African countries are highly dependent on imported medicines and related products despite a stated policy intention in the African Union and regional bodies to develop local pharmaceutical production, which is expected to facilitate responsiveness to local health needs and has stated advantages for employment, skills retention, and foreign currency savings. Noting these policy intentions, this paper explores how the stated policy of local production in African Union (AU), Southern African Development Community (SADC) and East African Community (EAC) policies is being implemented and the bottlenecks to implementation. The paper examines the efforts made in selected countries to overcome these obstacles and the role of international and south-south co-operation. Drawing upon document reviews and key informant interviews, it presents case studies of Uganda, Kenya and Zimbabwe and their co-operation agreements with China and India. The study found limited evidence of operational co-operation, especially that which is based on south-south collaborations, despite the potential contribution of such collaborations to overcoming bottlenecks to local medicines production. Although the evidence from the case studies had limitations, the research suggests that a convergence of interests between countries in east and southern Africa and emerging economies on trade and investment cannot be assumed and that national and regional economic and social interests need to be actively negotiated to overcome identified bottlenecks. The authors thus recommend measures to strengthen the enabling policy, legal, trade and investment environments, to strengthen oversight and regulation of medicines, and to enhance technical and strategic capacities in the east and southern African region needed to support local production of medicines.
1. Latest Equinet Updates
There has been increased interest in whether “South-South” co-operation by Brazil, Russia, India, China and South Africa (BRICS) advances more equitable initiatives for global health. This article examines the extent to which resolutions, commitments, agreements and strategies from BRICS and Brazil, India and China (BIC) address regionally articulated policy concerns for health systems in East and Southern Africa (ESA) within areas of resource mobilisation, research and development and local production of medicines, and training and retention of health workers. The study reviewed published literature and implemented a content analysis on these areas in official BRICS and ESA regional policy documents between 2007 and 2014. The study found encouraging signals of shared policy values and mutuality of interest, especially on medicines access, although with less evidence of operational commitments and potential divergence of interest on how to achieve shared goals. The findings indicate that African interests on health systems are being integrated into south-south BRICS and BIC platforms. It also signals, however, that ESA countries need to proactively ensure that these partnerships are true to normative aims of mutual benefit, operationalise investments and programs to translate policy commitments into practice and strengthen accountability around their implementation.
This paper presents the findings of research conducted under a wider two-year project (2012-14) that examined the role of African agency in global and south-south health diplomacy in addressing selected key challenges to health and health systems in east and southern Africa (ESA). This research synthesis draws from two desk reviews and a content analysis of three case studies on: (i) the involvement of African actors in global health governance on financing for health systems; (ii) overcoming bottlenecks to local medicine production, including through south-south co-operation; and (iii) health worker migration and the implementation of the World Health Organisation (WHO) Global Code of Practice on the International Recruitment of Health Personnel. Based on the content analysis, the paper reviews evidence on African intervention in four key areas of health diplomacy: agenda setting, policy development, policy selection and negotiation and implementation. The evidence highlights the political and complex nature of global health diplomacy. Effective engagement is enabled in ESA by political leadership and champions with clearly articulated policy positions, regional interaction and unified platforms across African countries and good communication between sectors within countries, between national actors and embassies and with allies in the international community. Negotiators’ understanding of issues and access to credible evidence mattered in policy development and selection. Technical actors, the domestic private sector and civil society appeared to play a weak role relative to the influence of development aid. The case studies suggest there is an opportunity cost in framing health diplomacy in the region within a ‘development aid’ paradigm, if the compromises agreed to lead to a dominance of remedial, humanitarian engagement in African international relations on health, with less sustained attention to structural determinants.
The WHO Global Code of Practice on the International Recruitment of Health Personnel (the Code) provides a global architecture that includes ethical norms and institutional and legal arrangements to guide international co-operation on the management of health worker migration and serves as a platform for continuing dialogue. This paper explores how the policy interests of African countries informed the development of the Code and how east and southern African (ESA) countries have used, implemented and monitored the Code. Data were collected using four approaches: literature review, policy dialogue at the 66th World Health Assembly, a regional questionnaire survey and three country studies in Kenya, Malawi and South Africa. Three years after adoption of the Code, the main concerns relating to human resources for health (HRH) in the region were internal migration and absolute shortages of health professionals, rather than external, or out-, migration. The final version of the Code was not perceived to adequately cover African policy interests on compensation and mutuality of benefits. Concern was also expressed about the voluntary nature of the Code. Dissemination and implementation of the Code was lacking in all countries in the region, and only one country had a designated authority. Beyond the shift in policy concerns, barriers to implementation included lack of champions or designated authorities, poor preparedness, weak mobilisation of stakeholders and low involvement of civil society. The authors recommend that negotiations on international instruments should include provisions relating to their implementation, that deliberate efforts should be made to plan for the mechanisms and resources for their implementation after their adoption, and that the involvement of civil society be promoted at all stages.
