Many children across Malawi experience severe diarrhoea caused by a virus called rotavirus. Rotavirus kills more than 500 000 children under the age of five years around the world each year—almost 1 400 deaths each day—the vast majority of them in sub-Saharan Africa and South Asia. In Malawi alone, rotavirus was estimated by Ministry of Health in Malawi to be responsible for nearly 5 000 deaths every year. Rotavirus attacks our families and threatens our nation’s future by targeting our most precious resource—our children. It spreads through the faecal-oral route, via contact with contaminated hands, surfaces and objects, but is not easily eliminated by improved sanitation. Those with the diarrhoea require oral rehydration and if properly rehydrated have a good chance of recovery. Death is usually through dehydration. .
The tragedy is that much of this death and suffering could be prevented right now, if children in Malawi had the same access to life-saving vaccines as children in industrialised countries. In the United States, rotavirus vaccines have been widely available for five years. Before the vaccine was introduced over 2.7 million cases of rotavirus gastroenteritis occurred annually, 60,000 children were hospitalised and around 37 died from the results of the infection in the USA. After the vaccination programme was introduced these rates went down dramatically. In Malawi, where the need is much greater, this vaccination is not yet widely available for children.
Vaccines are one of the best long-term investments to prevent disease and give children a healthy start to life —a few shots or drops can protect a child for a lifetime. And they are one of the most cost effective interventions to prevent illness in a country like ours Malawi many competing health priorities. With rotavirus (A), existing oral vaccines have been shown to provide significant protection against the disease. It is estimated that broad access to rotavirus vaccines in low-income countries could save up to 225 000 children annually. In fact, the World Health Organization strongly recommends including the rotavirus vaccine in all immunisation programmes because of its potential life-saving impact. But even the most effective vaccines will only have an impact if they are made available to people who need them. Yet rotavirus vaccines have been too expensive for low income countries, where health resources are scarce, and external funders have been hesitant to support the vaccine until costs come down.
In June, there has been new cause for optimism. Children in African countries could finally access the same vaccines for rotavirus as children living in high income countries. On June 6, the GAVI [the Global Alliance for Vaccines and Immunisation], an international organisation that supports the rollout of vaccines to low-income countries, announced it had been offered a significant price reduction for rotavirus vaccines from a pharmaceutical company, reducing the cost by a third to US$2.50 a dose. By comparison, measles vaccine still costs a lot less, at 19 to 30 cents a dose. So the cost is still relatively high. GAVI, which supports vaccine programmes in Malawi, now plans to rapidly accelerate its financial support for rotavirus vaccines, to scale up access. Malawi was one of the handful of countries that hosted clinical trials demonstrating that rotavirus vaccines save lives. The country is now planning to roll out new vaccines for pneumonia later this year—with the potential to give children protection against another big childhood killer. These signs of leadership give cause for optimism in a situation where the longer we wait, the more lives are lost.
At the same time, if this is to be sustainable, costs must be brought down even further. There is report of new, more affordable rotavirus vaccines on the horizon that will sustain our efforts to save children’s lives for the long-term. When GAVI announced the price cut for the existing rotavirus vaccine, it disclosed that an Indian rotavirus vaccine candidate – which should be available around 2015 – will cost US$1 per dose. While manufacturers in other parts of the South like India are developing vaccines that will assist in improving access and affordability, we should also be asking what we are doing to expand capabilities for vaccine production in Africa. Vaccines alone will not eliminate rotavirus or solve all of our persistent health problems. We still need to focus on long-term challenges such as improving sanitation, adequate water and strengthening health systems, to prevent faecal borne disease, and ensuring wide knowledge on and access to oral rehydration to prevent child mortality from diarrhoea. But in my view, ensuring access to rotavirus vaccines is a simple prevention measure that we can and should take today.
An earlier version of this oped appeared in the Daily Times-Malawi 13 June 2011 and the New Era Press Namibia 2 June 2011. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue or the full please visit Health Rights and Education Programme (www.hrep.org.mw/) or EQUINET (www.equinetafrica.org).
1. Editorial
2. Latest Equinet Updates
In July through various institutions EQUINET has participated in forums that are taking forward processes supporting equity in health in the region. In July 18-20, Open Society Foundation AMHI held a strategic convening on community monitoring for accountability in health in Johannesburg South Africa, bringing together experienced practitioners of community monitoring to facilitate networking, collaboration, and experience sharing for strengthening the field. In July 20 - 22 2011, the 3rd Meeting of the ECSA Health Community Regional Monitoring and Evaluation Expert Core Group met in Dar es Salaam Tanzania to review progress in implementing ministers resolutions, including report on progress on the Equity Watch work. In July 24-26, EQUINET contributed to discussions on framing IDRC work on strengthening equity through applied research capacity building in eHealth, with a focus on how the use of ICT (information technology) can influence health governance and health systems strengthening towards health equity outcomes. While these activities were hosted by different institutions and connected with different processes in EQUINET, they signalled a common concern with equity as outcome and a common preoccupation with the generation, control and exchange of information and evidence in addressing the imbalances in power and resources that underlie inequalities in health.
By involving citizens and health workers in producing evidence and learning, participatory action research has potential to organise community evidence, stimulate action, and challenge the marginalisation that undermines achievement of universal health coverage. In this paper, the authors summarise and analyse results of two sessions on this research model convened by the authors at the First Global Symposium on Health Systems Research in Montreux Switzerland, 16–19 November 2010. In so doing, it reviews case studies and experiences discussed, particularly their contribution to universal health coverage in different settings. The authors reflects on challenges faced by participatory action research, and outline recommendations from the two sessions, including the creation of a learning network for participatory action research.
3. Equity in Health
In this paper, the authors provide a comprehensive and up-to-date review of the epidemiological trends and public health implications of diabetes in Sub-Saharan Africa They conducted a systematic literature review of papers published on diabetes in Sub-Saharan Africa from 1999-March 2011, providing data on diabetes prevalence, outcomes (chronic complications, infections, and mortality), access to diagnosis and care and economic impact. Type 2 diabetes was found to account for well over 90% of diabetes in Sub-Saharan Africa, and population prevalence proportions ranged from 1% in rural Uganda to 12% in urban Kenya. Reported type 1 diabetes prevalence was low and ranged from 4 per 100,000 in Mozambique to 12 per 100,000 in Zambia. Gestational diabetes prevalence varied from 0% in Tanzania to 9% in Ethiopia. Screening studies identified high proportions (>40%) with previously undiagnosed diabetes, and low levels of adequate glucose control among previously diagnosed diabetics. Barriers to accessing diagnosis and treatment included a lack of diagnostic tools and glucose monitoring equipment and high cost of diabetes treatment. The total annual cost of diabetes in the region was estimated at US$67.03 billion, or US$8836 per diabetic patient. The authors argue that significant interactions between diabetes and important infectious diseases like HIV highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.
Cervical cancer is the second most common cancer among women in Africa, according to David Kerr, president of the European Society of Medical Oncology, yet there is a profound lack of reproductive health information for women and delayed access to treatment in rural areas in Africa. He notes that, in many parts of the continent, cancer is stigmatised as a death sentence, and he calls for a long-term strategy for vaccination, screening, treatment and awareness building. Although cancer is slowly receiving attention in Africa, the article notes that other diseases such as AIDS still absorb much of the health funding. The author also argues that many of the strategies aimed at preventing HIV could also help prevent the spread of the human papillomavirus too, which may play a role in the development of cancer. New research tackling AIDS and cancer simultaneously has shown that the anti-retroviral, lopanivir, can kill cells infected by HPV, while leaving healthy cells relatively unharmed. This might prove a useful way to prevent cervical cancer. Also, the drug could be used after a HPV infection, whereas vaccination is only effective prior to it – and is currently more expensive.
