The poorest countries in the world have been unable to reach agreement at the World Trade Organisation (WTO) on relief from global rules that would allow access to much needed medicines for their citizens. The 16 October 2015 meeting to resolve the impasse has been suspended indefinitely according to reports by IP-Watch in Geneva.
At the forefront of resistance to this application from least developed countries (LDCs) were the United States, Canada and Australia, in positions raised in June and again on 16 October. The LDCs have a two-fold demand that amounts to a request for a waiver from the application of WTO rules on intellectual property (IP) rights, such as patents (which protect owners of new medicines), data and marketing rights. Firstly, they have requested an extension of the 2013 waiver related to pharmaceutical products, currently expiring on 1 January 2016. Secondly, they have petitioned through Uganda, as LDC representative, for a general exemption from applying the WTO intellectual property rights agreement (TRIPS), granted until 2021. Their position is that it ought to be granted for as long as countries remain designated as least developed according to the United Nations. Most LDCs are in Africa.
Over 140 non-governmental organisations have come out in support of the LDC petition. Médecins Sans Frontières accused the US, Australia and Canada of seeking to worsen access to medicines in LDCs by weakening the exceptions granted to them.
Some reports imply that LDCs were ‘collateral damage’ for other IP interests for the US. The US Trade Representative failed to reach the high standards of protection sought in the mega-regional trade and regulatory agreement called the Trans-Pacific Partnership (TPP). Commercial US stakeholders were reported in an October 2015 paper by Knowledge Ecology International (KEI) to be upset with the concessions made in this flagship trade deal, with an informed but unnamed source stating, "the TPP did not deliver as expected on IP [Intellectual Property] and so we are under a lot of pressure not to give in more on IP."
In contrast, the LDCs’ proposals were supported by developing countries, including Cambodia, Cuba, Brazil, China, Uruguay and by the Africa Group. Norway and the European Commission also supported the LDCs request, as did the World Health Organization (WHO), the United Nations Development Programme and UNAIDS.
The costly nature of pharmaceutical drug production and the complex rules on production for export to countries with public health needs requires the certainty of a permanent waiver. According to James Love of KEI, "A permanent waiver of drug patent obligations is needed. No country will amend its patent laws if the waiver is limited in time, like the previous extensions...”
The public health basis for the LDC application is also evident. In a statement in June 2015, Uganda’s representative put the case to WTO members that 63% of people living with HIV in LDC countries still had no access to appropriate treatments. The United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States in its 2014 report indicated that most LDCs had not yet met the Millennium Development Goals on health, stating that LDCs “also need financial and technological support to derive maximum development benefits from the waivers granted under the WTO TRIPS agreement.”
LDCs, as the poorest countries in the world, serve as some measure of the level of civilisation of the global economic order. These countries are in effect asked to repeatedly expend scarce domestic resources and diplomatic capital supplicating rich countries at the WTO for exemptions from international rules that clearly do not take their interests into account. It is refreshing that the WHO is taking the side of the LDCs and access to medicines in this instance as the position has been less clear in the past. For example, Third World Network raised in 2010 that the WHO initiatives on “counterfeit” drugs threatened medicines access by conflating legitimately produced generic drugs with drugs that were illegally produced or traded, given that the term ‘counterfeit’ is used to denote trademark infringements in intellectual property rules.
The LDCs request for a waiver signals that the access to medicines activism that secured the 2001 WTO Doha Declaration on Public Health was just the start of a battle against vested interests pursuing profits at the expense of human life. The 2001 Declaration was in fact a statement of legal rights that all countries enjoyed already, but over which poor countries had to ensure legal certainty at global level as they were under threat. For example, the US Special 301 list designated countries deemed to violate intellectual property rights, as unilaterally imposed sanctions with negative economic and reputational effects. Given that the WTO disciplines unilateral action by states that affects multilateral trade, the US undertook to not use Special 301 in violation of the WTO, according to Chakravarthi Raghavan in 2000. However the US repeatedly breached this undertaking, such as in its placement of Thailand on the 2007 watch list for issuing compulsory licenses for patented pharmaceutical products.
The industry has significant lobbying power and the preponderantly US-based branded products pharmaceutical industry is one of the most profitable in the world. According to a 2014 BBC report, the sector made a 42% margin of profit in 2013 in the US, compared to about 29% for the banks. Many US pharmaceutical companies held tens of billions of dollars offshore to avoid US taxes, according to Bloomberg’s Richard Rubin on 4 March 2014.The cost of such concentrated corporate power is evident in the fact that US medicines prices are almost twice that compared to other developed countries. US policies are rationalised with ideas of free trade, competition and the full functioning of markets. The super-profits being made by branded pharmaceutical companies should lead even free trade proponents to be concerned about the enormous rents they extract from the market. The suspension of discussions on the LDC waiver on Friday coincided with the US and developed countries stating they would also not make binding commitments for special treatment of LDCs on other issues at the next WTO Ministerial meeting scheduled for 15 to 18 December in Nairobi.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
EQUINET is seeking a consultant with experience in writing media and promotional materials and knowledge of health and health systems for work in early 2016 to produce a document, drawing on existing materials and inputs provided by institutions in EQUINET, on EQUINETs nature, composition, work, and the impact it has had, that can be used to better explain and promote EQUINETs nature and role with partners and funders in and beyond the region. We ask consultants to submit a CV and a sample of similar work they have produced by November 24th 2015 to admin@equinetafrica.org
The equitable allocation of limited public sector health care resources across population groups is a critical mechanism for promoting health system equity and efficiency. The population groups are often defined by geographic areas that correspond to administrative authorities. The use of a needs-based resource allocation formula to calculate target allocations for each province or region and each district is becoming increasingly popular in countries where health care is publicly funded and provided. Target allocations are defined according to the relative need for health services in each geographic area, quantified using indicators such as population size, demographic composition, levels of ill health and socio-economic status. EQUINET has supported the development of needs-based resource allocation formulae in a number of east and southern African countries in the past. The methods for developing such a formula are summarised in this paper. Our work in the region has persuaded us that it is necessary to supplement the development of a formula with other initiatives to support the successful implementation of the resource allocation processes. To facilitate the gradual shifting of resources, the equity target allocations calculated through the formula must be linked explicitly to national and local planning and budgeting processes.
