There is longstanding stated policy support for health equity in East and Southern Africa. Social protest over inequality and pressure around delivery on these policies is equally longstanding, from struggles for political and economic rights to recent struggles over constitutional rights to food, water, shelter, healthy environments and health care, to hold the state and corporates accountable in relation to these entitlements, or to negotiate fairer benefit for Africa from use of its resources in the global economy.
So it confronts widely held social values when inequalities in health persist or widen, notwithstanding aggregate progress and economic growth. Why should women in Africa have 39 times the risk of dying in pregnancy and childbirth than those in high-income countries? Why, across the countries of East and Southern Africa should there be seven-fold differences in under five year mortality and 22-fold differences in the rate of women dying due to pregnancy and childbirth? Within some countries of the region nearly one in five children under five years die in the poorest households. Children of mothers with lowest education are five times more likely to be under-nourished than those with highest education.
People ask: Why shouldn’t all children, adolescents, mothers or households expect the nutrition, health and mortality outcomes of the most educated, wealthiest households or best performing geographical region of their country?
We live in an integrated regional community and global economy. Money, trade, raw materials and goods cross porous national borders. How then can such enormous differences between communities and countries be acceptable, particularly for conditions that can be prevented through technologies that have been known for over a century, including safe water, toilets, adequate food, decent shelter, access to midwives and so on? Why should huge numbers of people continue to suffer diseases of injustice?
In a 2007 Regional Equity analysis (http://tinyurl.com/9lrpl4e) , the EQUINET steering committee analysed the inequalities in health in East and Southern Africa and identified the policies and measures that could close them. The steering committee resolved to track what progress was being made in these areas, in a process called the Equity Watch. In 2012, EQUINET has produced a Regional Equity Watch that updates the 2007 analysis, drawing on a framework developed with review input from the East, Central and Southern African Health Community, WHO and UNICEF. The book is now available on the EQUINET website (www.equinetafrica.org) and acknowledges the many people and institutional contributors and processes that made input to it.
The 2012 Regional Equity Watch is essentially a watch on progress of what we know works to close gaps in health. It provides evidence on numerous policies and interventions that are being applied in health systems, agriculture, safe water and sanitation, in relation to employment and urbanisation and other areas that have closed gaps in inequality within the region. For example, investments in smallholder food production, especially for women farmers, have reduced inequalities in nutrition. Many countries have successfully implemented measures to encourage female children to enrol and stay in primary education. There are examples of activities that reduce urban poverty by enhancing employment, improving living conditions and investing in participatory planning, particularly in unplanned urban settlements. There are initiatives that have aligned national and international resources to support community management of safe water or to fund and support primary health care services and community health. There is promising practice in overcoming geographical differentials in access to health care through investments at primary care and community level, including through community health workers, community outreach, social organisation and participation, moving away from fee payments at point of care and integrating specific programmes within comprehensive primary care services. These practices underway repeatedly point to the possible.
However the 2012 Regional Equity Watch also asks why we are not making more progress in implementing the possible. It highlights that while there has been positive economic growth across most countries of the region in the whole of the 2000s, in many countries growth is occurring with increasing poverty and inequality, generating social disadvantage. Rapid, unserviced urbanisation, inadequate investment of profits and surpluses in new jobs, and significant disparities in access to agricultural resources, are common pathways found for growth with inequity. The Regional Equity Watch reports unacceptably slow progress in improving coverage of safe water and sanitation, low and unequal coverage of early childhood education and care and secondary education; inadequate public investment in improving access to land and other inputs for female smallholder food producers and inadequate resources - people, medicines and money- reaching and being absorbed by the community and primary care level of health systems. It raises concern about inadequate progress in formalising and resourcing mechanisms and capacities for participatory democracy and social power in health systems, particularly when observing the growing power that transnational corporates have in areas fundamental to health, such as in social determinants like food security or health service inputs like medicines.
Inequality within the region is overshadowed and underpinned by the scale of inequality globally. It points to a scale of inequality that needs to be more centrally and explicitly addressed in global dialogue, including on global development goals. At current rates of progress in narrowing the global gap in incomes, it would take more than 800 years for the bottom billion people – many of whom live in east and southern Africa – to achieve even 10 per cent of global income. The Watch points to the continuing net outflow of resources for health from the region, including through debt servicing, skilled worker out-migration, unfavourable terms of trade and extraction of unprocessed minerals and biodiversity. It questions the pro-cyclical, deflationary macroeconomic model that has dominated economic policy globally, given its failure to yield the sustained, inclusive or equitable growth needed to achieve social goals, and the unacceptable depths of deprivation and unacceptably wide and avoidable gaps in health and survival, and in coverage of services in our region. It raises frustration that slow progress in the strength, power and effectiveness of African voice in global decision making is being outstripped by a rapid pace of global extraction of African resources.
Many of the policy choices for a cohesive healthy society in East and Southern Africa raised in the 2012 Watch appear to be a matter of common sense. Beyond technical knowledge, therefore, their implementation depends on leadership and social action. In analysing progress and highlighting both the gaps and the possible, the 2012 Equity Watch aims to nurture and inform both the social intolerance for injustice and the affirmative leadership and demand for just alternatives.
Please send feedback or queries on the issues raised in this briefing or requests and comments in relation to the Regional Equity Watch 2012 to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org or download the 2012 Regional Equity Watch at http://tinyurl.com/8t2fqqf and http://tinyurl.com/8g6obf9.
1. Editorial
2. Latest Equinet Updates
In 2006-2009, as part of the regional learning network, the Lusaka District Health Management Team (LDHMT) used participatory action research (PAR) to strengthen joint planning and communication, co-operation and trust between communities and health workers. In 2010, building on positive changes found, LDHMT, with TARSC and with Cordaid support, piloted a programme to train health literacy facilitators and hold community health literacy sessions in three areas of Lusaka. The positive feedback from that programme led to dialogue with the Ministry of Health and the proposal for national level implementation of the health literacy programme. This national workshop hosted by Ministry of Health Zambia was thus held with lead stakeholders to review the work done to date and discuss the content, approach and steps towards implementing the programme at national level.
PART ONE OF A BOOK IN TWO PARTS. An Equity Watch is a means of monitoring progress on health equity by gathering, organizing, analysing, reporting and reviewing evidence on equity in health. This 2012 Regional Equity Analysis 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. The analysis shows past levels and current levels (most current data publicly available) and comments on the level of progress towards health equity. It raises the factors affecting progress and the challenges to be addressed. The analysis intends to be a comprehensive resource. As the report watches and supports progress, and not simply problems, it includes brief outlines of approaches being taken within the region to advance equity that appear to be yielding progress, with references where further information can be found. Finally, the report presents reflection on the experience of implementing equity analysis at country and regional level and on the experience of the Country Equity Watch work in institutionalising planning and monitoring for health equity.
PART TWO OF A BOOK IN TWO PARTS. This is part 2 of the 2012 Regional Equity Analysis. 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. The analysis shows past levels and current levels (most current data publicly available) and comments on the level of progress towards health equity. It raises the factors affecting progress and the challenges to be addressed. The analysis intends to be a comprehensive resource. As the report watches and supports progress, and not simply problems, it includes brief outlines of approaches being taken within the region to advance equity that appear to be yielding progress, with references where further information can be found.
The objective of this consultation was ‘to speed up and scale up country responses to the human resource needs of both the UN Global Strategy for Women’s and Children’s Health (Every Woman Every Child), and the Global Plan towards the Elimination of New HIV Infections Among Children by 2015 and Keeping their Mothers Alive (Global Plan) as a key aspect of both plans’. The intended outcomes of this consultation were broadly stated as: identification of concrete opportunities for progress as well as obstacles to such progress; and documentation of experiences on successes and failures. Through a combination of interactive sessions, the Consultation reviewed progress at country level, what technical support exists, and good practices within the countries. Participants at the Consultation underscored the need for ministries of health, continental mechanisms such as the AUC, regional organisations such as ECSA HC, SADC, WAHO and OCEAC, development partners, faith-based organisations, funding agencies, academic and research institutions, and civil society organisations to give priority to efforts towards increasing access to health workers at the frontline for better maternal and child survival and provided a communique of recommendations on actions to achieve this.