This report contains the twelfth annual Mothers’ Index, which documents conditions for mothers and children in 164 countries – 43 developed nations and 121 in the developing world – and shows where mothers fare best and where they face the greatest hardships. All countries for which sufficient data are available are included in the Index. Some countries from the east, central and southern African region fared poorly in the Index, notably the Democratic Republic of Congo (DRC), which was ranked 37th out of 42 least-developed countries (LDCs). The Central African Republic and Angola also performed poorly, positioned at 33 and 30 respectively. Rwanda, Lesotho, Malawi and Uganda were ranked highest among LDCs, surpassed only by the Maldives in the first place. South Africa’s performance was mediocre, as it was ranked at 19 out of 38 less-developed countries, far behind Cuba, which was ranked first.
In this paper, the authors investigate the cross-country determinants of health improvements and describe the implications for development policy. The authors argue that making improvements to health need not be expensive. Even very low income countries can make great strides with good technologies and good delivery, but the authors warn that this may take time. They argue that two major factors underlie improved global health outcomes: first,the discovery of cheap technologies that can dramatically improve outcomes; and second, the adoption of these technologies, thanks to the spread of knowledge. Other factors have played a role. Increased income not only allows for improved nutrition, but also helps to improve access to more complex preventative technologies. Institutional development is a second key to the spread of such complex technologies. Nonetheless, evidence of dramatic health improvements even in environments of weak institutions and stagnant incomes suggests that the role of institutional factors may be secondary.
Despite significant setbacks after the 2008-2009 economic downturn, exacerbated by the food and energy crisis, the United Nations notes that the world is on track to reach poverty-reduction targets, but also notes that progress has been inequitable. According to the United Nations. The number of deaths of children under the age of five declined from 12.4 million in 1990 to 8.1 million in 2009. The largest absolute drops in malaria deaths were in Africa, where 11 countries have reduced malaria cases and deaths by over 50%. New HIV infections are declining steadily, led by sub-Saharan Africa. Between 1995 and 2009, a total of 41 million tuberculosis patients were successfully treated and up to 6 million lives were saved, due to effective international protocols for the treatment of tuberculosis. In contrast, the report notes that progress has been inequitable: the poorest children have made the slowest progress in terms of improved nutrition, poor women and girls remain severely socially disadvantaged, and advances in sanitation often bypass the poor and those living in rural areas.
4. Values, Policies and Rights
This article reports on two women who died in the process of using or seeking maternal health services in Uganda. These cases are now subjects of a lawsuit filed in March by the Center for Health, Human Rights and Development, a Ugandan nonprofit group, who contend that the government violated the two women’s right to life by failing to provide them with basic maternal care. Dr. Olive Sentumbwe-Mugisa, a Ugandan obstetrician and adviser with the World Health Organization, participated in the Health Ministry’s investigations of the deaths of the women named in the lawsuit against the government concluded that both women arrived in time to be saved. “We are in a state of emergency as far as maternal services are concerned,” Dr. Sentumbwe-Mugisa said. “We need to focus on the quality of care in our hospitals and address it in the shortest period of time. That will mean more resources. We cannot run away from that.” While the attorney general’s office has responded that replied that “isolated acts” cited in the case “cannot be used to dim the untiring efforts in the Health Sector, ” the authors raise that the case has raised attention and debate, including amongst lawmakers, to the way government has spent its funds more widely, including on military equipment, given the poor improvement in maternal health services.
Human Rights Watch argues that migrants are also especially vulnerable to communicable disease because of substandard living environments, limited sanitation, and cultural and social dislocation, making them vital targets for public health surveillance and intervention. According to Department of Health policies, everyone in South Africa should have access to treatment for communicable disease without cost. Any barrier to prevention and treatment of communicable disease for vulnerable mobile and migrant populations is unwise from a public health perspective, but also a violation of South African and international law. South Africa has recognised the importance of access to health care for vulnerable and migrant populations in its laws and policy documents, yet continues to allow unlawful discrimination by health care staff, undermining efforts to contain disease and improve treatment outcomes. In over 100 interviews with migrants, advocates, health care and other service providers in both urban and border communities, Human Rights Watch found that South Africa’s failure to protect asylum seekers and refugees from deportation and violence leads both to increased disease and injury, and increased barriers to treatment for those conditions.
The author of this article examines the availability and strength of evidence on climate change, economics and health outcomes for policy makers to draw on in making health policy decisions. Eighteen available economic studies were included in the study. The author found that in those studies that put a value on the predicted increased mortality from climate change, the health damages represented an important fraction of overall economic losses. Equally health impacts were important in considering broader measures affecting the economics of climate change beyond the health sector such as agriculture and water supply. Global adaptation cost studies carried out so far indicate costs to the health sector of roughly US$2-5 billion annually (mid-estimates). However, these costs are argued to be an underestimate of the true costs, due to omitted health impacts, omitted economic impacts, and the costs of health actions in other sectors. No published studies compare the costs and benefits of specific health interventions to protect health from the negative effects of climate change. The authors suggest that until further climate change-specific economic studies have been conducted, decision makers should selectively draw on published studies of the costs and benefits of environmental health interventions.
5. Health equity in economic and trade policies
The authors of this study developed a generic framework which depicts the determinants and pathways connecting global trade with the rise of chronic disease in many low and middle-income countries (LMICs). They then applied this framework to three key risk factors for chronic disease: unhealthy diets, alcohol and tobacco. This led to specific 'product pathways', which can be further refined and used by health policy-makers to engage with their country's trade policy-makers around health impacts of ongoing trade treaty negotiations, and by researchers to continue refining an evidence base on how global trade is affecting patterns of chronic disease. The authors argue the need for a more concerted approach to regulate trade-related risk factors and thus more engagement between health and trade policy sectors within and between nations. An explicit recognition of the role of trade policies in the spread of non-communicable disease (NCD) risk factors should be a minimum outcome of the United Nations Summit on NCDs in September 2011, with a commitment to ensure that future trade treaties do not increase such risks.
The author of this article argues that intellectual property rights, in a number of ways, impede access to antiretroviral (ARV) drugs in most developing countries with heavy burdens of AIDS-related mortality and morbidity. He recommends that developing countries that lack the necessary pharmaceutical capacity should exploit emerging opportunities for South-South co-operation. While countries like Brazil and India have produced generic ARV drugs, most developing countries either do not have the technology to do so or they are “pressured” against doing so because of the consequences of violation of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) enforced by the Word Trade Organisation. Most recently, Uganda entered into an agreement with Cipla, an Indian generic manufacturer of ARV drugs to open a drug plant in Uganda. Because such opportunities for South-South co-operation abound in contemporary global AIDS diplomacy, developing countries should ingeniously exploit them in ways that do not violate TRIPS. The impediments to this framework would include circumventing the hurdles posed by TRIPS as well as the pressure by global pharmaceutical corporate giants against such initiatives.
