We always hear that maternal deaths are avoidable, yet they remain a main cause of mortality. Whenever a woman dies while giving birth, we absorb the fact as though it was normal, despite the pain caused to her family, her children and her partner. Silence engulfs the mourners and after burial, the deceased woman is registered into the records and included in public health statistics.
These are the facts: According to Cook, Dickens and Fathalla in 2003, every year more than 500 000 women die from pregnancy complications or childbirth globally, and 99 percent of these deaths occur in developing countries. According to the Road Map for Accelerating the Reduction of Maternal and Neonatal mortality and morbidity in Uganda 2007-2015, sixteen women die every day in Uganda due to maternal mortality. This means that 6000 women die every year and leads to an estimated maternal mortality rate of 345 per 100 000 live births.
This tide of death due to pregnancy and childbirth occurs for various reasons. The health sector is chronically underfunded compared to health need, leading to lack of available, well supervised trained midwives in services close to communities. Referrals for complicated cases face problems of lack of ambulances and of emergency obstetric care in referral hospitals. Health workers may be demoralized in such conditions and show poor attitudes to clients. Within communities, partners may give women inadequate support and resources to make timely use of services, especially when poorly equipped local services mean that they have to travel some distance to facilities. Participatory research carried out by HEPS (Uganda) in 2008/9 found that women get weak support in maternal health issues from their male partners.
These problems have contributed to the deaths of many women, especially the poorest women, who constitute a large share of the population. These women are also the bread winners of and carers for many rural families. The Ugandan government acknowledges in its Road Map for Accelerating the Reduction of Maternal and neonatal mortality and morbidity that maternal mortality occurs because of the three delays. The first of these is a delay in making the decision to seek care. The second delay is in identifying and reaching a medical facility, while the last is in receiving of adequate and appropriate treatment. It is a duty of government to address these delays, including any shortfalls in funding of the health sector that may be connected to the weaknesses in service delivery that lead to these maternal deaths.
In 2011, building on civil society advocacy on these three delays, the Centre for Health, Human Rights and Development (CEHURD) took a further step of petitioning the constitutional court, seeking declaration(s) that the non-provision of healthcare in government health facilities leading to the death of mothers is an infringement on rights to life and health.
The petition draws on maternal death reviews from government hospitals, where the cause of death has been cited as lack of facilities, equipment or consumables. Health workers cite that they did not have equipment for monitoring the deliveries in the theatre and labour suites, including materials like gloves, and noted that there were inadequate trained heath workers.
When complications happen, if women report late to services this reduces their chances of survival. However, the reported shortfalls in health care services have meant that even when they arrived early at hospitals, when labour pains started, women were still at risk. Two cases were cited in the petition. In one, a young woman arrived at 8:00am and died at around 9:00pm when her uterus ruptured, due to obstructed labour. In the second, the woman went to a government Health centre first before being taken to a government district hospital. She could not be saved after she had a retained twin. This woman was reported to have arrived at 2:30pm but to have not been attended to by health workers until she died just after midnight at 12:30am. In both instances, the hospital reports point to lack of basic equipment and supplies for deliveries and lack of staffing.
The petition contends that these deaths, arising from the non-provision of basic maternal health care services in government hospitals, is a violation of the right to life guaranteed under Article 22 of the Constitution of Uganda. The petition contends that the right to health under Objectives XIV and XXII is violated when government health workers and government fail to provide the required essential care during the period before and after childbirth. This happens when there is inadequate staffing for maternal health, specifically midwives and doctors, frequent stock-outs of essential drugs for maternal health and lack of Emergency Obstetric Care Services at Health Centres III, IV and hospitals.
In taking on this public interest litigation case, CEHURD, and the wider civil society groups who support the petition have acted for a wider concern in society on unacceptable levels of maternal death. Principal State Attorney Patricia Mutesi was reported on Sunday 23 October’s Monitor (www.monitor.co.ug) to have argued that a court determination would amount to usurping of power of the Executive and the Parliament to determine on economic policies. However, Mr David Kabanda, the petitioners’ attorney, said the State objection was misconceived because the matter before court is seeking for court interpretation whether the acts and omissions at the various health centres contravene the Constitution. Irrespective of its outcome, the petition has widened awareness of the right to health and social expectations on maternal health. Uganda National Health Consumers Organisation (UNHCO) has raised advocacy on the issue (http://unhco.or.ug/news) and a coalition of over 35 civil society organizations has since been formed on maternal health, which is taking up wider health issues, including budget monitoring. This coalition is providing learning and networking on health rights generally, building social activism using evidence from the real situation in health services and the social concerns in communities.
The petition sets a precedent on one of the ways of progressively realising the right to health in a resource constrained setting. It may inform the way we address other obligations and entitlements, like access to medicines. Social action through constitutionally set channels is one way society can act to prevent unacceptable death in vulnerable women and to advance health equity in Uganda.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: firstname.lastname@example.org. For more information on the issues raised in this op-ed please visit the CEHURD website: www.cehurd.org
2. Latest Equinet Updates
At the World Conference on the Social Determinants of Health, held in Rio de Janiero Brazil from 19-21 October 2011, reports from countries indicated a promising range of actions being taken to assess or monitor equity and the social determinants of health (SDH), measures to plan and review action on SDH, as well as actions to strengthen constitutional protection of the right to health and to strengthen intersectoral action and comprehensive primary health care. However, few countries reported on actions on economic determinants, and countries that have regulated commercial interests for public health reasons, such as introducing taxes on foods high in fat or sugars, or in implementing legal controls over tobacco, allege they have faced counter litigation from companies. Despite persuasive evidence, health equity has been a marginal consideration in trade, economic or climate forums. Public health advocates argue that equity should be included at the centre of wider economic, trade and development agendas, including the UN Conference on Sustainable Development in June 2012 (Rio+20) and the UN Millennium Development Goals. While a task force of UN agencies was set at the WCSDH, key economic and trade agencies were not present.
This report updates the 2008 Zimbabwe Equity Watch report using a framework developed by EQUINET in cooperation with the eastern, central and southern African health community and in consultation with WHO and UNICEF. The report introduces the context and the evidence within four major areas: equity in health, household access to the resources for health, equitable health systems and global justice. It shows past levels (1980–2005), current levels (most current data publicly available) and comments on the level of progress towards health equity. The 2011 Equity Watch indicates that improvements have been made in priority areas identified in the 2008 Equity Watch report, such as in primary education, in supplies of medicines and staff to primary care and district levels, in immunisation coverage, in access to antiretrovirals, and in recognition and support of community capacities for health. Nevertheless, the report shows that poverty and inequality in wealth remain high. Economic inequality affects access to key inputs to health, like improved incomes or safe water and the uptake of health services.
In recent years there has been increased private for-profit health sector activity in certain countries in East and Southern Africa. External funders and governments have subsidised some of these activities. Private ‘high-end’ hospitals have begun to service wealthy groups, even in very low income countries. A report published in 2007 by the World Bank’s International Finance Corporation (IFC) encouraged governments to facilitate further private sector growth. This policy brief explores these developments in East and Southern Africa. In contrast to the IFC report, it raises concerns about the adverse consequences of growth in the private for-profit sector, and proposes steps that Ministries of Health should take to protect the integrity and equity of their health systems.
The extent to which health rights are neglected or promoted is a major factor in the promotion of health equity in Africa. Central to this is the incorporation of the right to health in the national Constitution, as the supreme law of the country. Including the right to health as a constitutional right provides a bench mark for government, private sector and society to respect, protect, fulfil and promote it. In many countries in east and southern Africa (ESA) there is advocacy and debate on inclusion in the constitution of the right to health. This brief presents a review of how the constitutions of 14 countries covered by EQUINET include the right to health. It uses as a framework the six core obligations spelt out in General Comment 14 of the International Covenant on Economic and Social Rights (ICESR).
3. Equity in Health
Botaswana’s Minister of Health, John Seakgosing, has announced that Botswana has significantly reduced its burden of malaria from 77,555 unconfirmed cases in 2000 to 12,196 cases in 2010. Malaria deaths have decreased from 35 to seven over the same period. He said this success is due to the country's distribution programme of long lasting mosquito nets and indoor spraying in malaria-prevalent areas. The rolling out of artemisin-based combination treatment (ACT) in 2007 also contributed to the reduction of malaria cases and deaths. Moving towards the total elimination of the disease, Botswana has drafted malaria case based surveillance guidelines. According to the Minister, all malaria cases from disease-free areas will be notified, investigated and all contacts of the case will be screened. The country is committed to ensure an increase in diagnostics and ACT coverage to reach 100% of all malaria cases.
This publication presents in numerical and graphical formats the best data available for key health indicators in the 46 countries of the World Health Organisation’s African Region. It describes the health status and trends in the countries of the African Region, the various components of their health systems, coverage and access levels for specific programmes and services, and the key determinants of health in the region, and the progress made on reaching the United Nations’ Millennium Development Goals (MDGs). A major finding is improvement in progress towards reaching the MDGs – however, most improvements have been small and it does not appear that the continent will meet all the health-related MDGs set for 2015, notably those for child and maternal mortality, which remain very high. Communicable diseases make up the largest part of the disease burden (42.4% of disability-adjusted life years) versus only 15.9% for non-communicable diseases in second place (data from 2004). Utilisation of health services is low for antenatal care (44%) and contraceptive prevalence is a mere 24%, but immunisation coverage for children improved to 72%.