3. Equity in Health
Among the hot ideological wars South Africans wage, the author suggests that none is as violent to the truth as the rejigging of the Gini Coefficient measuring income inequality. (This number is zero if everyone shares income perfectly equally, and one if only a sole person gets it all.) The author suggests that if you measure income prior to state redistribution, South Africa’s Gini – as measured in November 2014 by the World Bank – is 0.77, the highest of any major country. The World Bank’s Pretoria office is reported to claim that the Gini is reduced from 0.77 to 0.59 once all manner of state social spending (social grants, education and health) is included in the calculation. The author projects, however, that the National Development Plan (NDP) will reduce the Gini only from 0.69 (in 2012 measured slightly differently from the Bank) to 0.60, i.e., with the income share earned by the poorest 40 percent rising from 6 to just 10 percent. This, it is noted, will make South Africa's levels of inequality higher than any other major country in the world. Bond indicates that a policy of growth-through-redistribution is needed for the country but that advancing this depends on the balance of political forces more than ideological debates.
Despite widespread gains toward the 5th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage. The authors used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014 in both relative and absolute equity. Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.
In 2000, world leaders agreed on the Millennium Development Goals (MDGs). MDG 4 called for a two-thirds reduction in the under-5 mortality rate between 1990 and 2015. The authors aimed to estimate levels and trends in under-5 mortality for 195 countries from 1990 to 2015 to assess MDG 4 achievement and then intended to project how various post-2015 targets and observed rates of change will affect the burden of under-5 deaths from 2016 to 2030. To provide insights into the global and regional burden of under-5 deaths associated with post-2015 targets, the authors constructed five scenario-based projections for under-5 mortality from 2016 to 2030 and estimated national, regional, and global under-5 mortality rates up to 2030 for each scenario. The global under-5 mortality rate has fallen from 90·6 deaths per 1000 livebirths (90% uncertainty interval 89·3–92·2) in 1990 to 42·5 (40·9–45·6) in 2015. The global under-5 mortality rate reduced by 53% (50–55%) in the past 25 years and therefore missed the MDG 4 target. Based on point estimates, two regions—east Asia and the Pacific, and Latin America and the Caribbean—achieved the MDG 4 target. 62 countries achieved the MDG 4 target, of which 24 were low-income and lower-middle income countries. Between 2016 and 2030, 94·4 million children are projected to die before the age of 5 years if the 2015 mortality rate remains constant in each country, and 68·8 million would die if each country continues to reduce its mortality rate at the pace estimated from 2000 to 2015. If all countries achieve the Sustainable Development Goal of an under-5 mortality rate of 25 or fewer deaths per 1000 livebirths by 2030, the authors project 56·0 million deaths by 2030. About two-thirds of all sub-Saharan African countries need to accelerate progress to achieve this target. Despite substantial progress in reducing child mortality, concerted efforts remain necessary to avoid preventable under-5 deaths in the coming years and to accelerate progress in improving child survival further. Urgent actions are needed most in the regions and countries with high under-5 mortality rates, particularly those in sub-Saharan Africa and south Asia.
4. Values, Policies and Rights
The Sustainable Development Goals (SDGs) identify achieving universal health coverage (UHC) as one component of the omnibus health goal, “to ensure healthy lives and promote well-being for all at all ages.” The components of UHC specified in goal 3.8 of the SDGs reflect World Health Organisation’s policy documents and include financial risk protection, access to quality essential health-care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all. On the positive side, UHC can be considered to be an expression of the right to health. Indeed, several health and human rights advocates had earlier proposed replacing the various health-related goals in the MDGs with the single overarching health goal of UHC in the SDGs, provided that it specify that international assistance is essential, not optional, for countries otherwise unable to pursue UHC. Significant progress toward UHC, consistent with the requirements of the right to health, would have the potential of enabling the one billion people currently estimated to not have access to the health services they need each year to obtain them. The author argues, however, that not all potential paths to a universal health system are consistent with human rights requirements, even ones that result in some expansion of health coverage. For that reason it is important that health and human rights advocates and scholars identify the essential features of UHC and policies for advancing toward this goal from a human rights perspective.