3. Equity in Health
As the 2015 deadline for the Millennium Development Goals (MDGs) approaches, development experts are debating a new question: What comes next? In this article, the writer suggests any new global agreement that follows the MDGs should focus more on rich countries’ responsibilities, an issue that was absent from the original MDGs. It should emphasise policies beyond aid and trade that have an equal, if not greater, impact on poor countries’ development prospects. A short list of such policies would include: carbon taxes and other measures to ameliorate climate change; more work visas to allow larger temporary migration flows from poor countries; strict controls on arms sales to developing nations; reduced support for repressive regimes; and improved sharing of financial information to reduce money laundering and tax avoidance. Most of these measures are actually aimed at reducing damage that results from rich countries’ conduct. While rich countries are certain to resist any new commitments, the author notes that most of these measures do not cost money, and, as the MDGs have shown, setting targets can be used to mobilise action from rich-country governments.
This 2012 progress report examines trends in child mortality estimates since 1990, and shows that major reductions have been made in under-five mortality rates in all regions and diverse countries. Data shows that the number of children under the age of five dying globally fell from nearly 12 million in 1990 to an estimated 6.9 million in 2011. Recommendations from the report include increasing efforts among high-burden populations, focusing on high-impact solutions and creating a supportive environment for child survival by addressing poverty, geographic isolation, educational disadvantage, child protection violations and gender exclusion. Governments should take bold steps that prioritise both efficiency and mutual accountability, and harness the growing consensus that economic and social progress should be equitable.
Many commentators, including the World Health Organisation (WHO), have advocated progress towards universal health coverage on the grounds that it leads to improvements in population health. In this report, the authors reviewed the most robust cross-country empirical evidence on the links between expansions in coverage and population health outcomes, with a focus on the health effects of extended risk pooling and prepayment as key indicators of progress towards universal coverage across health systems. The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people. However, the available evidence base is limited by data and methodological constraints, and further research is needed to understand better the ways in which the effectiveness of extended health coverage can be maximised, including the effects of factors such as the quality of institutions and governance.
According to this report, substantial progress has been made towards achieving Millennium Development Goal (MDG) 4, namely to reduce global child mortality by two-thirds by 2015. The number of under-five deaths worldwide has declined from nearly 12 million in 1990 to 6.9 million in 2011. Since 1990 the global under-five mortality rate has dropped 41% and the annual rate of reduction in under-five mortality has accelerated from 1.8% a year over 1990–2000 to 3.2% over 2000–2011, but it remains insufficient to reach MDG 4. Globally, more than a third of under-five deaths are attributable to undernutrition. The highest rates of child mortality are still in sub-Saharan Africa, where 1 in 9 children dies before age five and Southern Asia (1 in 16). As under-five mortality rates have fallen more sharply elsewhere, the disparity between these two regions and the rest of the world has grown. By 2050, 1 in 3 children will be born in sub-Saharan Africa, and almost 1 in 3 will live there, so the global number of under-five deaths may stagnate or even increase without more progress in the region.
South Africa is one of the countries in which neonatal mortality has remained the same or increased over the last 20 years. The major causes of neonatal deaths are related to prematurity and intrapartum hypoxia. In this paper, the authors discuss a number of interventions that have been shown to reduce neonatal deaths and, if implemented on a wider scale, could reduce neonatal deaths significantly. These interventions include providing basic and comprehensive emergency obstetric care, use of antenatal steroids for women in preterm labour, training in immediate care of the newborn and neonatal resuscitation, and post-resuscitation management and ongoing neonatal care (e.g. CPAP), especially to babies who are born preterm.
The objective of this paper was to determine how social and economic factors contribute to disability differences between older men and women. Researchers analysed World Health Survey data from 57 countries drawn from all income groups, including in their final sample a total of 63,638 respondents aged 50 and older, of whom 28,568 were males and 35,070 females. The researchers computed disability prevalence for males and females by socio-demographic factors, and estimated the adjusted effects of each social determinant on disability for males and females. Results indicated that prevalence of disability among women compared with men aged 50+ years was 40.1% vs. 23.8%. Lower levels of education and economic status were associated with disability in women and men. Approximately 45% of the sex inequality in disability could be be attributed to differences in the distribution of socio-demographic factors, while approximately 55% of the inequality resulted from differences in the effects of the determinants. The authors call for data and methodologies that can identify how social, biological and other factors separately contribute to the health decrements facing men and women as they age. This study highlights the need for action to address social structures and institutional practices that impact unfairly on the health of older men and women.
The main goal of South Africa’s new strategic healthcare and nutrition plan for women and children is to reduce by 10% by 2016: the maternal mortality ratio (MMR); the neonatal mortality rate (NMR); the infant mortality rate (IMR); and the child mortality rate. What are the key strategies for the implementation of the priority interventions? These include addressing inequity and social determinants of health; developing a framework for MNCWH and nutrition services; strengthening community-based MNCWH and nutrition interventions; increasing provision of key MNCWH and nutrition interventions at primary health care and district levels; strengthening the capacity of the health system, as well as human resource capacity, to support the provision of these services; and strengthening systems for monitoring and evaluation of outcomes. The plan indentifies a number of factors that can be considered critical for success. Government will have to address the social determinants of health, specifically targeting most under resourced districts, as well as commit to strengthening the country’s health system, with a specific focus on primary health care services. Support from key stakeholders will be crucial, including the National Department of Health, Provincial Departments of Health, developmental partners and civil society. Resource mobilisation should be undertaken, in terms of financial support and human resources and MNCWH and Nutrition capacity should be strengthened at national, provincial, district and sub-district levels.
4. Values, Policies and Rights
The writer of this article discusses conflicting conditions for homosexual people in Kenya with impact on health. On the one hand there has been increased visibility of Kenya’s gay community in recent years, despite the fact that homosexuality is illegal in the country, with greater social networking and collaborative efforts between the gay community and sex workers, civil society, parastatals and professional bodies. On the other hand the author also observes harmful practices of ‘corrective rape’ (where lesbians are raped), homophobia in schools, high suicide rates among gays and lesbians, and discrimination such as in the stoning of a suspected gay man in a Nairobi slum.
Since first publication of this guidance in 2003, a considerable amount of new data have been produced and published, relating to epidemiological, clinical, service delivery, legal and human rights aspects of providing safe abortion care. Therefore, preparation for this revision of the guidance included extensive literature review and updating of recommendations related to service delivery, legal and policy issues, and the conduct of new systematic reviews and updates of outdated systematic reviews to provide the evidence for recommendations related to clinical questions prioritised by an international panel of experts. The substantial revisions in this update reflect changes in methods of abortion and related care, service delivery as it applies to the availability and use of new methods, and application of human rights for policy-making and legislation related to abortion, among other topics. Recommendations in the 2003 guidance for which there was no new evidence remain unchanged and are also included in the new edition.
This report was submitted to the United Nations Human Rights Committee to inform its review of Kenya’s implementation of the Provisions of the International Covenant on Civil and Political Rights (ICCPR) in relation to torture. It adopts a thematic approach and specifically focuses on legal issues that relate to protection from torture and cruel and degrading treatment under the Covenant, including extra-judicial killings, the death penalty, the principle of non-refoulement, treatment of prisoners, access to adequate medical care for prisoners and the right to a fair trial. It integrates a gender and child-rights perspective and examines the problems related to domestic violence, female genital mutilation and reproductive health rights. The overall conclusion is that, while Kenya has endeavoured to include the principles of the ICCPR in its newly promulgated Constitution of 2010 and legislative framework, there continue to be important gaps, with inadequate legislation for criminalising torture and lenient sentences for those found guilty.
Urbanisation is one of Africa’s most pressing issues, according to this publication by African Centre for Cities. However, most political and policy leaders remain in denial about its centrality and urgency. The phenomenon represents the most complex and intractable policy questions and as long as Africans do not take responsibility to shift the contemporary situation of policy failure, we are in for a crisis, says the African centre for Cities. This publication is intended to be a resource to policy activists in African governments, development agencies, social movements, universities and business sectors who are committed to addressing the current inertia surrounding urbanisation policy development and should be of help activists to develop a clear agenda on urbanisation on the continent.
