December 1, World AIDS Day

A third of the world’s population still has no access to essential drugs. In the poorest countries of Africa and Asia this figure rises to half. With the global agreement on intellectual property rights (TRIPS) forcing countries to introduce new patent protection laws over the next decade, this situation could worsen, according to a new report from the London-based Panos Institute.

Developing countries have until 2005 or 2016 to implement TRIPS-compliant legislation on pharmaceuticals. So far many governments have drafted or enacted legislation that seems to prioritise patent rights over public health. Some countries are being pressurised into adopting policies that go further than TRIPS in protecting patents. Patents give big international pharmaceutical firms monopoly over production of new drugs, including, for example, those needed to treat HIV/AIDS.

There is concern they may push up prices, and the TRIPS rules could thus limit poor countries’ freedom to buy cheaper “generic” versions of patented drugs. For example, in January 2001, South African HIV/AIDS treatment activist Zackie Ahmat went to Thailand to buy 5,000 pills of the generic version of an anti-fungal drug patented by the US pharmaceutical giant Pfizer. He paid $0.21 a pill. The price of the patented version in South Africa was $13.

The Panos Report, 'Patents, Pills and Public Health: can TRIPS deliver?' warns that patent legislation is not being debated widely enough in most developing countries, and the process of introducing it needs to be more consultative and transparent. In Uganda, for example, American consultants were brought in to review the country’s patent laws and make proposals for reform. The result was the drafting of laws which, according to local campaigners, are skewed in favour of business interests rather than social or development needs. The principle of extending access to essential drugs in poor countries is widely supported, but the means of doing this is still hotly disputed, says the report.

According to the World Bank, middle-income countries may benefit from increased foreign investment, but if the cost of drugs rises as a result of patent systems spreading throughout the developing world, there is a real danger of restricting access to drugs, such as anti-AIDS drugs, where they are most needed. The World Health Organisation suggests that implementing patent protection where it did not already exist would result in the average price of drugs rising, with projected increases ranging from 12 to 200 percent.

The pharmaceutical industry argues that patent systems promote innovation and investment in research and development. Without patents, new ones would not be developed to tackle diseases such as tuberculosis and HIV/AIDS. They believe the real barriers to making drugs more available are poverty, weak political leadership, lack of trained health personnel and poor health infrastructures.

The report examines alternative approaches and gives examples where differential pricing (where poorer countries pay considerably less for a product than wealthier ones) and compulsory licensing (where a patent is overridden in return for a payment of a royalty) have potential, although they are not free of problems. Two countries highlighted in the report, show how differently patent protection can impact on the nation’s public health: Brazil is seen as a model for other countries of what can be achieved for public health by boosting local production of drugs such as the anti-AIDS drug AZT, lowering prices through competition and negotiating discounts on patented drugs. Between 1996 and 2001 around 358,000 AIDS hospitalisations were prevented, saving around $1.1 billion. On the other hand, Thailand’s capacity to provide essential drugs for its people has been severely limited in the last decade due to relentless pressure from the US to tighten up its patent laws which, they complained, meant the loss of $30 million a year in sales for the American pharmaceutical industry because it referred only to pharmaceutical processes and not products. The US went as far as imposing $165 millions’ worth of sanctions on eight Thai products exported to the US. The US continued to exert pressure until the patent laws were changed and made even more restrictive than the international TRIPS agreement requires.

“This report should be a wake-up call to developing countries to look carefully at how they go about complying with TRIPS legislation and make sure that access to essential drugs is kept as an overriding right for the entire population – not just a wealthy few” says Martin Foreman, author of the Panos report.

* The full report and additional country studies can be downloaded from this website http://www.panos.org.uk/

* The Panos Institute is an independent, non-profit organisation specialising in communication for development. It works to catalyse informed public debate, particularly in developing countries. It has 12 offices in Africa, Asia, Europe and the Caribbean.

Access to Food: a fundamental basis for health
Editorial by the EQUINET steering committee and secretariat

Cereal production in Southern Africa has remained stagnant for over a decade since 1990 at 22 million MT, despite a growth in population of 60 million in the period. This fact highlighted at the SADC Heads of state summit on food security brought sharp attention to unacceptable and mounting shortfalls in food security in the region. Rates of childhood stunting in Africa are predicted to increase to above 25 percent by 2015, more than double the Millennium Development Goal (MDG) for that year. Only 3 out 10 African countries have experienced an improved maternal nutritional status in the last decade.