Despite criticism, the MDGs are widely praised for having galvanised national and international development efforts in unprecedented ways. Currently proposed successor Sustainable Development Goals (SDGs) seek to address newly emerged policy issues and include a call to significantly reduce the burden of non-communicable diseases (NCDs). NCDs directly impact health inequality and poverty. Their recognition is timely and to be welcomed categorically. However, ambiguity in the SDGs’ current guidance risks that states’ efforts to reduce NCDs exacerbate socioeconomic and health inequalities, rather than reduce them. The authors urge that more attention needs to be given to improving the situation of the worst off and make three concrete proposals towards this end. Existing policy guidance highlights cost-effective interventions for NCDs, but focusing just on cost-effectiveness risks exacerbating socioeconomic and health inequalities rather than reducing them. The authors suggest that in implementing the SDGs, targets and interventions that benefit the worst off should be prioritised. The United Nations should develop practical guidance to assist policy makers at the country level with incorporating equity considerations.
Medecins Sans Frontieres (MSF) has called for an investigation by an international humanitarian fact-finding commission into a US airstrike on its hospital in the Afghanistan city of Kunduz and for one of the States, party to the Additional Protocols to the Geneva Conventions, to invoke it. MSF said the attacks took place despite the fact that it had provided the GPS coordinates of the trauma hospital to Coalition and Afghan military and civilian officials as recently as Tuesday, 29 September. The attack continued for more than 30 minutes after MSF first informed US and Afghan military officials in Kabul and Washington that it was a hospital that was being hit. The International Humanitarian Fact-Finding Commission was established under the Additional Protocols to the Geneva Conventions and was officially constituted in 1991 to investigate allegations of violations of international humanitarian law. According to the Commission's website, some 76 countries have recognised the Commission, which is based in Bern, but so far, it has not yet been called upon to conduct any investigation. In her remarks to the media, MSF President Liu said that international humanitarian law is not about ‘mistakes'. "It is about intention, facts and why....This was not just an attack on our hospital - it was an attack on the Geneva Conventions. This cannot be tolerated. These Conventions govern the rules of war and were established to protect civilians in conflicts - including patients, medical workers and facilities. They bring some humanity into what is otherwise an inhumane situation."
The 2030 Agenda for Sustainable Development has been agreed, along with 17 Sustainable Development Goals (SDGs) and their 169 targets seek to build on the Millennium Development Goals (MDGs) and “complete what these did not achieve”. MDG4: Reduce Child Mortality is one the goals which failed to achieve its single target to “Reduce by two-thirds, between 1990 and 2015 the under-five mortality rate (U5MR).” MDG4 mobilised global efforts to promote child survival and health, (and indeed between 1990 and 2013, the annual number of under-five deaths declined by half to 6.3 million) but was also critiqued from many diverse perspectives. Despite global progress towards MDG4, the poorest children and indeed the poorest countries, have been left behind. SDG Target 3.2, states: 'By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under five mortality to at least as low as 25 per 1,000 live births'. For SDGs to build on the lessons of the MDGs, the author indicates that the targets should be framed in the unambiguous terms of reducing inequalities. The author suggests that it is difficult to predict how target 3.2 will be measured, and how countries will be held globally accountable, but proposes that all countries should at least report on the gap in child survival between the richest and the poorest, and their progress towards equality of outcomes. To make sure this happens, civil society and human rights mechanisms need to be mobilized around the child’s right to survival and to health, without discrimination.
5. Health equity in economic and trade policies
Africa’s development agenda beyond 2015 was at the heart of discussions at the 15th International Economic Forum in Africa: “Africa beyond 2015”, in Berlin in September 2015. According to the OECD, Africa’s gross domestic product (GDP) growth is expected to strengthen to 2016 but poverty and hunger rates remain stubbornly high, progress in health and education is uneven, and huge inequalities persist between and within countries, and between women and men. Furthermore, low productivity and investment as well as weak or non-existent infrastructure are holding back economic and development progress. A panel of African leaders suggested that regional development strategies and local assets provide possible solutions to these challenges, and discussed special economic zones, economic corridors, strategies for lagging regions and slum upgrading for promoting regional development, overcoming spatial inequalities, mobilising local resources and creating productive employment opportunities. The importance of the Common African Position on the Post-2015 Development Agenda “to speak with one voice and to act in unity to ensure that Africa’s voice is heard and is fully integrated into the global development agenda,” was highlighted.
This satirical presentation by Swedish electronic music duo The Knife explores “the newest millennium goal” – end extreme wealth. More than 40 panels feature various experts expounding on the problems faced by the extremely wealthy using much of the same language that is used to describe the world’s poorest.
The author writes that the World Trade Organisation (WTO) is firmly located in an old ethical order which puts profit over people; where those in power make the rules to suppress the powerless; and where this iniquitous and unjust world “order” (disorder) is legitimised by the ideology of neoliberalism. He states that progressive people must defy this iniquitous system and overturn it as it is not reformable. He observes that it is one that could be neutralised if Africa was united to challenge the WTO and the "Big and Powerful". At the Seattle WTO Ministerial in November 1999 Africa and the global South neutralised the WTO with the help of world peoples' movements fighting for justice for the weak in the international trading system. The Tenth Ministerial Conference (MC10) of the WTO in Nairobi is not just Africa’s war. Trade negotiations in Geneva are said to be carried out in a "surreal" atmosphere where the forest is missed for the trees. In this piece the author argues that the Nairobi negotiations will be behind closed doors where the 'Empire' will use all means at its command to secure a "consensus" that serves its interest and where those from the grassroots resist being drawn into that consensus if that does not do justice to grassroots people and communities. He notes that economics is girded firmly in the politics of power and that power, in turn, is legitimised by an ideology, in this case the ideology of neoliberalism. Those who are fighting for justice thus have to tackle all three levels – economic, political and ideological.