The objective of this study was to explore the possibility of asbestos exposure during the process of diamond mining. Scanning electron microscopy and energy-dispersive X-ray spectroscopy analysis were used to identify asbestos fibres in the lungs of diamond mine workers who had an autopsy for compensation purposes and in the tailings and soils from three South African diamond mines located close to asbestos deposits. Tremolite-actinolite asbestos fibres were identified in the lungs of five men working on diamond mines. Tremolite-actinolite and/or chrysotile asbestos were present in the mine tailings of all three mines. Mesothelioma, asbestosis, and/or pleural plaques were diagnosed in six diamond mine workers at autopsy. The authors conclude that these findings indicate that diamond mine workers are at risk of asbestos exposure and, thus, of developing asbestos-related diseases. Even at low concentrations, asbestos has the potential to cause disease, and mining companies should be aware of the health risk of accidentally mining it. Recording of comprehensive work histories should be mandatory to enable the risk to be quantified in future studies, the authors argue.
Participants at an official high-level thematic debate on trade at the United Nations Conference on Least Developed Countries, held in Istanbul, Turkey, in May 2011, criticised excessive trade liberalisation as damaging to the economies of least-developed countries (LDCs). President Banda of Zambia, who gave a keynote speech, also criticised the lack of a positive response from the European Union to African demands in the Economic Partnership Agreement negotiations. Martin Khor, Executive Director of the South Centre, noted that many LDCs have higher ratios of exports to gross national product than some developed countries. He argued it is the way in which the LDCs are integrated in trade that has been a disadvantage because LDCs are too dependent on raw materials export, and prices of commodities have had a long-term trend decline, thus causing major revenue and income losses. All speakers agreed that LDCs face the basic problem of supply capacity which hinders them from taking advantage of any market opening and that their exports outside of commodities therefore remain small. Khor emphasised that it is thus vital that LDCs be assisted to increase their capacity to produce in agriculture, industry and services, including health services.
The World Health Organisation (WHO) has announced it will be entering a new phase in its Global Action Plan for Influenza Vaccines (GAP), in which the organisation will be giving more attention to the local health and policy environment. WHO held its first review of phase 1 of GAP on 12-14 July 2011. WHO’s estimate of the seasonal flu vaccine manufacturing capacities is 800,000 million doses per year, compared to 350,000 in 2006. The estimate rises to 1.7 billion doses by 2015 if all the projects going on now are successful. There are currently 37 manufacturers of influenza vaccine in the world, either operating now or operational by 2015. According to WHO, 10 manufacturers are in Europe, 14 in the Western Pacific region, 6 in the South East Asia region, and 5 in the Americas region. Included in the 37 are 11 new manufacturers in 11 low or middle-income countries are part of the GAP programme, which have been working with WHO to acquire technologies to produce influenza vaccine.
6. Poverty and health
East Africa is experiencing a severe food crisis, with at least 10 million people affected in Djibouti, Ethiopia, Kenya, Somalia and Uganda, says the UN Office for the Coordination of Humanitarian Affairs (OCHA). And according to the Mubarak Relief and Development Organisation (MURDO), a local NGO working in the Lower Shebelle region of Somalia, the international community is not helping. The recent March to May "long rains" in Kenya were poor for the second or third successive season in most rangelands and cropping lowlands, with many of these areas receiving 10-50% of normal rains. The consequences include declining water and pasture, and high levels of livestock death. In the predominantly pastoralist north, a low milk supply has contributed to malnutrition levels soaring above 35%. Nationally, at least 3.2 million people are currently food insecure, and even in Kenya's coastal region, thousands are food insecure, says the Kenya Red Cross Society.
According to this report by Oxfam, the global food system works only for the few but not for most of the world’s population. It leaves billions of consumers lacking sufficient power and knowledge about what they buy and eat and the majority of small food producers disempowered and unable to fulfill their productive potential. The failure of the system flows from failures of government – failures to regulate, correct, protect, resist and invest – which mean that companies, interest groups, and elites are able to plunder resources and to redirect flows of finance, knowledge, and food. Oxfam highlights the need to address the inequities which plague the food system. They argue that global agriculture produces more food than the world’s population needs, much of which is thrown away. Hunger and poverty are concentrated in rural areas, with smallholder food producers routinely deprived of the resources they need to thrive, like water, technology, investment and credit. Large areas of land in Africa and elsewhere are being sold off to foreign investors at rock bottom prices, in deals that offer little to local communities. The report presents new research forecasting price rises for staple grains in the range of 120–180% within the next two decades, as resource pressures mount and climate change takes hold.
Oxfam has launched a global campaign, GROW, to combat global hunger. Jeremy Hobbs, Executive Director of Oxfam, said that global agriculture is capable of feeding all of humanity yet one in seven go hungry. The GROW campaign will expose the governments whose failed policies are propping up the broken food system and the clique of 300–500 powerful companies who benefit from and lobby hard to maintain it. For example, four global companies control the movement of most of the world’s food. Three companies – Archer Daniels Midland, Bunge and Cargill – control an estimated 90% of the world’s grain trade. Their activities help drive up volatile food prices and they profit from them. In the first quarter of 2008, at the height of a global food price crisis, Cargill’s profits were up 86% and the company is now heading for its most profitable year yet on the back of further disruptions to global food supplies. Oxfam is calling on governments - especially the G20 - to lead the transformation to a fairer more sustainable food system by investing in agriculture, valuing the world’s natural resources, managing the food system better and delivering equality for women who produce much of the world's food. It is calling on the private sector to shift to a business model where profit does not come at the expense of poor producers, consumers and the environment.
Urban farming in the Democratic Republic of Congo (DRC) is providing a livelihood for thousands of city dwellers, with vegetables bringing in good money for small growers and helping to alleviate high levels of malnutrition, according to this article. The Food and Agricultural Organisation (FAO) has noted that the demand for vegetables and the high prices they command in DRC cities has pushed many jobless residents into becoming small-scale growers. Most of the green spaces along the roadsides of the capital, Kinshasa, have been transformed into small farms. City farmers now grow 122% more produce than they did five years ago, according to the FAO, which is supporting gardeners in five main DRC cities with a US$10.4 million urban horticulture project. Although the project has contributed to improving nutrition in urban areas, the project manager cautions that there is still a lot of work to be done and malnutrition levels remain high: 24% of children in the DRC under five are underweight, 43% are stunted, and 9% are wasted.
7. Equitable health services
This qualitative study was conducted in two malaria-endemic regions of Kenya - South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted. While support for local child immunisation programmes exists, limited understanding about vaccines and what they do was evident among younger and older people, particularly men. In general, parents and caregivers weigh several factors - such as personal opportunity costs, resource constraints, and perceived benefits - when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers. The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunisation focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender, the authors argue. It should involve influential community members and provide needed information and reassurances about immunisation. Efforts also should be made to address concerns about the quality of immunisation services, including health workers' interpersonal communication skills.
The authors of this study set out to define the patient population at Cape Town’s district-level hospital offering specialist tuberculosis (TB) services, concerning the noted increase in complex, sick HIV-TB co-infected patients requiring increased levels of care. They surveyed all hospitalised adult patients in Brooklyn Chest Hospital, a district-level hospital offering specialist TB services, from 27-30 October 2008. They found that more than two-thirds of patients in the acute wards were HIV-co-infected, of whom 98% had significant co-morbidities and 60% had a Karnofsky performance score ≤30. Twenty-eight per cent of patients did not have a confirmed diagnosis of TB. In contrast, long-stay patients with multi-drug-resistant (MDR), pre-extensively (pre-XDR) and extensively drug-resistant (XDR) TB had a lower prevalence of HIV co-infection, but manifested high rates of co-morbidity. Overall, one-fifth of patients required up-referral to higher levels of care. In conclusion, the authors note that district-level hospitals, such as Brooklyn Chest Hospital, that offer specialist TB services share the increasing burden of complex, sick, largely HIV-co-infected TB patients with their secondary and tertiary level counterparts. To support these hospitals effectively, outreach, skills transfer through training, and improved radiology resources are required, they argue.