This editorial welcomes the World Health Organisation’s (WHO) update of its 2003 publication ‘Safe abortion: Technical and policy guidance for health systems’. In updating its guidance on safe abortion, WHO has responded to a major neglected public health need of women, Fathalla and Cook argue here. Unsafe induced abortion is not only a public health problem, it is also a human rights issue. As governments are obligated by their national constitutions or by legally binding international human rights conventions to protect the right to the highest attainable standard of health, they should be increasingly applying human rights principles to facilitate women’s transparent access to safe abortion services in their countries. The WHO update highlights the growing trend for national courts and regional and international human rights bodies, including the United Nations treaty monitoring bodies, to take a rights-based approach to this issue. The authors call for abortion to be decriminalised, as well as for further research aimed at developing simpler, improved methods for performing induced abortion.
5. Health equity in economic and trade policies
The lack of a global legal framework to guide national action and international cooperation to reduce risk factors related to alcohol abuse and unhealthy diet significantly hinders the capacity of nations worldwide to unilaterally and collectively curb the expanding epidemics of non-communicable diseases (NCDs), according to this paper. A number of commentators have suggested the adoption of comprehensive treaties or framework conventions on obesity, or alcohol or both. Given the legal, political, budgetary, and time-related limitations to the development and adoption of all-encompassing treaty regimes to address obesity and alcohol abuse, the authors recommend an alternative legal strategy to counter these rising NCD epidemics. In particular, they call for the prompt adoption of a WHO/UNICEF global code of practice on the marketing of unhealthy foods and beverages to children. Such a non-binding international legal instrument has significant advantages over a treaty approach at the present time. It would provide a much-needed step towards advancing meaningful engagement with and holding to account all relevant actors, including national governments, private industry, and UN agencies, in protecting children everywhere from harm. The WHO Framework Convention on Tobacco Control (“FCTC”) addresses one of the major risk factors contributing to NCDs by establishing a global legal framework to counter the tobacco pandemic: in response, the authors call on the global community to act collectively to establish a legal architecture to regulate a central component of these two other major risk factors.
On 6 September 2012, Japan’s ruling party, the House of Representatives, ratified the controversial Anti-Counterfeiting Trade Agreement (ACTA) in the absence of opposition parties, counting only the votes of the ruling party. Critics have denounced the move as undemocratic, also claiming that the Japanese mass media has marginalised the issue in the arena of public debate. Meanwhile, processes in several ACTA signatory states seem to be stalled. The author of this article notes that it is unlikely that ACTA will become an international treaty, with an apparent stalemate between the United States administration and legislators about ratification procedures, and the European Union’s recent vote against ratifying the agreement. Besides Japan, seven governments are reported to have signed ACTA, namely Australia, Canada, Morocco, New Zealand, Singapore, South Korea and the United States. Switzerland has not signed nor ratified. ACTA will have significant repercussions for public health, as the treaty aims to strengthen patent protection for pharmaceutical companies, wuth negative consequences for the production of affordable generic medicines in the developing world.
African, Caribbean and Pacific countries have two more years to negotiate economic partnership agreements (EPAs) with the European Union (EU), before the decision is taken to withdraw their free access to the EU market, according to amendments to the market access regulation adopted on 13 September 2012. Members of the European Parliament (MEPs) voted to extend the 2014 deadline proposed by the Commission and give ACP countries until 2016 to ratify their EPAs before losing the right to duty-and-quota-free access to the EU that they have been enjoying since 2007. The content of the EPAs have been contested in some countries in Africa. MEPs consider that unlimited and unconditional preferences are not a sustainable option but also agree that the EU should allow them a ‘realistic timeframe’ to work towards ‘fair and development-focused’ EPAs with African, Caribbean and Pacific (ACP) partners. Eight countries have not ratified EPAs: Botswana, Namibia, Cameroon, Fiji, Ghana, Ivory Coast, Kenya and Swaziland.
Swiss pharmaceutical company Novartis has begun its court case to appeal in the Indian Supreme Court in a final bid to overturn a ruling earlier this year to prevent the company from renewing its patents on life-saving drugs. If Novartis wins the appeal, it will undermine a key public health safeguard in Indian patent law specifically designed to prevent drug companies from abusive patenting practices that keep medicine prices high, says international humanitarian medical organisation Médecins Sans Frontières (MSF), which relies on affordable generic drugs produced in India to carry out its work in 68 countries. MSF alleges that, for the past six years, Novartis has been trying to browbeat India into changing Section 3d of India’s patent law, which says that a new form of a known medicine can only be patented if it shows significantly improved therapeutic efficacy over existing compounds. This is a provision to stop the common industry practice of extending, or ‘evergreening,’ their patent monopolies for routine modifications of known compounds. Section 3d, which is in line with international trade rules, formed the basis for Novartis not being granted a patent for its cancer drug imatinib mesylate (marketed as Gleevec) in 2006, as Novartis’ patent application was on a new form of the imatinib molecule already described several years previously in patents in the United States and other developed countries.
Countries have reached universal health coverage by different paths and with varying health systems. Nonetheless, the trajectory toward universal health coverage regularly has three common features, identified in this paper. The first is a political process driven by a variety of social forces to create public programmes or regulations that expand access to care, improve equity, and pool financial risks. The second is a growth in incomes and a concomitant rise in health spending, which buys more health services for more people. The third is an increase in the share of health spending that is pooled rather than paid out-of-pocket by households. This pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care – in other cases it is mobilised in the form of contributions to mandatory insurance schemes. The predominance of pooled spending is a necessary condition (but not sufficient) for achieving universal health coverage. The authors describe common patterns in countries that have successfully provided universal access to health care and consider how economic growth, demographics, technology, politics, and health spending have intersected to bring about this major development in public health.
Much has changed in the world since economic partnership agreements (EPAs) negotiations between the European Union (EU) and African, Caribbean and Pacific (ACP) countries started 10 years ago. Emerging developing countries have increased their share of the world market and China has become one of the largest trading nations, while ACP countries have diversified trading partners and external funders. Today both the EU and the ACP countries struggle with the mess that the extended and deadlocked EPA negotiations have created. The interim EPAs have complicated the negotiations even further, causing rifts in the regions, and the refusal of the EU to swiftly amend them left the negotiations stuck with protracted discussions on contentious issues. The author of this article calls on the EU not to force ACP countries to accept agreements simply to avoid losing trade preferences. And he argues further that it is a problem when trade negotiations are held behind closed doors and policies are based on secret (unless leaked) mandates, with hardly any parliamentary involvement. Economic reform is too important to all layers of society to be left to behind closed door negotiations.
6. Poverty and health
Food security in Central Africa has been worsening over the last two decades. To address this challenge, Central African states have embarked on a process to develop a common agricultural policy and to put the Comprehensive Africa Agriculture Development Programme (CAADP) into practice. Farmers’ organisations from all member states are now shaping up to influence these policy-making processes at national and regional level in the coming months. The main challenge for them is to identify proposals that respond to the needs and priorities of all the farmers they represent, and to ensure that policy makers will take them into account during negotiations. In doing so, they could learn from their counterparts in West Africa, argues the writer of this blog, the Deputy Programme Manager for Food Security at ECDPM. West African farmers managed to play an important role in the formulation of the region’s common agricultural policy through their regional farmers’ network ROPPA. Key to ROPPA’s success was its participation in decision-making organs and meetings, but more so, its preparations for these events, which included consultations of ROPPA’s members at regional, national and local levels, analytical work to check and back their arguments, and a continuous search for allies among national and regional authorities and non-state actors.