This report aims to inform the ongoing discussions and processes on developing a new business model for antibiotics. It is based on the premise that delinkage, seeking to separate the return on investment from antibiotic sales volume, should be the principle underpinning any new business model. It calls on governments to invest significantly in antibiotic R&D by financing a broad menu of incentives across the antibiotic life-cycle, with the highest incentives targeted at the development of antibiotics directed at the greatest health threats arising from antibiotic resistance. Contributions from countries should be coordinated within a globally agreed framework. Finally, global access should, together with conservation, be a priority for any new business model fostering innovation. The report makes several recommendations based on findings. The authors suggest that a new business model needs to be developed in which the return on investment in R&D on antibiotics is delinked from the volume of sales.There should be increased public financing of a broad menu of incentives across the antibiotic life-cycle is required, targeted at encouraging the development of antibiotics to counter the greatest microbial threats. The assessment of current and future global threats arising from resistance should be updated periodically in order to identify which classes of product are a priority for incentives. The delinkage model should prioritize both access and conservation. Domestic expenditures on the model need to be globally coordinated, including through the establishment of a secretariat, and global participation in the model is the ultimate goal.
The United Nations Special Rapporteur in the field of right to culture recommended a new intellectual property regime for pharmaceutical products stressing that there is no human right to patent protection. This recommendation was made in the report to the 70th Session of the UN General Assembly. The Special Rapporteur recommended that “the United Nations should convene a neutral, high-level body to review and assess proposals and recommend a new intellectual property regime for pharmaceutical products that is consistent with international human rights law and public health requirements, and simultaneously safeguards the justifiable”. This is drawn from the recommendation of the Global Commission on HIV and the Law appointed by the UN Development Programme (UNDP). The report also recommends that states have a positive obligation to provide for a robust and flexible system of patent exclusions, exceptions and flexibilities based on domestic circumstances, including through the establishment of compulsory and government use licences when needed. The report further argues that states have a human rights obligation not to support, adopt or accept intellectual property rules, such as TRIPS-Plus provisions, that would impede them from using exclusions, exceptions and flexibilities and thus from reconciling patent protection with human rights. International agreements that do not provide sufficient flexibility should be renounced or modified. The report highlights Article 27 of the Universal Declaration of Human Rights and Article 15 of the International Covenant on Economic, Social and Cultural Rights which ensure that measure be put in place to ensure affordability of and access to technologies essential to life and realisation of all human rights.
The World Intellectual Property Organization (WIPO) is holding with the Japan Patent Office (JPO) an African ministerial conference on intellectual property (IP), in Senegal, November 3-5, in cooperation with the African Union (AU) and the Government of Senegal. The ministerial conference on ‘IP for an Emerging Africa” aims to “explore the opportunities as well as the challenges facing Africa in building a vibrant innovation system and in effectively using the IP system,” according to meeting’s provisional programme. The authors argue that the ministers should embrace a balanced and development-oriented approach to intellectual property. Such an approach ought to take into account the needs, priorities and socio-economic circumstances of African countries as well as the most recent empirical evidence on the dynamics of intellectual property and innovation on the continent.
6. Poverty and health
Agricultural experts and policymakers have formed a new institution to promote sustainable food systems in Sub-Saharan Africa and to deal with the challenges posed by climate change. The African Ecosystem Based Adaptation for Food Security Assembly (EBAFOSA) which aims to advocate for sustainable ecosystem-friendly agricultural systems was formed during the 2nd Africa Ecosystem Based Adaptation for Food Security Conference held in Kenya on 30-31 July, 2015. Africa loses about six million of productive land a year through deforestation, with almost 65 per cent of the continent’s land being under pressure from land degradation, the conference heard. The EBAFOSA will work towards achieving food security, ecological productivity, job creation, poverty reduction, value addition and sustainable industrial development in Africa.
7. Equitable health services
Growing international concern about the need for improved health systems in Africa has catalysed an expansion of the health systems literature. This review applies a bibliometric procedure to analyse the acceleration of scientific writing on this theme. The authors focus on research published during the Millennium Development Goal (MDG) era between 1990 and 2014, reporting findings from a systematic review of a database comprised of 17,655 articles about health systems themes from sub-Saharan African countries or subregions. Using bibliometric tools for co-word textual analysis, the authors analysed the incidence and associations of keywords and phrases to generate and visualise topical foci on health systems as clusters of themes. Results show that African health systems research is dominated by literature on diseases and categorical systems research topics, rather than on systems science that cuts across diseases or specific systemic themes. Systems research is highly developed in South Africa but relatively uncommon elsewhere in the region. Results identify several themes that are unexpectedly uncommon in the country-specific health systems literature. This includes research on the processes of achieving systems change, the health impact of systems strengthening, processes that explain the systems determinants of health outcomes, or systematic study of organisational dysfunction and ways to improve system performance. Research quantifying the relationship of governance indicators to health systems strengthening is nearly absent from the literature. Long-term experimental studies and statistically rigorous research on cross-cutting themes of health systems strengthening are rare. Studies of organisational malaise or corruption are virtually absent. Trend analysis shows the emergence of organisational research on specific priority diseases, such as on HIV/AIDS, malaria, and tuberculosis, but portrays a lack of focus on integrated systems research on the general burden of disease. If health systems in Africa are to be strengthened, then organisational change research must be a more concerted focus in the future than has been the case in the past.
