The September 2011 UN High-Level Meeting on Non-Communicable Diseases (NCDs) has come and gone. The political declaration adopted by governments, is included in this newsletter. It points to the need for multi-sectoral public policies that create equitable health-promoting environments. It calls for action across government sectors and partnership across government, civil society and private sector to implement these policies. It mandates WHO to develop for consideration ‘voluntary global targets’ and indicators for monitoring by 2012, for accountability on the declaration. The Commonwealth issued a statement on 21st September welcoming the declaration as a commitment to deal with NCDs. Others, some included in this newsletter, raised concerns about the absence of clear commitments on funds or targets, such as on access to medicines or on regulations to curb trade in unhealthy products. Questions were raised on what can be achieved through a reliance on partnership and voluntary arrangements, with a call for stronger exercise of public health authority. The High level meeting on NCDs opened a window into the competing influences of politics, commerce, social movement and science on global health negotiations. While evidence of health need and feasible strategy is persuasive input to these competing influences, Thomas Gebauer asserts in this month’s editorial that ethical principles, such as solidarity, are fundamental to health, and must be applied in global negotiations that affect the human right to health.
1. Editorial
In view of the wealth existing in today's world, the prospect of Health for All must not be an illusion any longer. The world doesn’t lack the resources for health; it requires a fair use of what is available, in other words: the redistribution of wealth guided by the concept of solidarity. The world is awash in money. What is missing is the political will of those in power and – to challenge ourselves – the public pressure to make change happen.
The struggle for Health for all starts with challenging the prevailing neoliberal paradigm. It is well known that globalisation has widened health inequalities. However, more emphasis should be given to the fact that the transformation of health services into commodities, the linkage of access to health care to individual purchasing power and the dismantling of public health systems has only been possible in the context of a specific ideology - an ideology that has widely affected even those who are suffering the negative consequences of neo-liberalism, the global poor.
At the core of the neo-liberal ideology is a concept that replaces social values and institutions such as solidarity and common goods by self responsibility and individual entrepreneurship. “There is no such a thing as society”, Maggie Thatcher said in the early 80’s - paving the way for the cynical credo of neoliberal politics: If everyone takes care for him/herself, then ‘all’ are taken care of.
Although there is plenty of evidence that health is primarily a political matter determined by the social environment, neo-liberalism has succeeded in pushing the responsibility for health away from public and state institutions to private actors and individuals, including individuals perceived as business entrepreneurs in a liberalised market. Even spheres of societies that traditionally do not belong to the field of business, such as health, education and culture, have been increasingly penetrated by market values.
It was the French revolution – calling for Liberty, Equality and Fraternity – that came up with the first comprehensive list of Human Rights in 1789. ‘Fraternity’, the revolutionary agenda’s third pillar, may be equated with ‘solidarity’ in today’s discourse. It has been under permanent siege during the last decades. Millions of people have been excluded from health and social care as a consequence of neglecting the social principles that nurture the cohesion of society. Only by revitalising solidarity – both as an ethical principle and in its public institutions –can health inequalities be tackled and Health for all achieved. Indeed, there is such a thing as society.
It is a fact that there are always and everywhere people too poor to afford adequate health care out of pocket. Even in a perfect world, in which all the social determinants of health are respected, people will fall ill and will be in need of support. Therefore Health for all requires the presence of a permanent and institutionalised redistribution of wealth. Those who are in the position to pay more should also pay for those who are in need. This balancing is exactly meant with the principle of solidarity. It is perhaps the most important key to establishing an effective health care system.
In this context it doesn’t matter whether a system is tax-financed or based on the idea of social insurance schemes. Both are socially agreed funding schemes guaranteeing that even members who are not in a position to contribute a single shilling or cent financially to national budgets or social insurance will receive the same services as all the others members when they need them. While individual contributions (in terms of taxes or insurance contributions) are dependent on financial capacities, the entitlement to and claiming of services however, is only determined by needs.
It is preciously the principle of solidarity that disconnects access to health care from individual purchasing power: those who are wealthier support those who are poorer, younger, or elderly; and those who are economically active support those who are unemployed, retired and children.
Thus, the principle of solidarity goes far beyond what is usually meant when solidarity refers to empathy and charity. The principle refers rather to an institutionalised solidarity that organises a fair burden sharing. It is fundamental to the “social infrastructure” of societies. Like the hard infrastructure, like transportation, energy, administration, law enforcement, police, and so on, the social infrastructure also needs to be publically regulated and funded. The term social infrastructure stands for an ensemble of common goods, such as effective health care services, proper education systems, social protection schemes, food security, and so on. In other words, it covers social institutions that are essential for the social cohesion of societies that should therefore accessible for everybody, independent from an individual’s purchasing power.
In view of the global poverty affecting one third of the world’s population fiscal policy-making should again focus on the redistribution of wealth. At an International Conference on “Strengthen Local Campaigns for National and International Accountability for Health and Health Services” held in Johannesburg in March 2011 delegates in their statement also called for “the principles of social solidarity that are an accepted part of governance within many nations to be extended to the international level”. That sounds quite radical, but even the World Health Organisation (WHO) makes this argument. The World Health Report 2010 invites WHO member states to introduce new fiscal measures to enhance governmental revenue capacities. The report particularly points to the taxation of large and profitable companies as one of the key policy instruments to widen the fiscal space, as well as a levy on currency transactions and a financial transaction tax. The latter would only make sense if it is agreed internationally as a global resource to enable all states to adequately finance health services, including countries in the north facing persistent health sector cuts and sale of public health care services.
Health care systems based on the principle of solidarity still exist. In countries like my own, Germany, they form part of the foundations of the society. Most likely these systems can only be defended by extending them to the international level. In fighting back neo-liberal extremists who are persistently posing deadly threats to societies by dismissing solidarity institutions as a proof of “devilish socialism”, it is crucial to again struggle for solidarity. This struggle needs to be waged at national level, but it also includes an international dimension, such as in the call for an “International Fund for Health” that serves as an international equalisation payment scheme to balance existing financial gaps. For this, countries with higher incomes that can support those at lower incomes would be obliged to contribute to the health budgets of poorer countries. Taking the principle of solidarity forward internationally is not a question of money. It is rather a question of the political will to create a new international treaty regulating that richer countries with higher fiscal capacity are obliged to transfer funds to poorer countries, as long as these are lacking adequate fiscal capacity. It is this principle of solidarity that will realise Health for all and other social rights.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please see the EQUINET website at www.equinetafrica.org. or the MEDICO website at http://www.medico.de/en/healthfund
2. Latest Equinet Updates
After much misinformation in the South African press about the proposed new National Health Insurance scheme, the author of this article restates the case for NHI. The proposed NHI is about achieving a universal health system, which means that everyone will enjoy financial protection from high health care costs and be able to access good health services when they really need them. To finance the scheme, government needs to increase public funding for health care to improve the efficiency of public health services and employ more staff in public health facilities – there are too few staff to cope with the current patient load. The government’s Green Paper on the NHI estimates that the scheme will cost about R125 billion in 2012, increasing to R256 billion in 2025. The author emphasises that this is the total amount of money needed for publicly funded health services, not extra funding. The government is already planning to spend over R112 billion in the 2011/12 financial year on the health system and has budgeted to spend over R120 billion in 2012/13. So, to move forward with the NHI, initially only a little extra funding is needed - about R5 billion in the first year. The gap for NHI funding could easily be funded by a relatively small health tax on personal income and a small payroll tax for employers, amounting to less than 2%. The author argues that, given that the richest 10% of the population has 51% of total income in South Africa, the idea of their cross-subsidising health care for the poor is perfectly equitable and affordable.
