In a changing global environment, African countries have made clear their intention for the World Health Assembly (WHA) to hold its global leadership in health. At the WHA in 2012, reforms of the World Health Organisation (WHO) were under discussion, with the aims of improving outcomes in agreed global health priorities, ensuring greater coherence in global health, and effective, efficient, responsive, objective, transparent and accountable performance. In a context of a multitude of new global institutions, foundations and alliances involved in health, African countries at the WHA collectively, through Senegal, raised that the WHO provides an organisational means for global processes to value multilateralism, inclusivity and respect for the authority of member states through the WHA. The Africa Group of countries called for the reform process to contribute “to the shaping of a stronger, more effective, more responsive and more responsible WHO.” In the discussion on the reforms, African countries unanimously urged for countries to ensure that whatever the reforms achieve, they must strengthen WHO’s position as the leading global agency for health.
Achieving this calls for more than rhetoric and statements of intent. In the past decades, the World Health Assembly provided a forum for states to review policies and strategies in health and make resolutions that they would implement. In recent years, a host of new players from non health sector agencies, non-governmental organizations, non-state providers of health, industry, faith-based organizations, civil society, foundations and corporates have become involved in decision making on and implementation of health strategies. Over the past decade more than 100 private global foundations have emerged working on different issues related to health. This multiplicity of actors bring multiple visions, mandates and modes of functioning to global policy processes. Alliances such as the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Health Workforce Alliance are now working on issues that the WHO has been working on over the years.
A Ugandan delegate to the 2012 WHA questioned the number of partnerships that WHO was now involved in, arguing that this detracted from its major mandate and role. African countries at the WHA observed that navigating this complex environment calls for WHO to rather strengthen its own intergovernmental nature and particularly the role of countries in its decision making processes. Permanent secretary of the Ministry of Health in Swaziland, Mr. Stephen Shongwe, said for example “As Swaziland we want to reiterate that the WHA is the supreme organ of the WHO and should have the final say in all the decisions. There should be flexibility for the WHA to make decisions. Resolutions should not just be crafted based on the recommendations of the Executive Board. Member states should be able to raise issues that may arise and not just be confined to the defined issues in the agenda.”
African countries’ concerns were addressed in part when the 65th WHA in 2012 resolved that any reform of the organisation be guided by the principle that the intergovernmental nature of WHO’s decision-making be paramount. The Director General was requested to present draft papers on WHO’s engagement with non governmental organisations and with private commercial entities.
However, while this may be a necessary condition for the organisation to claim global leadership in heath, will it be enough? Without the funds coming from the same member states, how will it deliver on its decisions? And will member states use their strengthened and collective decision making to safe guard public health, even in the face of corporates and foundations whose earnings exceed the GDP of many member states?
Global leadership in health demands an organisation that fearlessly and strategically protects public health. At a Special Session of the WHO Executive Board convened in November 2011 to consider the Reform Agenda, the WHO director General Margaret Chan then said that WHO, in "the interest of safeguarding public health", was "not afraid to speak out against entities that are far richer, more powerful, and better connected politically than health will ever be", adding that "we need to maintain vigilance against any real or perceived conflicts of interest."
Civil society actors at the WHA supported this role of public health protector, but questioned whether it is being delivered. They argued that the prospect of money has led the organisation to engage in partnerships that have weakened this leadership role. They held member states liable for this situation, observing that WHO can only become a stronger intergovernmental institution when member states increase their funding support.
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 visit www.equinetafrica.org
1. Editorial
2. Latest Equinet Updates
The EQUINET 2012 Regional Equity Watch has been produced and is being posted to the website in early September. The report updates the 2007 EQUINET Regional analysis of equity in health, drawing on the Equity Watch framework developed by EQUINET in cooperation with the East, Central and Southern African Health Community and in consultation with WHO and UNICEF, with some modifications given its regional nature. The report provides evidence from 16 countries in East and Southern Africa, including more detailed evidence from the country Equity Watch reports, on: Policy, political and legal commitments to equity in health; The current situation with respect to equity in health outcomes; Economic opportunities and challenges for health equity; Household access to the resources for health and the social determinants of health; Challenging inequities through redistributive health systems and Global (in)justice and the issues for global engagement. Visit the EQUINET website in early September to download the report!
This report provides an overview of resource-allocation decision making in South Africa as it impacts on the distribution of health budgets. It also looks at changes in the allocation of public health care resources since the early 1990s across provinces. Finally, it considers whether resources are allocated equitably between health districts. The report finds that while considerable progress has been made towards the equitable allocation of public sector health care resources among provinces, substantial disparities in spending on primary health care (PHC) services remain among health districts. It is critical that provincial health departments pay more attention to the equitable allocation of resources for PHC services among the districts within their province, the author argues. In the absence of such efforts, many South Africans will continue to be disadvantaged in their access to PHC services simply because of their place of residence.
This annotated literature review was prepared as a resource for the policy research programme led by EQUINET that is examining the role of global health diplomacy (GHD), including south–south diplomacy, in addressing selected key challenges to health and strengthening health systems. This review provides an annotated bibliography and a summary of key features of peer-reviewed articles, books, book chapters and academic reports published between 1998 and 2004 on three case study areas: research on GHD, particularly in the areas of the World Health Organisation's Code on International Recruitment of Health Workers; access to essential drugs through south-south partnerships; and involvement of African actors in global health governance. It focuses on the theoretical and conceptual frameworks used in peer-reviewed literature on global health diplomacy and on the authors’ methodological choices to reach their conclusions. The report highlights theories that guided the research, the types of conceptual frameworks used and the research strategy and research tools employed in the publications reviewed.
Fair financing of health services requires that countries reduce their reliance on out-of-pocket (OOP) funding for health services and improve their pre-payment financing through general tax revenue and health insurance (particularly mandatory health insurance). While many countries in east and southern Africa (ESA) receive high levels of external funding, it is critical to increase domestic government funding for the health system to support this move away from out-of-pocket funding to provide effective financial protection from the costs of health care. This policy brief reviews progress in reducing out-of-pocket payments in ESA countries and in increasing government funding for health, particularly in terms of meeting the Abuja target of 15% of the government budget being devoted to the health sector and a target of government spending of US$60 per capita. While there has been some progress in some countries, most ESA countries are still far from achieving these fair financing targets. The brief highlights areas that merit action to meet policy commitments on fair financing.
3. Equity in Health
In this study, researchers investigated whether maternal obesity is a risk factor for neonatal death in sub-Saharan Africa and the effect on the detailed timing of death within the neonatal period. Cross-sectional Demographic and Health Surveys from 27 sub-Saharan countries (2003-09) were pooled, comprising a total of 81,126 women. Of these women, 15,518 were overweight, 4,266 were obese, 52,006 had an optimum body mass index (BMI) and 13,602 were underweight. Maternal obesity was associated with an increased odds of neonatal death after adjustment for confounding factors, and it was a significant risk factor for neonatal deaths occurring during the first two days of life. Strategies to prevent and reduce obesity need to be considered, the authors argue, and obese women should be advised to deliver in a health-care facility that can provide emergency obstetric and neonatal care.
The aims of this study were to assess international shortfall inequalities in life expectancy among women and men and to quantify how much specific geographic regions and country income groups contribute to them. Researchers used estimates of life expectancy at birth by sex for the 12 five-year periods between 1950–1955 and 2005–2010. Data for life expectancy at birth by sex were available for 179 of the 193 Member States of the World Health Organization (WHO) (as of 2010). Results indicated large shortfall inequalities in life expectancy among women in low-income countries. Additionally, there were large differences between shortfall inequalities of women and men in low-income countries. The authors call for urgent action is necessary to reduce these inequities. Although they acknowledge that behaviour change policies and programmes focusing on the individual are important in improving the health of women, action at economic, social, cultural and environmental levels is equally vital. Broader strategies such as poverty reduction, increased labour force participation, increased literacy, training and education, improvements in the provision of and access to health services (including reproductive health care), and increased opportunities for participation in economic, social and political activities will contribute to progress in women’s health.
After the United Nations announced the members of its new High-level Panel to advise on the global development agenda beyond 2015, Oxfam responded by calling on the Panel to accelerate delivery on the Millennium Development Goals (MDGs) first. There are still three years left before the MDGs expire, and with declining contributions from external funders, Oxfam argues that one way to finance the MDGs is to introduce a financial transaction tax in Europe, with at least 50% of the revenues committed to development and climate change.
This report measures progress on the health Millennium Development Goals (MDGs) to 2015 and beyond. The authors gathered data from a combination of literature reviews, interviews with key stakeholders in the health field, and a roundtable discussion. They found that the past decades have seen a gradual shift from a focus on a single disease to a more systemic approach by including a variety of health (and non-health) inputs which have to be integrated at the national, district and local levels. Although the authors predict that achievement of the health MDGs will almost surely be uneven, the available evidence suggests that the health MDGs have been effective in accelerating progress on target indicators, in stimulating global political support in the creation of significant global institutions dedicated to helping countries achieve the MDGs and in stimulating research and debate on systemic approaches to improving health outcomes. The authors argue that the current health MDGs will need continued focus beyond 2015 and must be included in some form in the post-2015 goals. The new goals should be simple enough to be politically intelligible and acceptable, and meaningful to politicians and laypeople. The report recommends that a mechanism be set up to ensure decision-makers and external funders are held accountable and to help countries get back on track.
