines for primary care. The global market for traditional medicines was estimated at US$ 83 billion annually in 2008, with an exponential rate of increase. Traditional medicines are used as prescription or over-the-counter (OTC) medications, as self-medication or self-care, as home remedies, or as dietary supplements, health foods, functional foods, phytoprotectants, and under any of many other titles in different jurisdictions, with only minimal consistency between the definitions of these terms from country to country and significant communication issues as a result. It is difficult to control quality and to ensure safety and efficacy in production of traditional medicines. WHO, in cooperation with the WHO Regional Offices and Member States, has produced a series of technical documents in this field, including publications on Good Agricultural and Collection Practices (GACP) and Good Manufacturing Practices (GMP), along with other technical support, to assist with standardization and creation of high quality products. Regulation of traditional medicines is a complicated and challenging issue as it is highly dependent upon experience with use of these products. Model countries such as China, India, and South Africa present usable templates, as do the guidelines on regulation and registration of traditional or herbal medicines produced in the WHO African, Eastern Mediterranean, and South-East Asian regions and in the European Union.
During 2004-2008, several FIDELIS projects (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) in Tanzania were conducted by the National Tuberculosis and Leprosy Programme to strengthen tuberculosis (TB) diagnostic and treatment services. The authors of this study assessed the duration and determinants of treatment delay among new smear-positive pulmonary TB patients in FIDELIS projects, and compared delay according to provider visited prior to diagnosis. They included 1,161 cases, 10% of all patients recruited in the FIDELIS projects in Tanzania. Median delay was 12 weeks. Compared to Hai district, Handeni had patients with longer delays and Mbozi had patients with shorter delays. Urban and rural patients reported similar delays. In conclusion, half of the new smear positive pulmonary tuberculosis patients had a treatment delay longer than 12 weeks. Delay was similar in men and women and among urban and rural patients, but longer in the young and older age groups. Patients using traditional healers had a 25% longer median delay.
8. Human Resources
Workplace health promotion (WHP) is a common strategy used to enhance on-the-job productivity. The primary objective of this study was to determine if WHP programmes are effective in improving workers presence at work. The Cochrane Library, Medline, and other electronic databases were searched from 1990 to 2010. After 2,032 titles and abstracts were screened, 47 articles were reviewed, and 14 were accepted (4 strong and 10 moderate studies). These studies contained preliminary evidence for a positive effect of some WHP programmes. Successful programmes offered organisational leadership, health risk screening, individually tailored programs, and a supportive workplace culture. Potential risk factors contributing to presenteeism included being overweight, a poor diet, a lack of exercise, high stress, and poor relations with co-workers and management.
This qualitative study was undertaken to understand how practising doctors and medical leaders in Ghana describe the key factors reducing recruitment and retention of health professionals into remote areas, and to document their proposed policy solutions. In-depth interviews were carried out with 84 doctors and medical leaders, including 17 regional medical directors and deputy directors from across Ghana, and 67 doctors chosen to represent progressively more remote distances from the capital of Accra. All participants felt that rural postings must have special career or monetary incentives given the loss of locum (i.e. moonlighting income), the higher workload, and professional isolation of remote assignments. Career 'death' and prolonged rural appointments were a common fear, and proposed policy solutions focused considerably on career incentives, such as guaranteed promotion or a study opportunity after some fixed term of service in a remote or hardship area. Short-term service in rural areas would be more appealing if it were linked to special mentoring and/or training, and led to career advancement.
9. Public-Private Mix
Kenyan pharmacists are taking advantage of government-subsidised anti-malarial medications to maximise their profits, according to this article. Media reports from different parts of the country, including rural areas, revealed that retail prices of the subsidised anti-malarial drugs varied from 80 KES (US$1) to 240 KES ($3). Some private pharmacists claimed that they inflated the price to cover distribution costs and other inputs, while many do not stock the subsidised drugs, as profits from subsidised medications were considered too marginal. In order to reduce instances where pharmacists are inflating the cost of the subsidised drugs, the Kenyan government has embarked on awareness campaigns through the media to inform Kenyans of the availability of the drugs, and the recommended prices per dose. Technically, the government of Kenya does not have control over drugs sold in pharmacies in the private sector because the pharmaceutical market in the country is based on ‘a willing seller, willing buyer’ concept, but the author argues that this does not appear to be working for poor consumers.