The EQUINET steering committee highlighted at the June 2004 regional conference its agreement with SADC heads of state that food security and food sovereignty are now an important focus to achieve wider goals of health equity and social justice in the region. The gross statistics were further debated as they mask the fact that it is the lowest income rural and urban communities, women and children who are most at risk of food insecurity and its consequences.

Mary Materu, from the Centre for Counselling, Nutrition and Health Care (COUNSENUTH), Tanzania highlighted the massive inequity of the fact that “when the world is producing enough food to feed everybody, more than 800 million people, most in developing countries, do not have enough food to cover their nutritional needs.”

Mickey Chopra, from the University of the Western Cape School of Public Health, highlighted the wider fallout from this deprivation of the right to food: “Adequate food and nutrition is a basic right. The deprivation of this right has immense consequences for addressing inequities across the region. Poor nutritional status stunts educational development as well as increasing the risk of acquiring, and the severity of, infectious diseases (including HIV/AIDS). The lack of household food security has led to increased vulnerability, especially of women, to diseases such as HIV. If the huge cost of burden of disease suffered by the poorest is to be tackled addressing lack of household food security and malnutrition is essential.”

This deprivation arises from a combination of increasing food prices and falling food production. These immediate causes are driven by macro level factors such as trade relations, domestic food and agricultural polices and micro level factors such as intrahousehold food distribution, gender roles and caring practices.

The EQUINET steering committee noted that the current food insecurity cannot be traced purely to drought or to AIDS. “The 2002/3 food crisis in Southern Africa was more widespread and impacted much more severely on households than could be predicted from rainfall patterns. The destructive effect of AIDS on household labour and incomes clearly compounded other threats to food security, such as inequities in access to productive resources and to market access, particularly for women.”

Current trade policies were identified as having a profound and negative impact on food security in Africa. Chopra highlighted how OECD subsidies to agriculture between 2000 and 2002 of about US$250billion placed protectionist barriers against food imports from Africa, undermining returns from production and thus effectively suppressing production. Kenya, for example, more than doubled production of processed milk between 1980 and 1990. When subsidised milk powder imports could be sold more cheaply than Kenyan processed milk, imports soared, increasing from 48 tonnes in 1990 to 2 500 tonnes in 1998 and domestic production of processed milk plummeted by almost 70 percent. Kenya's ability as a nation to diversify into processing was undermined. More importantly small producers bore the brunt of this decline in demand for local milk. At national level production for export has led to decreasing land areas planted with food crops for domestic consumption. Domestic food production has also been weakened by falling investment in agricultural research.

These trade and economic barriers, harming small producers and thus women farmers, worsen the impacts of HIV/AIDS on household-level labour, assets and skills, on burdens of care and household productive capacities that have set up a vicious interaction between malnutrition and HIV. Mary Materu of COUNSENUTH further highlighted the need for improved nutrition to be supported by access to education, water and sanitation.

This understanding of the immediate and underlying factors driving food insecurity and malnutrition underlined the view at the EQUINET conference that addressing food security and nutrition called for action across a wide range of sectors. At global level it was clear that Millennium Development Goals that call for improved nutrition cannot co-exist with trade policies that undermine the production basis for achieving the goals in the most vulnerable regions of the world. At regional and national level Chopra presented evidence to show that improved food security calls for more equitable access to land, improved investment in small holder farming, and increased access by women farmers to production inputs.

Dr Erika Malekia of the Southern African Development Community (SADC) echoed this call for “an integrated plan of action, focused on addressing inequalities in areas such as land distribution, gender equity.”

The conference delegates resolved to advocate for trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production. EQUINET will be following up on this resolution in a more focused future programme of work on food security and health equity. The conference suggested that EQUINET support for SADC regional strategies for food security should include two critical components, particularly if equity issues are to be addressed. The first is to strengthen and inform from a health perspective the challenges to trade policies that undermine national food production. The second is to inform and strengthen the health dimensions of policies and programmes that support land redistribution, smallholder production and increased access by women smallholder farmers to production inputs.

The EQUINET Conference abstract book and resolutions are available on the EQUINET website at www.equinetafrica.org and the conference report will be posted on this site in the coming month. EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org

Accountability for Health Equity: Reflections for Southern Africa
Cynthia Ngwalo Lungu, Johannesburg, South Africa

In July 2017, I attended a conference by the Institute of Development Studies (IDS) themed ‘Unpicking Power and politics for transformative change: Towards Accountability for health equity’. The conference examined the practices and politics shaping accountability in health systems from local to global levels. As a southern African, these are my reflections on this from the conference discussions.

