EQUINET NEWSLETTER 144 : 01 February 2013

1. Editorial

An emerging voice for health equity? Communique of the Second BRICS Health Ministers’ Meeting

In this issue we provide in full the communique of the Second BRICS Health Ministers’ Meeting held in January 2013. How far does this emerging concerted voice provide new impetus for the social justice needed for equity in health? While the familiar commitments are included to reducing major disease burdens, there are also welcome signs in the communique of attention to dealing upstream with the "risk" environments for health, of assessing the impact on health "of all public policies at national and international levels" and of commitment to "community empowerment". Equally the communique refers to a commitment to implementing measures for technology transfer and co-operation across low and middle income countries, such as for ensuring production and access to generic medicines as part of realising the right to health. The communique was less clear on two aspects: the active role of the 43% of the world’s population living in BRICS countries in realising these commitments, and the regional solidarity and integration needed in each of their regions to ensure to benefit to the weaker economies of their regions.

Delhi Communique of the Second BRICS Health Ministers’ Meeting
Ministers of Health of the Federative Republic of Brazil, the Russian Federation, India, People’s Republic of China and Republic of South Africa, New Delhi, 11 January 2013

The BRICS countries, represented by the Ministers of Health of the Federative Republic of Brazil, the Russian Federation, India, People’s Republic of China and Republic of South Africa, met in New Delhi on 11 January 2013 at the Second BRICS Health Ministers’ Meeting.

The meeting recalled the Delhi Declaration of 29 March 2012 during the BRICS leaders summit and the Joint Communiqué of the BRICS Health Ministers at Geneva of 22 May 2012 including specific areas of work under the BRICS Health Platform for each Member State, focussed on the theme “BRICS Partnership for Global Stability, Security and Prosperity” to address emerging health threats.

The Ministers recalled that BRICS is a platform for dialogue and cooperation amongst countries representing 43% of the world’s population. The Ministers reiterated their commitment to the Beijing Declaration of July 2011 for strengthened collaboration in the area of access to public health and services in BRICS States including implementation of affordable, equitable and sustainable solutions for common health challenges. The Ministers committed to strengthen intra-BRICS cooperation for promoting health of the BRICS population. The BRICS Health Ministers resolved to continue cooperation in the sphere of health through the Technical Working Group.

The Ministers drew attention to the current global threat of non-communicable diseases and noted that in 2008, around 80% of all NCD deaths occurred in low and middle income countries. The Ministers recognized the significant role of BRICS countries in the global process of prevention and control of NCDs including the Moscow Declaration of April 2011, the WHA Resolution 64.11 of May 2011 and the Political Declaration of the UN General Assembly of September 2011.The Ministers recognized the need for more research into the social and economic determinants leading to occurrence of non-communicable diseases, amongst the BRICS countries. They resolved to collaborate and cooperate to promote access to comprehensive and cost-effective prevention, treatment and care for the integrated management of non-communicable diseases, including access to medicines and diagnostics and other technologies.

The Ministers also recognized the need to combat mental disorders through a multi-pronged approach including the World Health Assembly Resolution 65.4, consideration of a Comprehensive Mental Health Action Plan through sharing of innovations in the field of Mental Health Promotion, diagnosis and management, exchange of best practices and experiences amongst BRICS countries.

The Ministers renewed their commitment to the WHO Framework Convention on Tobacco Control and stressed the importance of research and study by WHO and other stakeholders into the social and economic determinants of tobacco use and its control.

The Ministers recognized that multi-drug resistant tuberculosis is a major public health problem for the BRICS countries due to its high prevalence and incidence mostly on the marginalized and vulnerable sections of society. They resolved to collaborate and cooperate for development of capacity and infrastructure to reduce the prevalence and incidence of tuberculosis through innovation for new drugs/vaccines, diagnostics and promotion of consortia of tuberculosis researchers to collaborate on clinical trials of drugs and vaccines, strengthening access to affordable medicines and delivery of quality care. The Ministers also recognized the need to cooperate for adopting and improving systems for notification of tuberculosis patients, availability of anti-tuberculosis drugs at facilities by improving supplier performance, procurement systems and logistics and management of HIV-associated tuberculosis in the primary health care system.

The Ministers called for renewed efforts to face the continued challenge posed by HIV. They committed to focus on cooperation in combating HIV/AIDS through approaches such as innovative ways to reach out with prevention services, efficacious drugs and diagnostics, exchange of information on newer treatment regimens, determination of recent infections and HIV-TB co-infections. The Ministers agreed to share experience and expertise in the areas of surveillance, existing and new strategies to prevent the spread of HIV, and in rapid scale up of affordable treatment. They reiterated their commitment to ensure that bilateral and regional trade agreements do not undermine TRIPS flexibilities so as to assure availability of affordable generic ARV drugs to developing countries.

The Ministers committed to strengthen cooperation to combat malaria through enhanced diagnostics, research and development and committed to facilitate common access to the technologies developed or under development in the BRICS countries.

The Ministers renewed their commitment for effective control of both communicable and non-communicable diseases through cooperation in sharing of existing resource information, development of risk assessment tools, risk mitigation methods, referral systems, life course approaches, community empowerment, monitoring health impact assessments of all public policies at national and international levels.

Recognizing that an effective health surveillance, including injury surveillance, is the key strategy for controlling both communicable and non-communicable diseases, that surveillance is also the cornerstone around which the implementation of the International Health Regulations (2005) is based and further recognizing that the countries may be using different models for surveillance based on different realities and best practices, the Ministers committed to strengthen cooperation in the mechanisms for planning, monitoring and evaluating disease prevention and control activities and capacity-building for effective health surveillance systems.

The Ministers urged focus on the unique strength of BRICS countries such as capacity for R & D and manufacturing of affordable health products, and capability to conduct clinical trials. The Ministers called for strengthened cooperation in application of bio-technology for health benefits for the population of BRICS countries.

The Ministers emphasized the importance of child survival through progressive reduction in the maternal mortality, infant mortality, neo-natal mortality and under-5 mortality, with the aim of achieving the Millennium Development Goals. They confirmed their commitment to a renewed effort in this area and to enhance collaboration through exchange of best practices.

The Ministers discussed the recommendations of the Consultative Expert Working Group on Health on coordination and financing of R & D for medical products and welcomed the proposal to establish a Global Health R&D observatory as well as the move on holding regional consultations to set up R&D demonstration projects. The Ministers urged that the entire process, including priority setting, should be driven by WHO Member States and should be based on public health needs, in particular those of developing countries, with the cost of R & D delinked from the final products.

The Ministers reiterated their support to the continued discussions on the process of reform of WHO, to better respond to global challenges in programmatic, organizational and operational terms, including the future financing of WHO, and welcomed the proposal to establish a financing dialogue based on priorities collectively set by WHO Member States in a structured and transparent process.

The Ministers acknowledged the value and importance of traditional medicine and need of experience and knowledge-sharing for securing public health needs. They urged for cooperation amongst the BRICS countries through visits of experts, organization of symposia to encourage the use of traditional medicine, in all spheres of health.

The Ministers confirmed their support for the United Nations General Assembly Resolution on universal health coverage and committed to work nationally, regionally and globally to ensure that universal health coverage is achieved.

The Ministers recalled the Beijing Declaration of the 1st BRICS Health Ministers’ Meeting in 2011, emphasizing the importance and need of technology transfer as a means to empower developing countries. In this context, they underlined the important role of generic medicines in the realization of the right to health. The Ministers renewed their commitment to strengthening international cooperation in health, in particular South-South cooperation, with a view to supporting efforts in developing countries to promote health for all and resolve to establish the BRICS network of technological cooperation. The Ministers acknowledged the need of use of ICT in Health services to promote cost-effective treatment in remote areas. They encouraged strengthened cooperation amongst the BRICS countries to share their experiences in e-Health including tele-medicine. The Ministers agreed to cooperate in all international fora regarding matters relating to TRIPS flexibilities with a public health perspective.

