EQUINET NEWSLETTER 143 : 01 January 2013

1. Editorial

Choosing pathways that lead to universal coverage: what are the options?
Di McIntyre, University of Cape Town Health Economics Unit, University of Cape Town

There is consensus that states have an obligation to ensure Universal coverage (UC), through creating and realising an entitlement for everyone to be protected against the costs of health services and to have access to the effective, quality services they need. From an equity perspective, social solidarity is essential to achieve UC, through income cross-subsidies (from the rich to the poor) so that payments are based on the ability to pay, and risk cross-subsidies (from the healthy to the ill) so that people access health services based on need and not ability to pay.

So what options do east and southern African (ESA) countries have to reach this goal? While there may be some distance before reaching UC, the choices made at this stage are critical for ensuring steady progress towards it.

The 2010 World Health Organisation’s World Health Report unequivocally states that it is not feasible to achieve UC through voluntary enrolment in health insurance schemes. A number of ESA countries are introducing community-based health insurance (CBHI) as one means of pre-payment. These schemes will not move a country towards UC, although they may temporarily assist vulnerable households until mandatory pre-payment funding increases considerably and user fees are removed. However there is a potential danger that their existence may allow governments to abrogate their responsibility to promote mandatory pre-payment funding mechanisms.

Voluntary schemes can only be complementary or supplementary to mandatory pre-payment financing mechanisms, including tax and mandatory insurance. From international experience, mandatory pre-payment funding is well over 60% (and often over 70%) of all health service expenditure in countries that have health systems that are regarded as universal.

Many African countries are now discussing or introducing mandatory health insurance (MHI) schemes. However, caution should be exercised. If MHI contributions are placed in a separate pool to benefit the contributors only (which often is the case) this creates a tiered and inequitable system that does not ensure that all have the same service benefit entitlements. If the goal is to achieve universal coverage, then it is critical to minimise fragmentation in funding pools to achieve cross-subsidies. This means that if MHI is introduced, the funds collected from it should be pooled with those from government revenue to fund benefits for the whole population.

There has also been some investigation into introducing MHI contributions by those outside the formal employment sector. This should receive more critical assessment than there has been to date, especially as such contributions are strongly regressive and generate little revenue. If there is political insistence on generating funding from those outside the formal employment sector, indirect taxes, such as VAT, are a more equitable and efficient mechanism for achieving this goal, particularly in low-income countries. However, in the context of the large income inequalities present in many east and southern African countries, efforts to improve the collection of taxes from high net-worth individuals and multinational corporations may be more appropriate. Further, some countries are generating revenue for health from royalties on natural resources such as gold, copper and oil, and not only from taxes.

There is often an almost automatic assumption that there is no ‘fiscal space’ to increase funding of health services from government revenue. It is important to critically examine this assumption.

Government revenues in ESA countries range widely from about 12% of GDP in Madagascar to 33% in the DRC, while government expenditure ranges from less than 13% of GDP in Madagascar to 33% in Mozambique. These ranges are considerably lower than the levels in advanced economies for both government revenue (36%) and expenditure (44%). Government debt levels are considerably lower in ESA countries, ranging from less than 26% of GDP in Zambia to 64% in Madagascar, than the average for advanced economies of over 100%. Given that all of these measures are expressed relative to GDP and that some lower-income countries are able to attain higher levels of revenue and expenditure, there does appear to be scope to explore increasing the fiscal space within the so-called emerging markets and low-income countries.

Health financing policy choices not only relate to how revenue is mobilised for UC. Purchasing involves determining service benefit entitlements (what services are purchased with the pooled funds and how people will be able to access these services) and how service providers will be paid. Attention should be given to more active purchasing. This requires identifying the health service needs of the population, aligning services to these needs, paying providers in a way that creates incentives for the efficient provision of quality services, monitoring the performance of providers and taking action against poor performance. Active purchasing is critical for ensuring that available funds translate into effective health services accessible to all.

Moving towards universal coverage also requires improvements in service delivery and management. In particular, emphasis should be placed on improving services at the primary health service level, which are effective in reaching the poor and which are able to address most of the health service needs of the population in ESA countries. Improving primary health services offers the greatest potential for increasing population coverage affordably. In addition, it is important to broaden the decision-space of managers at facility and district level, so that they can be more responsive to patients’ and staff needs and to the incentives created through active purchasing. Equally decentralisation of management responsibility should be accompanied by development of governance structures that allow for accountability to the local community.

East and southern African countries have some way to go in moving toward UC. The choices made at various points in the journey will be important for achieving that goal. While the detail of those choices will depend on the context in each country, international experience and regional evidence suggest that far more emphasis should be placed on government revenue funding for health services and that funds from mandatory health insurance schemes should be pooled with funds from government revenue. We also need a richer body of evidence, including from research, to support active purchasing of services and measures for addressing service delivery and management challenges, as these are essential if universal access to services of appropriate quality is to be achieved.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org and read EQUINET Discussion paper 95: McIntyre D (2012) ‘Health service financing for universal coverage in east and southern Africa’

2. Latest Equinet Updates

Discussion paper 94: Resource Mobilisation for Health under the Zimbabwe Investment Case 2010-2012
Shamu S: EQUINET, 2012

This review assesses the resource mobilisation and allocation performance and challenges faced by the MoHCW in meeting the target set out in its Investment Case. As the Investment Case was meant to complement the annual government budget and resource mobilisation efforts by other players, the review took these resources into account in assessing the level and direction of funding. The review specifically looked at the response from funders of the health sector to the Investment Case, in terms of what resources were raised and the successes and challenges associated with raising the intended resources. It assesses the resources raised and some of the health outputs from these resources. The study included interviews with key informants in the Ministry, review of policy documents and analysis of financial data from government and external funders.

Discussion paper 95: Health service financing for universal coverage in east and southern Africa
McIntyre D: EQUINET, 2012

In this paper, the author considers elements of the design of health systems and how these relate to moving towards universal care in the context of Africa. She focuses particularly on health financing issues (revenue collection, pooling and purchasing), but also raises health service delivery and management issues. In relation to revenue collection, the global consensus is that in order to pursue universal coverage, it is critical to reduce reliance on out-of-pocket payments as a means of funding health services. The author notes that the key focus in moving towards universal coverage should be on mandatory prepayment mechanisms and discusses the options for these. The common assumption of limited fiscal space for increased government spending on the health sector should be challenged and the fiscal space envelop pushed. While mandatory health insurance schemes can also contribute to generating additional revenue for health services, these funds should be pooled with funds from government revenue. Although there is limited evidence in relation to purchasing in east and southern African countries, introducing active purchasing of services, as well as addressing service delivery and management challenges, will be essential if universal access to services of appropriate quality is to be achieved.

3. Equity in Health

Early life opportunities for prevention of diabetes in low- and middle-income countries
Hanson MA, Gluckman PD, Ma RCW, Matzen P and Biesma RG: BMC Public Health 12(1025), 23 November 2012

Research has shown that if prospective parents lose weight and reduce weight gain during pregnancy, this may lower the risk of their unborn children from developing non-communicable diseases in later life. Interventions have been launched in low- and middle-income countries (LMICs) to get these adults to lose weight, yet they have limited impact. As an alternative, the authors of this paper argue that the most promising strategy to improve prospective parents' body composition and lifestyle is the promotion of health literacy in adolescents. Multiple but integrated forms of community-based interventions that focus on nutrition, physical activity, family planning, breastfeeding and infant feeding practices are needed. They need to address the wider social economic context in which adolescents live and to be linked with existing public health programmes in sexual and reproductive health and maternal and child health initiatives. Addressing the promotion of such health literacy in parents-to-be in LMICs requires a wider social perspective. A range of multisectoral agencies will have to work together and could be linked to issues of women's empowerment, reproductive health, communicable disease prevention and Millennium Development Goals 4 and 5 (maternal and child health).

Global Income Inequality by the Numbers: In History and Now
Milanovic B: World Bank Research Working Paper 6259, November 2012

This paper offers an overview of calculations of global inequality, recently and over the long-run as well as main controversies and political and philosophical implications of the findings. The author focuses in particular on the winners and losers of the most recent episode of globalisation, from 1988 to 2008. He suggests that the period might have witnessed the first decline in global inequality between world citizens since the Industrial Revolution. The decline however can be sustained only if countries’ mean incomes continue to converge (as they have been doing during the past ten years) and if internal (within-country) inequalities, which are already high, are kept in check. Mean-income convergence would also reduce the huge “citizenship premium” that is enjoyed today by the citizens of rich countries.