The author, citing evidence from World Health Organisation, argues that climate change raises challenges for health in Africa for a variety of reasons. African countries have a high burden of climate sensitive diseases and poor public health capability to respond. Under-nutrition and weak infrastructures may reduce the capacity to mitigate the effects of health risks from climate change. Negative effects of climate change on socioeconomic development may also seriously undermine health and well-being of people in such countries. WHO reports that many of the projected impacts on health are avoidable and could be dealt with through a combination of public health strategies, support for adaptation measures in health-related sectors such as agriculture and water management, and an overall long-term strategy to reduce health impacts. In Africa the author argues that countries should implement the priority actions outlined at the 2008 first Inter-ministerial Conference on Health and Environment held in Libreville, Gabon, contained in the Libreville Declaration. This Declaration was signed by 52 African countries and commits them to address challenges relating to health and the environment.
An Equity Watch is a means of monitoring progress on health equity by gathering, organizing, analysing, reporting and reviewing evidence on equity in health. The aim is to assess the status and trends in a range of priority areas of health equity and to check progress on measures that promote health equity against commitments and goals. This first scoping report in Zambia introduces the context and the evidence within four major areas: equity in health, household access to the resources for health, equitable health systems and global justice. It shows past levels (1980–2005), current levels (most current data publicly available) and comments on the level of progress towards health equity. The report describes the recovery in health indicators after 2000, given the harsh decline in health and health care from the period of structural adjustment reforms and the AIDS epidemic in 1980-2000. It also indicates that aggregate improvements do not tell the whole story. Inequality in wealth in Zambia remains high and is reflected in rural–urban, wealth, gender and regional differentials in health and in the social determinants of health. Within the health sector steps underway to organize and distribute funds, heath workers and medicines towards primary and district level services are identified AS fundamental to overcome inequalities, but limited by the limited improvement in per capita domestic public sector funding and the increasing reliance on external funding in the heath sector. The report shows that measures such as closing rural–urban inequalities in primary health care, reducing cost barriers by removing user fees or stimulating female uptake of schooling have contributed to overcoming inherited and unfair opportunities for health.
Three years have passed since the World Health Organisation (WHO) Commission on the Social Determinants of Health (CSDH) report was launched and adopted by the World Health Assembly. Progress since 2008 at the international level has been built on the experience and initiative of different countries. For example in Africa in April 2008, work on social determinants of health (SDH) was located in the context of commitments to revitalise primary health care. The first global ministerial conference on healthy lifestyles and non-communicable disease (NCD) control in April 2011 and the UN High-level Meeting on NCD Prevention and Control in September 2011 provide important global platforms to address the SDH. Nevertheless there is debate whether adequate attention has been given to SDH in these forums. On 19-21 October 2011, WHO and the Government of Brazil are convening a global conference on the SDH in Rio de Janeiro, Brazil. The conference will hopefully provide a platform to tackle issues of social justice in development, to address the deficiencies in present economic thinking on and measures in globalisation.
3. Equity in Health
In this editorial, the author argues that a comprehensive response to Non Communicable Diseases (NCDs) not only calls for systemic changes in our physical and social environments. It also demands that we focus on equitable and universal access to prevention, diagnosis, and treatment, as well as on improving the quality of life of those living with NCDs. The interconnections between policies in agriculture, education, environment, transportation, labor, trade, finance, and health run deep and their contribution to NCDs is as yet underappreciated. Thus, the response to NCDs requires an intersectoral approach – which includes civil society - that embeds health in policies across the board. Stakeholders need to educate and focus public interest, as well as that of government and industry, on the positive value of health and well-being. This will require a social movement and maximising the use of social media to generate more consumer demand for healthier products and healthier environments.
The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. Forecasts suggest that high rates of obesity will affect future population health and economics. The authors of this study identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. The authors call for a sustained worldwide effort to monitor, prevent, and control obesity.
Rather than call for a new ‘mega-fund’ for NCDs, the author of this article argues that we need to use the growing focus on NCDS to build a global social movement for Universal Health Coverage (UHC) to address all health needs according to national and local epidemiology and priorities. The UHC movement calls on nations to reform their health plans and financing structures toward access to essential diagnostics, prevention, and treatment for all. Strong equitable health systems are the tipping point for universal health coverage. As demographics change and people with communicable diseases live long enough to develop chronic diseases, a responsive, performance-driven, integrated health systems approach will have the greatest health impact. A strong health system grounded in UHC, working to address NCDs must: be coordinated and integrated to reach people who may otherwise go undetected; deliver integrated care and include all players in the health system; have strong information systems and an educated health workforce; and support local private sector health providers.
Mental and behavioural disorders account for about one third of the world’s disability caused by all ill health among adults, with unipolar depressive disorders set to be the world’s number one cause of ill health and premature death in 2030, affecting high- and low-income countries. There is a range of evidence-based cost-effective interventions that can be implemented in parenting, at schools, at the workplace, and in older age that can promote health and well-being, reduce mental disorders, lead to improved productivity, and increase resilience to cope with many of the stressors in the world. These facts need to be better communicated to policymakers to ensure that the silent burden of impaired mental health is adequately heard and reduced.
4. Values, Policies and Rights
A new national HIV and AIDS strategic plan for Uganda is due to be finalised before the year's end, and gay rights activists are reported in this article to be urging its authors to break with tradition and, for the first time, provide for programming for men who have sex with men (MSM). A draft version of the new strategic plan distributed to civil society organisations mentioned the MSM community by name under an introductory section outlining groups that have prevalence rates above the national average, but the strategy concluded that MSM did not play ‘a big role’ in the transmission of HIV in Uganda and did not warrant a high rank among prevention activities. The draft strategy did recommend that more research be done within communities of MSM and injecting drug users to determine whether the groups were at risk of an upsurge in new infections. However, James Kigozi, spokesman for the Uganda AIDS Commission, said that because homosexual activity was illegal in Uganda, programming for MSM was unlikely to make it into the final version on the plan.
Alcohol, like mental health, is a neglected topic in public health discussions. However, the authors argue that there is sufficient evidence for it to be defined as a priority public health concern. Although only half the world’s population drinks alcohol, it is the world’s third leading cause of ill health and premature death, after low birth weight and unsafe sex, and the world’s greatest cause of ill health and premature death among individuals between 25 and 59 years of age. This paper outlines current global experiences with alcohol policies and suggests how to better communicate evidence-based policy responses to alcohol-related harm using narratives. The text summarizes six incentives for a healthier relationship with alcohol in contemporary society. These include price and availability changes, marketing regulations, changes in the format of drinking places and on the product itself, and actions designed to nudge people at the time of their purchasing decisions. Communicating alcohol narratives to policymakers more successfully will likely require emphasis on the reduction of heavy drinking occasions and the protection of others from someone else’s problematic drinking.
The health of prisoners is among the poorest of any population group and the apparent inequalities pose both a challenge and an opportunity for country health systems. The high rates of imprisonment in many countries, the resulting overcrowding, characteristics of prison populations and the disproportionate prevalence of health problems in prison should make prison health a matter of public health importance, the authors of this paper argue. Women prisoners constitute a minority within all prison systems and their special health needs are frequently neglected. The urgent need to review current services is clear from research, expert opinion and experience from countries worldwide. Current provision of health care to imprisoned women fails to meet their needs and is, in too many cases, far short of what is required by human rights and international recommendations. National governments, policy-makers and prison management need to address gender insensitivity and social injustice in prisons. There are immediate steps which could be taken to deal with public health neglect, abuses of human rights and failures in gender sensitivity.
In preparation for the United Nations (UN) High-Level meeting on non-communicable diseases (NCDs) in New York from September 19-20, 2011, the UN released an Outcome Document, called the ‘Zero Draft’, which affirmed the UN’s commitment to combat non-communicable diseases (NCDs). Civil society has voiced concern over the Zero Draft though, saying their input at the 16 June 2011 Informal Interactive Hearing on NCDs was not taken into account. Concerns include the lack of concrete targets and goals, the lack of specific mechanisms for resource mobilisation, and the lack of substantial follow-up to the meeting within the draft document. The role of the private sector in preventing NCDs is also another point of contention, and particularly the role of regulatory approaches, vs the adoption of the voluntary guidelines and targets favoured by the food and beverage industry representatives.