The Ministers agreed to establish platforms for collaboration within BRICS framework and with other countries with a view to realizing the goals and objectives outlined in this Declaration.

This statement is drawn from the Government of India communique on the BRICS Health Ministers meeting at http://pib.nic.in/newsite/erelease.aspx?relid=91533. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.

2. Latest Equinet Updates

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

In this paper, the author considers elements of the design of health systems and how these relate to moving towards UC 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, she argues. 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 ESA 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.

Uganda Health Literacy Training Report, Entebbe, September 24-26 2012
Training and Research Support Centre and HEPS Uganda: EQUINET, December 2012

Participatory Reflection and Action work in EQUINET has shown that health workers suffer problems of poor work environments, poor remuneration, lack of growth opportunities and motivational incentives. This may pose a barrier to their interaction with communities, despite the role that communication plays in patient-centred care. Communities on their side may not possess the skills and capacities to negotiate or communicate with service providers, leading to misunderstanding, lack of knowledge and even anger. In 2011, building on work done on health literacy in Zimbabwe, Malawi and Botswana, and in the EQUINET PRA equity network to strengthen communication between health workers and communities, TARSC implemented a one year programme with HEPS Uganda and, with Cordaid support, to extend health literacy in Uganda and use the skills built to promote dialogue and accountability between health workers and communities. In 2012-2014 TARSC and HEPS-Uganda are building on this work to widen and deepen the capacity of civil society organisations (CSOs) for Health Literacy (HL) in Uganda. This report outlines a meeting that was a first step in this two-year programme. It brought together five CSOs working within districts on health. The workshop trained facilitators, education and lead personnel from five CSOs in Uganda to plan, implement and monitor HL programmes at district level, including a specific focus on women’s health.

3. Equity in Health

A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H et al: The Lancet 380 (9859): 2224-2260, 15 December 2012

The authors of this study estimated deaths and disability-adjusted life years (DALYs), years lived with disability (YLD) and years of life lost (YLL) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. They included estimates from published and unpublished literature, and data from the Global Burden of Disease Study 2010. Worldwide, the contribution of different risk factors to disease burden appears to have changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than five years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children.

Age-specific and sex-specific mortality in 187 countries, 1970—2010: a systematic analysis for the Global Burden of Disease Study 2010
Wang H, Dwyer-Lindgren L, Lofgren KT, Rajaratnam JK, Marcus JR et al: The Lancet 380 (9859): 2071-2094, 15 December 2012

In this study, researchers estimated life expectancy and mortality rates for children under five and adults for 187 countries from 1970 to 2010. Findings showed that from 1970 to 2010, global male life expectancy increased from 56.4 years to 67.5 years and global female life expectancy increased from 61.2 years to 73.3 years. Substantial reductions in mortality occurred in eastern and southern sub-Saharan Africa since 2004, coinciding with increased coverage of antiretroviral therapy and preventive measures against malaria. Globally, 52.8 million deaths occurred in 2010, which is about 14% more than occurred in 1990, and 22% more than occurred in 1970. Deaths in children younger than 5 years declined by almost 60% since 1970. Yet substantial heterogeneity exists across age groups, among countries, and over different decades. Greater efforts should be directed to reduce mortality in low-income and middle-income countries, the authors argue. Improvement of civil registration system worldwide is crucial for better tracking of global mortality.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V et al: The Lancet 380 (9859): 2095–2128, 15 December 2012

In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010, researchers aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, separately by age and sex. They collected data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. Findings revealed a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases, which appears to be driven by population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of years of life lost due to premature mortality (YLLs) in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.

Health and Health Care in South Africa
Van Rensburg HCJ (Ed): Van Schaik Publishers, 2012

The changes that have taken place, and continue to take place, in South Africa’s post-1994 health sphere are often difficult to comprehend for both those inside and outside the country’s health care system. This book presents a coherent “big picture” of health and health care in South Africa. The contributing authors chart the evolving health system, along with the ensuing changes and challenges, and contextualise these developments historically and globally, as well as critically assess them. Contents include the following: national health care systems: trends, changes and reforms; the changing biophysical environment: impact on health and health conditions; HIV, AIDS and tuberculosis: trends, challenges and responses; health care expenditure: using resources efficiently and equitably; revitalisation and re-engineering of primary health care; hospitals and hospital reform; complementary and alternative medicine and traditional health care; and medical ethics and human rights. The book is aimed at researchers and lecturers, as well as senior and postgraduate students in the health and health-related professions, the social sciences, and health planning, policy and management-related disciplines.

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010
Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M et al: The Lancet 380 (9859): 2163-2196, 15 December 2012

In the Global Burden of Disease (GBD) studies done in 1990 and 2000, 289 diseases and injuries were identified as causing disability. The authors of this study undertook a systematic global analysis of these diseases and injuries to calculate and interpret years lived with disability (YLDs). They found that, in 2010, there were 777 million years lived with disability (YLDs) from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. Neglected tropical diseases, HIV and AIDS, tuberculosis, malaria and anaemia were important causes of YLDs in sub-Saharan Africa. Overall, rates of YLDs per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Health systems urgently need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality, the authors argue. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges.

4. Values, Policies and Rights

Africa Youth Declaration on Post-2015 Agenda
Delegates at the African Youth Conference: 4 January 2012

The African Youth Conference on Post-2015 Development Agenda, held in Nairobi, Kenya, from 12-16 December 2012, has adopted a Youth Declaration on the Post-2015 Agenda. This Agenda identifies 13 actions for accelerating progress on the Millennium Development Goals (MDGs) and makes recommendations for the post-2015 development agenda. On accelerating MDG progress, the Declaration recommends that governments: increase commitments to achieve the MDGs and honour pledges; strengthen institutions to fight corruption and empower youth; and provide sufficient resources to children, women and youth ministries. It also recommends, inter alia: increasing equitable access to sustainable water and sanitation services and promoting hygienic behaviour; planning and implementing poverty eradication programmes to reach youth; strengthening communication, data collection and monitoring; and empowering and mobilising youth to participate in the MDGs and hold governments accountable. The Declaration asks the UN and its development partners to support projects that mitigate climate change and encourage sustainable consumption. It calls for civil society to engage communities to understand the causes of poverty and to address these challenges.

Interim report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health
United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health: 3 August 2011

In this report, the Special Rapporteur considers criminal laws and other legal restrictions relating to sexual and reproductive health and the right to health. These include criminal and other legal restrictions on: abortion; conduct during pregnancy; contraception and family planning; and the provision of sexual and reproductive education and information. These restrictions violate the right to health by restricting peoples’ access to quality goods, services and information, as well as violating their right to make their own decisions about their bodies. Moreover, the application of such laws as a means to achieving certain public health outcomes is often ineffective and disproportionate, according to the report. In cases where a barrier is created by a criminal law or other legal restriction, it is the obligation of the State to remove it. In response to countries that are calling for the progressive realisation of the right to health, the Rapporteur argues that the removal of such laws and legal restrictions is not subject to resource constraints; therefore he calls for the immediate scrapping of laws and policies undermining sexual and reproductive health to ensure everyone can enjoy full realisation of their right to health.