On 16 September 2011, the United Nations (UN) General Assembly unanimously adopted a political declaration at the end of its High-Level Summit on Non-communicable Diseases (NCDs), the response to which has been largely positive. But the authors of this article argue that the declaration missed a number of opportunities to effect real change in the fight against NCDs. They note that the declaration did not establish a special funding mechanism devoted to improving access to treatment of NCDs globally, nor did it commit donors and international organisations to invest more resources in that area, as was requested by developing country members of the Group of 77. Also, the final document did not include a reference to the Doha declaration on TRIPs and Public Health adopted in 2001, which re-affirmed the right of governments to adopt measures to protect health, despite this issue being emphasised during the process by the G77. Likewise, the declaration does not include new specific targets in reducing NCDs or concrete measures to be undertaken by governments, thanks largely to the United States, the European Union, and Canada, which generally opposed mandatory targets. The influence of the private sector was also clearly felt in this regard, as, in various side-meetings during the Summit, private sector companies argued for a voluntary rather than a regulatory approach for industry practices. Next steps include the development of targets and of a monitoring framework by the World Health Organisation by 2012. So far, the 68th session of the UN General Assembly in 2014 does not appear to include any discussion of NCDs.
Inequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s. The study demonstrates the existence of socio-economic gradients in self-reported ill-health in South Africa. The burden of the major categories of ill-health and disability is greater among lower than higher socio-economic groups. Even non-communicable diseases, which are frequently seen as diseases of affluence, are increasingly being reported by lower socio-economic groups. For instance, the concentration index of flu (and diabetes) declined from about 0.17 (0.10) in 2002 to 0.05 (0.01) in 2008.
Globally, 12% of women smoke, 22% in developed and 9% in developing countries, according to this article. While smoking has peaked in men and begun a slow decline, it is predicted that by 2025, 20% of women worldwide will be smokers, with so many younger women taking up the habit. Tobacco transnationals minimise the dangers of smoking in powerful advertising that goes round the globe, while health agencies and institutions strive to counter these media messages on shoestring budgets - an astounding asymmetry that endangers the health of millions, the author notes. The author argues that we have to go beyond banning tobacco advertising and ‘demarket’ smoking and counter the positive images that permeate our culture with more sophisticated presentations of the threat to health. Stakeholders also need to create more barriers to tobacco access - in addition to those already banning sales to youngsters and raising cigarette prices - aligning education and legislation for greater effect. And finally, policy makers need to understand more fully the forces that influence people - particularly young women - to start smoking. It is not enough to simply warn people of the dangers of smoking, the article concludes – stronger measures are needed.
4. Values, Policies and Rights
In many areas of the world where HIV prevalence is high, rates of unintended pregnancy and unsafe abortion have also been shown to be high. Of the estimated 21.6 million unsafe abortions occurring worldwide in 2008 (around one in 10 pregnancies), approximately 21.2 million occurred in developing countries, often due to restrictive abortion laws and leading to an estimated 47,000 maternal deaths and untold numbers of women who will suffer long-term health consequences. Despite this context, little research has focused on decisions about and experiences of women living with HIV with regard to terminating a pregnancy, although this should form part of comprehensive promotion of sexual and reproductive health rights. In this paper, the authors explore the existing evidence related to global and country-specific barriers to safe abortion for all women, with an emphasis on research gaps around the right of women living with HIV to choose safe abortion services as an option for dealing with unwanted pregnancies. The main focus is on the situation for women living with HIV in Brazil, Namibia and South Africa, as examples of three countries with different conditions regarding women's access to safe legal abortions: a very restrictive setting, a setting with several indications for legal abortion but non-implementation of the law, and a rather liberal setting. Similarities and differences are discussed, and the authors outline global and country-specific barriers to safe abortion for all women, ending with recommendations for policy makers and researchers.
The Global Strategy to Reduce the Harmful Use of Alcohol has much to learn from learn from the Framework Convention on Tobacco Control, according to this article. Over the years, many have called for the creation of a Framework Convention on Alcohol Control. Despite this push and despite the fact that alcohol and tobacco are relatively equal in terms of global disease burden, the international community has been less willing to be tough on the alcohol industry. The debate around alcohol is less clear in some ways than work on tobacco. In the case of tobacco, the efforts have focused on eliminating use. In terms of alcohol, the debate is about reducing the harmful level of consumption. In many countries, consumption of alcohol is acceptable and forms part of many cultural events. But the author notes that we need to pay increased attention to the harm alcohol consumption can inflict on others. Often the debate is framed in terms of the individual right to have a drink, neglecting the true extent of the level of harm others can be exposed to by the drinker.
How governments should address sex work is a major topic of debate in Rwanda and other countries. Some constituencies propose harsher punishment of sex workers as the cornerstone of an improved policy. The authors of this paper argue that an adequate policy response to sex work in the Rwandan context must prioritise public health and reflect current knowledge of the social determinants of health. This does not imply intensified repression, but a comprehensive agenda of medical and social support to improve sex workers’ access to health care, reduce their social isolation, and expand their economic options. Evidence from social epidemiology converges with rights-based arguments in this approach. Recent field interviews with current and former sex workers strengthen the case, while highlighting the need for further social scientific and epidemiological analysis of sex work in Rwanda. Rwanda has implemented some measures that reflect a rights-based perspective in addressing sex work. For example, recent policies seek to expand access to education for girls and support sex workers in the transition to alternative livelihoods. These policies reinforce the model of solidarity-based public health action for which Rwanda has been recognised. Whether such measures can maintain traction in the face of economic austerity and ideological resistance remains to be seen.
Public health practitioners and theorists are diverse and have various social goals that they promote, but the unique status of public health can be traced to the fact that most of what it has historically concerned itself with can be classified as the provision of health-related public goods, the author of this paper argues. He asserts that a public goods framework serves as a useful criterion for distinguishing public health from private health, and it explains why public health goals have special urgency. Public health goals, properly understood, generally require collective action to achieve, and can be endorsed by a wide variety of moral and political theories. The public goods account has the further advantage of establishing a relatively clear and distinctive mission for public health. It also allows a consensus of people with different comprehensive moral and political commitments to endorse public health measures, even if they disagree about precisely why they are desirable.
In this statement, a number of international non-governmental organisations (NGOs) working in health express their support for the report by the United Nations (UN) Special Rapporteur on the right to health. They believe the report is of fundamental importance in securing the right to health, in particular because it consolidates years of health and human rights legal analysis, supporting the conclusion that criminal law is an inappropriate tool for regulating sexual and reproductive health matters. Empirical evidence demonstrates that the misuse of criminal laws and punitive policies in the area of sexual and reproductive health cause disproportionate suffering for women; people engaging in same-sex sexual conduct; people identified as lesbian, gay, bisexual and transgender persons; those living with HIV or AIDS; and other groups who already suffer discrimination. The NGOs support the report’s call to immediately decriminalise abortion, ensure access to a full range of modern contraceptive methods, and facilitate access to full, complete, and accurate information on sexual and reproductive health.
5. Health equity in economic and trade policies
In this final output document from the G20 Summit, held from 3-4 November in Cannes, France, the G20 outlines its decisions to ‘re-invigorate economic growth, create jobs, ensure financial stability, promote social inclusion and make globalisation serve the needs of the people’. Members at the Summit agreed on an Action plan for Growth and Jobs to address short-term vulnerabilities and strengthen medium-term foundations for growth, and promised to reform the international monetary system to make it more representative, stable and resilient. They agreed on actions and principles that are intended to help reap the benefits from financial integration and increase the resilience against volatile capital flows. This includes coherent conclusions to guide the G20 in the management of capital flows, common principles for co-operation between the International Monetary Fund and regional financial arrangements, and an action plan for local currency bond markets. Other areas in which members agreed to co-operate include: reforming the financial sector and enhancing market integrity; addressing commodity price volatility and promoting agriculture; improving energy markets and pursuing the fight against climate change; avoiding protectionism and strengthening the multilateral trading system; addressing the challenges of development by committing to ensure a more inclusive and resilient growth; fighting against corruption and reforming global governance.
In the run-up to the United Nations (UN) Climate Change Conference, hosted in South Africa from 28 November-9 December 2011, the author of this article points to the ‘David and Goliath’ nature of the Conference as civil society faces the industrial giants of the first world, with the poor of the developing world on the sidelines. The failure of Durban’s COP17 is certain, the author agues. Binding emissions-cutting commitments under the Kyoto Protocol are impossible, given Washington’s push for an alternative global architecture that is inequitable to developing countries. The author expressed concern about plans for climate finance and technology, which include an extension of private-sector profit-making opportunities at public expense. Politically, the author argues that global climate policy makers, especially from the United States State Department and the World Bank, will aim to distract global attention from any potential overall UN solution to the climate crisis, from the severe global power imbalance between nations and from the progressive demands and solutions by civil society, which include demands for a better environment in townships, including increased housing, electricity, water and sanitation, and improved waste removal, healthcare and education. ‘Connecting the dots’ to climate will be the primary challenge for all attendees at the Conference, the author notes.