Green Economy or Green Society? Contestation and Policies for a Fair Transition
Smith K, Utting P and Cook S: United Nations Research Institute for Social Development (UNRISD), November 2012

In this paper, the authors outline a conceptual and policy approach to bring social concerns more centrally into green economy and sustainable development debates. They first examine a wide range of social problems and other issues associated with the green economy, reasserting that any development transformation must be both green and fair, leading to a green society, not just a green economy. The authors argue in favour of comprehensive or transformative social policy, which goes beyond social protection, human capital formation or green jobs by also focusing on redistribution and social reproduction. Achieving a shift towards such policies will depend crucially on addressing the politics of governance itself, specifically, the ways different actors - particularly social movements and those most disadvantaged - contest ideas and policies, participate in governance, and organise and mobilise to resist and influence change. Such arenas of policy and action are crucial both from the perspective of distributional and procedural justice, as well as for driving deeper structural transformations. The authors conclude by highlighting issues of fragmentation associated with knowledge, institutional arrangements and social agency, and point to the need for "joined-up analysis, policy and action".

Inequalities and the Post-2015 Development Agenda
Al-Adhami R and Razavi S: United Nations Research Institute for Social Development (UNRISD), November 2012

In this policy brief, the authors highlight worsening income inequalities between and within countries in recent decades, while noting that gender inequalities are narrowing at a snail’s pace. They argue that increases in inequality are partly due to the neglect of policy instruments to promote equality of outcome in favour of approaches that claim to create equality of opportunity. Current social discontent and distrust of government highlight the urgency of addressing inequality head-on: reducing inequality should be should be high on the post-2015 development agenda and should be seen as a goal in itself. It should also be reflected in other goals. The authors recommend that development targets should be set for within-country inequalities, including inequalities across regions, gender, ethnicity and income status. Proposed targets and indicators could include: inequality expressed in terms of the top and bottom deciles/ventiles; wages vs. profits (functional distribution of income); gender-based wage gaps; other labour market indicators, such as median wage, existence of minimum wage, percentage of labour force with social protection (female, male); and female/male ratio of unpaid work.

4. Values, Policies and Rights

UN General Assembly encourages member states to plan and pursue transition of national health care systems towards universal coverage
United Nations General Assembly: 12 December 2012

Recognising the intrinsic role of health in achieving international development goals, the United Nations (UN) General Assembly has adopted a resolution on global health and foreign policy which encourages Member States to plan or pursue the transition towards universal access to affordable and quality health-care services. It urges Member States, civil society and international organisations to incorporate universal health coverage in the international development agenda and in the implementation of the internationally agreed development goals, including the Millennium Development Goals. The Assembly also recognised the importance of universal coverage as part of a transition to a more sustainable, inclusive and equitable economy. The resolution encourages Member States to continue investing in health-delivery systems to increase and safeguard the range and quality of services and meet the health needs of their populations. It calls on Member States to recognise the links between the promotion of universal health coverage and other foreign policy issues, such as the social dimension of globalisation, inclusive and equitable growth and sustainable development.

Constitutional Court victory over prison TB infection
South African Broadcasting Corporation: Wednesday 12 December 2012

In a landmark case, South Africa’s Constitutional Court ruled on 10 December 2012 in favour of a claimant who contracted tuberculosis (TB) during a stint in Pollsmoor Prison, Cape Town. The Constitutional Court decided that prison authorities had failed to implement adequate TB prevention measures among inmates, arguing that there was a causal link between this and the spread of TB. Section 27, a health rights group, has meanwhile warned prison authorities against neglecting TB prevention in prisons. Crowded cells in the prison leading to the spread of TB are argued to be a violation of prisoners’ right to health.

Filling the gap: A learning network for health and human rights in the Western Cape, South Africa
London L, Fick N, Tram KH and Stuttaford M: Health and Human Rights 14(1): 1-18, June 2012

The authors of this paper draw on the experiences of a Learning Network for Health and Human Rights (LN) involving collaboration between academic institutions and civil society organisations in the Western Cape, South Africa. The LN’s work in materials development, participatory research, training and capacity-building for action, and advocacy for intervention illustrates important lessons for human rights practice, they argue. These include: actively translating knowledge and awareness into action to make rights real; civil society’s role in holding services accountable in terms of the right to health; the need for civil society to promote rights in general; and the critical importance of networking and solidarity for building civil society capacity to act for health rights. Civil society can play a key role in bridging a gap between formal state commitment to creating a human rights culture and realising services and policies that enable the most vulnerable members of society to advance their health. Rights violations can be redressed through access to information and the creation of safe, participatory spaces. Civil society agency is critical to such action.

Financial Regulation, Human Rights and Sustainability
CIVICUS: December 2012

How can an integrated and inclusive approach of human rights and sustainable development be applied to financial regulation? CIVICUS argues that it will have to begin by giving the financial sector a role that is subservient to the ‘real’ economy, a real economy that in turn should support ecological sustainability and human rights and not a ‘paper’ economy based on futures trading. It points out that the recent financial crisis shows that market self-regulation does not work, calling for government intervention and regulation. CIVICUS makes three major proposals. First, given that markets in natural resources offer a field to expand paper profits while worsening equity in access to resources and conservation, CIVICUS call for new economic benchmarks and note that the Gross Domestic Product-based (GDP) is not an accurate benchmark of progress. Second, financing should be provided for sustainable modes of production, often small scale endeavours. Third, financial regulation should incentivise investment in production activities vs the paper economy.

SADC regional assessment report of policies and programmes on child and adolescent HIV, TB and malaria: October 2011-July 2012
Southern African Development Community: October 2012

This regional assessment showed that the foundations for integration and harmonisation of child and adolescent HIV, TB, malaria policies and programming frameworks are already in place in the SADC region. However, in all countries’ national strategic frameworks/plans and guidelines, there is a need to reinforce child specific issues in prevention, diagnostics, and treatment and care. Major gaps remain in strategic frameworks/plans in articulating the integration of HIV-malaria and TB-malaria programmes, and on linking TB and malaria programmes to basic child services. In addition, policies and programming frameworks on HIV are not harmonised across the region, and monitoring and evaluation of all child- and adolescent-focused health programmes is urgently required. Despite these shortcomings, SADC argues that member states can build on the strong foundations and seize invaluable opportunities to scale up a harmonised continuum of care for the three diseases and integrate them with basic child services. This could have a real impact on child health, survival and development in the region and help SADC member states to achieve Millennium Development Goals 4 (reduce child mortality) and 6 (combat HIV, malaria and other diseases), as well as other regional and international commitments.

5. Health equity in economic and trade policies

African trade and agriculture ministers seeking closer cooperation
Rampa F and Lui D: ECDPM Talking Points, 7 December 2012

African Union ministers of trade and agriculture gathered in early December 2012 at a joint conference in Addis Ababa to discuss their growing and increasingly overlapping work agendas. Agriculture remains the key source of income and employment for most Africans, while efforts intensify across the continent to liberalise intra-regional trade. In this blog, the authors summarise the main resolutions from the summit, while the final outcomes document is being drafted. Ministers agreed to accelerate implementation of the Plan of Action for Boosting Intra-Africa Trade in both agricultural commodities and processed food products. This is hoped to lead to an early deal to liberalise key regional food staples markets, as part of the continental free trade area. They also identified the national and regional compacts and investment plans of the Comprehensive Africa Agriculture Development Programme (CAADP) as the main instruments to define and operationalise trade-agriculture collaboration, while strengthening the capacity of relevant institutions and producers to effectively participate in these innovative practices and monitor their impact at country level. While they acknowledged the need to work at national, regional and continental levels to remove trade barriers in agricultural commodities, they emphasised that without immediate follow-up, food security will remain uncertain.

Biotechnology: Growing Partnerships amongst Developing Countries
Thorsteinsdottir H (ed): International Development Research Centre (IDRC), 2012

This book presents a detailed account of South-South collaboration in the health biotechnology sector. In particular, it casts light on the factors that guide effective scientific partnerships and exchanges. The authors explore these issues by combining a wide range of quantitative and qualitative methodologies, including co-publications analyses, in-depth surveys of biotechnology firms and interviews with around 350 researchers, entrepreneurs and policy-makers in developing countries. The key findings indicate that the level of South-South collaboration among researchers in health biotechnology remains low but is slowly increasing and that entrepreneurial collaboration seems to be more prevalent. Collaboration has helped to extend capacity in health biotechnology research, manufacturing and innovation to an increasing number of developing countries and thereby lessened the divide between them. Such collaboration has strongly focused on shared health needs and has helped to increase the availability of more affordable health products and services. Governments and non-governmental organisations have also been able to foster closer ties between researchers by establishing programmes and extending funding for collaboration. Nevertheless there is still a lack of dedicated resources.

Hazards in Bilateral Investment Treaties (BITs): Investors’ rights vs public health
Correa C: South Views, 6 December 2012

Many developing countries have entered into bilateral investment treaties (BITs) to protect foreign direct investment (FDI), which entail substantial restrictions on the sovereignty of recipient countries. At the end of 2011, 2,833 BITs had been signed worldwide. The granting of legal protection to foreign investors under BITs and other agreements (such as chapters in free trade agreements negotiated with developed countries) has often been seen as necessary to attract FDI. However, the author of this article argues that it is doubtful whether they have actually been effective in generating investment flows and promoting development gains. Moreover, many low or middle income countries that have signed BITs have been sentenced by international arbitral tribunals to pay millions of dollars as a result of alleged violations to these treaties. The authors caution that awards by tribunals have been based on overbroad definitions in the agreements and ambiguous legal standards such as “fair and equitable treatment” that have led to negative court outcomes for policies adopted in the public interest. The author presents a case study of Uruguay, where the government is being sued by a major tobacco manufacturer for issuing stricter packaging and labelling requirements for cigarettes to reduce tobacco consumption.