In this study, researchers quantified and compared education- and wealth-based inequalities in the prevalence of five non-communicable diseases in low- and middle-income country groups: angina, arthritis, asthma, depression and diabetes. Using 2002-04 World Health Survey data from 41 low- and middle-income countries, the prevalence estimates of angina, arthritis, asthma, depression, diabetes and comorbidity in adults aged 18 years or above was analysed by wealth quintile, education level, sex and country income group. Results indicated that wealth and education inequalities were more pronounced in the low-income country group than the middle-income country group. Both wealth and education were inversely associated with angina, arthritis, asthma, depression and comorbidity prevalence, with strongest inequalities reported for angina, asthma and comorbidity. Diabetes prevalence was positively associated with wealth and, to a lesser extent, education. Adjustments for confounding variables tended to decrease the magnitude of the inequality.
South Africa fares worse on health than the residents of any other BRICS country, according to the country’s Health Minister Aaron Motsoaledi. In a speech delivered on 29 July 2012, the Minister presented standard health indicators for life expectancy, with the average South African expected to live until 54, far behind the Chinese at 74, Brazilians at 73, Russians at 68 and Indians at 65. He quoted South Africa’s maternal mortality rates at 410 per 100,000 births, almost double India’s rate of 230, which lags behind Brazil (58), Russia (39) and China (38).
The United Nations (UN) has named the 26 members of its new High-level Panel to advise on the global development agenda beyond 2015, the target date for the Millennium Development Goals (MDGs). Three co-chairs have been appointed, including President Ellen Johnson Sirleaf of Liberia. The Panel is expected to prepare its development vision to present to UN Member States in 2013, with sustainable development and eradicating poverty at its core. The Panel is part of the Secretary-General’s post-2015 initiative mandated by the 2010 MDG Summit. It intends to take an open, inclusive approach, with consultations involving civil society, the private sector, academia and research institutions from all regions, in addition to the UN system, to advance the development agenda beyond 2015. The work of the Panel will reflect new development challenges while also drawing on experience gained in implementing the MDGs, both in terms of results achieved and areas for improvement.
4. Values, Policies and Rights
On 4-5 July 2012, the African Development Bank (AfDB), as a key partner of the Harmonisation for Health in Africa (HHA) mechanism, organised a high-level dialogue on ‘Value for Money, Sustainability and Accountability in the Health Sector’ in Tunis. The conference gathered over African 50 Ministers of Finance and Health and their representatives from 33 African countries, Parliamentarians as well as over 400 participants from the public and private sectors, academia, civil society and media globally. The conference emphasised the urgent need for greater domestic accountability, reduced dependence on foreign aid and the role of Parliamentarians as well as using e-health in achieving greater value money in the delivery of health services in Africa. Participants also stressed the need to tackle critical shortages, maldistribution and inadequate performance of health workers in Africa. Ethiopia’s Health Extension Worker (HEW) Programme was put forward as a good example of innovative policy interventions to health worker shortages.
Three countries in Southern Africa have the highest adult HIV prevalence in the world: Swaziland (25.9%), Botswana (24.8%), and Lesotho (23.6%). Fiscal policy is crucial for addressing this HIV and AIDS crisis, the authors of this paper argue. Utilising a calibrated model, they investigated the impact of fiscal policy on reducing the HIV and AIDS incidence rates in these countries. In particular, they studied the welfare impact of different taxation and debt paths in reducing the HIV and AIDS prevalence rates. This is particularly important given the current concerns about dwindling foreign aid (especially the Global Fund), and fiscal deterioration and sustainability in these countries. The results show that acting optimally has not only positive societal welfare effect but also positive fiscal effects. For example, it will alleviate the debt burden by 5%, 1% and 13% of the GDP respectively for Botswana, Lesotho and Swaziland by the year 2020. Thus, at a time of fiscal crisis in developed countries and dwindling international HIV and AIDS resources, the future of effective and efficient HIV and AIDS intervention in Africa is clearly domestic, they conclude.
5. Health equity in economic and trade policies
In this report, the authors consider the four biggest global agricultural commodity traders: Archer Daniels Midland, Bunge, Cargill, and Louis Dreyfus, often collectively referred to as ‘the ABCD companies’. The ABCD companies are often invisible in policy debates about farmers and consumers, and they are careful about where and when they get involved in such debates, rarely seeking the limelight. The report looks at critical issues in agriculture and food security, such as the ‘financialisation’ of agricultural products, the emergence of Asian competitors to the ABCDs and the impact of the large-scale biofuel industry on food security. The authors argue that food price volatility is a problem and commodity speculation and biofuels, alongside other factors such as export bans, are helping to drive volatility. The role played by the ABCD trading firms is important, but that how to address them and limit their power is not obvious, and regulations and changes will probably need to target broader reforms. But understanding the economic and political power of the ABCDs is essential to developing policies that will protect the interests of smallholder farmers and poor consumers in developing countries, the authors conclude.
Although technology transfer and innovation feature in the final outcome of the Rio+20 United Nations Conference on Sustainable Development (UNCSD), held 20-22 June 2012, intellectual property rights (IPRs) - which are closely related to them - are barely mentioned, according to this brief. While the mention of IPRs in the Rio+20 outcome document signals their relevance for efforts to achieve sustainable development, no consensus was reached on how to ensure they are equitable and relevant to green technology. However, the stalemate may be addressed in several ways, the author proposes. Clear parameters are needed to foster a more constructive and pragmatic dialogue. Intellectual property should be seen in a broader context of appropriate policies, adequate institutions and human resources to both encourage green innovation and to ensure that its benefits are widely diffused. Other recommendations include improving access to technological information on green technologies, facilitating licensing of green technologies, fast-tracking green patents and ensuring open innovation for sustainability.
According to this study, the rate of increase in consumption of ‘unhealthy commodities’ - namely soft drinks, processed foods, tobacco and alcohol - is fastest in low- and middle-income countries (LMICs), with little or no further growth expected in high-income countries (HICs). The pace at which consumption is rising in LMICs is even faster than has occurred historically in HICs thanks to multinational companies, which have now achieved a level of penetration of food markets in middle-income countries similar to what they have achieved in HICs. Higher intake of unhealthy foods correlates strongly with higher tobacco and alcohol sales, suggesting a set of common tactics by industries producing unhealthy commodities, the authors argue. Contrary to findings from studies undertaken several decades ago, urbanisation no longer seems to be a strong risk factor for greater consumption of risky commodities at the population level, with the exception of soft drinks. Rising income has been strongly associated with higher consumption of unhealthy commodities within countries and over time, but mainly when there are high foreign direct investment and free-trade agreements. Economic growth does not inevitably lead to higher unhealthy-commodity consumption.
As the nineteenth International AIDS Conference took place in Washington DC, thousands of protesters marched on the White House with a set of demands to end the epidemic. The march consisted of a coalition of AIDS advocacy and activist groups organised under the mantra ‘We Can End AIDS’. At the forefront were calls for an end to free trade deals that protesters argue make vital AIDS medicines unaffordable. They pointed out that free trade deals with the Barack Obama administration contain excessively stringent protections for pharmaceutical patents on AIDS drugs. A spokesperson for the demonstration urged governments to accept recommendations related to intellectual property rights in a July 2012 report issued by the Global Commission on HIV and The Law (included in last month's newsletter), an independent high-level legal commission made up of former heads of state and leading legal, human rights and HIV experts. The Commission recommended a moratorium on TRIPS patent enforcement on pharmaceutical products, which they argue will allow developing countries to manufacture low-cost generic medicines urgently needed for their populations.
Local users are now the main source of electronic waste in Africa, but illegal imports of old computers, televisions, and other electronics devices from Europe, Asia, and North America still make their way there. That’s the finding of Where Are WEEE in Africa?, a new United Nations Environment Programme (UNEP) report about waste electronic and electrical equipment—also known as WEEE, or e-waste—in Benin, Côte d’Ivoire, Ghana, Liberia, and Nigeria.1 A large portion of these imports are of good quality, have a decent life expectancy, and bring many socioeconomic benefits, according to the report, but the rest is hazardous junk that is often resold and recycled under unsafe conditions. This article discusses the findings from the Where Are WEEE in Africa? report and the problems of its safe recycling and disposal.
Traditional long-established food systems and dietary patterns are being displaced in Brazil and in other countries in the South (Africa, Asia, and Latin America) by ultra-processed products made by transnational food corporations (‘Big Food’). This displacement, the authors of this paper argue, is increasing the incidence of obesity and of major chronic diseases and affects public health and public goods by undermining culture, meals, the family, community life, local economies, and national identity. In Brazil, the penetration of transnational companies has been rapid, but the tradition of shared and family meals remains strong and is likely to provide protection to national and regional food systems. The Brazilian government, under pressure from civil society organisations, has introduced legislation to protect and improve its traditional food system - by contrast, the governments of many industrialised countries have partly ceded their prime duty to protect public health to transnational companies. The authors recommend that the experiences of countries like Brazil in the South that still retain traditional food systems should be used as a basis for policies that protect public health.
