A growing number of the world’s workers are invisible to mainstream occupational health and safety (OHS): The vendor in Maputo or Nairobi trading on a city pavement, the person sorting waste on Durban’s municipal garbage dump, or the garment worker using her own home to make clothes for the local or international market.
These ‘atypical’ places of work have existed for many years, especially in developing countries. But OHS generally deals with formal workers in formal workplaces such as shops, factories, offices and mines. It does not accommodate much understanding of the social determinants of health, that is the relationship between risk, poverty and informal work, or how community health is affected by the conditions people work in.
Some risks are general to all forms of informal work, such as the low and unreliable incomes earmed, and the lack of cover by work-related health insurance. In addition, the different places of work present different types of specific risk: for example, street vendors are exposed to the sun and to vehicle fumes; stall holders in built markets face fire hazards; and those sorting waste are exposed to broken glass, putrid meat and discarded batteries on waste dumps. The different employment relationships, including self-employment, disguised waged work and informal waged work, also influence the risks that workers and their families face.
These employment patterns present challenges to the discipline and the practice of OHS. Profound institutional disconnects are becoming more apparent because of the numbers of workers involved, in the global north and south, and because of the growing public awareness of the informal economy.
OHS policies, norms and standards are usually set nationally, but it is local government that has most control over day-to-day working conditions. For example, street vendors’ conditions of work are vitally affected by the presence or absence of local government provision of public toilets, shelters for trading, lighting and refuse removal. Industrial out-workers who use their homes as places of production are affected by zoning and planning regulations, housing density and roads (including for access to health services and to markets). While calls are being made nationally for job creation through support to informal enterprises, local governments have in contrast smashed people’s livelihoods through evictions and confiscation of assets, undermining workers incomes and health. Better vertical institutional coherence between local and national levels could enhance opportunities for informal workers to earn better and more reliable incomes.
There are also horizontal institutional tensions and gaps. At national level, macro-economic policies lead to increased poverty and inequality that cannot easily be redressed by social policies. At local government level, informal workers engage with local government officials from departments such as sanitation, public health and environmental health that may have different policies and practices for regulating informal work, and that have limited understanding of the positive economic role played by the informal workers.
Is a reformed and more inclusive occupational health and safety possible, not only conceptually, but also in terms of enabling realistic compliance, with shared responsibilities between the state, informal workers, and employers (where these exist)?
Innovative work done by the ILO and others have tended to allocate most of the responsibility for ensuring health and safety to the informal workers themselves. But it is known that poorer informal workers do not easily prioritise their own health above their need to earn better incomes and thus may not invest in improving the safety of their working conditions. For example, industrial outworkers earning piece rates for stitching garments may not take regular breaks; waste pickers may not use personal protective equipment if it slows their work down; or headload porters may not carry lighter loads when they earn according to loadweight.
New evidence of opportunities for informal workers to engage constructively with local government over improved OHS is emerging from a five-country research and advocacy study in Brazil, Ghana, India, Peru and Tanzania, being done by Women in Informal Employment: Globalizing and Organizing (WIEGO). WIEGO is a network that seeks to improve the status of the working poor in the informal economy, especially women, through support for increased organization and representation; improved statistics and research; more inclusive policy processes; and more equitable trade, labour, urban planning, and social protection policies. The network implemented participatory research with worker groups, many of whom are affiliates of WIEGO, followed by institutional mapping of OHS in each country and in selected major cities. The studies highlighted that new worker movements – organizations and associations, often structured along sectoral lines – are critical for effective engagement over recognition and improved conditions. These movements emphasise the right to work, advocate for recognition of informal work and many are collecting rigorous data about the contribution of informal work to the local and national economy, in order to strengthen their position. Their highest expressed priority, after higher and more reliable returns to their labour, is for access to health services.
We are now exploring pathways of policy influence, engaging in international and national OHS platforms and dialogues, and encouraging a change in the curriculum for OHS training. Powerful vested interests are obviously stacked against such reforms, including from within mainstream OHS disciplines, and from global owners of capital who are presently ‘off the hook’ in terms of their responsibility for the health and safety of the millions of workers who produce for them. However the research in each of the countries has identified encouraging points of entry and increasingly organized advocacy for a more inclusive OHS.
For more information on the issues raised in this op-ed please visit www.wiego.org and the OHS newsletter at http://wiego.org/ohs/newsletter , or write to Francie Lund lundf@ukzn.ac.za or Laura Alfers Laura.Alfers@wiego.org
1. Editorial
2. Latest Equinet Updates
EQUINET has supported the development of needs-based resource allocation formulae in a number of east and southern African countries in the past, and the methods for developing such a formula are summarised in this paper. EQUINET's work in the region has persuaded us that it is necessary to supplement the development of a formula with other initiatives to support the successful implementation of equity in resource allocation. We believe that for real progress to be made the equity target allocations calculated through a formula must be linked explicitly to planning and budgeting processes to facilitate the gradual shifting of resources. EQUINET through UCT HEU has been developing such an approach in collaboration with the Ministry of Health in Mozambique. A broad overview of this approach, which may be of value to other countries, is outlined in this paper. A needs-based formula is used to identify the provinces and districts that are furthest from their equity targets and that should receive priority for the allocation of additional budgetary resources. A detailed ‘gap analysis’ focuses on comparing the current physical and human resources in each of these provinces and districts to national norms (developed by the Mozambique Ministry of Health based on what is regarded as the ideal or good practice).
There has been recent growth in the private for-profit health sector in East and Southern African countries. African governments are being encouraged to facilitate private sector growth through changing their policies and laws and providing funding for the private sector. This poster / leaflet explores what parts of the private sector are growing, the consequences of a growing private health sector and what civil society organisations and Ministries of Health should be doing to protect the integrity of their health systems.Civil society should contribute to monitoring funded of the private sector. Governments should not use tax funds to support the development of the private for-profit sector and should assess the impact of any proposed for-profit activities on the overall health sector before allowing it to proceed, make this impact
assessment report publicly available and put in place adequate regulations
and collect accurate information on private sector health services.
3. Equity in Health
In this article, the authors describe five children who died of clinical rabies in a three month period (September to November 2011) in the Queen Elizabeth Central Hospital. From previous experience and hospital records, this number of cases is higher than expected. The authors express concerned that difficulty in accessing post-exposure prophylaxis (PEP) rabies vaccine may be partly responsible for this rise. They make three recommendations: prompt course of active immunisation for all patients with significant exposure to proven or suspected rabid animals; the use of an intradermal immunisation regime that requires a smaller quantity of the vaccine than the intramuscular regime and gives a better antibody response; and improved dog rabies control measures.
These two challenge papers were commissioned by DANIDA to address two key questions. First, how has the development challenge changed, and how could it be understood for the future? Second, what are the implications for development agencies and development partnerships? Paper 1 by Andrew Norton, aims to support high-level discussion on the challenges facing global development. He reviews four key challenges: persistent poverty; globalisation and socio-economic transitions; sustainable development in the context of climate change; and human security, violence and conflict. He identifies major potential risks as shocks in the world economy, civil conflict and fragility, long-term resource scarcities and climate change. As a result, policy needs to engage with change, he argues, focusing on the supra-national level to deliver global public goods. Paper 2 by Andrew Rogerson picks up the themes emerging from Paper 1 to address the policy and institutional responses that are needed for inclusive and sustainable development. Like Norton, he calls for collective action within the complex institutional space occupied by many actors, policies and instruments. He further outlines three main options available to development agencies: concentrate on being an efficient disburser of official development assistance (ODA); become brokers and managers of ODA and ODA-like funds; or become deal-makers and brokers across government and internationally.