The United Republic of Tanzania has implemented countrywide anti-malarial interventions over more than a decade, including national insecticide-treated net (ITN) rollouts and subsequent monitoring. While previous analyses have compared spatial variation in malaria endemicity with ITN distributions, no study has yet compared Anopheles habitat suitability to determine proper allocation of ITNs. This study assesses where mosquitoes were most likely to thrive before implementation of large-scale ITN interventions in Tanzania and determine if ITN distributions successfully targeted those areas. The spatial distribution of ITN ownership across Tanzania was near-random spatially. Mosquito habitat suitability was statistically unrelated to reported ITN ownership and very weakly to the proportion of households with ≥1 ITN. ITN ownership declined significantly toward areas with the highest vector habitat suitability among households with lowest ITN ownership. In areas with lowest habitat suitability, ITN ownership was consistently higher. Insecticide-treated net ownership is critical for malaria control. While Tanzania-wide efforts to distribute ITNs has reduced malaria impacts, gaps and variance in ITN ownership are unexpectedly large in areas where malaria risk is highest. Supplemental ITN distributions targeting prime Anopheles habitats are likely to have disproportionate human health benefits.
8. Human Resources
This paper explored the reasons African health workers raised for migration to Austria, as well as their personal experiences concerning the living and working situation in Austria. The authors conducted semi-structured, qualitative interviews with African health workers approached via professional networks and a snowball system. For most of the participants, the decision to migrate was not professional but situation dependent. Austria was not their first choice as a destination country. Several study participants left their countries to improve their overall working situation. The main motivation for migrating to Austria was partnership with an Austrian citizen. Other immigrants were refugees. Most of the immigrants found the accreditation process to work as a health professional to be difficult, resulting in some not being able to work in their profession. There was also reported experience of discrimination, but also of positive support.
9. Public-Private Mix
This paper considers evidence on the effectiveness, equity and sustainability of for-profit private provision, and the effectiveness of government’s stewardship of the sector, in East and Southern Africa. It draws conclusions about policy and regulatory requirements to encourage for-profit providers to make a more useful contribution towards achieving universal health coverage in the region. The author observes a recent increase in the size of a formerly relatively small for-profit private sector in some countries in the region, but also the emergence of 'boutique’ hospitals (targeted at the high-income local market, expats and foreign NGO workers, as well as medical tourism) in otherwise underdeveloped settings. As warned by the international literature that critiques the commercialisation of health care, such developments could worsen inequity and destabilise national health systems if inadequately regulated.
In Uganda and elsewhere, the private sector provides an increasing and significant proportion of maternal and child health services. However, little is known whether private care results in better quality services and improved outcomes compared to the public sector, especially regarding care at the time of birth. This study described the characteristics of care-seekers and assess newborn care practices and services received at public and private facilities in rural eastern Uganda. The authors collected data from mothers with infants at baseline and endline using a structured questionnaire among private and public health facilities. Private health facilities did not perform significantly better than public health facilities in terms of coverage of any essential newborn care interventions, and babies were more likely to receive thermal care practices in public facilities compared to private (68% compared to 60%). Babies born at public health facilities received an average of 7.0 essential newborn care interventions compared to 6.2 at private facilities. Women delivering in private facilities were more likely to have higher parity, lower socio-economic status, less education, to seek antenatal care later in pregnancy, and to have a normal delivery compared to women delivering in public facilities. In this setting, private health facilities serve a vulnerable population and provide access to service for those who might not otherwise have it. However, provision of essential newborn care practices was slightly lower in private compared to public facilities, calling for quality improvement in both private and public sector facilities, and a greater emphasis on tracking access to and quality of care in private sector facilities.
10. Resource allocation and health financing
Achieving the 2030 Agenda for Sustainable Development requires trillions of dollars annually. The authors indicate that global public and private investment would be sufficient – but only if financial resources were invested in and aligned with sustainable development. This requires a comprehensive approach, which mobilises public finance, sets appropriate public policies and regulatory frameworks, unlocks the transformative potential of people and the private sector, and incentivises changes in consumption, production and investment patterns in support of sustainable development. The Addis Ababa Action Agenda (AAAA) presents a policy framework that realigns financial flows with public goals. Official development assistance (ODA) remains crucial, particularly for countries most in need, but alone is not be sufficient. The AAAA addresses all sources of finance: public and private, domestic and international and stresses the importance of long-term investment, and the need for all financing to be aligned with sustainable development. It includes several new commitments by Governments: A new social compact to provide social protection and essential public services for all; A global infrastructure forum to bridge the infrastructure gap; An ‘LDC package’ to support the poorest countries; A Technology Facilitation Mechanism to advance to the SDGs; Enhanced international tax cooperation to assist in raising resources domestically; Mainstreaming women’s empowerment into financing for development. Additional cross-cutting issues include scaling up efforts to end hunger and malnutrition, promoting inclusive and sustainable industrialisation, full and productive employment and decent work for all, peaceful and inclusive societies, and protecting the ecosystem.
Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.03–7.5 % in Kenya, with a statistically significant difference in the proportion of spending on SRH services across income quintiles. The poorest households in Kenya spent ten times more on seeking care than the least poor households. The most common coping mechanisms were receiving [money] from partner or household members and using own savings or regular income. Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings.