Although HIV and tuberculosis (TB) prevalence are high in prisons throughout sub-Saharan Africa, little research has been conducted on factors related to prevention, testing and treatment services. To better understand the relationship between prison conditions, the criminal justice system, and HIV and TB in Zambian prisons, the study conducted a mixed-method study, including: facility assessments and in-depth interviews with 246 prisoners and 30 prison officers at six Zambian prisons; a review of Zambian legislation and policy governing prisons and the criminal justice system; and 46 key informant interviews with government and non-governmental organization officials and representatives of international agencies and donors. The study found serious barriers to HIV and TB prevention and treatment, and extended pre-trial detention that contributed to overcrowded conditions. Disparities both between prisons and among different categories of prisoners within prisons were noted, with juveniles, women, pre-trial detainees and immigration detainees significantly less likely to access health services. The authors argue that current conditions and the lack of available medical care in Zambia's prisons violate human rights protections and threaten prisoners' health, and that prison-based health services should make linkages to community-based health care, and address general prison conditions and failures of the criminal justice system that exacerbate overcrowding.
The aim of this study was to investigate latent classes of users in Mozambique based on their preferences for mosquito-control technology attributes and covariates of these classes, as well as to explore which current technologies meet these preferences. Surveys were administered in five rural villages in Mozambique. The data showed that users' preferences for malaria technologies varied, and people could be categorised into four latent classes based on shared preferences. The largest class, constituting almost half of the respondents, would not avoid a mosquito-control technology because of its cost, heat, odour, potential to make other health issues worse, ease of keeping clean, or inadequate mosquito control. The other three groups are characterised by the attributes which would make them avoid a technology - these groups are labelled as the bites class, by-products class, and multiple-concerns class. Those with multiple concerns, mostly men, were likely to avoid using a malaria product as they would still hear or be bitten by mosquitoes, or found it it expensive or uncomfortable. Participants in the by-products group, more likely to be females, avoid a malaria product based on heat, odour and side effects. Participants in the bites class
avoid a product if they would still be bitten by mosquitoes. To become widely diffused, the authors suggest that end-users should be included in product development to ensure that preferred attributes or traits are considered. This study demonstrates that end-user preferences can be very different and that one malaria control technology will not satisfy everyone.
The Joint Learning Network (JLN) for Universal Health Coverage held its third workshop, “Expanding Coverage to the Informal Sector,” in Mombasa, Kenya on 6-10 June 2011. Over 65 country level policymakers and practitioners from developing countries, including Kenya, Nigeria and Rwanda, participated in four days of discussions and problem-solving on issues related to providing health coverage to poor and informal sector populations. Participants also exchanged ideas about how to improve operations. Topics included partnerships with community organisations for targeting and enrollment, new information communications technologies for premium payment and enrollment verification, and innovative models to ensure access to health services, such as health camps and partnerships with social franchise networks. Participants also discussed how to deal with multiple schemes in moving toward universal coverage, looking at the case study of Kenya’s National Hospital Insurance Fund and the path to universal health coverage.
Controlled medicines are medicines that are listed under the international conventions on narcotic and psychotropic drugs and their precursors. Global morphine consumption – an indicator of access to pain treatment – has increased over the past two decades, but mainly in a small number of developed countries. Developing countries, which represent about 80% of the world’s population, accounted for only about 6% of global morphine consumption.
8. Human Resources
According to the authors of this study, in southern Africa, the sector most impacted by the brain drain is health. Despite the fact that Southern African Development Community (SADC) countries have adopted a number of financial and non-financial incentives to try to get doctors and nurses to stay, the pull factors attracting health professionals to foreign countries are strong and health workers remain very dissatisfied with existing work conditions. With regard to the migration of health professionals there has been a policy shift away from the early reactive ad hoc policy responses to the development of more comprehensive strategic responses which seek to manage the mobility of health professionals. The authors recommend improving the existing lack of knowledge and data to monitor flows of health professionals into and out of SADC. They also call for bilateral agreements with individual countries involving codes of practice for recruitment and treatment of health workers, exchange programmes for training and development and the provision of health professionals from specific countries. In addition, there is a need for a SADC-wide policy on the movement of health professionals within the region to discourage movement from the poorest and neediest countries to those which are relatively well-endowed, like South Africa.
Rather than making progress towards the Millennium Development Goal of reducing maternal mortality by 75% by 2015, the number of deaths resulting from pregnancy or childbirth in South Africa has doubled in the past 20 years, according to government figures. For every 100,000 babies born, up to 625 mothers die due to childbirth complications. Loveday Penn-Kekana, from the University of the Witwatersrand in Johannesburg, believes South Africa's poor maternal health outcomes are linked to the lack of midwifery services. She called for the government to invest in more and better trained midwives, especially as they bore most of the responsibility for day-to-day operations in maternity wards. Midwives are classified as nurses in South Africa so there are no figures on their numbers, but she argues that there are too few. Low enrolment at nursing colleges is part of the problem, but many midwives have also left the public sector to work for higher salaries overseas or in managerial positions, because of the limited opportunities for career development and advancement in the clinical area. The Society of Midwives of South Africa has noted that lack of midwives means that the quality of the services they provide is declining, as existing midwives are overworked. Also, because they argue that people are first trained as a nurse and then given midwifery skills, midwifery is not prioritised. A plan by South Africa's Health Minister to reopen unused nursing colleges across the country and increase the number of nurses may result in more midwives being trained.
In this brief, Capacity Plus notes that people living in rural areas have less access to health workers, and fail to receive vital preventive, curative, and life-saving services. The problem is especially acute in countries with predominately rural populations. Investment in the development of doctors and nurses is wasted if countries cannot place or keep them in the areas where they are most needed, Capacity Plus argues, nor can they achieve their Millennium Development Goals. A number of recommendations are made. Departments of health should aim to understand and test the factors and incentives that influence health workers’ decisions to accept and remain in rural posts, and develop tailored retention schemes. They should prioritise rural retention schemes and strategies in national health workforce plans, involve professional medical and nursing associations in retention advocacy, strengthen and streamline human resources management (HRM) systems that can affect retention, and address gender discrimination in HRM and gender-based violence in health facilities. Furthermore, they should recruit primary health workers from their own communities and from rural backgrounds, locate health professional schools in rural regions and subsidise health worker education in return for service in rural areas.
Most of the 58 countries covered in this report have been identified as suffering from a crisis in human resources for health. Collectively, across these countries women gave birth to 81 million babies in 2009, accounting for 58% of the world’s total births. The inequitable ‘state of the world’ is most evident in the disproportionate number of deaths in these countries: 91% of the global burden of maternal mortality, 80% of stillbirths and 82% of newborn mortality. These figures partly reflect the distribution of the global workforce: less than 17% of the world’s skilled birth attendants are available to care for women in the 58 countries. There is a triple gap, consisting of competencies, coverage and access. The triad of education, regulation and association has insufficient focus on quality of care, the authors argue. Policy coherence is disjointed and access to the necessary strategic intelligence or evidence for action weak. They urge governments to recognise midwifery as a distinct profession, core to the provision of maternal and newborn health services, and promote it as a career with posts at the national policy level. They also make a number of recommendations for governments, regulatory bodies, schools and training institutions, professional midwifery organisations, international organisations and global partnerships, external funders and civil society organisations.