In Kenya, the Jua Kali (“hot sun,” in Swahili) industry is a major economical component of the urban informal sector, consisting primarily of outdoor manufacturing and repair shops. In August 2005, a cross-sectional survey was conducted in a large Jua Kalii area in Eldoret, Kenya. Most of the interviewees described their working conditions as poor, with about 30% of the subjects without easy access to toilets. They identified the three occupational risks as: breathing difficulties due to exposure to smoke, fumes or gases; work accidents; and eye injuries. In many of the work facilities, tools and practices require major improvements in order to provide appropriate working conditions in compliance with modern scientific knowledge and current legislation in Kenya. Changes in these areas require major financial investments and administrative commitments that are probably not easily achievable, the authors warn. But in such areas as institutional training, safety practices, and prevention, much can be accomplished with limited, affordable resources, including the provision of safe drinking water, accessible clean toilets, changes in working conditions (chairs, tables, lighting), training in safe work practices, the provision of basic protective devices such as goggles, gloves and aprons, improved methods of handling hazardous materials, and assistance in training to update work skills in light of changing technologies in their areas of employment.
In a new discussion paper prepared for the UN consultation on health in the post-2015 development agenda, WHO makes the case for using Universal Health Coverage as single overarching health goal. The current MDGs were conceived as a compact between what developing countries aspired to achieve and what the developed world needed to do to ensure progress. Future goals are argued to be more likely to be framed in terms of global challenges that require shared solutions.WHO argues that health is central to development: it is a precondition for, as well as an indicator and an outcome of progress in sustainable development. Nevertheless, while there is no doubt that health must have a place in the next generation of development, a convincing case needs to be made for how a health goal should be framed. In contrast to the current set of health-related MDGs, there is now a greater recognition of the need to focus on means as well as ends: health as a human right; health equity; equality of opportunity; global agreements (International Health Regulations, Pandemic Influenza Preparedness framework) that enhance health security; stronger and more resilient health systems; innovation and efficiency as a response to financial constraints; addressing the economic, social and environmental determinants of health; and multi-sectoral responses that see health as an outcome of all policies. In the current context promoting a long list of competing health goals will be counterproductive. The alternative is to build the case that health is a concern to all people, and is influenced by and as well contributing to policies across a wide range of sectors. The challenge then becomes one of deciding how “health” in this broad sense can be characterized in a way that is measurable and generates political traction and public understanding. The goal of achieving UHC is argued to have two inter-related components – coverage with needed health services (prevention, promotion, treatment and rehabilitation) and coverage with financial risk protection, for everyone. Universal Health Coverage is argued to be a dynamic process. It is not about a fixed minimum package, it is about making progress on several fronts: the range of services that are available to people; the proportion of the costs of those services that are covered; and the proportion of the population that are covered. Few countries reach the ideal, but all – rich and poor – can make progress. It is thus argued to have the potential to be a universal goal.
According to this article, most urban informal sector workers in Kenya live in slums, and they lack basic health and welfare services and social protection, and work in an unhealthy and unsafe work environment. Many small-scale workers operate in ramshackle structures, lack sanitary facilities or potable water, and have poor waste disposals. As their home and workplace are often the same place, this increases their vulnerability to diseases and poor health by combining undesirable living and working conditions. The blurring of the distinction between working and living conditions is related to broader problems of poverty and underdevelopment, the author argues. The major challenge is sustaining continuous improvement and making improvements that are long-lasting. He calls for greater collaboration among the different government agencies concerned with small-scale enterprises and the informal sector, such as the Department of Small and Micro-enterprises, the Ministry of Trade and Industry, and the Directorate of Occupational Safety and Health Services (DOSHS). The DOSHS should continue to collect, analyse and disseminate consistent, disaggregated statistics on safety, health and welfare in the informal economy. These statistics will enable and promote the identification of specific policies and programmes aimed at ensuring that the informal economy provides more decent jobs, as well as bringing the informal economy into the mainstream formal economy.
4. Values, Policies and Rights
A landmark ruling on 12 October 2012 by Gaborone's High Court found that gender discrimination based on Botswana's customary law is unconstitutional. The court ruled on a case brought by three sisters, all over 65 years old, challenging a Ngwaketse customary law that holds the right of inheritance to the family home belongs to the youngest son. Critically, the judge made it clear that discrimination cannot be justified on cultural grounds before rejecting out of hand the argument put forward by the Attorney General that Botswana society was not ready for gender equality, said the Southern Africa Litigation Centre (SALC), which supported the sisters' case.
In the 2010/2011 period, South Africa’s Compensation Fund in the Department of Labour paid over US$307 million in compensation for injuries and diseases sustained in the workplace, according to this press release. A department spokesperson said South Africa continued to be plagued by lack of adherence to occupational health and safety, arguing that loss of work-time because of occupational hazards means a loss of income for workers and a decline in gross domestic product (GDP). According to the Department, high-risk sectors accounted for huge compensation fund claims, including iron and steel for $49.5-million, air road transport for $41 million, building and construction for $33 million, agriculture $21 and the chemical sector for $12 million. In the light of these high costs, the Department has announced plans to start working on amendments in the country’s Occupational Health and Safety Act to be completed by the end of the 2012/13. This would include a review of amendment to regulations. The International Labour Organisation welcomed the move, calling for greater emphasis on the importance of prevention in the workplace.
These new guidelines from South Africa’s Department of Labour cover various aspects related to HIV and AIDS in the workplace, especially concerning the elimination of unfair discrimination and promotion of equal opportunity and fair treatment. The Department argues for a multilateral approach to deal with HIV, AIDS and tuberculosis (TB), and the guidelines show how to promote a safe working environment and manage the diseases in the workplace, as well monitoring and evaluation of intervention programmmes. They were developed in partnership with the International Labour Organisation (ILO). The guidelines call for prevention programmes to be sensitive to culture, gender and language with relevant information that is accessible. Employees with HIV or AIDS may not be dismissed on the basis of their status.
Hundreds of Kenyan girls, including some as young as three years old, filed a petition in the High Court on 11 October 2012 to try to force the police to investigate and prosecute rape cases they say have been ignored. The group of more than 240 girls accuse police of demanding bribes to investigate rape, refusing to record rapes unless the victims produced witnesses, and claiming victims had consented. One in five women and girls are victims of sexual violence in Kenya, according to a 2008/9 government survey. Rape is rarely reported due to stigma and a lack of faith in the police and the criminal justice system, although Kenya has strong legislation to protect children from sexual assault. Activists point out it is the first time in Kenya that action has been taken to hold police accountable for failing to protect girls from rape.
The International Conference of the Great Lakes Region (ICGLR) seeks to coordinate the efforts of a regional security community while simultaneously addressing the difficult and deep-rooted problems of sexual and gender-based violence (SGBV) in its eleven member states. However, according to the author of this brief, the ICGLR’s 2011 Kampala Declaration on SGBV puts forward the right decisions, but with too many unrealistic timeframes. If the ICGLR tries to implement all 19 decisions from the summit simultaneously, it runs the risk of trying to implement too much, in too short a timeframe. The author argues that the ICGLR and its member states should rather focus on strengthening justice mechanisms at the national and local levels, as well as increase and enhance national and local competencies to investigate, police, prosecute and punish perpetrators of SGBV. Such efforts must be aligned with a second overall ambition of reducing stigma and assisting survivors. Justice and ending stigma are vital to future prevention and punishment efforts.