According to the CIDSE, a coalition of Catholic welfare organisations in the North, the much-anticipated G20 London Summit has ended in an anti-climax. CIDSE’s presents four main criticisms of the G20 outcomes. First, the International Monetary Fund (IMF) will continue to regulate global finance and has been given a US$500 billion boost to continue to be the guardian of the global financial system, a role it has failed at so far. Although the G20 outcome acknowledges the need to reform global financial institutions, to take steps (unspecified though they be) to make these institutions more accountable and credible and to appoint the heads and senior management on merit through open and transparent process, CIDSE argues this is unlikely to have much impact on low-income countries. Second, tax havens will continue to flourish so long as they sign bilateral agreements that have proven not to be effective. The black-listing measures that the G20 has announced will do little to return the millions of euros that have been illegally taken out of developing countries and deposited in secret European bank accounts. Third, the announced US$50 billion in aid for low-income countries is little more than a repackaging of existing resources, as many countries in the European Union – the largest external funder in the world – are set to default on their aid commitments, having not yet made concrete allocations to their development budgets. The G20 communiqué is also vague regarding the modalities and the timeline for the disbursement of these funds. Fourth, a balanced and development-friendly system for international monetary stability remains elusive. The call by China to review the current monetary system based on a single reserve currency is not reflected in the communiqué. The adverse impacts of currency exchange rate instability on developing countries’ terms of trade also remain unaddressed, while the recommendation of the Expert Commission of the United Nations General Assembly President to adopt a new Global Reserve System does not appear on the agenda of the G20.
This document provides responses to the concerns expressed by the International Treatment Preparedness Coalition (ITPC) regarding the Gilead-Pool licences issued by the Pool in October 2011. The ITCP was concerned that the licences might undermine TRIPS flexibilities that would allow developing countries to manufacture and purchase cheaper generic medicines, but the Pool refutes this, arguing that one of the core principles of the Pool is to ensure that the terms and conditions it negotiates do not undermine the use of other mechanisms that can improve access to affordable medicines. Least-developed countries (LDCs) still have the option of not introducing patent protection for pharmaceuticals until 2016, the Pool notes. The licences do not require countries to apply to Gilead for ‘prior permission’ for use of a compulsory licence (CL), as countries retain their sovereign rights under the TRIPS Agreement to issue CLs for any reason, and licensees are expressly required to supply countries that do so. Further, the Pool argues that the licences do not block the ability of excluded countries to parallel import generic medicines – countries that have adopted appropriate provisions in their national laws may still be able to purchase the patented product at a lower price in a different country. In addition, the Gilead-Pool licences do not prevent licensees from challenging the validity of any of the licensed patents. Generic companies and civil society groups are free to oppose the grant of any patents they feel do not meet the requirements of patentability. Although the Pool does not have the authority to set patentability criteria or to grant patents (this rests with national governments), it can play a role in ensuring they do not block access to medicines.
According to this article, economic growth is not constitutively the same thing as development, in the sense of a general improvement in living standards and enhancement of people’s well-being and freedom. Growth, of course, can be very helpful in achieving development, but the authors argue that this requires active public policies to ensure that the fruits of economic growth are widely shared, as well as making good use of the public revenue generated by fast economic growth for social services, especially for public healthcare and public education. Yet it is also important to recognise that the impact of economic growth on living standards is crucially dependent on the nature of the growth process (for instance, its sectoral composition and employment intensity) as well as of the public policies - particularly relating to basic education and healthcare - that are used to enable common people to share in the process of growth. There is also an urgent need for greater attention to the destructive aspects of growth, such as environmental degradation and involuntary displacement of communities that have strong roots in a particular ecosystem.
At a formal meeting of the regular session of the TRIPS Council on 24-25 October 2011, Member States conducted their annual review of the implementation of the ‘Paragraph 6’ solution in respect of the TRIPS Agreement and public health. The solution aims to help developing countries with insufficient or no pharmaceutical manufacturing capacities to import cheaper generic medicines produced under compulsory licensing. Ecuador and Venezuela continued to argue that, since the system has only been used once, it is too complicated to be effective, while other Member States questioned whether it is working and said they need more information. Members also agreed to extend the period for acceptance of the protocol amending the TRIPS Agreement (of 2005) for a further two years – till 31 December 2013 – until two thirds of World Trade Organisation (WTO) Members accept the amendment, which is required for it to take effect. Discussions were also held on the Anti-Counterfeiting Trade Agreement (ACTA), during which India, the world’s largest generic manufacturer, stressed that ACTA border measures constituted a grave threat to trade in generics. India argued that ACTA is not legitimate, as it bypasses the multilateral processes of WTO or the World Intellectual Property Organisation and goes far beyond the enforcement levels laid down in the TRIPS Agreement. It noted that ACTA proposals that are underway could undermine the provisions and flexibilities in the TRIPS Agreement by requiring patentability of new uses and minor variations of older known drugs, resulting in indefinite lengthening of the patent life and undermine the generics industry.
According to this press release by the Treatment Action Campaign (TAC), a South African coalition of HIV and AIDS treatment activists, South Africa currently provides patent protection beyond what is required by the international TRIPS agreement, which regulates patents, including those governing production of medicines. Flexibilities in TRIPS allow developing countries to produce or procure affordable generics and countries like India, Brazil and Thailand have used these flexibilities to curb excessive patenting of pharmaceuticals and promote public health. Yet South Africa has not followed their example, argues TAC, having granted 2,442 pharmaceutical patents in 2008 alone, while Brazil only granted 278 pharmaceutical patents between 2003 and 2008. Although President Jacob Zuma has signed on to a joint declaration with India and Brazil recognising the urgent need to scale up production of generic medicines by using TRIPS flexibilities, TAC argues that government has not yet taken the concrete steps needed to fulfill this commitment.
Chinese economic success is not the product of free market accidental coincidence, according to this article – rather, it is orchestrated by the State through a mixture of nationalism (‘big think’) and pragmatic decisions (disjointed incrementalism) in agriculture, finance and industry. By following the Chinese example, the author argues for Pan-Africanism, a form of ‘big think’. The main obstacle to development in Africa, he argues, may well be how to align the vested, narrow interests of territorially bound rulers with their citizens, whose languages and cultures tend to transcend the colonially determined national boundaries and who are more likely to support development efforts if they are consonant with existing practices and values. The author argues that Pan-Africanism would allow Africa to take advantage of the economies of scale that accrue with larger markets, give Africa better leverage on its natural resources, allow for easier sharing of resources between rich and poor communities and give the continent greater international clout.
6. Poverty and health
In the run up to the 2011 United Nations climate conference – hosted in Durban, South Africa, from 28 November to 1 December – Oxfam is supporting communities to speak out about the impact that climate change is having on their lives. In drought-prone areas of Kenya, Oxfam has worked with communities to organise climate hearings. This document reports that at time of writing four million Kenyans faced hunger as a result of failed rains. The northern regions of Turkana and Wajir experienced chronic drought, leaving over half the population dependant on food aid. The hearings are seen as a vital opportunity for communities to speak out about the dramatic impact that climate change is having on their lives. Testimony from the hearings paints a devastating picture of lives and livelihoods that have been severely disrupted by what communities see as a changing climate. Feedback from the hearings indicate that cattle are crucially important to pastoralists, but with changing weather patterns, cattle-rearing is more and more difficult, and livestock are reduced to feeding on polythene paper and human waste. Women in particular are found to suffer from the consequences of a changing climate, with livestock death leading to food insecurity, falling household incomes and child school drop out. The findings of the hearings were taken to the United Nations Climate Change Summit in Durban in end November 2011.
The Alliance for a Green Revolution in Africa (AGRA) and the Gates Foundation represent the interests of biotechnology companies like Monsanto that are attempting to monopolise Africa’s seed industry, according to the author of this article. With Monsanto among the Foundation's portfolio investments, the author questions the legitimacy of the Foundation’s drive to promote genetically modified (GM) crops produced and patented by Monsanto. The risks to farmers of fully adopting industrial agriculture in general and GM seeds in particular include: transferring their food and farming decisions to global corporations; losing ecological and agricultural diversity as GM crop varieties spread; increased use of pesticide and fertiliser normally required for GM crops; and driving small- and medium-scale family farmers off their land because they cannot afford the expensive inputs that industrial agriculture demands, like patented GM seeds. Instead, the author argues for an approach based on traditional knowledge, with small-scale farmers growing diverse crops for local markets, planting farmer-selected crops from seed saved year-on-year (referred to as heirloom varieties), and, drawing on case studies, argues that integrated farm management based on traditional knowledge – without using pesticides or chemical fertilisers – have proven to yield greater harvests. To address the issues of nutrition security, poverty and health in Africa, farmers and governments should not be coerced into following the Western industrial agricultural model, and the Gates Foundation and AGRA should not be regarded as genuine partners in finding solutions to the food crisis in the continent.