The authors of this article examined the influence of gender on workplace violence, and synthesised their findings with other research from Rwanda, before they examined the subsequent impact of the study on Rwanda's policy environment. Fifteen out of 30 districts were selected at random. Forty-four facilities at all levels were randomly selected in these districts. From these facilities, 297 health workers were selected at random, of whom 205 were women and 92 were men. Researchers administered health worker survey, facility audits, key informant and health facility manager interviews and focus groups to collect data in 2007. They found that 39% of health workers had experienced some form of workplace violence in year prior to the study. The study identified gender-related patterns of perpetration, victimisation and reactions to violence. Negative stereotypes of women, discrimination based on pregnancy, maternity and family responsibilities and the 'glass ceiling' affected female health workers' experiences and career paths and contributed to a context of violence. Addressing gender discrimination and violence simultaneously should be a priority for workplace and violence research, workforce policies, strategies, laws and human resources management training, the authors conclude.
9. Public-Private Mix
This investigation by ActionAid used published financial information, interviews with government officials and research to follow up on corporate tax avoidance across Africa and India. They estimate that as much as £20 million per year may have been lost in the form of corporate taxes or a fifth of the corporate tax bill that could have paid for education, health and infrastructure. The authors argue for strengthened tax law and revenue administration capacity to deal with taxing multinational companies; improved transparency around corporate reporting; for countries to not give away their right to tax royalties, management fees and other foreign payments at source; and to examine and, where necessary, reform the way they tax multinationals.
In this article, the author presents global data on access to pharmaceuticals and discusses underlying barriers. Two are highly visible - pricing policies and intellectual property rights – while two are less recognised - the regulatory environment and scientific and technological capacities. Two ongoing transitions influence and even distort the problem of universal access to medications, the author argues, namely the epidemiologic transition to an increasing burden of chronic non-communicable diseases, and the growing role of biotechnology products (especially immunobiologicals) in the pharmacopeia. Examples from Cuba and Brazil are used to explore what can and should be done to address commercial, regulatory, and technological aspects of assuring universal access to medications.
While African governments, such as Zambia, are often singled out as grossly corrupt, not enough is said about corporate tax ‘avoidance’ on the part of mining companies, which costs the nation billions of US dollars annually, according to this article. And the much-lauded Extractive Industry Transparency Initiative (EITI) is not helping, the author argues. The EITI standard is meant to ‘facilitate transparency’ by assessing net discrepancies between resource rents - royalties and taxes remitted by multinationals and received by governments. In 2010, Zambia published its EITI report, disclosing payments from mining companies for the year 2008. It revealed that mining companies remitted US$463 million in payments to the government in 2008, with ‘significant discrepancies’, noting a net total of ‘unresolved discrepancies’ of $66 million. Tax havens such as Switzerland are essential to resource-seeking corporations operating in Africa, the author of this article argues, and she estimates more than 85% of asset portfolios for sub-Saharan Africa passes through tax havens. She concludes that EITI’s figures for revenue leakage are underestimated by billions because it does not consider what multinationals ought to have paid Zambia, and it never investigates the means through which corporations were able to circumvent taxation.
Multinational companies may be engaged in high-risk activity which is eroding the tax base and warrants a tax audit in their respective countries, say senior tax officials of South Africa, Mozambique, Ghana, Tanzania and Zambia. They met at the offices of the African Tax Administration Forum in South Africa on 23 June 2011. Logan Wort, executive secretary of the forum, said that tax authorities in Africa agreed that they would begin work on a multilateral agreement to exchange information on taxpayers, such as multinational companies, for tax purposes. Wort argues that multinationals should not enter into high-risk transactions, such as transfer pricing arrangements, which pose a risk to the tax base. Unfortunately, there is no legal instrument to take collective action against such companies, he said.
Product development partnerships, non-profit research institutes and private sector groups have come together over the past years to conduct research and development (R&D) in the areas of the development of drugs, vaccines and diagnostics for neglected diseases, including tropical diseases and other major infectious diseases like HIV and AIDS, tuberculosis and malaria. However, arguments have been put forward 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 and unnecessary efforts. In response, several pooled funding mechanisms have been proposed to address what proponents see as the key problem(s) in the current system: 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). The goal of this paper is to provide insight into the extent to which these three proposed mechanisms would have a positive effect on accelerating R&D for neglected diseases. It considers how these proposals are likely to perform 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 of the paper use a literature review, interviews with key stakeholders and illustrative modelling to assess the proposals against these two criteria. Most interviewees expressed doubts that common ground could be found with regard to the metrics on resource allocation if the fund were covering a large and diverse part of the R&D space. However, stakeholders overwhelmingly agreed that a pooled fund focused on late stage work only would be a more feasible and useful proposition.
10. Resource allocation and health financing
In this study, researchers analysed Global Fund grant data from 122 recipient countries as an initial exploration into how well these grants are performing in fragile states as compared to other countries. Since 2002, the Global Fund has invested nearly US$ 5 billion in 41 fragile states, and most grants have been assessed as performing well, the researchers found. Nonetheless, statistically significant differences in performance exist between fragile states and other countries, which were further pronounced in states with humanitarian crises. This indicates that further investigation of this issue is warranted: variations in performance may be unavoidable given the complexities of health governance in fragile states, but may also have implications for how the Global Fund and others provide aid. For example, faster aid disbursements might allow for a better response to rapidly changing contexts, and there may need to be more of a focus on building capacity and strengthening health governance in these countries.
South Africa’s provincial health departments have dramatically improved their financial management, according to Treasury officials. The nine departments collectively under-spent by US$380 m. in 2010, reversing the trend which saw them run into the red to the tune of $350 m. in the fiscal year 2009-10. The provinces had a combined health budget of $14.7 bn in 2010. This reduction reduces pressure on the Treasury to bail out cash-strapped provinces, a measure it has been loathe to consider for fear of sending the wrong message to provinces that have failed to manage their resources. However, these improvements can mask overspending on some areas at the expense of under- spending on others. The Treasury’s figures show provincial health departments collectively overspent on personnel budgets, but under-spent on capital assets and goods and services in 2010. This created the risk that staff costs might be crowding out expenditure in other critical areas, says the Treasury. It is calling on the government to look carefully at the reasons for underspending in each province, and ensuring that departments are aiming for savings such as negotiating cheaper medicines or more competitively priced tenders.
The authors of this paper reviewed aid to health and borrowing from the International Monetary Fund (IMF) between 1996 and 2006. They found that, on average, for each US$1 of development assistance for health, only about $0.37 is added to the health system. In their comparison of IMF-borrowing versus non-IMF-borrowing countries, non-borrowers add about $0.45 whereas borrowers add less than $0.01 to the health system. Health system spending grew at about half the speed when countries were exposed to the IMF than when they were not.
Held in Istanbul, Turkey on 9-13 May 2011, a United Nations summit to assist least-developed countries (LDCs) ended with new pledges, but the results were disappointing, according to this article. The Istanbul Programme of Action, adopted by the Conference, merely states that those countries already providing more than 0.20% of their gross national product (GNP) as aid to LDCs will continue to do so; those which have met the 0.15% target will undertake to reach 0.20%; and others which have committed themselves to the 0.15% target will either achieve the target by 2015 or try their best to do so. This weak statement with its loopholes was rebuked by the civil society groups attending the Conference. The author of this article notes that the Programme of Action seems to contain more commitments by LDCs to take their own actions than commitments by rich countries to assist them, which is a reversal from previous LDC conferences.