In 1978, at the Alma‐Ata Conference, ministers from 134 member countries in association with WHO and UNICEF declared ‘Health for All by the Year 2000’ selecting Primary Health Care as the best tool to achieve it. Unfortunately, the health status of third-world populations has not improved, according to the People’s Health Movement (PHM). In this Charter, PHM lays five health principles that may be applied globally. First, the attainment of the highest possible level of health and well‐being is a fundamental human right, regardless of a person's colour, ethnic background, religion, gender, age, abilities, sexual orientation or class. Second, the principles of universal, comprehensive Primary Health Care (PHC), envisioned in the 1978 Alma Ata Declaration, should be the basis for formulating policies related to health. Now more than ever an equitable, participatory and intersectoral approach to health and health care is needed. Third, Governments have a fundamental responsibility to ensure universal access to quality health care, education and other social services according to people’s needs, not according to their ability to pay. Fourth, the participation of people and people's organisations is essential to the formulation, implementation and evaluation of all health and social policies and programmes. Finally, health is primarily determined by the political, economic, social and physical environment and should, along with equity and sustainable development, be a top priority in local, national and international policy‐making.
The United Nations General Assembly adopted by consensus the resolution titled "Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases" (document A/66/L.1). The declaration calls for the development of multisectoral public policies that create equitable health-promoting environments that empower individuals, families and communities to make healthy choices and lead healthy lives. It commits governments to accelerate implementation of the WHO Framework Convention on Tobacco Control (FCTC) and encourages countries, which have not yet done so, to consider acceding to the FCTC. In addition to price and tax measures to reduce tobacco consumption, governments committed to steps that include curbing the extensive marketing to children of foods and beverages that are high in saturated fats, trans-fatty acids, sugars, or salt. Other measures seek to cut the harmful consumption of alcohol, promote overall healthy diets and increase physical activity. It calls for countries to promote, establish or strengthen by 2013, and to implement multisectoral national policies and plans for the prevention and control of NCDs, taking into account, as appropriate, the 2008-2013 WHO Action Plan for the Global Strategy for the Prevention and Control of NCDs.
In South Africa, drug and alcohol abuse should be an issue of national concern, the author of this article argues. Yet little has been done to curb the use of drugs and reduce their impact on public health outcomes. Alcohol is legal, widely available and relatively inexpensive, which makes it one of the main burdens of disease in the country, ranking third after unsafe sex and interpersonal violence. All three have contributed to the country’s high HIV prevalence rate, while alcohol abuse is increasingly becoming recognised as a key determinant of sexual risk taking and sexual violence, and as a consequence, a direct contributor to HIV transmission rates, and to challenges in HIV treatment and mitigation interventions in sub-Saharan countries. The author also indicates that heavy consumption of alcohol and regular binge drinking by people on anti-retroviral treatment (ART) is also linked to lower levels of treatment adherence and treatment efficacy. The South African government has agreed to several interim resolutions to curb alcohol abuse and better regulate the industry: possibly raising the legal age for purchasing and consuming alcohol from 18 to 21 years; limiting alcohol advertising; reviewing alcohol license fees; harmonising existing liquor legislation; imposing restrictions on the times and days of the week that alcohol can be legally sold and decreasing the number of taverns (shebeens).
In the run-up to the United Nations (UN) High-level Summit on Non-communicable Diseases (NCDs) in September 2011, a number of international women’s rights organisations joined together in a global campaign - Women for a Healthy Future - to demand solutions to NCDs among women. NCDs are the leading cause of death among women, the campaign argues, estimated at 18 million deaths each year. Key NCDs include breast and cervical cancer, with heart disease the primary cause of mortality among women. Girls and women are at a particular disadvantage for getting NCDs, as 60% of the world’s poor are women, and many are malnourished and uneducated. In developing countries, women often cook over open fires and get chronic lung diseases. Women for a Healthy Future has sent a petition to the UN as the new campaign’s first step in a planned programme of action.
5. Health equity in economic and trade policies
At the BRIC Health Minister’s meeting, held on 11 July 2011 in Beijing, the theme was access to medicine, framed by the Beijing Declaration’s affirmation of the importance of technology transfer among the BRICS countries (Brazil, Russia, India, China, South Africa) and the critical role of generic medicines in expanding access to antiretroviral medicines for all. The Health Ministers agreed to establish and encourage a global health agenda to promote innovation and universal access to affordable medicines, vaccines and other health technologies with assured quality, in support of reaching the MDGs and meeting other public health challenges. A powerful alliance could be expected on increasing access to new and innovative antiretroviral therapies (ART) for HIV and AIDS, and developing additional diagnostic tools and treatment for tuberculosis (TB), malaria as well as the neglected diseases. While committed to supporting the TRIPs safeguards and the Doha declaration on TRIPs, the BRICS countries are also determined to ensure that international trade agreements do not undermine TRIPs flexibilities, so as to ensure the sustainable delivery of low-cost quality medicines to low- and middle-income countries.
Kenya is allegedly among the top ten developing countries in terms of revenue lost to the European Union and the United States. But what can be done? The author of this article makes a number of recommendations. At national level, he urges the Kenyan government to implement reforms to tax policy, trade policy, customs and laws and to promote inclusive growth. To make this work, he calls for both political will and active civil society participation. He calls on government to change the law to insist on maximum transparency for all international transactions, and for banks to give full disclosure to tax and relevant national authorities. The author argues for using the price filter model used by the United States Customs to monitor trade misinvoicing. The best solution, he notes, will be an international agreement for automatic exchange of tax information globally. In the meantime, he argues for Kenya to sign bilateral information exchange agreements with the major tax havens and secrecy jurisdictions, to be given information on accounts and companies registered in these jurisdictions that trade and do business with Kenya. He also argues for government to require all transnational companies to publish every year Kenya-specific accounts showing the profits or losses they make. Finally, he argues that Kenya follow the lead of Nigeria, which has sued major international companies for corruption and has been compensated through out-of-court settlements.
Universal access to medicines was a key topic of discussion at a meeting on 11 July 2011 of health ministers from Brazil, Russia, India, China and South Africa (BRICS) in Beijing, China. The meeting, hosted by the Government of China, aimed to identify opportunities for BRICS countries to promote wider access to affordable, quality-assured medicines, with a view to reaching the Millennium Development Goals and other public health challenges. A ‘Beijing Declaration,’ issued on 11 July and signed by ministers of health from the five BRICS countries, underscored the importance of technology transfer among the BRICS countries, as well as with other developing countries, to enhance their capacity to produce affordable medicines and commodities. The Declaration also emphasised the critical role of generic medicines in expanding access to antiretroviral medicines for all. By signing the Declaration, leaders committed to working together to preserve the provisions contained in the Doha Declaration on TRIPS and Public Health—provisions that allow for countries to overcome intellectual property rights restrictions on medicines in the interest of public health. The five BRICS countries face similar health challenges, including a double burden of communicable and non-communicable diseases, inequitable access to health services and growing health care costs. Through collective action and influence, the BRICS coalition promises to deliver cost-effective, equitable and sustainable solutions for global health.
The Economic Partnership Agreements (EPAs) between the European Union (EU) and regions of African, Caribbean and Pacific states (ACP) are designed to encourage regional integration and improve trade capacity building and other aid interventions into the developing partner regions. The agreements cover not only trade in goods but also in services and other trade-related areas including intellectual property rights, which affect the production and availability of cheaper generic medicines for developing countries. The objective of this paper is to analyse why the trade and cooperation discussions with the EU have not made further progress towards the objective of African regional integration. This paper first presents an overview of the EPAs negotiations and outlines the main debates about EPAs. It then looks into regional integration in sub-Saharan Africa. It goes on to describe the precise integration objective associated with EPAs and how results have generally been disappointing in meeting the objective of furthering regional integration. The conclusion proposes recommendations on how to boost the negotiation process.
In this article, the author considers ways in which multinational companies avoid paying taxes in Africa, thereby undermining government commitments to education, housing and health, among others. The predominant way in which capital is hidden in trade and moved abroad is argued to be through the pricing of imports and exports. While a wide range of actors are argued to use this strategy, the author argues that multinational companies are more easily able to do so as they operate through subsidiaries scattered across the world, and have multiple subsidiaries, with trading between and among subsidiaries of multinational companies comprising as much as 60% of global trade. This gives significant scope for the use of transfer pricing.