Accountability for health equity is essentially about citizens being able to hold governments to account to deliver health for all. It is about inclusivity and ensuring better health for the less privileged, marginalised and vulnerable people.

It is commonly known that within Southern Africa public sector financing for health is meagre and below the 15% committed to in the Abuja declaration. People in need struggle to access health care. In some countries people walk up to 30 km to get to the nearest health centre, only to find that it doesn’t have the basic resources to function. In countries where the health system has largely been privatised it can be virtually impossible for poor people to afford health care. This situation is worsened when there is abuse of resources, a lack of transparency in health management, a lack of public information on health budgets and expenditures, when budget and policy processes are centralised in a top down approach that allows for little or no citizen participation in decision-making.

In response, the region has seen a rapid development of social accountability initiatives that trigger active citizenship, where communities actively participate in health decision making and hold governments to account on how resources are mobilised and used. The Centre for civil society capacity building, a Mozambican organisation, recounted in conference how social accountability initiatives in that country have improved transparency in resources for health and but influenced the development of formal national mechanisms for health accountability using scorecards for citizens to input to decisions and provide feedback on services.

While these efforts have achieved varying positive outcomes, they often tackle ‘low hanging fruit’, addressing local challenges like health worker attitudes or cleanliness within the vicinity of health facilities, thereby bringing about change in local practice. While these changes are commendable, they are often tied to project timelines, are localised and often do not trigger national level changes. Community level initiatives have struggled to address more systemic challenges, such as access to information, budget setting or expenditure tracking and bottlenecks in procuring and supplying medicines. The IDS meeting argued that this is because social accountability efforts have failed to respond to higher level constraints affecting the ability of local service providers to respond to community feedback. Much more broadly social accountability initiatives have in some cases failed to recognise the complex power dynamics that are typical of health systems. Social accountability efforts ought to engage with power if they are to bring about equity and social justice, otherwise, there is the risk that initiatives will simply replicate existing social hierarchies.

Another factor affecting these social accountability initiatives is sustainability and ability to outlive short-term project timelines. There is a need to cultivate an active citizenship that raises voice to point out accountability concerns without relying on external drivers. Given the weaknesses in general environments to support this, we need to recognise and explore the role of formal structures for accountability in health, notwithstanding their pitfalls. This implies critically considering the extent to which the community voice can be integrated with local level formal accountability structures without being compromised or ‘swallowed’ by them. In the Northern part of Malawi, for example, the Catholic Commission for Justice and Peace has cultivated an active citizenship that engages within the formal mechanisms in health, as a form of structured and sustainable citizen engagement with the health system.

From the convening it was very clear that social accountability initiatives should respond to particular contexts. For example, in the case of politically charged states within Southern Africa, communities and civil society pushing for health rights and social justice are often tackling a wide range of issues that may confront power and carry unintended political connotations. Traditional social accountability tools and approaches which work in accommodative participatory environments may not be useful in politically charged contexts as Social accountability proponents become human rights defenders who need a unique set of skills to pursue issues without risking their own lives and security. The operating environment calls for unique capacities, language, strategies and mechanisms to achieve results without exacerbating conflict.

While many of these social accountability initiatives appear to focus on public sector services, there are other non-state and private for profit actors involved in the delivery of health care. Across the region health has attracted markets and business operators resulting in a range of providers, in some cases in public -private -partnerships. How do we ensure that in the face of a growing private sector, public interests continue to take centre stage as a means to achieving equity in health? What mechanisms can be used to hold these private actors to account on social goals and health needs, when their preoccupation is with profit margins and ‘fair returns’? Lessons from the negative effects of pluralistic health markets in other countries, such as Mongolia, can be used by the region to inform the development and implementation of sound regulation of the ‘business of health’ and to ensure that PPP’s and health financing schemes including health insurance are developed in an accountable manner and in line with equity goals.

These are significant challenges, but there are also opportunities to strengthen accountability through innovation. Despite low internet penetration and high telecommunication charges in some parts of the region, information technology is spreading. Throughout the region, technology is fast becoming a powerful tool in pushing for social economic rights- with the click of a button communities can voice public health concerns or access critical health sector information. With these tools, the means to accountability for transformative change may indeed lie in people’s hands!