The United Nations Children's Fund has publicly listed for the first time the price it pays for vaccines. The decision - which immediately revealed wide disparities in what vaccine makers charge - could lead to drastic cuts in prices for vaccines that save millions of children's lives. UNICEF paid US$747 million for vaccines in 2010, buying over two billion doses for 58% of the world's children. Shanelle Hall, director of UNICEF's supply division and the driving force behind the new transparency policy, said she hoped to extend it to other goods that the organisation buys, including mosquito nets, diagnostic kits, essential medicines and ready-to-eat foods for starving children. Newer procurement agencies like the Global Fund to Fight AIDS, Tuberculosis and Malaria routinely reveal what they pay for drugs. But vaccines have been largely exempt because UNICEF has avoided confrontation with its suppliers, posting only the average prices it pays; and external funders had not demanded more details. Doctors Without Borders have commented that when external funders see the differentials they will insist on procurement at better prices.
Health insurance cover is gradually increasing among the Tanzanian population since its introduction over a decade ago, according to this policy brief. 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 effect 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. CHF members are more likely to use public primary care, than their non‐insured rural counterparts, consistent with their benefit package. Despite equal contributions, NHIF members in urban areas use a much wider range of outpatient care than those in rural areas. SHIELD makes three recommendations for health policy: addressing the lack of publicly available data on use of health services, increasing the availability of affordable insurance options for poorer groups and ensuring greater consistency in benefits offered, and taking into account the inequity in service availability between urban and rural areas when setting premiums for schemes.
Financial protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". An important element of financial risk protection is to distribute health care financing fairly in relation to ability to pay. The distribution of health care financing burden across socio-economic groups has been estimated for European countries, the USA and Asia. Until recently there was no such analysis in Africa and this paper seeks to contribute to filling this gap. It presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana.
11. Equity and HIV/AIDS
The purpose of this study was to evaluate the relationship between the coping self-efficacy (CSE) scale and adherence to HIV medication in men and women enrolled in a large HIV treatment programme in Kenya. Data were collected from a sample of 354 volunteers attending Nazareth Hospital's nine satellite clinics located in parts of Nairobi, and the central province of Kenya. A social demographic survey, Adult Clinical Trials Group adherence questionnaire, and CSE scale were used to obtain information. Descriptive statistics and logistic regressions were performed to analyse data and to test study hypotheses. The researchers found that females were less likely to be nonadherent than males: the odds of adherence for females were 3.7 of the odds of adherence for males. When controlling for gender, CSE was found to be significant. Adherence to antiretroviral therapy can be partially explained by CSE, the authors conclude. Efforts aimed at building self-efficacy are likely to improve and maintain adherence to HIV and other medication, they argue.
Concurrent sexual partnerships are widely believed to be one of the main drivers of the HIV epidemic in sub-Saharan Africa. For this population-based cohort study, researchers used data from the Africa Centre demographic surveillance site in KwaZulu-Natal, South Africa, to try to find support for the concurrency hypothesis. A total of 2,153 sexually active men and 7,284 HIV-negative women from the surrounding local community were included in the study. During five years' follow-up, 693 new female HIV infections occurred and the researchers found that - after adjustment for individual-level sexual behaviour and demographic, socioeconomic and environmental factors associated with HIV acquisition - mean lifetime number of partners of men in the immediate local community was predictive of hazard of HIV acquisition in women. A high prevalence of partnership concurrency in the same local community was not associated with any increase in risk of HIV acquisition. The researchers argue that, in similar hyperendemic sub-Saharan African settings, there is a need for straightforward, unambiguous messages aimed at the reduction of multiple partnerships, irrespective of whether those partnerships overlap in time.
In 2008, the Capacity Project partnered with the Lesotho Ministry of Health and Social Welfare in a study of the gender dynamics of HIV and AIDS caregiving in three districts of Lesotho to account for men's absence in HIV and AIDS caregiving and investigate ways in which they might be recruited into the community and home-based care (CHBC) workforce. The researchers used qualitative methods, including 25 key informant interviews with village chiefs, nurse clinicians, and hospital administrators and 31 focus group discussions with community health workers, community members, ex-miners, and HIV-positive men and women. Study participants uniformly perceived a need to increase the number of CHBC providers to deal with the heavy workload from increasing numbers of patients and insufficient new entries. HIV and AIDS caregiving is a gender-segregated job, at the core of which lie stereotypes and beliefs about the appropriate work of men and women. This results in an inequitable, unsustainable burden on women and girls. The authors recommend that HIV and AIDS and human resources stakeholders must address occupational segregation and the underlying gender essentialism and male primacy if there is to be more equitable sharing of the HIV and AIDS caregiving burden and any long-term solution to health worker shortages.
Criminalisation and legal and policy barriers play a key role in increasing HIV vulnerability for men who have sex with men (MSM) and transgender people, says the World Health Organisation in this report. More than 75 countries currently criminalise same-gender sexual activity and transgender people lack legal recognition in most countries. These legal conditions force MSM and transgender people to risk criminal sanctions if they want to discuss their level of sexual risk with a service provider and also give police the authority to harass organisations that provide services to these populations. Long-standing evidence indicates that MSM and transgender people experience significant barriers to quality health care due to widespread stigma against homosexuality and ignorance about gender variance in mainstream society and within health systems. Social discrimination against MSM and transgender people has also been described as a key driver of poor physical and mental health outcomes in these populations across diverse settings. In addition to being disproportionately burdened by STI and HIV, MSM and transgender people experience higher rates of depression, anxiety, smoking, alcohol abuse, substance use and suicide as a result of chronic stress, social isolation and disconnection from a range of health and support services.
This cross-sectional facility-based survey was based on 70 structured face-to-face interviews combined with qualitative research that included two focus group discussions with pregnant women and five in-depth interviews with providers at antenatal care clinics in Marondera. Studies elsewhere have shown that the greatest barriers to the use of PMTCT services are linked to socio-cultural beliefs and influences, including fear of discrimination associated with testing and being HIV positive, and negative perceptions about the effectiveness of anti-retrovirals. None of these barriers were raised by participants in this study. Instead the main barriers were linked to the health system’s failure to meet the needs of pregnant women. Thus, SHIELD concludes, the main reasons why women cannot access PMTCT services are barriers faced in accessing antenatal services, including the cost and acceptability of these services. SHIELD makes a number of recommendations: remove or reduce the cost of antenatal care and delivery user fees for pregnant women, increase women’s access to reliable information, improve the quality of services, and provide training courses for health workers about how to engage with patients in a more acceptable manner.
In this study, researchers assessed whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. Ten communities participated in Project Accept in Tanzania, and eight in Zimbabwe. At each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT (SVCT), and the other community was assigned to receive community-based VCT (CBVCT) plus access to SVCT. The researchers found that the proportion of clients receiving their first HIV test during the study was higher in CBVCT communities than in SVCT communities in all three countries. Although HIV prevalence was higher in SVCT communities than in CBVCT communities, CBVCT detected almost four times more HIV cases than did SVCT across the three study sites. Repeat HIV testing in CBVCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. The researchers conclude that CBVCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing.
In this study, researchers investigated whether anti-retroviral therapy (ART) services for urban HIV-positive adults in two urban areas in South Africa are distributed in an equitable manner, in terms of socio-economic status and gender. HIV-positive people were found to be relatively poor. Over 60% of those with HIV fell into the poorest 40% of the South African population. The users of ART services were in general poorer than the HIV-positive population. Seventy percent of these users fell into the poorest 40% of the South African population. This finding was however not statistically significant, and the proportion of HIV-positive people that were women (or men) was no different to the sex distribution in the users of ART services. Taken together, these findings suggest that the use of ART services in urban South Africa is equitable. The researchers expressed hope that their study will add impetus to commitments to reaching and sustaining full coverage of ART for all in need.