This report maps progress in water supply and sanitation of 32 countries in Sub-Saharan Africa. According to the report, political stability has heavily influenced progress in improving access to water supply and sanitation services with low-income stable countries outperforming low-income fragile and resource-rich countries, breaking with the common perception that access to sanitation and water increases with gross domestic product (GDP). The good progress of low-income stable countries has been assisted by their receiving three times more aid than low-income fragile countries and two times more aid than resource-rich countries, per unserved person. Low-income stable countries making most progress have capitalised on harmonised and aligned aid modalities to successfully transition to more programmatic, ‘country-led’ forms of service delivery. The authors emphasise that a shift in aid modalities from external funder-driven projects to country-led programmatic approaches can potentially increase access to water and sanitation services for millions of people by 2015. To accelerate progress to meet Millennium Development Goals for water and sanitation, at least an additional US$6 billion a year of domestic and external funding is needed, they add.
In this paper, the author argues that poverty robs children of their rights, forcing parents to sell their daughters in exchange for money. The trio of poverty, sexual assaults and HIV are argued to be are complementary to one another. In this paper, five case cases are described, as presented at Sinawe Centre as victims of rape, where money has played a role in the delay in reporting the crime to the police. First, a 13 year old girl was raped by a known person. The cost of settlement was a mere R500 (equivalent to US$70). The second victim was paid R10 or R20 for each sexual act. Third, fourth and fifth cases were young girls who were forced to marry by their parents. The history, physical examination and laboratory investigations are given. Psychosocial and economic aspects are also discussed, such as the cultural practice of lobola (bride price). The author argues that South Africa’s high incidence of HIV and AIDS may be partly linked to the custom of lobola, which is often seen as a monetary transaction, whereby the wife is a bought object and the husband often feels free to acquire mistresses. This increases the possibility of infection, which is turn can be transmitted to the wife. In addition, the author argues that high rates of sexual assault in South Africa run parallel with high levels of HIV prevalence, and mental health problems resulting from rape are seldom treated. Although the South African government Has pledged to provide HIV post-exposure prophylaxis if the survivors of rape present within 72 hours of the event, none of the girls and women in the case studies qualified, as they reported the incidences too late.
As African farmers experience escalating anxiety over the appropriation and control of land, seeds and farming techniques by foreign governments and corporations, the multi-million dollar Alliance for a Green Revolution in Africa – a Gates Foundation-funded initiative – promises to increase food production and defeat poverty in Africa by implementing vigorous Western-style agricultural techniques and genetically modified crops. Modelled on the previous Green Revolutions of Latin America and the Indian sub-continent, the African Green Revolution should heed the environmental devastation these previous experiments in agriculture have wrought, the author of this article cautions, such as seriously depleted water tables and impoverished soil. Although new seeds and tools may bring higher production in the short term, some Africans are concerned about the consolidated control that foreign corporations will exercise over food supply, as well as the precarious dependence on large amounts of water and energy inputs, and the environmental toll such methods may eventually take. A growing movement of local farmers – largely led by women – argues that the surest path to food security is ensuring food sovereignty. The article points to a number of international organisations and alliances, like Via Campesina and Groundswell International, which advocate for community-level control over food production. These organisations target primarily women farmers who, according to the article, are responsible for up to 70% of food production in the developing world. The author asserts that supporting small-scale women farmers is crucial to ensuring food sovereignty in poor countries.
7. Equitable health services
This study identified childbirth information needs of Malawian women as perceived by Malawian mothers and midwives in order to design a childbirth education programme. A total of 150 first-time mothers who attended antenatal clinics at selected central, district and mission hospitals were interviewed. Four focus group discussions were conducted with four different types of midwives, followed by individual interviews with midwives in key positions in government and non-governmental organisations. Results indicated the view that the content of the childbirth education programme for pregnant mothers should include: self-care during pregnancy, nutrition during pregnancy, common discomforts of pregnancy, danger signs of pregnancy, sexually transmitted diseases and preparation for delivery. It was also proposed that programmes address possible complications during labour and birth, caesarean birth and non-pharmaceutical pain relief measures in labour, as well as self-care during postnatal period, exclusive breast feeding, care of the newborn baby, danger signs of puerperium, care of the newborn baby and family planning.
The primary aim of this study was to identify progress and challenges in mental healthcare in South Africa, as well as future mental health services research priorities. A systematic literature review of mental health services research was conducted, including studies from January 2000 to October 2010. Hand searches of key local journals were also conducted. Of 215 articles retrieved, 92 were included. The authors found that, while progress in epidemiological studies has been good, there was a paucity of intervention and economic evaluation studies. Most studies reviewed were on the status of mental healthcare services, which indicated some progress in decentralised care for severe mental disorders, but also insufficient resources to adequately support community-based services, resulting in the classic ‘revolving-door’ phenomenon. Common mental disorders remain largely undetected and untreated in primary healthcare. Cross-cutting issues included the need for promoting culturally congruent services, as well as mental health literacy to assist in improving help-seeking behaviour, stigma reduction, and reducing defaulting and human rights abuses. Intervention research is needed to provide evidence of the organisational and human resource mix requirements, as well as cost-effectiveness of a culturally appropriate, task shifting and stepped care approach for severe and common mental disorders at primary healthcare level.
Early identification of tuberculosis (TB) treatment failure using cost effective means is urgently needed in developing nations. The authors of this study set out to describe affordable predictors of TB treatment failure in an African setting by determining the predictors of treatment failure among patients with sputum smear-positive pulmonary TB clinic at Mulago Hospital in Kampala, Uganda. This was an unmatched case control study where fifty patients with a diagnosis of TB treatment failure (cases) and 100 patients declared cured after completing anti-TB treatment (controls) were recruited into the study. Cases were compared with controls to determine predictors of treatment failure. Significant predictors of treatment failure in this study included a positive sputum smear at two months of TB treatment and poor adherence to anti-TB treatment. The authors found that positive sputum smear at two months of TB treatment and poor adherence to anti TB treatment were reliable and affordable predictors of TB treatment failure. These predictors may be used in resource-limited settings for early recognition of those at risk and early intervention, they conclude.
In this study, researchers prospectively assessed the functional impairments and rehabilitation needs of Africans admitted to a regional trauma centre in Ghana. It also acts as a pilot study to demonstrate the practical use of the Language Independent Functional Evaluation (L.I.F.E.) software in an acute hospital setting. A five-page questionnaire was used to gather demographic data, cause of disability/injury, severity of disability or functional impairment, and rehabilitation treatment received. Functional status on discharge was evaluated with the L.I.F.E. scale. A total of 84 consecutive consenting subjects were recorded. The predominant disability/injury of respondents involved the lower extremities (70%), followed by upper extremities (23%). The mechanisms of injury were largely related to auto accidents (69%). Falls made up 17% of these injuries and 14% were related to violence. Eleven subjects had disability measured using L.I.F.E and all were classified as having major disabilities. Only 14 patients (17%) received any rehabilitation therapy which consisted of only physical therapy provided at a frequency of once a day for less than one week duration. The researchers found that most persons admitted to a sophisticated trauma unit in Ghana are discharged without adequate rehabilitation services, and that the level of disability experienced by these people can be measured, even while they are still sick and in the hospital, using L.I.F.E. The researchers call on African trauma units to measure the long-term outcomes from their treatments and provide the inpatient medical rehabilitation services that are a standard of care for trauma victims elsewhere in the world.
8. Human Resources
Communication between non-language-concordant health care workers (HCWs) and patients has been shown by international studies to adversely affect patient and staff satisfaction, yet the authors of this study note that, to the best of their knowledge, no such intervention studies have been conducted in Africa. They conducted research in South Africa to determine whether teaching Xhosa language skills and cultural understanding to HCWs affects patient satisfaction, HCWs’ ability to communicate effectively with Xhosa-speaking patients and HCWs’ job satisfaction levels. A before-and-after interventional study was performed at two community health centres and a district hospital in the Western Cape Province. Fifty-four randomly selected patients (27 pre- and 27 post-intervention) assessed communication with HCWs and rated their satisfaction. Six non-Xhosa-speaking HCW participants completed pre- and post-intervention questionnaires. HCWs completed a ten-week basic language course consisting of ten 120-minute interactive contact sessions developing basic Xhosa speaking and listening skills and cultural competence. Results showed that patient satisfaction showed significant improvements after the intervention. Patients perceived HCWs to be more understanding, respectful and concerned, and to show better listening skills, after the intervention. They were also better able to understand HCWs and their instructions. HCWs’ ability to communicate improved and HCWs experienced decreased frustration levels.
The aim of this study was to determine the need for resuscitation at the birth of babies delivered by elective caesarean section (CS) and to record the time spent by doctors attending such deliveries. Data were collected prospectively on all elective CSs performed at Groote Schuur Hospital in Cape Town, South Africa, over a three-month period. Data collected included: total time involved for paediatrician from call to leaving theatre, management of infant (requiring any form of resuscitation), Apgar scores and neonatal outcome (e.g. admission to nursery). The CSs were classified as low-risk or high-risk. Data were recorded for 138 deliveries. One-hundred-and-fifteen deliveries were classified as uncomplicated and 20 as high-risk. Only one of the babies born from the 115 low-risk CSs needed brief resuscitation, whereas nine of the 20 high-risk deliveries resulted in newborn resuscitation. The reasons for low-risk CS were: previous CS (81); infant of diabetic mother (IDM) and previous CS (16); IDM alone (6); estimated big baby (10); and other (2).The average time spent at each elective CS by the paediatrician was 37 minutes. The authors conclude that, for low-risk CS, the same medical attendance (i.e. a midwife) as for an uncomplicated normal vaginal delivery (NVD) would be appropriate. This would free up a doctor for other duties and assist in de-medicalising a low-risk procedure.