6. Poverty and health
Failure to achieve desired human development outcomes in the water supply and sanitation sector over the last decade has prompted this re-assessment of sector strategies and a focus on issues of governance and political economy. The authors assess the applicability of the various political economy analysis (PEA) frameworks for the water and sanitation (WATSAN) sector, drawing out five key points to take into account when developing a sector level PEA framework. First, the sector’s diversity (both the sub-sectors of water supply, sanitation and geographical locations of sub-sector service delivery contexts urban, rural, peri-urban) does not mean that different elements of the WATSAN sector require the application of separate frameworks, but the different historical, institutional and political contexts do need to inform the tailoring of questions and areas of focus across the subsectors. Second, a multi-sector and multi-scalar analysis can help to identify actions and decision making influenced by external processes and actors operating at various scales. Third, a combined sector governance and political economy analysis for the sector is not recommended: a joint analysis requires considerable time and research, and leads to overly normative and prescriptive mindset preventing consideration of a full scope of non-obvious opportunities for intervention. Fourth, a PEA framework for WATSAN requires flexibility in its application to the sector. Fifth, a PEA WATSAN framework needs to focus on both process and outcomes: the majority of PEA and governance studies have failed to drive forward change in the water and sanitation sector.
On 2-3 March 2011, Partners in Health, Harvard University and other organisations met to discuss the non-communicable diseases (NCDs) of the world’s poorest billion people. The Conference was held in Boston, United States, and attended by a wide range of government, civil society and academic organisations who have advocated for the inclusion of NCDs as a priority on the global health agenda. This Statement allies itself with a number of World Health Organisation (WHO) and United Nations (UN) agreements and resolutions, such as the WHO’s Framework Convention on Tobacco Control and its Global Strategy on NCDs and the UN Resolution ‘Keeping the Promise: United to Achieve the Millennium Development Goals’. The Statement calls on all UN member state Heads of Government and Heads of State to take urgent action to address NCDs amongst the world’s billion poorest people by: leading at global and national levels for NCDs; strengthening health systems and NCD prevention, treatment and care; strengthening research and data systems; and addressing poverty, vulnerability and discrimination.
South Africa's high child mortality rates have forced the government to rethink its policy on infant feeding and move to discontinue the free provision of formula milk at hospitals and clinics, as well as promote an exclusive breastfeeding strategy for all mothers, including those living with HIV. Minister of Health Aaron Motsoaledi made the announcement on 23 August 2011 after a two-day national consultation on breastfeeding, where participants unanimously recommended the changes. Until now, the country's health system has not supported the practice of breastfeeding and mothers are often discharged as soon as six hours after birth, with no or little counselling on infant feeding, the Minister of Health acknowledged. Formula milk manufacturers and distributors have also promoted their products aggressively, because of the absence of legislation to regulate the marketing of formula milk, according to UNICEF. In December 2009, the UN World Health Organisation (WHO) issued guidelines recommending that infants born to HIV-positive women be exclusively breastfed for the first six months, but South Africa's programme to prevent mother to child HIV transmission has continued to provide free formula to HIV-positive mothers. Representatives of WHO in South Africa are calling on government to implement the guidelines.
The food crisis in the Horn of Africa is affecting people in informal urban settlements, but they remain largely overlooked by the aid community, according to IRIN. IN Kenya, emergency relief efforts are focused on the arid north, yet over the past five months, Concern Worldwide has recorded a 62% increase in cases of severe acute malnutrition (SAM) at clinics it supports in Nairobi slum areas, while estimating that the need is much greater. The UN Children's Fund (UNICEF) concurred that the food crisis is probably affecting people in urban areas more than in the north. Part of the reason malnutrition in urban slums is paid relatively scant attention is that it rarely reaches the emergency level of 15% global acute malnutrition (GAM) rate, at which point government is obliged to take action. In Turkana in the north, 15% GAM would translate to 13,000 children. But in Nairobi district, 13,000 malnourished children would reflect just a 3.45% GAM rate. Currently, the estimated GAM rate is 2.3% in Nairobi's slums.
7. Equitable health services
The authors of this study examined the feasibility of using community health workers (CHWs) to implement cardiovascular disease (CVD) prevention programmes within faith-based organisations in Accra, Ghana. Faith-based organisation capacity, human resources, health programme sustainability/barriers and community members’ knowledge were evaluated. Data on these aspects were gathered through a mixed method design consisting of in-depth interviews and focus groups with 25 church leaders and health committee members from five churches, and of a survey of 167 adult congregants from two churches. Findings indicated that the delivery of a CVD prevention programme in faith-based organisations by CHWs is feasible. Many faith-based organisations already provide health programmes for congregants and involve non-health professionals in their health-care activities, and most congregants have a basic knowledge of CVD. Yet despite the feasibility of the proposed approach to CVD prevention through faith-based organisations, sociocultural and health-care barriers such as poverty, limited human and economic resources and limited access to health care could hinder programme implementation.
The objective of this study was to assess adherence to community-based directly observed treatment (DOT) among Tanzanian tuberculosis patients using the Medication Event Monitoring System (MEMS) and to validate alternative adherence measures for resource-limited settings using MEMS as a gold standard. This was a longitudinal pilot study of 50 patients recruited consecutively from one rural hospital, one urban hospital and two urban health centres. Treatment adherence was monitored with MEMS and the validity of a range of adherence measures was assessed, including the Morisky scale, adapted AIDS Clinical Trials Group (ACTG) adherence questionnaire, pill counts and medication refill visits. The mean adherence rate in the study population was 96.3%. Adherence was less than 100% in 70% of the patients, less than 95% in 21% of them, and less than 80% in 2%. The ACTG adherence questionnaire and urine colour test had the highest sensitivities but lowest specificities. The Morisky scale and refill visits had the highest specificities but lowest sensitivities. Pill counts and refill visits combined, used in routine practice, yielded moderate sensitivity and specificity, but sensitivity improved when the ACTG adherence questionnaire was added. In conclusion, patients on community-based DOT showed good adherence in this study. The combination of pill counts, refill visits and the ACTG adherence questionnaire could be used to monitor adherence in settings where MEMS is not affordable.
In this study, researchers investigated community case management of malaria (CCMm) through community medicine distributors (CMD) in urban areas in Ghana, Burkina Faso, Ethiopia and Malawi. CMDs were trained to educate caregivers, diagnose and treat malaria cases in <5-year olds with ACT. Household surveys, focus group discussions and in-depth interviews were used to evaluate impact. In all sites, interviews revealed that caregivers' knowledge of malaria signs and symptoms improved after the intervention. Preference for CMDs as providers for malaria increased in all sites. In addition, 9,001 children with an episode of fever were treated by 199 CMDs in the five study sites and, of these, 6,974 were treated with an ACT and 6,933 (99%) were prescribed the correct dose for their age. Fifty-four percent of the 3,025 children for which information about the promptness of treatment was available were treated within 24 hours from the onset of symptoms. The researchers conclude that the concept of CCMm in an urban environment was positive, and caregivers were generally satisfied with the services. Quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm.
Physical inactivity has been identified as the fourth leading risk factor for the prevention of non-communicable diseases (NCDs), preceded only by tobacco use, hypertension, and high blood glucose levels, and accounting for more than three million preventable deaths globally in 2010. Physical inactivity is a global public health priority but, in most countries, this has not yet resulted in widespread recognition nor specific physical activity–related policy action at the necessary scale, the authors of this article argue. The authors identify and discuss eight possible explanations why inactivity is overlooked and the need for more effective communication on the importance of physical activity in the NCD prevention context. Although not all of the issues identified will be relevant for any one country, it is likely that at different times and in different combinations these problems continue to delay national-level progress on addressing physical inactivity in many countries. The authors confirm that there is sufficient evidence to act, and that much better use of well-planned, coherent communication strategies are needed in most countries and at the international level. Significant opportunities exist. The Toronto Charter on Physical Activity and the Seven Investments that Work are two useful tools to support increased advocacy on physical activity within and beyond the context of the crucial UN High-Level Meeting on NCDs in September 2011.