Researchers speaking on the final day of the Sixth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention, held in Rome, Italy, from 17-20 July 2011, focused on the growing interest in the scientific path to an HIV cure. Discussions around an HIV cure have been growing over the past 12 months and are now gaining momentum with the establishment of an-IAS convened working group concentrating its initial efforts on establishing a global scientific strategy. IAS hopes to unveil their new global scientific strategy at the Seventh International AIDS Conference in Washington in 2012. Researchers also highlighted the need to scale up programmes that could more effectively address both the issues of injecting drug use linked HIV transmission and the still unacceptably high mortality rates amongst pregnant women and young children in sub-Saharan Africa.
12. Governance and participation in health
Amid discussion of how global health governance should and could be strengthened, the potential role of civil society organisations has been frequently raised. In this paper, the author considers the role of civil society organisations (CSOs) in four health governance instruments under the auspices of the World Health Organisation – the International Code on the Marketing of Breastmilk Substitutes, Framework Convention on Tobacco Control, International Health Regulations and Codex Alimentarius. She draws several conclusions about CSO engagement for strengthening global health governance (GHG). First, CSOs have played the biggest roles in initiating, formulating and implementing formal rules in GHG. Second, CSOs cannot perform certain functions, which should be fulfilled by the state to ensure GHG instruments are effective, such as formal mechanisms for monitoring and enforcement by government institutions, with punitive measures for non-compliance embodied in national legislation. Third, GHG remains far from pluralist in a true sense. The case studies suggest that, like global governance as a whole, GHG is being characterised by greater, rather than lesser, concentration of power in fewer hands. CSOs can bring much-needed diversity to the GHG landscape.
Between 2007 and April 2011, 35 governments across Africa have either passed or are about to pass legislation restricting activities and the existence of civil society organisations (CSOs), according to this review. The trend is even more troublesome, the African Civil Society Platform on Principled Partnership (ACPPP) argues, when one considers that, in about 20 of these cases, the laws are similar in content. What began as a genuine call for mutual accountability and harmonisation of development effort between external funders, governments and CSOs has turned into a wave of legislation and policies targeting CSOs that do not appear to conform to government choices. The review draws from over 17 studies conducted between 2008-2011, discussions with CSOs from 30 countries across Africa, and review of work of several CSOs in conflict prevention and peace building. The ACPPP argues that neither the Paris Principles nor the CSO Principles for Development Effectiveness will be sufficient to deal with the current wave of legislation limiting CSOs. In seeking to reverse this trend, ACPPP proposes that the problem of shrinking space for civil society participation be addressed in its broader perspective, and not just as a violation of human rights, freedom of association or of CSO regulation. The attack on CSOs is about control of power and not regulation. This calls for support for democracy and good governance as drivers of development, the authors argue, particularly in situations of conflict and fragility.
Mining in southern Africa has amplified HIV and tuberculosis (TB) epidemics across the continent through social, political, and biological risks posed to miners and their communities, according to this article. Aware of these risks for decades, policymakers have done little to regulate the mining sector’s remarkable impact on Africa’s two largest epidemics, the authors note. They analyse the governance of mining in southern Africa to evaluate the sources of ineffective responses and identify mechanisms for ensuring effective cross-border care and global norms of responsible mining. Their primary argument is that international agencies need to take action to spur the development of effective governance systems currently being constrained by domestic vested interests.
Much theorising about global health governance has taken a view from above and the authors of this article aimed to complement this with perspectives from grassroots organisations and service providers. Based on a qualitative field study conducted in 2009, they investigated the implications of multiple major international financing structures for HIV on local and district-level responses in Kenya, Malawi and Zambia. They conducted 130 interviews at national level and in six districts, triangulated across public and private sectors. The authors found positive as well as negative experiences of engagement with global health initiatives, concluding that these initiatives should engage with each other, with governments and with local stakeholders to develop a joint Code of Practice for more coherent systems down to community levels.
The configuration of economic actors has shifted dramatically in recent decades as a consequence of the shift from an international to global economy, according to this article. The 21st century thus faces a fundamentally different economic landscape, with governance far less about formal nation-state negotiation, and far more about informal mechanisms of state and non-state negotiation. Although economic power has always played a role in defining international health governance, this changing global economic context has increased the role of economic power in the development of global health governance. To ensure the continued protection and enhancement of global health, the author argues it is imperative for the health profession to recognise and more actively engage with this changing economic context, in order to seize opportunities and minimise risks to global health. If it does not, the danger is that global health governance will increasingly be determined by economic organisations with the principle concern not of health but of market liberalisation, ultimately constraining the capacity of nation-states to undertake measures to protect and enhance the health of their populations.
On 4 and 5 November 2010, representatives from across Africa met in Tunis to discuss an African agenda on development effectiveness to take to the Fourth High-Level Forum in Busan in 2011. The Tunis Consensus on an African development effectiveness agenda consists of the following main items: building capable states, with African countries taking leadership on capacity development; developing democratic accountability; promoting South-South co-operation; embracing new development partners; and outgrowing aid dependence.
Following the 11 September 2001 terrorist attacks, the United States (US) military expanded its global health engagement as part of broader efforts to stabilise fragile states, formally designating “medical stability operations” as use of Department of Defense (DoD) medical assets to build or sustain indigenous health sector capacity. Medical stability operations have included medical assistance missions launched by US Africa Command throughout Africa. The public health impact of such initiatives, and their effectiveness in promoting stability is unclear, the author notes. Moreover, humanitarian actors have expressed concern about military encroachment on the “humanitarian space,” potentially endangering aid workers and populations in need, and violating core principles of humanitarian assistance. The DoD should draw on existing data to determine whether, and under what conditions, health engagement promotes stability overseas and develop a shared understanding with humanitarian actors of core principles to guide its global health engagement.
The authors of this article argue that health is an important component of global security. However, the precise meaning and scope of global health security remains contested partly due to suspicions about clandestine motives underlying framing health as a security issue. Consequently, low and middle-income countries have not engaged global discourse on health security, resulting in an unbalanced global health security agenda shaped primarily by the interests of high-income countries, which focuses on a few infectious diseases, bioterrorism and marginalises health security threats of greater relevance to low and middle-income countries. Focusing primarily on African countries, the authors of this paper examine the implications of the participation deficit by the African Group of countries on their shared responsibility towards global health security. After analysing the potential benefits of regional health security co-operation, they conclude that, to ensure that global health security includes the interests of African countries, they should develop a regional health security co-operation framework.
13. Monitoring equity and research policy
This case study from South Africa focuses on the lessons learnt from communicating the results of four trials evaluating treatment for herpes simplex virus type 2 (HSV-2) as a new strategy for HIV prevention. The authors show that contextual factors such as misunderstandings and mistrust played an important role in defining the communications response. Use of different approaches in combination was found to be most effective in building understanding, credibility and trust in the research process. During the communication process, researchers acted beyond their traditional role of neutral observers and became agents of social change. This change in role is in keeping with a global trend towards increased communication of research results and presents both opportunities and challenges for the conduct of future research. Despite disappointing trial results which showed no benefit of HSV-2 treatment for HIV prevention, important lessons were learnt about the value of the communication process in building trust between researchers, community members and policy-makers, and creating an enabling environment for future research partnerships.