Almost eighteen years after the South African government signed the ICESCR, Cabinet has approved that South Africa will ratify the United Nations International Covenant on Economic, Social and Cultural Rights (ICESCR). The ICESCR, together with the International Covenant on Civil and Political Rights (ICCPR) and the Universal Declaration on Human Rights, constitutes the International Bill of Rights. The ICESCR has been ratifed by over 160 states since it was adopted in 1966, 48 of which are African states and 11 of which are member states of the Southern African Development Community. South Africa’s ratification of the ICESCR will unambiguously signal its commitment to be legally bound by the full range of human rights recognised under international law. The ICESCR Ratification Campaign Driver Group also encourages South Africa to also ratify the Optional Protocol to the ICESCR (OP-CESCR). The Optional Protocol is an extra treaty that promotes a culture of accountability around the ICESCR, empowering vulnerable and marginalised groups to lodge individual complaints at the international level regarding violations of their socio-economic rights. The Optional Protocol is yet to come into force, as it requires 10 states to ratify it and, at present, only eight states have done so.
This Guidance Note has been developed to provide a coordinated human-rights-based approach to promoting universal access to HIV prevention, treatment, care and support in the context of adult sex work. It provides clarification and direction regarding approaches to reduce HIV risk and vulnerability in the context of sex work. Its policy and programmatic emphasis rests on three interdependent pillars: access to HIV prevention, treatment, care and support for all sex workers and their clients; supportive environments and partnerships that facilitate universal access to needed services, including life choices and occupational alternatives to sex work for those who want to leave it; and action to address structural issues related to HIV and sex work. Comprehensive rights-based programmes on HIV and sex work are argued to be critical to the success of the HIV response, and policies and programmes to address the links between HIV and sex work must recognise the social and geographic diversity of sex work, as well as the rapid changes that may occur in patterns of sex work.
5. Health equity in economic and trade policies
The world’s financial and economic crisis has taken a toll on children and poor households. High food and commodity prices, unemployment and austerity measures have aggravated persistent inequalities and contributed to a substantial rise in hunger and social tensions. Now, more than ever, investments for the world’s poor are needed to recover lost ground in pursuit of development objectives. People everywhere are demanding change. This book describes the social impacts of the crisis, policy responses to date and United Nations alternative proposals for ‘A Recovery for All.' The book guides us through the effects of the multiple crises on the poor, but it also demonstrates convincingly that the fiscal space for a basic floor of social protection that would provide effective protection from the worst social fall-out of such crises can be found. The book reminds that fiscal space is not a question of economic performance or state of development, it is first and foremost a question of political will. It is the lack of political will, i.e., cruel indifference vis-à-vis avoidable ill health, hunger, destitution and deaths, that prevents us from reducing vulnerability of those who have no means to fend for themselves.
Africa’s Pulse provides an analysis of issues shaping Africa’s economic future. According to the report, global economic activity has slowed significantly in recent months, weighed down by policy uncertainty. Despite difficult global conditions, growth in Sub-Saharan Africa has remained largely on track. However, the region’s economic prospects are vulnerable to heightened downside risks. Because Africa’s growth recovery since 2000 - the longest expansion since independence - was based on improved macroeconomic policies and political stability, the prospects of sustained growth are strong. Discoveries of minerals are bringing the prospect of large revenues for newly resource-rich countries. The challenges for these countries will be to strengthen mineral governance and also to ensure that the new revenues are invested in better health, education and jobs for their people, according to the report.
While bilateral investment treaties (BITs) can make a positive contribution to sustainable development, the benefits to host countries are not automatic, according to this speech by South African Minister of Trade and Industry, Rob Davies. He says BITs pose risks and limitations on the ability of the Government to pursue its Constitutional-based transformation agenda. As a result, Cabinet has concluded that South Africa should refrain from entering into BITs in future, except in cases of compelling economic and political circumstances. Cabinet also seeks to incorporate legitimate exceptions to investor protection where warranted by public policy considerations such as, for example for national security, health, environmental reasons or for measures to address historical injustice and or promote development. South Africa’s updated approach would aim to achieve an appropriate balance between the rights and obligations of investors, the need to provide adequate protection to foreign investors, while ensuring that constitutional obligations are upheld, and that government retains the policy space to regulate in the public interest.
There were sobering messages on global economic prospects emerging from the meeting of the World Bank and International Monetary Fund in Tokyo in early October 2012. Developing countries’ Finance Ministers and Central Bank officials voiced their concerns on the failure of developed countries to deal with their economic situation and on the policy and political paralysis preventing solutions. They argued that developing nations were also suffering from the spillover effects of policies adopted by some developed countries, particularly their provision of huge volumes of credit credit, the continuing European debt crisis, and the looming threat of the United States’ “fiscal cliff”. A major setback was the missing of the deadline to resolve the issue of altering the quotas of the International Monetary Fund with the aim of providing developing countries with a higher overall share, to improve their say over the policies of the institution. The Tokyo meeting was supposed to settle the question but was unable to come to a decision. The G24 group of developing countries argued that failure to meet the deadline undermined the IMF’s credibility.
In response to the early online release of a French study in September 2012, which suggested that genetically modified (GM) maize may promote cancer and early death in rats, a number of environmental and development organisations working in South Africa have written this open letter to government demanding an immediate ban on human consumption of GM maize. In contrast to the 90-day studies conducted by Monsanto, which developed the particular variety of maize in question, th French study ran for two years and revealed long-term health hazards. Monsanto has repeatedly asserted Roundup Ready maize is safe. Over 70% of maize consumed in South African is GM, according to this letter, and over 40% of the national crop is of the Roundup Ready variety. The letter notes that in many high income countries Roundup Ready maize is considered fit for consumption by livestock only.
The main aim of this assessment was to identify the existing occupational safety and health, working conditions, and environmental challenges in the weaving sector in Addis Ababa and their impact on productivity, quality and access to external markets. Researchers targeted women weavers in the three categories namely the micro-level weavers who weave in their homes, weavers in cooperatives and those weaving in small-scale enterprises. Respondents from all three categories reported poor working conditions and environment, and had low productivity and product quality. Weavers and owners of the small-scale enterprises were not aware of the benefits of improving working conditions, occupational safety and occupational health. Comfort in terms of the design of their workstations and ease-of-use of machinery was often not even considered by respondents to be of any importance. Most work rooms had poor light and little ventilation and were often overcrowded, as micro-level weavers shared their work space with children and other family members, all of whom are exposed to occupational hazards as well. Participants called for continuous support and especially the development of policy tools and bilingual guides for continuous improvement that would not only support their survival, but also their growth and ability to compete on local and export markets.
In developing countries, jobs are a cornerstone of development, with a pay off far beyond income alone. They are critical for reducing poverty, making cities work, and providing youth with alternatives to violence, according to the World Development Report 2013. The report focuses on employment, stressing the role of strong private sector-led growth in creating jobs, and outlines how jobs that do the most for development can spur a virtuous cycle. These jobs include those that raise incomes, make cities function better, connect the economy to global markets, protect the environment, and give people a stake in their societies. The report finds that poverty falls as people work their way out of hardship and as jobs empower women to invest more in their children. Efficiency increases as workers get better at what they do, as more productive jobs appear, and as less productive ones disappear. And ultimately, the report concludes, societies flourish as jobs foster diversity and provide alternatives to conflict.
