In recent years, many low and middle-income countries have removed user fees in their health care sector. However providing free health care is more complex than it is usually thought.
Researchers have studied these policies in Afghanistan, Burundi, Burkina Faso, Mali, Nepal to see what lessons can be learned from them. These country experiences highlight that decisions to remove user fees are often taken by authorities at the highest level in countries, sometimes during electoral campaigns. Many countries are opting for selective free health care, such as for children under five years, free delivery for mothers. This aligns access to areas of the Millennium Development Goals. It is probably reasonable, given the costs to governments of free health care policies. Leadership developed by African leaders in favour of vulnerable populations such as young children and pregnant women has to be praised. Good outcomes for these groups however require a long term commitment in terms of public resources and policies which are sound from a technical perspective.
The country assessments found, for example, that when these decisions are taken in a hasty manner, without sufficient consultation of stakeholders, including of the technicians working for the concerned ministries, health systems may experience a shock. They are found to have difficulties with coping with the increase in patients and drug shortages. Lucy Gilson, Professor at the London School of Hygiene & Tropical Medicine and at the University of Cape Town said “As leaders take important decisions to strengthen health systems for the benefit of the poorest, their engagement with communities, health workers and technicians is vital in bringing those decisions alive in the day to day practice of health care delivery”.
In contrast, when the policies are well-designed, implemented with the appropriate accompanying measures and sufficiently funded, they can improve access to health services. Funding levels are important. Insufficient funding may lead to a situation where the increased utilisation of services by the population after fees are lifted paradoxically leads households to spend more for their treatment. This happens, for instance, when there are drug shortages in free public health facilities, so that households have to buy their drugs in private pharmacies.
There are different ways to reduce financial barriers to health care. Free health care is one option. Another option is to introduce health insurance, so that any changes are paid in advance and people are charged according to their ability to pay and not their health need. Any good solution, that works for both vulnerable people and for the public budget requires a certain level of complexity. It is therefore important that leaders consult their technicians who plan and deliver services. They can help leaders to build fair, efficient and sustainable health care systems.
External funders, aid agencies and Northern Non-Governmental Organizations were also found in the country studies to play a role, such as in assisting countries to monitor and evaluate their policies, a step overlooked in too many countries. It is however important to note that any involvement of international agencies should be in full respect of sovereign choices made by low-income countries. Abdelmajid Tibouti of UNICEF New York observed for example that equity is a major challenge in many countries. “Technical and financial partners have probably a stronger support role to play, in full respect of course of options chosen by countries themselves. A first track is to network countries implementing similar policies”.
In this respect, there are some positive trends. African experts working on these issues have organised themselves in a community of practice and are using information and communication technology to share their experience and knowledge. An African regional meeting was held in Bamako in November 2011 where those involved from 10 Anglophone and Francophone countries gathered to review free care policies in maternal health. This direct exchange between countries in such communities of practice provides a critical means for learning by doing, as countries face the complex challenges of providing free health care.
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 http://heapol.oxfordjournals.org/content/26/suppl_2.toc to access the Health Policy & Planning supplement with the findings of the studies. You can contact the Financial Access Community of Practice at email@example.com.
2. Latest Equinet Updates
This publication reports from stakeholders the information and knowledge gaps and research priorities on global health diplomacy (GHD) in Africa to inform regional discussion on a research agenda for GHD. The findings indicate that research on GHD should identify factors that support the effectiveness of GHD in addressing selected key challenges to health strengthening systems in Eastern and Southern Africa, in a way that strengthens the capacity of key African policy actors and stakeholders within processes of health diplomacy. . The findings indicate a preference from officials and policy makers to do this in three broad areas: i. Firstly, to explore the implementation of existing global commitments in the region, to learn lessons from the current experience, generate evidence for input to monitoring and review of the commitments, and to inform future health negotiations. ii. Secondly, to explore the extent to which African interests are advanced in areas under global health negotiation, to assess the implications, costs and benefits of specific issues for the diverse countries in the region, and the different negotiating positions of countries in and beyond the region. iii. Thirdly to explore how effectively interests in the region are being represented in the current global architecture and governance, including of the global initiatives that fund health, to inform African engagement on global governance reforms.
The Equity Watch monitors progress in areas of equity in health, household access to the resources for health, equitable health systems and global justice. This report provides evidence on the performance of Uganda’s public policies and systems in promoting and attaining equity in health using the Equity Watch framework. The evidence presented in this report indicates progress in some key areas, such as in closing social and geographical gaps in access to education, safe water, immunisation and other areas of primary health care. It also highlights challenges, including in coverage of maternal health services and in the distribution of health workers.
3. Equity in Health
Nearly two decades after the United Nations Conference on Environment and Development (the Rio Summit), the world still needs to alleviate poverty and improve human lives through more equitable access and use of resources and healthier environments. Understanding that human health depends on ecosystems, researchers are cutting a new path toward a more sustainable future. An ecosystem approach to health, integrating research and practice from such fields as environmental management, public health, biodiversity, and economic development, is based on an understanding that people are part of complex socio-ecological systems. Featuring case studies from around the world, Ecohealth Research in Practice demonstrates innovative practices in agriculture, natural resource management, community building, and disease prevention, reflecting the state of the art in research, application, and policymaking in the field. The book demonstrates how ecohealth research works and how it has led to lasting changes for the betterment of peoples’ lives and the ecosystems that support them.