There is increasing interest in understanding how Results Based Financing (RBF) can improve efficiency, effectiveness and accountability in programming towards
Universal Health Coverage and improved health outcomes at scale. The Northern Uganda Health (NU Health) is a controlled implementation study to assess the costs and benefits of RBF relative to conventional Input Based Financing (IBF). The study design aimed to isolate the main effect of the financing modality in terms of quality and quantity of health service provision. Programme data and the results of an independent evaluation confirm a range of key findings. These include: A significant reduction in barriers to access and increase in health service utilisation; a three to eight fold improvement in adherence to standard treatment algorithms/quality of care for the major childhood killers: diarrhoea, malaria and pneumonia; and, particularly dramatic improvements in care and utilisation at the lowest level facilities, harbouring the promise of real progress toward Universal Health Coverage.
Africa has enjoyed a growth momentum since 2000 after the wasted years of the 1980s and much of the 1990s. However, eradicating poverty will require huge resources, which existing funding strategies will be unable to generate. Global commodity prices have fallen sharply; capacity to mobilise domestic revenues is waning; and aid has been insufficient in plugging funding gaps. Revenue bargains in which states extract revenues from citizens in exchange for investments that impact positively on well-being may be key to financing Africa’s development. They can substantially increase revenues, nurture effective state-citizen relations, force companies to pay correct taxes, push fragmented systems of service provision in the direction of universalism, improve policy space and make aid more effective.
11. Equity and HIV/AIDS
After a late start and poor initial performance, the South African Prevention of Mother-To-Child Transmission (PMTCT) programme achieved rapid progress in achieving effective national-scale implementation of a complex intervention across a large number of different geographic and socioeconomic contexts. This study shows how quality-improvement methods played a significant part in PMTCT improvements. The South African rollout of the PMTCT programme underwent significant evolution, from a largely ineffective, context-insensitive, top-down cascaded training approach to a sophisticated bottom-up health systems’ intervention that used modern adaptive designs. Several demonstration projects used quality-improvement methods to improve the performance of the PMTCT programme. These results prompted a national redesign of key elements of the PMTCT programme which were rapidly scaled up across the country using a unified, simplified data-driven approach. The scale up of the quality-improvement approach contributed to a dramatic fall in the nationally reported transmission rate for mother to child transmission of HIV. By 2012, measured infection rate of HIV-exposed infants at around 6 weeks after birth was 2.6%, close to the reported transmission rates under clinical trial conditions. Quality-improvement methods can be used to improve reliability of complex treatment programmes delivered at primary-care level. Rapid scale up and effective population coverage can be accomplished through a sequence of demonstration, testing and rapid spread of locally tested implementation strategies supported by real-time feedback of a simplified indicator dataset and multilevel leadership support.
12. Governance and participation in health
"Sembene!" is a feature documentary on continental Africa's most celebrated filmmaker, the late Ousmane Sembene, from co-directors Samba Gadjigo (author of Sembene’s official biography) and Jason Silverman. SEMBENE! tells the true story of the self-taught novelist and filmmaker who fought, against enormous odds, a 50-year battle to give Africans the power to tell their own stories. SEMBENE! is told through the never-before-seen archival footage and verite footage. It follows an ordinary man who transforms himself from a manual labourer into a fearless and often polarizing spokesman for the marginalized, becoming a hero to millions. The film is about, not only Sembene, but also about the importance of reclaiming African stories.
This paper explores the extent, nature and quality of community participation in health systems intervention research in low- and middle-income countries.
It used peer-reviewed, English language literature published between January 2000 and May 2012 through four electronic databases. Search terms combined the concepts of community, capability/participation, health systems research and low- and middle-income countries. Most articles were led by authors in high income countries and many did not consistently list critical aspects of study quality. Articles were most likely to describe community participation in health promotion interventions (78%, 202/260), even though they were less participatory than other health systems areas. Community involvement in governance and supply chain management was less common (12%, 30/260 and 9%, 24/260 respectively), but more participatory. Articles cut across all health conditions and varied by scale and duration, with those that were implemented at national scale or over more than five years being mainstreamed by government. Most articles detailed improvements in service availability, accessibility and acceptability, with fewer efforts focused on quality, and few designs able to measure impact on health outcomes. With regards to participation, most articles supported community’s in implementing interventions (95%, n = 247/260), in contrast to involving communities in identifying and defining problems (18%, n = 46/260). Many articles did not discuss who in communities participated, with just over a half of the articles disaggregating any information by sex. Articles were largely under theorized, and only five mentioned power or control. Majority of the articles (57/64) described community participation processes as being collaborative with fewer describing either community mobilization or community empowerment. Intrinsic individual motivations, community-level trust, strong external linkages, and supportive institutional processes facilitated community participation, while lack of training, interest and information, along with weak financial sustainability were challenges. Supportive contextual factors included decentralization reforms and engagement with social movements. Despite positive examples, community participation in health systems interventions was variable, with few being truly community directed. Future research should more thoroughly engage with community participation theory, recognize the power relations inherent in community participation, and be more realistic as to how communities participate and cognizant of who decides that.