During the recent years of economic decline in Zimbabwe, many of the formal processes for land transfer have been weakened or even abandoned, local government has faced a rolling crisis of sustainability and the collapse of the national currency has ascribed a greater value to urban land as a commodity, according to this report. At the same time, there are signs now emerging of community-driven innovation and participation in urban management. The need to revive and renew human resources within local government has been widely supported, while UN-Habitat has recommended that the Town and Country Planning Acts should be reviewed, and various external funders are considering future assistance to the reform of legal and policy frameworks for urban development. There is thus a strong probability that fundamental changes to the systems and structures of urban land governance in Zimbabwe will be implemented in the foreseeable future, the authors argue. In this scoping study on urban land markets in Zimbabwe, they investigate and identify opportunities for practical partnerships in the field of urban management and land studies, and propose a potential programme of work that could contribute to the more effective functioning of Zimbabwe’s urban land markets.
This cross-sectional community-based nutrition survey was conducted in Northwest Ethiopia with 356 urban residents (71.3% female and 28.7% male). Subjects were selected by random sampling. Socio-demographic data was collected by questionnaire and body measurements taken. Results indicated that, of the sample, 12.9% were undernourished, 21.3% were overweight and 5.9% were obese. Men were taller, heavier and had a higher waist-to-hip ratio compared to women. Fish, fruits and vegetables were consumed ‘less frequently’ or ‘never at all’ by a large proportion of the subjects. Mean energy intake fell below the estimated energy requirements in women, but was significantly higher in men. Protein intake was inadequate in 11.2% of the participants whereas only 2.8% reported carbohydrate intake below the recommended dietary allowance. Significant micronutrient deficiencies were also noted. The overall risk of nutritional inadequacy among the study participants was high, along with their poor dietary intake. The authors call for nutritional programmes in urban settings to address the micronutrient and macronutrient deficiencies identified here, to help prevent nutrition-related diseases later in life.
In 2010, Urban LandMark undertook a survey of 568 households in two peri-urban sites in Maputo, Hulene B and Luis Cabral, to understand how ordinary urban dwellers access, hold and transact land. Although they are both located in the suburbs of Maputo city, Luis Cabral was established as a settlement for workers from the Maputo harbour, and has a longer history of urban settlement than Hulene B. Hulene B houses mainly internally displaced people from the civil war and floods. While most the plots in Luis Cabral have been surveyed, have wider roads and are generally better planned, Hulene B is largely unplanned. Despite the differences between the two neighbourhoods, the study found no variations in the nature of land ownership and tenure. In both settlements, the vast majority of households do not have formal title. Most land is acquired through mechanisms that are outside the formal land registration system. These findings challenge conventional understandings of the formal and informal sector in African cities. First, informal systems are not always the chaotic mess they are perceived to be. Secondly, although much of the land is accessed and secured verbally or through agreements with social networks, state agents are often critical to lending credibility to informal practices. Thirdly, despite the fact that few households in the study areas have formal title to land or documentation, 68% of households reported that their sense of rights to place were strong because the local land practices had social legitimacy.
For this report, researchers interviewed 200 farmers in Zambia, Zimbabwe, Mozambique, Malawi and South Africa about their experiences of changes in climate. They found considerable agreement between farmers across countries that they are observing changes in climate. Climate change is likely to reduce yields and increase food prices, with serious effects on both farmers and consumers. But farmers are already actively experimenting and changing agricultural practices and pursuing ways to diversify livelihoods in light of both the new changes to their climate and other multiple stresses. In some cases, these changes can be considered actual or potential successes in adapting to climate change; in other cases they may be simply coping or using maladaptive strategies, particularly where they create environmental degradation. Furthermore, whereas large-scale farmers, in the main, have access to the resources needed to adapt, small-scale farmers face major obstacles. These obstacles may not only prevent adaptation but also lead farmers into maladaptation, for want of other choices. Major new resources must be raised from domestic, regional and international levels to focus on and build the adaptive capacity of small-scale farmers and sustain levels of food production into the future, the report concludes.
7. Equitable health services
In this study, researchers evaluated the effect of a community health worker-based, interpersonal communication campaign for increasing insecticide-treated mosquito net (ITN) use among children in Luangwa District, Zambia, an area with near universal coverage of ITNs and moderate to low malaria parasite prevalence. Results indicated that ITN use among children younger than five years old in households with one ITN increased overall from 54 % in 2008 to 81 % in 2010. However, there was no difference in increase between the treatment and control arms in 2010. ITN use also increased among children five to 14 years old from 37 % in 2008 to 68 % in 2010. There was no indication that the community health worker-based intervention activities had a significant effect on increasing ITN use in this context, over and above what is already being done to disseminate information on the importance of using an ITN to prevent malaria infection. Contamination across control communities, coupled with linear settlement patterns and subsequent behavioural norms related to communication in the area, likely contributed to the observed increase in net use and null effect in this study, the authors conclude.
The authors of this study prospectively assessed resistance to second-line anti-tuberculosis drugs in eight countries, including South Africa. From 1 January 2005 to 31 December 2008, they enrolled consecutive adults with locally confirmed pulmonary multi-drug-resistant (MDR) tuberculosis at the start of second-line treatment. Among 1,278 patients, 43.7% showed resistance to at least one second-line drug, 20% to at least one second-line injectable drug and 12.9% to at least one fluoroquinolone. A total of 6.7% of patients had extremely drug-resistant (XDR) tuberculosis. Previous treatment with second-line drugs was consistently the strongest risk factor for resistance to these drugs, which increased the risk of XDR tuberculosis by more than four times. Fluoroquinolone resistance and XDR tuberculosis were more frequent in women than in men. Unemployment, alcohol abuse and smoking were associated with resistance to second-line injectable drugs across countries. Other risk factors differed between drugs and countries. The authors recommend that representative drug-susceptibility results should guide in-country policies for laboratory capacity and diagnostic strategies.
This study was initiated to establish if any South African ethnomedicinal plants (indigenous or exotic) that have been reported to be used traditionally to repel or kill mosquitoes may exhibit effective mosquito larvicidal properties. Researchers tested extracts of a selection of plant taxa sourced in South Africa for larvicidal properties. Preliminary screening of crude extracts revealed substantial variation in toxicity with 24 of the 381 samples displaying 100% larval mortality within the seven-day exposure period. The researchers then selected four of the high-activity plants and subjected them to bioassay guided fractionation. The results of the testing of the fractions generated identified one fraction of the plant Toddalia asiatica as being very potent against the An. arabiensis larvae. These results have initiated further research into isolating the active compound and developing a malaria vector control tool.
Induction of labour is being increasingly used to prevent adverse outcomes in the mother and the newborn. In this study, researchers assessed the prevalence of induction of labour and determinants of its use in Africa. They performed secondary analysis of the WHO Global Survey of Maternal and Newborn Health of 2004 and 2005 and assessed unmet needs for specific obstetric indications at country level. A total of 83,437 deliveries were recorded in the seven participating countries, including Angola, the Democratic Republic of Congo, Kenya and Uganda. The average rate of induction was 4.4% and the researchers found that induction was associated with reduction of stillbirths and perinatal deaths. Unmet need for induction ranged between 66% and 80.2% across countries. Determinants of having an induction were place of residence, duration of schooling, type of health facility and level of antenatal care. As utilisation of induction of labour in health facilities in Africa is very low and unmet need very high, the authors call for improvements in social and health infrastructure.
8. Human Resources
To increase the quality of service delivery in the public health sector, Tanzania has implemented the Open Performance Review and Appraisal System (OPRAS) and a new results-based payment system, Payment for Performance (P4P). This paper addresses health workers' experiences with OPRAS, expectations towards P4P and how lessons learned from OPRAS can assist in the implementation of P4P. The broader aim is to generate knowledge on health worker motivation in low-income contexts. The authors conducted focus group discussions and in-depth interviews with public health nursing staff, clinicians and administrators. Results showed a general reluctance towards OPRAS as health workers did not see the system as leading to financial gains nor did it provide feedback on performance. In contrast, great expectations were expressed towards P4P due to its prospects of topping up salaries, but the links between the two performance enhancing tools were unclear. The authors conclude that health workers respond to performance enhancing tools based on whether the tools are found appropriate or yield any tangible benefits.