A new High-Level Taskforce on Women, Girls, Gender Equality and HIV for Eastern and Southern Africa was launched at the 16th International Conference on AIDS and STIs in Africa (ICASA). The Taskforce will engage in high-level political advocacy in support of accelerated country actions and monitoring the implementation of the draft Windhoek Declaration for Women, Girls, Gender Equality and HIV, which calls for action in seven key thematic areas including sexual and reproductive health, adopting a multi-stakeholder approach to address violence against women and HIV and the law, gender and HIV. Young women are particularly vulnerable to HIV, accounting for about 70% of young people living with HIV in sub-Saharan Africa. The Taskforce members outlined the directions the group will follow to empower women as well as to hold governments accountable to ensure positive policy development and implementation of legal environments to protect women and girls. Participants outlined the need to engage political leadership to challenge harmful cultural norms and laws such as early marriage and wife inheritance. They argued that the involvement of men and boys in the gender equality equation was equally important.
What have the Millennium Development Goals (MDGs) achieved? And what might their achievements mean for any second generation of MDGs or MDGs 2.0? The authors of this paper argue that the MDGs may have played a role in increasing aid and that beyond aid, development policies have seen some limited improvement in high income countries, but with more limited evidence of policy change in low income countries. There is some evidence of faster-than-expected progress improving quality of life in low income countries since the Millennium Declaration, but the contribution of the MDGs themselves in speeding that progress is difficult to demonstrate, even assuming the MDGs induced policy changes after 2002. The authors reflect on what the global goal setting experience of the MDGs has taught us and how things might be done differently if there is a new round of MDGs after 2015. They conclude that any MDGs 2.0 need targets that are set realistically and directly link external funding flows to social policy change and to results.
Economic indicators suggest that there are adequate global resources to guarantee the essential needs of all of the world's seven billion inhabitants. Nevertheless more than 850 million people in the world are undernourished, according to this new report by Social Watch. To monitor trends in global deprivation, Social Watch developed a basic capabilities index (BCI), which combines infant mortality rates, the number of births attended by trained personnel and enrolment rates in primary school. These indicators are considered as a ‘minimum social floor’. Nevertheless the report notes that the world is far from achieving these basic targets. The BCI rose only seven points between 1990 and 2010, and progress was faster in the first decade than the second. This trend is the opposite for trade and income, both of which grew faster after the year 2000 than in the decade before. The authors warn that the global financial crisis is likely to worsen this inverse trend. The reason for the divergence between the trends in economic and social indicators is posited to be the growing inequality within and between countries.
The primary objectives of this study were to measure within-country wealth-related inequality in the health service coverage gap of maternal and child health indicators in sub-Saharan Africa and quantify its contribution to the national health service coverage gap. Coverage data for child and maternal health services in 28 sub-Saharan African countries were obtained from the 2000–2008 Demographic Health Survey. The researchers found that, in 26 countries, within-country wealth-related inequality accounted for more than one quarter of the national overall coverage gap. Reducing such inequality could lower this gap by 16% to 56%, depending on the country, they argue. Wealth-related inequality was more common in services such as skilled birth attendance and antenatal care, and less so in family planning, measles immunisation, receipt of a third dose of vaccine against diphtheria, pertussis and tetanus and treatment of acute respiratory infections in children under five years of age. In conclusion, the contribution of wealth-related inequality to the child and maternal health service coverage gap differs by country and type of health service, warranting case-specific interventions. Targeted policies are most appropriate where high within-country wealth-related inequality exists, and whole-population approaches, where the health-service coverage gap is high in all quintiles.
Malaria mortality rates have fallen by more than 25% globally since 2000, and by 33% in the World Health Organisation (WHO) African Region, according to latest World Malaria Report. This is the result of a significant scaling-up of malaria prevention and control measures in the last decade, including the widespread use of bed nets, better diagnostics and a wider availability of effective medicines to treat malaria. However, WHO warns that a projected shortfall in funding threatens the fragile gains and that the double challenge of emerging drug and insecticide resistance needs to be proactively addressed. Long-lasting insecticidal nets have been one of the least expensive and most effective weapons in the fight against malaria. According to the new report, the number of bed nets delivered to malaria-endemic countries in sub-Saharan Africa increased from 88.5 million in 2009 to 145 million in 2010. An estimated 50% of households in sub-Saharan Africa now have at least one bed net, and 96% of persons with access to a net use it. There has also been further progress in rolling out diagnostic testing, which is crucially important to separate malaria from other febrile illnesses. The number of rapid diagnostic tests delivered by manufacturers climbed from 45 million in 2008 to 88 million in 2010, and the testing rate in the public sector in the WHO African Region rose from 20% in 2005 to 45% in 2010.
4. Values, Policies and Rights
The author of this article points to research suggesting that rape by non-military actors in the Democratic Republic of Congo may account for up to 40% of cases in the DRC, that not all rapists are men and not all victims women. She also points to the need to maintain a focus on comprehensive health care needs, noting that a humanitarian focus on rape alone creates perverse incentives, undermines more comprehensive service delivery and feeds into negative stereotypes, undermining recognition and measures to address the political crisis or areas of failure of service delivery.
As COP 17, the latest round of UN climate talks in South Africa, drew to a close Greenpeace declared that it was clear governments across the world listened to the carbon-intensive polluting corporations instead of listening to the people - people who want an end to global dependence on fossil fuels and real and immediate action on climate change. Negotiators blocking the imperative to set concrete goals, led by the United States, have succeeded in inserting a vital get-out clause that could easily prevent the next big climate deal being legally binding, according to Kumi Naidoo, Greenpeace International Executive Director. And the deal is due to be implemented 'from 2020' leaving almost no room for increasing the depth of carbon cuts in this decade when scientists say we need emissions to peak. Naidoo said that the global climate regime amounts to nothing more than a voluntary deal that’s being put off for a decade. Greenpeace campaigners decried the failure of political leadership to prosecute polluters and provide a fair, ambitious and legally binding agreement, thereby ignoring the poor in Africa and other parts of the world that stand to be most severely affected by climate change.