In June 2010 a conference entitled ‘Innovative Health Management in the Public Sector’ was held in Cape Town under the banner of the Oliver Tambo Fellowship Programme at the University of Cape Town. Participants offered a number of key messages for policy makers. 1. Prioritise leadership and management development as a key element of health systems strengthening, providing strong political support yet avoiding political interference. 2. Develop a recruitment strategy that appoints appropriately skilled and committed managers to appropriate positions. 3. Recognise that improving physical infrastructure and the quality of services is essential to successful retention. 4. Build and affirm managers’ good values while challenging those who exhibit inappropriate values. 5. Prioritise leadership and management training across the Department of Health and at all levels by developing mentoring mechanisms. 6. Remove unnecessary bureaucratic obstacles that impede dynamic health systems management, decentralise authority for decision-making and reduce management fragmentation to create an enabling environment for managers. 6. Adopt a systemic approach to health systems transformation that includes experimenting with new management practices, creating the space for managers to act proactively rather than simply reacting to daily crises. 7. Explore team work and the creative use of information in developing interventions and assessing progress in an iterative cycle of change. 8. Strengthen the accountability of managers within a supportive environment that allows some mistakes to be made as part of the process of innovation. 9. Develop a strategy and mechanisms for managers around the country to share best practices and experience on an ongoing basis. 10. Create a platform for managers to express their views to senior provincial and national policy-makers. 11. Recognise, value and celebrate the achievements of managers.
This presentation was delivered at BioMed’s Open Access Conference, held from 24-26 October 2011, in Kumasi, Ghana. It documents work by the African Medical And Research Foundation (AMREF), an international African non-governmental organisation (NGO) that focuses on community health development, with programme offices in seven African countries and direct reach through training, partnerships and consultancy in 33 other African countries. With major information challenges facing African health workers and systems, the use of emerging information and innovations have a huge role to play in improving health and health systems in Africa, the presenter argues, but he warns that tools alone cannot do it – the content needs to be developed and made available. Therefore, publishing and making information available to Africa’s health workers and practitioners is an urgent issue for the improvement of health services delivery in Africa. AMREF focuses on three broad health system approaches: capacity building for community and health systems including development and support to community health workers; improving health information; and human resources for health, particularly regarding the issues of health worker numbers and skills, training approaches including task shifting, and deployment and retention. Challenges in accessing research were identified as: low investment in research within the continent; lack of infrastructure for accessing research online in appropriate platforms to share research; and the prohibitive cost of accessing research (in print or online).
To address the shortage of healthcare workers providing comprehensive emergency obstetrical care (CEmOC) in Tanzania, an intensive three-month course was developed to train non-physician clinicians for remote health centres. Competency-based curricula for assistant medical officers' (AMOs) training in CEmOC, and for nurses, midwives and clinical officers in anaesthesia and operation theatre etiquette were developed and implemented in Ifakara. A total of 43 care providers from 12 health centres located in 11 rural districts in Tanzania and two from Somalia were trained from June 2009 to April 2010. Of these 14 were AMOs trained in CEmOC and 31 nurse-midwives and clinical officers trained in anaesthesia. The first eight months after introduction of CEmOC services in three health centres resulted in 179 caesarean sections, an increase of institutional deliveries by up to 300%, decreased fresh stillbirth rate and reduced obstetric referrals. There were two maternal deaths, both arriving in a moribund condition. The authors conclude that the training was a success and their model can be used for further training.
9. Public-Private Mix
A Kenyan pharmaceutical company, Universal Corporation, is reported to have been certified by the World Health Organisation (WHO) to start producing antiretroviral (ARV) drugs. The company alleges that the cost of its medicines will be at least 30% cheaper than those the government is currently buying from foreign manufacturers in countries like India, largely as it will avoid high importation costs. The authors note that whether or not the government will buy medicines locally depends on their pricing. Activists have called on WHO to certify more local manufacturers to produce high-quality generic drugs. Government officials have welcomed the development as a step in providing universal coverage to all HIV-positive Kenyans.
The concept of ‘water operator partnerships’ (WOPs) has increasingly been promoted as a means to improving water services provision in developing countries. The International Water Association (IWA)defines WOPs as ‘any formal or informal collaboration or structured partnership aimed at capacity building on a not-for-profit basis. In the WOPs approach emphasis is on capacitating (rather than replacing) the public organisation. Researchers assessed the potential of such partnerships as a ‘model’ for contributing to the Millennium Development Goals (MDGs), by focusing on four water utilities in Mozambique. Although, the study found these partnerships to be successful, their replicability and potential for scale up was found to be quite limited. The study found that WOPs depended for success on the availability of investment funds, and the level of commitment to the partnership, both financial commitment and time and effort of the organisations involved.
10. Resource allocation and health financing
The district hospital has been considered a critical avenue for the delivery of child-saving interventions. It has been suggested that improving the performance of district hospitals would reduce child mortality by 3-30% in the areas they serve. It has however been
shown that the quality of care delivered in these hospitals in Kenya is inadequate. To improve the quality of care of children admitted in district hospitals in Kenya, the study developed clinical guidelines
in selected district hospitals. The guidelines were linked with health
worker training, job aids, follow-up and supervision and performance feedback termed the 'Emergency Triage and Treatment Plus (ETAT+) strategy. The strategy improved the quality of care of children admitted in hospitals by 25%. The total cost of scaling up the intervention was calculated at about US$ 3.6 million, estimated to be only 0.6% of the annual child health budget in Kenya. The ETAT+ strategy is argued to be cost-effective in improving the quality of care of children admitted in hospitals in Kenya.
The global financial transaction tax (FTT) is a key proposal that civil society campaigned for at the G20 Cannes Summit, hosted in Cannes, France, from 3-4 November 2011. It has the potential to raise billions of dollars to support social justice goals – estimates of the amount that FTT could generate range from about US$50 billion to as much as $250 billion if a wide range of transactions are included. The author identifies seven global taxes that could be included as ‘further transactions’. 1. A tax of 5% on First and Business class air tickets already funds UNITAID, and raises US$200 million annually – if generalised, it could raise $8 billion globally. 2. A tax on polluting activities, amounting $20-25 for every ton of CO2 would raise $300 billion, while taxation of air and sea international transportation could raise US$40 billion. 3. An additional tax on top of national taxes on transnational societies would eliminate tax havens and would turn these companies into global tax payers, thereby raising $100 billion. 4. A tax on arm sales could garner US$30 billion a year. 5. A tax on capital profits could amount to US$50 billion if it was generalised, if it covered all tax havens and if it was controlled. 6. The tax on currency exchange transactions limited to a rate of 0.005%, and applied to principal currency exchange markets (US$, pound and yen) would generate at least US$33 billion – if increased to 0.1%, this tax would raise $150-300 billion, as well as becoming an efficient instrument against rampant speculation. 7. A tax of $0.05 on every pack of cigarettes in rich countries (and of $0.01 in poorest countries) would raise an additional $7.7 billion.
This paper presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana. Secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used, triangulated with data from the Ministry of Finance and other relevant sources, and further complemented with primary household data collected in six districts. Results showed that Ghana's health care financing system is generally progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes, which account for close to 50% of health care funding. The national health insurance (NHI) levy (part of VAT) is mildly progressive and formal sector NHI payroll deductions are also progressive. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are regressive form of health payment to households. For Ghana to attain adequate financial risk protection and ultimately achieve universal coverage, it needs to extend pre-payment cover to all in the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the National Health Insurance. Furthermore, the pre-payment funding pool for health care needs to grow so budgetary allocation to the health sector can be enhanced.
11. Equity and HIV/AIDS
Although South Africa is committed to providing anti-retroviral treatment (ART) to all South Africans who need it, there are insufficient pharmacists working in public sector facilities to dispense ART to all these patients, according to this policy brief, which means that dispensing tasks must be shifted to pharmacists assistants and/or nurses. The Health Economics Unit (HEU) argues that the pharmacists assistant pharmaceutical care model has the lowest cost to the health system and would support a more integrated primary health care service. Patients getting their ART by attending facilities staffed by pharmacists assistants and nurses experienced relatively better geographic access to facilities and lower transport costs, compared to those attending more central facilities that employ pharmacists. Patients prefer a nurse to dispense their ARTs as this reduces the risk of being identiﬁed by other patients as being HIV-positive. The pharmacists assistant model can be made more acceptable to patients by ensuring that there are no differences between patient folders (e.g. those on ART should not have differently coloured folders) and dispensing all medication (not only anti-retrovirals) in brown paper bags.