On 30 May 2011, the Drugs for Neglected Diseases initiative (DNDi) signed an agreement with pharmaceutical manufacturer Sanofi for a three-year research project on nine neglected tropical diseases. Sanofi will bring molecules from its libraries into the partnership, and DNDi and Sanofi will collaborate on the research. According to the agreement, the intellectual property (IP) rights resulting from the partnership will be co-owned by DNDi and Sanofi. Publication of results is hoped to benefit the wider research community and the partnership has commited to improving access to health interventions for patients in all endemic countries, irrespective of their level of economic development. The agreement will cover nine diseases: leishmaniasis, Chagas disease, human African trypanosomiasis (sleeping sickness), lymphatic filariasis (elephantiasis), onchocerciasis (river blindness), helminthiasis, dracunculiasis (Guinea-worm disease), fasciolosis, and schistosomiasis.
10. Resource allocation and health financing
BetterAid, a coalition of over 1,000 civil society organisations, is calling on G8 leaders to commit to improving the effectiveness and impact of development aid by sending a strong political message to the Fourth High-Level Forum on Aid Effectiveness, which will take place from 29 November to 1 December 2011. In the run up to the summit, the G8 has been accused of deliberately hiding shortfalls in meeting aid commitments made by world leaders in 2005 in Gleneagles by failing to take into account the impact of inflation on their figures. Yet official development assistance plays an integral and complementary role to the broader concerns of the G8 agenda like fighting poverty, mitigating climate change, promoting decent work and stopping corruption. BetterAid highlights four areas where the G8 should push aid effectiveness forward. First, the G8 should ensure democratic ownership and full transparency in development co-operation in line with previous commitments. Second it should commit to a human rights-based approach to development and development cooperation with gender equality, decent work and environmental sustainability at the centre. Third, it should agree to minimum standards to support the work of civil society organisations as development actors in their own right. Fourth, it should initiate fundamental reforms of aid governance at the crucial High-Level Forum on Aid Effectiveness.
IRIN News has compiled this summary of aid successes and shortfalls among major external funders (donors) in 2010. European Union (EU) member states made pledges to provide 0.56% of gross national income (GNI) as official development aid by 2010, with a view to increasing to 0.7% by 2015. Together, they missed this target by US$21 billion; delivering just under four fifths of the commitment. The UK met the 0.56% goal, putting US$8.5 billion towards development aid in 2010; Germany gave 0.38% at $7.8 billion; and the US $18.5 billion - or 0.21% of GNI. The worst EU aid performers in terms of the proportion of GNI are Italy, Greece, Portugal, Austria and Germany. Best-performing are Sweden, Denmark, Luxembourg, Netherlands and Belgium. G8 and EU aid to sub-Saharan Africa was the highest on record in 2010 at US$18.2 billion; but lower than commitments pledged by G8 leaders in 2005. Assistance to sub-Saharan Africa has increased to $19.6 billion since 2000 - $15.6 billion of it coming from G7 countries (France, Germany, Italy, Japan, UK, USA and Canada). The G7 delivered 60% of the increase they promised to sub-Saharan Africa in 2005 - largely because the USA, Japan and Canada surpassed their targets, and the UK delivered 86% of its commitment, with an increase of $2.55 billion. Italy, Germany and France are mainly responsible for the shortfall. Italy's aid to sub-Saharan Africa has declined by $78million since 2004.
In March 2009, the Task Force for Innovative International Financing for Health Systems recommended a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others, and the Health Systems Funding Platform was soon launched. Despite its potential significance, there has been little comment in peer-reviewed literature, though some disquiet in the international development community around the scope of the Platform and the capacity of the partners, which appears disproportionate to the available information. This case study uses documentary analysis, participant observation and 24 in-depth interviews to examine the processes of development and key issues raised by the Platform. The findings show a fluid and volatile process, with debate over whether ongoing engagement in health system strengthening by the Global Fund and GAVI represents a dilution of organisational focus, risking ongoing support, or a paradigm shift that facilitates the achievement of targeted objectives, builds systems capacity, and will attract additional resources. The tensions, however, appear to have been resolved through a focus on national planning, applying International Health Partnership principles, though the global financial crisis and key personnel changes may yet alter outcomes. Despite its dynamic evolution, the Platform may offer an incremental path towards increasing integration around health systems that has not been previously possible, the authors conclude.