As significant numbers of medical school students continue to emigrate from Malawi upon graduation, the authors of this study explored the postgraduate plans of current medical students to find out why, and to determine the extent to which their decision is influenced by their background. A self-administered questionnaire was distributed to all medical and premedical students on campus over one week and collected by an independent researcher. One hundred and forty-nine students completed the questionnaire out of a student body of 312, a response rate of 48%. When questioned on their plans for after graduation, 49% of students said they planned to stay in Malawi. However, 38.9% were planning to leave Malawi immediately upon graduation. Medical students who completed a 'premedical' foundation year at the medical school were significantly more likely to have immediate plans to stay in Malawi compared to those who completed A-levels, an advanced school-leaving qualification. The authors caution that the government’s plans to substantially upscale medical education may be undermined unless more medical students plan to work in Malawi after graduation.
In this study, researchers examined health care workers' attitudes toward sexual and reproductive health services to unmarried adolescents in Ethiopia. The study took the form of a descriptive cross-sectional survey, which was conducted among 423 health care service providers working in eastern Ethiopia in 2010. A pre-tested structured questionnaire was used to collect data. The results showed that most health workers had a positive attitude towards providing reproductive health services to unmarried adolescents, with 30% having a negative attitude. Close to half (46.5%) of the respondents were opposed to providing family planning to unmarried adolescents, while about 13% of health workers felt penal rules and regulations should be implemented against adolescents who practice pre-marital sexual intercourse. Negative attitudes were associated with being married, lower education level, being a health extension worker and lack of training on reproductive health services. The authors call for a targeted effort toward alleviating negative attitudes toward adolescent-friendly reproductive health service and re-enforcing the positive ones.
In 2011 an experienced HIV nurse from the UK was deployed for three months to act as a mentor to nurses learning to initiate antiretroviral therapy (ART) in primary care clinics in a small town in the Eastern Cape, South Africa. In this study, researchers assessed effectiveness of the mentoring process. A review of 286 existing pre-ART patient files was carried out and lost-to-follow-up HIV patients were recalled. Results showed that only 24% of patients had attended the clinics within the preceding six months and 20% had not attended for longer than two years. Two lay counsellors visited 222 patients to encourage them to return to care: of these 23% were untraceable, 4% had relocated, 10% declined and 3% had died. In the six weeks following recall, 18% of patients returned to the clinics. CD4 count testing was repeated and screening for tuberculosis (TB) and other opportunistic infections was performed for all patients. ART was initiated in 25% of patients, while isionazid prophylaxis was initiated in 45%. The cost of recall was R130 (US$16) per patient. Within six months, all clinics began providing full ART services, 17 professional nurses were mentored and they initiated ART in 55 patients. The authors conclude that mentoring played an important role in professional nurse training and support. Recall of lost-to-follow-up patients was shown to be feasible and effective in improving ART services in rural settings.
The authors of this study aimed to assess the effects on mortality, viral suppression, and other health outcomes and quality indicators of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) programme, which provides educational outreach training of nurses to initiate and represcribe ART, and to decentralise care. They undertook a pragmatic, parallel, cluster-randomised trial in South Africa between 28 January 2008 and 30 June 2010, randomly assigning 31 primary-care ART clinics to implement the STRETCH programme (intervention group) or to continue with standard care (control group). A total of 5,390 patients in cohort 1 and 3,029 in cohort 2 were in the intervention group, and 3,862 in cohort 1 and 3,202 in cohort 2 were in the control group. Median follow-up was 16.3 months in cohort 1 and 18 months in cohort 2. In cohort 1, 20% of patients analysed in the intervention group and 19% of patients in the control group with known vital status had died at the end of the trial. Time to death did not differ. In a preplanned subgroup analysis of patients with baseline CD4 counts of 201-350 cells per μL, mortality was slightly lower in the intervention group than in the control group, but it did not differ between groups in patients with baseline CD4 of 200 cells per μL or less. In cohort 2, viral load suppression 12 months after enrolment was equivalent in intervention (71%) and control groups (70%). Interpretation suggests that expansion of primary-care nurses' roles to include ART initiation and represcription can be done safely, and improve health outcomes and quality of care, but might not reduce time to ART or mortality.
9. Public-Private Mix
In this annual report, the South African Council for Medical Schemes details its support for the Department of Health in its efforts to strategically review the entire health system of South Africa. Council provided input to the technical sub-committees of the Ministerial Advisory Committee on the proposed National Health Insurance (NHI) system, and submitted a formal document on the NHI policy paper. Ever-escalating costs in the industry, which are driven by private hospitals and medical specialists, have always been one of Council’s concerns, and this financial year proved no different. This worrying trend of inflation-exceeding price increases in the private health sector has serious and negative implications for the well-being and sustainability of the entire health system. Council therefore continued to motivate for the establishment of a regulator to oversee the price determination of private healthcare provision. Council believes that a real need exists for a platform where medical schemes and healthcare providers can meet and negotiate prices for the benefit of all South African consumers. Private healthcare providers should also be regulated, specifically the hospitals and specialists. The practice where beneficiaries are exposed to unfair billing practices must be addressed.
The authors identify two types of capital for foreign investment: capital of type K and capital of type N. While capital of type K is used in production of all the sectors of the economy, capital of type N is specific to the healthcare sector. Their analysis finds that an FDI of capital of type N although it raises the human capital formation may lower social welfare. On the contrary, an inflow of foreign capital of type K is likely to be welfare-improving. Although these effects crucially hinge on different structural factors e.g. the degree of
labour market imperfection, trade-related and technological factors these can at least question the desirability of allowing the entry of foreign capital in the healthcare sector directly.
10. Resource allocation and health financing
South Africa suffers a particularly severe lack of pharmacists, a problem that could possibly be addressed by task shifting. In this study, researchers compared the costs of two task-shifting approaches to the dispensing of anti-retroviral therapy (ART) - indirectly supervised pharmacist's assistants (ISPA) and nurse-based pharmaceutical care models - against the standard of care, where only a pharmacist may dispense ART. They sampled six facilities in the Western Cape province of South Africa, and interviewed 230 patients. Data from patient exit interviews, time and motion studies, expert interviews and staff cost calculations were collated to estimate cost from the societal perspective. The ISPA model was found to be the least costly task-shifting pharmaceutical model. However, patients preferred receiving medication from the nurse. This related to a fear of stigma and being identified by virtue of receiving ART at the pharmacy. While these models are not mutually exclusive, and a variety of pharmaceutical care models will be necessary for scale up, the authors argue that it is useful to consider the impact of implementing these models on the provider, patient access to treatment and difficulties in implementation.
Members of Parliament in Uganda threatened in September to block the passage of Uganda’s 2013 budget unless there was a substantial increase in funding to address the health crisis in the country. After the three-week deadlock, Parliament last week agreed to pass this financial year’s budget after the executive promised to boost health sector funding in a supplementary budget. The government also announced that salaries for doctors working in health centres threes and fours would be doubled to Shs 2.5m per month. The impasse emanated from the report of Parliament’s health committee, which indicated that the health sector had a funding gap of Shs 260bn. The report further noted that Shs 121bn was required to retain health workers currently on the payroll. Besides, the sector also desires Shs 61bn to recruit an additional 6,905 health workers countrywide, and Shs 78bn to motivate health workers on duty. This prompted the Budget committee to propose a cut of Shs 39.2bn from consumptive allocations in other government departments to fill the funding gap, something that the executive objected to. It took the charm offensive of President Museveni to persuade NRM MPs –the dominant majority in the House – that the funding gap be addressed through a supplementary.
From 2005 and leading up to the 2010 FIFA Soccer World Cup, South Africa massively stepped up its investment in rail, road and air transport infrastructure. Typically, the resultant increase in demand for nearby land for business and so on tended to increase property values, providing local government with the opportunity to accumulate some of the value created by using various 'value capture' mechanisms. Value capture is a public financing technique that 'captures' a part or all of the increases in private land values that result from public investment by imposing a tax on the property or requiring an in-kind contribution, such as land or improvements. The additional revenue can be used to finance infrastructure for economic growth and urban development, or for poverty alleviation. The infrastructure financed in turn leverages private investment in the area as it improves. Despite these advantages, local authorities in South Africa have adopted few value capture mechanisms to date. Urban LandMark has therefore developed this booklet, which provides the user with an opportunity to learn about how value is created at transport interchange sites, which value capture instruments would most effectively capture that value for public good, and what legislative, policy and fiscal changes are required to allow for greater use of such mechanisms.