6. Poverty and health
In this report, IFPRI describes the evidence on land, water, and energy scarcity in developing countries and offers two visions of a future global food system: an unsustainable scenario in which current trends in resource use continue, and a sustainable scenario in which access to food, modern energy, and clean water improves significantly and ecosystem degradation is halted or reversed. The report provides on-the-ground perspectives on the issues of land tenure and title as well as the impacts of scarce land, water, and energy on poor people in Sierra Leone and Tanzania and describes the work of their organisations in helping to alleviate these impacts.
This new book by UNICEF details how the economic crisis continues to inflict devastating social consequences worldwide. In it, the authors note how access to public goods and services is also increasingly being challenged in the worldwide drive toward austerity measure in terms of reduced social spending. While the average gross domestic product of developing countries is contracting at nearly double the rate as their developed counterparts, combined price, income and service delivery shocks in these nations have potentially severe and irreversible consequences, especially for children, the authors argue. Among these include increased hunger and malnutrition, worsening health outcomes, lower school attendance, higher rates of child labour and domestic violence, rising vulnerability to future shocks and widespread social unrest. Even when faced with shrinking budgets, governments can expand their fiscal space without incurring immense cost, the authors argue. This can be achieved by: re-allocating public expenditures; increasing tax revenues; lobbying for increased aid and transfers; tapping into fiscal and foreign exchange reserves; borrowing and restructuring existing debt; and/or adopting a more accommodating macroeconomic framework.
To keep its mostly maize-growing small farms productive through cycles of drought, Malawi spends 60% of its agricultural budget subsidizing fertilisers. But the findings of this 12-year study suggest farmers in Malawi and elsewhere could increase yields consistently without applying fertilisers, using instead 'fertiliser trees'. To thrive, maize requires phosphorus and nitrogen, large quantities of which have been depleted from African soils. The 'fertiliser tree' or gliricidia, a leguminous tree, has the ability to draw nitrogen from the air and fix it into soil, changing it into a form that plants can use. The trees also restore some amount of phosphorus to the soil, according to the study. In addition, the leaves shed by gliricidia return organic matter to the soil, increasing its structural stability, erosion resistance and capacity to store water. Three consecutive experiments, begun in 1991 in Malawi and Zambia, showed that when gliricidia was planted in rows between maize plants, maize yields were good year after year.
In this background paper, the author argues that the concept of the right to food is an invaluable in development policy as it recognises the links between food security, culture and resource rights, and as a legal principle, it requires a state to ensure that its people are free from hunger. In recent years, the right to food among Kenya’s indigenous peoples has been challenged by climate change and state interventions that have resulted in land loss and resettlement. Past policies aimed at pastoral development - such as the Maasai Group Ranches - have failed in light of their lack of economic, social and cultural viability. Ultimately, the effectiveness of right to food is not only predicated on claimants’ ability to make demands on the state, but also on the state’s compliance with international law, the author argues. In terms of policy, she points out that Kenya is bound by the International Covenant on Economic, Social and Cultural Rights (ICESCR) of 1976, which stipulates the right to food, as well as its new constitution, signed in August 2010, which includes a provision related to the right to food. This provision is a significant step at the national level in regards to addressing food security. The next step ultimately involves the development of legislation, policies and programs to ensure the principles of the right to food are realised at the local level.
This Background Note is an initial exploration of the political economy of adopting public works programmes (PWPs) to promote social protection and employment in low-income countries and fragile states. The author found that one main reason why some external funders (donors) and governments favour public works programmes over other forms of social protection is their anticipated economic and political benefits, such as household, local and national economic development, increased productivity and graduation out of poverty, and the promotion of political stability. This preference for PWPs is not entirely evidence-based, however, as current data on the impacts of PWP implementation are inadequate. The popularity of PWPs may be linked in part to political and organisational interests as well as concerns about programme outcomes, and political dynamics can lead to inflated expectations about impact if programme design and institutional capacity are not given adequate attention. The author recommends political economy analysis as a useful tool for better understanding these issues. It can contribute to the development and design of interventions that are more likely to deliver significant welfare and employment benefits, while also being politically acceptable.
Economic growth is necessary but not sufficient to accelerate the reduction of hunger globally according to this report by the FAO, which presents new estimates of undernourishment based on a revised and improved methodology. The new estimates show that progress in reducing hunger during the past 20 years has been better than previously believed, and that, given renewed efforts, it may be possible to reach the Millennium Development Goal hunger target at the global level by 2015, namely eradicate extreme hunger. Policies and programmes that will ensure “nutrition-sensitive” growth include supporting increased dietary diversity, improving access to safe drinking water, sanitation and health services and educating consumers regarding adequate nutrition and child care practices. Economic growth takes time to reach the poor, and may not reach the poorest of the poor. Therefore, social protection is crucial for eliminating hunger as rapidly as possible. Finally, rapid progress in reducing hunger requires government action to provide key public goods and services within a governance system based on transparency, participation, accountability, rule of law and human rights.
Civil society is calling on the Tanzanian government and agri-business for a frank discussion on the objectives and benefits of the ongoing Southern Agricultural Growth Corridor of Tanzania (Sagcot) project, which forms part of the Alliance for a Green Revolution in Africa (Agra). Agra is considered by activists fighting poverty as a means to destroy small-scale farming in Africa and introduce large-scale, mechanised agriculture producing genetically modified crops, with disastrous results for food security on the continent. Critics argue that the government’s version of green revolution is fundamentally flawed, as it seeks the participation of large-scale, mostly foreign, investors, while conveniently ignoring the fact that agriculture in the country is overwhelmingly small-scale, sustaining about 80% of the population. The fate of these farmers is uncertain. As the implementation of most of these projects also seems complex, lacks transparency and raises accusations of land grabbing, civil society organisations are also calling on coordinators of the project to explain the nature of partnership with key international partners, some of whom have controversial commercial and agricultural undertakings. The ensuing discussions should address issues such as how local societies will be key players in farming, technological advancement and value addition.
In the last decade, enough agricultural land has been sold off to grow food for a billion people, which is equivalent to the number of people who go hungry in the world each night, according to Oxfam. Over 60% of investments in agricultural land by foreign investors between 2000 and 2010 were in developing countries with serious hunger problems. However, two-thirds of those investors plan to export everything they produce on that land. While Oxfam supports greater investment in agriculture and to small-scale producers, it argues that the unprecedented rush for land has not been adequately regulated or policed to prevent land grabs. This means that poor people continue to be evicted, often violently, without consultation or compensation. Many lose their homes and are left destitute, without access to the land they rely on. Oxfam calls on the World Bank to temporarily freeze investments involving large-scale land deals so it can review its advice to developing countries, help set standards for investors, and introduce more robust policies to stop land grabs.
7. Equitable health services
Since 2002, an estimated 4.7 million long-lasting insecticide-treated nets (LLINs) have been distributed in the Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia among a population of approximately 10 million people at risk for contracting malaria. This study sought to determine the status of current net ownership, utilisation and rate of long-lasting insecticide-treated nets (LLIN) loss in the previous three years. A total of 750 household respondents were interviewed in SNNPR. Approximately 67.5% of households currently owned at least one net. An estimated 31% of all nets owned in the previous three years had been discarded by owners, most of whom considered the nets too torn, old or dirty. Households reported that one-third of nets (33.7%) were less than one year old when they were discarded. These results suggest that the life span of nets may be shorter than previously thought, with little maintenance by their owners. With the global move towards malaria elimination it makes sense to aim for sustained high coverage of LLINs, the authors argue. However, in the current economic climate, it also makes sense to use simple tools and messages on the importance of careful net maintenance, which could increase their lifespans.