The authors of this paper argue that substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. The authors propose a strategic investment framework that is intended to support better management of national and international HIV and AIDS responses than exists with the present system. The framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV and AIDS. The framework is cost effective at US$1,060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.
11. Equity and HIV/AIDS
According to this UNAIDS report, the global rate of new HIV infections declined by nearly 25% between 2001 and 2009. In South Africa, the rate of new HIV infections fell by more than 35%, with above-average declines in new HIV infections recorded in sub-Saharan Africa. The report found that in the third decade of the epidemic, people were starting to adopt safer sexual behaviours, reflecting the impact of HIV prevention and awareness efforts. However, there are still important gaps – for example, young women are less likely to be informed about HIV prevention than young men. While the rate of new HIV infections has declined globally, the total number of HIV infections remains high, at about 7,000 per day. According to the report, investments in the HIV response in low- and middle-income countries rose nearly 10-fold between 2001 and 2009, from US$ 1.6 billion to US$ 15.9 billion. However, in 2010, international resources for HIV declined, despite the fact that many low-income countries remain heavily dependent on external financing.
The Soweto Men’s Study assessed HIV prevalence and associated risk factors among men who have sex with men (MSM) in Soweto, South Africa. Using respondent-driven sampling (RDS) recruitment methods, researchers recruited 378 MSM over 30 weeks in 2008. All results were adjusted for RDS sampling design. Overall HIV prevalence was estimated at 13.2%, with 33.9% among gay-identified men, 6.4% among bisexual-identified men, and 10.1% among straight-identified MSM. In multivariable analysis, HIV infection was associated with being older than 25, gay self-identification, monthly income less than ZAR500, purchasing alcohol or drugs in exchange for sex with another man and reporting between six and nine partners in the prior six months, including a regular female partner. The results of the study confirm that MSM are at high risk for HIV infection, with gay men at highest risk. HIV prevention and treatment for MSM are urgently needed, the authors conclude.
Do orphaned children and adolescents have elevated risk for HIV infection? In this study, researchers examined the state of evidence regarding the association between orphan status and HIV risk in studies of youth aged 24 years and younger. Using systematic review methodology, they identified 10 studies reporting data from 12 countries comparing orphaned and non-orphaned youth on HIV-related risk indicators, including HIV serostatus, other sexually transmitted infections, pregnancy and sexual behaviours. Meta-analysis of HIV testing data from 19,140 participants indicated significantly greater HIV seroprevalence among orphaned (10.8%) compared with non-orphaned youth (5.9%). Trends across studies showed evidence for greater sexual risk behaviour in orphaned youth. In conclusion, studies on HIV risk in orphaned populations, which mostly include samples from sub-Saharan Africa, show nearly two-fold greater odds of HIV infection among orphaned youth and higher levels of sexual risk behaviour than among their non-orphaned peers. Interventions to reduce risk for HIV transmission in orphaned youth are needed to address the sequelae of parental illness and death that might contribute to sexual risk and HIV infection.
In June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. In this study, researchers assessed progress toward this UNGASS target in Manicaland, Zimbabwe, using repeated household-based population sero-survey data. Progress towards the target was measured by calculating the proportional change in HIV prevalence among youth and young ANC attendees over three survey periods (rounds 1 to 3). The researchers found that HIV prevalence among youth in the general population declined by 50.7% from round 1 to 3. Among young ante-natal care (ANC) attendees, the proportional decline in prevalence of 43.5% was similar to that in the population, although ANC data significantly underestimated the population prevalence decline from round 1 to 2 and underestimated the increase from round 2 to 3. Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines. In Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends.
The Health4Men Clinic at Baragwanath Hospital, South Africa, is an HIV and Aids advocacy network specifically devoted to the needs of men who have sex with men (MSM). Nthato Ramushu from the Clinic says that the term MSM is quite new for many people. Because same-sex sexuality is easily misunderstood, this group is often neglected in HIV prevention and treatment campaigns. He states that almost half of those men living in Soweto, Gauteng who are gay or are MSM are too afraid to identify themselves as gay or MSM, despite their needs for health services and higher risk of HIV infection and transmission. Ramushu noted that many MSM are married men who are not open about their sexuality, fearing rejection by their families and communities.