The commitment made by economically advanced Northern countries to spend 0.7% of their gross national income on aid may no longer be a major factor in the progress of developing countries, according to this blog. Instead, the biggest sources of financing for development now available to Southern governments are domestic revenue and remittance flows from migrants to their home countries. So if the 0.7% target is irrelevant, how can development efforts be measured in a ‘post-0.7 world’? The writer argues that future assessments of overseas development assistance will need a much stronger focus on actions in policy areas beyond aid. For instance, a reporting system could be put in place to check how far external funders promoted development other than by giving development assistance. This requires monitoring national policies and international policy positions on issues such as visa facilitation, banking secrecy, arms export, agricultural subsidies, fisheries and renewable energy. Information on these and other areas could be compiled and quantified to compare countries' performance over time or with peers. This would provide good indications of how development friendly a external funder’s policies and international positions actually are. For this purpose, the writer recommends the 2003 Commitment to Development Index.
Researchers in this study analysed nine low-income and lower-middle-income countries in Africa and Asia that have implemented national health insurance reforms designed to move towards universal health coverage. Using the functions-of-health-systems framework, they first describe these countries' approaches to raising prepaid revenues, pooling risk, and purchasing services. Then, using the coverage-box framework, they assess their progress across three dimensions of coverage: who, what services, and what proportion of health costs are covered. Their findings revealed some patterns in the structure of these countries' reforms, such as use of tax revenues to subsidise target populations, steps towards broader risk pools, and emphasis on purchasing services through demand-side financing mechanisms. However, none of the reforms purely conformed to common health-system archetypes, nor were they identical to each other. Trends in these countries' progress towards universal coverage include increasing enrolment in government health insurance, a movement towards expanded benefits packages, and decreasing out-of-pocket spending accompanied by increasing government share of spending on health. Common, comparable indicators of progress towards universal coverage are needed to enable countries undergoing reforms to assess outcomes and make midcourse corrections in policy and implementation.
The objective of this study was to evaluate the impact of health insurance on resource mobilisation, financial protection, service utilisation, quality of care, social inclusion and community empowerment in low- and lower-middle-income countries in Africa and Asia. A literature review was undertaken and 159 studies were included – 68 in Africa and 91 in Asia. Most African studies reported on community-based health insurance (CBHI) and were of relatively high quality, whereas social health insurance (SHI) studies were mostly Asian and of medium quality. Only one Asian study dealt with private health insurance (PHI). Most studies were observational, while four had randomised controls and 20 had a quasi-experimental design. In these studies, financial protection, utilisation and social inclusion were far more common subjects than resource mobilisation, quality of care or community empowerment. Strong evidence shows that CBHI and SHI improve service utilisation and protect members financially by reducing their out-of-pocket expenditure, and that CBHI improves resource mobilisation too. Weak evidence pointed to a positive effect of both SHI and CBHI on quality of care and social inclusion. The effect of SHI and CBHI on community empowerment was inconclusive and findings for PHI were also inconclusive because of a lack of studies. The authors conclude that health insurance offers some protection against the detrimental effects of user fees and a promising avenue towards universal health-care coverage.
In this study, the authors argue that a better understanding of the impact of aid on both state capacity for, and elite commitment to, sustainable development has the potential to improve practices in the field of international development. This requires better empirical insight into how external funders interact with formal and informal institutions in the countries where they work, particularly in aid-dependent countries. Furthermore, it is critical to see aid as part of a spectrum of international exchange, rather than in isolation. This implies a significant research agenda, combining quantitative and in-depth qualitative analysis, as there are barriers for more informed political analysis to inform practice. Little analysis exists of how external funders, even where they do start adopting a political perspective, do influence local institutions and the people they work with. The authors review large research programmes on politics of international development, consider the role and impact of external funders’ political economy approaches, scan the literature on aid modalities, and discuss the practices of emerging external funders, particularly China.
11. Equity and HIV/AIDS
The Cash Transfer for Orphans and Vulnerable Children programme (CT-OVC) is Kenya's flagship social protection programme, reaching 150,000 poor families with OVC aged 17 or below. Households are provided a flat unconditional cash transfer of US$25 per month. The objective of this study is to assess whether the CT-OVC has reduced HIV-related behavioral risk among adolescents. Researchers included 1,912 households in seven districts across Kenya and gathered data on sexual behaviour and other risk-related behaviours for residents aged 15-25. Main study findings indicated that the CT-OVC programme has reduced the probability of sexual debut by 6.73%. This result appears to be driven by males. The programme also reduced the proportion of adolescents with two or more partners in the last 12 months by 7.2%, and reduced the probability of two or more unprotected sex acts in the last three months for females. The authors urge government to consider establishing a large-scale, national cash transfer programme aimed at preventing HIV among adolescents by postponing sexual debut, reducing the number of partners and reducing the number of unprotected sex acts.
This study assessed the effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda on young people's sexual behaviour, HIV knowledge and attitudes. Fourteen schools were selected in two neighbouring districts, Bugesera (intervention group) and Rwamagana (control group), and 1,950 students participated. Researchers found that time trends in sexual risk behaviour (being sexually active, sex in last six months, condom use at last sex) were not significantly different in students from intervention and control schools, nor was the intervention associated with increased knowledge, perceived severity or perceived susceptibility. However, stigma was reported as significantly reduced. To explain the failure of the intervention, the authors argue that young people may prefer receiving HIV information from sources other than peers. In addition, outcome indicators were not adequate. They call for integration of peer-led prevention in holistic interventions, as well as redefining peer educators' role as focal points for sensitisation and referral to experts and services. Interventions with a narrow focus on sexual risks should be avoided.
The main aim of this study was to identify predictors of HIV testing and condom use in Mozambique. Researchers analysed nationally representative survey data collected in 2009 for two outcomes: HIV testing and condom use. Results indicated that women at a higher risk of HIV were less likely to be tested for HIV than women at a lower risk. Large wealth differentials were observed: compared to the poorest women, HIV testing was higher among the wealthiest women. Perceived quality of health services was an important predictor of HIV testing, as HIV testing was higher among women who rated health services as being of very good quality. In terms of condom use, condom use was higher among men with girlfriends or those who had casual sex. Interestingly, being tested for HIV more than two years ago was not associated with condom use, and frequent mass media exposure was neither associated with HIV testing nor with condom use. The authors argue that the focus of HIV testing should shift from married women (routinely tested during antenatal care visits) to unmarried women and women with multiple sexual partners. Although services are free, transport costs to health facilities prove a major financial barrier to HIV testing. Mechanisms should be developed to cover the cost of transport, and the cost can also be reduced by substantially increasing community-based counselling. Men should be encouraged to test for HIV periodically.
In this study, researchers aimed to identify the infant-feeding challenges that Malawian women with HIV faced when they were advised to wean their children at an early age of six months, and explore how the women adhered to their infant-feeding options while facing and managing these challenges. The study was conducted between February 2008 and April 2009 at two public health facilities in Malawi where services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were conducted with 20 HIV-positive women. Several interdependent factors including the conflicting pressures of sexual morality and the demands of nurturing and motherhood in conditions of abject poverty, impeded the participating women from following medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty maintaining their ascribed roles as respected wives, mothers and members of the society at large. Given that the infant-feeding dilemmas for women with HIV are complex, the integration of public health efforts with context-specific socio-cultural understanding is essential, the authors argue, pointing to the recent 2010 WHO guidelines on breastfeeding, which recommend breastfeeding for two years for HIV-positive Malawian mothers.