LDCs seek exemption from TRIPS agreement
Raja K: South Views, 12 December 2012

Least developed countries (LDCs) that are members of the World Trade Organisation (WTO) have submitted a request to the TRIPS Council for an extension of the transition period for them to comply with the TRIPS Agreement for as long as they are classified as LDCs. The request was submitted by Haiti, on behalf of the LDCs, at a meeting of the TRIPS Council on 6-7 November 2012. The exemption will continue to allow LDCs to access affordable medicines without the risk of violating patents on the medicines. Haiti argued that because of their extreme poverty, LDCs need the policy space to access various technologies, educational resources, and other tools necessary for development. Furthermore, LDCs have such small economies that they do not represent a significant loss of profits for pharmaceutical patent owners. Most intellectual property-protected commodities are simply priced beyond the purchasing power of these countries’ governments and their nationals, the spokesperson for Haiti added. Haiti has asked for this issue to be put on the agenda of the next TRIPS Council meeting, scheduled to take place in March 2013.

Mineral Rents and the Financing of Social Policy: Options and Constraints
McCorley C, Hujo K and Al-Adhami R: United Nations Research Institute for Social Development (UNRISD), December 2012

In this policy brief, the authors argue that mineral wealth can be harnessed for equitable and sustainable development if countries: design and implement comprehensive, inclusive and rights-based social policies; build strong democratic institutions; and develop the policy space to foster productive diversification while safeguarding macroeconomic stability. Public revenues generated through mineral production can provide a starting point for building state capacity that delivers on economic and social development objectives. States should enhance their capacity to strategically mobilise and allocate resources, the authors argue, as well as enforce standards and regulations, and establish social pacts through funding, delivering and regulating social services and social programmes. For countries that are dependent on mineral revenues, social policy is a crucial instrument to harness the development potential of mineral wealth while helping to avoid the pitfalls associated with the resource curse.

Trade, investments and aid in China-Africa relations
Centre for Chinese Studies (CCS): May 2012

From a mere US$2 billion in 1999, annual Sino-African trade has now reached $160 billion, making China a leading trade partner for Africa. China’s economic cooperation with Africa is also fuelled by investments and aid. In this report, CCS argues that Africa needs to include transparency, governance and public service delivery are included in the agenda for the Forum on China-Africa Cooperation (FOCAC), which was set up in 2000 to formalise bilateral engagement between China and Africa.

6. Poverty and health

Five Reasons Why Urban Farming is the Most Important Movement of our Time
Kumar R: GOOD, 19 November 2012

In this article, the author, an environmental blogger, puts forward five reasons why urban farming is one of the major social movements in the world today. First, the urban farming movement has the potential to reinvigorate local commerce by encouraging local farmers to trade with one another. Second, urban farmers are usually better stewards of their land because they directly bear the ecological costs of their actions, whereas industrial agriculture usually manoeuvers to avoid paying for environmental costs. Rather than using chemicals that destroy soil biology, urban farming culture stresses sustainable organic techniques that enrich the topsoil. Third, urban farming makes it clearer and easier for people to be involved in local politics by bringing issues that directly affect communities to the fore. Fourth, urban agriculture can also bring about a revolution of health and nutrition because it supplies fresh, organic produce. And finally, urban farming is inherently an activity that helps build a sense of community. Growing food is, after all, a cooperative effort, as knowledge of how and what to grow is exchanged, seeds are swapped, labour is shared, and the harvest is traded. As urban farming grows, the author predicts a stronger interdependence within urban communities is likely to result as local food systems bring more community interaction into people’s daily lives.

Harmonisation of Africa’s seeds laws: a recipe for disaster
African Centre for Biosafety: December 2012

This report raises that World Bank, USAID, the Food and Agriculture Organisation and the Alliance for a Green Revolution in Africa (AGRA) are pressuring African governments into harmonising seed laws relating to border control measures, phytosanitary control, variety release systems, certification standards and intellectual property rights, and indicate that this is to the detriment of African small-holder farmers and their seed systems. Harmonised intellectual property rights over seeds are based on the 1991 Act of the International Union of the Protection of Plant Varieties (UPOV) as developed by industrialised countries, and the authors argue that this Act is inappropriate for Africa where 80% of all seeds are still produced and disseminated by smallholder farmers. The authors report that seed harmonisation efforts have excluded farmer and civil society participation and that the current practices of small-scale African farmers and their contribution to seed breeding, genetic diversity and food security are not recognised.

Low nutrient intake among adult women and patients with severe tuberculosis disease in Uganda: a cross-sectional study
Mupere E, Parraga IM, Tisch DJ, Mayanja HK and Whalen CC: BMC Public Health 12(1050), 5 December 2012

In this cross-sectional study, researchers screened 131 adults with or without pulmonary tuberculosis (TB) for HIV, wasting and disease severity using the 13-item validated clinical TB score and 24-hour dietary intake recall. Of the 131 participants, 61 were males and 70 females. Overall men and women had similar age. In average 24-hour nutrient intake, the following were low among patients with severe TB: energy, protein, total fat, carbohydrate, calcium, vitamin A and folate. Patients with moderate-to-severe clinical TB score had lower average energy intake than patients with mild TB scores (6.11 vs. 9.27 megajoules [MJ], respectively). The average 24-hour nutrient intakes of wasted and non-wasted TB patients were comparable. Nutrient intake among men was higher when compared to women regardless of wasting and severity of TB. Among those with wasting, men had higher average energy intake than women (8.87 vs. 5.81 MJ, respectively). Among patients with mild disease, men had higher average energy intake than women with mild disease (12.83 vs. 7.49 kcal, respectively). These findings suggest that severity of pulmonary TB and female gender were associated with reduced nutrient intake. Early diagnosis and nutritional support may be important in management of patients.

South Africa’s sanitation cesspools
Bond P: Pambazuka News 609, 6 December 2012

Neoliberal sanitation experts visiting Durban, South Africa for the Toilet Summit in early December 2012 may argue that South Africa should embrace low-water toilets, yet community critics regularly report that Durban’s water-less ‘Ventilated Improved Pitlatrine’ (VIP) and ‘Urinary Diversion’ (UD) strategies are failing. The author argues that middle- and upper-class South Africans could easily cross-subsidise their low-income fellow residents by paying more for the privileges of filling swimming pools and bathtubs, watering gardens and running washing machines, and that government can at the same time adjust tariffs downwards for poor people. If such reforms were made to water and sanitation prices, then better health and gender equity would result, and more funds could be raised for installing decent toilets in South African cities, as well as to repair sewage pipes whose cracks infect rivers and harbours. The construction capability and subsidised funding for projects is available in South Africa so that 'toilet apartheid' is argued to relate more to political choices in how these resources are used.

Tipping The Balance: Policies to shape agricultural investments and markets in favour of small-scale farmers
Vorley B, Cotula L and Chan M: Oxfam, December 2012

Four country case studies undertaken for this report provide examples of innovations in policy design and implementation that have improved the investment climate for smallholders, such as decentralisation of land management responsibilities in Tanzania. Implementation of progressive policies in the face of major power imbalances between beneficiaries and vested interests seeking to maintain the status quo remains a major challenge. There are six inter-related sets of conclusions from the study. 1. Policy is currently biased against smallholders. 2. The investment climates that support smallholder investment and corporate investments in agriculture, while having elements in common, are not the same. 3. Policies must respond to the diversity of rural societies. 4. Policy innovations in inclusive investment do exist and should be copied. 5. Effective implementation is vital. 6. Politics matter: Vested interests undermine socially optimal outcomes, yet without a political analysis there is a risk of assuming that politicians choose policy in a socially optimal way and of constructing a normative analysis that focuses on technical solutions to the challenges of economic liberalisation.

7. Equitable health services

Alternatives to Privatisation: Public Options for Essential Services in the Global South
McDonald DA and Ruiters G: Routledge, 27 February 2012

Those who are against privatisation of public services are often confronted with the objection that there is no alternative. This book takes up that challenge by establishing theoretical models for what does (and does not) constitute an alternative to privatisation, and what might make them ‘successful’, backed up by a comprehensive set of empirical data on public services initiatives in over 40 countries. This is the first such global survey of its kind, providing a rigorous and robust platform for evaluating different alternatives and allowing for comparisons across regions and sectors. The book helps to conceptualise and evaluate what has become an important and widespread movement for better public services in the global South. The contributors explore historical, existing and proposed non-commercialised alternatives for primary health, water/sanitation and electricity. The objectives of the research have been to develop conceptual and methodological frameworks for identifying and analysing alternatives to privatisation, and testing these models against actually existing alternatives on the ground in Asia, Africa and Latin America. Information of this type is urgently required for practitioners and analysts, both of whom are seeking reliable knowledge on what kind of public models work, how transferable they are from one place to another and what their main strengths and weaknesses are.