Information Communication Technology (ICT) has revolutionized modern living, international business, global governance, communication, entertainment, transport, education, and health care. This has been driven by unprecedented high volumes of production and usage of consumer electronic products, in particular, personal computers, mobile phones, and television sets. Access to ICT has been identified as an indicator of a country’s economic and social development. The difference in access to ICT between developed and developing countries is commonly referred to as the “digital divide”. Africa has been undergoing rapid ICT transformation in recent years, attempting to bridge this divide by importing second-hand or used computers, mobile phones, and TV sets from developed countries. The countries of the region, however, lack the infrastructure and resources for the environmentally sound management (ESM) of electrical and electronic waste (e-waste) arising when such imports reach their end-of-life. The report analyses the flows of electrical and electronic equipment and e-waste and makes recommendations for African countries to prevent the import of e-waste and near-end-of-life equipment without hampering the socio-economically valuable trade of EEE of good quality.
In South Africa, as elsewhere in the world, large commercial entities that dominate the food and beverage environment (‘Big Food’) are becoming more widespread and are implicated in unhealthy eating. Interestingly, the authors of this study found that small independent producers (‘Small Food’) remain significant in the food environment in South Africa, and are both linked with, and threatened by, Big Food. Big Food in South Africa involves South African companies, some of which have invested in other (mainly, but not only, African) nations, as well as companies headquartered in North America and Europe. These companies have developed strategies to increase the availability, affordability, and acceptability of their foods in South Africa, as well as having developed a range of ‘health and wellness’ initiatives. Whether these initiatives have had a net positive or net negative impact is not clear. The authors recommend that the South African government act urgently to mitigate the adverse health effects in the food environment in South Africa through education about the health risks of unhealthy diets and regulation of Big Food, including support for healthy foods.
6. Poverty and health
According to this paper, in Ghana, alcohol consumption and unwanted pregnancies are on the ascendancy. The authors examined the association between alcohol consumption and maternal mortality from induced-abortion, as well as the factors that lie behind the alcohol consumption patterns in the study population. They extracted data from the Ghana Maternal Health Survey 2007, identifying 4,203 female deaths through verbal autopsy, among which 605 were maternal deaths in the 12 to 49 year-old age group. Alcohol consumption was significantly associated with abortion-related maternal deaths. Women who had ever consumed alcohol, frequent consumers and occasional consumers were about three times as likely to die from abortion-related causes compared to those who abstained from alcohol. Maternal age, marital status and educational level were found to have a confounding effect on the observed association. The authors recommend that policy actions directed toward reducing abortion-related deaths should consider alcohol consumption, especially among younger women. Policy makers in Ghana should also consider increasing the legal age for alcohol consumption. In addition, information on the health risks posed by alcohol and abortion be disseminated to communities in the informal sector where vulnerable groups can best be reached.
Despite being a critical component of interventions to reduce child mortality, exclusive breastfeeding practice is extremely low in South Africa. This paper investigates why. The authors conducted a sub-group analysis of a community-based cluster-randomised trial (PROMISE EBF) promoting exclusive breastfeeding in three South African sites between 2006 and 2008. By 12 weeks postpartum, results showed that 20% of HIV-negative women and 40% of HIV-positive women had stopped breastfeeding. About a third of women introduced other fluids, most commonly formula milk, within the first three days after birth. Antenatal intention not to breastfeed and being undecided about how to feed were most strongly associated with stopping breastfeeding by 12 weeks. Self-reported breast health problems were also associated with a three-fold risk of stopping breastfeeding. The authors conclude that early cessation of breastfeeding is common amongst both HIV-negative and positive women in South Africa. There is an urgent need to improve antenatal breastfeeding counselling taking into account the challenges faced by working women as well as early postnatal lactation support to prevent breast health problems.
Speaking at the World Congress of Rural Sociology, the Director-General of the Food and Agricultural Organisation (FAO) José Graziano da Silva challenged academics to get involved in essential and politically important research into rural poverty and the food and agriculture business as it pertains to small-scale producers. He identified the most pressing issues in the fight against hunger and rural underdevelopment as food insecurity, nutrient deficiencies and unsafe food, as well as unequal competition between small-scale and large food producers. He singled out large-scale investments in agriculture or ‘land-grabbing’ as a politically important area where universities could conduct research into principles for responsible agricultural investments. Such research could feed into the work of the Committee on World Food Security, the leading global forum for discussions on food security issues, he said. How to integrate small-scale farmers into the agricultural and food chains should be another area of academic concern. Academics should look into the issue of governance of the food and agriculture sector, both at global and local levels, and how to achieve a fair distribution of benefits.
With the world's highest population growth rate, the East African highlands have historically undergone extensive transformation to feed a poor population largely dependent on subsistence farming. Most available land has been adapted for agricultural use as dairy pastures or croplands. The lost of forest areas, mainly due to subsistence agriculture, between 1990 and 2010 ranged between 8,000 ha in Rwanda and 2,838,000 ha in Ethiopia. These unmitigated environmental changes in the highlands have led to a rise in temperature and a correlated increase in numbers of malarial mosquitoes, with several epidemics observed in the late 1980s and early 2000s. Although malaria has decreased through intensified interventions from the mid-2000s onwards, the authors of this study argue that environmental changes might further increase the risk of malaria in the region, particularly if the current interventions are not sustained.
The authors of this paper argue that the effects of relative deprivation, shame and social exclusion call for a reconsideration of how we assess global poverty. However, the authors do not support use of standard measures of relative poverty. Instead they call for using a weakly relative measure as the upper-bound complement to the lower-bound provided by a standard absolute measure. New estimates of global poverty are presented, drawing on 850 household surveys spanning 125 countries over 1981–2008. The absolute line is US$1.25 a day at 2005 prices, while the relative line rises with the mean, at a gradient of 1:2 above $1.25 a day. The authors show that these parameter choices are consistent with cross-country data on national poverty lines. The results indicate that the incidence of both absolute and weakly relative poverty in the developing world has been falling since the 1990s, but more slowly for the relative measure. While the number of absolutely poor has fallen, the number of relatively poor has changed little since the 1990s, and is higher in 2008 than 1981.
In the context of increased food prices in Ethiopia, the authors of this study hypothesised that adolescents in low income urban households are more likely to suffer from chronic food insecurity than those in the rural areas who may have direct access to agricultural products. They gathered data from the first two rounds of the Jimma Longitudinal Family Survey of Youth (JLFSY) and interviewed a total of 1,911 adolescents aged 13-17 years on their personal experiences of food insecurity both at baseline and at year two. Overall, 20.5% of adolescents were food insecure in the first round survey, while the proportion of adolescents with food insecurity increased to 48.4% one year later. Female sex of adolescents, high dependency ratio and household food insecurity were independent predictors of chronic adolescent food insecurity. The fact that the prevalence of chronic food insecurity increased among adolescents who are members of chronically food insecure urban households as income tertiles decreased suggests that the resilience of buffering is eroded when purchasing power diminishes and food resources are dwindling. Food security interventions should target urban low income households to reduce the level of chronic food insecurity and its consequences, the authors argue.
The objective of this study was to explore trends in perceived drinking water safety in South Africa and its association with disease outbreaks, water supply and household characteristics. The authors drew on General Household Surveys from 2002-2009, which included a question about perceived drinking water safety. Trends in responses to this question were examined from 2002-2009 in relation to reported cholera cases. The results suggest that perceptions of drinking water safety have remained relatively stable over time in South Africa, once the expansion of improved supplies is controlled for. A large cholera outbreak in 2000-2002 had no apparent effect on public perception of drinking water safety in 2002. Perceived drinking water safety is primarily related to water taste, odour, and clarity rather than socio-economic or demographic characteristics. This suggest that household perceptions of drinking water safety in South Africa follow similar patterns to those observed in studies in developed countries. The stability over time in public perception of drinking water safety is particularly surprising, given the large cholera outbreak that took place at the start of this period.
This WBTI (World Breastfeeding Trends Initiative) report assesses infant and young child feeding (IYCF) policies and programmes in 33 countries located in Asia, Africa and South and Central America. The authors highlight the fact that universalising the coverage of infant and young child feeding practices is one of the most effective interventions to reduce infant and young child mortality, morbidity and malnutrition. Yet their research points to major gaps in both policies and programmes in all 33 countries, with limited support for breastfeeding women. They argue that the United Nations and external funders should commit substantial financial resources in order to universalise key interventions related to breastfeeding and complementary feeding. This calls for a coordination mechanism for planning and supervising the implementation of relevant policy in an integrated manner at all levels, from policy making to service delivery at the grassroots level. Key breastfeeding and complementary feeding indicators will need to be regularly monitored and the results may be used to make policy and programmes more effective. The authors also call for integration of infant feeding in related comprehensive national policies, as well as building human resources and social welfare for exclusively breastfeeding women.