In this study, researchers investigated the prevalence, patterns and associated factors of intimate partner violence against women in Western Ethiopia. A cross-sectional, population based household survey was conducted from January to April 2011, using the World Health Organisation’s standard multi-country study questionnaire. A sample of 1,540 ever married/cohabited women aged 15-49 years was randomly selected from urban and rural settings of East Wollega Zone, Western Ethiopia. Results indicated that lifetime and past 12 months prevalence of intimate partner violence against women stood at 76.5% and 72.5%, respectively. The overlap of psychological, physical and sexual violence was 56.9%. Abduction, polygamy, spousal alcoholic consumption, spousal hostility and previous witnesses of parental violence were factors associated with an increased likelihood of lifetime intimate partner violence against women. The authors of the study call for immediate action at all levels of societal hierarchy, including policymakers, stakeholders and professionals, to alleviate these extremely high levels of domestic violence.
In a speech to a plenary session of the 2011 International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) in Ethiopia in December 2011, Stephen Lewis, Co-Director of AIDS-Free World, pointed to the failure globally to apply knowledge to prevent vertical transmission, and expressed concern that the same not happen in relation to the elimination of pediatric AIDS. He pointed to the profound influence of gender inequality on the spread of HIV and in the burden placed on women to manage the epidemic. He noted the cancellation of the Global Fund's Round Eleven as a "punch below the belt" that will cost Africa lives, and not acceptable at a time when funds are available to finance wars or bail out banks. He called for a high-level crisis meeting on the funding situation for HIV and AIDS, to challenge any 'right to withdraw' in those funding the Global Fund. He argued that "If the MDGs are as important as everyone says, then AIDS must be subdued".
Seychelles has one of the most extensive social policy programmes in the developing world, and has been identified as a model for the rest of Africa. This book provides comprehensive analysis of social policy development in the country from the colonial era onward, focusing on the political and economic developments that have led to the current situation. The challenge now is to maintain current levels of social policy interventions in the face of severe indebtedness and stagnant economic growth. Since the Primary Health Care convention at Alma Ata in 1978, the provision of primary healthcare for all has been achieved in the Seychelles. Private healthcare has been abolished. Public health services are comprehensive with specialised in-patient and out-patient services provided by the main hospital in Victoria. Among the most significant improvements in healthcare was the drop in maternal and child deaths, from 50 per 1000 live births in the 1960s to an average of 10 in the 2000s. Maternal deaths have become a rare occurrence. There has been continued and increasing investment in the health system throughout the past two decades, largely in response to soaring healthcare costs and changing patterns of disease.
In this study, researchers aimed to determine whether the Mexico City Policy, a United States government policy that prohibits funding to non-governmental organisations performing or promoting abortion, was associated with the induced abortion rate in sub-Saharan Africa. Women in 20 African countries who had induced abortions between 1994 and 2008 were identified in Demographic and Health Surveys. A country’s exposure to the Mexico City Policy was considered high (or low) if its per capita assistance from the United States for family planning and reproductive health was above (or below) the median among study countries before the policy’s reinstatement in 2001. The study included 261,116 women aged 15 to 44 years. A comparison of 1994–2000 with 2001–2008 revealed an adjusted odds ratio for induced abortion of 2.55 for high-exposure countries versus low-exposure countries under the policy. There was a relative decline in the use of modern contraceptives in the high-exposure countries over the same time period. In conclusion, the induced abortion rate in sub-Saharan Africa rose in high-exposure countries relative to low-exposure countries when the Mexico City Policy was reintroduced. Reduced financial support for family planning may have led women to substitute abortion for contraception, the authors argue. Regardless of one’s views about abortion, the findings may have important implications for public policies governing abortion.
This report focuses on violence documented in economically marginalised black communities against lesbian, gay, bisexual and transgendered (LGBT) people. The economic and social position of LGBT people in South Africa has a significant impact on their experience, as middle-class members of the group tend to experience less discrimination. The report documents 121 cases of discrimination, harassment, and violence both from private individuals and sometimes state agents, including in terms of police inaction or service provider unwillingness to provide services to this social group. The author highlights that this situation deviates from the equality and non-discrimination on the basis of sexual orientation guaranteed in the Bill of Rights section of the South African Constitution.
5. Health equity in economic and trade policies
Even though Africa’s mineral resources are fuelling growth and development in many industrialised and emerging economies of the world, Africa still remains poor, under-developed and dependent on external funding, according to Jean Noel Francois of the African Union’s Department of Trade and Industry. He was speaking at the opening of the second conference of African Ministers responsible for mineral resources and development held from 12-16 December 2011 in Addis Ababa, Ethiopia. Mr Francois said the 21st century’s commodity boom has alerted emerging global players to link mineral resource exploitation to infrastructure development, but Africa has yet to seize the opportunity to extract better benefits from its mineral resources to promote broad-based and integrated growth and economic development. Another presenter, Stephen Karinga, expressed frustration that Africa has not benefitted from the dramatic increase in prices for minerals since 2003 due to a number of structural weaknesses in its mineral sector. According to Karingi, in 2010, net profits for the top 40 global mining companies grew by 156% to US$110 billion, prompting countries like Australia and India to increase taxes on windfall earnings, yet Africa has been hesitant to do the same for fear of driving away mining companies.
In its Foreign Trade White Paper, China positions its foreign trade policy as based on constructing all-round economic and trade partnerships with mutually beneficial co-operation. China' s trade with Brazil, India and South Africa has been enjoying rapid growth in recent years, which the Chinese government argues promotes the development of the member countries' respective advantageous industries and shows the broad development prospects of emerging markets. In recent years China has seen relatively fast growth in its trade with other developing countries, including bilateral trade with African countries. Currently over 150 countries and regions have signed agreements on bilateral trade or economic co-operation with China, which has established and maintains high-level economic dialogue mechanisms. Although China's foreign trade is still hampered by many uncertainties and is bound to meet new difficulties and challenges, during the 12th Five-year Plan (2011-2015) the government intends to open itself wider to the outside world as a driver for further reform, development and innovation, and integrate itself into the world economy on a wider scale and at a higher level.