Crossing the quality chasm in resource-limited settings
Maru DS, Andrews J, Schwarz D, Schwarz R, Acharya B, Ramaiya A, Karelas G et al: Globalization and Health 8(41), 30 November 2012

Despite extensive scientific and policy innovations in quality of care, the authors raise a gap in quality in resource-limited areas that undermine effective access to healthcare for poor people. In this perspective piece, the authors propose six actions to address this: revise global health investment mechanisms to value quality; enhance investment in the role of health persinnel for improving quality; scale up data capacity; deepen community accountability and engagement initiatives; implement evidence-based quality improvement programmes; and develop an implementation science research agenda.

Does treatment collection and observation each day keep the patient away? Analysing the determinants of adherence among patients with TB in South Africa
Birch S, Govender V, Fried J, Eyles J, Daries V, Moshabela M and Cleary S: Health Economics Unit, University of Cape Town, November 2012

In this presentation given at the Second Global Symposium on Health Systems Research in November 2012, researchers presented the results of a study in which they evaluated the effectiveness of daily observation of drug consumption at tuberculosis (TB) clinics in South Africa. They conducted 1,200 patient exit interviews with patients in 30 different TB facilities, as well as 17 in-depth interviews to understand patient access barriers. Findings indicated that the requirement for daily observation of drug consumption at clinics imposes substantial costs on patients, and this may impact adversely on adherence. In multivariate regressions, patients that visited the facility on a daily basis (versus other) were more than twice as likely to report missing their TB medication (after controlling for other factors). Qualitative findings suggest that long travel distances to facilities, the cost of transport, and the opportunity cost of clinic attendance were some of the factors influencing adherence. Less frequent clinic visits may be a win-win for TB treatment because of: improved efficiency through reduced provider costs; higher adherence; and lower patient access barriers to care.

Geographical access to care at birth in Ghana: a barrier to safe motherhood
Gething PW, Johnson FA, Frempong-Ainguah F, Nyarko P, Baschieri A, Aboagye P et al: BMC Public Health 12(991), 16 November 2012

Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many regions with high maternal mortality. In this study, the authors combined a detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana. They estimated journey-time for all women of childbearing age (WoCBA) to their nearest health facility. Findings indicated that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the ‘partial’ standard or better. Nearly half (45%) live that distance or further from ‘comprehensive’ EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. The authors conclude that their approach, using detailed data assembly combined with geospatial modeling, can provide accurate nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes, they argue, because they fail to take account of the location and accessibility of services relative to the women they serve.

Prevalence and predictors of giving birth in health facilities in Bugesera district, Rwanda
Joharifard S, Rulisa S, Niyonkuru F, Weinhold A, Sayinzoga F, Wilkinson J et al: BMC Public Health 12(1049), 5 December 2012

The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services amongst women living in rural villages in Bugesera District, Eastern Province, Rwanda. Using census data, researchers selected 30 villages for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Their analysis of 3,106 lifetime deliveries from 859 respondents showed a sharp increase in the percentage of health facility deliveries in recent years. The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health centre.

Risk factors for VIA positivity and determinants of screening attendances in Dar es Salaam, Tanzania
Kahesa C, Kjaer SK, Ngoma T, Mwaiselage J, Dartell M, Iftner T, Rasch V: BMC Public Health 12(1055), 7 December 2012

In response to a high incidence of cervical cancer, Tanzania implemented “visual inspection of the cervix after acetic acid application” (VIA) as a regional cervical cancer screening strategy in 2002. With the aim of describing risk factors for VIA positivity and determinants of screening attendances in Tanzania, this research paper presents the results from a comparative analysis performed among women who are reached and not reached by the screening programme. Researchers studied 14,107 women aged 25–59 enrolled in a cervical cancer screening programme in Dar es Salaam in the period 2002–2008. The women underwent VIA examination and took part in a structured questionnaire interview. Results indicated that women who are widowed/separated, of high parity, of low education and married at a young age are more likely to be VIA positive and thus at risk of developing cervical cancer. Although women who participated in the screening were more likely to be HIV positive in comparison with women who had never attended screening, the authors point out that this may be due to a referral link that exists between the HIV programme and the cervical cancer screening programme, which means that HIV positive were more likely to participate in the cervical cancer screening programme than HIV negative women.

SADC Minimum Standards for Child and Adolescent HIV, TB and Malaria Continuum of Care: 2011-2012
Southern African Development Community: 2012

When Southern African Development Community (SADC) member states signed the SADC Protocol on Health in 2008, they committed themselves to dealing with communicable diseases - particularly HIV, tuberculosis (TB) and malaria - in a harmonised manner. However, until now, the key regional strategic frameworks and minimum standards developed to guide action in the control of these three diseases did not adequately cover children and adolescents. To address this shortcoming, SADC commissioned a regional assessment in the 14 active SADC Member States between October 2011 and July 2012. On the basis of this data, the SADC Secretariat developed the SADC Minimum Standards for Child and Adolescent HIV, TB and Malaria Continuum of Care. It establishes the minimum package of services that member states should have in place to achieve a common response in the region. Because of the bi-directional links between the HIV, TB and malaria and child vulnerability, it is crucial that access to services such as health, education, social and child protection, food security and nutrition and psychosocial services are adequately integrated into this response, as established in the SADC Strategic Framework and Programme of Action for Orphans and Vulnerable Children and Youth.

8. Human Resources

A descriptive study on health workforce performance after decentralisation of health services in Uganda
Lutwama GW, Roos JH and Dolamo BL: Human Resources for Health 10(41), 7 November 2012

The purpose of this study was to investigate the performance of health workers since decentralisation of health services in Uganda in the 1990s in order to identify and suggest possible areas for improvement. Researchers conducted a cross-sectional descriptive survey, using quantitative research methods to collect quantitative data from 276 health workers in the districts of Kumi, Mbale, Sironko and Tororo in Eastern Uganda. The study revealed that even though the health workers are generally responsive to the needs of their clients, the services they provide are often not timely. Health workers take initiative to ensure that they are available for work, although low staffing levels undermine these efforts. While the data shows that the health workers are productive, over half (50.4%) of them reported that their organisations do not have indicators to measure their individual performance. In general, the results show that health workers are proficient, adaptive, proactive and client-oriented. Although Uganda is faced with a number of challenges as regards human resources for health, these findings show that the health workers that are currently working in the health facilities are enthusiastic to perform. This may serve as a motivator for the health workers to improve their performance and that of the health sector.

ART adherence clubs to help overburdened health workers
Health-e News: 30 November 2012

Antiretroviral therapy (ART) adherence clubs, already operating in several high burden areas in Cape Town, have the potential to revolutionise the treatment of millions of HIV-positive South Africans and lighten the load on overburdened health workers, according to Medecins Sans Frontieres (MSF). In a nutshell, the ART adherence clubs are a long-term retention model of care for stable patients on ARVs. Between 20 and 30 patients meet and are facilitated by a non-clinical staff member who provides a quick clinical assessment, a referral where necessary and peer support in the form of a short group meeting. Pre-packed ARVs are distributed, enough to last for two months until the next meeting. Once a year, the patient is referred for blood tests and is seen by a doctor. This means that for one year the patient does not need to be seen by a professional health worker, essentially freeing the workers up to treat more complex cases and creating space in waiting rooms. By August 2012, 149 new clubs had been established in Khayelitsha, Cape Town, totalling 5,195 patients, which represents 20% of those enrolled for ART in the township. A spokesperson from the provincial health department said the province was also looking at integrating the clubs into a chronic care model, which means that patients with for example diabetes or high blood pressure could benefit.

Knowledge and performance of the Ethiopian health extension workers on antenatal and delivery care: a cross-sectional study
Medhanyie A, Spigt M, Dinant GJ and Blanco R: Human Resources for Health 10(44), 21 November 2012

In recognition of the critical shortage of human resources within health services, community health workers in Ethiopia have been trained and deployed to provide primary health care in developing countries. In this study, researchers investigated the knowledge and performance of these health extension workers (HEWs) on antenatal and delivery care, as well as the barriers to and facilitators for the provision of maternal health care. A total of 50 HEWs working in 39 health posts, covering a population of approximately 195,000 people, were interviewed. Almost half of the respondents had at least five years of work experience as a HEW. More than half (54%) of the HEWs had poor knowledge on contents of antenatal care counseling, and most (88%) had poor knowledge on danger symptoms, danger signs, and complications in pregnancy. Health posts, which are the operational units for HEWs, did not have basic infrastructure like water supply, electricity, and waiting rooms for women in labour. On average, within six months, a HEW assisted in only 5.8 births. Only a few births (10%) were assisted at the health posts, most (82%) were assisted at home and only 20% of HEWs received professional assistance from midwives. Based on these findings, there is an urgent need to design appropriate strategies to improve the performance of HEWs by enhancing their knowledge and competencies, while creating appropriate working conditions.