7. Equitable health services
To explore perceptions of malaria and utilisation of insecticide-treated bed-nets after a noticeable reduction in malaria incidence in Zanzibar, the authors of this study conducted 19 in-depth interviews with caretakers of children under five in North A district on the island. They found that awareness of malaria among caretakers was high but the illness was now seen as easily curable and uncommon. The discomfort of sleeping under a net during the hot season was identified as the main barrier to consistent bed-net usage. The main cue to using a bed-net was high mosquito density, and children were prioritised when it came to bed-net usage. Caretakers had high perceived self-efficacy and did not find it difficult to use bed-nets. Indoor Residual Spraying (IRS), which was recognised as an additional means of mosquito prevention, was not identified as an alternative for bed-nets. A barrier to net ownership was the increasingly high cost of bed-nets. The authors call on the government to continue providing bed nets through sustainable and affordable delivery mechanisms.
In this study, researchers assessed challenges and enablers for the Expanded Programme on Immunisation (EPI) in South Africa, in light of the approaching 2015 deadline for the Millennium Development Goals. Between September 2009 and September 2010 they requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. Systematic reviews on the effectiveness of the proposed solutions were added. Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes. The findings from reliable systematic reviews indicate that interactive educational meetings, audits and feedback, and supportive supervision improve healthcare worker performance. The authors conclude that numerous promising strategies for improving EPI performance in South Africa were found but their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation.
In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy. In the last decade, the disproportionate majority of global health funding has been allocated to vertical programmes targeting HIV and AIDS, malaria, and tuberculosis. The renewed calls for action to raise the priority of chronic non-communicable diseases in global health planning and research are encouraging, however, the authors note. Funding commitments from domestic governments, international funders, nongovernmental organisations, industry, and private philanthropists will be critical, the authors argue, to scaling up access to anti-epileptic medications and building capacity in human resources for epilepsy care in sub-Saharan Africa. A Global Fund for Epilepsy should be established to accelerate support from external funders and coordinate programme development and implementation.
This study had two purposes: to evaluate the impact of a universal coverage campaign (UCC) of long-lasting insecticidal nets (LLINs) on LLIN ownership and usage, and to identify factors that may be associated with inadequate coverage. In 2011 two cross-sectional household surveys were conducted in 50 clusters in Muleba district, north-west Tanzania. Prior to the UCC 3,246 households were surveyed and 2,499 afterwards. The proportion of households with at least one ITN increased from 62.6% before the UCC to 90.8% afterwards. Eighty percent of households surveyed received LLINs from the campaign. ITN usage in all residents rose from 40.8% to 55.7%, and after the UCC, 58.4% of households had sufficient ITNs to cover all their sleeping places. Households with children under five years and small households were most likely to reach universal coverage, while poverty was not associated with net coverage. The authors conclude that UCC in Muleba district of Tanzania was equitable, greatly improving LLIN ownership and, more moderately, usage. However, the goal of universal coverage in terms of the adequate provision of nets was not achieved. Multiple, continuous delivery systems and education activities are required to maintain and improve bed net ownership and usage.
This study aimed to assess feasibility, uptake, yield, treatment outcomes and costs of adding an active tuberculosis case-finding programme to an existing mobile HIV testing service in South Africa. All HIV-negative individuals with symptoms suggestive of tuberculosis and all HIV-positive individuals, regardless of symptoms, were eligible for participation. Of the 6,309 adults who accessed the mobile clinic, 1,385 were eligible and 1,130 (81.6%) were enrolled. The prevalence of smear-positive tuberculosis was 2.2%, 3.3% and 0.4% in HIV-negative individuals, individuals newly diagnosed with HIV, and known HIV+ individuals, respectively. Of the 56 new tuberculosis cases detected, 42 started tuberculosis treatment and 34 (81%) completed treatment. The cost of the intervention was US$1,117 per tuberculosis case detected and US$2,458 per tuberculosis case cured. In conclusion, mobile active tuberculosis case finding in deprived populations with a high burden of HIV and tuberculosis was found to be feasible, and had high uptake, yield and treatment success. Further work is now required to examine cost-effectiveness and affordability, and to establish if the same results may be achieved after scaling up services.
In this study, researchers compared vaccine coverage achieved by two different delivery strategies for the quadrivalent human papillomavirus (HPV) vaccine in Tanzanian schoolgirls. In a cluster-randomised trial, 134 primary schools were randomly assigned to class-based or age-based vaccine delivery. Of the 3,352 and 2,180 eligible girls included in the study, HPV vaccine coverage was 84.7% for dose 1, 81.4% for dose 2, and 76.1% for dose 3. For each dose, coverage was slightly higher in class-based schools than in age-based schools. Vaccine-related adverse events were rare. Reasons for not vaccinating included absenteeism (6.3%) and parent refusal (6.7%). In conclusions, the authors argue that HPV vaccine can be delivered with high coverage in schools in sub-Saharan Africa. Compared with age-based vaccination, class-based vaccination located more eligible pupils and achieved higher coverage. HPV vaccination did not increase absenteeism rates in selected schools. Innovative strategies will also be needed to reach out-of-school girls.
Current malaria control strategies rely heavily on repeated application of single neurotoxic insecticides that quickly kill adult mosquitoes, yet the effectiveness of insecticide-treated bed nets (ITNs) and indoor insecticide sprays to control adult mosquito vectors is being threatened by the spread of insecticide resistance. This narrow insecticide-based paradigm is beginning to fail, the authors of this paper argue, as it did in agriculture, as well as in previous malaria eradication campaigns of the '50s and '60s. They note that ITNs, indoor spraying programmes and other malaria control measures should be integrated in the same way as pest management is integrated in agriculture. Integrated approaches have the potential to provide more effective and durable pest management. To achieve the equivalent for malaria control requires additional tools to manage malaria vectors, as well as a better understanding of the impact of individual tools and their interactions, appropriate training for end users and strategies that maximise impact and fit the local ecological and socioeconomic context. Given the current lack of any clear alternative to the current insecticide paradigm, the authors urge researchers, policy makers, and funding agencies to act now to support this more diverse and adaptive approach.
The dominant approach used to promote sexual health relies on centralised public clinic service delivery, unisectoral implementation, and vertically organised support (national/state/local public health structures). But the authors of this study argue that these systems have failed to test, link and retain a large portion of most-at-risk populations. Instead, the authors favour a social entrepreneurship for sexual health (SESH) approach, which focuses on decentralised community delivery, multisectoral networks, and horizontal collaboration (business, technology, and academia). Although SESH approaches have yet to be widely implemented, they show great promise, according to this study. Social marketing and sales of point-of-care, community-based tests for HIV and other sexually transmitted diseases, conditional cash transfers to incentivise safe sex, and microenterprise among most-at-risk-populations are all SESH tools that can optimise the delivery of comprehensive sexual health interventions.
8. Human Resources
This observational study was conducted to estimate the degree of internal and external brain drain among Mozambican nationals qualifying from domestic and foreign medical schools between 1980 and 2006. Data were collected 26 months apart in 2008 and 2010, and included current employment status, employer, geographic location of employment and main work duties. Results showed that of 723 qualifying physicians between 1980 and 2006, a quarter had left the public sector, of which 62.4% continued working in-country and 37.6% emigrated. Of those cases of internal migration, 66.4% worked for non-governmental organisations (NGOs), 21.2% for external funders and 12.4% in the private sector. Annual incidence of physician migration was estimated to be 3.7%, predominately to work in the growing NGO sector. An estimated 36.3% of internal migration cases had previously held senior-level management positions in the public sector. The authors conclude that internal migration is an important contributor to capital flight from the public sector, accounting for more cases of physician loss than external migration. They call on external funders and NGOs to assess how their hiring practices may undermine the very systems they seek to strengthen.
In Tanzania, the authors of this study found that increasing numbers of universities are training many more health professionals to address the country’s extreme shortage of health care workers. In 2009 six universities admitted 756 medical students, but this is still many fewer than are needed based on population growth. Tanzania’s universities have the ability to support health professionals to build and maintain critical competencies by strengthening curricula and pre-service and internship training, and providing opportunities for continuing professional development, according to the study. For example, Muhimbili University of Health and Allied Sciences (MUHAS), the oldest health sciences academic institution in Tanzania, is partnering with the University of California San Francisco to transform MUHAS's educational environment through curricula revision and faculty development. However, enhancing the educational process involves a great deal of commitment from faculty across MUHAS and will only succeed if supported by long-term institutional reform. Sharing of early lessons learned by institutions undergoing educational reform will start to build a body of knowledge and experience to inform transformation of health professions education in Tanzania and elsewhere in Africa.