The tenth anniversary of the November 2001 Doha Ministerial Declaration on TRIPS (Trade-Related Aspects of Intellectual Property Rights) and Public Health was celebrated at the Symposium on Global Health Diplomacy, held in November 2011 at the World Trade Organisation (WTO) headquarters in Switzerland. According to Pascal Lamy, head of the WTO, before the declaration was issued, intellectual property (IP) protection and the WTO’s TRIPS Agreement were often considered simply to be an obstacle to public health, but stakeholders have realised the two issues are not contradictory. Lamy added that the main responsibility for ensuring coherence on the public health/IP agenda is within national governments, including how IP is handled in bilateral or regional free trade agreements. Lamy highlighted two benefits of the Declaration. First, it allowed ministers to alter the TRIPS agreement so that developing countries could use compulsory licences to manufacture generic medicines exclusively for export to countries unable to make them themselves (the Paragraph 6 system). Second, the Declaration led the WTO to scale up technical assistance to developing countries on understanding and implementing various flexibilities (such as compulsory licensing and parallel importing) in the TRIPS Agreement.
The Deputy Chairperson of the African Union (AU) Commission, Erastus Jarnalese Onkundi Mwencha, says the structure of the economic partnership agreement between the continent and the European Union is not to Africa’s advantage, arguing instead for regional integration. He explained that regional integration will help develop larger markets, foster greater competition and improve the policy stance in many areas of the development agenda. Progress towards increased intra-African trade as a major objective of an economic integration agenda has been less than impressive, he added. The structures of African economies have been intended to produce raw materials for export. Mwencha argues that African countries need to add value to their raw materials and use the rest of the continent as a base for industrialisation and trade.
According to the World Health Organisation, the right mix of climate change mitigation policies for the housing sector could lead to very large health co-benefits, including reductions in noncommunicable and infectious diseases. Non-communicable diseases can be reduced through mitigation measures that: reduce exposure to extreme heat and cold; reduce mould and dampness; improve natural ventilation and provide for safer, more energy-efficient home heating and appliances. There is also evidence that housing improvements increase well-being and mental health. Infectious diseasescan be prevented through low-energy and climate-friendly designs to: improve natural ventilation; limit vector and pest infestations (e.g. sealing of cracks, window screening); and improve access to safe drinking water and sanitation as part of planning and siting. Good ventilation is critical to ensure health gains from energy-efficient and weather-tight housing, as insufficient natural ventilation is associated with higher risk of airborne disease transmission, dampness and accumulation of indoor pollutants that are risk factors for allergies and asthma. Energy-efficient biomass and gas cookstoves can help avert a large proportion of chronic obstructive pulmonary disease in poor countries by reducing exposure to indoor cookstove smoke.
Low-carbon transport measures can provide ‘win-win’ options for developed and developing countries that benefit health as well as reducing climate change, suggests this new report by the World Health Organisation, launched at COP17 in Durban, South Africa on 6 December 2011. Among the measures are better systems for rapid transit, walking and cycling, as well as urban land use that emphasises greater ‘access’ to key destinations by these modes. These strategies all can help to: promote physical activity, which can prevent heart disease some cancers and type 2 diabetes; reduce health-harming air pollution exposures; and reduce injury risks when cycle/pedestrian networks are made safer.
According to this study, Malawi’s anti-money laundering (AML) framework has revealed that the main sources of ill-gotten money in the country are corruption and tax evasion, including trade mispricing. Other prevalent forms of crime for profit in Malawi are smuggling of (counterfeit) goods, the production and export of cannabis, organised motor vehicle theft, violent housebreakings, human trafficking and labour exploitation. According to World Bank estimates, income derived from corruption amounts to about 5% of gross domestic product (GDP) in Malawi, while tax evasion constitutes about 8-12% percent of GDP. However, the authors of the study note that these estimates should be treated with caution, as they are not conclusive. The Malawi Revenue Authority is reported to have recovered millions of Kwacha by using the AML tools available to it. Namibia is also reported to be implementing its AML system since May 2009. Further in that country tax evasion stands at an estimated 9% of GDP.
The international trade union movement has warned of growing social unrest and increased social hardship if trade liberalisation continues against the backdrop of harsh unemployment and austerity measures. Sharan Burrow, General Secretary International Trade Union Confederation (ITUC), said that the World Trade Organisation (WTO) has done nothing to prevent trade imbalances growing to unsustainable levels accompanied by dangerously widening income inequality. Burrow expects that the deal emerging from the eighth meeting of Trade Ministers in Geneva 15 -17 December 2011 will not help trade to drive economic recovery, employment creation and genuine economic development, and ultimately puts the multilateral trading system at risk. The ITUC is calling for an evaluation of the Doha round outcomes to assess its impact on providing decent work, improved living standards and diversifying the economies of developing countries. It argues that, without measuring the impact on developing countries and workers, it makes little sense to move forward with trade liberalisation.
On 15 November 2011, least-developed countries (LDCs) tabled a proposal on extending the current deadline of 1 July 2013 for them to implement the World Trade Organisation's (WTO) TRIPS Agreement, which affects patents on medicines and access to medicines in their countries. The proposal has been submitted for the upcoming eighth WTO Ministerial Conference (MC8) taking place in Geneva from 15-17 December 2011. The proposal recognises that LDCs continue to face serious economic, financial and administrative constraints in their efforts to bring their domestic legal system into conformity with the provisions of the TRIPS Agreement. It also takes note of the challenges faced by most LDCs to submit their priority needs for technical and financial co-operation under the Decision of 29 November 2005 and the lack of resource mobilisation to support their individual priority needs. The proposal recalls the commitment by Developed Country Members to provide enhanced technical and financial co-operation in favour of LDCs to assist them in implementing the TRIPS Agreement and develop a viable technological base in line with their special needs and requirements.