This paper is part of a series of outputs from the research project on The Politics of Domestic Resource Mobilisation for Social Development. It examines the linkages between resource mobilisation and social outcomes by looking at institutions that play a key role with respect to resource mobilisation and social spending in Uganda. It looks at three institutions—the Uganda Revenue Authority (URA), Kampala Capital City Authority (KCCA) and the Ministry of Health (MoH)—which were selected because they are key organisations in either revenue collection or social service delivery or both, and all three were targets of reforms with varying degrees of success. The paper analyses how these institutions compare with respect to political prioritization, and in particular, to what extent they benefit from key institutional reforms and organizational capacity. The analysis reveals how varying political interests in, and priorities of, public institutions serve to explain differences in the delivery of public services and their organizational capacity. It illustrates the bigger picture that only politically important organizations—those perceived to be key for the political survival of the ruling elite—are well equipped with resources. The findings also stress the point that organizations that tend to perform better do so because they are politically prioritized and offered political protection.
With the recent adoption of a new global development agenda for the next 15 years and negotiations on a new climate regime ongoing, what’s changed for governance of the global economy in the last two decades, and what have we learned? This article maps the shifting context for trade, investment, and sustainable development. It puts global governance efforts into historical context of a globalised economy with lesser attention paid to questions of equity and social inclusion, and an underestimation of persistent and deep-rooted asymmetries in capabilities among countries at different levels of development and perilous levels of inequality among and within most countries around the world. The author suggests that global governance will continue to be a matter of striking the balance between global direction-setting, monitoring the ongoing leadership role of government policy, and supporting the subsidiary implementation of commitments at ground level. The paper points to aligning national policies and ensuring trade and investment systems work for sustainable development rather than funding discrete projects. The author argues that policies, their frameworks and the institutions needed to implement them constitute the most powerful lever for change.
13. Monitoring equity and research policy
The World Social Science Forum 2015 served as a platform for presenting new knowledge and insights, re-thinking received wisdom, charting new directions, promoting innovation in the research-policy-action nexus, and nurturing new international partnerships. Issues of justice and growing inequalities at global, regional, national and local levels and their impact on the quality of life of populations as well as on the sustainability of resources justified the theme: 'Transforming Global Relations for a Just World'. Participants declared their concern with the consequences of injustice and inequality for the quality of life for global populations as well as with the sustainability of global resources. The participants declared to: (a) Pursue theoretical and empirical research including development of reliable and multi-dimensional indicators on inequalities and injustices; (b) Produce evidence to highlight issues requiring urgent attention and action, support advocacy and inform policies to respond to them; (c) Support efforts to address asymmetries, disparities, divides, and lack of autonomy in knowledge production through the creation of transformative knowledge programs; (d) Participate in programs and efforts that aim to end injustice and inequality; (e) Make every effort to reduce income inequalities and promote equity, starting with scientific institutions where they have influence; (f) Support measurable progress to overcome inequalities, including through the implementation of the Sustainable Development Goals; (g) Promote policies, programs, and values that act to end gender inequality; (h) Promote the integration of youth in work places through providing them with the necessary skills to enter the labour force; (i) Support efforts to achieve legally binding and universal agreement on avoiding dangerous anthropogenic interference with the climate system; and (j) Promote inclusive societies based on universal values and human rights.
14. Useful Resources
The household economy approach (HEA) is a method for assessing the vulnerability of rural populations to economic shocks and changes, based on their livelihood patterns and market information. It is now widely used as a method of famine early warning by many governments and humanitarian agencies, and also has important applications for managing the impacts of climate change on poverty and food security in developing countries.
BMJ has partnered with the University of Cape Town Lung Institute's Knowledge Translation Unit (UCTLI KTU), to develop and distribute the Practical Approach to Care Kit (PACK) programme to healthcare workers in low to middle income countries. The PACK programme is a comprehensive clinical practice aid that enables healthcare practitioners to diagnose and manage common conditions. It covers 40 common symptoms and 20 conditions including cardiovascular disease, respiratory diseases, tuberculosis, HIV/AIDS, women’s health, and end-of-life care. PACK is updated annually to comply with local clinical policy, regulations and essential drug lists, and is translated where necessary. It incorporates regular evidence updates from BMJ and other credible sources including WHO, to ensure that it is relevant and provides the latest best practice guidance. The programme has been implemented in Botswana and in the Zomba district of Malawi. Extensive interest in PACK has been received from other middle to low income countries.
15. Jobs and Announcements
Formed in 2006, the One in Nine Campaign is a network of organisations and individuals driven by feminist principles and the desire to live in a society where women are the agents of their own lives, including their sexual lives. The Campaign supports and advocates for the rights of women who speak out against sexual violence as well as other survivors in five ways: Solidarity in Action and Building Feminist Activism, Feminist Knowledge Production and Research, Media Advocacy, Justice and Legal Transformation and Direct Action. The One in Nine Campaign is calling for application from all interested individuals/service providers in the following fields: Organisational Development, Strategic planning and reviews, Resource Mobilisation /Fundraising for NGOs, Research, Documentation (written and/or visual), Monitoring and Evaluation, Staff development/Team building, Creative Arts for social change (all art forms welcomed), Health and Wellness, Marketing (especially for small businesses, NGOs, Cooperatives) and Setting up and registering of Cooperatives. The organisation seeks to update its Consultants database and preference will be given to individuals who identify as Women and feminists and registered service providers that are led by Women.