Little is known in Kenya on the extent to which community health workers (CHWs) are utilised, the characteristics of families who report utilising CHWs and whether utilisation is associated with improved access to prompt and effective malaria treatment. This paper addresses this research gap by examining factors associated with utilisation of CHWs in improving access to malaria treatment among children under five years of age by women caregivers in 113 hard-to-reach and poor rural villages in Malindi and Lamu districts Results indicate an increase in reported utilisation of CHWs as source of advice/treatment for child fevers from 2% to 35%, accompanied by a decline in care-seeking from government facilities (from 67% to 48%) and other sources (26% to 2%) including shops. The most poor households and poor households reported higher utilisation of CHWs at 39.4% and 37.9% respectively, compared to the least poor households (17%). Prompt access to timely and effective treatment was 5.7 times higher when CHWs were the source of care sought. The authors conclude that the utilisation of CHWs in improving access to malaria treatment at the community level will not only enhance access to treatment by the poorest households but also provide early and appropriate treatment to vulnerable individuals, especially those living in hard to reach areas.
Ethiopia is preparing for a major influx of medical doctors within three to four years, as government intends to save a public health system that has been losing doctors and specialists to internal and external migration. Medical schools report enrollment of more than 3,100 students, representing a tenfold increase from 2005, when less than 300 students enrolled. A draft of the country's Human Resource for Health Strategic Plan shows an intended increase in the number of physicians to 1 per 5,000 people by 2020. The plan seems on course, with a report presented to parliament in May 2012 revealing that 2,628 students had been enrolled in 22 universities over the previous nine months. Currently fewer than 200 doctors graduate annually. With the strong emphasis on health personnel numbers, experts have expressed concerns about the quality of medical education, a allegation that the Health Minister acknowledges, adding that government is taking steps to strengthen training of doctors through the Medical Education Partnership Initiative (MEPI), networking with known universities in the United States and offering students incentives to study further.
Salaries and other benefits are an obvious pull factor towards foreign countries, given the often-extreme differences in wages internationally. The introduction of the Occupation Specific Dispensation (OSD) in 2007 sought to address the challenge of high levels of South African health workers migrating overseas. In this study, researchers evaluate the effectiveness of the OSD by comparing salaries of health workers in South Africa with their counterparts in developed countries. Using a representative basket of commonly bought goods (including food, entertainment, fuel and utilities), they used a purchasing power parity (PPP) ratio to adjust earnings in order measure real differences in salaries. Their results showed that salaries of most South African health workers, particularly registered nurses, are dwarfed by their international counterparts, notably in the United States, Canada and Saudi Arabia, although the OSD has gone some way to reduce that disparity. These countries generally offer higher salaries on a PPP-adjusted basis, while other foreign countries also show large salary advantages if health workers emigrated. Given that their findings suggest that the OSD has narrowed the gap between South African and overseas salaries, the authors call for further research into the push factors underlying high levels of worker out-migration in the country.
9. Public-Private Mix
To investigate medicine retailer knowledge about anti-malarials and their dispensing practices, a survey was conducted of all retail drug outlets that sell anti-malarial medications and serve residents of the Webuye Health and Demographic Surveillance Site in the Bungoma East District of western Kenya. Results indicated that most (65%) of the medicine retailers surveyed were able to identify artemether-lumefantrine (AL) as first-line anti-malarial therapy for uncomplicated malaria recommended by the Kenyan Ministry of Health. Retailers who correctly identified this treatment were also more likely to recommend AL to adult and paediatric customers. Retailer training and education were found to be correlated with anti-malarial drug knowledge, which in turn was correlated with dispensing practices. While the Kenya Ministry of Health (MoH) guidelines were found to influence retailer drug stocking and dispensing behaviours, the authors argue that knowing the MoH recommended anti-malarial medication does not always ensure it is recommended or dispensed to customers. Retailer training and education are both areas that could be improved. Considering the influence that patient demand has on retailer behaviour, future interventions focusing on community education may positively influence appropriate dispensing of anti-malarials.
In addressing the problem of global obesity, our greatest failure may be collaboration with and appeasement of the food industry, argues the author of this article. She warns against current initial steps in this direction in the form of so-called ‘public–private partnerships' with health organisations, ‘healthy eating’ campaigns and corporate social responsibility initiatives. These occur at the same time as the private sector food and beverage sectors fight against meaningful change such as limits on marketing food to children, taxes on products such as sugared beverages, and regulation of nutritional labelling. The food industry distorts science, creates front groups to do its bidding, compromises scientists, professional organisations and community groups with contributions, and blocks needed public health policies in the service of shareholder, the author notes. This is normal ‘business as usual’. While respectful dialogue with industry is desirable, she argues that there must be recognition that this will bring small victories only and that to take the obesity problem seriously will require courage, leaders who will not back down in the face of harsh industry tactics, and regulation with purpose.
10. Resource allocation and health financing
The authors of this paper argue that at the sub-national level - where most health services are delivered - critical knowledge and capacity gaps exist, which prevent evidence from making a direct contribution to health plans and budgets. To remedy this problem, they propose an Investment Case Framework, which pairs locally led problem-solving analysis with quantitative techniques to inform local planning and decision-making. The framework allows for the development of locally appropriate strategies to overcome identified health system constraints and it estimates cost and impact should such strategies be implemented. The varied success of this initiative in terms of influencing annual plans and budgets reflects the political nature of resource allocation and the need to embed such approaches in the local policy process. To sustain evidence-based planning, the authors recommend a collaborative arrangement that allows researchers to address specific evidence gaps and health managers to focus on their core business of delivering universal health coverage.
The aim of this study was to model the cost-effectiveness in Uganda of combination antiretroviral therapy (ART) to prevent mother-to-child transmission of HIV. The cost-effectiveness of ART was evaluated on the assumption that it reduces the risk of an HIV-positive pregnant woman transmitting HIV to her baby from 40% (when the woman is left untreated) to between 3.8% and 25.8%. Compared with single-dose nevirapine, dual therapy and no therapy, 18 months of ART averted between 3.22 and 8.58 disability-adjusted life years (DALYs), at a cost of between US$34 and $99 per DALY averted. The corresponding figures for lifetime ART range from 11.87 to 31.6 DALYs averted, at a cost of between $172 and $354 per DALY averted. According to these findings, it appears ART is highly cost-effective for the prevention of mother-to-child HIV transmission, even if continued over the patients’ lifetimes. Given the additional public health benefits of ART, efforts to ensure that all HIV-positive pregnant women have access to lifelong ART should be intensified, the authors conclude.
The primary objective of this study was to identify decision criteria reported in the literature on healthcare decision-making. An extensive literature search was performed and, out of 356 articles assessed for eligibility, 39 were included in the study. Large variations in terminology used to define decision criteria were observed and 338 different terms were identified. The most frequently mentioned decision criteria were: equity/fairness (33 times), efficacy/effectiveness (28), healthcare stakeholder interests and pressures (28), cost-effectiveness (24), strength of evidence (20), safety (19), mission and mandate of health system (18), need (16), organisational requirements and capacity (18) and patient-reported outcomes (16). This study highlights the importance of considering both normative and feasibility criteria for fair allocation of resources and optimised decision-making. It may be used to develop a questionnaire for an international survey of health decision-makers on criteria, with the ultimate objective of developing sound multicriteria approaches.
The authors of this paper oppose the view put forward by some analysts that economic evaluations of antiretroviral therapy (ART) may be used to evaluate HIV treatment as prevention (TasP) programmes. ART outcomes and costs assessed in currently existing programmes are unlikely to be generalisable to TasP programmes programmes for several fundamental reasons, the authors argue. First, to achieve frequent, widespread HIV testing and high uptake of ART immediately following an HIV diagnosis, TasP programmes will require components that are not present in current ART programmes and whose costs are not included in current estimates. Second, the early initiation of ART under TasP will change not only patients' disease courses and treatment experiences - which can affect behaviours that determine clinical treatment success, such as ART adherence and retention - but also quality of life and economic outcomes for HIV-infected individuals. Third, the preventive effects of TasP are likely to alter the composition of the HIV-infected population over time, changing its biological and behavioural characteristics and leading to different costs and outcomes for ART.
In this study, the authors reviewed the available literature on modelled estimates of the cost of providing antiretroviral therapy (ART) to different populations around the world, and they suggest alternative methods of characterising cost when modelling several decades into the future. In past economic analyses of ART provision, costs were often assumed to vary by disease stage and treatment regimen, but for treatment as prevention, in particular, most analyses assume a uniform cost per patient. This approach disregards variables that can affect unit cost, the authors note, such as differences in factor prices (i.e., the prices of supplies and services) and the scale and scope of operations (i.e., the sizes and types of facilities providing ART). They go on to discuss several of these variables, and then present a worked example of a flexible cost function used to determine the effect of scale on the cost of a proposed scale-up of treatment as prevention in South Africa. Adjusting previously estimated costs of universal testing and treatment in South Africa for diseconomies of small scale, i.e., more patients being treated in smaller facilities, adds 42% to the expected future cost of the intervention.