The promise of competency-based education in the health professions for improving global health
Gruppen LD, Mangrulkar RS and Kolars JC: Human Resources for Health 10(43), 16 November 2012

Competency-based education (CBE) is argued to provide a useful alternative to time-based models for preparing health professionals and constructing educational programmes. In this paper, the authors describe the concept of 'competence' and 'competencies' as well as the critical curricular implications that derive from a focus on 'competence' rather than 'time'. These implications include: defining educational outcomes, developing individualised learning pathways, setting standards, and the centrality of valid assessment so as to reflect stakeholder priorities. They also highlight four challenges to implementing CBE: identifying the health needs of the community, defining competencies, developing self-regulated and flexible learning options, and assessing learners for competence. While CBE has been a prominent focus of educational reform in resource-rich countries, the authors argue that it has even more potential to align educational programmes with health system priorities in more resource-limited settings. Because CBE begins with a careful consideration of the competencies desired in the health professional workforce to address health care priorities, it provides a vehicle for integrating the health needs of the country with the values of the profession.

9. Public-Private Mix

Closing the access barrier for effective antimalarials in the private sector in rural Uganda: consortium for ACT private sector subsidy (CAPSS) pilot study
Talisuna AO, Daumerie P, Balyeku A, Egan T, Piot B, Coghlan R et al:Malaria Journal 11(356), 29 October 2012

Between August 2007 and May 2010, the Uganda Ministry of Health and the Medicines for Malaria Venture conducted the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study to test whether access to artemisinin-based combination therapy (ACT) for malaria in the private sector could be improved through the provision of a high level supply chain subsidy. Four intervention districts were purposefully selected to receive branded subsidised medicines, while the fifth district acted as the control. Researchers analysed the intervention's impact on: ACT uptake and price; purchase of ACT within 24 hours of symptom onset; ACT availability and displacement of sub-optimal anti-malarial. At baseline, ACT accounted for less than 1% of anti-malarials purchased from licensed drug shops for children less than five years old. However, at evaluation, it accounted for 69 % of anti-malarial purchased in the interventions districts. Purchase of ACT within 24 hours of symptom onset for children under five years rose from 0.8 % at baseline to 26.2 % at evaluation in the intervention districts. These data demonstrate that a supply-side subsidy and an intensive communications campaign significantly increased the uptake and use of ACT in the private sector in Uganda.

Incentivising private specialists to work in the public health sector: Expanding ‘session work’ in South Africa
Ashmore J: Health Economics Unit (HEU), University of Cape Town: Policy Brief, November 2012

This policy brief aims to understand whether or how session work in hospitals could be expanded to help achieve universal health coverage. About 14% of private sector specialists work part-time in public hospitals, through what is known as ‘session work’. Private specialists undertake session work for a number of mainly non-financial reasons, such as to ‘give back’ to the public sector and to teach in academic hospitals. There are a number of private specialists who seem interested in working in the public sector in future, but the pay is very low for session work. The author argues that higher session wages may induce specialists to leave full-time public work to undertake private and session work. Thus it may be important to only give new session worker posts to those who have already left the public sector.

10. Resource allocation and health financing

CSOs, policy-makers and the private sector meet to discuss the future of aid
Villota C: European Network on Debt and Development (Eurodad), 29 November 2012

On 15 November 2012 Eurodad and Oxfam International organised the public seminar ‘The future of aid and development effectiveness’ to debate the role of aid in the post-Busan agenda. At the seminar, presenters highlighted how the ineffective practices of external funders and recipient countries continue to constrain the full potential of aid to deliver development outcomes. Participants agreed that it is essential to monitor progress towards commitments on a rolling basis, but called for caution when using results-based approaches to aid, arguing that increasing pressure on aid budgets and calls for greater accountability should not be translated into modalities that undermine aid effectiveness principles. In order to prevent this from happening, the aid effectiveness agenda should serve as a reference framework to ensure that new aid modalities are an improvement over existing ones. While some considered a results-based approach as a way to ensure that aid is effective, others regarded it as quick win and a funder-driven agenda for times of crisis that could reverse the progress made so far in developing more equitable aid programmes.

Does the equity fund in Madagascar target benefits to the poorest members of society and those most in need?
Honda A, University of Cape Town: November 2012

Targeting to identify the poorest or those most in need of exemptions has proven a major challenge under exemption schemes in terms of protecting the poor from financial risk. In this presentation given at the Second Global Symposium on Health Systems Research in November 2012, the author discusses her research into Madagascar’s Equity Fund, which is intended to exempt the poorest in Madagascar from costs such as user fees at health facilities. She assessed the accuracy of the Fund’s targeting process to determine who receives benefits by examining whether the socio-economic status of equity fund beneficiaries was lower than that of non-beneficiaries, as well as identify factors influencing the targeting outcomes. Results suggested that beneficiaries were reasonably well targeted; however, both leakage and under-coverage occurred. Coverage remains very low, with conflicts of interest between health administrators and village level agents. The local health administration could not monitor or influence village level agents’ behaviour during beneficiary identification. Monitoring, decision-making and managerial mechanisms were re-shaped to allow health administrators to influence the number of indigents registered on the list. In addition, a re-orientation of the policy objectives changed the emphasis of equity fund operations to favour financial performance.

Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage
Mills , Ataguba JE, Akazili J, Borghi J, Garshong B, Makawia S, Mtei G, McIntyre D et al: The Lancet 380(9837): 126–133, 14 July 2012

In this study, researchers conducted a whole-system analysis - integrating both public and private sectors - of the equity of health-system financing and service use in Ghana, South Africa and Tanzania. They used primary and secondary data to calculate the progressivity of each health-care financing mechanism, catastrophic spending on health care, and the distribution of health-care benefits. Overall, health-care financing was found to be progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries. These findings raise questions over the appropriate financing mechanism for the health care of people outside the formal sector. Physical and financial barriers to service access must be addressed if universal coverage is to become a reality.

Gender differences in public perceptions on National Health Insurance
Evans M and Shisana O: South African Medical Journal 102(12): 918-924, December 2012

South Africa is in the process of implementing a National Health Insurance (NHI) scheme to address drastic inequalities in the health sector and transform the health system. In particular, NHI is expected to have a significant positive impact on females, who are disadvantaged under the current system, with higher rates of poor health and lower rates of medical scheme membership. Despite NHI’s transformative potential, however, the public discourse on NHI as portrayed in the media suggests that it is an unpopular policy. The authors of this paper assessed the general public’s opinion on NHI and explored gender differences in perceptions, using data from a 2010 survey of the South African population that looked at social attitudes. They found that there is broad public acceptance of NHI, with an overwhelming majority of South Africans preferring an NHI system to the current two-tiered system. More females than males said they supported NHI, reflecting the potential of the NHI system to have a positive impact on gender equality and the health of women and girls. It appears that support for NHI has increased since similar studies in 2005 and 2008, with the simultaneous growth of public discourse on the policy.

Hitting the Target? Evaluating the Effectiveness of Results-based Approaches to Aid
Pereira J and Villota C: European Network on Debt and Development (Eurodad), September 2012

In this report, the authors assess the potential of results-based approaches to deliver long-term and sustainable results by measuring the performance of different initiatives against widely agreed aid effectiveness principles. They found that, in general, results-based approaches are not particularly good at supporting aid effectiveness principles but broader approaches do appear to be better aligned with the principles. Ownership tends to be higher when the responsibility for designing programmes falls on recipient governments. This does not mean that funder-led approaches cannot achieve significant degrees of ownership, but results are likely to be less consistent, have higher costs and impose a significant burden on host governments and civil society. Results-based approaches tend to reinforce accountability to external funders and in doing so, undermine mutual accountability. In general, the problem is less acute with country-wide initiatives and it is most pressing when working through third party service providers. In addition, the level of harmonisation of results-based approaches is low because of their widespread use of parallel structures. Eligibility and public financial management criteria demanded by funders can further influence and limit the type of country systems that recipient countries can implement.

The beginning of the end? Tracking global commitments on AIDS
ONE: 2012

Despite progress in the fight against AIDS over the past few years, this report warns that the gains that the world has made are in danger of being lost. There is not yet shared global responsibility for achieving the goal of ending AIDS, nor have stakeholders mapped out a collective plan for how to achieve the goal with specific responsibilities or time-bound milestones. ONE argues that there must be a renewed effort to examine, improve and scale up the financial, political and programmatic efforts needed to turn vision into action. In this report, ONE monitors progress on improving access to treatment and reducing new HIV infections; provides an assessment of the G7 countries’ and the European Commission’s past and current efforts in the fight against HIV and AIDS globally; and sets a baseline for monitoring future progress towards the beginning of the end of AIDS. The organisation calls on external funders from the West to work in closer partnership with each other and with African governments, emerging economy governments, the private sector and civil society groups to leverage unique skill-sets and resources, all aimed towards the achievement of common targets. While funding remains one of the largest hurdles in making progress towards this vision, additional efforts to address the AIDS pandemic cannot come at the expense of financing for other global health and development initiatives.