The author of this book argues that natural resources in Africa are a blessing, but the way they are plundered and used has turned them into a curse. Rich in natural resources, Africa has for a long time been a net supplier of energy and raw materials to the North. The current global climate crisis is rooted mainly in the wealthy economies' abuse of fossil fuels, indigenous forests and global commercial agriculture. But, without agreement about how to tackle this reality, the question often simply becomes ‘What can be done about Africa?’ rather than ‘What can we do together?’ Bassey examines the oil industry in Africa, probes the roots of global warming, warns of its insidious impacts and explores false 'solutions'. He demonstrates that the issues around natural resource exploitation, corporate profiteering and climate change must be considered together if Africa and the rest of the world are to save ourselves.
6. Poverty and health
One of the lingering effects of the food price crisis of 2007–08 on the world food system is the proliferating acquisition of farmland in developing countries by other countries seeking to ensure their food supplies. Increased pressures on natural resources, water scarcity, export restrictions imposed by major producers when food prices were high, and growing distrust in the functioning of regional and global markets have pushed countries short in land and water to find alternative means of producing food. These land acquisitions have the potential to inject much-needed investment into agriculture and rural areas in poor developing countries, but they also raise concerns about the impacts on poor local people, who risk losing access to and control over land on which they depend. the authors argue that it is crucial to ensure that these land deals, and the environment within which they take place, are designed in ways that will reduce the threats and facilitate the opportunities for all parties involved.
In Africa, agricultural land covers less than 15% of the land area, yet demand from transnational companies is increasing for arable terrain, driven by the assumption that biofuels are a viable long-term solution to current energy and ecological challenges, combined with a decline in land allocated to agriculture in developed countries. The inclusion of biofuels as part of the green economy agenda jeopardises the immediate and long-term food security of many regions in the developing world, according to this paper. In sub-Saharan Africa, rising food prices, land grabs, and precarious and informal labour conditions are key social threats linked to the emphasis on biofuel production. In Africa, a region already under pressure from population growth, famine, drought and conflict, increases in biofuel production and concomitant land grabs can only contribute to weakening food security and keeping achievement of the Millennium Development Goals far beyond reach.
Archaic agricultural practices and erratic rainfall in the recent planting period is expected to lead to an increase in food insecurity for most of Swaziland's 1.1 million people in 2012, according to Thembumenzi Dube, a Swazi government agriculture official. He predicted that the country will soon need food assistance for most of its population. Rains failed during the October planting season in the usually productive central middleveld, as well as the generally drought-prone eastern and southern regions. The virtual absence of irrigation systems makes the country dependent on rainfall. Small-scale farmers, who depend on rain-fed agriculture, do not have title deeds, and so cannot use their land as collateral to secure loans for irrigation equipment or other improvements.
The objective of this study was to assess the status of food security in South Africa. The authors conducted a systematic search of national surveys that used the Community Childhood Hunger Identification Project (CCHIP) index to measure food security in South Africa over a period of 10 years (1999–2008). Anthropometric data for children aged 1–9 years were used to assess food utilisation, and household food inventory data were used to assess food availability. The authors found that only three national surveys had used the CCHIP index, namely, the 1999 and 2005 National Food Consumption Surveys (NFCS) and the 2008 South African Social Attitudes Survey. These surveys showed a relatively large decrease in food insecurity between 1999 and 2008. However, the consistent emerging trend indicated that in poorer households women were either feeding their children a poor diet or skipping meals so their children could eat. In terms of food access and availability, the 1999 NFCS showed that households that enjoyed food security consumed an average of 16 different food items over 24 hours, whereas poorer households spent less money on food and consumed fewer than 8 different food items. Moreover, children had low mean scores for dietary diversity and dietary variety scores. In terms of food utilisation, the NFCS showed that stunting in children decreased from 21.6% in 1999 to 18% in 2005. Despite these improvements, the authors conclude that the South African government still needs to implement measures to improve the undesirably high level of food insecurity in poorer households.
The vast majority (70%) of the world’s population is fed and nourished by local, ecological systems of food production, according to this paper. But these systems are severely threatened and undermined by industrial systems of agriculture that are controlled by corporations and promoted by governments. These industrial systems have exacerbated or even created the multiple crises of rising food prices, poverty, climate change and biodiversity loss. The Food Sovereignty movement prioritises the protection of domestic and local agricultural production. This will require a fundamental shift in global trade rules, resulting in less international trade. Long-distance trade in foods should focus on those things which cannot be produced in every region, such as traditional ‘cash crops’ of coffee and tea. And if international trade in goods such as coffee, tea and bananas is to continue, and to still contribute to food sovereignty through the rediversification of local economies and environmental protection, it must follow the principle of ‘Fair Trade Miles’. This involves a mixture of ‘fair trade’ and the limiting of ‘miles’ between producer and consumer in order to minimise fossil fuel contributions to climate change. The creation of national and regional common markets is crucial, as well as a changing the aim of international trade to favour localism, rather than global competitiveness.