The cost of a highly accurate, rapid diagnostic test for tuberculosis (TB) has been reduced by 40% under a new agreement between the US government, the Bill and Melinda Gates Foundation, and the health financing mechanism, UNITAID. GeneXpert is recommended by the World Health Organisation and it provides a two-hour diagnosis of TB, the TB/HIV co-infection, and drug-resistant TB. To date, the high unit cost of Xpert MTB/RIF cartridges has proven a barrier to their introduction and widespread use in low- and middle-income countries. According to the WHO Stop TB Partnership, 45 developing countries and those with a high TB burden will benefit from the price cut. Research suggests that increased use of the test in countries with high TB burdens could allow the rapid diagnosis of 700,000 cases of TB, and save health systems in low- and middle-income countries more than $18 million in direct costs. The test can be used outside of conventional laboratories because it is self-contained and does not require specialised training.
The primary aim of this research paper was to analyse interventions for the prevention of mother-to-child-transmission of HIV (PMTCT) included in HIV proposals approved for funding by the Global Fund to fight AIDS, Tuberculosis and Malaria. A total of 345 original HIV proposals approved for funding from Rounds 1 to 9 were reviewed according to the four components of the global PMTCT strategy. The researchers found that performance across the components varied. On one hand, prevention of unintended pregnancies in HIV-infected women (component 2) was the least represented, appearing in 34% of the proposals, while on the other, PMTCT (component 3) was present in approximately 90%. Component 2 was the only component that consistently increased throughout the Rounds, with signs of the greatest increase between Rounds 3 and 7. The authors call on countries to support comprehensive PMTCT interventions that are balanced across the four components. Their study highlights interventions that countries could capitalise on to scale-up PMTCT efforts as well as synergise efforts in linking with other global and national initiatives in maternal, reproductive and child health.
11. Equity and HIV/AIDS
Women comprise nearly half of the HIV-infected population worldwide, but these 15.5 million women tend to be under-represented in clinical trials of anti-HIV drug therapies, according to this study. The authors used the US Food and Drug Administration (FDA) database created from 40 clinical studies to assess gender differences in the efficacy of antiretroviral treatments. They found that women represented only about 20% of the subjects in randomised clinical trials submitted to the FDA between 2000 and 2008. When they compared the effectiveness of anti-HIV drug regimens reported for women versus men overall and among various subgroups, they found no statistically or clinical significant differences between women and men in outcomes with regard to viral load after 48 weeks. However, they did report significant gender differences favouring males based on subgroup analyses. They argue that this is a critical area of research in terms of developing new HIV therapies, as mounting evidence indicates that metabolism of certain drugs varies in men vs. women, and side effects that interfere with adherence to these medications may also be manifested differently.
Stigma is increasingly regarded as a key driver of the HIV and AIDS epidemic and has a major impact on public health interventions. The objective of this ‘creativity initiative’ was to provide activities in an HIV clinic while patients waited to be seen by healthcare professionals. It was envisaged this would contribute to reduction of clinic-based stigma felt by clients. The study took the form of a cross-sectional survey carried out in October-November 2005 and March-April 2007 at the Infectious Diseases Institute clinic (IDC) at Mulago, the national referral hospital in Uganda. Comparisons were made between patients who took part in activities and those who did not. Results suggest that clients who attended the IDC before the creativity intervention were about twice as likely to fear catching an infection as those who came after the intervention. The proportion that had fears to be seen by a friend or relative at the clinic decreased. Thus during the implementation of the creativity intervention, HIV-related stigma was reduced in this clinic setting.
In this paper, the author investigates uptake of prevention of mother-to-child transmission of HIV (PMTCT) services, infant feeding recommendations and specific drug regimens necessary to achieve the virtual elimination of paediatric HIV in Zimbabwe. She used a computer model to simulate a cohort of HIV-infected pregnant or breastfeeding women, and evaluated three PMTCT regiments: single-dose nevirapine; ‘Option A’ from the 2010 World Health Organisation guidelines (zidovudine in pregnancy, infant nevirapine throughout breastfeeding for women without advanced disease, lifelong combination antiretroviral (ARV) therapy for women with advanced disease); and WHO ‘Option B’ (limited combination ARV drug regimens without advanced disease during pregnancy and breastfeeding; lifelong ARV therapy with advanced disease). Results indicated that the latest WHO PMTCT guidelines (Options A and B) plus better access to PMTCT programmes, better retention of women in care, and better adherence to drugs are needed to eliminate paediatric HIV in Zimbabwe.
12. Governance and participation in health
Mitchell Sutika Sipus is an urban planning advisor to the Mayor of Mogadishu. He also lives and works in Kabul, Afghanistan. Here he writes about the rebuilding of Mogadishu’s physical infrastructure and the need for ‘psychological healing’ amongst the residents of the city. He writes of the initiation of trauma workshops for residents. Rebuilding the physical landscape is only part of the struggle. How can the city heal psychologically? Mogadishu's deputy mayor, Iman Icar, believes that to transform the city it is essential to transform the minds of residents. The mayor set up a new initiative to provide training in trauma healing and reconciliation for 50 people in each district. On July 19, 2012, the program concluded with a grand ceremony attended by President Sharif Sheikh Ahmed. The first 800 graduates will train another group of 800. In a city of three million, 1600 people may not be much, but it is argued to be a ripple in the pond that, with continued effort and support, will grow ever wider.
The outcome of Rio+20, held in June 2012, with negotiating countries unable to reach consensus on most issues, left most commentators disappointed as the summit failed to live up to its ambitious title “The Future We Want”. However, UHC Forward argues that health activists have a minor victory to celebrate, as issues regarding health, absent in the initial drafts circulated in advance of the Summit, are now mentioned in the texts. Health has had its relationship with sustainable development firmly recognised in terms of Universal Health Coverage by: strengthening health systems; complying with Beijing, Cairo and TRIPs flexibilities to ensure access to essential medicines; reducing infant and maternal mortality; and providing universal access to family planning and sexual and reproductive health. However, UHC Forward acknowledges that the Rio+20 outcome text contains too many divergent viewpoints and no tangible political commitments. It does, though, mark the beginning of the next phase of negotiations, and UHC Forward calls on all activists to demand that new agreements must reflect the challenges of the new global landscape, accounting for new health challenges, widening inequality and the increased proportion of the world’s poor in middle-income countries.
Zambian civil society organisations, especially those devoted to women’s rights, have welcomed Zambia’s new Constitution, which contains progressive provisions on gender equality and the promotion of women’s rights. The public is expected to vote on the Constitution in a national Referendum in 2013. Women’s rights organisations are reported to be preparing for educational campaigns amongst women to vote in favour of the new Constitution in the proposed Referendum in 2013. The parties to the Women’s Declaration on Engendering the Republican Constitution include the labour movement, the private sector, traditional leaders and groups under the umbrella of the Non-Governmental Organisations Coordinating Council (NGOCC). The draft version will enshrine gender equity in the Constitution in terms of economic empowerment. Activists have further demanded for the recognition of education as an important tool for the empowerment of women and women’s political empowerment through proportional representation in all decision making structures.
In this statement, a group of international civil society organisations welcomes the appointment by the UN Secretary-General of a diverse High-level Panel to advise on a post-2015 development agenda. However, the statement also expresses concern the Panel does not include the voices of people living in poverty, and their representative associations. The current composition of the Panel is largely state-centric with insufficient civil society representation, the organisations argue, and the Panel should include people from women's associations, farmers cooperatives, indigenous groups, workers or organisations of the impoverished. They highlight the fact that such voices must be represented as part of any effort to tackle poverty and in building a just, equitable and sustainable world.
This review investigated international cooperation in health, particularly between developed and developing nations. Standard database and web-based searches were conducted for publications in English between 1990 and 2010, from which 65 articles were included in the final analysis. While some articles identified intangible benefits accrued by developed country partners, most pointed to developing country innovations that can potentially inform health systems in developed countries. Ten key health areas in which developing countries led the way were identified, such as rural health service delivery, skills substitution, decentralisation of management, creative problem-solving and innovation in mobile phone use, and health financing. The authors argue that combined developed-developing country learning processes can potentially generate effective solutions for global health systems. However, the global pool of knowledge in this area is still basic and further work needs to be undertaken to advance understanding of health innovation diffusion. Even more urgently, a standardised method for reporting partnership benefits is needed for realising the full potential of international cooperation between developed and developing countries.
In 2008, South Africa’s National Tuberculosis Programme (NTP) implemented a community mobilisation programme in all nine provinces to trace TB patients that had missed a treatment or clinic visit. The objective of this study was to assess the impact of the NTP’s TB Tracer Project on treatment outcomes among TB patients. The study population included all smear positive TB patients registered in the Electronic TB Registry from Quarter 1 2007-Quarter 1 2009 in South Africa. Results for all provinces combined suggested that, in tracer districts, fewer patients defaulted on their treatment and there was an increase in successful treatment outcomes. However, the results were not consistent across all provinces, and significant differences in treatment default were observed between tracer and non-tracer sub-districts over time in five of nine provinces. The authors conclude that community mobilisation of teams to trace TB patients that missed a clinic appointment or treatment dose may be an effective strategy to mitigate default rates and improve treatment outcomes. Additional research is called for to identify best practices and elucidate discrepancies across provinces.