The World Health Organization Health Workforce Department is inviting you to participate in a Delphi study to be conducted as part of a broader agenda to develop and implement National Health Workforce Accounts (NHWA) in support of the implementation of the Global strategy on human resources for health: health workforce 2030 (GSHRH) which will be submitted to the Sixty-ninth World Health Assembly in May 2016. The concept of NHWA calls for a harmonized, integrated approach for annual and timely collection of health workforce information. Fundamentally, the purpose of NHWA is to structure the information architecture and interoperability, to define core workforce indicators, to enable strategic workforce planning and to facilitate comparability of the health workforce landscape (within countries and across regions). The purpose of this study is to acquire the views of a global group of health systems experts on the relevance, availability and use of existing health workforce indicators working towards a core set of well-defined indicators. These indicators will be mapped against the proposed NHWA modules. Should you be interested to participate, the study tool will be available on line from 1-15 November 2015 and would require about 30 minutes to complete. Please confirm your interest and availability by return email to workforce2030@who.int with a subject line: NHWA – Delphi Study, with the following information: First name; Surname; professional title;
affiliation; country; email address and telephone.
People's Health Movement (PHM) is preparing for another round of watching at the 138th Executive Executive Board (EB138) meeting taking place from 25 to 30 January 2016 in Geneva, Switzerland. PHM believes that the World Health Organisation (WHO) is the legitimate space for global health policy making. Through the WHO Watch initiative, PHM intervenes in the discussion of WHO's key decisions making bodies and brings the voice of the movements struggling for Health for All. PHM are in the early stages of putting together the Watch and hope to get more and new watchers from around the world involved, consulting with country circles on key issues, and developing a solid commentary on issues of interest discussed at the meetings. During the meeting, PHM will have a skype channel open where the key points of the discussions will be shared.
The Conservation, Food and Health Foundation is currently accepting concept notes for its first round of 2016 Grants. Non-profit organisations in developing countries that are focusing in one of the three fields – conservation, food and health are invited to apply. The foundation supports projects that demonstrate strong local leadership, promote professional development in the conservation, agricultural, and health sciences; develop the capacity of local organisations; and address a particular problem in the field. Average grant size is US$17,000. Grant request can be made for maximum US$25,000. Conservation Grants aims to improve ecological and environmental conditions in the developing world. Research activities, training, and technical assistance efforts are supported under Conservation Grants. Food Grants are allocated to efforts aimed at improving access to food for consumption in developing countries. Health Grants are focused at programs that are preventive in nature. Research, technical assistance, and training projects are supported under Health Grants. It supports research, technical assistance, and training projects that improve public health through community-based efforts that address health promotion, disease prevention, family planning, and reproductive health; and increase the understanding and treatment of tropical diseases.
University College London (UCL) invite staff members or students of any African university to submit photographs which capture personal stories and experiences of contemporary Africa. The winning selections will be exhibited in physical form and online as part of the AfricanVoices season at UCL and then displayed by the UCL African Studies Research Centre (Institute of Advanced Studies) on walls, online and at other events with the photographer’s name displayed clearly in each case. The best overall entry will be awarded a tablet and there will be four runners-up prizes for the best photograph in each category. Photographs will be judged in four categories: Cities, Health, Human Wellbeing and Intercultural Interaction. The competition is not open to professional photographers.
Health System Global announces the Call for Abstracts for the Fourth Global Symposium on Health Systems Research on the Symposium website. The theme os Resilient and responsive health systems for a changing world. Submissions are invited for both organized sessions and individual abstracts. Please visit the site to find out about: key dates and deadlines, how to submit your abstract and other details on taking part in the Symposium. Please also make sure to visit the site regularly as HSG will keep updating it with announcements and relevant resources in the coming months. Please share the call with colleagues and anyone else who might be interested.
The General Council, on 10 December 2014, agreed that the 10th Ministerial Conference be held in Nairobi, Kenya from 15 to 18 December 2015.
The South African Health Review (SAHR), published annually by Health Systems Trust (HST) for 18 years, is an accredited peer-reviewed journal that is widely respected as an authoritative source of research, analysis and reflection on health systems. The SAHR advances knowledge agenda-setting, production and sharing. Being published in the Review affords authors the opportunity to participate in and contribute to a recognised and established community of expertise which offers a South African perspective on prevailing local and international public health issues. Concepts for chapter submissions should represent manuscripts that highlight critical commentary on current areas of significant interest or debate, and offer empirical understandings for improving South Africa’s health systems reform and application of health policy, focusing on innovative and good practice models. Researchers, educators, students, policy-makers, planners, capacity-builders, managers and specialist practitioners in the field of health systems and related health development disciplines are invited to submit abstracts for the 2015/16 SAHR to editor@hst.org.za Guidelines for authors can be downloaded via the below link. Strict adherence to these guidelines is essential. Submission of an abstract for the SAHR does not guarantee acceptance. All manuscripts will undergo systematic peer review according to documented standards.
The Mandela Washington Fellowship for Young African Leaders, begun in 2014, is the flagship program of President Obama’s Young African Leaders Initiative (YALI) that empowers young people through academic coursework, leadership training, and networking. In 2016, the Fellowship will provide 1,000 outstanding young leaders from Sub-Saharan Africa with the opportunity to hone their skills at a U.S. higher education institution with support for professional development after they return home. The Fellows should be between the ages of 25 and 35, have established records of accomplishment in promoting innovation and positive change in their organizations, institutions, communities, and countries. The 2016 fellowships include: A six-week Academic and Leadership Institute at U.S. colleges and universities; A Summit with President Obama in Washington, DC and an optional six-week professional development experience (PDE) at a U.S.company, civil society organization, or public sector agency.
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