This article examines how national health actors in South Africa, Tanzania and Zambia perceive the participatory quality of negotiation processes associated with the performance‐based funding mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank. Through analysis of qualitative fieldwork consisting of 101 interviews within the case countries as well as in Geneva and Washington DC, the research results show that African actors within national governments generally set and negotiate performance targets of performance‐based funding schemes. Nevertheless, the results also show that the quality of those negotiations with external funders were inconsistent, suggesting the existence of asymmetrical power and influence in relation to the quality of those negotiations. This raises questions about the level of power and influence being exerted by external funders and how much leverage African political actors have available to them within global health diplomacy. It also provides evidence that certain key aspects of these negotiated processes are closed off from negotiation for African actors, therefore undermining African participation in significant ways.
2. Equity in Health
People with albinism (PWA) face a variety of medical and social problems, ranging from poor vision and skin cancer to murder for their body parts for witchcraft in East Africa. PWAs are reported to face enormous challenges in East Africa. They have very poor, uncorrectable vision and, as a result, they are disadvantaged in schools and in employment opportunities. At best, the authors report, they are discriminated against; at worst, they are hunted and often killed for their body parts for witchcraft use. If they survive these attacks, they are very likely to develop skin cancer that is most often untreated, leading to a preventable premature death. However, awareness and activism can help PWAs to lead more normal lives by addressing their medical and social needs. Above all, the authors urge people to make efforts to stop atrocities against PWA.
Health priorities since the UN Millennium Declaration have focused strongly on children younger than 5 years. The health of older children (age 5–9 years) and younger adolescents (age 10–14 years) has been neglected until recently, especially in low-income and middle-income countries, and mortality measures for these age groups have often been derived from overly flexible models. The authors report global and regional empirical mortality estimates for children aged 5–14 years in low-income and middle-income countries, and compare them with ones from existing models, using birth-history data from a 25-year period from 1986 of Demographic and Health Surveys programme for 84 World Bank low-income and middle-income countries, and data about household deaths in China from their 1990 and 2010 censuses. The mean risk of a child dying at age 5–14 years in low-income and middle-income countries is about 19% of the risk of dying between birth and age 5 years (12% at age 5–9 plus 7% at age 10–14). According to their estimates, the total number of deaths at ages 5–14 years in low-income and middle-income regions fell from about 2·4 million in 1990 to about 1·5 million in 2010. From estimates the authors concluded there to have been 200 000 (16%) more deaths at ages 5–14 than in the UN report; however, the estimates exceeded GBD estimates by more than 700 000 (87%). The average annual rate of decline in mortality at age 5–9 years (about 3%) slightly exceeded that for ages 0–4 years (2·8%), but progress has been slower for age 10–14 years (about 2%). Their analysis suggests that mortality risks nowadays in the age range 5–14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. The authors argue that global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents.
3. Values, Policies and Rights
It is widely recognised that the Sustainable Development Goals (SDGs) need to be supported by more effective follow-up and review—or accountability—processes than were available to the Millennium Development Goals (MDGs). But what should these processes be? In the last three or four years, this question has generated a wealth of literature within the UN and beyond. Here the author highlights five key points: Monitoring is not accountability, but one step towards accountability; although experts have a significant role to play, accountability should not be reduced to a technocratic exercise; it should be as transparent, accessible and participatory as possible. Accountability at the global level is important, but the primary locus for accountability must be at the national and sub-national levels; it is difficult for States at the national-level to hold accountable stakeholders, including non-state actors, for their transnational contributions and commitments to development, such as SDG17. One of the most important roles for global-level accountability is to strengthen accountability for these transnational contributions and commitments - because the SDGs are a colossal challenge of extraordinary complexity, they need to be supported by diverse accountability arrangements, including independent review of stakeholders’ progress, promises and commitments.