8. Human Resources
This Draft Human Resources for Health (HRH) Strategy for South Africa was developed through reviewing policy and research reports and consolidating them in consultation with key informants. It addresses a range of issues affecting HRH in South Africa including: sectoral analysis by professional category and the costs; skills mix; level of human resources; equity and maldistribution; factors affecting shortages; provincial HR and Service Transformation (STP) plans and their use in workforce planning, the re-engineered primary health care (PHC) approach and its impact on HRH, retention and recruitment issues, and management and leadership. The draft strategy also provides projections on future staffing needs, how these quotas will be filled and projected training and educational requirements.
This study was conducted to determine the prevalence of substance use and identify factors that influenced the behaviour among undergraduate medical students of Addis Ababa University in Ethiopia. A cross-sectional study using a pre-tested structured self-administered quantitative questionnaire was conducted in June 2009 among 622 medical students (Year I to Internship programme) at the School of Medicine. Results showed that in the 12 months prior to the study, alcohol was consumed by 22% of students and khat use was reported by 7%. Being male was strongly associated with alcohol use in the last 12 months. Khat use and use of tobacco was strongly and positively associated with alcohol consumption. In conclusion, concordant use of alcohol, khat and tobacco was observed and exposure to friends' use of substances was often implicated. While the findings of this study suggest that substance use among the medical students was not alarming, but its trend increased among students from Year I to Internship programme. The authors caution the university to be vigilant in monitoring and educating the students about the consequences of substance use.
Health worker training is a key component of the integrated management of childhood illness (IMCI). The researchers in this study conducted in-depth case studies in two east African countries to examine the factors underlying low training coverage ten years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007 and 2008. The researchers found that Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitisation and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and external funding for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI. Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally, the authors conclude.
In this study, researchers assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya. From March 6, 2009, to May 31, 2010, they conducted a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. Health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for six months, or the control group, in which health workers did not receive any text messages. They found that 119 health workers received the intervention. Case-management practices were assessed for 2,269 children who needed treatment, indicating that correct artemether-lumefantrine management improved by 23.7% immediately after intervention and by 24.5% six months later. The authors conclude that in resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices.
9. Public-Private Mix
The study is based on multiple rounds of Demographic and Health Survey data from four selected countries (Nigeria, Uganda, Bangladesh, and Indonesia) in which there was an increase in the private sector supply of contraceptives. The methodology involves estimating concentration indices to assess the degree of inequality and inequity in contraceptive use by wealth groups across time. The results suggest that the expansion of the private commercial sector supply of contraceptives in the four study countries did not lead to increased inequity in the use of modern contraceptives. In Nigeria and Uganda, inequity actually decreased over time; while in Bangladesh and Indonesia, inequity fluctuated. The study results do not offer support to the hypothesis that the increased role of the private commercial sector in the supply of contraceptive supplies led to increased inequity in modern contraceptive use.
The main objective of this study was to conduct a baseline study of the private market for anti-malarials in Muheza town, an area with widespread anti-malarial drug resistance, prior to the implementation of a provider training and accreditation programme that will allow accredited drug shops to sell subsidised Artemether-lumefantrine (ALu). All drug shops selling prescription-only anti-malarials in Muheza voluntarily participated from July to December 2009. Qualitative in-depth interviews were conducted with owners or shopkeepers on saleability of anti-malarials, and structured questionnaires provided quantitative data on drugs sales volume. Results showed that all surveyed drug shops illicitly sold sulphadoxine-pymimethamine (SP) and quinine (QN), and legally amodiaquine (AQ). In community practice, the saleability of ACT was negligible. SP was best-selling, and use was not reserved for Intermittent Preventive Treatment (IPTp), as stipulated in the national anti-malarial policy. The authors express concern that such drug-pressure in the community equals de facto intermittent presumptive treatment. In an area where SP drug resistance remains high, unregulated SP dispensing to people other than pregnant women runs the risk of eventually jeopardising the effectiveness of the IPTp strategy.
The One Million Campaign’s petition to the President of the United Nations (UN) General Assembly urges the UN to re-consider proposed partnerships with the private sector for future work in prevention of non-communicable diseases (NCDs). The UN’s draft Political Declaration, developed in preparation for the High-level Summit on Non-communicable Diseases (NCDs) in September 2011, contained proposals to allow manufacturers of unhealthy foods - including infant foods and junk foods -to influence future global and national health strategies to control NCDs. The One Million Campaign asserts that strategies to prevent NCDs should emphasise support to women to continue breastfeeding up to two years, especially exclusive breastfeeding for the first six months and end promotion of all foods for infants, and children. Research indicates that this breastfeeding regimen significantly reduces the risk of NCDs. They argue that manufactures of unhealthy foods, breast milk formula and infant foods should not be allowed to participate in developing strategies or making decisions regarding healthy foods and prevention of NCDs, as there is a clear case of conflict of interest.
10. Resource allocation and health financing
Rwanda’s mutuelle health insurance scheme has been consistently held up as an example of how community health insurance can be scaled up to achieve large scale improvements in access and health outcomes. However, the author argues that the role of the mutuelle scheme in achieving recent health improvements in Rwanda has not considered other important factors, particularly the five-fold increase in health spending. The author draws a number of conclusions. First, premiums and co-payments, while less harmful than traditional point-of-service fees, remain a financial barrier without whose removal true universal access to healthcare cannot be achieved. Second, even with high enrollment, the mutuelle generates minimal financing. In order to increase the funds collected, Rwanda is now introducing higher premiums. Third, Rwanda has made unparalleled progress in health by doing what its leadership has felt best for the country and its people. The author indicates that it is important for all aspects of Rwanda’s success to be acknowledged and studied for broader adaptation and, in particular, its increasing and strategic investments in health, strong economic performance, uniquely effective public administration, and popular buy-in to government initiatives, as these factors are part of the reason why the mutuelle as a programme has been as successful as it has.
Over the past 15 years, performance-based financing has been implemented in an increasing number of developing countries, particularly in Africa, as a means of improving health worker performance. Scaling up to national implementation in Burundi and Rwanda has encouraged proponents of performance-based financing to view it as more than a financing mechanism, but increasingly as a strategic tool to reform the health sector. The authors of this study argue that results-based and economically driven interventions do not, on their own, adequately respond to patient and community needs, upon which health system reform should be based. They argue that the debate surrounding performance-based financing is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the performance-based financing package.
Developing countries reliant on aid want to escape this dependence, and yet they appear unable to do so. This book shows how they may liberate themselves from the aid that pretends to be developmental but is not. The author cautions countries of the South against falling into the aid trap and endorsing the collective colonialism of the OECD – the club of rich ‘donor’ countries. An exit strategy from aid dependence requires a radical shift in both the mindset and the development strategy of countries dependent on aid, and a deeper and direct involvement of people in their own development. It also requires a radical restructuring of the global institutional aid architecture. The author explains how ‘aid’ is an instrument of imperialism's strategy of domination, which he strongly contrasts with proposals for another form of aid, one rooted in the principles of international and anti-imperialist solidarity.
South Africa’s National Health Insurance (NHI) scheme is due to be piloted in April 2012. The purpose of this Green Paper is to outline the broad policy proposals for the implementation of NHI. The document is published for public comment and engagement on the broad principles. The NHI will offer all South Africans and legal residents access to a defined package of comprehensive health services. The state is committed to offering as wide a range of services as possible. Although the NHI service package will not include anything and everything, it will offer care at all levels, from primary health care, to specialised secondary care, and highly specialised tertiary and quaternary levels of care. After the consultation process the policy document or White Paper will be finalised. Thereafter draft legislation will be developed and published for public engagement. After public engagement the legislation will be finalised and submitted to Parliament for consideration. After Parliamentary approval, the Bill has to be approved by the President of the Republic. The first five years of NHI will include pilot studies and strengthening the health system in the following areas: management of health facilities and health districts; quality improvement; infrastructure development; medical devices including equipment; human resources planning, development and management; information management and systems support; and the establishment of an NHI Fund.