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the IDS meeting can be found at http://www.ids.ac.uk/opinion/naming-the-moment

Acting on health through theatre for a change
Ethel Chavula, Grace Mathanga, Theatre for a Change, Malawi

Grace was born in a family of 9 children. She was still in school when her mother became ill, so she dropped out to care for her. She married when she was young. “God blessed us with 2 children, both girls. Then my two children and my husband died of AIDS. I too have HIV and will never marry again”, she says. When her husband died she had no support for her life as their property was taken by her late husband’s relatives. She was left with nothing and helpless. She did not want to do commercial sex work, but she couldn’t see another option, and it gave her a means to earn enough to live a poor, risky and insecure daily life in Lilongwe.

This is not an unusual story. For some even younger than Grace, the AIDS epidemic has increased the risk of sexual, physical and emotional harm and neglect. Young women and children who have been deprived of care and support are particularly susceptible to working in the commercial sex industry. They face risk environments for HIV transmission for themselves and their clients, as well as of violence and other forms of abuse.

Today the story, at least for Grace, is different. She describes the changes she has brought in her own life and in her community. She herself has a more secure and healthy life. She also talks about commercial sex workers that have now accessed loans and are moving out of bars and running small businesses. Others have gone back to school. A meeting of women involved in commercial sex work raises rights and decisions, where to get counselling, testing and treatment for HIV, how to get greater control over their sexual activities and fertility, and how to build skills for other forms of work.

Grace points to the lever for this health affirming change - theatre.

“In 2007 some of us in commercial sex work trained on legislative theatre. Theatre for a Change contributed to the transformation of my life.”

Theatre for Change in Malawi equips socially and economically marginalised communities with the communications skills, knowledge and awareness to transform their lives and the lives of others personally, socially and professionally. In Malawi, it works with groups including commercial sex workers to reduce the risk of HIV. It involves women from the core group of former commercial sex workers who work as peer facilitators among younger people getting involved in sex work. Through the theatre and by performing their stories to a variety of audiences, the women access a voice and a platform to raise concerns and open debate. The process known as Legislative Theatre. The performances involve the audiences in coming up with solutions to the issues these women face, in the process changing attitudes and catalysing change in both the women themselves, their communities and even in policy makers when they are involved. The theatre work is supported by other programmes to provide access to female and male condoms, to HIV testing and counselling, and to relevant health services, including antiretroviral treatment. These services are available, but their uptake has been blocked by barriers like stigma. This process provides a vehicle for raising the health, gender and sexual rights and responsibilities of sex workers and their clients.

As Grace comments: “Now I know my rights and no one can violate my rights. I have self esteem and I am able to make decisions about my own body.”

It is already known that it is more effective to send former commercial sex workers to mobilise and reach out to others, as much as positive peer pressure from men has influenced other men to go for testing and counselling. For the women who have been involved in commercial sex work, the theatre work has helped to reach other commercial sex workers, especially adolescents. It has led to greater openness on health problems and changed attitudes towards commercial sex workers, including amongst the health workers who used to stigmatise commercial sex workers.

Those involved learn while they teach. They are trained in psychosocial issues and counselling to support their interactions with people of different ages, gender, place and occupation. They also build a more affirmative view of themselves, from being victims of economic insecurity and social stigma to people who plan and set goals for their own and their family lives.

Grace sums it up: “Everyday of my life brings an opportunity for a new beginning…I waste not a moment mourning yesterday’s misfortunes, defeats and challenges. These have been my stepping stones."

While antiretrovirals provide a therapy for the physical effects of HIV and AIDS, it seems that theatre can also be a powerful and equally necessary therapy for its social effects.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed, a film and further information on the Theatre for a Change programme visit www.tfacafrica.com/What-we-do/TfaC-in-Malawi/Sex-worker-programme

Activism as a social determinant of health
Mark Heywood, SECTION27, South Africa

We are living during a time of unprecedented threat and opportunity for the right to health. We are seeing cutbacks in the funding for prevention and treatment of HIV, retreats from commitments to ‘universal access’ to HIV and TB treatment, attacks on human rights and new threats to national and global health, including through climate change and food insecurity. At the same time there are new and better technologies available for health, new medicines and diagnostics for common diseases like tuberculosis, and an array of interventions that could improve health and reduce malnutrition. Some states, particularly South Africa and Brazil, are seriously seeking to improve health on the principle that health is a human right. But it is questionable whether they have the resources to do it. There are examples of growing global co-operation and legal agreement around social challenges, such as climate change, although not yet around the most immediate social challenges that face the poor. Activist movements exist around AIDS, health and around social justice.