4. Health equity in economic and trade policies
The mining industry in South Africa is argued by the authors to contribute significantly to the hardship experienced by black women in rural areas of South Africa. For decades, mining houses have drawn in young black men for labour. Those who have contracted the preventable but incurable lung disease, silicosis, come home to die a slow and painful death. It is then the women in rural communities who are left to provide support and care under the most adverse conditions. As part of its efforts to support pending litigation against the mining industry to secure long overdue compensation to mineworkers who contracted silicosis and for the women who took care of them, Sonke Gender Justice (Sonke) has been conducting research in the rural Eastern Cape. The research is making visible how the gold mining industry’s failure to prevent silicosis has forced rural black women further into the margins of society. There are several ongoing cases on this. The Legal Resources Centre, Richard Spoor Attorneys and Abrahams Kiewitz are representing 56 applicants in a class action lawsuit where current and former mineworkers and surviving dependants of mineworkers who died from the disease are demanding their right to compensation for silicosis and TB contracted in mines. The case will be heard in the South Gauteng High court in October 2015.
5. Poverty and health
There has been growing policy interest in social justice issues related to both health and food. The authors sought to understand the state of knowledge on relationships between health equity and food systems, where the concepts of ‘food security’ and ‘food sovereignty’ are prominent. Combinations of health equity and food security (1414 citations) greatly outnumbered pairings with food sovereignty (18 citations). Prominent crosscutting themes that were observed included climate change, biotechnology, gender, racialization, indigeneity, poverty, citizenship and HIV as well as institutional barriers to reducing health inequities in the food system. The literature indicates that food sovereignty-based approaches to health in specific contexts, such as advancing healthy school food systems, promoting soil fertility, gender equity and nutrition, and addressing structural racism, can complement the longer-term socio-political restructuring processes that health equity requires. The authors’ conceptual model is argued to offer a useful starting point for identifying interventions with strong potential to promote health equity.
Transforming Our World, the 2030 Agenda for Sustainable Development, which is likely to be adopted by UN Member States, contains astonishingly bold and ambitious aspirations for transforming global health. The Agenda includes a series of “zero targets” to be achieved by 2030, including to “end preventable deaths of newborns and children under 5 years of age” and to “end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases.” The author argues that such targets are simply unattainable unless there’s a massive scale-up in research and development (R&D) for conditions that disproportionately affect poor communities in low- and middle-income countries (LMICs). Unfortunately, the SDGs as currently written say way too little on the essential role of scientific innovation in achieving SDG 3 (the health goal) and they say nothing at all about the crucial importance of monitoring progress in global health R&D. A compelling August 2015 report by Policy Cures, an independent research group, made the case that the SDG 3 targets “will not be achieved without R&D to develop new health technologies—such as new and improved drugs, vaccines, diagnostics, and other critical innovations—and to improve our understanding of how to best target the tools we already have.” The author argues that the SDG health targets are a fairytale without a renewed global commitment to meet the R&D needs—and rights—of the world’s poor people.
6. Equitable health services
The objective of this study was to assess the cost–effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Incremental cost–effectiveness ratios for the three programmes were estimated from a government perspective. Cost data were collected for 2012. For Ethiopia and Kenya, estimates of coverage before and after the implementation of the programme were obtained from empirical studies. Based on the results of probabilistic sensitivity analysis, there was greater than 80% certainty that each programme was cost-effective. Community-based approaches are likely to be cost-effective for delivery of some essential health interventions where community-based practitioners operate within an integrated team supported by the health system. The authors suggest that community-based practitioners may be most appropriate in rural poor communities that have limited access to more qualified health professionals. Further research is required to understand which programmatic design features are critical to effectiveness.
A cross-sectional survey was conducted in neonatal and maternity units of five Kenyan district public hospitals. Data for 1 year were obtained: A fifth of the admitted neonates died. Compared with normal birth weight, odds of death were significantly higher in all of the low birth weight (LBW, <2500 g) categories, with the highest odds for the extremely LBW (<1000 g) category. The observed maternal mortality, stillbirths and neonatal mortality rates are argued to call for implementation of the continuum of care approach to intervention delivery with particular emphasis on LBW babies.
7. Human Resources
The World Health Organization defines a “critical shortage” of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. The authors aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. This study is a review of published and unpublished “grey” literature on human resources for health in Mali, Sudan, Uganda, Botswana and South Africa. Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. There is an “inverse primary health care law” in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. The author argues that information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.