While the official Rio+20 outcome from June 2012 was a disappointment, a smaller side event saw the initiation of a host of Peoples’ Sustainability Treaties, dealing with a range of issues and actions, starting from the very local, going all the way up to the global level. Peoples’ Sustainability Treaties are aimed at coalescing the thinking of civil society organisations in the direction of a strong social movement towards an alternative and desirable future. A network of Treaties is being created, with each Treaty being driven by a collaboration of partners, and with all the Treaty circles being linked together through a loose coalition structure. By the time Rio+20 commenced, 14 Treaties were already established and from these a common Manifesto emerged, which contained an action plan identifying the issues of equity and sustainability for all as the foundation of any collective global response. Localising our economic systems, decentralising governance, and advancing sustainable lifestyles and livelihoods are promoted in the Manifesto. Localism was a major theme emerging from stakeholders, linked to the principles of devolution and decentralisation, and they argued in favour of turning localism into a world-wide movement.
This brief provides a summary of the events from mid June until mid July at the Peoples Health Assembly in Cape Town.
13. Monitoring equity and research policy
Greater health systems research and development is needed to support the global malaria eradication agenda, argues the malERA Consultative Group on Health Systems and Operational Research. In this paper, the Group focuses on the health systems needs of the elimination phase of malaria eradication and analyses groupings of countries at different stages along the pathway to elimination. It examines the difference between the last attempt at eradication of malaria and more recent initiatives, and considers the changing health system challenges as countries make progress towards elimination. The paper contains a review of recent technological and theoretical developments related to health systems and the renewed commitment to strengthening health systems for universal access and greater equity. The Group identifies a number of needs for research and development, including tools for analysing and improving effective coverage and strengthening decision making and discuss the relevance of these needs at all levels of the health system from the community to the international level.
A pool of 38 pan-African Centers of Excellence (CoEs) in health innovation has been selected and recognised by the African Network for Drugs and Diagnostics Innovation (ANDI), through a competitive criteria based process. The process identified a number of opportunities and challenges for health research and development (R&D) and innovation in the continent. The CoEs are envisioned as an innovative network of public and private institutions with a critical mass of expertise and resources to support projects and a variety of activities for capacity building and scientific exchange, including hosting fellows, trainees, scientists on sabbaticals and exchange with other African and non-African institutions. The authors argue that a credible and sustainable solution to the health challenges in Africa must leverage existing R&D, manufacturing and commercialisation capacity across the continent to support integrated capacity utilisation and economic development. They call for greater and better integrated funding for health R&D. As a pan-African initiative focusing on health R&D, promoting local manufacturing and access to medicines, the ANDI initiative is in a good position to contribute in the actualisation of an integrated and coordinated product R&D platform in the African continent, the authors conclude.
In this study, researchers evaluated the effectiveness of South Africa’s national prevention programme for mother-to-child transmission (PMTCT) of HIV. They included a total of 10,820 eligible infants from 572 facilities in their survey, conducted 10,735 interviews and drew 10,178 dried blot spot specimens. Findings indicated a 3.5% national MTCT rate in pregnancy and intrapartum with varying distribution across the nine provinces (1.4% to 5.9%). Maternal HIV acquisition since the last HIV test was potentially high at 4.1% and therefore repeat HIV testing at 32 weeks pregnancy and couple testing is critical, the authors argue. While uptake of PMTCT services is over 90%, CD4 testing and early infant diagnosis (EID) uptake are considerably lower and represent on-going missed opportunities in the PMTCT programme. The authors call for a review of EID strategies that routinely offer infant HIV testing only to known HIV-exposed infants, as virtual elimination of paediatric HIV infection is possible with intensified effort. Only 20% of HIV-positive women were exclusively breastfeeding, 62% were formula feeding and 18% were practicing high-risk mixed feeding, suggesting a need for increased attention to infant feeding.
Increased urbanisation means there are an estimated 800 million slum-dwellers globally, according to World Health Organisation (WHO), who face increased health hazards and risks. Health is an important benchmark of sustainability of urban policies, WHO argues. It proposes health indicators that reflect progress on the social equity, environment and development dimensions of sustainable cities. WHO calls for slum housing improvements that benefit health, as assessed by well-defined measures for safe, resilient, and climate-adapted structures that also have access to clean energy and basic utilities. Urban air quality must be monitored in terms of particulate pollution with respect to WHO air quality guidelines. Healthy, efficient transport in urban areas must be promoted and violence reduced in terms of intentional homicides. Governance indicators can assess how cities account for health in urban planning and building codes, and in monitoring air/water quality and sanitation risks. WHO argues that indicators should include access to urban services, which is essential to public health and sustainable cities, and suggests indicators for health care services, green spaces, fresh food markets and waste management.
In this brief prepared for Rio+20 in June 2012, the world Health Organisation (WHO) argues that a healthy workforce is a prerequisite for social and economic development, and fair terms of employment and decent working conditions are critical to the health of the working-age population. Yet global occupational health statistics from 2011 reveal that an estimated 2.3 million people died from work related injuries, illnesses, and accidents. WHO calls for more systematic measurement and reporting of workers' health to help reduce work-related injuries, illnesses and deaths. Compliance with basic national occupational safety and health standards, at country level and by sector, can support improved workers' health, including in the transition to a green economy. Monitoring progress on the ratification and implementation of core international labour conventions covering occupational safety and health policies and occupational health services is a third measure supporting improved workers' health and safety.
Measurement of access to safe and climate resilient drinking-water resources, as well as sanitation, is increasingly critical in an era of continued population growth and climate change. Therefore ensuring access to safe, resilient and sustainable water and sanitation will accelerate attainment of multiple environment and health-related goals for sustainable development, according to this brief by the world Health Organisation. Indicators of access to safe drinking water require greater refinement to reflect the large, continuing gaps in access to safe drinking water among the world's poorest populations, and measure progress towards attainment of the universal right to water. Monitoring access to adequate climate-resilient water and sanitation systems is particularly critical in light of the increasing impacts of temperature change and extreme weather on water sources, sanitation systems and human health. WHO calls on public health agencies to embrace Integrated Water Resource Management, an approach that provides a comprehensive and multisectoral approach for the identification and management of water-related health risks.
A major obstacle to the progress of the Millennium Development Goals has been the inability of health systems in many low- and middle-income countries to effectively implement evidence-informed interventions. This paper looks at the relationships between implementation research and knowledge translation and identifies the role of implementation research in the design and execution of evidence-informed policy. After a discussion of the benefits and synergies needed to translate implementation research into action, the authors consider how implementation research can be used along the entire continuum of the use of evidence to inform policy. The paper provides specific examples of the use of implementation research in national level programmes by looking at the scale up of zinc for the treatment of childhood diarrhoea in Bangladesh and the scaling up of malaria treatment in Burkina Faso. A number of tested strategies to support the transfer of implementation research results into policy-making are provided to help meet the standards that are increasingly expected from evidence-informed policy-making practices.
Online, open access (OA) medical publishing has provided new opportunities for increased transparency and innovation in clinical trial reporting, which if widely adopted can ultimately help enhance the quality and reliability of evidence, argue the authors of this article. They discuss the OA movement’s role in medical research and provide an up-to-date analysis of recent initiatives and trends. Access to original research remains the driving force behind OA, recently exemplified in the United States by a Whitehouse petition for open access publication of tax-funded research as well as the negative reaction to the controversial Research Works Act, which would restrict sharing data between researchers. Meanwhile the British government has also announced its support for OA. Improving availability of data, increasing access to research in developing countries and creating new services for easier location and reuse of clinical information are all priorities for the future and can contribute to the advancement of clinical medicine, according to the article.
In the past few years there has been an ongoing debate as to whether the proliferation of open access (OA) publishing would damage the peer review system and put the quality of scientific journal publishing at risk. The aim of this study was to inform this debate by comparing the scientific impact of OA journals with subscription journals, controlling for journal age, the country of the publisher, discipline and (for OA publishers) their business model. A total of 610 OA journals were compared with 7,609 subscription journals using Web of Science citation data, while an overlapping set of 1,327 OA journals were compared with 11,124 subscription journals using Scopus data. Results showed that average citation rates were about 30% higher for subscription journals. However, after controlling for discipline (medicine and health versus other), age of the journal and the location of the publisher (four largest publishing countries versus other countries) the differences largely disappeared in most subcategories except for journals that had been launched prior to 1996. In medicine and health, OA journals founded in the last 10 years are receiving about as many citations as subscription journals launched during the same period.
The 20th anniversary of the report of the Commission on Health Research for Development inspired a Symposium to assess progress made in strengthening essential national health research capacity in developing countries and in global research partnerships. Significant aspects of the health gains achieved in the 20th century are attributed to the advancement and translation of knowledge, and knowledge continues to occupy center stage amidst growing complexity that characterizes the global health field. The way forward is argued to entail a reinvigoration of research-generated knowledge as a crucial ingredient for global cooperation and global health advances. The authors argue that this needs to overcome in the divides between domestic and global health, among the disciplines of research (biomedical, clinical, epidemiological, health systems), between clinical and public health approaches, public and private investments, and between knowledge gained and action implemented.