What healthcare financing changes are needed to reach universal coverage in South Africa?
McIntyre D: South African Medical Journal 102(6), June 2012

Moving towards a predominantly publicly funded health system with a specified role for private voluntary health insurance will take time, according to this article. What is required in the short term is for Treasury to be responsive to submissions to gradually increase the allocations to the health sector from general tax revenue, to enable the Department of Health to implement its plans to strengthen substantially both primary healthcare and hospital services, as outlined in the National Health Insurance (NHI) Green Paper and other recent policy documents. It is likely that it will be necessary to supplement this with additional taxes dedicated to the health sector, such as an income tax surcharge, payroll tax on employers and/or ‘sin taxes’ on tobacco and alcohol, which can be phased in after initial improvements to the public health system have been achieved. The author argues that when universal entitlements to specified services are formalised in legislation, it will be important to specify the complementary role of private voluntary insurance. Through this overall process, the relative distribution of healthcare funding across different financing mechanisms will, it is argued, shift gradually to the pattern seen in countries that have already achieved universal coverage.

11. Equity and HIV/AIDS

Assessment of water, sanitation, and hygiene practice and associated factors among people living with HIV/AIDS home based care services in Gondar city, Ethiopia
Yallew WW, Terefe MW, Herchline TE, Sharma HR, Bitew BD, Kifle MW, Tetemke DM et al: BMC Public Health 12(1057), 7 December 2012

This cross-sectional study was carried during 2009 to assess water, sanitation status and hygiene practices and associated factors among People Living with HIV and AIDS (PLWHAs) in home-based care services in Gondar City, Ethiopia. Researchers collected data from 294 PLWHAs in the form of in-depth interviews (72.8% females and 27.2% males). They found that 42.9% of the households had “unimproved” water status, 67% had “unimproved” sanitation status, and 51.7% had poor hygienic practice. Diarrhoea with associated with water status, while educational status and latrine availability were associated with sanitation status. Lack of hand washing devices and the unaffordable cost of soap reduced hygienic practices. In conclusion, the authors found a high burden of water, sanitation and hygiene problems in home-based care services for PLWHAs. They recommend hygiene education and additional support for the provision of water, sanitation and hygiene services.

SEYCOHAIDS 2012: Consensus Statement and Conference Road Map
Delegates at the SEYCOHAIDS 2012: November 2012

The Southern and Eastern Africa Youth Conference on HIV and AIDS and Reproductive Health Rights for Sustainable Development (SEYCOHAIDS 2012) was held in Malawi, 6-8 November 2012, and delegates produced this statement at the end of the conference. During the conference, delegates were able to share best practices and lessons in HIV and adolescent Sexual Reproductive Health (SRH) interventions in the region. Although regional governments have ratified the African Youth Charter; the signatories to this statement recommend that it is domesticated and used to inform the Youth policies and development programmes in the respective countries. Funding alone cannot deal with the issues of child marriages, as well as HIV and SRH support. The community systems require strengthening in order to support effective HIV and SRH programmes and interventions for adolescents at the community level to achieve universal access to health and the Millennium Development Goals by 2015. The statement points to best practices and models of HIV and SRH capacity building in the region that can be replicated and scaled up, including improved family planning programmes targeted at the youth, to prevent unplanned pregnancies and unsafe abortions.

South Africa finally announces single pill for HIV
Health-e News: 29 November 2012

The South African Government has taken a major step towards improving HIV treatment compliance and cost with the announcement that the new antiretroviral (ARV) tender will include a triple fixed dose combination (FDC) tablet, which combines three pills into one. FDCs have shown to have major benefits for ART patients in terms of easier compliance and fewer side effects, with the added benefit for hospitals of reduced logistics and less storage space needed. The cost of the FDC is only R89.37, making it arguably the world’s lowest priced FDC. From April 2013 all pregnant women will be given the fixed dose combination during pregnancy and breast feeding and thereafter if their CD4 count is less than 350. According to Health Minister Aaron Motsoaledi, the fixed dose combination is more effective than dual therapy and has fewer side effects for the pregnant mother, in addition to its convenient dosage regimen. He confirmed that the most of the patients currently on the three ARV drugs would switch to the FDC from April 2013. Government will continue to stock the current ARVs for those unable to switch. Activists, who have been campaigning for FDCs for a number of years, welcomed the decision.

World AIDS Day 2012: Closing in on global HIV targets
World Health Organisation: 1 December 2012

Much of the progress in recent years in the fight against HIV may be attributed to increased use of antiretrovirals (ARVs), argues the World Health Organisation (WHO) in this short article to commemorate World AIDS Day on 1 December 2012. The latest global statistics suggest that, provided countries are able to sustain current efforts, the goal of getting 15 million HIV-infected people worldwide on ARVs will be reached by 2015. Currently eight million people in low- and middle-income countries are accessing the treatment they need, up from only 0.4 million in 2003. However, vulnerable and marginalised groups are still not able to access HIV prevention and treatment services, including adolescent girls, sex workers, men who have sex with men, drug users and migrants. And children are lagging badly behind: only 28% of children who need ARVs can obtain them. Some countries are considering initiating treatment at an even earlier stage in the course of HIV, as well as offering all HIV-positive pregnant women ARV therapy for life. WHO is currently reviewing new scientific research and country experiences in order to publish updated and consolidated guidance on the use of ARVs in mid-2013.

Zeroing in on AIDS and global health Post-2015
Buse K, Blackshaw R, Harakeye and Ndayisaba M: Globalization and Health 8(42), 30 November 2012

In light of the emerging debate on what a post-2015 development agenda and accountability framework should look like, the authors of this paper call on policy makers and other stakeholders to look at the AIDS response for lessons in global health responses, where the most marginalised are at the centre of the debate, human rights are protected under the rule of law, strong accountability is in place for results for people, and community and participatory processes are the norm. These hard-won principles of the AIDS response should be incorporated into the post-2015 global health agenda, while at the same time acknowledging that a rapidly changing world, including a shifting geopolitical and economic landscape, requires policy responses that are context sensitive. Three years ago, UNAIDS articulated what was then considered to be an ambitious vision: zero new HIV infections and zero-AIDS related deaths by 2015, underpinned by zero discrimination. The authors argue that the post-2015 development agenda calls for the reconceptualision of this vision as a set of concrete goals. They discuss the Shared Responsibility-Global Solidarity agenda, as pioneered by the African Union in its recent Roadmap on AIDS, Tuberculosis, and Malaria, to illustrate ways in which global health can be re-thought to tackle twenty-first century challenges.

12. Governance and participation in health

African Civil Society Statement: Call for a ban on GM crops and food
African Centre for Biosafety: 15 November 2012

In the wake of the recent ban by Kenya on the importation of genetically modified (GM) products until proper health evaluation has been completed, African civil society in this paper is requesting the African Union (AU) discuss banning all GM products throughout the continent at the next AU summit in January 2013. Civil society represented by 400 African organisations consisting of small-scale farmers, social movements, non-governmental organisations, faith-based groups, organic producers and consumers, business people and ordinary citizens issued a statement pointing out the lack of safety data on GM foods, as well as condemning the patenting of life and privatisation of agriculture, which threatens to displace African food producer control over their production systems.

Challenges and Opportunities for HIV, AIDS and TB Budget Monitoring at Local Level in South Africa
Centre for Economic Governance and AIDS in Africa: 10 September 2012

This evaluation of the South African Budget Monitoring and Expenditure Tracking (BMET) project, which was launched in 2009, demonstrates that citizen involvement in economic governance is both possible and progressing. The project is aimed at improving the delivery, accessibility and affordability of treatment for people living with HIV and AIDS and TB. Project interventions have reached a range of targeted beneficiaries and achieved a positive impact in four key aspects. First, community engagement has stimulated community members’ interest in budget issues relating to health care provision and mobilising for improvements. Second, health workers have a better understanding of their own and their client-community needs towards enhancing facility systems. Third, citizens are empowered with skills to research and track the quality of HIV and AIDS and TB services in their community and demand answers. Finally, collaboration on resolving longstanding and complex health service delivery problems has been enhanced because citizens, organisations and health authorities have a shared, relational understanding of both the barriers to and the opportunities for change.

Civil Society Call to Action at the GAVI Partner’s Forum 2012
ACTION and the GAVI civil society constituency: 7 December 2012

ACTION and the GAVI civil society constituency have issued this statement urging the GAVI Alliance to support increased participation from civil society in its funding, strategy and governance. The GAVI Alliance is a public-private partnership that works to increase access to immunisation in developing nations. This Call to Action was presented at the GAVI Alliance Partners’ Forum in Dar es Salaam, Tanzania, where more than 600 global health leaders gathered in early December to discuss accelerating progress in global immunisation. The statement calls on GAVI to recognise the vibrant role played by civil society representatives in the Forum and their vital contributions to delivering vaccinations and care, reaching unimmunised children, as well as mobilising resources for health and immunisations. The signatories are hoping that GAVI will articulate in its next business plan how civil society contributes to each of GAVI’s strategic objectives, and will create a second seat on the GAVI Alliance Board for a civil society representative.