The Commission on the Social Determinants of Health pointed to the demand for a response to this moment of contradiction between threat and opportunity from a leadership and governance that is driven by social justice. It stated: “In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.”

This is not a new call. It resonates with the recognition of the right to health as a human right found in the 1946 World Health Organisation Constitution, the 1966 International Covenant on Economic Social and Cultural Rights (ICESCR), the 1978 Alma Ata Declaration and the 2000 UN Committee on Economic, Social and Cultural Rights ‘General Comment 14’ on Article 12 of ICESCR. Increasingly it is also reflected in the incorporation of the right to health into the national constitutions of over seventy countries in the last decade.

Nevertheless good health and access to adequate health care services remains out of reach to billions of people. Nearly two billion people (a third of the world’s population) lack access to essential medicines and about 150 million people suffer financial catastrophe annually due to ill health, while the costs of care pushes 100 million below the poverty line.

The world is well aware of these facts. They are published by the WHO and others. When these facts are raised in international forums, it has led states to make bold promises….that they later do not keep. In Africa, 19 of the African countries who signed the 2001 Abuja Declaration to spend 15% of their government budget on health al¬locate less now than they did in 2001. Yet the WHO indicate that low-income countries could raise an additional US$ 15 billion a year for health from domestic sources by increasing health’s share of total government spending to 15%. Neither are high income countries meeting their promises. According to the ‘Africa Progress Report 2010’, published by a unique panel chaired by Kofi Annan, when the $25 billion Gleneagles commitment comes due at the end of 2011, the resources allocated by G8 countries will have fallen short by at least $9.8 billion. The panel calls this a “staggering shortfall.”

Does this mean that the right to health has no value? No. Has the right to health been sufficiently popularised or used? No. Are the state and United Nations institutions who have a duty to protect and realise the right to health fulfilling their obligations? No.

In the last decade AIDS activists have established in practice the principle that states must fund treatment as a right, with the organisation of resources globally to meet this obligation. Currently we are seeing a reversal of this basic entitlement, as the right to these resources are being challenged by arguments over cost effectiveness, a retreat from funding treatment in middle income countries, despite the fact that three quarters of the poorest people in the world live in middle income countries; and a claim that too much money is going to AIDS treatment, despite the fact that an estimated ten million people still need treatment globally. Some states in low income countries claim to have inadequate resources for health even while their political and economic elites grow visibly wealthier, and even states who have met the Abuja commitment try to fairly distribute unfairly inadequate amounts of money for health.

The Commission on the Social Determinants of Health called for conditions that would enable civil society to organize and act in a way that promotes and realises the political and social rights affecting health equity. It seems that we should go further than this, given the reversals in progress and growing inequalities in health. We need to see the level of activism by civil society as a key social determinant of health. The fight for health should be a central pillar of all movements for social justice and equality, not in the abstract, but for the specific goods, institutions, demands and resources that will realise the right to health.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.This is an edited extract of a speech given at the Southern African Regional Dialogue on Realising the Right to Health in March 2011. For more information on the issues raised in this op-ed and for this and other presentations made at the conference see: www.section27.org.za.

Addressing health inequities through Universal Health Coverage
Lara Brearley, Save the Children

Addressing inequities in access to quality needed care and financial risk protection must be a first priority in efforts to achieve Universal Health Coverage (UHC). We have the opportunity to implement equitable pathways towards UHC by including appropriate targets and measures in the post-2015 development framework. These are the main messages of a joint report titled ‘Universal Health Coverage: A commitment to close the gap’ launched this month by Save the Children, the Rockefeller Foundation, UNICEF and WHO and available at http://www.savethechildren.org.uk/resources/online-library/universal-health-coverage.

Prioritising equity in pathways towards UHC is not just the right thing to do from a moral perspective, but it also brings value for money. Research implemented for the report reveals that the deaths of 1,8 million children under-five and 100 000 mothers could be averted each year by eliminating wealth related inequities that occur within countries in the coverage of essential maternal and child health interventions in 47 of the 75 countries where more than 95% of all maternal and child deaths occur (http://www.countdown2015mnch.org/). If in 2013 to 2015 all groups were able to reach the coverage levels of the highest fifth of people by wealth, this would reduce maternal and child mortality by almost one-third and one-fifth respectively.