According to this policy brief, significant gains for both health and climate can be attained by providing access to clean cookstoves and fuels for the 2.7 billion people still dependent on the use of rudimentary, traditional biomass and coal stoves. These stoves are estimated to directly cause about two million deaths annually, including over one million deaths from chronic obstructive pulmonary disease and almost another million deaths from pneumonia in children under the age of five. The World Health Organisation estimates that 11% of all chronic lung disease burden in Latin America and sub-Saharan Africa among adults over 30 could be averted in less than a decade by the introduction of more advanced biomass or biogas stoves, in pace with United Nations targets for universal energy access, which would also help avoid 17% of all pneumonia deaths among children under five in the same regions. Recent evidence suggests that exposure to indoor air pollution is also associated with non-communicable diseases such as heart disease, stroke, cataract and cancers, notably lung cancer.
There is concern that increased consumption of palm oil could exacerbate mortality from ischemic heart disease (IHD) and stroke, particularly in developing countries where it represents a major nutritional source of saturated fat. The authors of this study analysed country-level data from 1980-1997 derived from the World Health Organisation's Mortality Database, United States Department of Agriculture international estimates, and the World Bank (234 annual observations; 23 countries). They found that, in developing countries, for every additional kilogram of palm oil consumed per-capita annually, IHD mortality rates increased by 68 deaths per 100,000, whereas, in similar settings, stroke mortality rates increased by 19 deaths per 100,000 but were not significant. Inclusion of other major saturated fat sources including beef, pork, chicken, coconut oil, milk cheese, and butter did not substantially change the differentially higher relationship between palm oil and IHD mortality in developing countries. The authors urge policy makers to consider palm oil consumption as a saturated fat source relevant for policies aimed at reducing cardiovascular disease burdens.
The Food Sovereignty Campaign is a movement of emerging farmers and farm dwellers is based in the Western and Northern Cape provinces. They point out that while property rights are enshrined in the constitution of the country, in a land reform programme based on a ‘willing buyer, willing seller’ model, land is being priced out of reach of the poor and of the state. The authors argue that there is no provision in law, as in Brazil, to allow hungry people to grow food on unused land of absent owners. Land occupations are happening in South Africa, fuelled by growing frustration among the rural poor due to persistent and unaddressed inequality. The Food Sovereignty Campaign argues that land occupations are an expression amongst small farmers and farm dwellers of their frustration over their landlessness, powerlessness and exploitation.
7. Equitable health services
This study reported on a participatory quality improvement intervention designed to evaluate TB, HIV and STI priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal, South Africa. A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified. The researchers highlighted weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. Eighty percent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for anti-retroviral therapy and starting treatment was 47 days. Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level.
Ownership of insecticidal mosquito nets has dramatically increased in Ethiopia since 2006, but the proportion of persons with access to such nets who use them has declined. The authors of this study argue that it is important to understand individual level net use factors in the context of the home to modify programmes so as to maximise net use. They investigated net use using individual level data from people living in net owning households from two surveys in Ethiopia: baseline 2006 included 12,678 individuals from 2,468 households and a sub-sample of the Malaria Indicator Survey (MIS) in 2007 included 14,663 individuals from 3,353 households. In both surveys, they found that net use was more likely by women, if nets had fewer holes and were at higher net per person density within households. School-age children and young adults were much less likely to use a net. Increasing availability of nets within households (i.e. increasing net density), and improving net condition while focusing on education and promotion of net use, especially in school-age children and young adults in rural areas, are crucial areas for intervention to ensure maximum net use and consequent reduction of malaria transmission.
An ongoing Phase 3 study of the efficacy, safety and immunogenicity of candidate malaria vaccine RTS,S/AS01 is being conducted in seven African countries, including Ghana, Kenya, Malawi, Mozambique and Tanzania. From March 2009 through January 2011, 15,460 children were enrolled in two age categories - 6 to 12 weeks and 5 to 17 months old - for vaccination with either RTS,S/AS01 or a non-malaria comparator vaccine. After 250 children had an episode of severe malaria, researchers evaluated vaccine efficacy in both age categories. Vaccine efficacy in the combined age categories was 34.8% during an average follow-up of 11 months. Serious adverse events occurred with a similar frequency in the two study groups. Among children in the older age category, the rate of generalised convulsive seizures after vaccination was 1.04 per 1,000 doses. The researchers conclude that the RTS,S/AS01 vaccine provided protection against both clinical and severe malaria in African children.
While hospitals and health clinics are not a specific focus of mitigation assessment by the Intergovernmental Panel on Climate Change, this policy brief notes that adoption of safe and sustainable building measures by health facilities will offer more health co-benefits than the same measures applied to other commercial buildings. This is partly due to health facilities’ large demands for reliable energy, clean water and temperature/air flow control in treatment and infection prevention. Significant health gains also can be expected from specific interventions, such as the use of natural ventilation as an effective energy-saving and infection-control measure. Resilience of health care services may be enhanced through use of (clean) onsite energy co-generation that ensures more reliable energy supply in cities where frequent energy outages occur, and particularly in remote, resource-poor settings, where a basic electricity supply will allow life-saving procedures to be performed. Health risks to health workers, patients and communities will be reduced by improved management of health care and waste – and so will the carbon footprint. The health care sector is well-positioned to ‘lead by example’, the World Health Organisation argues, in terms of reducing climate change pollutants and by demonstrating how climate change mitigation can yield tangible, immediate health benefits.
In southern coastal Kenya, insecticide-treated bed net use was negligible in 1997-1998 but since 2001, bed net use has increased progressively and reached high levels by 2009-2010 with corresponding decline in malaria transmission. In this study, researchers evaluated the impact of the substantial increase in household bed net use in this area. Compared to 1997-1998, and following more than five years of 60-86% coverage with bed nets, the density, human biting rate and entomological inoculation rate of indoor-resting mosquitoes were reduced by more than 92% for Anopheles funestus and by 75% for An. gambiae. In addition, the host feeding choice of both vectors shifted more toward non-human vertebrates. Besides bed net use, malaria vector abundance was also influenced by type of house construction and according to whether one sleeps on a bed or a mat (both of these are associated with household wealth). Mosquito density was positively associated with presence of domestic animals. The researcher conclude that, while increasing bed net coverage beyond the current levels may not significantly reduce the transmission potential of An. arabiensis, they anticipate that increasing or at least sustaining high bed net coverage will result in a diminished role for An. funestus in malaria transmission.