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14. Useful Resources
The aim of this scoping review is to investigate and report stakeholders' objectives for planning or participating in large multi-day conferences and how these objectives are being evaluated. The authors conducted a scoping review supplemented by a small number of key informant interviews. Eight bibliographic databases were systematically searched to identify papers describing conference objectives and/or evaluations, 44 of which were included in this study. The evaluation framework connects five key elements in planning a conference and its evaluation: conference objectives, purpose of evaluation, evaluation methods, indicators of success and theories/models. The authors found that conference objectives and evaluations were largely correlated with the type of conference (i.e. academic, political/governmental or business) but diverse overall. While much can be done to improve the quality and usefulness of conference evaluations, there are innovative assessments that are currently being utilised by some conferences and warrant further investigation. This review provides conference evaluators and organisers a simple resource to improve their own assessments by highlighting and categorising current objectives and evaluation strategies.
This film reconstructs the narrative of how a dalit women’s collective in Karnataka, a small village in Belgaum district, defied class, caste and gender barriers and rose up against the failing public health system. The film draws from the rich and first hand experiences of the village women who, with the support of various village level peoples’ organisations and activists, stake claim to their health entitlements. The film concludes by asserting the importance of people’s struggles in creating a functional, responsive, people-centric health care systems and in the larger context of holding the State accountable for its duties and responsibilities towards its citizens. This film was one of the outcomes of the efforts to address the issue of health as a human right and taking forward the issue of revitalizing the public health system by various state and national level networks and activists. Karnataka state unit of the People’s Health Movement(JAA-K) screened this film extensively to intensify their Health as a Human Right campaign. Other health activists drew ideas from it to carry out similar actions to get their local government health centres functioning.
Virgem Margarida (Virgin Margarida) is a new feature film, set in 1975. The revolutionary government wants to eradicate all the traces of colonialism, including commercial sex work. All the sex workers are taken to the most isolated forest in the country where they are to be reeducated and transformed into new women, under the watch of guerrilla women fighters. Amongst the 500 women is 14-year-old Margarida, who was in town to buy her bridal trousseau. Because she doesn't have her ID documents, she is taken by mistake. In the reeducation center, the revelation that Margarida is a virgin changes everything. The commercial sex workers start to worship her like a saint. Shot in Azevedo’s signature style, the film is a combination of a documentary/scripted fiction style, intended to reflect the varied real-life stories in Mozambique, his home country.
The Academy of Women’s Health has launched a new regular column on its website that provides timely updates on diseases and conditions that are prevalent among women to help physicians and other healthcare providers optimise patient outcomes. The column provides opinions from eminent researchers and clinicians and presents the most up-to-date management strategies.
15. Jobs and Announcements
The International Union for Health Promotion and Education (IUHPE) and Thai Health Promotion Foundation (ThaiHealth) are hosting the 21st IUHPE World Conference on Health Promotion, 25 – 29 August, Pattaya, Thailand.
The conference aims to contribute to the development of equity and social justice across the globe by offering a unique platform for dialogue on the best investments for health between participants from various sectors from all over the world.
The South African Cochrane Centre (SACC) is celebrating its 15th Anniversary. To mark this achievement SACC is inviting all African Cochrane contributors to participate the African Cochrane Indaba entitled ‘Global Evidence, Local Application’. This event will create opportunities for sharing, learning and development. Participants will have a chance to: share experiences in working in evidence-based healthcare; participate in relevant workshops and capacity development events to promote on-going learning related to Cochrane Review production and dissemination; and engage in rigorous discussion about how to ensure the evidence that Cochrane generates is promoted and communicated optimally to healthcare decision-makers. The objectives of the African Cochrane Indaba are: capacity development on methods issues for Cochrane reviews; sharing best practices regarding dissemination of evidence; deciphering and using the evidence; and sharing experiences and networking.
The Royal Society-DFID Africa Capacity Building Initiative is a programme for scientists in sub-Saharan Africa who want to collaborate on research between themselves and a research institution in the United Kingdom (UK). The overall aim of the scheme is to strengthen the research capacity of universities and research institutions in sub-Saharan Africa by supporting the development of sustainable research networks. The programme consists of two awards and will be delivered in two stages: Scientific Network Awards and Programme Grants. Applicants must be based in one of the eligible sub-Saharan African countries or the UK. Applications will be accepted in these research priority areas: water and sanitation, renewable energy, soil-related research, and value and tenure. The next round of funding opens on 1 November 2012.
The University of Cape Town (UCT) and University of the Western Cape (UWC) Schools of Public Health are calling for interested candidates to apply for two Postdoctoral Research Fellowships to start in January 2013. The successful candidates will be required to register at UCT or UWC and will join the CHESAI team, where they will be expected to contribute to its work and to facilitate communication and joint learning between UCT and UWC. This collaboration is based on the understanding that Health Policy and Systems Research (HPSR) is an emerging field within the broader terrain of health research, with conceptual and methodological foundations that require substantial development. The overall aim for CHESAI is, therefore, to contribute to expanding and strengthening the health policy and systems knowledge base in Africa through building an intellectual hub for HPSR in Cape Town, South Africa, creating spaces for engagements between researchers and practitioners, supporting African HSPR capacity development and sharing/disseminating HPSR conceptual and methodological innovation.
The Africa Focus on Intervention Research for Mental Health (AFFIRM) is a research and capacity development Hub established in six countries: South Africa, Ghana, Uganda, Zimbabwe, Malawi and Ethiopia. It aims to investigate strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa, to build individual and institutional capacity for intervention research in sub-Saharan Africa, to establish a network of collaboration between researchers, NGOs and government agencies, and to collaborate with other regional hubs. In order to meet its aim of building capacity for intervention research, AFFIRM is offering five fellowships to candidates from Hub countries (excluding South Africa) to complete the MPhil in Public Mental Health in the Centre for Public Mental Health in 2013. Only one fellowship will be awarded per country. To be eligible, candidates must come from one of the Hub countries, successfully gain entry to the MPhil in Public Mental Health and undertake a research project that is aligned with the goal of AFFIRM, which is to use task shifting interventions to narrow the treatment gap in sub-Saharan Africa.
The Catholic Organisation for Relief and Development Aid (Cordaid) is seeking nominations from organisations that show outstanding vision, commitment and leadership in making use of local resources to implement sustainable care and support initiatives for children living with or affected by HIV. Cordaid will award the most outstanding organisation nominated with an award of €10,000 to further strengthen its activities in this field. Organisations that are eligible to be nominated for this year’s award should be active in the above-mentioned field in one of the following countries: Burundi, Cameroon, Central African Republic, Democratic Republic of the Congo, Ethiopia, Ghana, Sierra Leone, South Sudan, Malawi and Uganda.
Healthcare around the world is unaffordable for millions of people. At the same time, states are responsible for delivering universal access to health systems according to their legal commitments to the Right to Health. However, Action for Global Health argues that this is only possible if they develop sustainable health financing mechanisms to support strong and equitable national health systems. To make Universal Health Coverage (UHC) a reality, there is still the need for greater political will both, at national level, to put into practice the reforms needed and, at international level, to promote and revitalise a general consensus towards ‘health for all’, facilitating technical support and additional resources. Making progress towards UHC will accelerate social and economic growth, is fundamental to sustainable development and is fair, argues Action for Global Health. The organisation, which consists of a network of non-governmental organisations, has been working on a common statement for UHC, asking for greater political support and promoting a joint movement for UHC. If your organisation wants to sign on, please contact Action for Global Health.
Grand Challenges Canada has announced Round 4 of its Stars in Global Health programme. The current round is open to anyone with a Masters degree or above and whose qualification is less than 10 years old. PhD students can use this funding to finance their projects. Applicants should submit bold ideas in global health to apply for US$100,000 seed grants to test their concepts. The focus could be on science and technology and/or social and business interventions. The definition of global health may be considered as very broad here, hence potential applicants could come from Universities (departments of engineering, law, agriculture and veterinary sciences, food science and nutrition, medicine, pharmacy, nursing, public health, business schools, computer science, arts and science, education, anthropology, sociology) research institutes, for-profit and non-profit organisations etc. A new round will be launched every six months.
Global Maternal Health Conference 2013 (GMHC2013) is a technical conference for scientists, researchers, and policy-makers to network, share knowledge, and build on progress toward eradicating preventable maternal mortality and morbidity by improving the quality of maternal health care. The conference is co-sponsored by Management and Development for Health, Dar es Salaam, Tanzania, and the Maternal Health Task Force at the Harvard School of Public Health, Boston, USA.
DRC offers these research awards (formerly known as the IDRC Internship Awards) annually to Canadians, permanent residents of Canada, and citizens of developing countries pursuing masters or doctoral studies at a recognized university or having completed a master’s or doctoral program at a recognized university. As a research award recipient, you will undertake a one-year paid program of research on the topic you submitted when competing for the award. During part of the time (often around 50%), you will be trained in research management through hands-on experience with your chosen program. You will be mentored by an IDRC staff member.
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