The authors of this study analysed demographic and contextual factors associated with sexual risk taking among HIV-infected patients on antiretroviral treatment (ART) in Africa's largest informal urban settlement, Kibera in Nairobi, Kenya. In the study, they included 515 consecutive adult patients on ART attending the African Medical and Research Foundation clinic in Kibera in Nairobi. Interviewers used structured questionnaires covering socio-demographic characteristics, time on ART, number of sexual partners during the previous six months and consistency of condom use. Twenty-eight% of patients reported inconsistent condom use. Female patients were significantly more likely than men to report inconsistent condom use. Shorter time on ART was significantly associated with inconsistent condom use. Multiple sexual partners were more common among married men than among married women. ART needs to be accompanied by other preventive interventions, the authors conclude, to reduce the risk of new HIV infections among sero-discordant couples and to increase overall community effectiveness.
This ethnographic study in Dzivaresekwa district, Harare, Zimbabwe, examines the issue of sexuality among the elderly and their challenges in accessing information, education, and communication (IEC) campaigns in the face of HIV and AIDS. The research depended heavily on collecting life histories through key informant interviews. The theory of structuration as proposed by Anthony Giddens was adopted as a framework to analyse the findings. The findings reveal that although the sample of elderly people in Dzivaresekwa district were sexually active, HIV/AIDS-related interventions in the form of IEC campaigns mainly focus on the age group of 14–49-year-olds, and otherwise consider the elderly only as a group indirectly affected by the epidemic and less at risk of HIV infection. This is mainly a result of society’s presumption that people withdraw from sexual life with advanced age. Thus, the elderly are incorrectly regarded as sexually inactive and not susceptible to contracting sexually transmitted infections. A fuller understanding of the sexuality of the elderly is important to increase the usefulness HIV/AIDS efforts, while IEC campaigns that target them are still needed.
In this study, the authors explored acceptability of child transmission (PMTCT) programme components and identified structural and cultural challenges to male involvement in pregnancy and childbirth in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used, including focus group discussions with fathers and mothers, in-depth interviews with fathers, mothers and health personnel, and a survey of 426 mothers bringing their four-week-old infants for immunisation at five reproductive and child health clinics. Routine testing for HIV of women at the antenatal clinic was found to be highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance. Very few men joined their wives for testing and thus missed out on PMTCT counselling. The main barriers reported were that women did not have the authority to request their husbands to test for HIV and that the arena for testing, the antenatal clinic, was defined as a typical female domain where men were out of place. The authors conclude that deep-seated ideas about gender roles and hierarchy are the major obstacles to male participation in the PMTCT programme. Empowering men to participate by creating a space within the PMTCT programme that is male friendly should be feasible and should be highly prioritised for the PMTCT programme to achieve its potential.
12. Governance and participation in health
World leaders should use the Organisation for Economic Cooperation and Development (OECD) 50th anniversary forum to press for concrete improvements in sustainable development and fighting poverty, CIVICUS said at the opening of the two-day summit in Paris, France, on 24 May 2011. The 34-member institution should make clear that real improvements in poverty eradication depend on countries living up to their aid commitments, CIVICUS said. The organisation stated that it is critical that OECD leaders assess the impact of their efforts and the policies being advanced by international financial institutions to tackle poverty and climate change. The gap between commitments and aid pledges in 2011 has widened. In 2005, members of the OECD Development Assistance Committee (DAC) collectively promised to commit 0.56% of gross national income to aid. However, in 2010 aid has reached just 0.32%. At current levels, there is little chance that more than a handful of countries will reach the agreed commitment of 0.7% by 2015, CIVICUS warns, arguing that aid effectiveness is being damaged by inflated budgets, a lack of transparency and the failure of several large countries – namely Germany, Italy and Spain - to honour their commitments laid out in the Accra Agenda for Action.