5. Health equity in economic and trade policies

Building blocks for equitable growth: lessons from the BRICS
Vandemoortele M, Bird K, Du Toit A, Liu M, Sen K and Veras Soares F: Overseas Development Institute Working Paper 365, January 2013

Five key emerging market economies, commonly termed the BRICS (Brazil, Russia, India, China and South Africa), have been lauded for their stellar economic growth and resilience through the 2008/09 financial crisis. According to this paper, they are becoming models of development for development practitioners, researchers and other emerging economies. However, not all people in these countries have benefited equally from growth. Some countries have seen enormous increases in income inequality – specifically China, India and South Africa – while Brazil has enjoyed a reduction. What can be learnt, in terms of the challenges and successes of reconciling growth and equity, from the BRICS’ recent growth? The authors examine the experiences of four of the BRICS – Brazil, China, India and South Africa – and identify four key factors shaping the countries’ pattern of growth: access to assets, above all skills, to enable people to participate in activities that generate income, and ensuring access to land; investment in productive activities that generate jobs and opportunities for the majority; social transfers to guarantee minimum incomes to those who cannot work or cannot find work; and a political-economic context that has inclusion as a priority.

Collaborative Capacity Building In Intellectual Property: Leveraging On African Diaspora Exchange
Oguamanam C: Intellectual Property Watch, 2 January 2013

Africa’s ability to leverage its increasing visibility and preference for South-South economic partnerships will significantly depend on how well it is equipped to manage the intellectual property complements and components of the contemporary economic transformations, according to this article. The continent suffers from a lack of IP manpower in the judiciary and academia, as the development of capacity and expertise has not kept pace with the expansion and sophistication of intellectual property. That state of affairs depicts a structural fault line in Africa’s ability to optimise on-going economic and social transformations. The author argues that Africa needs need expertise in IP such as patent rights, especially in biotechnology at large, including health, food, agriculture, chemistry, pharmaceuticals. He recommends stronger collaboration between members of the Africa diaspora and those back home in Africa as a way forward. Strong local institutional commitment is needed to buy into this vision. To achieve this, countries will require a culture of transparency, accountability and efficiency in the management of collaborative research funds and other forms of assistance and partnership.

Private Chinese investment in Africa: myths and realities
Shen X: Policy Research Working Paper WPS 6311, World Bank, 2013

Private Chinese outbound investment, not as well-known as government-led investment, offers both opportunities and challenges for Africa, according to this paper. The significance of Chinese private-sector investment is already visible in the burgeoning manufacturing sector in some parts of Africa, and the trend will continue to grow in the near future. The underlying force behind this trend is the increased pressure of industrial restructuring in coastal China, a force that drives some labour-intensive firms to relocate to other parts of the developing world, including Africa. The author argues that African host country governments can respond to this phenomenon with proactive development policies and strategies to maximise private Chinese investment for the benefit of their own economies.

Secret structures, hidden crimes: Urgent steps to address hidden ownership, money laundering and tax evasion from developing countries
Eurodad: January 2013

In this new report, Eurodad reports that hidden ownership of companies and other legal structures facilitate tax evasion, and argues that better information about who owns and controls companies and other set-ups is key to bringing trillions of dollars of offshore wealth back into the tax net and to help prevent future capital flight. The authors call for governments to create publicly available registers of the owners and controllers of companies, trusts and other legal structures and to improve compliance with, enforcement of and sanctions for anti-money laundering rules.

Seychelles to launch new corporate social responsibility fund
The People: December 2012

Pierre Laporte, Minister of Finance for the Seychelles, revealed government’s new plans for a Corporate Social Responsibility (CSR) Fund in his budget speech in December 2012. Businesses now have four options to contribute to social development, namely sponsorship, donations, direct funding of community projects, or contribute to the new Fund. All businesses that make a turnover of SR 1 million and above will be expected to contribute to the Fund a rate of 0.5% of their turnover. The Minister clarified that Government will continue to fund infrastructure projects in districts, and CSR funds would be expected to go to areas such as environment, beach and coastal management projects, health and wellness including sports, renewable energy and others to be decided upon. Supporters of the Fund are hoping it will become a sustainable funding mechanism for civil society groups.

Sipopo Declaration from the Seventh Summit for ACP Heads of State and Government and the 96th ACP Council of Ministers
Participants at the ACP Summit: December 2012

Senior delegates from 63 of the 79 African, Caribbean and Pacific (ACP) countries, including some 15 Heads of State, attended the ACP Summit in December 2012. This summit declaration highlights members’ determination to “stay united as a Group” and retain relevance by “enhancing the ACP-European Union (EU) relationship as a unique North-South development cooperation model, while developing South-South and other partnerships. A new working group will reflect on the response of the ACP Group to global challenges. Officials also decided to set up a high-level panel to advance trade negotiations with the EU.

6. Poverty and health

Ending poverty in our generation: Save the Children’s vision for a post-2015 framework
Save the Children: December 2012

Save the Children’s suggested post-2015 development framework champions universal and equitable development, with human rights as its guiding principle and evidence as a foundation for its approaches. And, unlike with the Millennium Development Goals (MDGs), these principles must be visible in the targets established. Save the Children argues that it is possible to set zero targets for absolute poverty, hunger, and preventable child and maternal deaths, as well as 100% access to safe drinking water and sanitation. Five lessons can be learnt from the MDGs, according to the report. 1. The MDGs do not consistently confront inequality, whether it is because of age, gender, caste, disability, geography or income. 2. A robust, effective accountability mechanism is missing from the MDG framework. 3. The MDGs do not pay attention to synergies and interaction of systems, like poverty, health and education. 4. The MDGs focus inputs and not outcomes, which might result in greater access but this does not automatically mean that the aims of that service are being realised. 5. Since 2000 little has been achieved in improving the long-term sustainability of the natural resource base.

Farmers in Swaziland struggle to afford inputs
IRIN News: 9 January 2013

Faced with increasingly unpredictable rains and rising agricultural input costs, many of Swaziland's smallholder farmers are no longer able to make a living relying on traditional methods to grow maize, the staple crop, according to IRIN News. Externally funded schemes to subsidise the cost of seed and fertiliser have dried up and a Ministry of Agriculture service to provide affordable tractor hire has been a casualty of the government's cash flow problems. Distribution schemes to the needy are failing because of a lack of technical assistance to ensure that recipients use the inputs correctly for maximum benefit. Their reach was also small, with experts estimating that only about a tenth of Swaziland's 260,000 farming households benefited. As the cost of both inputs and food has risen significantly over the past year, many subsistence farmers have had to prioritise food over fertiliser in the context of declining maize production during the 2011-12 season.

How long will it take to lift one billion people out of poverty?
Ravallion M: Policy Research Working Paper WPS 6325, World Bank, 2013

In this paper, the author considers alternative scenarios for reducing by one billion the number of people living below $1.25 a day. The low-case, "pessimistic," path to that goal would see low income countries outside China returning to the slower pace of growth and poverty reduction of the 1980s and 1990s, though with China maintaining its progress. This path is projected to would take 50 years or more to lift one billion people out of poverty. The author asserts that a more optimistic path would maintain the rate of progress in reducing poverty since 2000, reaching the target by around 2025-30, although this assumes inequality-neutral growth.

Innovative financing for agriculture, food security and nutrition
High-Level Expert Committee to the Leading Group for innovative financing for agriculture, food security and nutrition: December 2012

In this report, the High-Level Expert Committee argues in favour of innovative financing for agriculture, food security and nutrition to achieve food security and nutrition objectives. Although they are progressing, budgets for food security, including agriculture and nutrition components, in low income countries are severely constrained. Proposed mechanisms for funding include: national taxes, such as a tax on financial transactions; voluntary contributions from consumers, firms and employees and food- and nutrition-correlated industries; allocation of funds generated by the carbon emissions allowances auctions in the European Union Emissions Trading System; and migrants’ remittances, which already represent considerable financial flows from industrialised to developing countries. To maximise their contribution to food security objectives, these innovative financing mechanisms should, as much as possible, be targeted at food production and supply, as well as family farming with the specific intention to make agriculture work for nutrition.