This qualitative study focuses on the research communication and policy influencing objectives, strategies and experiences of four research consortia working on sexual and reproductive health (SRH), HIV and AIDS. The researchers carried out 22 in-depth interviews with researchers and communications specialists (research actors) from the four consortia and their partners, working in nine countries in sub-Saharan Africa and Asia. They found that the characteristics of researchers and their institutions, policy context, the multiplicity of actors, and the nature of the research evidence all play a role in policy influencing processes. Research actors perceived a trend towards increasingly intensive and varied communication approaches. Effective influencing strategies include making strategic alliances and coalitions and framing research evidence in ways that are most attractive to particular policy audiences. Tensions include the need to identify and avoid unnecessary communication or unintended impacts, challenges in assessing and attributing impact and the need for adequate resources and skills for communications work.
This article presents the most recent World Health Organisation framework for strengthening health systems and considers how health economics research can be used to measure achievements against each of the goals of the framework. Benefits to health systems strengthening of incorporating health economics tools into operational research are highlighted. Finally, health economic tools are placed within an impact assessment framework that facilitates the capture of health systems considerations in implementation research for innovations in tuberculosis diagnosis.
In the case-studies presented in this paper, the authors analyse findings from sexual and reproductive health (SRH) and HIV research programmes in sub-Saharan Africa. In their analysis, they emphasise the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change – especially in SRH – where there are complex interactions between policy actors. Policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximise research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural and practical.
14. Useful Resources
The aim of this training tool kit is to increase the monitoring and evaluation (M&E) capacity, skills and knowledge of those who plan, implement, and evaluate innovative, integrated health and community development programmes in low-resource settings. The tool kit provides managers, technical specialists, and M&E staff with user-friendly, modifiable training components to adapt for a specific developing-country and programmatic context. Users will learn to conduct effective M&E from programme inception to indicator selection through assessment design. The tool kit also promotes M&E efforts that highlight the integrated nature of these programmes and the unique contributions Population, Health and Environment (PHE) programmes make over traditional single-sector efforts.
15. Jobs and Announcements
The Africa Regional Association of Occupational Health (ARAOH) Congress is to be hosted by the South African Society of Occupational Medicine Conference (SASOM) from 25–27 August 2011 in Johannesburg, South Africa. To register for the event visit the link provided.
The BRAC University is calling for applicants for its Masters of Public Heath programme. Since its inception, the School has received 191 diverse students from different corners of the globe such as South Asia, Southeast Asia, Africa, Australia, North and South Americas, and Europe. The graduates move on to work for their respective governments, national and/or international NGOs, or with various donor and UN agencies. Additionally, universities and research organizations also acquire a large number of our MPH students. The MPH curriculum is structured to maximize learning around the health problems faced by communities in Bangladesh, and elsewhere. This includes extensive field-based instructions complemented by interactive classroom based work in teams. The School has a generous scholarship programme that aims to promote global access to the MPH amongst potential students from all over the world based on merit. The admission process includes an application, reference letters, statement of interest in public health, individual and group interviews, as well as written and oral tests.
IDRC's Non-Communicable Disease Prevention programme (NCDP) is a newly approved programme, running from 2011 to 2016, that will provide a response to the major development challenges associated with the rapid rise in non-communicable diseases (NCDs) in low- and middle-income countries. The goal of the NCDP programme is to generate new knowledge to inform the adoption and effective implementation of policies and programmes that are low cost but can have a high impact on reducing the NCD burden and improving overall population health in low-and middle-income countries. To that end, the programme will focus on healthy public policies by targeting its research funding on: regulation, legislation and fiscal policies that address the common NCD risk factors, and cost-effective population-wide programmes or community-based interventions that address the common NCD risk factors and that have the potential to be scaled up or translated to policy. IDRC is calling for concept notes on research to expand fiscal policies for global and national tobacco control and research to support interventions that promote healthy diets.
The World Health Organisation (WHO) is calling for papers for all sections of the Bulletin and encourage authors to consider contributions that address any of the following topics: disease burden assessments in low-income countries, since information in this area is scarce; vaccination implementation and policy, particularly on the cost and public health benefit of vaccination programmes; and the evaluation of nonpharmaceutical public health measures since these are widely described as control measures, but there is less published evidence on their effectiveness than for pharmaceutical interventions (vaccines and medicines). In particular, WHO seeks submission of papers that document experiences from low-resource settings.
On the occasion of the ten-year anniversary of the Doha Declaration, Medicins sans Frontieres (MSF) is launching an ‘ideas contest’ on how to revise TRIPS so that it genuinely meets global public health needs. Contestants are asked to respond to the following question: Can TRIPS be reformed to meet public health needs? If your answer is YES, describe your idea for how the treaty should be changed. If NO, explain why not, and propose an alternative. Anyone is eligible to submit an entry, either as an individual, a team, and/or on behalf of an institution. The contest seeks to attract ideas from around the world from creative thinkers who may be academics, students, activists, analysts, government officials, journalists, or from the private sector. Submissions from low- and middle-income countries are particularly encouraged. There are two submission options: Option 1: A written essay of 500-1000 words (excluding footnotes and references). Option 2: An audio visual entry: video, audio, slideshow or photofilm of no more than five minutes. Submissions should succinctly describe a proposal to change the TRIPS Agreement so that it is conducive to global public health.
The Open Society Foundations seek a full-time Program Officer in its New York office to work with the Public Health Program’s Access to Essential Medicines Initiative. The overall goal of the Access to Essential Medicines Initiative (AEMI) is to promote increased access to essential medicines in developing countries and countries in post-socialist transition, especially for poor and marginalized populations for whom this access is likely to be elusive. The AEMI pursues this goal by developing civil society capacity for advocacy and leadership on access to medicines at national, regional, and international level, with a specific focus on global South/Eastern European advocates.
The Second Summit of the Movement for Global Mental Health forms part of the World Congress of the World Federation for Mental Health. The event will provide a shared platform for professionals and persons affected by mental disorders, active participation of delegates in discussions and debates, and the launch of a new Lancet series on Global Mental Health. The Wellcome Trust will also be providing free registration to a limited number of delegates from low- and middle-income countries. In order to receive free registration, please log onto to www.wmhc2011.com and click on the link to register online.
With increasing global evidence of the widening international, intergroup and interpersonal inequalities in all dimensions of health and human well-being, the 2011 PHASA conference will focus on scientific debate and discussion on health inequities and the role of public health leadership, education and practice in reducing health equity gaps. The programme includes speakers who are policy-makers, leading local and international academics and representatives of international organisations, such as the World Health Organisation and the World Federation of Public Health Associations. The conference theme, ‘Closing the health equity gap: Public health leadership, education and practice’, forms the basis of a review of the progress that South Africa has made in achieving equity in health status, health care, the social determinants of health and access to resources. The conference will also serve as a country-level build-up to the 2012 conference of the World Federation of Public Health Associations, which will focus on global progress in achieving equity.
The United Nations (UN) General Assembly will be holding a UN Summit on Non-Communicable Diseases (NCDs) from 19-20 September 2011. The Summit will focus on the four most prominent non-communicable diseases, namely, cancers, cardiovascular diseases, chronic respiratory diseases and diabetes. The aim of the summit is to agree on a global strategy to address NCDs. The UN Summit on NCDs is the second of its kind to focus on a global disease issue. The first UN Summit related to health was the HIV/AIDS meeting in 2001 which led to the creation of the Global Fund. Non-communicable disease indicators are on the agenda for discussion and acceptance of the goals could lead to the future earmarking of overseas development aid to address cancer and other NCDs in developing countries.
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