Civil Society Statement on the occasion of the Second Southern Africa Regional Child Rights Conference
Save the Children et al: 5 November 2012

At a meeting on 1-2 November 2012 in Johannesburg, child rights organisations from across Southern Africa brought together a number of stakeholders – including parliamentarians, government officials and various civil society organisations – to meet under the auspices of the Child Rights Network for Southern Africa (CRNSA) and to reflect on building a strong child rights movement in Southern Africa. In this statement, they call on the Southern African Development Community (SADC) to adopt a specific children’s protocol, ensuring meaningful participation of children at various levels of decision making, in particular helping each country to establish a state-funded children’s Parliament. At the same time, SADC should make state parties implement its basic minimum package of services for children, domesticate regional and international instruments that state parties have ratified and allocate and increase budgets for children at all levels while guaranteeing meticulous budget monitoring. The signatories further call on SADC governments to ensure timeous reporting to treaty bodies, especially the African Charter on the Rights and Welfare of the Child – to whom only Tanzania has reported – as well as prioritise child abuse prevention and early intervention programmes, expeditiously pass comprehensive child-related laws and policies, act as role models in championing children rights and address the contradictions arising from the existence of dual legal systems (customary law and civil law), notably in the case of harmful cultural practices.

Comprehensive family hygiene promotion in peri-urban Cape Town: Gastrointestinal and respiratory illness and skin infection reduction in children aged under 5
Cole EC, Hawkley M, Rubino JR and Crookst BT: South African Journal of Child Health 6(4):109-117, November 2012

In this study, researchers hypothesised that a participatory learning and action (PLA) family hygiene education approach plus the regular use of hygiene products could result in marked reduction of morbidity in children aged under five years. They sampled 685 households in two separate areas in Cape Town. Two groups received hygiene education only (control) and the other two groups hygiene education plus hygiene products (intervention). Results indicated that children aged under five years in all communities had significant reductions in gastrointestinal and respiratory illnesses and skin infections over time. The first control group with hygiene education only was 2.46 times more likely to experience gastrointestinal illnesses and 4.56 times more likely to experience respiratory illnesses at study follow-up than the corresponding intervention group. The second control group with hygiene education only was 1.64 times more likely to experience gastrointestinal illnesses, 4.62 times more likely to experience respiratory illnesses and 1.29 times more likely to experience skin infections than the intervention group. In conclusion, while hygiene education alone resulted in meaningful reductions in the three conditions, families with hygiene education plus consistent use of provided hygiene products had greater reductions.

Defending civil society
International Centre for Not-for-Profit Law (ICNL), World Movement for Democracy Secretariat the National Endowment for Democracy (NED): International Journal of Not-for-Profit Law 14(3): 5-61, September 2012

While many civil society activists continue to face traditional forms of repression, like imprisonment, some governments have become more subtle in their efforts to curb civil society organisation (CSO) space. This report provides illustrative examples of the legal barriers used to constrain this space. It also considers major challenges, such as restrictions on the use of new technologies, measures against public movements and peaceful assemblies, and the unintended consequences of efforts to enhance the effectiveness of foreign aid. After a discussion of the international principles protecting civil society, which are embedded in international law, ICNL calls on democratic governments and international organisations to recognise, protect, and promote fundamental rights to freedom of assembly and of association, and to raise the level of their engagement with CSOs in platforms such as the Community of Democracies’ Working Group on Enabling and Protecting Civil Society and the UN Special Rapporteur’s mandate. At the same time, CSOs are urged to deepen their understanding of legal frameworks governing them and build capacity to engage in reform of regressive frameworks.

Feminism and intellectual property: Will women judges make a difference?
Hamalengwa M: Pambazuka News 609, 6 December 2012

In this article, the author asks whether the increasing number of women in the judiciary and politics will affect intellectual property regimes in both law and in politics. The author briefly describes articles written by feminists analyse the gendered nature of intellectual property law. Some papers argue that an increase in the past 40 years in the encroachment of private ownership rights at the expense of the public domain has raised gender inequalities. The public domain recognises the communal roots of creation, rather than the individual “inventor”, and has a primary concern of looking after people, not individual success based on money, which is a concern of business. These different features of public and private interests and social and collective spaces are analysed for the gender norms they reflect and their gender related consequences.

Medical Internationalism in Cuba
Kirk JM: Weekend Edition 14-16 December 2012

This article, based upon seven years of research and some 70 interviews with Cuban medical personnel, both in Cuba and abroad, seeks to provide a broad overview of the importance of Cuban medical internationalism. The article reviews several, different, programmes of medical cooperation in terms of basic data on their evolution and impact, and analysis of the rationale for their development. As of April 2012 there were 38,868 Cuban medical professionals working in 66 countries–of whom 15,407 were doctors (approximately 20% of Cuba’s 75,000 physicians). In Africa some 3,000 Cuban medical personnel are currently working in 35 of the continent’s 54 countries, while in Venezuela alone there are approximately 30,000. But that is only part of the story, since there are many other significant facets to Cuban medical internationalism. In all cases the author suggests that 'human capital' is the most important common denominator. For over fifty years Cuban medical personnel have served the poorest and most neglected areas of the world, going where other doctors refused to go.

Further details: /newsletter/id/37529
Shaping Our Shared Future: Beyond 2015: Perspectives from the Global South
Gupta D (ed): Wada Na Todo Abhiyan, 2012

This collection of essays looks at the post-2015 development agenda. In it, researchers and activists argue that the process undertaken to shape the new development agenda must be organised around seven priorities. 1. Integrating community experiences, expectations and insights at the heart of the process. 2. Widespread dialogue to capture and consolidate expectations of civil society organisations (CSOs) with regard to the second round of development goals. 3. Supporting and including evidence from research and analysis by institutions and experts located in the global south 4. consultations held with community groups, CSOs and academicians and engagement with the relevant policy makers. 5. Meaningful engagement by regional blocs like the African Union and trade forums such as BRICS and the G20. 6. Reaching out to young people and urban populations, and 7. Monitoring and enforcing corporate accountability.

Time to listen: Hearing People on the Receiving End of International Aid
Anderson MB, Brown D and Jean I: CDA Collaborative Learning Projects, November 2012

This book captures the experiences and voices of over 6,000 people who have received international assistance, observed the effects of aid efforts or been involved in providing aid. More than 125 international and local aid organisations in 20 aid-recipient countries were interviewed about their experiences with, and judgments of, international assistance. The researchers also spoke with people who represented broad cross-sections of their societies, ranging from fishermen on the beach to government ministers with experience in bilateral aid negotiations. The voices reported here convey four basic messages: first, international aid is a good thing that is appreciated; second, assistance as it is now provided is not achieving its intent; third, fundamental changes must be made in how aid is provided if it is to become an effective tool in support of positive economic, social, and political change; and fourth, these fundamental changes are both possible and doable. What people want is an international assistance system that integrates the resources and experiences of outsiders with the assets and capacities of insiders to develop contextually appropriate strategies for pursuing positive change. The idea of international assistance needs to be redefined away from a system for delivering things and reinvented to support collaborative planning.

13. Monitoring equity and research policy

Capacity for Health Policy and Systems Research and Analysis in seven African universities
Mirzoev T, Le G, Kalliecharan R, Agyepong I, Erasmus E, Goudge J, Kamuzora P et al: November 2012

The Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA) project (2011-2014) is a four-year collaboration between seven African and four European universities aimed at strengthening the capacity of universities in Ghana, Kenya, Nigeria, Tanzania and South Africa to: produce high quality health policy and systems research (HPSR); provide HPSR training; engage with networks; and communicate research into policy and practice. In this presentation given at the Second Global Symposium on Health Systems Research in November 2012, the authors present the results of their study to evaluate the performance of CHEPSAA and to evaluate HPSR capacity in the seven universities. The university-based institutes were found to share a vision for HPSR that relates to wider institutional purpose. While structures and processes to support HPSR exist, and HPSR ‘champions’ were identified in the study, the authors found these were undermined by succession challenges. Staff shortages were problematic, especially among especially senior staff. The institutes also exhibited different income patterns including unpredictable external funding. The authors conclude that local universities are central to strengthening HPSR capacity in Africa and CHEPSAA African partners already have sufficient capacity to build upon; however, HSPR in Africa is still an emerging field that needs support.

Health in South Africa: changes and challenges since 2009
Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Karim SSA, Coovadia HM: The Lancet 380(9858): 2029-2043, 8 December 2012

According to this evaluation, South Africa has improved most of its health indicators since 2009, significantly expanded its programme of antiretroviral therapy and launched an ambitious government policy to address lifestyle risks, as well as an integrated strategic framework for prevention of injury and violence, which remains to be implemented. A radical system of national health insurance and re-engineering of primary health care will be phased in over 14 years to enable universal, equitable and affordable health-care coverage. National consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2% of national health spending. However, large racial differentials still exist in the social determinants of health, Integration of services for HIV, tuberculosis and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered more widely. The authors conclude that transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve the health-related Millennium Development Goals 4, 5 and 6.