What went wrong? Lessons from Malawi’s food crisis
Tafirenyika M: Pambazuka News, 613, 17 January 2013

Malawi has gone from bountiful maize crops to food insecurity in the past seven years. Thanks to increased farm subsidies for small-holder farmers in 2004, Malawi harvested a bumper crop the following year. But the author reports that subsidies fell thereafter and Malawi became a net importer of maize, with domonishing agricultural outputs. What can be learned from Malawi’s story? With a population of more than a billion, will Africa produce enough food for its people? The author argues it is possible, but under several conditions. First, an essential ingredient for success in agriculture is strong political will at the highest level. Second, while foreign funds help to feed the hungry and revive agriculture in Africa, food security is argued to be too important to be left to the generosity of external partners. It also requires the same importance and resources as national security. Africa needs a strong food policy backed by resources from African Union (AU) members, to be invested in institutions that promote agriculture. One tangible AU response has been the Comprehensive Africa Agriculture Development Programme (CAADP), which requires countries that sign up to it to spend at least 10% of their national budgets on agriculture.

“The hidden hunger”: Understanding the burden of anaemia and its determinants among pregnant and non-pregnant women in Ethiopia
Wondu T and Bijlsma M: Journal of Food, Agriculture, Nutrition and Development, 12(7), December 2012

The objective of this study was to assess the burden of anaemia and its determinants among pregnant and non-pregnant women in Ethiopia. Researchers used data from the 2005 Demographic and Health Survey of Ethiopia. A total of 5,960 women of child-bearing age were included in the analysis. The general prevalence of anaemia among women was 27.7%, while the prevalence of anaemia was 33% and 27.3% among pregnant and non-pregnant women respectively. Analysis revealed a significant negative association between prevalence of anaemia and women’s educational status, grouped altitude of residential places and household wealth index categories. The authors found that anaemia is a moderate public health problem among women in Ethiopia but there exist significant differences in magnitude by socio-economic status of women and their families and where they live. They call for interventions designed to address maternal anaemia that pay attention to both nutritional and non-nutritional intervention strategies, including environmental sanitation, de-worming, and provision and promotion of family planning methods.

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.

Assessment of the health care waste generation rates and its management system in hospitals of Addis Ababa, Ethiopia, 2011
Debere MK, Gelaye KA, Alamdo AG and Trifa ZM: BMC Public Health 13(28), 12 January 2013

This study aimed to assess the health care waste generation rate and its management system in some selected hospitals located in Addis Ababa, Ethiopia. Researchers randomly selected six hospitals in Addis Ababa, three private and three public. Data was recorded by using an appropriately designed questionnaire. Results revealed that the management of health care waste at hospitals in Addis Ababa city was poor. The median waste generation rate was found to be varied from 0.361- 0.669 kg/patient/day, consisting of 58.69% non-hazardous and 41.31% hazardous wastes. The amount of waste generated was increased as the number of patients flow increased, and it was positively correlated with the number of patients. Public hospitals generated high proportion of total health care wastes (59.22%) in comparison with private hospitals (40.48%). The waste separation and treatment practices were very poor. The authors recommend that other alternatives for waste treatment rather than incineration such as a locally made autoclave should be evaluated and implemented.

Decomposing Kenyan socio-economic inequalities in skilled birth attendance and measles immunisation
Van Malderen C, Ogali I, Khasakhala A, Muchiri SN, Sparks C, Van Oyen H and Speybroeck N: International Journal for Equity in Health 12(3), 7 January 2013

The main objective of this study was to decompose wealth-related inequalities in skilled birth attendance (SBA) and measles immunisation into their contributing factors. Researchers used data from the Kenyan Demographic and Health Survey 2008/09 to investigate the effects of socio-economic determinants on coverage and wealth-related inequalities of the two health services. Results indicated that SBA utilisation and measles immunisation coverage differed according to household wealth, parent’s education, skilled antenatal care visits, birth order and father’s occupation. SBA utilisation further differed across provinces and ethnic groups. The overall C for SBA was 0.14 and was mostly explained by wealth (40%), parent’s education (28%), antenatal care (9%), and province (6%). The overall C for measles immunisation was 0.08 and was mostly explained by wealth (60%), birth order (33%), and parent’s education (28%). Rural residence (−19%) reduced this inequality. The authors conclude that both health care indicators require a broad strengthening of health systems with a special focus on disadvantaged sub-groups.

Health seeking behaviour for cervical cancer in Ethiopia: a qualitative study
Birhanu Z, Abdissa A, Belachew T, Deribew A, Segni H, Tsu V, Mulholland K and Russell FM: International Journal for Equity in Health 11(83), 29 December 2012

Although cervical cancer is a leading cause of cancer related morbidity and mortality among women in Ethiopia, there is lack of information regarding the perception of the community about the disease. In this study, researchers conducted focus group discussions with men, women and community leaders in the rural settings of Jimma Zone southwest Ethiopia and in the capital city, Addis Ababa. Participants had very low awareness of cervical cancer. The perceived benefits of modern treatment were also very low, and various barriers to seeking any type of treatment were identified, including limited awareness and access to appropriate health services. Women with cervical cancer were excluded from society and received poor emotional support. Moreover, the aforementioned factors all caused delays in seeking any health care. Traditional remedies were the most preferred treatment option for early stage of the disease. However, as most cases presented late, treatment options were ineffective, resulting in an iterative pattern of health seeking behaviour and alternated between traditional remedies and modern treatment methods. Prior to the introduction or scale up of cervical cancer prevention programmes, socio-cultural barriers and health service related factors that influence health seeking behaviour must be addressed through appropriate community level behaviour change communications.

Medical inpatient mortality at Groote Schuur Hospital, Cape Town, 2002-2009
Myer L, Smith E and Mayosi B M: South African Medical Journal 103(1): 28-35, January 2013

In this study, researchers analysed first admissions of adult medical inpatients to Groote Schuur Hospital, Cape Town, from January 2002 to July 2009, disaggregating data according to age, sex, medical specialty, date of admission and discharge, and socio-economic status (SES). There were 42,582 first admissions. Patient demographics shifted towards a lower SES. Median age decreased from 52 years in 2002 to 49 years in 2009, while patients aged 20-39 years increased in proportion from 26% to 31%. The unadjusted proportion of admissions which resulted in in-hospital deaths increased from 12% in 2002 to 17% in 2009. Corresponding mortality rates per 1,000 patient days were 17 and 23.4, respectively. Annual increases in mortality rates were highest during the first two days following admission (increasing from 30.1 to 50.3 deaths per 1,000), and were associated with increasing age, non-paying patient status, black population group and male sex, and were greatest in the emergency ward.

Operational scale entomological intervention for malaria control: strategies, achievements and challenges in Zambia
Chanda E, Mukonka VM, Kamuliwo M, Macdonald MB and Haque U: Malaria Journal 12(10), 8 January 2013

This paper reports on the strategies, achievements and challenges of the past and contemporary malaria vector control efforts in Zambia. Researchers reviewed all available information and accessible archived documentary records on malaria vector control in Zambia. They also conducted a retrospective analysis of routine surveillance data from the Health Management Information System (HMIS), data from population-based household surveys and various operations research reports on implementing policies and strategies. Results suggested that Zambia has made great progress in implementing the World Health Organisation’s integrated vector management (IVM) strategy within the context of the IVM Global Strategic framework with strong adherence to its five key attributes. In conclusion, the country has solid, consistent and coordinated policies, strategies and guidelines for malaria vector control. The authors highlight the Zambian experience as a successful example of a coordinated multi-pronged IVM approach effectively operationalised within the context of a national health system.