8. Public-Private Mix
The UN post-2015 development agenda includes 17 Sustainable Development Goals (SDGs) and a “revitalized” Global Partnership to ensure their implementation. Formal inclusion of the private sector (in addition to governments, civil society, the UN system and other actors) is one of the defining features of this Global Partnership. Plenty of studies have shown how corporate actions can have significant impacts, positive and negative, for vulnerable people and for marginalised communities. However the author argues that it also raises an important question. How will the private sector be held accountable for its contribution to the Global Partnership? The latest draft of the 2030 Agenda for Sustainable Development provides that a High Level Political Forum (HLPF) under the auspices of the General Assembly and the Economic and Social Council will have the central role in overseeing follow-up and review at the global level. Interestingly, the HLPF will be tasked to carry out regular reviews that will include relevant stakeholders, including the private sector. The author argues that measuring businesses is as fundamental as measuring governments and that rigorous benchmarking of pharmaceutical companies will be crucial.
9. Resource allocation and health financing
How to finance progress towards universal health coverage in low-income and middle-income countries is a subject of intense debate. The authors investigated how alternative tax systems affect the breadth, depth, and height of health system coverage. The authors used cross-national longitudinal fixed effects models to assess the relationships between total and different types of tax revenue, health system coverage, and associated child and maternal health outcomes in 89 low-income and middle-income countries from 1995–2011. Tax revenue was a major statistical determinant of progress towards universal health coverage. Each US$100 per capita per year of additional tax revenues corresponded to a yearly increase in government health spending of $9·86, adjusted for GDP per capita. This association was strong for taxes on capital gains, profits, and income, but not for consumption taxes on goods and services. In countries with low tax revenues (<$1000 per capita per year), an additional $100 tax revenue per year substantially increased the proportion of births with a skilled attendant present by 6·74 percentage points and the extent of financial coverage by 11·4 percentage points. Consumption taxes, a more regressive form of taxation that might reduce the ability of the poor to afford essential goods, were associated with increased rates of post-neonatal mortality, infant mortality, and under-5 mortality rates. The authors did not detect these adverse associations with taxes on capital gains, profits, and income, which tend to be more progressive. Increasing domestic tax revenues is integral to achieving universal health coverage, particularly in countries with low tax bases. Pro-poor taxes on profits and capital gains seem to support expanding health coverage without the adverse associations with health outcomes observed for higher consumption taxes. Progressive tax policies within a pro-poor framework might accelerate progress toward achieving major international health goals.
10. Equity and HIV/AIDS
Poverty, family stability, and social policies influence the ability of adolescents to attend school. Likewise, being enrolled in school may shape an adolescent’s risk for HIV and pregnancy. In this paper the authors identified trends in school enrolment, factors predicting school enrolment (antecedents), and health risks associated with staying in or leaving school (consequences). Data from the Rakai Community Cohort Study (RCCS) were examined for adolescents 15–19 years. School enrolment and socioeconomic status (SES) rose steadily from 1994 to 2013 among adolescents; orphanhood declined after availability of antiretroviral therapy. Antecedent factors associated with school enrolment included age, SES, orphanhood, marriage, family size, and the percent of family members <20 years. In qualitative interviews, youths reported lack of money, death of parents, and pregnancy as primary reasons for school dropout. Among adolescents, consequences associated with school enrolment included lower HIV prevalence, prevalence of sexual experience, and rates of alcohol use and increases in consistent condom use. Young women in school were more likely to report use of modern contraception and never being pregnant. Young men in school reported fewer recent sexual partners and lower rates of sexual concurrency. Rising SES and declining orphanhood were associated with rising school enrolment in Rakai. Increasing school enrolment was associated with declining risk for HIV and pregnancy.
11. Monitoring equity and research policy
The new Alliance for Accelerating Excellence in Science in Africa (AESA) was launched on the 10th of September 2015 in Nairobi, Kenya. AESA, which is hosted at AAS headquarters in Nairobi, is intended to bring the centre of gravity for health research funding decision-making from places such as Seattle in the United States and London in the United Kingdom to Africa itself. Its African backers include the New Partnership for Africa’s Development, a continental policy implementation agency. Three big international research funders — the UK-based Wellcome Trust, the UK's Department for International Development (DFID) and the Bill and Melinda Gates Foundation in the United States — have earmarked funding programmes that they plan to let AESA administer. From next year, AESA is expected to take over the management of the Wellcome Trust's five-year US$70 million DELTAS programme, which involves seven new African centres of health research and training excellence in subjects ranging from biostatistics to mental health in six African countries: Ghana, Kenya, Mali, South Africa, Uganda and Zimbabwe.