South African government to allocate more funds for health research
Bateman C: South African Medical Journal 102(6): 345-346, June 2012

The South African Government is to allocate more funds to health research over the next decade and add clinical research centres to hospitals earmarked for revitalisation so that it can build relevant evidence-based knowledge into the public health system. Deputy Minister of Health, Dr Gwen Ramokgopa, said that her department was currently spending 0.6% of its budget on health research, less than the 2% minimum it committed to in its 2001 health research policy.

14. Useful Resources

2013 Human Development Report: The Rise of the South: Human Progress in a Diverse World
United Nations Development Programme: December 2012

The next Human Development Report – “The Rise of the South: Human Progress in a Diverse World” – will be published in March 2013. It will examine the profound shift in global dynamics that is being driven by the fast-rising powers of the developing world - and the implications of this phenomenon for human development. China has already overtaken Japan as the world’s second biggest economy, lifting hundreds of millions out of poverty in the process. India is actively reshaping its future with entrepreneurial creativity and social policy innovation. Brazil has become another major engine of growth for the South, while reducing inequality at home through antipoverty programs that are emulated worldwide. Turkey, Thailand, South Africa, Mexico, Indonesia and other dynamic developing nations are also leading actors on the world stage today, offering important policy lessons and valuable new partnerships for the South as a whole, including today’s least developed countries. The Report will feature a new Human Development Index (HDI) as well as the Report’s three complementary indices: the Inequality-adjusted HDI, the Gender Inequality Index (GII) and the Multidimensional Poverty Index (MPI).

Getting Started: A medical research and development primer
FasterCures: 2012

This Primer contains tools and resources to help navigate the medical research and development (R&D) paradigm. The Primer provides information on discovery research; translational research; clinical research; regulatory application and approval; and nonprofit actors and their roles in the R&D process.

Global Health Primer
Bio Ventures for Global Health (BVGH): Last updated 15 August 2012

The Global Health Primer connects the innovators that drive research and development for new drugs, vaccines and diagnostics to the neglected diseases where innovation is desperately needed. It provides a source of compiled and synthesised information for 25 neglected diseases of the developing world and the drugs, vaccines, and diagnostics in use or in development for the management of these diseases. The Primer tracks and analyses progress in global health research and development, provides an evidence base to support decision making, policy change and action, and brings new innovators to the table to address the main medical needs of poor people.

How to keep ART patients in longer-term care: ART adherence club report and toolkit
Médecins Sans Frontières: 1 November 2012

Piloted by Médecins Sans Frontières (MSF) in Khayelitsha, Cape Town, the antiretroviral therapy (ART) Adherence Club model focuses on patient participation and peer support for improved treatment adherence. This simple model allows patient groups to collect pre-packed, two-month supplies of treatment from lay health workers either at the clinic or outside of the clinic, such as a local library or a fellow patient’s home. ART Adherence Clubs give stable, adherent HIV patients easier access to their treatment, while unclogging clinics and freeing up scarce nurses and doctors to manage new or at-risk HIV patients. This practical toolkit includes a step-by-step ‘How-to’ guide, two short films and additional information on tailoring the model to various contexts.

Right to Food website
Food and Agricultural Organisation: December 2012

This new Right to Food website was launched on Human Rights Day, 10 December 2012. In addition to a new design, improved functionalities and user friendly navigation, it also displays the diverse work of the Right to Food in the Food and Agricultural Organisation (FAO). The Team’s work at global, national, sub-national and regional level is divided into ‘Projects’ and according to activities in the ‘Our Work’ section making it easier for users to find the information needed. There is also a ‘Publications’ section, where you will find information on all aspects related to the human right to food – from principle to practice.

15. Jobs and Announcements

Call For Abstracts: Ninth World Congress On Health Economics: "Celebrating Health Economics": Sydney, Australia: 7-10 July 2013
Deadline: 15 January 2013

All interested parties are invited to submit abstracts for the Ninth World Congress on Health Economics: "Celebrating Health Economics". Individual abstracts should not exceed 500 words. All accepted presenters are expected to register and pay by the deadlines listed on the Congress website.

Call for abstracts: Transnational Health Care: A Cross-Border Symposium: Regions & Development (20-21 June 2013, Wageningen, Netherlands) and Itineraries & Transformations (24-25 June 2013, Leeds, United Kingdom)
Closing date: 3 February 2013

At a time in which the provision and regulation of health care within national boundaries is profoundly shifting, the growing numbers of people going abroad in pursuit of health care mean that the social, political and economic significance and impacts of these flows at a range of levels cannot be ignored. This symposium provides those involved in cutting-edge empirical and conceptual studies on this issue to share their work, explore emerging research agendas and foster research collaborations. Abstracts of no more than 250 words are welcomed on topics that include but are not limited to: empirical and conceptual studies of specific medical tourisms or locations; innovative methodologies and methods for researching medical travel; national and transnational medical cultures and their impacts on medical mobilities and ‘translations’; and new and emerging agendas for transnational healthcare research. Please submit abstracts to the symposium organisers as on the website.

Call for applications: Research Methods Course in Sexual and Reproductive Health, HIV and Gender-Based Violence: 12–28 August 2013: Johannesburg, South Africa
Closing date : 1 March 2013

Are you a clinician, researcher or other professional in the field of sexual and reproductive health (SRH) or HIV looking to improve your research skills? Are you currently conducting or planning to conduct SRH or HIV research in the near future and wanting to learn more about research methodology? The Research Methods Course in Sexual and Reproductive Health, HIV and Gender-Based Violence offers an opportunity to strengthen your research skills and your contribution to increased capacity for SRH and HIV research on the African continent. At the end of this intensive three-week course will you should be able to: initiate and participate in qualitative and quantitative research; critically appraise research findings; understand the major SRH/HIV issues affecting the African region; and access a network of other professionals in your field for information exchange and research collaboration. For more information on eligibility and course fees or to request an application form please contact Janine White-Jacobs at the email address given.

Commonwealth Foundation's Grants for Civil Society Organisations
Deadline: 31 January 2013

The Commonwealth Foundation has announced a new grant opportunity for civil society organisations (CSOs) for projects to be implemented in Commonwealth developing countries. The Foundation’s grants programme contributes to sustainable development in the context of effective, responsive and accountable governance with civil society participation. There are two types of grants: Commonwealth Theme Grants and Participatory Governance Grants. Commonwealth Themes grants will open for applications in 2013 while the Participatory Governance Grants can now be applied for. Grants will be given to selected organisations for a period of three years amounting up to £30,000 per year. The objectives of the grant programme are to: deliver an efficient and effective programme which is responsive to the development needs of CSOs across the Commonwealth; complement the effectiveness of the Foundation’s projects by providing grants to CSOs beyond those supported through the projects; and generate knowledge and understanding of participatory governance and its benefits in promoting effective, responsive and accountable governance within the Commonwealth by supporting models of good practice.

Course on resource mobilisation: Malawi Country training on Resource Mobilisation, Project Planning and Proposal Writing
28 January-1 February 2012: Lilongwe, Malawi

The Malawi Country Training on Resource Mobilisation, Project Planning and Proposal Writing is part of a series of workshops designed to help strengthen the resource base of non-profit organisations in the region. The training is intended to equip participants with skills in resource mobilisation, business planning and proposal writing in order to promote their activities, services and benefits. The training seeks to build and enhance the capacity of participants to actively mobilise resources in order to meet the increasing challenges facing them and their institutions. It will help participants to gain an understanding of resource mobilisation principles and practices. Participants will learn the time-tested principles that govern the resource mobilisation process and fundamentals that lead to resource mobilisation success. For more information, contact Dr John Chikati at the email address given.

Global Maternal Health Conference 2013
15-17 January 2013: Dar Es Salaam, Tanzania

The Global Maternal Health Conference is a technical conference for scientists, researchers, and policy-makers to network, share knowledge, and build on progress toward eradicating preventable maternal mortality and morbidity by improving quality of care. The conference is co-sponsored by Management and Development for Health, Dar es Salaam, Tanzania, and the Maternal Health Task Force at the Harvard School of Public Health, Boston, US.

United Nations Trust Fund Call for Proposals 2012: Ending Violence against Women
Deadline: 21 January 2013

UN Women (United Nations Entity for Gender Equality and the Empowerment of Women) has issued a call for proposals to provide grants of US$100,000-$300,000 to both small grassroots-based non-governmental organisations, as well as large organisations, for implementing projects that address violence against women. The United Nations (UN) Trust Fund in Support of Actions to Eliminate Violence against Women, established in 1996 by the UN General Assembly, is a global, multilateral mechanism supporting national efforts to end one of the most widespread human rights violations in the world. The Fund invites proposals in the following areas of action: closing the gap on the implementation of national and local laws, policies and action plans that address violence against women; and addressing violence against adolescent and young girls.

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