The authors of this short opinion piece argue that the current debate on performace-based financing (PBF) is misdirected, as external funders try to prove the effectiveness of their contribution by isolating it as the main reason for success while their opponents attempt to prove that another factor is actually the cause of an observed change. Instead, the authors call for comprehensive evaluation of PBF as part of complete health system reform. To respond to some of these key questions, health systems should be analysed using a complex adaptive systems lens. Health system ‘behaviour’ and particularly counterintuitive behaviour (unexpected changes or lack of change) can be analysed using a complex adaptive systems lens when PBF is introduced, often with a mix of other interventions such as in a context of system reform. The purpose of this analysis is not to isolate causal factors but rather to identify ‘macro’ characteristics of the system that may explain behaviour change.
This article was written as Zambia went to the polls in September 2011. The author evaluated the impact of the government’s policy to abolish user fees over the past five years. When the Zambian President announced the policy change in January 2006, only three months were allocated for planning and communication, and this he notes resulted in understaffing and a lack of resources including drugs. Measures were not taken to reduce the risk of drug stock-outs and in the first year 60% of essential drugs were unavailable. Many health facilities experienced a loss of income, as compensation for lack of income from user fees was delayed by months. Between 2004 and 2006 there was a large reduction in district non-wage and district drug expenditure (down by 13% and 34% respectively). Overall, quality of health care suffered and patients faced longer waiting times, fewer drugs, and overworked staff. The author argues that, despite the significant shortcomings of the current system, canceling free health care is not an option in a poor country like Zambia. He urges that the issues identified in the evaluation be urgently addressed by the Government of Zambia with aligned support from development partners.
Before free care for pregnant women and children was introduced in Sierra Leone, 88% of citizens said that their inability to pay was by far the greatest barrier to accessing care when sick. Just 12 months after the introduction of free care, medical care for children under five has increased by 214% and the proportion of children getting approved treatment for diagnosed malaria increased from 51% to 90%. Forty-five percent more pregnant women are delivering in formal clinics and hospitals and the number of delivery complications treated in health units increased 150%, while fatality rate in these cases fell by 61%. Success was achieved, the author of this article argues, through a high level of political commitment and leadership from the President of Sierra Leone and key staff within the Ministry of Health, as well as health worker reform including the elimination of 850 ghost workers from the payroll and salary increases of at least 100% for all staff. Over 1,000 additional workers were hired, facilities were upgraded and major resources and effort went into sorting out the key issue of medicines supply. Countries that want to implement free health care shouldn’t have to wait for external funders to get their house in order, the author concludes – like Sierra Leone, they should kick start progressive policies in the interests of their citizens that external funders will be forced to follow.
The authors of this paper suggest that the debate around performance-based financing (PBF) has become polarised, and argue for a more balanced approach. PBF is not a panacea and the provision of inputs, provider training, supervision and health-system strengthening should continue with the aim of producing results. A research agenda and an effective community of practice embracing all views on PBF is critical to understanding more about its potential for helping developing countries to reach some of the United Nations Millennium Development Goals.
Dependency on aid (external funding) among 54 of the world’s poorest countries has declined by a third over the last decade, according to this new report from ActionAid. The number of low income countries (LICs) receiving external funding equivalent to 30% of government expenditure or more has reduced from 42 to 30 in the past decade. In Zambia, for instance, external funding has fallen from 84% of government expenditure to just 44%. ActionAid notes the apparent paradox that while external funding has increased globally, dependence on the funding has reduced because of strong economic growth. Allied to growth is a new-found determination among poor countries to end 30 or more years of dependence on funding that has seldom delivered the kind of development for which they had hoped. Some of the poorest countries in the world, including Ghana, Rwanda, and Uganda, have set reducing this type of dependence as a key medium-term goal in their national development or aid-management policies. Reliance on external funding in Ghana has reduced from 46% to 27%, Mozambique from 74% to 58% and Rwanda from 86% to 45%.
11. Equity and HIV/AIDS
Researchers in this study investigated sub-optimal patient adherence to antiretroviral therapy in 18 clinical sites in rural Zambézia Province, Mozambique. They conducted 18 community and clinic focus groups in six rural districts, interviewing 76 women and 88 men, of whom 124 were community participants (CPs) and 40 were health care workers (HCWs) who provide care for those living with HIV. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff, doubt as to the benefits of antiretroviral therapy and sharing medications with family members. Men expressed a greater concern about poor treatment by HCW than women and health care workers blamed patient preference for traditional medicine and the side effects of medication for poor adherence. In conclusion, perspectives of CP and HCW likely reflect differing socio-cultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.
The objective of this study was to investigate whether in utero exposure to highly active antiretroviral therapy (HAART) is associated with low birth weight and/or preterm birth in a population of South African women with advanced HIV disease. A retrospective observational study was performed on women with CD4 counts ≤250 cells/mm3 attending antenatal antiretroviral clinics in Johannesburg between October 2004 and March 2007. Effects of different HAART regimen and duration were assessed. Among HAART-unexposed infants, 27% were low birth weight compared with 23% of early HAART-exposed and 19% of late HAART-exposed infants. In the early HAART group, a higher CD4 cell count was protective against low birth weight and preterm birth. HAART exposure was associated with an increased preterm birth rate, with early nevirapine and efavirenz-based regimens having the strongest associations with preterm birth. The authors conclude that in utero HAART exposure was not significantly associated with low birth weight.
In a long-standing general population cohort in rural Uganda researchers assessed the prevalence of concurrency and investigated its association with socio-demographic and behavioural factors and with HIV prevalence, using the new recommended standard definition and methodological approaches. Among those eligible, 3,291 (66%) males and 4,052 (72%) females participated in the survey. Among currently married participants, 11% of men and 25% of women reported being in a polygynous union. Among those with a sexual partner in the past year, the proportion reporting at least one concurrent partnership was 17% in males and 0.5% in females. Polygyny accounted for a third of concurrency in men and was not associated with increased HIV risk. Among men there was no evidence of an association between concurrency and HIV prevalence (but too few women reported concurrency to assess this after adjusting for confounding). Regarding sociodemographic factors associated with concurrency, females were significantly more likely to be younger, unmarried, and of lower socioeconomic status than males. Behavioural factors associated with concurrency were young age at first sex, increasing lifetime partners, and a casual partner in the past year (among men and women) and problem drinking (only men). These findings are intended to provide a baseline for measuring changes in concurrency and HIV incidence in future surveys, and a benchmark for other studies.
This study aimed at exploring determinants of HIV testing and counselling in two Nairobi informal settlements. Data are derived from a cross-sectional survey nested in an ongoing demographic surveillance system. A total of 3,162 individuals responded to the interview and out of these, 82% provided a blood sample which was tested using rapid test kits. Approximately 31% of all respondents had ever been tested for HIV through client-initiated testing and counselling (CITC), 22% through provider-initiated testing and counselling (PITC) and 42% had never been tested but indicated willingness to test. Overall, 62% of females and 38% of males had ever been tested for HIV. Males were less likely to have had CITC and also less likely to have had PITC compared to females. Individuals aged 20-24 years were more likely to have had either CITC or PITC compared to the other age groups. Although the proportion of individuals ever tested in the informal settlements is similar to the national average, it remains low compared to that of Nairobi province especially among men. Key determinants of HIV testing and counselling include; gender, age, education level, HIV status and marital status. These factors need to be considered in efforts aimed at increasing participation in HIV testing, the authors conclude.
HIV and AIDS has always been one of the most thoroughly global of diseases. In the era of widely available anti-retroviral therapy (ART), it is also commonly recognised as a chronic disease that can be successfully managed on a long-term basis. This article examines the chronic character of the HIV and AIDS pandemic and highlights some of the changes we might expect to see at the global level as HIV is increasingly normalised as ‘just another chronic disease’. The article also addresses the use of this language of chronicity to interpret the HIV and AIDS pandemic and calls into question some of the consequences of an uncritical acceptance of concepts of chronicity.