The objective of this study was to assess the extent to which children may be falsely diagnosed as HIV-infected, using data from an antiretroviral therapy (ART) site in Pretoria, South Africa, between April 2004 and March 2010. Researchers analysed 1,526 patient files, with a male-to-female ratio of 1.01:1 and median age at first visit of 20 months. Nearly half (47%) of the children were aged less than 18 months. Fifty-one children (3.3%) were found to be HIV-uninfected after repeated diagnostic tests. Incorrect laboratory results for children aged less than 18 months included 40 false-positive HIV DNA PCR tests (6.3%) and one false-positive HIV p24Ag test. An additional four children were inappropriately referred after being incorrectly labelled as HIV-infected and one child aged younger than 18 months was referred after an inappropriate diagnostic test for age was used. The authors acknowledge that urgency in ART initiation in HIV-infected children is life-saving, especially in infants, but HIV tests may produce false-positive results so health care workers should meticulously check a child’s HIV-positive status before committing them to lifelong ART.
The authors of this study argue that the promotion of harm reduction as part of a more united and comprehensive global effort will be essential to halving HIV infections among people who inject drugs by 2015. They call for legal reform aligned with HIV prevention and treatment, complemented by the meaningful involvement of people who use drugs in policy formulation, arguing that drugs users who inject are often the most marginalised in the global HIV response. However, establishing the prevalence of drug use among men who have sex with men (MSM) in different parts of the world remains a challenge, as homosexuality is criminalised and stigmatised in many countries. Recommendations to government include ensuring sufficient programme funding and staff training to generate new interventions aimed at injecting drug users and MSM, as well as disseminating information to users regarding the risks of drug abuse. The authors also call for decriminalisation of users, provided that drug rehabilitation interventions are adequately devised and implemented.
The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which researchers examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilisation of maternity services. From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up of whom 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews were conducted with community health workers, childbearing women and family members. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery. These findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.
12. Governance and participation in health
State of the Union (SOTU), a coalition of 10 civil society organisations, has urged national, regional and continental Parliaments to take a leading role in promoting the ratification and implementation of key African Union (AU) instruments and policy standards. SOTU says that the slow rate of ratification and domestication of key instruments is alarming and undermines the credibility of the AU and all its key organs, while denying millions of African citizens their fundamental freedoms and basic human rights as intended by the protocols. Although there has been some progress in the rate of ratification with a total of 118 new ratifications have been entered against the 43 instruments, more needs to be done to ensure the ratifications go hand in hand with domestication and implementation. In east, central and southern Africa, Zambia, Congo and Rwanda have performed best, having ratified five instruments each. By August 2012, only two countries, Kenya and Mauritius, had ratified the African Charter on the Values and Principles of Public Service & Administration (2011) and only 14 countries had ratified the Charter for Democracy, Elections and Governance. At this current rate, universal ratification of AU treaties would not be complete before 2053, says SOTU.
When specifically viewed with Africa’s history in mind, administrative corruption, though rampant across Africa today, is an alien culture, argues the author of this article. Pre-colonial Africa, for the most part, was founded on strong ethical values sometimes packaged in spiritual terms, but with the end result of ensuring social justice and compliance. The author argues that colonialism introduced systemic corruption across much of sub-Saharan Africa, repudiating indigenous values, standards, checks and balances. The author makes several recommendations: restoration of indigenous values and institutions; improving access to formal, informal and non-formal education; promotion of the ‘African’ nation state; and strengthening of anti-corruption institutions. The author argues that African countries should not just seek the deceptive increment in Gross Domestic Product, but real development in terms of standard of living, with health, education, food security and infrastructural growth given prominence.
Today, civil society is facing serious threats across the globe, according to this report. Civil society activists continue to face traditional forms of repression, such as imprisonment, harassment, disappearances and execution. In addition, many governments have increasingly become more subtle in their efforts to limit the space in which civil society organisations (CSOs), especially democracy and human rights groups, operate. In the report, the World Movement for Democracy (WMD) highlights the well-defined international principles protecting civil society and underscoring proper government-civil society relations, which are already embedded in international law. These principles include: the right of CSOs to entry (that is, the right of individuals to form and join CSOs); the right to operate to fulfill their legal purposes without state interference; the right to free expression; the right to communication with domestic and international partners; the right to freedom of peaceful assembly; the right to seek and secure resources, including the cross-border transfer of funds; and the state’s positive obligation to protect CSO rights. WMD calls for greater collaboration between civil society and government.
To address the research gap on health care leadership in low-income settings, researchers in this qualitative study documented the experiences of individuals in key health-care leadership roles in sub-Saharan Africa. They conducted in-person interviews with health care leaders in four countries in sub-Saharan Africa: Ethiopia, Ghana, Liberia and Rwanda. Individuals were identified by their country's minister of health as key leaders in the health sector and were nominated to serve as delegates to a global health leadership conference in June 2010, at Yale University in the United States. Five key themes emerged as important to participants in their leadership roles: having an aspirational, value-based vision for improving the future health of their countries, being self-aware and having the ability to identify and use complementary skills of others, tending to relationships, using data in decision making, and sustaining a commitment to learning. While current models of leadership capacity building only address the need for core technical and management competencies, skills relevant to managing relationships are also critical in the sub-Saharan African context, the authors argue. Developing such skills may require more time and a deeper level of engagement and collaboration than is typically invested in efforts to strengthen health systems.
Civil society space in Uganda is rapidly shrinking, says international civil society network, CIVICUS, and Uganda-based East and Horn of Africa Human Rights Defenders Project (EHAHRDP). Independent civil society organisations are being openly threatened and placed under excessive scrutiny by senior government officials. The Ugandan Parliament is currently considering the Public Order Management Bill, which would place a number of restrictions on the freedom of assembly, and violations of the proposed law carry a high penalty of two years’ imprisonment. Both CIVICUS and EHAHRDP urge the Ugandan government to respect the right of civil society actors to freely express, associate and assemble, in line with the country’s obligations under the Constitution and the International Covenant on Civil and Political Rights, to which Uganda is a party.
13. Monitoring equity and research policy
This paper examines the challenges and opportunities in establishing and sustaining north– south research partnerships in Africa through a case study of the UK-Africa Academic Partnership on Chronic Disease, which brought together multidisciplinary chronic disease researchers based in the UK and Africa to collaborate on research, inform policymaking, train and support postgraduates and create a platform for research dissemination. During the funded period researchers created a platform for research dissemination through international meetings and publications, but other goals, such as engaging in collaborative research and training postgraduates, were not as successfully realised. Enabling factors included trust and respect between core working group members, a shared commitment to achieving partnership goals, and the collective ability to develop creative strategies to overcome funding challenges. Barriers included limited funding, administrative support, and framework for monitoring and evaluating some goals. As chronic disease research partnerships in low-income regions operate within health systems that prioritise infectious diseases, their long-term sustainability will therefore depend on integrated funding systems that help build capacity, the authors argue. They identify social capital, measurable goals, administrative support, creativity and innovation and funding as five key ingredients that are essential for sustaining research partnerships.
Although most countries in sub-Saharan Africa lack an effective and comprehensive national civil registration and vital statistics system (CRVS), in the past decades the number of Health and Demographic Surveillance Systems (HDSSs) has increased throughout the region. The authors of this paper argue that, in the absence of an adequate national CRVS, HDSSs should be more effectively utilised to generate relevant public health data, and also to create local capacity for longitudinal data collection and management systems. If HDSSs get strategically located to cover different geographical regions in a country, data from these sites could be used to provide a more complete national picture of the health of the population. Strategic planning is needed at national levels to geographically locate HDSS sites and to support these through national funding mechanisms. The authors emphasise that HDSSs should not be seen as a replacement for civil registration systems. Rather, they should serve as a short- to medium-term measure to provide data for health and population planning at regional levels with possible extrapolation to national levels. HDSSs can also provide useful lessons for countries that intend to set up nationally representative sample vital registration systems in the long term.
Health decision-makers need to rely more on data to inform their decision making, according to this paper. The failure to consider empirical evidence regularly before making programme and policy decisions is due primarily to the complex causal pathway between data collection, its use, and improvement in health outcomes, she argues. Further, specific and comprehensive guidance to improve data demand and use is lacking. This paper fills this gap by providing specific recommendations for how to improve data-informed decision making by suggesting domains of interventions, activities, actors, tools, and resources to involve in the process in each step. The eight activity areas listed in the conceptual framework and the further detail provided in the logic model provide a comprehensive roadmap for how to design, monitor, and evaluate interventions to improve the demand for and use of data in decision making. More experience is needed applying the comprehensive framework in different contexts, the authors warn. The factors influencing demand for and use of data are dependent on the local context and specific needs. It is probable that all of the activity areas discussed in this paper may not need to be implemented as part of an intervention to improve the demand for and use of data; and that other activity areas not listed here, will be relevant instead. Moreover, the relative importance of each activity area is unknown, as is the level of intensity of each activity area. Nonetheless, this conceptual framework and logic model should contribute to the literature on comprehensive approaches to improving the use of data in decision making.