This article presents a detailed description of a community mobilization intervention involving women's groups in Mchinji District, Malawi. The intervention was implemented between 2005 and 2010. The intervention aimed to build the capacities of communities to take control of the mother and child health issues that affect them. To achieve this it trained local female facilitators to establish groups and using a manual, participatory rural appraisal tools and picture cards guided them through a community action cycle to identify and implement solutions to mother and child health problems. The groups then catalysed community collective action to address mother and child health issues to improve te health and reduce the mortality of mothers and children. Their impact, implementation and cost-effectiveness have been rigorously evaluated through a randomized controlled trial design and the results of these evaluations will be reported in 2011.
Dissatisfaction emerged among many Member States over the World Health Organisation’s (WHO) financial reform plans at the 129th session of the WHO Executive Board, held on 25 May 2011. They expressed concern over the lack of detail on the reforms proposed, the stress on "donor funding" to resolve the financial difficulties of the WHO, as well as proposals such as the convening of the World Health Forum, which is aimed at increasing the influence of the private sector and external funders in setting the health agenda in the WHO. They also emphasised that the WHO's reform process must be driven by Members States themselves. The discussion resulted in the adoption of a new decision EB 129(8), which sets out a more transparent and inclusive consultative process for the finalisation of a reform plan by November 2011, when the Executive Board will convene for a special session.
The author argues that European powers appear set on perpetuating their arbitrary ‘entitlement’ to the position of Managing Director of the International Monetary Fund in the wake of the controversy that precipitated the resignation earlier in May 2011 of Managing Director, Dominique Strauss-Kahn. Despite claims from the IMF that the selection this time around would ‘take place in an open, merit-based, and transparent manner‘ as well as a longstanding commitment to open the position to nationals of all member states, most developed country representatives had expressed clear preferences for European candidates even before nominations opened on 23 May, according to this article. Their stances raise fears among developing countries and civil society that pledges to address unrepresentative governance at the Bretton Woods institutions are mere window dressing. Developing countries and emerging economies that account for most of the world's population, over half the world's output and who are being pressed to increase their capital contributions, will have negligible influence in the decision on the Managing director unless they are willing to take a firm, collective stance behind a consensus candidate.
With external funders moving towards making randomised controlled trials (RCTs) yet another conditionality of aid, How Matters questions the rationale behind the trend and its implications for non-governmental organisations in least-developed countries. According to the article, most local organisations and grassroots movements in the developing world lack both resources and capacity, and will struggle to meet arduous requirements from external funders to provide evidence that their programmes work, as RCTs are complicated and costly to undertake. How Matters argues that development aid hasn’t reduced poverty, but instead has squashed local initiatives by not giving the due attention to how that aid (and the accompanying monitoring, surveys etc) makes people feel, largely because of prevalent, yet hidden, negative attitudes towards local people and organisations in the aid sector. How Matters calls for greater participation by communities and individuals who are on the receiving end of aid, rather than the current one-way approach whereby researchers and policy makers tell recipients what they need, without considering issues of dignity and respect.
Tanzania’s performance in recent international corruption surveys shows a mixed picture. In international ratings, the country has experienced recent set-backs as regards the supply side of good governance, but this is coming from a high level of earlier performance, according to this report. In a household survey, respondents were asked to assess the quality of health services in terms of staff, facilities and surroundings. The findings show that, in general, the quality of services provided by the health sector is favourably perceived by households, with over 65% of respondents rating these services as ‘good’ or ‘very good’. However, over 50% of respondents considered medical personnel as corrupt. The authors could not understand how such corrupt medical personnel can deliver good quality services and argue that this apparent contradiction merits further research. Respondents identified a number of barriers to quality health services as serious, namely poor working conditions for medical staff, inadequate coverage of medical services, inadequate infrastructure facilities and equipment, low professional capacity of medical staff, outdated health sector reform programmes and prohibitive cost of accessing health services.
The Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) is a coalition of civil society organisations and academics researching key conceptual questions involving health rights and responsibilities, with the goal of securing a global health agreement and supporting civil society mobilisation around the human right to health. This agreement - such as a Framework Convention on Global Health - would inform post-Millennium Development Goal (MDG) global health commitments. Using broad partnerships and an inclusive consultation process, JALI seeks to clarify the health services to which everyone is entitled under the right to health, the national and global responsibilities for securing this right, and global governance structures that can realise these responsibilities and close major health inequities. Mutual benefits to countries in the Global South and North would come from a global health agreement that defines national and global health responsibilities. JALI aims to respond to growing demands for accountability, and to create the political space that could make a global health agreement possible.