The implementation of Integrated Disease Surveillance and Response in Uganda: a review of progress and challenges between 2001 and 2007
Lukwago L, Nanyunja M, Ndayimirije N, Wamala J, Malimbo M, Mbabazi W et al: Health Policy and Planning 28: 30-40, January 2013

In 2000 Uganda adopted the Integrated Disease Surveillance and Response (IDSR) strategy, which aims to create a co-ordinated approach to the collection, analysis, interpretation, use and dissemination of surveillance data for guiding decision making on public health actions. In this study, researchers used a monitoring framework recommended by World Health Organisation and the United States’ Centres for Disease Control and Prevention to evaluate performance of the IDSR core indicators at the national level from 2001 to 2007. Findings showed improvements in the performance of IDSR, including: improved reporting at the district level (49% in 2001; 85% in 2007); an increase and then decrease in timeliness of reporting from districts to central level; and an increase in analysed data at the local level. The case fatality rate for two target priority diseases (cholera and meningococcal meningitis) decreased during IDSR implementation (cholera: from 7% to 2%; meningitis: from 16% to 4%), most likely due to improved outbreak response. However, decreased budgetary support from the government may be eroding these gains. Renewed efforts from government and other stakeholders are necessary to sustain and expand progress achieved through implementation of IDSR.

8. Human Resources

'Going private': a qualitative comparison of medical specialists' job satisfaction in the public and private sectors of South Africa
Ashmore J: Human Resources for Health 11(1), 3 January 2013

In this paper, the author elaborates what South African medical specialists find satisfying about working in the public and private sectors, at present, and how to better incentivise retention in the public sector. He conducted 74 qualitative interviews among specialists and key informants in one public and one private urban hospital in South Africa. All qualitative specialist respondents were engaged in dual practice, generally working in both public and private sectors. Results demonstrate that although there are strong financial incentives for specialists to migrate from the public to the private sector, public work provides more of a team environment, more academic opportunities, and greater opportunities to feel 'needed' and 'relevant'. However, public specialists suffer under poor resource availability, lack of trust for the Department of Health, and poor perceived career opportunities. These non-financial issues of public sector dissatisfaction appeared just as important, if not more important, than wage disparities. Policy recommendations centre around boosting public sector resources and building trust of the public sector through including health workers more in decision-making, inter alia. These interventions may be more cost-effective for retention than wage increases, and imply that it is not necessarily just a matter of putting more money into the public sector to increase retention.

A descriptive study on health workforce performance after decentralisation of health services in Uganda
Lutwama G, Roos J and Dolamo B: Human Resources For Health 10(41), 7 November 2012

In this cross-sectional descriptive survey the authors investigated the performance of health workers after decentralisation of the health services in Uganda to identify and suggest areas for improvement. A structured self-administered questionnaire was used to collect quantitative data from 276 health workers in the districts of Kumi, Mbale, Sironko and Tororo in Eastern Uganda. Results revealed that even though the health workers are generally responsive to the needs of their clients, the services they provide are often not timely. The health workers take initiative to ensure that they are available for work, but low staffing levels undermine these efforts. While the study 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. The findings indicated that health workers are competent, adaptive, proactive and client oriented.

Professionalism in the intimate examination: How healthcare practitioners feel about having chaperones present during an intimate consultation and examination
Guidozzi Y, Gardner J and Dhai A: South African Medical Journal 103(1):25-27, January 2013

Despite the clear prohibition against sexual relations with one’s patients, complaints of a sexual nature against practitioners registered with the Health Professions Council of South Africa (HPCSA) have been increasing. The authors of this paper set out to ascertain how a group of medical practitioners felt about the presence of chaperones during the consultation and intimate examination of patients. They distributed a self-administered, questionnaire-based survey to gynaecologists and medical practitioners. There was a 43% response rate with 72% of practitioners in favour of using a chaperone during an intimate examination, although only 27% always do so. Most practitioners felt that consensual sexual relationships with patients are unacceptable; 83% felt that ethical guidelines on this topic were needed. The authors recommend that the HPCSA should develop guidelines on the use of chaperones to assist practitioners. With medical litigation increasing, using chaperones will benefit patients and practitioners.

The evolution of global health teaching in undergraduate medical curricula
Rowson M, Smith A, Hughes R, Johnson O, Maini A, Martin S et al: Globalization And Health 8(35), 13 November 2012

Undergraduate teaching on global health has seen a marked growth over the past ten years, partly as a response to student demand and partly due to increasing globalisation, cross-border movement of pathogens and international migration of health care workers. In this study, researchers carried out a survey of medical schools across the world in an effort to analyse their teaching of global health. Results indicate that global health teaching is moving away from its previous focus on tropical medicine towards issues of more global relevance. The authors suggest that there are three types of doctor who may wish to work in global health - the 'globalised doctor', 'humanitarian doctor' and 'policy doctor' - and that each of these three types will require different teaching in order to meet the required competencies. This teaching needs to be inserted into medical curricula in different ways, notably into core curricula, a special developing countries track, optional student selected components, elective programmes, optional intercalated degrees and postgraduate study. The authors argue that teaching of global health in undergraduate medical curricula must reflect the social, political and economic causes of ill health.

9. Public-Private Mix

Strengthening medical product regulation in low- and middle-income countries
Preston C, Valdez ML and Bond K: PLoS Medicine 9(10), 23 October 2012

The World Health Organisation (WHO) includes regulatory system functions as one of the six core building blocks of health systems: access to medical products, vaccines, and technologies of assured quality, safety, and efficacy. However, little attention has been focused on regulatory systems in low- and middle-income countries. They have not featured prominently in global health and development assistance programmes, according to this paper, and few strategic documents of major global health initiatives, including the United States Global Health Initiative, reference regulatory systems. The global activities that do involve regulatory systems typically involve high-income countries, such as the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH), which harmonises regulatory standards and processes for the pharmaceutical industry. ICH includes regulatory authorities from the European Union, Japan and the United States. The authors argue that lack of attention to medical product regulatory systems in low- and middle-income countries is a significant gap that needs to be bridged. They thus propose that strengthening regulatory systems in low- and middle-income countries must become a global health priority.

Talking about the impact of private sector for development, are we using the same language?
Rosengren A: ECDPM talking Points blog, 18 January 2013

ECDPM organised an informal multi-stakeholder meeting in Brussels in December 2012 to highlight and share the different views of the opportunities and challenges, as well as potential ways forward, in measuring the impact of the private sector on development. Participants included European Union (EU) officials, research institutes, development agencies, African, Caribbean and Pacific (ACP) and EU ambassadors, civil society organisations and private sector actors and confederations. Despite the private sector’s often-cited move beyond corporate social responsibility, delegates agreed that the focus for some still seems to be predominantly placed within the (often marginal) add-on projects on the side of the core business. By choosing to not address this, private sector actors are avoiding the fact that their main business activities most likely are their main development impact. The author recommends that partnerships between public-private and/or civil society actors should be balanced and in the interest of all partners, and that assessment of these partnerships should not only capture corporate social responsibility-type activities, but also core business impacts.