8. Human Resources
This study compares what is known about insecticide-treated nets (ITNs) to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). In the survey, few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: training in acquiring systematic reviews through the Cochrane Library and ability to read and write English well or very well. Statistically significant factors associated with better clinical practices within each country included: reading scientific journals from their own country; working with researchers to improve their clinical practice or quality of working life; training on malaria prevention since their last degree; and easy access to the internet. The researchers conclude that improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilisation and preventing malaria. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.
Lay health workers are key to achieving universal health-care coverage, therefore measuring worker attrition and identifying its determinants should be an integral part of any lay health worker programme. Both published and unpublished research on lay health workers has largely focused on the types of interventions they can deliver effectively. This is an imperative since the main objective of these programmes is to improve health outcomes. However, high attrition rates can undermine the effectiveness of these programmes. There is a lack of research on lay health worker attrition, the authors of this paper note. Research that aims to answer the following three key questions would help address this knowledge gap. What is the magnitude of attrition in programmes? What are the determinants of attrition? What are the most successful ways of reducing attrition? With community-based interventions and task shifting high on the United Nations Millennium Development Goals’ policy agenda, research on lay health worker attrition and its determinants requires urgent attention, the authors conclude.
The objective of this study was to estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States. Researchers calculated the financial cost of educating a doctor in nine source countries with a high HIV and AIDS burden (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), which ranged from US $21,000 in Uganda to $58,700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn, with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m). They conclude that destination countries should consider investing in measurable training for source countries and strengthening of their health systems.
9. Public-Private Mix
Markets for life-saving vaccines do not often generate the most desired outcomes from a public health perspective in terms of product quantity, quality, affordability, programmatic suitability and/or sustainability for use in the lowest income countries, according to this paper. The perceived risks and uncertainties about sustainably funded demand from developing countries often leads to underinvestment in development and manufacturing of appropriate products. The pilot initiative Advance Market Commitment (AMC) for pneumococcal vaccines, launched in 2009, aims to remove some of these market risks by providing a legally binding forward commitment to purchase vaccines according to predetermined terms. To date, 14 countries have already introduced pneumococcal vaccines through the AMC with a further 39 countries expected to introduce before the end of 2013. The authors of this paper describe early lessons learnt on the selection of a target disease and the core design choices for the pilot AMC. They highlight the challenges faced with tailoring the AMC design to the specific supply situation of pneumococcal vaccines and points to the difficulty – and the AMC’s apparent early success – in establishing a long-term, credible commitment in a constantly changing unpredictable environment. One of the inherent challenges of the AMC is its dependence on continuous external funding to ensure long-term purchases of products. The authors examine alternative design choices and aim to provide a starting point to inform discussions and encourage debate about the potential application of the AMC concept to other fields.
This paper examines the experuence of the the new Queen Mamohato Memorial Hospital, a US$120 million privately financed hospital in Lesotho's capital Maseru, the first in Africa to be built through a “Public Private Investment Partnership” (PPIP). According to the World Bank, the new hospital is supposed to operate as the national referral hospital as well as the district hospital for the greater Maseru area. It was built and is run by a consortium headed up by South African private medical giant Netcare, and replaced the Queen Elizabeth II Public Hospital. In return, the Lesotho government will pay a US$32.6m index-linked annual ‘unitary charge’ to Netcare for the hospital and services, representing a 100% increase in costs from the 2007/08 budget and despite the fact that the government had already invested $62 million in the project. The new hospital is expected to treat all patients who present, up to a maximum of 20,000 in-patient admissions and 310,000 outpatient attendances annually, against an estimated need of 64,000 patients annually. The annual charge for the hospital is a third of Lesotho’s recurrent health budget. The author suggests that this can distort national health spending, especially for the expansion of primary health care for Lesotho’s majority rural population. The unfavourable terms of the contract are traced back to an imbalance in expertise among those negotiating the contract terms. The authors questioned why the International Finance Corporation, who acted as consultants on the project, failed to support the Lesotho negotiators to prevent these unfavourable terms.
10. Resource allocation and health financing
The demand for induced abortions in Uganda is high despite legal and moral proscriptions. Abortion seekers usually go to illegal, hidden clinics where procedures are performed in unhygienic environments by under-trained practitioners. This study was performed to estimate the costs associated with induced abortions in Uganda. Data were obtained from a primary chart abstraction study, an on-going prospective study, and the published literature. Results showed that the average societal cost per induced abortion was US$177, equivalent to $64 million in annual national costs. Of this, the average direct medical cost was $65 and the average direct non-medical cost was $19. The average indirect cost was $92, while patients incurred $62 costs on average while government incurred $14 on average. In conclusion, induced abortions are associated with substantial costs in Uganda and patients incur the bulk of the healthcare costs. This reinforces the case made by other researchers - that efforts by the government to reduce unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions are critical.
At the 16th International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA), held in December 2011 in Ethiopia, the Global Fund announced that it has put transitional funding mechanisms in place to ensure continued treatment for people living with HIV and AIDS. The mechanisms will bridge funding gaps that may arise following delayed payments by those who had pledged contributions to the Fund. In November 2011 the Fund adopted exceptional measures to suspend Round 11 but denied that the Fund is in financial trouble, arguing that only one of its funders has announced a decrease in funding. It identified the main problem as delayed payments. According to United States president, Barack Obama, the Fund remains on track to support more than US$8 billion in grant renewals and new grant commitments between 2011 and the end of 2013. The Fund is undergoing reforms to allow it to transition to a more flexible, sustainable and predictable funding model that will ensure that resources go to high-impact interventions and to people who need the help most. The Board has also taken steps to better target Global Fund resources on countries with the greatest need and least ability to pay. The article indicates that this means that at least 55% of Fund resources will be directed to low-income countries.