Exploring some of the assumptions underlying ‘evidence based’ approaches to poverty reduction, this paper argues that the discourse of Evidence-Based Policy (EBP) offers poor guidance to those who seek to ensure that social policy making is informed by the findings of social science. EBP discourse relies on a technocratic, linear understanding of the policy making process and on a naïve empiricist understanding of the role of evidence. This renders it unable to engage with the role of the underlying discursive frameworks and paradigms that render evidence meaningful and invest it with consequence: EBP discourse does not help us understand either how policy changes, or what is at stake in dialogue across the ‘research-policy divide’. Rather than simply focusing on evidence, approaches to policy change need to focus on how evidence is used in the politically loaded and ideologically compelling ‘policy narratives’ that contest rival policy frameworks. The paper considers an example from the South African context – the shift to the ‘two economies’ framework and the policy interventions associated with the Accelerated and Shared Growth Initiative for South Africa (ASGISA)– and explores the implications for approaches to research more attuned to the realities of the policymaking process. It concludes with a discussion of the implications for social researchers and policy makers.
As there is little published evidence about processes in research-policy partnerships in different contexts, this paper aims to help fill this research gap by analysing experiences of research-policy partnerships between Ministries of Health and research organisations for the implementation of the Mental Health and Poverty Project in Ghana, South Africa, Uganda and Zambia. The authors developed a conceptual framework for understanding and assessing research-policy partnerships to guide the study and collected data via semi-structured interviews with Ministry of Health Partners (MOHPs) and Research Partners (RPs) in each country. The principles of trust, openness, equality and mutual respect were identified by respondents as constituting the core of partnerships. The MOHPs and RPs had clearly defined roles, with the MOHPs largely providing political support and RPs leading the research agenda. The authors also found that taking account of influences on the partnership at individual, organisation and contextual/system levels can increase its effectiveness. A common understanding of mutually-agreed goals and objectives of the partnership is essential. Although partnerships are often established for a specific purpose, such as carrying out a particular project, the effects of partnership go beyond a particular initiative.
14. Useful Resources
This free online course is available in English and French and is intended to expose the participant to basic concepts, issues, and standards related to gender equality in the health workforce. Participants will need to complete a free registration to take the course.
This free online course provides a basic introduction to monitoring and evaluation concepts and how they apply to the field of human resources for health to inform evidence-based planning and decision-making. Participants will need to complete a free registration to take this course.
This website contains up-to-date data on global child mortality estimates. On the website, you can download the latest estimates on child mortality by the United Nations Inter-agency Group for Child Mortality Estimation. Also available for download: under-five mortality rate: country info summary, estimates and 90% uncertainty intervals; infant mortality rate: country info summary, estimates and 90% uncertainty intervals; sex-specific under-five mortality rate: estimates; neonatal mortality rate: estimates; and annual rate of reduction of under-five mortality: estimates and 90% uncertainty intervals.
Making or acting in your own film is possible with an innovative project in downtown Johannesburg, South Africa. The Home Movie Factory is a space in which anyone can go to make a movie. The project is free and is open to interested individuals or school groups, or orgabisations. The process takes about three hours from your entry into the Factory to the watching of your short movie, which will probably be between 10 and 20 minutes long. Arriving at the Factory, you start in the meeting rooms where your group’s ideas will be workshopped into a script. Each person will take a different role as the process unfolds - you may want to act, you may want to operate the camera, or you may want to be a timekeeper. You will then make use of the sets available to construct your movie and an hour or two later you will be able to watch it. The project runs for two months, starting on 1 September 2012.
15. Jobs and Announcements
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.
To celebrate its 20th anniversary, Health Systems Trust has initiated an annual Emerging Public Health Practitioner Award and is calling on all young and emerging public health professionals to submit articles for inclusion in the South African Health Review (SAHR). The winning entry will be published in the SAHR and the winner will receive a cash prize of R5,000 (US$600), as well as meet with senior HST staff members to discuss areas for future interaction and collaboration. The competition is open to South Africans under the age of 35. Judges will be assessing submissions according to the following criteria: relevance of the topic to the local and international public health community and current policy environment in South Africa; scientific rigour and intellectual clarity; degree of innovation and originality; identification of good practices and hindrances to policy implementation; and possible policy implications.
The Centre for Addiction and Mental Health (CAMH) is calling for applicants for its new Postdoctoral Fellowship in Community-Based Research. CAMH trains students and fellows in the field of mental health and addictions and the purpose of the fellowship is to provide a postdoctoral fellow with training in the techniques and principles of community-based research on mental health and addictions. Fellows can propose research in any area related to mental health and addictions, and can be supervised by any CAMH scientist. In addition to the usual academic requirements of CAMH fellows, successful candidates for this fellowship will be required to show that: their proposed research question is seen as a priority for the community under study; community members and/or organisations will be actively and meaningfully engaged in the research; and the research is likely to have a tangible impact for the community.
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 Centre for Civil Society within the School of Built Environment and Development Studies, University of KwaZulu-Natal is calling for expressions of interest in a funded PhD position supporting AIDS advocacy research. Specifically, drawing upon experiences in South Africa and other African countries in which civil society advocacy has promoted stronger HIV/AIDS policies, the project considers how systems of governance help or hinder effective policies and implementation. The candidate will be based at the Centre for Civil Society for a period of 3 years commencing in 2013, and receive a generous bursary and tuition support.
The People's Charter for Health is a statement issued by the People’s Health Movement coalition calling for universal health care. It is the most widely endorsed consensus document on health since the Alma Ata Declaration of 1978, which was the first international declaration underlining the importance of primary health care and health as a human right. The Charter was formulated by the participants of the First People's Health Assembly held at Dhaka, Bangladesh in December 2000. Nearly one-and-a-half thousand participants from 92 countries attended the Assembly, which was the culmination of 18 months of preparatory action around the globe. At the Assembly, they reviewed their problems and difficulties, shared their experiences and plans, and created the Charter, which is now the common tool of a worldwide citizen's movement committed to making universal health care a reality. All organisations and individuals who agree that health is a social, economic and political issue and, above all, a fundamental human right are invited to endorse the Charter if they have not already done so.
CHESAI is calling for expressions of interest from African policy-makers and mid- to senior-level managers in the public health system in a short-term sabbatical of one to three months in Cape Town, South Africa. CHESAI is a four-year collaborative endeavour between the Schools of Public Health of the University of Cape Town (UCT) and the University of the Western Cape (UWC), funded by the Canadian International Development Research Centre (IDRC). UCT and UWC are engaged in research and policy development with health system decision-makers on a range of health policy and systems’ issues, and also offer teaching programmes in these fields. Applicants must be working as a policy maker or manager in the public health system in an African country and have substantial experience in public health sector management and leadership to share and draw on. The sabbatical is an opportunity for you to contribute to and participate in health policy and systems research activities, such as a seminar series, and the wider academic life of the hosting organisations, an opportunity to read and engage with other practitioners and with researchers working in this field, and you will be given space to write up and present some of your experiences, with the aim to publish a paper or article.
The theme of this year’s South African HIV Clinicians Society Conference is 'Striving for Clinical Excellence'. The Conference will focus on clinical content, setting it apart from other conferences held to date in South Africa. Doctors, nurses, and pharmacists are welcome to attend presentations by senior faculty members from the region and abroad delivering talks relevant to clinical care.
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.
Are you planning to attend the Second Global Health Symposium? If so, UHC Forward is looking for bloggers to write about universal health care at the symposium for the UHC Forward website. Please email Nkem Wellington for more information at the email address given.
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