10. Resource allocation and health financing

African countries support the establishment of the African Public Health Emergency Fund but the coffers remain empty
Machemedze R: Health Diplomacy Monitor 3 (7): 14-16, December 2012

The 46 African member states of the World Health Organisation (WHO) have reiterated the importance of the African Public Health Emergency Fund (APHEF) at the 62nd session of the WHO Regional Committee for Africa. At the same time, the meeting urged all members to remit their outstanding 2012 contributions to the APHEF and requested the regional director in the interim period to mobilise, manage and disburse the contributions to the APHEF whilst waiting for a decision from the African Development Bank (AfDB) to take up the proposed role of trustee for the APHEF. The ministers of health were urged to work with their finance ministers to gain support for the creation of the trust fund account by the AfDB and ensure the inclusion of a budget line in their national budget for 2012 outstanding contributions to the APHEF. Some countries noted that there was a need to consider an interim mechanism to ensure that payments are made since there were still logistical issues to be dealt with by the AfDB, while Malawi criticised the AfDB for being too bureaucratic and a delegate from West Africa argued progress in creating the fund was moving too slowly.

Concerns over HIV/AIDS funding cuts in Ethiopia
Plus News: 9 January 2013

Major projected cuts in United States (US) government funding for Ethiopia's health sector could greatly undermine the progress the country has made in the fight against HIV, authorities and experts say. Next year, Ethiopia will experience a 79% reduction in US HIV financing from the US President's Emergency Plan For AIDS Relief (PEPFAR). Most of the cuts are going to be around softer programmatic activities that can be taken care of by mobilising internal resources as well as using some innovative approaches like the health development army. A major cut would be felt in HIV and AIDS programmes, which would receive only US$54.1 million, a dramatic cut from the $254.1 million allocated in 2012. Between 2006 and 2011, Ethiopia received an estimated $1.4 billion from PEPFAR. Since 2004, Ethiopia has also received $1.23 billion from the Global Fund, making it one of the Fund's biggest recipients globally.

Equity of the premium of the Ghanaian national health insurance scheme and the implications for achieving universal coverage
Amporfu E: International Journal for Equity in Health 12(4), 7 January 2013

The purpose of this study is to examine the vertical and horizontal equity of the premium collection of the Ghanaian National Health Insurance Scheme (NHIS), which was introduced to help ensure universal coverage. Horizontal inequity was measured through the effect of the premium on redistribution of ability to pay of members. The extent to which the premium could cause catastrophic expenditure was also examined. The results showed that revenue collection was both vertically and horizontally inequitable. The horizontal inequity had a greater effect on redistribution of ability to pay than vertical inequity. The computation of catastrophic expenditure showed that a small minority of the poor were likely to incur catastrophic expenditure from paying the premium a situation that could impede the achievement of universal coverage. The author provides recommendations to improve the inequitable system of premium payment to help achieve universal coverage.

How countries cope with competing demands and expectations: perspectives of different stakeholders on priority setting and resource allocation for health in the era of HIV and AIDS
Jenniskens F, Tiendrebeogo G, Coolen A, Blok L, Kouanda S, Sataru F et al: BMC Public Health 12(1071), 11 December 2012

Drawing on a study conducted in five African countries, the authors of this paper explore different stakeholder perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and health and how different stakeholders perceive this. The countries were Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi. Key background documents were analysed and 258 semi-structured interviews and 45 focus group discussions were held. Although the researchers found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS.

Rising fees at public hospitals hit patients hard
Kahn T: Business Day, 10 December 2012

For the past ten years, the South African government has not adjusted the means test for patients using public hospitals, leaving more and more poor people without medical aid to foot their own bills, according to this article. In addition, treatment and hospital fees have risen by up to 75% since the means test was first set in 2002. As a result, many families that have had to contend with serious illness face debts that can take years to pay off. Between four and six million South Africans have no medical aid insurance and do not qualify for discounted fees at public hospitals, putting them at risk of huge medical bills. The Uniform Patient Fee Schedule policy says patients who cannot afford the fees levied according to their classification "may be reclassified" as exempt from fees "by the person in charge of the health facility", enabling hospitals to write off part or all of a patient’s debt. But many patients have neither the energy or skills to navigate the bureaucracy, and staff do not always verify patient claims, leaving the process open to corruption. In the long run, the state’s plans to introduce National Health Insurance (NHI), which would be free at the point of service, should do away with the financial burden facing public sector patients, the author argues. But in the short term, the NHI plan could inadvertently make things worse. This is because the NHI pilot project includes funding to improve hospitals’ revenue collection. If that aspect of the project is not carefully managed, more patients could find themselves in severe financial straits.

The Future of Foreign Aid: Development Cooperation and the New Geography of Global Poverty
Sumner A and Mallett R: Palgrave Pivot, December 2012

The landscape of foreign aid is changing, according to this book. New development actors are on the rise, from the 'emerging' economies to numerous private foundations and philanthropists. At the same time the nature of the global poverty 'problem' has also changed: most of the world's poor people no longer live in the poorest countries. Sumner and Mallet review of research on foreign aid to outline a series of policy proposals for global development cooperation in the twenty-first century.

Tuberculosis and poverty: the contribution of patient costs in sub-Saharan Africa: a systematic review
Barter DM, Agboola SO, Murray MB and Bärnighausen T: BMC Public Health 12 (980), 14 November 2012

To comprehensively assess the existing evidence on the costs that tuberculosis (TB) patients incur in Sub-Saharan Africa, researchers undertook a systematic review of the existing literature for articles containing a quantitative measure of direct or indirect patient costs, finally including 30 articles that met all of the inclusion criteria. Depending on type of costs, costs varied from less than US$1 to almost $600 or from a small fraction of mean monthly income for average annual income earners to over 10 times the annual income that the average person in the income-poorest 20% of the population earns. Out of the eleven types of TB patient costs identified in this review, the costs for hospitalisation, medication, transportation, and care in the private sector were largest. The authors argue that it is likely that for many households, TB treatment and care-related costs were catastrophic because costs commonly amounted to 10% or more of per-capita income. These results suggest that policies to decrease direct and indirect TB patient costs are urgently needed to prevent poverty due to TB treatment and care for those affected by the disease.

11. Equity and HIV/AIDS

Gender differences in HIV disease progression and treatment outcomes among HIV patients one year after starting antiretroviral treatment (ART) in Dar es Salaam, Tanzania
Mosha F, Muchunguzi V, Matee M, Sangeda RZ, Vercauteren J, Nsubuga P et al: BMC Public Health 13(38), 15 January 2013

In this study, researchers investigated gender differences in treatment outcome during first line antiretroviral treatment (ART) in a hospital setting in Tanzania, assessing clinical, social demographic, virological and immunological factors. They used structured questionnaires and reviewed patients’ files, including a total of 234 patients about to start ART, and followed up one year later. Seventy percent of participants were females. After one year of standard ART, a higher proportion of females survived although this was not significant. They showed a worse CD4 cell increase than men, even though they had a higher BMI. Although women were starting treatment at a less advanced disease stage, they had a lower socio-economical status. After one year, both men and women had similar clinical and immunological conditions. It is not clear why women lose their immunological advantage over men despite a better virological treatment response.

Religiosity for HIV prevention in Uganda: a case study among Muslim youth in Wakiso district
Kagimu M, Guwatudde D, Rwabukwali C, Kaye S, Walakira Y and Ainomugisha D: African Health Sciences 12(3): 282-290, January 2013

Evidence for the association between religiosity and HIV infections is limited. Sujda, the hyper-pigmented spot on the forehead due to repeated prostration during prayers and fasting to worship, involving abstaining from food, drink and sex during daytime in Ramadhan and other specified days, are measures of religiosity among Muslims In this study, researchers assessed the association between religiosity and HIV infections. They included 29 HIV positive cases and 116 HIV negative controls, from a total of 1,224 Muslims, 15-24 years. Respondents without Sujda had more HIV infections. Those with Sujda were more likely to abstain from sex and be faithful in marriage. Respondents without Sujda were more likely to have ever taken alcohol before sex and to have ever used narcotics.