We present evidence in the report that more equitable health financing saves lives. Pooled funding comes from prepayments and pooling makes it available to distribute to those with higher need. If the share of health financing that is pooled were to increase by ten percentage points, while keeping total health expenditure constant, we estimate in the report that there would be fifteen fewer deaths in children under five years of age for every 1000 live births in the same 75 countries on average. This could enable thirteen countries that are currently off-track to achieve their Millennium Development Goal (MDG) 4 target of a two-thirds reduction in the rate of child mortality. In countries where health services are more equitably distributed, the reduction in child deaths may be even greater.

It is thus possible to make huge improvements in health outcomes and access to health care. It is possible, for instance, to reduce by almost half the number of children who die each year when compared to the rates in 1990. Despite this, too many people are denied their right to health. In 2012 for instance, 6,6 million children died before the age of five and most of these deaths could have been prevented. High levels of out-of-pocket payments (cash at point of care) for health care act as a barrier for poor people to access the care they need or can lead to an increase in poverty due to health spending. About 150 million people are estimated to incur catastrophic (impoverishing) expenditures for health care each year. This is a scandal that must be addressed.

The health system’s response to this challenge must be Universal Health Coverage – which we define as ensuring “that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them”. Momentum for UHC is soaring at country and global levels, and this must be seized to ensure the needs of the poor and vulnerable are prioritised as countries design and implement the policy reforms for UHC.

In the report we identify a number of policy lessons for equitable pathways towards UHC in low- and middle-income countries, particularly in relation to health financing. One policy lesson is that countries increase equitable funding for health through mandatory, progressive prepayment mechanisms, including revenues from taxation, and eliminate out-of-pocket spending. Risk and resource pools must be consolidated to facilitate effective redistribution. A universal benefit package should be designed for all, and delivered in a manner that meets the needs of the poorest and most vulnerable in society, through strategic purchasing of services and through providing incentives that ensure health providers promote quality of care. The policy lessons point to the importance of taking a ‘whole-system’ approach to UHC, and for coordinating reforms across health system building blocks such as financing, health workers, commodities, social participation and others. To overcome pervasive inequities in the coverage of quality health services and to ensure that people are not impoverished from health spending we need to also act on the wider social determinants of health. Political will and strong mechanisms for effective accountability are critical for implementing the measures needed for equitable pathways towards UHC.

As the MDGs have shown, what gets measured is more likely to get done. Negotiations on the sustainable development agenda must guide equitable progress towards UHC, with clear indicators of and targets for such measures that strengthen health systems and close the equity gap.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed visit www.savethechildren.org.uk/resources/online-library/universal-health-coverage and www.equinetafrica.org

Adolescent health: What they don’t know CAN hurt them
Barbara Kaim, Training and Research Support Centre, Zimbabwe

A quarter of the population in Sub-Saharan Africa are young people between the ages of 10 and 19 years. These young people carry the hopes and dreams of their families, their communities and their nation. They are the future leaders and, perhaps as important, the future parents of the next generation.

They live in a world where to be an adolescent is increasingly risky. Adolescents typically take risks, but with the AIDS epidemic, risk-taking can be fatal. When adolescents have unplanned and unprotected sex, sexually transmitted infections can cause infertility or cervical cancer, and pregnancy in adolescents is more risky, with higher rates of death in both adolescent mothers and their babies than in adults. Unsafe abortions amongst adolescents are unacceptably high, and early sexual activity may limit educational attainment and deprive young people of the opportunity to form mature, loving relationships. So it’s a tragic and unacceptable sign that most new HIV infections in sub-Saharan Africa occur among adolescents and young adults.

Adolescents grow up today in a different world. High rates of urbanization, extended periods of schooling and growing poverty contribute to a challenging social context for young people.

Traditional ways of preparing young people for adulthood, which relied on extended family members, are less practiced and might not be adequate to address the pressures that adolescents face. In the past, sexual maturity was closely followed by marriage. Today, young people reach puberty at younger ages and wait longer to marry. Because the aunt or uncle may not be available, or may not be considered relevant, many adolescents turn to other sources. Today, many young people learn from peers or the media. Much of this information is inadequate and sometimes it is just plain wrong.