In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy. In the last decade, the disproportionate majority of global health funding has been allocated to vertical programmes targeting HIV and AIDS, malaria, and tuberculosis. The renewed calls for action to raise the priority of chronic non-communicable diseases in global health planning and research are encouraging, however, the authors note. Funding commitments from domestic governments, international funders, nongovernmental organisations, industry, and private philanthropists will be critical, the authors argue, to scaling up access to anti-epileptic medications and building capacity in human resources for epilepsy care in sub-Saharan Africa. A Global Fund for Epilepsy should be established to accelerate support from external funders and coordinate programme development and implementation.
This retrospective study of the introduction of district-wide community-level malaria rapid diagnostic test (RDT) was conducted in Livingstone District, Zambia, to assess its impact on malaria reporting, incidence of mortality and on district anti-malarial consumption. Reported malaria declined from 12,186 cases in the quarter prior to RDT introduction in 2007 to an average of 12.25 confirmed and 294 unconfirmed malaria cases per quarter over the year to September 2009. Consumption of artemisinin-based combination therapy (ACT) dropped dramatically at all levels, but remained above reported malaria, declining from 12,550 courses dispensed by the district office in the quarter prior to RDT implementation to an average of 822 per quarter over the last year. From these results, it’s clear that RDT introduction led to a large decline in reported malaria cases and in ACT consumption in Livingstone district. Reported malaria mortality declined to zero, indicating safety of the new diagnostic regime, although adherence and/or use of RDTs was still incomplete. However, a deficiency is apparent in management of non-malarial fever, with inappropriate use of a lowc-ost single dose drug, SP, replacing ACT. While large gains have been achieved, the authors conclude that the full potential of RDTs will only be realised when strategies can be put in place to better manage RDT-negative cases.
In this study, the authors compare the health system and other contexts between Tanzania and Ghana that are relevant to the scaling up of continuous delivery of insecticide treated nets (ITNs) for malaria prevention. While both countries have made major efforts and investments to address this intervention through integrating consumer discount vouchers into the health system, the schemes have been more successful in Tanzania. The authors found that contextual factors that provided an enabling environment for the voucher scheme in Tanzania did not do so in Ghana. The voucher scheme was never seen as an appropriate national strategy, other delivery systems were not complementary and the private sector was under-developed. The extensive time devoted to engagement and consensus building among all stakeholders in Tanzania was an important and clearly enabling difference, as was public sector support of the private sector. This contributed to the alignment of partner action behind a single co-ordinated strategy at service delivery level which in turn gave confidence to the business sector and avoided the ‘interference’ of competing delivery systems that occurred in Ghana.
A Health Policy Dialogue was held in Accra, Ghana, on 26 July 2012 to identify ways in which to help Kayayei (headload porters) better access health services, and to help integrate these workers into the Ghanaian National Health Insurance Scheme (NHIS). At the Dialogue, a case study of the Ghana NHIS was presented, which showed that the Kayayei were unable to easily use the health services in Accra. A large number of Kayayei were not registered with the NHIS. Most could not afford the premium, even though the minimum annual premium is set at US$5. In practice, $15-$20 is charged as a minimum in urban areas and many Kayayei earn $2-3 or less a day, making this unaffordable for them. Those few who could afford to join complained that they were mistreated or ignored when they went to use the health services. The Ministry of Health has indicated a willingness to enter into discussions with the Kayayei associations and WIEGO on the poor quality of care received by these workers when accessing health services. Ministry of Health officials proposed that clinics and hospitals in areas where Kayayei live and work should have doctors and nurses specially mandated to look after their needs.
Many patients present to an emergency centre (EC) with problems that could be managed at primary healthcare (PHC) level. This has been noted at George Provincial Hospital in the Western Cape province of South Africa. In order to improve service delivery, researchers in this study aimed to determine the patient-specific reasons for accessing the hospital EC with PHC problems. A descriptive study using a validated questionnaire to determine reasons for accessing the EC was conducted among 277 patients who were triaged as green (routine care), using the South African Triage Score. The duration of the complaint, referral source and appropriateness of referral were recorded. Of the cases 88.2% were self-referred and 30.2% had complaints persisting for more than a month. Only 4.7% of self-referred green cases were appropriate for the EC. The three most common reasons for attending the EC were that the clinic medicine was not helping (27.5%), a perception that the treatment at the hospital is superior (23.7%), and that there was no PHC service after-hours (22%). Increased acceptability of the PHC services is needed, the authors conclude. The current triage system must be adapted to allow channelling of PHC patients to the appropriate level of care. Strict referral guidelines are needed.
While reaching consensus on future plans to address current global health challenges is far from easy, there is broad agreement that reductionist approaches that suggest a limited set of targeted interventions to improve health around the world are inadequate. The authors of this paper argue that a comprehensive systems perspective should guide health practice, education, research and policy. They propose key ‘systems thinking’ tools and strategies that have the potential for transformational change in health systems. Three overarching themes span these tools and strategies: collaboration across disciplines, sectors and organisations; ongoing, iterative learning; and transformational leadership. The proposed tools and strategies in this paper can be applied, in varying degrees, to every organisation within health systems, from families and communities to national Ministries of Health.
Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. This paper assesses the progress in scaling up mental health services worldwide, using a survey of key national stakeholders in mental health. The authors note that major barriers to scaling up of mental health services in countries with low and middle incomes include absence of financial resources and government commitment and over-centralisation. In addition, challenges of integration of mental health care into primary care settings, scarcity of trained mental health personnel and shortage of public health expertise among mental health leaders are tangible barriers as well. As a result, the authors argue that a systemic and strategic approach to scaling up is needed.
8. Human Resources
This paper presents policy-makers and programme managers with key considerations for a model to improve the work environment as an important approach to increase community health worker (CHW) productivity and, ultimately, the effectiveness of community-based strategies. Researchers conducted a desk review of selective published and unpublished articles and reports on CHW programmes in developing countries to identify the elements that influence CHW productivity. They found that CHW productivity is determined in large part by the conditions under which they work. Attention to the provision of an enabling work environment for CHWs is essential for achieving high levels of productivity. They present a model in which the work environment encompasses four essential elements: workload, supportive supervision, supplies and equipment, and respect from the community and the health system. Establishing a balance among the four elements that constitute a CHW’s work environment will help make great strides in improving the effectiveness and quality of the services provided by CHWs.
This study aimed to document the kinds of leadership styles are practiced at primary health care (PHC) centres and how these styles can be explained by the contexts, characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS). Self-administered questionnaires were distributed at 47 centres in three districts. A total of 347 STHSs (95%) and 46 ICs (98%) responded. Two leadership styles were revealed: ‘trans’ style contained all relation and the majority of task and change items, while ‘control’ style focused on health statistics, reporting and evaluation. The researchers found that frontline PHC leadership may be forced by situation and context to use a comprehensive style, which could lack the diversity and flexibility needed for effective leadership. The missing associations between staff characteristics and leadership styles might indicate that this group is not sufficiently considered and included in leadership processes in the PHC organisation. Leadership competency for the ICs seems not to be based on formal training, but substituted by young age and work experience. In conclusion, the authors call for a reassessment of PHC leadership and formal leadership training.