The objective of this paper was to describe the long-term virological, immunological and mortality outcomes of providing highly active antiretroviral therapy (HAART) with strong adherence support to African HIV-infected female sex workers (FSWs) and contrast outcomes with those obtained in a cohort of regular HIV-infected women. FSWs and non-FSWs initiated on HAART between August 2004 and October 2007 were included in the study. Patients were followed monthly for drug adherence (interview and pill count), and at six-monthly intervals for monitoring CD4 counts and HIV-1 plasma viral loads (PVLs) and clinical events. Results showed no statistical differences between outcomes of FSWs and non-FSWs. The authors conclude that clinical and biological benefits of HAART can be maintained over the long term among FSWs in Africa and could also lead to important public health benefits.
The experiences of the past ten years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings. Achieving the levels of antiretroviral (ARV) coverage necessary to impact the course of the HIV epidemic remains a challenge and ARV coverage in most nations remains short of even current recommendations. Though treatment as prevention and seek, test, treat and retain strategies are attractive, the authors of this article argue that realising the benefits of these strategies means that they must cover hard to reach populations such as sex workers. While evidence on reach of these populations in research settings is encouraging, there are questions on the sustainability of these efforts as patients are transitioned back into national HIV control programmes, many of which are struggling even to maintain the current coverage in the face of declining external funding. The authors conclude that advocacy from both medicine and public health providers will be critical to sustain and enhance the necessary HIV and AIDS treatment and prevention programmes worldwide.
12. Governance and participation in health
There is a long history of advocacy to place non-communicable diseases higher on the global public health agenda. Although attempts have been made and action is well under way, there is still no co-ordinating mechanism that helps identify action, tracks progress, and stimulates multistakeholder collaboration while preventing duplication of efforts. The September 2011 United Nations High Level Meeting on Non-Communicable Diseases and the call by all parties for more efficient responses to the growing problems of non-communicable diseases presents a unique opportunity to create an institutional mechanism that incentivises coordination. The authors argue that an apex coordinating arrangement would allow efficient global information exchange, mapping existing gaps in action, and identifying and catalysing collaboration across sectors and regions of the world.
The Inaugural Conference of the Global Health Diplomacy Network was held on 28 June 2011 in London, United Kingdom. More than 190 diplomats, health professionals, senior government officials, academics, and representatives of business and non-governmental organisations gathered to discuss contemporary issues in global health diplomacy and outlooks for the future of the Network. After the presentations were held, the Network made a number of resolutions, concluding that the Network should help the health sector understand that the top priorities of foreign policy are national security and economic growth, not health. The health sector must not view the link between health and foreign policy as an opportunity to exploit the foreign policy sector to reach health goals. Instead, it must think how it can advance foreign policy goals and be aware and acknowledge that health policy can have a positive or negative impact on foreign policy and its goals, just as foreign policy can have positive or negative impacts on health. Participants acknowledged that much health diplomacy in Geneva focuses on trade and about intellectual property issues, while there is a wider lack of coherence across the different global institutions and their goals, a problem which has been exacerbated by the proliferation of global actors.
Anti-tobacco mass media campaigns have had good success at changing knowledge, attitudes, and behaviors with respect to smoking in high-income countries provided they are sustained. Mass media campaigns should be a critical component of tobacco control programs in low- and lower-middle-income countries, the authors of this article argue. Mounting evidence shows that graphic campaigns and those that evoke negative emotions run over long periods of time have achieved the most influence. These types of campaigns are now being implemented in low- and middle-income countries. The authors provide three case studies of first-ever graphic warning mass media campaigns in China, India, and Russia, three priority high-burden countries in the global Bloomberg Initiative to Reduce Tobacco Use. In each of these countries, message testing of core messages provided confidence in messages, and evaluations demonstrated message uptake. The authors argue that given the initial success of these campaigns, governments in low- and middle-income countries should consider resourcing and sustaining these interventions as key components of their tobacco control strategies and programmes.
In this interview with Gino Govender, who recently joined Amnesty International’s International Mobilisation team, Govender reveals that Amnesty International has decided to grow in the global south and move closer to the communities and rights holders with whom the human rights organisation works. One of the outcomes of an extensive consultative process is the development of an Africa Growth Strategy, which involves the creation of three regional offices, one of which will be located in and responsible for Southern Africa. With regard to the current state of civil society in the Southern African Development Community (SADC) region and in South Africa in particular, Govender is optimistic, arguing that, regionally, civil society is undergoing an important stage of evolution. However, within SADC there are important political, social and economic challenges still to be confronted if the vision of a people-centred regional community that is thriving on the values of solidarity, social justice, equality, dignity, freedom, democracy and production that meets basic human needs are to be realised. He points to a general consensus on the need for a strong and effective civil society in the region and argues that collective leadership united under a common vision for the region is the key. The future for civil society in the region lies in a blend between historically vital sectors that have a wealth of organisational knowledge and experience - like the labour movement, faith-based organisations, womens’ organisations and intellectuals – and newly established organisations that are dedicated to a single campaign.
13. Monitoring equity and research policy
Mahmood Mamdani, director of Makerere University's Institute of Social Research in Uganda, has accused universities in Sub-Saharan Africa of not creating researchers but churning out native informers for national and international non-governmental organisations. Addressing academics and students at Makerere, Mamdani said academic research and higher education in most African universities is controlled and dominated by a corrosive culture of consultancy. The little research capacity that exists in Africa, especially in universities, is driven by culture of consultancy and global market trends, with African researchers being used to provide raw material - in form of data - to foreign academics who process it and then re-export it back to Africa. He told his audience that research proposals from African universities are increasingly simply descriptive accounts of data collection and the methods used to collate data. According to the United Nations Educational Scientific and Cultural Organisation (UNESCO), Africa is home to only 2.3% of the world's researchers.
There remains considerable disconnect between globalisation scholars about how to conceptualise its meaning and how we understand how its processes operate and transform our lives. The authors of this article argue that to better understand what globalisation is and how it affects issues such as global health, we can explore how the multiple processes of globalisation are encountered and informed by different social groups within particular contexts. The article reviews how qualitative field research assist in doing this. Three recent case studies conducted on globalisation and HIV and AIDS are reviewed for their use of qualitative methods in understanding the contexts and processes of globalisation and their impact on health.
In this paper, the author considers how operational research and management science can improve the design of health systems and the delivery of health care, particularly in low-resource settings. He identifies some gaps in the way operational research is typically used in global health and proposes steps to bridge them, before outlining some analytical tools of operational research and management science and illustrating how their use can inform some typical design and delivery challenges in global health. The paper concludes by considering factors that will increase and improve the contribution of operational research and management science to global health.
According to this report by UNESCO, in sub-Saharan Africa, social science themes have over the years evolved from topics such as structural adjustment, poverty, gender, the spread of armed confl icts, and HIV and AIDS to more recent concerns such as citizenship and rights in an era of crisis, and the response to neoliberalism. The big challenge, however, is to reconstruct autonomous social science research in Africa. But as the Council for the Development of Social Science Research in Africa (CODESRIA) points out, the lack of a research infrastructure prevents social scientists from contributing as much as they could to these social endeavours. In low-income countries, the increasing role of consultancy firms and NGOs in social science research follows the relative or absolute shrinking of public funds allocated to universities, for research in general and for the social sciences in particular. In such conditions, academics rarely have the chance of working on long-term projects involving strong theoretical considerations. The report also points to the corrosive effect of the ‘brain drain’ on research in low-income countries and acknowledges many of these countries have instituted measures to help retain professionals, but the efficiency of these measures remains limited as long as working conditions do not improve significantly.
14. Useful Resources
Every Saturday at 12 noon Eastern Standard time, African Views Radio holds regular discussions on health care systems in Africa in a show called African Health Dialogues. The forum is accessible to online audiences live on air and also via podcast. There is also an opportunity for people to call in via phone to participate in the discussions from any part of the world. The first show aired on 30 July 2011 and explored the status of healthcare systems in Africa with respect to the past, present and future. The producers of the programme are inviting participants to call in and join the discussions.