In this study researchers explored the level of awareness and practice on HIV prevention among married couples from selected communities in Malawi. They carried out the study from October to December 2008 in four communities, two each from Chiradzulu and Chikhwawa districts of Malawi. They conducted face-to-face in-depth interviews with 30 couples in each district using a semi-structured interview guide. The couples’ ages ranged from 20 to 53 years, most (52%) being in the 20-31 year-old age group. All couples were aware of HIV prevention methods and talked about them in their marriages. For most couples (54) there was mutual trust between husbands and wives, and members of only a few couples (six) doubted their partners’ ability to maintain mutual fidelity, but researchers detected infidelity among 25 couples. A few couples (5) had been tested for HIV. No couples favoured the use of condoms with a marriage partner as an HIV prevention method. The researchers conclude that the level of HIV prevention awareness among couples in Malawi is high and almost universal. However, there is low adoption of the HIV prevention methods among the couples because they are perceived to be couple unfriendly due to their incompatibility with the socio-cultural beliefs of the people. There is a need to target couples as units of intervention in the adoption of HIV prevention methods by rural communities.
This policy brief draws on evidence from a recent study that investigated the factors influencing the choices of infant feeding of HIV-positive mothers in Ghana through an assessment of the perspectives of HIV-positive mothers and family members (i.e., fathers and grandmothers) in two districts in Ghana. Results from the study showed that HIV-positive mothers had good knowledge and understanding of exclusive breastfeeding and exclusive replacement feeding, however adherence to these feeding options was poor and mixed feeding was common. HIV-positive mothers had access to counseling on replacement infant feeding options but there was an emphasis on exclusive breastfeeding and exclusive replacement feeding and not on other replacement options. HIV-positive mothers faced various obstacles (socio-economic, familial and stigma) in carrying out replacement feeding. Family members and communities have a strong influence on mothers’ infant feeding practices. The authors of the study recommend introducing a multi-dimensional behaviour change strategy which involves mothers, family members and significant community members in order to change perceptions, understanding and attitudes to exclusive replacement feeding and exclusive breastfeeding and at the same time, explicitly deal with the risk in terms of infant survival associated with mixed feeding. Male partners should be involved and counselors should explore why the full range of feeding options (like heat-treated breast milk, animal milk and wetnursing) are not discussed.
Since the establishment of free HIV and AIDS care and treatment services in Tanzania a lot of research has been done to assess how health care providers discharge their duties in these clinics. Little research however has been done regarding satisfaction of HIV patients with free health care services provided. The authors of this study aimed to determine satisfaction of HIV patients with health care services provided at the HIV clinics and specifically, to determine patients’ satisfaction with the general physical environment of the clinic and with services offered by doctors, nurses, laboratory, and pharmacy. A cross-sectional study was conducted at Muhimbili National Hospital (MNH) and Amana hospital. A total of 375 patients attending outpatient HIV clinics were selected randomly and interviewed using a questionnaire, after obtaining a verbal consent. Results showed that patients at Amana Hospital clinic were either very satisfied (44.3%) or satisfied (55.7%) and none were dissatisfied, while at MNH clinic 1.1% patients were very satisfied while (94.7%) were satisfied and (4.2%) were dissatisfied with health care services provided. Lack of privacy when consulting with doctors and the dispenser contributed to patients’ dissatisfaction with the services.
This study aimed at determining the prevalence and factors associated with use of traditional herbal medicines (THM) among HIV-infected patients on highly active antiretroviral therapy (HAART) attending the AIDS Support Organisation (TASO), a non-governmental organisation offering HIV and AIDS services in Uganda. This was a cross-sectional study carried out in two TASO treatment centres among 401 randomly selected eligible participants. Participants were 18 years and older, and were enrolled on HAART. The authors found that the average prevalence of THM use was 33.7%. Patients on HAART for less than four years were more likely to use THM, as well as those who experienced HAART side effects. Patients older than 39 years old were less likely to use THM. Participants with HAART adherence levels greater than 95% were less likely to use THM. Overall, the prevalence of THM use among participants on HAART was high, which raises clinical and pharmacological concerns that need attention by the health care service providers, the authors conclude.
The objective of this study was to establish the reliability of the scored Patient-Generated Subjective Global Assessment (PG-SGA) in determining nutritional status among antiretroviral therapy (ART) naive HIV-infected adults. A descriptive, cross sectional study was conducted among outpatient medical clinics in the AIDS Support Organisation (TASO), Mulago Centre, Kampala, Uganda. The study sample totalled 217 HIV-positive patients, consisting of 60 male and 157 female patients, aged 18-67 years old. Data collection was done from April-May 2008. Results showed that only 12% of the subjects were underweight and over half (58.2%) had normal weight. The PG-SGA had low sensitivity (69.2%) and specificity (57.1%) at categorising the risk for malnutrition indicated by Body Mass Index of less than 18.5. The authors note that there was a high prevalence of malnutrition among the study group, but the PGSGA could not adequately discriminate between underweight and normal patients. The tool was not reliable enough for determining nutritional status in this population.
The objectives of this study were to compare undernutrition between groups of HIV-positive and HIV-negative children undergoing anti-retroviral therapy (ART) in Dar es Salaam, Tanzania. From September to October 2010, researchers conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. They found that ART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Food insecurity was prevalent in over half of ART-treated HIV-positive children's households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children. The researchers conclude that HIV and AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhoea.
12. Governance and participation in health
The authors of this study evaluated community-based education and service (COBES) programmes at Makerere University College, Uganda, from a community perspective. A stratified random sample of eleven COBES sites was selected to examine the community’s perception of the programmes. Key informant interviews were held with 11 site tutors and 33 community members. Communities reported that the university students consistently engaged with them with culturally appropriate behavior and rated the student’s communication as very good even though translators were frequently needed. They also reported positive changes in health and health-seeking behaviours but remarked that some programmes were not financially sustainable. The major challenges from the community included community fatigue, and poor motivation of community leaders to continue to take in students without any form of compensation.
Led by the slogan ‘People First, Not Finance’, the People’s Forum held in November raised that the G20’s ‘cosmetic’ economic solutions to the global recession in 2008 would do little to ease the cyclical problems of the financial system, adding that much deeper, structural changes were required to address global inequity. It argued that the G20 will only increase the ‘financialisation’ of this world, instead of fundamentally changing it. The forum raised that social movements ranging from the ‘Occupy’ protests in Wall Street in the United States to the ongoing demonstrations in Tahrir Square need to ‘coordinate, exchange views' towards this deeper structural change.
Globally, increasingly vigilant and vocal civil society groups - important actors in the new multilateralism - are demanding openness, transparency and citizen participation in the discourse and practice of governance, which includes the right to information. This movement is facilitated by new technologies in the form of social media platforms like Twitter and Facebook and sources like Wikileaks. A new generation of technology-enabled applications and innovations for open government is also being developed in the South. Numerous examples are emerging including the use of mobile phones, SMS (short message service) technologies and web-based platforms for providing feedback on services, reporting on corruption, and accessing services. For example, Global Voices, a virtual organization of bloggers, tracks and shares many of the more innovative applications, emerging in both middle-income and poorer countries. Although the impetus for openness comes from civil society, open government is, at its core, an enterprise of government transformation, the author of this article argues. The author believes that, eventually, citizens will be able to participate actively in the governance ecosystem, but only if governments create the right enabling environment for transparency through appropriate policies and disclosure rules for making information available, and if it creates the kinds of processes that enable citizens to participate in policy making.
This Declaration of Commitment by Speakers of Parliament is based on the resolution to the Speakers from the fifth Session of the Second Pan African Parliament held on 3-14 October 2011, in Midrand, Johannesburg, South Africa, urging speakers of Parliament in the continent to prioritise the implementation of Maternal, Newborn and Child Health programmes with country reports on actions taken. The commitment promises high-level parliamentary support to hasten implementation of the Africa Parliamentary Policy and Budget Action Plan on Maternal, Newborn and Child Health, agreed by Chairs of Finance and Budget committees of national parliaments in October 2010.
According to this article, the recent G20 summit in France and the Commonwealth Heads of Government Meeting in Australia were both noteworthy for the continuing lack of substantive action on financial sector reform, climate negotiations, trade and the reform of international institutions. And the prognoses for the Fourth High Level Forum on Aid Effectiveness in South Korea and the 17th Conference of the Parties (COP17) to the United Nations Framework Convention on Climate Change (UNFCCC) in South Africa - scheduled for November 2011 - suggest more of the same will follow. The author argues that COP-17, originally billed as the People’s COP and the African COP, now appears unlikely to live up to either label. Nor, according to the author, does it appear likely that disagreements on the design of the new Green Climate Fund or on a second commitment phase for the Kyoto Protocol will be resolved in time for the conference. What will it take to break the deadlocks and spur leadership capable of responding to the crises, current and impending? As the 2011 movements in the Middle East and North Africa demonstrated, it is argued that civil society needs to challenge the legitimacy of the institutions charged with global governance and demand their radical overhaul or replacement.