This study compared the effectiveness of trained Health Surveillance Assistants (HSAs) versus trained volunteer Key Informants (KIs) in identifying blind children in southern Malawi. A cluster community based study was conducted in Mulanje district, population 435 753. Six clusters each with a population of approximately 70,000 to 80,000, 42% of whom were children were identified and randomly allocated to either HSA or KI training. A total of 59 HSAs and 64 KIs were trained. HSAs identified five children of whom two were confirmed as blind (one blind child per 29.5 HSAs trained). On the other hand, the KIs identified a total of 158 children of whom 20 were confirmed blind (one blind child per 3.2 KIs trained). More blind boys than girls were identified (77.3% versus 22.7%) respectively. Key Informants were found to be much better at identifying blind children than HSAs, even though both groups identified far fewer blind children compared with WHO estimates. HSAs reported lack of time as a major constraint in identifying blind children. Based on these findings using HSAs for identifying blind children would not be successful in Malawi, the authors argue. Gender differences need to be addressed in all childhood blindness programs to counteract the imbalance.
9. Public-Private Mix
The Council for Medical Schemes and the Department of Health are planning new amendments to the Medical Schemes Act to beef up governance on medical scheme boards and stop unscrupulous trustees enriching themselves at members’ expense. In the past decade, 10 medical schemes have been placed under curatorship after trustees milked their reserves to line their own pockets and dish out contracts to friends and family. The most recent examples include Medshield and Sizwe. To date, not a single trustee from a scheme placed under curatorship had been convicted, and many of those identified by the council as behaving inappropriately were at liberty to circulate in the industry and join other schemes, said its head of compliance and investigations, Stephen Mmatli. Mmatli said member apathy, combined with weaknesses in the Medical Schemes Act, meant there was insufficient control over the skills and qualifications of the people elected as trustees and too few checks and balances. While many schemes have highly qualified trustees, some of whom take home modest remuneration (or none at all), the converse is also true: the Council’s latest annual report (in last month’s newsletter) shows trustees awarding themselves massive fees of up to R700,000 (US$81,000) a year.
A group of international civil society organisations (CSOs) have called on the World Bank to implement smart procurement guidelines that support the development of the domestic private sector of developing countries. This submission calls on the World Bank to review its procurement guidelines so that they become an economic policy tool which is pro-poor, promotes domestic industry development and empowerment, reduces asymmetries between local and foreign companies in order to create a truly level playing field, focusing in particular on SMEs and works towards poverty eradication, sustainable development and mitigating climate change. The Bank should become a development tool, considers social and environmental criteria, and creates incentives for all private actors to behave in a socially and environmentally responsible fashion. It should also respect transparency and accountability, emphasising that accountability to citizens in developing countries matters most. The Bank can play a catalytic role in strengthening domestic accountability through its procurement practices, the CSOs argue. Finally the Bank should increase the effectiveness and developmental impact of aid and ensures that the larger share of aid inflows remain in the recipient countries.
10. Resource allocation and health financing
After grappling for years with difficult issues – including coordination of aid activities, recipient country ownership and predictability – it appears that external funders, recipients and civil society alike have realised that very little of the aid effectiveness agenda can be achieved without greater and systematic transparency. And while aid has become more transparent, progress is slow and uneven, according to the new edition of the Aid Transparency Index. The report finds that transparency can be improved, without great difficulty, when political commitment is translated into effective implementation. Aid information must be shared openly in a timely, comprehensive, comparable and accessible way. The report discusses the role of the International Aid Transparency Initiative (IATI), which offers a common standard for publishing aid information that satisfies all of these elements. So far 33 external funders have signed IATI and thereby committed to publishing to its common standard. These funders account for over 75% of official development finance.
The Board of the Global Fund has voted to adopt a new model for funding grants that it believes will help the Fund target countries with the highest disease burden and least ability to pay. From now on, applicants will submit a concept note and then get early feedback from the Fund, other external funders and technical experts on how the proposal may need adjusting before moving forward. This is reported to be an improvement on the old grant process, which was considered too cumbersome and technical. Another important change will be more flexible timing for grant applications, allowing countries to better align the submission of grant proposals with their own national budgeting schedules. In addition, countries will be grouped in bands and funds will be allocated to each band, and then divided in a way that identifies a range of funding for each country.
'Resilience’ is topping the list of new buzzwords in international cooperation rhetoric lately and the European Commission (EU) has now issued a policy proposal addressing resilience. In this article, the author criticises the EU’s proposed new policy approach to foreign aid, arguing it has several fundamental weaknesses. First, it airs a highly “top-down” and “state-centric” approach to resilience that risks overlooking the existence of a multitude of local communities and groups that have their own sources of resilience. In situations where government structures are absent or not genuine in the partner country, the EU should try to discover, research and link up with these groups. Second, the EU proposal fails to incorporate and to refer to lessons learnt from its own work on capacity development. While it recognises the leading role of partner countries – fully in accordance with aid effectiveness principles – there is a risk that this will remain rhetoric as long as the EU does not lay out its approach on how it, as an outsider, can support, facilitate or stimulate change. Third, it is questionable whether the proposal is based on a solid understanding of policy coherence, as it aims to undertake a wide range of resilience-enhancing actions that link up diverse sectors, including agriculture, health, natural resource management, regional trade and national reconciliation. The fact that such actions are risky and can be at odds with each other is not sufficiently addressed.
Is prioritising services for the poorest and most marginalised more effective and cost effective than mainstream approaches? In this study, researchers addressed this question by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches: an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. Results showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. This suggests that an equity-focused approach offers higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-of-pocket spending between the most and least deprived groups and geographic areas within countries. Further research is needed to address gaps in the researchers’ evidence base. They call for increasing prioritisation of the most deprived communities and the increased use of community-based interventions.
In this article, the authors compare domestic resource mobilisation (DRM) with foreign direct investment (FDI), arguing that developing countries, like those in Asia, that have achieved and sustained high rates of growth have typically done so largely through the DRM, and not through FDI. DRM at a significant level is essential to solidify ownership over development strategy and to strengthen the bonds of accountability between governments and their citizens. In effect, it provides ‘policy space’ to developing countries, which is often constrained under the terms and conditions of external funders. In contrast, FDI tends to be pro-cyclical and volatile, particularly affecting African countries with smaller economies, and typically flows into sectors and projects dictated by the commercial interests of the foreign investors, like natural resource extraction. While external funding or trade and investment opportunities can make significant contributions to development, they alone will not be sufficient for Sub-Saharan Africa to achieve sustainable, equitable growth and poverty reduction, the authors conclude. As happened in the 90s with Malaysia, South Korea and the other ‘Asian Tigers’, development success depends primarily on the efforts of developing countries themselves, which ultimately means enhancing their ability to mobilise their own human and financial resources.
11. Equity and HIV/AIDS
This qualitative study set out to identify gaps between policy and practice of HIV and AIDS workplace interventions in the University of Malawi, in particular the College of Medicine, in line with University HIV and AIDS policy. The researchers randomly sampled 25 students and 15 members of staff for interviews. Results indicated that there are a number of activities relating to HIV and AIDS in place while others are still in the pipeline, however the majority of respondents did not know about the University HIV and AIDS policy or any HIV and AIDS activities that are guided by the policy. This is due to lack of interest on their part or lack of knowledge on the existence of the workplace programme. The authors recommend that the University’s HIV and AIDS committee should strive to fast track key programme areas such as the voluntary counseling and testing centre, and clinic and coordination of different activities to increase programme visibility and patronage.