Schools are an ideal setting in which to reach large numbers of young people with the information they need, including reproductive knowledge and life skills. Yet, wherever it has been introduced, the teaching of reproductive health in schools has generated controversy. Debate exists around what information should be given and how much, especially regarding sexual intercourse, pregnancy and disease prevention. Some adults are resistant to even acknowledging that teenage sex is taking place. Others are concerned that sex education will lead to sexual activity. These viewpoints are often based more on values and beliefs than on facts. Hence the same arguments are repeated again and again, year after year, despite contrary evidence. Its very likely these same views will continue to be expressed into the future.

Nevertheless, facts do help. Studies have shown, both regionally and internationally, that comprehensive sex education is effective in improving knowledge and reducing sexual risk behaviours, and that it does not increase sexual activity. In 1997, a UNAIDS study reviewing 53 sex education programmes globally found that 22 had a positive effect of safer adolescent sexual behaviour, and 27 had no impact. In the 3 studies where there was an increase in sexual activity, there were concerns about the design of the assessment and the validity of conclusions.

Such studies suggest that rather than sex education causing young people to have sex, the opposite is more likely to be the case: Giving young people more complete and accurate information, and more opportunities to discuss issues in an open and non-judgemental environment enables them to make more responsible choices.

Clearly the design and quality of the programme matters. Strengthening sex education programmes can be difficult in resource-strained countries. However some aspects of effective programmes that have been identified from reviews can be applied across different settings, including those where resources are scarce. These include:
• adopting school curricula that provide comprehensive, accurate sexual and reproductive health information;
• supporting teacher training;
• reaching young adolescents with information early, before they leave school and before they begin sexual activity;
• strengthening health and other community services for young people and ensuring that these services are youth-friendly, and
• helping adolescents stay in school. Even if they do not receive sex education, young people who stay in school are less likely then their peers to have sex.

Successful reproductive health programmes are not simply a matter of education. They involve youth issues, gender issues, human rights issues, and health issues. They involve and give a central role to youth themselves. They encourage young people to articulate and discuss issues, to talk about their lives, to understand their options, and to get the skills and support they need for healthy choices. And of course, for young people, they must also be fun.

Our efforts towards reducing maternal mortality or new HIV infection cannot be said to be successful as long as we have not made significantly more progress in reducing the risk for adolescents. Achieving this and reaching young people can’t be left to teachers alone. Parents, civic leaders, health providers, other government ministries all have a role to play. Support of youth is a multi-sectoral effort. As adults planning for a better future for our young people, we are all their parents.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see as an example of resources for adolescent reproductive health the Auntie Stella materials on the TARSC website at http://www.auntiestella.org/

Advancing public health calls for wider public health skills
K Tibazarwa

With the major public health challenges that are found in Africa, making progress in public health clearly demands a significant spread of public health skills. While health workers are making tireless efforts to address preventable diseases across the continent, and many successful experiences exist, revitalizing primary health care oriented systems calls for revitalized public health leadership and skills.

Part of the challenge is filling the gaps created by out-migration. At a conference held in mid-June 2007 on 'Sustaining Africa’s Development through Public Health Education', hosted by the University of Pretoria School of Health Systems and Public Health, Professor Erich Buch, health advisor to NEPAD, depicted the prevailing health worker situation in Africa, including the extensive brain drain, low funding and insufficient, often inadequately compensated, staff. He emphasised the need to shift focus from the current responses taking place country-by-country to building wider continental responses, informed by vision, leadership, and energy. This leadership demands public health skills, and Professor Buch asserted that building 'centres of excellence and networks in Africa are key … to strengthen[ing] public health capacity at public health schools and institutions across the continent'.

The meeting discussed options for how to achieve this. With limited financial and institutional resources, governments and institutions can best maximise what is available by sharing existing African expertise across organisations and countries, and strengthening formal mentorship programmes for public health practitioners. This needs to be backed by investments in user-friendly technology to support the communication, collaboration and networking between research institutions, and to stimulate collaborative research and discussion forums and strong alumni systems.

Networking between institutions and professionals in Africa is sometimes weaker than between Africans and colleagues in the developed world. Building African networks needs active support and investment. One key area of concerned raised in the NEPAD strategy is establishing and maintaining an inventory of public health education capacity in Africa, enabling standardisation and accreditation of training institutions and encouraging innovative methods of training and the use of technology supported learning. As Professor Buch stated “We need to … build more cost-effective capacity on the continent'.