In this study, researchers investigated use and understanding of nutrition labels on food packages among urban and rural consumers in Lilongwe, Malawi. They also examined the effect of socio-demographic factors and nutrition knowledge on use of nutrition labels. The researchers surveyed 206 consumers, approached randomly after they checked out at grocery stores. Shop managers and owners gave their consent to conduct the study outside the shops to avoid affecting customer behaviour and revenues. A pre-tested questionnaire was used to collect data for analysis and interpretation. The findings show that self-reported use and understanding of nutrition labels were low, suggesting much lower use and comprehension in real-life retail environments. Urban, educated and female consumers were more likely to read nutrition panels when purchasing food. Nutrition labels were seen as important, particularly when purchasing a product for the first time and when considering buying certain products. In terms of nutrition knowledge, rural consumers were as knowledgeable as urban consumers, but they were less likely to connect their knowledge to emerging non-communicable diseases. The researchers caution that the study had some limitations: for example, they surveyed a small sample of shoppers drawn from one geographical area, therefore their findings are not conclusive. Objective, cross-sectional and longitudinal investigations in future would improve understanding of actual consumer behaviour in retail shops and homes in Malawi, the researchers argue. As this study is the first of its kind in Malawi, it is intended to provide baseline information useful to the healthcare professionals, the government, the food industry and consumers.
The World Health Organisation (WHO) Director-General’s proposal for reform of WHO has sparked controversy among WHO Member States, resulting in a meeting of the Executive Board (EB) convened on 1-3 November 2011. Member States expressed concern over the speed of the reform process; lack of information, analyses and independent evaluation to guide the reform; WHO's donor-driven approach and growing partnerships; the scope of independent evaluation; and proposals to limit WHO's scope. The EB meeting decided to establish a process for priority-setting of WHO's programme activities as part of the reform agenda, advocating a Member-driven process for priority-setting of the WHO programme, urging the Director-General not to be too hasty in pushing for the reforms until proper consultation with Member States had been made.
13. Monitoring equity and research policy
This is the third of a series of three papers addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR). The authors of this paper assert that there is an urgent need to build the Health Policy and Systems Research (HPSR) field and in particular to develop understanding across different disciplinary boundaries. The development of HPSR is impeded by a cluster of related issues: a heavy reliance on international funding for HPSR; an excessive focus on the direct utility of HPSR findings from specific studies; and a tendency to under-value contributions to HPSR from social sciences. Innovations in funding HPSR are needed so that local actors, including policy-makers, civil society, and researchers, have a greater say in determining the nature of HPSR conducted. Strategic investment should be made in promoting a greater shared understanding of theoretical frames and methodological approaches for HPSR including, for example, the development of HPSR journals, methodological workshops, and shared HPSR teaching curricula. Dedicated and supportive homes for HPSR need to be found within universities, and also be developed as independent research institutes, the authors conclude.
This is the first of a series of three papers addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR). HPSR is a multidisciplinary and interdisciplinary field identified by the topics and scope of questions asked rather than by methodology. The focus of discussion is HPSR in low- and middle-income countries. Topics of research in HPSR include international, national, and local health systems and their interconnectivities, and policies made and implemented at all levels of the health system. Research questions in HPSR vary by the level of analysis (macro, meso, and micro) and intent of the question (normative/evaluative or exploratory/explanatory). Current heightened attention on HPSR contains significant opportunities, but also threats in the form of certain focus areas and questions being privileged over others; “disciplinary capture” of the field by the dominant health research traditions; and premature and inappropriately narrow definitions. The authors call for greater attention to fundamental, exploratory, and explanatory types of HPSR; to the significance of the field for societal and national development, necessitating HPSR capacity building in low- and middle-income countries; and for greater literacy and application of a wide spectrum of methodologies.
This is the second of a series of three papers addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR). According to this paper, all researchers hold a knowledge paradigm that frames their understanding of reality and of the functions and nature of research. Some disciplines are dominated by a particular paradigm and some are spread across paradigms. The criticisms that Health Policy and Systems Research (HPSR) is too context specific, does not offer clear lessons for policy makers, and is not rigorous are partly a reflection of differences in knowledge paradigms between those with predominantly clinical, biomedical, and epidemiological backgrounds, underpinned by a positivist paradigm, and those with social science backgrounds underpinned by a relativist paradigm. Health policies and systems are complex social and political phenomena, constructed by human action rather than naturally occurring. Therefore, the authors argue, relativist social science perspectives are of particular relevance to HPSR as they recognise that all phenomena are in essence constructed through human behaviour and interpretation. Social science insights that can advance the science of HPSR include: approaches to generalising from rich understanding of context; supporting policy learning; and enhancing research rigour and quality.
In South Africa, the number of papers produced in health and rehabilitation sciences is insignificant compared with other health-related disciplines, according to the authors of this paper. To identify strategies to increase the number of these papers, the authors reviewed published papers that examined the effectiveness of interventions designed to promote research publications among academics and clinicians in health and rehabilitation sciences programmes. Seven of the papers reported on interventions for academics, and six reported on the interventions for academics in the nursing profession. The most common interventions were ‘writing support groups’, ‘writing retreats’, and ‘writing courses’ that lasted from three days to five years. The interventions were designed to meet the needs of the participants for structured time, motivation, improved writing skills and peer support. All the interventions produced significant research output relating to submission or publication of academic papers. The implementation of these interventions by South African tertiary institutions where health and rehabilitation sciences are offered may improve the number of papers published by the health research community, the authors conclude.
In this article, the author argues that international agreements and planning instruments such as the World Bank’s Poverty Reduction Strategy Papers (PRSPs) often fail to question the parameters within which national plans are prepared. Home grown solutions can only be produced from knowledge and policies that are locally generated and context specific. Southern knowledge centres (or think tanks) – which are estimated to number about 2,000 – then have a crucial role to play in promoting economic and social development in the global South, particularly in the poorer economies. In an increasingly interconnected world, Northern and Southern think tanks are joining forces in partnerships and networks to generate and use knowledge more systematically to address national, regional, and global challenges. A number of examples of North-South collaborations are discussed in the article, including the Chronic Poverty Research Centre and the Climate and Development Knowledge Network. Networks of think tanks can provide an extremely effective mechanism for learning and innovation, the author notes, and they can enable collaboration beyond the usual institutional, cultural, and functional boundaries of an organisation.
Despite the benefits to collaborative approaches and sharing of best practices, none of this can take place in the absence of adequate funding, the authors of this article argue. They call for re-examination of funding initiatives that bypass academic institutions because of a reluctance to fund ‘Ivory Tower’ initiatives. Recent initiatives will invest approximately US$130 million over the next five years to strengthen Africa’s educational institutions to produce the quantity and quality of scientists and health care workers needed to address the healthcare problems in the region. Whereas this represents a step in the right direction, substantially more funding will be required, including funding from the African governments themselves, to address national health priorities. The authors challenge conventional notions that academia is hesitant to come down from their ivory towers. Universities can and must be socially relevant. Funding and investments are needed now to make these collaborations sustainable, they conclude.
Complementary medicine research, including naturopathic medicine research, is plagued with many methodological challenges, the authors of this paper argue. Many of these challenges have also been experienced in public health research. Public health research has met these challenges with a long history of multidisciplinary, multimethod, and whole systems approaches to research that may better resonate with the “real world” clinical settings of naturopathic medicine. Additionally, many of the underlying principles of naturopathic medicine are analogous to the underlying principles and activities of public health, specifically in such areas as health promotion, prevention, patient education, and proactive rather than reactive approaches to disease management and treatment. Future research in the field of naturopathic medicine may benefit from adopting public health research models rather than focusing exclusively on biomedical models, the authors argue. A complementary and collaborative relationship between these fields may provide an opportunity to deliver research that more accurately reflects naturopathic medicine practice, as well as providing the opportunity to improve health outcomes more generally.
At the Berlin 9 conference, held in Washington DC, United States from 9-10 November 2011, it was announced that 33 research institutions, associations and foundations in North America have added their signatures to the Berlin Declaration on Open Access to Knowledge in the Sciences and Humanities, committing to support open access research in the future. The signing brings the total signatories to nearly 300, including many of the top research institutions in the world. The Berlin Declaration aims to ‘make scientific and scholarly research more accessible to the broader public by taking full advantage of the possibilities offered by digital electronic communication.’
14. Useful Resources
Most international external funders (external funders) are not publishing enough information about the money they give, undermining the effectiveness of development spending and damaging public trust, according to Publish What You Fund’s 2011 Aid Transparency Index. Major external funders - including the United States, Japan, France, Germany, Spain, Norway, Canada, Italy and Australia - perform poorly in the Index, despite repeated pledges to improve. The five best-ranked donors (external funders) are the World Bank, the Global Fund, the African Development Bank, the Netherlands’ Ministry of Foreign Affairs and the United Kingdom’s Department for International Development. Publish What You Fund has expressed disappointment with the results, noting that most external funders are simply not providing enough good information about their aid. It argues that this lack of transparency leads to waste, overlap and inefficiency, impedes efforts to improve governance and reduce corruption and makes it hard to measure results. Publish What You Fund calls on all external funders to sign up to and implement the International Aid Transparency Initiative (IATI), which provides a common standard for publishing data and has the potential to transform the way external funding is managed. It urges external funders to use the upcoming High Level Forum on Aid Effectiveness in Korea (29 November – 1 December 2011) to commit to publish timely, comprehensive and comparable information on external funding by 2015.