Today’s HIV response: flagging global leadership but countries forge ahead
Vlassoff C and Del Riego A: Health Diplomacy Monitor 3 (7): 7-11, December 2012

In this article, the authors summarise the main points of the UNAIDS World AIDS Day Report 2012 (included in this newsletter), which evaluated global progress in reaching the goals of Zero New HIV Infections, Zero Discrimination and Zero AIDS-Related Deaths. While the report includes quantitative information on two of the “Getting to Zero” goals – zero new infections and AIDS-related deaths – there is very little information on the third - zero discrimination - the authors note. Challenges persist in treatment and prevention, and progress is further impacted on by politics, poor governance, prohibitive costs and failure to build on evidence in the multisector response. Despite the flagging global response, countries have managed to move ahead, albeit slowly, to treat HIV-affected people, prevent transmission from mother to child and promote safe sexual behaviour. With treatment now available for only US$100 annually in some countries, the authors argue it is time for another bold move such as 3 by 5, focused on direct support to countries and a more strategic and efficient allocation of global resources toward evidence-based strategies that have been shown to work.

World AIDS Day Report 2012: Results
UNAIDS: 2012

In this new report, UNAIDS reports that there are 700,000 fewer new HIV infections globally in 2011 than in 2001, eight million people on life-saving antiretroviral (ARV) therapy (a 60% increase in the last two years), and a drop of more than half a million deaths from AIDS-related illnesses between 2005 and 2011 in people living with HIV. However, new HIV infections continue to outpace ARV treatment coverage. Sub-Saharan Africa has realised a 25% reduction in new infections, although the region still accounted for 72% of new HIV infections globally in 2011. Progress in treatment has been impressive, saving lives and transforming HIV into a chronic illness rather than a death sentence. In addition to their therapeutic effects, ARVs have been found to play a preventive role by significantly reducing the amount of virus in the blood and therefore reducing the risk of transmission to sexual partners. A major weakness in both prevention and treatment programmes in many countries is reported by UNAIDS to be their failure to decrease mother-to-child transmission of HIV, which is the most easily preventable form of transmission.

12. Governance and participation in health

Distinguishing between civil society groups is divisive and will weaken cohesion among different sectors: An interview with Lewis Mwape of the Zambia Council for Social Development
CIVICUS: 20 December 2012

If implemented, new provisions governing the registration of civil society organisations (CSOs) and non-governmental organisations (NGOs) under Zambia’s NGO Act will be extremely problematic, according to Lewis Mwape of the Zambia Council for Social Development. Under the law CSOs and NGOs must re-register every five years, creating a major administrative workload. Prior to registering, they must explicitly state their sources of funding and proposed activities, which Mwape regards as impractical. The NGO Act also greatly narrows the definitions of CSOs and NGOs, no longer recognising labour unions, faith-based organisations and professional groups. Distinguishing between civil society groups is divisive and will weaken cohesion among different sectors, says Mwape. Advocacy and human rights organisations can also be subjected to arbitrary and/or discriminatory application of the law, and the law gives the Minister too much discretionary power. Zambian civil society has initiated a campaign calling for the amendment of the law but they are facing major difficulties in accessing and mobilising the hundreds of NGOs and CSOs based in less accessible areas to engage in the campaign to re-evaluate the law.

Online Civil Society Consultation on the Global health Theme of the Post-2015 UN Agenda
Global Health South (The Alliance of Southern CS in Global Health)/CHESTRAD in partnership with Campaign 2015+ and the Call for Action on Universal Health Coverage With Support from the Health Thematic Group, Post 2015 UN Agenda: January 2013

From the 9th of December 2012 to 11th January 2013, an online consultation on global health Theme in the Post-2015 UN Agenda was conducted. Researchers targeted a total of 785 institutions across partner organisations and networks and attracted participation from over 180 organisations active across 48 countries, notably community based and regional organisations in Africa, which constituted 69.5% of all participants. A number of key messages emerged. 1. There is no strong support for one health goal framed around Universal Health Care. 2. There is a very clear emphasis given to prioritising the needs of women and children. 3. There are strong calls to broaden the focus of the goals towards health systems strengthening and away from disease- and issue-specific interventions. 4. Strong support is given to the importance of a multisectoral action for health, alongside recognition of the need to address the socio-economic determinants and the rapidly evolving economic realities between countries. 5. The health-related post-2015 development goals should take into account the context in which action will be taken, and must be founded on guiding principles that are adaptable at the national level, and flexible for local implementation. They should also be based on shared, coherent understanding that enables global level solidarity and differentiated accountable action where necessary and appropriate.

Further details: /newsletter/id/37581
Project Matchstick
HDI Youth Marketers: January 2013

In this 2012 survey, the opinions on their social conditions of 1,360 young South Africans from various backgrounds of the country were gathered. Individuals across age groups (kids, teens and young adults) from Gauteng, KwaZulu Natal and the Western Cape responded to the survey and expressed their opinions on numerous issues and attributes relevant to South African society. Generally, respondents expressed high levels of nostalgia towards the country’s previous leaders, specifically Nelson Mandela, and were critical of the current leadership. Across all the regions, crime was ranked as the country’s biggest problem, and education was cited repeatedly as being crucial to ensure the future success of young South Africans. Freedom of expression was highlighted as a key issue throughout the interviews, yet many young people felt they were not given the opportunity to be heard. Many respondents argued that relying on the government to bring about change is not good enough, and expressed a desire for youth to play a greater role.

Resilience: A Trojan horse for a new way of thinking?
De Weijer F: ECDPM Discussion Paper 139, January 2012

According to this paper, the current widespread use of the term ‘resilience’ in development circles is at risk of being diluted by current ways of thinking about change because the term has not brought about genuine change in thinking about social systems. The author argues that if the term ends up being used in a very linear manner, where change is controllable from the outside and follows a linear path, it will have failed to achieve its mission. The author calls for a break from expert-led technocratic solutions and renewed focus on human agency as the main vehicle for change. Resilience-based thinking underlines the importance of leadership and reinvents the task of the international community as supporting constructive leadership rather than designing expert solutions. For leaders, it opens up space for creative thinking and hybrid, localised solutions.

When ‘solutions of yesterday become problems of today’: crisis-ridden decision making in a complex adaptive system (CAS): the additional duty hours allowance in Ghana
Agyepong IA, Kodua A, Adjei S and Adam T: Health Policy and Planning 27 (suppl): Iv20–iv31, 27 September 2012

Implementation of policies (decisions) in the health sector is sometimes defeated by the system’s response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or ‘fixes’. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper, researchers use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, they unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimise negative unintended effects.

Where next? US-Africa foreign relations under a second term
This is Africa: 16 January 2013

While Barack Obama’s re-election has been met with enthusiasm across Africa, the article reports that many are frustrated about a lack of delivery on past promises. Where does Africa fit into the new administration’s foreign policy? The author argues that Obama’s current rhetoric about Africa makes generalisations about common aspirations, opportunity and African potential. He asserts that future engagement with African countries may be focused on the New Alliance for Food Security and Nutrition, part of the G8 plan to boost food production in Africa by introducing large-scale, mechanised agriculture with genetically modified crops. The author poses that this is expected to impact negatively on small-scale farmers and possibly increase food insecurity.

13. Monitoring equity and research policy

A simple, generalisable method for measuring individual research productivity and its use in the long-term analysis of departmental performance, including between-country comparisons
Wootton R: Health Research Policy and Systems 11(2), 14 January 2013

In this study, researchers developed a simple, generalisable method for measuring research output to support attempts to build research capacity, and in other contexts. They developed an indicator of individual research output, based on grant income, publications and numbers of PhD students supervised. They then used the indicator to measure research output from two similarly-sized research groups in different countries. Research output scores of 41 staff in Research Department A had a wide range, from zero to 8; the distribution of these scores was highly skewed. Only about 20% of the researchers had well-balanced research outputs, with approximately equal contributions from grants, papers and supervision. Over a five-year period, Department A's total research output rose, while the number of research staff decreased slightly, in other words research productivity (output per head) rose. Total research output from Research Department B, of approximately the same size as A, was similar, but slightly higher than Department A. The authors conclude that their proposed indicator can be used for comparisons within and between countries. Modelling can be used to explore the effect on research output of changing the size and composition of a research department.

Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010
Salomon JA, Vos T, Hogan DR, Gagnon M, Naghavi M, Mokdad A et al: The Lancet 380 (9859): 2129–2143, 15 December 2012

The primary objective of this study was a comprehensive re-estimation of disability weights that quantify health losses for all non-fatal consequences of disease and injury for the Global Burden of Disease Study 2010. A total of 13,902 respondents were interviewed in Bangladesh, Indonesia, Peru and Tanzania, and 16,328 in a web survey. Analysis of paired comparison responses indicated a high degree of consistency across surveys: correlations between individual survey results and results from analysis of the pooled dataset were 0.9 or higher in all surveys except in Bangladesh (0.75). Most of the 220 disability weights were located on the mild end of the severity scale, with 58 (26%) having weights below 0.05. Five (11%) health states had weights below 0.01, such as mild anaemia, mild hearing or vision loss, and secondary infertility. The health states with the highest disability weights were acute schizophrenia (0.76) and severe multiple sclerosis (0.71). The researchers identified a broad pattern of agreement between the old and new weights (0.70), particularly in the moderate-to-severe range. However, in the mild range below 0.2, many states had significantly lower weights in this study than previously. In contrast with the popular hypothesis that disability assessments vary widely across samples with different cultural environments, the results of this study suggest highly consistent results.

Healthy life expectancy for 187 countries, 1990-2010: a systematic analysis for the Global Burden Disease Study 2010
Salomon JA, Wang H, Freeman MK, Vos T, Flaxman AD, Lopez AD, Murray Christopher JL et al: The Lancet 380 (9859): 2144-2162, 15 December 2012

In this study, researchers examined current rates for healthy life expectancy (HALE) and changes over the past two decades in 187 countries, using data from the Global Burden Disease Study 2010. They calculated HALE estimates for each population defined by sex, country and year, and estimated the contributions of changes in child mortality, adult mortality, and disability to overall change in population health between 1990 and 2010. Findings showed that, in 2010, global male HALE at birth was 58.3 years and global female HALE at birth was 61.8 years. HALE increased more slowly than did life expectancy over the past 20 years, with each one-year increase in life expectancy at birth associated with a 0.8-year increase in HALE. Between countries and over time, life expectancy was strongly and positively related to number of years lost to disability. HALE also differs substantially between countries. As life expectancy has increased, the number of healthy years lost to disability has also increased in most countries, consistent with the expansion of morbidity hypothesis, which has implications for health planning and health-care expenditure, the authors argue. Compared with substantial progress in reduction of mortality over the past two decades, relatively little progress has been made in reduction of the overall effect of non-fatal disease and injury on population health. The authors propose that HALE may be a useful indicator for monitoring health post-2015.

The African Health Observatory should deliver in addressing priority health issues
Machemedze R: Health Diplomacy Monitor 3 (7): 11-13, December 2012

The 46 African member states of the World Health Organisation (WHO) have commended WHO for operating the African Health Observatory (AHO) and requested that individual countries be assisted to establish their own national health observatories (NHOs). The need for NHOs was highlighted by the concerns raised by a number of countries at a regional committee meeting on the unavailability of timely information as hampering progress in providing quality health services in their countries. Zambia called for the inclusion of ‘community information systems’ to complement conventional data gathering. A number of countries raised the issue of integrating the NHOs into national health information systems (NHIS) as crucial to avoid burdening the NHIS. They noted that the NHOs should be simple and work towards harmonising data collection and coordination. Most countries saw the establishment of NHOs through technical support from the WHO as an opportunity to deal with the challenges of data fragmentation and the attendant problems of policy incoherencies.

14. Useful Resources

Rapid Retention Survey Toolkit: Designing Evidence-Based Incentives for Health Workers
CapacityPlus: 2012

In the context of severe health worker shortages in rural areas, this toolkit is intended to help health leaders find out what motivates health workers to accept posts in rural areas and to stay there. The toolkit builds on the World Health Organisation’s global policy recommendations for rural retention and is based on the discrete choice experiment, a powerful research method that identifies the trade-offs health professionals are willing to make between specific job characteristics and determines their preferences for various incentive packages, including the probability of accepting a post in a rural health facility. The toolkit guides human resources managers through a survey process to rapidly assess health professional students’ and health workers’ motivational preferences to accept a position and continue working in underserved facilities. It allows for rapid data-gathering and analysis, and the results can be used to create evidence-based incentive packages. It includes step-by-step instructions, sample formats, and examples that can easily be adapted to a specific country context, including survey planning, survey design, survey instrument development using a specialised software programme, survey administration, data analysis and interpretation, and how to present results to stakeholders.

15. Jobs and Announcements

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.

Fifth Annual HIV-in-Context Research Symposium: Urbanisation, Inequality and HIV
13 March 2013 - 15 March 2013: Cape Town, South Africa

From its base in the University of the Western Cape’s School of Public Health, this year’s HIV in Context Research Symposium looks beyond biomedicine at some of the social determinants of HIV, and of responses to HIV, within and outside the health sector. The Symposium will examine the links between HIV, inequality and the dynamics and impacts of urbanisation – dynamics that play out between settings as people move permanently or temporarily to urban centres, and within the highly unequal spaces constituting South African cities. The particular experience of Cape Town as a destination and transit point on migration trajectories will be examined in relation to other cities in South Africa and beyond. Through diverse disciplinary and sectoral lenses,practitioners, researchers, policy makers and civil society activists will examine the many ways in which urbanisation, inequality and HIV interact and affect people’s lives.

Free online course on primary health care
23 January-26 February 2013

The short course "Health for All through Primary Health Care" by Henry Perry of the Johns Hopkins Bloomberg School of Public Health begins on 23 January 2013 and runs for five weeks. It will involve four hours of student work per week – one hour of lecture, one hour of course readings, and two additional hours of work. A statement of completion will be provided for those who successfully complete the assignments. This course is time-limited in the sense that the work must be completed weekly according to the time schedule for the course, and it will not be available to take except for the period between January 23rd and February 26th. However, it is free and open to anyone with internet access. Almost 14,000 people are currently enrolled.

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.

Sixth South African AIDS Conference
18-21 June 2013: Durban, South Africa

The Sixth South African AIDS Conference will be held in Durban from 18-21 June 2013. The conference theme is "Building on our successes: Integrating responses". As South Africa enters the fourth decade of HIV and AIDS, the conference aims to look back at lessons learnt and reflect, celebrate the gains made, and find ways to build on past successes by integrating HIV with other health responses. The conference will bring together various members of the HIV research community, including clinicians, academics, civil society and government.

Third Global Forum on Human Resources for Health
Recife, Brazil: 10–13 November 2013

The World Health Organisation’s Workforce Alliance convened the First and the Second Global Forums on Human Resources for Health, in 2008 in Uganda, and 2011 in Thailand respectively. The Global Forums brought together key experts, fellow champions as well as frontline health workers around the common goal of improving the human resources for health to achieve the health-related Millennium Development Goals. Both Forums concluded with the adoption from committed participants of ambitious agendas suitable to translate political will, leadership and partnership into sustainable and effective actions. The Third Global Forum will be held in Recife, Brazil, from 10–13 November 2013.

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