Good governance is increasingly understood as necessary for improving access to medicines and contributing to health systems strengthening. This chapter reviews the findings of studies carried out in 25 countries that have examined governance of key functions of pharmaceutical systems within the framework of WHO’s Good Governance for Medicines (GGM) programme. The country studies, which are based on a common methodology, have revealed strengths and several weaknesses in existing pharmaceutical systems and have provided policy-makers with relevant information to help them better understand the nature of the problems facing the sector and where interventions need to take place. Common strengths in the pharmaceutical systems and procedures include the use of standard application forms in the registration process of medicines, use of national essential medicines lists, existence of standard operating procedures for procurement of medicines and well-established tender committees. Common weaknesses include a lack of access to information, poor enforcement and implementation of laws and regulations, absence of conflict of interest policies among members of various committees, and an inability to ensure that the proper incentives are in place to lessen the likelihood of corruption at both the individual and institutional levels. Governments can reduce corruption by promoting transparency and ethical practices, and by introducing simple measures, such as justification for committee membership, terms of reference, conflict of interest policies and descriptions of the purpose of the committees. International organisations, such as WHO, can provide technical support for these efforts.
13. Monitoring equity and research policy
It is estimated that more than US$130 billion is invested globally into health research each year, yet, according to this paper, priority setting in health research investments remain inequitable. The authors reviewed selected priority-setting processes at national level in low and middle income countries, and outlined a set of criteria to assess the process of research priority setting and use these to describe and evaluate priority setting exercises that have taken place at country level. Data were gathered from presentations at a meeting held at the World Health Organisation in 2008 and a web-based search. A number of findings emerged. Across the countries surveyed there was a relative lack of genuine stakeholder engagement, while countries varied markedly in the extent to which the priority setting processes were documented. None of the countries surveyed had a systematic or operational appeals process for outlined priorities, and in all countries (except South Africa) the priorities that were outlined described broad disease categories rather than specific research questions. The authors argue that priority setting processes must have in-built mechanisms for publicising results, effective procedures to enforce decisions as well as processes to ensure that the revision of priorities happens in practice.
The GAVI Alliance was created in 2000 to increase access to vaccines. More recently, GAVI has supported evidence-based health systems strengthening to overcome barriers to vaccination. The objectives of this study were: to explore countries' priorities for health systems strengthening; to describe published research summaries for each priority area in relation to their number, quality and relevance; and to describe the use of national data from surveys in identifying barriers. From 44 health systems-strengthening proposals submitted to GAVI in 2007 and 2008, the researchers analysed the topics identified, the coverage of these topics by existing systematic reviews, and the use of nation-wide surveys with vaccination data to justify the needs identified in the proposals. Thirty topics were identified and grouped into three thematic areas: health workforce, organisation and management, and supply, distribution and maintenance. The researchers found no reviews that dealt with health information systems, however. Only seven of the reviews were categorised as ‘highly relevant for policy’. In conclusion, researchers found little quality research that was relevant to managers’ needs. Few proposals used national surveys evidence to identify barriers to vaccination. The author recommends that researchers generating or adapting evidence about health systems need to be more responsive to managers' needs.
Malaria is highly endemic in the Democratic Republic of Congo (DRC), but the limits and intensity of transmission within the country are unknown. It is important to discern these patterns as well as the drivers which may underlie them in order for effective prevention measures to be carried out, the authors of this study argue. Using the 2007 Demographic and Health Survey (DHS) for the DRC, the authors generated prevalence estimates and explored the ecological drivers of malaria. Of the 7,746 respondents, 29.3% were parasitaemic, with males were more likely to be parasitaemic than older people or females, while wealthier people were at a lower risk. Increased community use of bed nets and community wealth were protective against malaria at the community level but not at the individual level. This research demonstrates the feasibility of using population-based behavioural and molecular surveillance in conjunction with DHS data and geographic methods to study endemic infectious diseases. The authors suggest that spatial information and analyses can enable the DRC government to focus its control efforts against malaria.