BioMed, a major open-access medical research provider, has relaunched its website with a number of new features. These include: a redesigned homepage showcasing the most recent and popular published research; new-style journal homepages for the BMC series (e.g. BMC Biology, BMC Cancer); a revamped ‘My BioMed Central’ page, in which you can see the latest articles in your subject areas and easily manage email preferences and stored searches; an updated ‘My manuscripts’ page, with improved display of the status of all your submitted/published manuscripts, and any that you are currently reviewing or have reviewed; and revised ‘Institutional Member’ pages, which now show all articles from a Member institution, not just those from the last 12 months. Other improved features include an ‘Advanced search’ option with additional options for selecting and downloading search results, and subject gateways that offer a quick way to see the latest research from across BioMed Central’s open access journals on a particular topic, while regional gateways showcase research from particular countries.
Improving knowledge management in health systems is a priority of the platform Harmonization for Health in Africa (HHA). Building commonly shared knowledge is at the core of the philosophy of communities of practice. Those within the financing pillar - namely, "Performance-based financing", "Financial Access", "Public-Private Partnerships" and "Evidence-based Budgeting and Planning" are particularly active.
In recent months, their facilitators have found that some lively CoP debates are of broader interest and should be made accessible more widely. This blog was created as a platform to meet this need, to give greater visibility to our CoPs and contribute to consolidating their role and voice in health financing in Africa, to become the reference point for discussions on health financing in Africa.
BetterAid and the Open Forum have developed this toolkit for use in the run up to and during the Fourth High Level Forum on Aid Effectiveness (HLF4) (29 November-1 December 2011 in Busan, Korea) and the Busan Civil Society Forum that precedes it. The Toolkit is intended to support national advocacy and media activities, which can be conducted by concerned civil society organisations (CSOs). For CSOs, HLF4 is a particularly significant milestone as it marks the first time that CSOs will participate as full and equal stakeholders in aid effectiveness negotiations alongside governments and external funders. The objectives of this media tool kit are to: attract and focus media attention to effectively communicate the CSO perspective on aid and development effectiveness and reaction to the meeting outcomes to the widest audience possible; and support the lobby initiatives of CSOs with governments and official representatives on the Draft Outcome Document at the HLF4. The Toolkit has a number of templates that can be used and adapted according to national activities.
15. Jobs and Announcements
The Third South African Tuberculosis (TB) Conference will assess progress towards reaching TB/HIV targets. Abstracts must be in line with one of three tracks. Track 1: Basic Science: This track will focus on improving and expanding the understanding of basic science issues required for the development of new tools and advancing the knowledge base on TB infection. Track 2: Clinical, Epidemiological and Operational Research: This track will focus on the latest findings from controlled clinical trials and research studies aimed at improving the epidemiological, programmatic, health systems and policy components of TB control. Track 3: Patient and Civil Society Mobilisation and Advocacy: This track will focus on achieving broad-based partnerships built on the principles of greater involvement of persons with TB, targeted advocacy, partnerships and the role of civil society in TB control and increasing access to TB diagnosis, treatment and adherence support service.
The University of Oxford is seeking applications from students ordinarily resident in South Africa for the 2012 Oppenheimer Fund Scholarships to pursue graduate studies in a variety of fields at Oxford. The Oppenheimer Fund Scholarships are available for ordinarily resident South African students wishing to start any new degree bearing course, with the exception of Post Graduate Certificate and Post Graduate Diploma courses, at the University of Oxford.
Applications are now open for African Doctoral Dissertation Research Fellowships (ADDRF). The overall goal of the ADDRF programme is to support the training and retention of highly-skilled, locally-trained scholars in research and academic positions across the region. The ADDRF will award about 20 fellowships in 2012 to doctoral students who are within two years of completing their thesis at an African university. The fellowships targets doctoral students with strong commitment to a career in training and/or research. Candidates whose dissertation topics address health policy or health systems issues will be given special consideration. There are also three fellowships for doctoral students conducting research on health inequities in urban areas or the reproductive health of marginalised urban communities, and two additional fellowships for students whose research focuses on unintended pregnancy and unmet need for family planning in Africa.
The Africa Initiative announces a call for applications for the 2012 graduate research grant program. Grants of up to $10,000 (CAD) will be awarded to 15 African students applying to study in Canada and 15 Canadian students to conduct field-based research in Africa. Applications must be submitted by January 15, 2012. As part of the Africa Initiative, a joint undertaking by The Centre for International Governance Innovation (CIGI) in cooperation with Makerere University and the South African Institute for International Affairs, the Africa Initiative Graduate Research Grant will give special consideration to proposals that present new and policy relevant research, and that cover one or more of the areas of conflict resolution, energy, food security, health, migration and climate change. Successful applicants who are currently enrolled in an African university will spend up to three months at a Canadian university undertaking research funded by the program. The research will lead to a major paper to be considered for publishing.
The Youth Initiative of the Open Society Foundations (OSF) is currently seeking proposals from eligible registered NGO’s for up to US$10,000 in funding to develop and curate thematic pages on a new global youth portal and community being developed at www.youthpolicy.org. Youthpolicy.org aims to consolidate knowledge and information on youth policies across the international sector, ranging from analysis and formulation to implementation and evaluation. Themes include, but are not limited to: participation and citizenship; activism and volunteering; children and youth rights; youth with disabilities; global drug policy; community work; research and knowledge; informal learning; youth, environment and sustainability; multiculturalism and minorities; and youth justice.
The Healthcare in Africa conference will take place from 6-7 March 2012 in Cape Town, South Africa. It aims to bring together influential healthcare stakeholders from government, providers, suppliers and patient groups to confront and explore key issues around healthcare systems in Africa. Activities include interactive online brainstorming sessions, presentations of case studies and lectures form specialists and other stakeholders in healthcare in Africa. The following topics will be addressed: What is the right balance of private and public healthcare for Africa? How can healthcare systems best meet the demands of both infectious and chronic diseases? What are the best practices for affordable medicine in Africa, and what can be learnt from other emerging markets?
Forum 2012 will bring together key actors to make research and innovation work for health, equity and development: governments, industry, social enterprise, non-governmental organisations, researchers, media, funders , international organisations and others. Partipcipants will explore who will explore ways to go ‘beyond aid’ by building on the rapidly expanding research and innovation capacity of low- and middle-income countries as basis for development. The Forum has three main themes: improving and increasing investments in research and innovation; networking and partnerships in research, technological innovations, social innovations and delivery of better health care; and improvement of health, equity and development of low-income countries by creating a supportive environment, including priority setting in research for health, fair research contracting, research cooperation and ethics, nanotechnologies, technological and social innovations, and using the web as a tool for planning research.
SEYCOHAIDS 2012 is the largest international gathering for young people on HIV and AIDS in the Eastern and Southern Africa region, where young researchers, policy makers, activists, educators and people living with HIV will be able to link with people in other countries and meet to share and learn about HIV prevention methods, treatments, care policies and programmes relating to HIV and AIDS in Africa. The broad objectives for the Conference are to: ensure effective and meaningful youth participation in international AIDS response; identify gaps and challenges in government policies in providing youth-friendly HIV and AIDS services; develop regional and country-level strategic programmes for youth and HIV and AIDS; identify and build the capacity of new and emerging youth leaders for the AIDS response to ensure sustainability of youth initiatives at the national, regional and international levels; sustain adult-youth partnerships and dialogue; develop the Southern and Eastern Africa youth network on HIV and AIDS; develop country specific youth networks on HIV and AIDS; establish funding mechanisms for regional and country youth networks; and monitor government and donor commitments to youth and HIV and AIDS. Applicants must be no older than 35 years old at the time of the application.
The Third Annual Healthcare Summit will be held from 24 to 26 January 2012 in Johannesburg, South Africa. It is a three-day event that deals with all the current issues facing the stakeholders in the healthcare industry. This year’s Summit will focus on the latest developments surrounding healthcare reform in South Africa in both private and public sectors and in particular the impact the NHI is likely to have on the industry. Key topics being addressed include: the impact the NHI will have on the healthcare industry; how the Consumer Protection Act affects the industry; the escalating cost of private healthcare; the pricing structure of doctors vs. those of medical schemes; international benchmarking of pharmaceuticals; the funding of hospitals and how it will improve healthcare facilities; quality assurance in the healthcare industry; the latest fraud trends and their effect on the healthcare industry; and balancing technology advancements against costs.
The First Global Climate and Health Summit aims to bring together key health sector actors to discuss the impacts of climate change on public health and solutions that promote greater health and economic equity between and within nations. The Summit is geared to build the profile of the health sector vis-à-vis the COP17 negotiations in Durban, and to also help build a broader, longer lasting global movement for a healthy climate. Objectives of the Summit include: raise the profile of public health and the health sector vis-à-vis the public debate and global negotiations on climate change; catalyse greater health sector engagement on climate issues in a broad diversity of countries; build a common, more coordinated approach to addressing the health impacts of climate change; and develop shared advocacy strategies for strong national and global policy measures to mitigate and adapt to climate change.
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