In line with these goals, the AfriHealth Project at the University of Pretoria recently completed a three-year mapping project of public health education and training institutions in South Africa. The project has developed a database of public health workers and educators to inform collaborations in Africa. While the mapping focused on South Africa, the information would be useful to strengthen the networking of institutions and individuals in Africa and to share these institutional resources. The AfriHealth Project seeks to secure a Pan-African Public Health body that is effective, inclusive, scientifically and politically supported, and well-resourced. The project has identified the strategic importance of developing a continental approach to improving public health in line with new socio-political realities, strengthening public health capacity by networking institutions, programmes and individuals, and promoting technology-supported learning and communication.

These initiatives do not see current skills scarcities as being an insurmountable block to development of new skills. Mentors can be drawn from existing academic institutions. But public health education must also move beyond universities, to provide other skills not always available from university education, such as for cultural sensitivity in health practice, or for strategic management. Short courses for public health practitioners can also bridge the gap between different entry levels and Masters' degrees in public health. Public health educators and researchers must also bridge the gap in research to reduce the drop out rate in Masters' courses.

There are new and emerging challenges to public health in the rapidly changing global environment. The content of public health training needs to match the new needs and opportunities for action in public health.

Gender issues have a major impact on health in the continent, and institutions should include gender in public health curricula. Improving women’s rights, eliminating violence against women and advancing health rights more generally calls for recognition of the central role played by women in providing health care. This doesn’t only mean looking at women's roles. As Dr Alena Petrakova from WHO (Geneva) noted at the conference, mainstreaming gender in public health curriculum design and development also means involving men and examining their impact on health. A recently-formed African Network for Public Health Educators on Gender (ANPHEG) is taking the issue of how gender is mainstreamed in the public health curricula on a sustainable basis.

Achieving the commitments set out in the continent and those set globally, like the Millennium Development Goals, calls for clear skills to best protect, use and advance the health resources in the region. Much focus has rightly been placed on retaining and valuing health workers. Beyond this, equal concern is now being voiced in the continent that those who do work in African health systems are adequately equipped at all levels with the knowledge and skills to lead effective and innovative responses to the continent's public health challenges.

K Tibazarwa is a masters' student, School of Public Health at the University of Cape Town. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.

Africa Civil Society Letter to July 2010 African Union Summit on upholding African Health and Social Development Commitments
Africa Public Health Alliance & 15% Plus Campaign, June 2010

African civil society through the Africa Public Health Alliance & 15% Plus Campaign are petitioning AU Heads of States through Malawi President Bingu wa Mutharika, Chairperson of the African Union on the grave concerns of African citizens that some Heads of State are being advised to repudiate crucial commitments on health and social development, in particular the 2001 Abuja pledge on health financing. They note that despite some recent progress, healthy life expectancy in Africa is at a low of 45 years resulting in un-fulfilled personal, national and continental potential and aspirations, and the loss of billions of dollars in productivity. They note that it would be a historic setback for African governments to drop health and social development commitments, or suggest in anyway that the health of African economies exists in isolation from the overall health of African citizens. Giving evidence to support the need for adequate health sector financing, the petition urges heads of state to ensure that the July 2010 AU Summit restates the Abuja commitments; and supports the AU Commission in working with governments and civil society to monitor and report on health gains, and ensure a 10th year review of the 2001 Abuja commitments by April 2011.

Further details: /newsletter/id/35201
African finance ministers dismiss development declarations
Njora G: Pambazuka News April 2010

The author flags concern about the actions of some African finance ministers to reverse their Heads of state commitments, such as those made on 15% government funding to health in Abuja in 2001. South African, Rwandan and Egyptian finance ministers succeeded in deleting any reference to budgetary targets for education, health, agriculture and water from the report and resolutions of the annual meeting of the African Union and Economic Commission for the Africa Conference of Ministers of Finance, Planning and Economic Development held in Malawi in March 2010. Many consequences are seen to flow from this, if heads of state follow the same path. It could indicate an abandonment of the bold financing that has gone into reversing vulnerability to food insecurity, disease and denial of access to health care and education. It questions how Africa would, after reversing from its own commitments, hold the G8 and international community to their commitments to contribute 0.7% of their gross national product and to double development assistance to Africa. The dismissive nature with which the finance ministers have treated these targets begs the question of whether the MDGs and all the other decisions taken under the auspices of the African Union will go the same way.

Further details: /newsletter/id/35133