In this study, researchers aimed to validate vaccination data from a longitudinal population-based demographic surveillance system (DSS) against data from a clinical cohort study. The sample included 821 children in the Vertical Transmission cohort Study (VTS), and researchers found that vaccination data in matched children in the DSS was based on the vaccination card in about two-thirds of the cases and on maternal recall in about one-third. In conclusion, the addition of maternal recall of vaccination status of the child to the child’s card information significantly increased the proportion of children known to be vaccinated across all vaccines in the DSS. The authors recommend that information based on both maternal recall and vaccination cards should be used to identify which children have received a vaccination and which have not.
14. Useful Resources
The African Health Observatory website is intended to provide an open, transparent, collaborative platform that supports and facilitates the acquisition, generation, diffusion, translation and use of information, evidence and knowledge by countries to improve national health systems and outcomes. It consists of: a web portal for easy access to the best available information; a data-statistics platform enabling data download, processing and analysis, or access to ready-made statistics; a wiki-based collaborative space for the production and updating of comprehensive and analytical country profiles based on both quantitative and qualitative information; a repository of key publications from or associated with the Observatory; the African Health Monitor a quarterly periodical; and, a platform and relevant tools that enable networking, collaborative work and learning within and between groups, communities of practice, institutions, and national health observatories.
This report is a collaboration between traditional medicine practitioners and scientists, and identifies 22 plants used in east Africa with possible anti-malarial properties. In recent years, there has been an emphasis on the use of artemisinin-based medicines based on the Artemisia annua shrub. The recent interest in Artemisia annua, the development of resistance to existing drugs and the limited access of poor communities to modern drugs have stimulated research in the current use and future potential of other plant products in treating malaria, both as part of traditional health care practices and in developing new conventional medicines. This guide describes a range of trees and shrubs that are used as anti-malarial treatments in East Africa. The species chosen for description have been determined by traditional medical practitioners, rural communities and scientists as among those that have potential for further study and development as tree and shrub crops. The intention of this guide is to support the further development of the cultivation of these species by smallholders in the East Africa region.
The Global Health Observatory theme pages provide data and analyses on global health priorities. Each theme page provides information on global situation and trends highlights, using core indicators, database views, major publications and links to relevant web pages on the theme. Comprehensive information is also provided on the Millennium Development Goals. The Health Equity section is focused on urban health and women and health.
This tool is intended to support countries as they design and implement national health sector strategies in compliance with legal obligations and commitments. It focuses on practical options and poses critical questions for policy-makers to identify gaps and opportunities in the review or reform of health sector strategies as well as other sectoral initiatives. It is intended for use by various actors involved in health planning and policy making, implementation or monitoring of health sector strategies, namely ministries of health and other sectors, national human rights institutions, development partners and civil society organisations. The tool provides support, as opposed to a set of detailed guidelines, to assess health sector strategies. It allows for assessment at three levels: 1) state obligations and commitments, 2) national legal, policy and institutional frameworks, and 3) health sector strategies, using the various components/building blocks of a health system.
Tips and Tricks is intended to be a resource to grant seekers, as it will provide a source of detailed information on grant-giving organisations existing in Tanzania in the following areas: reproductive health; safe motherhood; adolescent and sexual reproductive health; HIV and AIDS; population and development; women empowerment/gender; health integrated projects; and livelihood.
This guide gives information on funding opportunities relevant to civil society organisations with particular interest to those addressing sexual and reproductive health and rights in Uganda. Tips & Tricks seeks to increase transparency of European Union and other donors’ resource allocation for sexual and reproductive health and rights, HIV and AIDS, and population assistance in Uganda. It lists funding priorities in Uganda of the European Commission, European funders, governmental agencies, international NGO’s and private foundations, so that each applicant and funding agency can clearly see what efforts other agencies are undertaking and direct their own endeavours accordingly.
15. Jobs and Announcements
Help stop the global food crisis with Oxfam's new campaign, GROW. Spiraling prices have driven many millions more into poverty already. This crisis threatens to worsen in future. Oxfam calls on governments to act urgently to stabilise the food markets by agreeing on rules for transparency and responsibility, stopping excessive speculation and other abuses, reforming flawed policies turning grain into biofuels, and increasing investment in food security and climate adaptation in developing countries. To sign the petition, visit the link provided.
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