In this paper, researchers describe the increase in the treatment of South African pediatric HIV-infected patients assisted by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) from 2004 to 2010. They reviewed routine programme data from PEPFAR-funded implementing partners among persons receiving antiretroviral treatment (ART) aged 15 years old and less. From October 2004 through September 2010, the number of children newly initiated on ART in PEPFAR-assisted programmes increased from 154 to 2,641 per month resulting in an increase from 2,412 children on ART in September 2005 to 79,416 children in September 2010. Of those children who initiated ART before September 2009, 0–4 year olds were 1.4 times as likely to transfer out of the programme or die as 5–14 year olds; males were 1.3 times as likely to stop treatment as females. Approximately 27,548 years of life were added to children under-five years old from PEPFAR-assisted antiretroviral treatment. While pediatric antiretroviral treatment in South Africa has increased substantially, the authors call for additional case-finding and a further acceleration in the implementation of pediatric care and treatment services to meet the current treatment need.
This report consolidates all known information about sex work and HIV in Namibia, and aims to provide an objective knowledge base that can inform programming and advocacy efforts. In Namibia, sex work is formally illegal and criminalised. The author found that sex workers are severely affected by HIV (reportedly, around 70-75% HIV prevalence), and they are vulnerable to different health problems. This is compounded by problems in accessing services (i.e. stigma and discrimination), the excessive costs of obtaining services, and the frequent non-availability of drugs and staff. While overall knowledge of HIV seems to be acceptable, problems arise in negotiating condom use with clients, whereas alcohol and violence play an important role in facilitating sexual risk taking.
In 2011, three international organisations and a number of Namibian sex worker organisations conducted a series of rapid assessments on sex work and HIV in five towns in Namibia. In the assessments, a number of issues were raised in case of most or all the towns. These include stigma from health care providers and the community, a preference for traditional medicine, violence from a number of sources, and extortion and abuse from police officers. Yet, the way these affect sex workers are different in each location. The authors note that much more support is required to help sex workers organise and collaborate more effectively and to tackle the problems they face. Active participation of sex workers, as well as addressing HIV through a framework of human rights, are essential to making HIV programmes aiming to reach sex workers more effective. Violence, stigma in access to services, and discrimination should be identified and addressed as a matter of course in any HIV programmes aiming to reach sex workers. At the same time, relevant ministries, NGOs, UN agencies and external funders should use the findings drawn in this paper to raise awareness and advocate for national level action.
12. Governance and participation in health
In this Call to Action, the People’s Health Movement (PHM) argues that the underlying cause of health inequities are the neoliberal economic policies that are the hallmark of present day capitalism. PHM says the global health crisis is a consequence of the failure to address the social, political and environmental determinants of health. Ironically, the response of national and international institutions to the current financial crisis has been merely to restore the confidence’ of the same institutions and financial markets that caused the crisis in the first place. Governments have meanwhile enacted an austerity agenda by cutting health and social spending, effectively deepening and reinforcing inequities between rich and poor. PHM puts forward an alternative vision in which a reformed economic system values individuals over capital, with just, fair and democratic political and economic processes and institutions, and better and transformed global heath governance that is free from corporate influence and the influence of unaccountable private actors. It calls for equitable public health systems that are universal, integrated and comprehensive, and also provide a platform for appropriate action on social determination of health.
Since the Global Fund to Fight AIDS, Tuberculosis and Malaria announced its new model for allocating funds in September 2012, African civil society organisations have stated that they were not included in the process, arguing that consultations were held behind closed doors and that most non-governmental organisations (NGOs) on the continent are unaware that a new model exists. The Rights Alliance of Southern Africa (ARASA), the South Africa-based World AIDS Campaign and almost 40 African non-governmental organisations (NGOs) have called for the Fund to develop a more robust and inclusive communication and consultation process around the model's development, which is ongoing.
In this open letter to the World Bank, a group of 110 international civil society organisations (CSOs) call on the Bank to play a truly progressive and transformative role in health by supporting countries to achieve universal health coverage (UHC). The World Bank is well-placed to be a vocal champion of UHC by deploying its knowledge and experience in health system reform, as well as its financial support. However, the Bank must reform the approach of its programmes and policy advice in order to deliver on this potential, and ensure it positively impacts poor and vulnerable populations. The CSOs call on the Bank to actively support countries to offer care that is free at the point-of-use for all people, as well as scale up investment in public health systems in developing countries, by supporting them to expand public financing, and by offering balanced policy advice that does not privilege private sector solutions over publicly financed and delivered health systems. The Bank can take further steps to promote UHC by ensuring all Bank programs benefit the poorest two quintiles in the countries where it works, actively supporting involvement of civil society in national health policy development, in order to improve democratic oversight and accountability for improved health outcomes, and collaborating with the World Health Organization and other global health institutions in the push for UHC.
This cross-sectional study was carried out in Jinja Town in Uganda in order to assess the level of awareness of occupational hazards and the use of safety measures among small-scale industrial welders in a low-income setting. A total of 218 roadside welders with a mean age of 31 years participated in the study. The researchers found that these roadside welders had a high level of awareness of occupational hazards (83%), but their use of safety measures was less than optimal. Awareness was positively influenced by age, educational status, marital status, work experience, type of training and supervision. The researchers speculate that the great discrepancy between the level of awareness and the use of personal protective equipment could be attributed to factors such as discomfort of wear, not being aware that even ‘simple tasks’ require protection and the unavailability of personal protective equipment because of the high costs associated with their acquisition, leading to sharing of the equipment available among colleagues. Strategies are therefore needed not only to enforce policy but also to cover the informal work sector, in order to ensure the safety of welders. Generally, their high level of awareness may be used as a window of opportunity for involving welders in decision-making as regards their working conditions.
Implementation of policies (decisions) in the health sector is sometimes defeated by the system’s response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or ‘fixes’. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper, researchers use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, they unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimise negative unintended effects.
13. Monitoring equity and research policy
The Foundation for Professional Development (FPD) collects information annually on HIV and AIDS service provision and estimates service needs in the City of Tshwane Metropolitan Municipality (CTMM). In this study, researchers used antiretroviral therapy (ART) data from the Department of Health and Statistics South Africa (SSA) mid-year population estimates to approximate the ART need among adults in the CTMM. According to SSA data, ART need decreased dramatically from 2010 to 2011 and was lower than the number of adults receiving ART. Although the noted difference was probably due to changes in the calculations by SSA, no detailed or confirmed explanation could be offered. The authors hope that their paper may provide a constructive contribution to the discussion about the use of model-derived estimates of ART need. They argue that it is critical that those providing estimates (in this case, SSA) clearly indicate whether any significant changes exist compared with earlier reports and, if so, the cause and implications of these changes.