The individual household method (IHM) provides estimates of household income, with detailed information on household assets, demography and specific income sources. This data can be used to support the design and evaluation of programmes, and seeks to collect information on actual households directly from their members. This enables IHM studies to identify more complex variation across populations and to model the impact of changes on a much wider range of population groups, with data disaggregated by demographics (gender and age), income levels and other chosen characteristics.
12. Useful Resources
This series of infographics and a video show urbanization by region and separate countries. It identifies factors which are driving urbanization and shows through graphics how birth rates, fertility and migration are drivers of urban growth. It compares through bar charts the differences between urban and rural housing and explores whether the rural – urban gap may be shrinking. Finally, it shows some projections for the future of urbanization.
13. Jobs and Announcements
TrustAfrica, under the administration of the School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa is pleased to announce 2 Post-Doctoral Fellowships for 2015. The fellowship awards are for R200,000 per annum and there is the possibility for a maximum of 2 years. The selected fellowships will be attached to the DST/NRF Research Chair (SARChI) in Applied Poverty Reduction Assessment. Funding for two fellowships has been made possible by TrustAfrica. The purpose is to promote and undertake research on government, private sector and civil society interventions that have been designed to reduce poverty. The two TrustAfrica fellowships will follow research topics around the political economy of illicit financial flows. Preference will be given to South African applicants.The deadline for bursary applications is 15 October 2015.
The theme of the Health Systems Trust (HST) Conference is "Strengthened health systems for sustainable development: sharing, supporting, synergising". The sub-themes are the general heading under which abstracts should be submitted: Track 1 Overcoming the Burden of Disease, Track 2 Strengthening Service Delivery and Access; Track 3 Better Policy Design, Implementation and Practice; Track 4 Sustainable Development Post 2015. All abstract submissions should be written in Arial type, font size 11 if completing the downloadable form on the conference website. As of 1 September 2015, all abstracts should be submitted online through the conference website.
The East, Central and Southern Africa Health Community (ECSA-HC), in collaboration with the Ministry of Health and Quality of Life, in the Republic of Mauritius will host the 62nd ECSA Health Ministers Conference (HMC) from 23rd – 27th November 2015 in Mauritius. The Health Ministers Conference will be preceded by the 9th Best Practices Forum and the 25th Directors’ Joint Consultative Committee. The Conference will bring together Ministers of Health, Senior Officials from Ministries of Health, Heads of Health Research and Training Institutions from Member States, Health Experts and diverse collaborating Partners in the region and beyond with the aim of identifying policy issues and making recommendations to facilitate the transitioning from MDGs to Sustainable Development Goals.
SHAPE Consulting Limited, in collaboration with the Swiss Tropical and Public Health Institute (Swiss TPH) and First Quantum Minerals, announce a training course in Health Impact Assessment (HIA) for the energy, mining and infrastructure sectors, with a focus on low- and middle-income countries. The course will be held at the First Quantum Kalumbila Mine in North-Western Zambia. This setting will allow the unique experience of gaining theoretical knowledge and practical experience in an actual operational mine in its human and natural environment. The objectives of the course are to introduce the concept of HIA and equip participants with knowledge, methods and tools to undertake an HIA in a low- and middle-income country context; to enable participants to apply the theoretical knowledge provided in the course into real life situations through use of case studies and field visits in the project area; and to equip attendees with the ability to commission and review HIA’s, including development of adequate terms of reference and effective review of outputs.The content of the course will include theoretical and practical elements specific to the extractive industry sector: Introduction to the concept of HIA and current global practice; HIA standards, guidelines and links to relevant best practice documents; The phases of HIA and respective tools and methods; Application of the phases of HIA based on case studies.; Integration of HIA into social and biophysical studies and sustainable development planning.; Field visits to the First Quantum Kalumbila Mine project area, where specific contents of the course will be revisited in real life situations (ongoing activity throughout the course) A certificate of attendance will be presented on completion of the course.
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