The People's Health Movement Students' Coalition (PHMSC) is an international, broad-based students' movement representing students' voices within the wider People's Health Movement and beyond. Its primary goal is health for all, i.e. a socially conscious, grassroots approach to health and human rights. The mobilisation of students is crucial to overcoming social, educational, environmental and other injustices that undermine the indivisible health rights of people the world over. PHMSC invites all students and student organisations who believe in a healthier future for everyone (regardless of their background or where they come from), to join the movement. You can sign the People's Charter for Health, join PHMSC’s mailing list or join their Facebook group.
The World Health Statistics report is an essential resource for policy-makers and researchers working on the identification and reduction of health inequities. A dedicated section in the 2011 report presents data from 93 countries using three health indicators - percentage of births attended by skilled health personnel, measles immunisation coverage among 1-year-olds, and under-five mortality rate - disaggregated according to urban or rural residence, household wealth and maternal education level. The data presented refer to ratios and differences between the most-advantaged and least-advantaged groups.
15. Jobs and Announcements
The James P Grant School of Public Health in Bangladesh is calling for applicants for their Masters in Public Health (MPH) programme. The MPH programme is suited to individuals who wish to build or further enhance their career in public health or allied areas. The MPH is a 51 credits residential programme which begins early in the year and runs full time for 12 consecutive months. There are vacation breaks (2-3 weeks) interspersed through the programme; Multi-disciplinary in design, the programme emphasizes development of the core public health competencies: epidemiology, biostatistics, medical anthropology, qualitative and quantitative and mixed research methods, health systems management, health economics and health care financing, environment and health, health communication, monitoring & evaluation, public health nutrition, demography, sexual and reproductive health, aging and health and non-communicable diseases; The MPH programme here is about one-third the cost of similar programmes in North America and in Europe and is cheaper than even similar programmes in developing countries. The School has a scholarship programme for students from developing countries to promote global access to the MPH based on need, merit and other selection criteria.
The International Development Research Centre and the Canadian Global Tobacco Control Forum are calling for concept notes concerning the expansion of fiscal policies for global and national tobacco control. The key objective of this call is to generate knowledge designed to accelerate the adoption of effective fiscal policies for tobacco control in low-and middle-income countries (LMICs). Key thematic areas include: research on the impact of various types of tobacco taxes or pricing policies; region-based research to establish actual and model budgets for tobacco control; research on coordinated regional and global taxes, tariffs and/or other levies on tobacco products and the profits from tobacco sales; and research to identify barriers to, and strategies for, accessing Official Development Assistance for tobacco control. The principal applicant must be a citizen or permanent resident of a LMIC and with a primary work affiliation in a LMIC institution.
The International Development Research Centre is calling for concept notes concerning the promotion of healthy diets as a key strategy for the prevention of non-communicable diseases (NCDs) in low- and middle-income countries(LMICs). The key objective of this call is to support Southern-led research designed to influence the adoption and implementation of effective policies and programmes for the promotion of healthy diets in LMICs. Key thematic areas include: research on policies, population-wide programs and community-based interventions that aim to discourage production and consumption unhealthy food products and promote healthy eating; and evidence syntheses or situation analyses to inform policy dialogues and the adoption and implementation of key interventions to address unhealthy diets as a key NCD risk factor. Please note that three major cross-cutting issues are central to the NCD programme: equity, intersectoral action and commercial influence on public health-related policy. The principal applicant must be a citizen or permanent resident of a LMIC and with a primary work affiliation in a LMIC institution.
Forum 2012 marks the beginning of a new series of the annual Global Forum for Health Research meetings. It will bring together seven key constituencies: governments, research institutions, business, social enterprises/civil society organisations, international organisations, research funders and media. Under the theme of ‘Beyond aid: Research and innovation as key drivers for health, equity and development’, the Forum will focus on potentials, solutions, and developing capacities – specifically in low- and middle-income countries and emerging economies – and how global collaboration can leverage this for a new era of global development support. It aims to contribute to health, equity and development in a measurable way. Forum 2012 will focus on three key areas to achieve this goal: investing in research and innovation for health; networks and networking for research and innovation; and creating an enabling environment for research and innovation (government policies). COHRED and the Global From for Health Research are calling for contributions to setting the agenda for Forum 2012.
At the Fourth High-Level Forum on Aid Effectiveness, approximately 2,000 delegates will review global progress in improving the impact and effectiveness of aid, and make commitments that set a new agenda for development. The Forum follows meetings in Rome, Paris and Accra that helped transform aid relationships between donors and partners into true vehicles for development cooperation. Based on 50 years of field experience and research, the five principles that resulted from these fora encourage local ownership, alignment of development programmes around a country’s development strategy, harmonisation of practices to reduce transaction costs, the avoidance of fragmented efforts and the creation of results frameworks.
The Youth Initiative of the Open Society Foundations (OSF) is currently seeking proposals from eligible registered NGO’s for up to $10,000 in funding to develop and curate thematic pages on a new global youth portal and community being developed at www.youthpolicy.org. Youthpolicy.org aims to consolidate knowledge and information on youth policies across the international sector, ranging from analysis and formulation to implementation and evaluation. Themes include, but are not limited to: participation and citizenship; activism and volunteering; children and youth rights; youth with disabilities; global drug policy; community work; research and knowledge; informal learning; youth, environment and sustainability; multiculturalism and minorities; and youth justice.
The First Global Climate and Health Summit aims to bring together key health sector actors to discuss the impacts of climate change on public health and solutions that promote greater health and economic equity between and within nations. The Summit is geared to build the profile of the health sector vis-à-vis the COP17 negotiations in Durban, and to also help build a broader, longer lasting global movement for a healthy climate. Objectives of the Summit include: raise the profile of public health and the health sector vis-à-vis the public debate and global negotiations on climate change; catalyse greater health sector engagement on climate issues in a broad diversity of countries; build a common, more coordinated approach to addressing the health impacts of climate change; and develop shared advocacy strategies for strong national and global policy measures to mitigate and adapt to climate change.
In the run-up to the Third People’s Health Assembly (PHA3), the People’s Health Movement (PHM) is releasing monthly updates on preparations for the Assembly – this is the first issue. PHM reports that, in the Africa region, various pre-PHA3 mobilisation activities have begun and in attempt to have co-ordinated efforts towards the assembly, mobilisation committees have been set up. Four sub-regional committees have been formed: West Africa, East Africa, Southern Africa and Central. A regional mobilisation committee will be developed from representatives of these sub-regions aiming to support national initiatives and bring regional health issues to the foreground in PHA3 discussions. Other countries which have started PHA3 activities and discussions are Zimbabwe, Kenya, Pakistan, Togo, Niger, Congo Brazzaville, Italy, Belgium and many others. Join the PHA3 facebook group to stay updated on preparatory events taking place around the world. PHM is calling on all interested parties to inform them what is happening in their countries so it can be shared through the monthly updates.
The World Health Organisation (WHO) is convening a global conference on 19-21 October, 2011, in Rio de Janeiro, Brazil, to build support for the implementation of action on social determinants of health. The Brazilian Ministry of Health, the Oswaldo Cruz Foundation (Fiocruz) and the Brazilian Ministry of Foreign Affairs are working closely with WHO on preparing the event. The conference will bring together Member States and stakeholders to share experiences on policies and strategies aiming to reduce health inequities. The event will provide a global platform for dialogue on how the recommendations of the WHO Commission on Social Determinants of Health (2008) could be taken forward. The key aim of the process is to draw lessons learnt and to catalyse coordinated global action in five key areas: governance to tackle the root causes of health inequities by implementing action on social determinants of health; the role of the health sector, including public health programmes, in reducing health inequities; promoting participation through community leadership for action on social determinants; global action on social determinants by aligning priorities and stakeholders; and monitoring progress in terms of measurement and analysis to inform policies on social determinants.
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