The authors of this paper assessed recent evaluations of health systems (HS) strengthening interventions in low- and middle-income countries from 2009–10. Out of 106 evaluations, less than half (43%) asked broad research questions to allow for a comprehensive assessment of the intervention’s effects across multiple HS building blocks. Only half of the evaluations referred to a conceptual framework to guide their impact assessment. Overall, 24% and 9% conducted process and context evaluations, respectively, to answer the question of whether the intervention worked as intended, and if so, for whom, and under what circumstances. None incorporated evaluation designs that took into account the characteristics of complex adaptive systems such as non-linearity of effects or interactions between the HS building blocks. The authors call for more comprehensive evaluations of the range of effects of an intervention, when appropriate. They identify some barriers to more comprehensive evaluations as limited capacity, lack of funding, inadequate time frames, lack of demand from both researchers and research funders, or difficulties in undertaking this type of evaluation.
The current trend towards the devolution of government responsibility is usually accompanied by severe cuts in public sector budgets, forcing government departments to develop different ways of working via partnerships of various types (government and non-government) and at various levels (national, regional and local). The challenge, the authors of this paper argue, will be finding ways for these partnerships to engage all partners fully in delivering public policy whilst recognising that each partner has a different mandate and different objectives that will align to different degrees with the policy’s stated goals. They argue that devolution of government responsibility has negatively affected policymaking as Ministers tend to focus on a small number of core activities, or outputs, rather than being accountable for delivering the final outcomes that solve or ameliorate societal problems. And any further devolution of responsibility is likely to give rise to ‘messy’ partnerships as well. The authors propose that current policy-making tools based on logic and prediction will fail to deal with the complexity of partnership working, and instead they recommend techniques like outcome mapping and social frameworks, which are covered in detail in the paper.
Strengthening health systems for improved policy making in low- and middle-income (LMIC) countries requires sustained efforts from many people, working collaboratively across multiple levels. Accordingly, the authors of this paper argue that the complexity of health systems necessitates approaches that are grounded in systems thinking at the global, national and subnational levels, and that recognise the need for ways of working that promote integration rather than fragmentation. Network structures represent a broad set of collaborative approaches that are useful for bringing stakeholders together. The authors propose that health systems in LMIC countries will be strengthened if policy researchers, policy makers and other stakeholders are able to explicitly and purposefully apply systems thinking concepts to the design, implementation, monitoring and evaluation of networks.
Malaria vector studies are a very important aspect of malaria research as they assist researchers to learn more about the malaria vector. Research programmes in various African countries include studies that assess various methods of preventing malaria transmission including controlling the malaria vector. Various institutions have also established mosquito colonies that are maintained by staff from the institutions. Malaria vector research presents several dilemmas relating to the various ways in which humans are used in the malaria vector research enterprise. A review of the past and present practices reveals much about the prevailing attitudes and assumptions with regard to the ethical conduct of research involving humans. The focus on the science of malaria vector research has led some researchers in African institutions to engage in questionable practices which reveal the ethical tensions inherent in the choice between science and the principles of justice, nonmaleficence and respect for individuals. The analysis of past and present choices in malaria vector research has relevance to broader questions of human dignity and are in line with the current emphasis on ethical research worldwide.
14. Useful Resources
Médecins Sans Frontières (MSF) has announced the launch of the “Patent Opposition Database,” an online resource to help patient groups or others to oppose wrongful patent applications as a way to ensure access remains open for affordable generic drugs. A patent opposition is a legal challenge aimed at blocking the granting of an unwarranted patent, MSF said. The database was launched on the tenth anniversary of a landmark decision by the central intellectual property court in Thailand to overturn a patent on a key HIV drug based on opposition filed by patients. India and Brazil also have used this process. It provides interested parties with all the information they need to know about patents, medicines and how to build an opposition to cases where pharmaceutical companies are trying to push through patents that will negatively impact on public health.
The Africa Portal’s Community of Practice blog signals important policy research topics and trends in Africa. Contributors include top researchers and practitioners conducting on-the-ground, field-based research in Africa. The blog aims to share their work and document the challenges and learning that emerge from efforts to inform African policymaking.
The Guardian, a leading newspaper in the United Kingdom, has launched a new blog on Africa, where participants will debate and discuss contentious issues such as quality of leadership, the legacy of colonialism, identity politics that pitch women's and homosexuals' rights against a form of cultural fundamentalism. What is "Africa" anyway and should it look east, or west, or within? This is one of the main questions posed by this blog. The Guardian intends to showcase strong, sometimes conflicting opinions from inside and outside the continent in collaboration with a dozen independent sites. Partners include solo bloggers from Uganda and Nigeria, collectives from South Africa and Zimbabwe, and pan-African commentators. Some are from established institutions such as the Royal Africa Society's African Arguments or media groups such as the Mail & Guardian's ThoughtLeader and the online magazine Think Africa Press. There's also the development blog A View from the Cave, voices from the diaspora in Africa on the Blog, and the resource site Africa Portal.
This platform, launched and run by the United Nations’ programme, The World We Want 2015, is an open and inclusive consultation space to discuss the role of health in the post 2015 development agenda. The platform is hoping to draw a representative cross section of views and start to build consensus in five key areas: What are the lessons learnt from the health related MDGs? What is the priority health agenda for the 15 years after 2015? How does health fit in the post 2015 development agenda? What are the best indicators and targets for health? And how can country ownership, commitment, capacity and accountability for the goals, targets and indicators be enhanced? The platform is co-convened by the World Health Organisation and the United Nations Children’s Fund, in collaboration with the Government of Sweden, and will run from October to March 2012.
Help promote open access research in your work environment by downloading one or the posters on this webpage by Biomed Central, a United Kingdom-based publisher specialising in publishing open access online research. You can print the posters out and display them prominently around your lab, your department and your library to raise awareness of the need for open access research, as well as encourage your colleagues to submit their papers to BioMed Central's journals, which are all open access, so their research will be available to everyone free of charge.
This guide has been produced for health activists who want to improve the response to the HIV-related needs of men who have sex with men (MSM) in Africa. It provides a set of activities that may be used when facilitating a meeting with key stakeholders who are responsible for improving local and national responses to HIV among MSM. It includes step-by-step advice about how to run sessions, together with a variety of useful resource material and presentations. It also provides basic information to increase one’s understanding about MSM and, in particular, MSM and the HIV epidemic. The guide is designed to help participants: explore their own attitudes and feelings about working with MSM; identify what is being done already, or has been done elsewhere, that could be usefully adapted to their local setting; and identify and plan a course of action in response to local situations.
15. Jobs and Announcements
The International Health Economics Association (iHEA), which is hosting the July 2013 World Congress on Health Economics, is looking for abstracts and session proposals for the Congress. While all submissions in the field of health economics are welcome, the programme committee is particularly interested in the following topics: health care reform; universal coverage; health workforce; health technology assessment; econometrics; history of health economics; health status measurement; paying for health care; and reporting system performance. Session description and individual abstracts should not exceed 500 words.
As part of the United Nations (UN) led effort to catalyse a “global conversation” on the post-2015 agenda through a series of global thematic and national consultations, the World Health Organisation (WHO) and the UN Children’s Fund (UNICEF), together with the Government of Sweden, have launched a global consultation around health. The purposes of the consultation are to: stimulate wide ranging discussion at global, regional and country levels, on progress made and lessons learnt from the present Millennium Development Goals (MDGs) relating to health; and discuss and develop a shared understanding on the positioning of health in the post-2015 development framework. WHO and UNICEF will also propose health goals and related targets and indicators for the post-2015 development agenda, as well as approaches for implementation, measurement and monitoring. The online global health consultation has now been launched online, at the address given above. You are urged to visit the website to review key documents, submit background papers, join moderated e-discussions and contribute to the discussion on twitter using the hashtag #health2015.
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.
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