Speaking at the opening of the national consultative health forum’s National Health Insurance (NHI) conference on 7 December 2011, Organisation for Economic Co-operation and Development economist Ankit Kumar said South Africa should look to South Korea, which achieved universal health care for its entire population in just 12 years by investing in a strong primary healthcare system, eliminating fragmentation and containing hospital prices. South Koreans achieved universal coverage by starting the rollout of health insurance with the informal labour market before gradually expanding coverage to the formal labour market. In preparation for the roll out of South Africa’s NHI, the country’s Health Minister, Aaron Motsoaledi, reiterated his call for the establishment of a pricing commission to tackle uncontrolled commercialism and the exorbitant cost of private healthcare. Fragmentation in the form of private health care for the wealthy and public health care for the poor was also contributing to low levels of access to health care, he added.
This study focuses on two main areas, namely aid agency effectiveness (cost effectiveness of agencies) and aid policy effectiveness (the cost of parallel development policy making). Whereas other areas of the Paris agenda are equally important (like ownership, mutual accountability, and a focus on results), this study explored the costs, and put a price-tag on not implementing the Paris agenda. The study reviewed the aid effectiveness literature to date, most of which point to benefits of coordination. The European Commission found direct savings for the European Union (EU) through lower administrative costs from harmonising, from reducing the number of partner countries, changing the aid modality towards Budget Support (general or sectoral), untying aid and eliminating aid volatility. The total efficiency gains were estimated at € 5 billion per year.
In 2001, the World Health Organisation’s Commission for Macroeconomics and Health (CMH) released its report, ‘Macroeconomics and Health: Investing in health for economic development’, urging the international community to invest substantially in health as a means of promoting development. According to this article, many observers credit the report as one of the key drivers for successfully raising the profile of global health in the international arena and promoting the long-neglected link between health and wealth. But reports on the success of the Commission are mixed. Howard Stein of the University of Michigan criticises the Commission for failing to mention the causes of poverty and poor health, including the gross inequities of the global economy caused by neoliberalism, suggesting that this is a consequence of the fact that most Commission members supported neoliberal economic policies at the time. Although at least 60 countries now offer a basic health care package, the concept failed to be supported by external funders, who continue to fund specific vertical interventions rather than an integral set of services. The Commission expected the pharmaceutical industry to voluntarily lower prices, which the authors argue has not happened.
11. Equity and HIV/AIDS
The recent rise of health systems strengthening as a policy priority suggests that a move away from single-disease approaches to global health may be occurring. As the largest attempt by far to tackle one disease, the global AIDS effort has acted as a lightning rod for criticisms of global health initiatives focused on single diseases, according to the author of this paper. Global AIDS institutions have sought to respond by broadening their mandates to incorporate some wider systemic interventions into their activities. However, as the debate over addressing particular diseases or investing in health systems continues, five important underlying political and ethical questions are being neglected, including whether there is an ideal health system, the timescales involved, the definition of sustainability, governance/structural capacity and political will. If a more sustained and coordinated effort to improve health outcomes is to become a reality, these difficult questions will need to be tackled, the author concludes.
Speakers at a session on stigma at the 16th International Conference on AIDS and Sexually Transmitted Infections in Africa, held in December 2011 in Ethiopia, noted that HIV patients in Africa frequently suffer shame and depression but the continent’s health systems were ill-equipped to handle the issue, which not only affected their quality of life, but could lead to poor adherence to HIV treatment regimens. They said while HIV programmes focus heavily on reducing externalised stigma and ill-treatment of HIV patients by society, little is done to deal with a patients’ self-perception and how that might deteriorate following an HIV diagnosis. Studies from Zambia and Uganda have shown that depression is the most common psychiatric disorder among people living with HIV, and is more prevalent among HIV-positive people than in the general population. The Mbabane Mental Health Support Group, an advocacy group from Swaziland, calls for the integration of mental health services into primary healthcare as well as that of HIV positive people.
Published data on adherence to antiretroviral therapy (ART) in Kenya is limited. This study assessed adherence to ART and identified factors responsible for non-adherence in Nairobi. This is a multiple facility-based cross-sectional study, where 416 patients aged over 18 years were systematically selected and interviewed using a structured questionnaire about their experience taking ART. Additional data was extracted from hospital records. Overall, 403 patients responded: 35% males and 65% females, of whom 18% were non-adherent, and the main (38%) reasons for missing therapy were being busy and forgetting. Accessing ART in a clinic within walking distance from home and difficulty with dosing schedule predicted non-adherence. The study found better adherence to HAART in Nairobi compared to previous studies in Kenya. However, the authors argue that adherence can be improved further by employing fitting strategies to improve patients' ability to fit therapy into their lifestyles and implementing cue-dose training to impact forgetfulness. Further work to determine why patients accessing therapy from ART clinics within walking distance from their residence did not adhere is recommended.
A meeting to address issues around HIV and men who have sex with men went ahead as scheduled in Addis Ababa, Ethiopia, on 3 December 2011, despite protests and calls for its cancellation by local religious leaders. The meeting - held a day before the opening of the 16th International Conference on AIDS and Sexually transmitted infections in Africa (ICASA) - was organized by the South African-based NGO, African Men for Sexual Health and Rights (AMSHeR). Originally due to be held at a local hotel, the venue quietly shifted to the UN compound in Addis Ababa. According to participants, it attracted more than 150 participants from 25 African countries, and focused on addressing the problems MSM faced in accessing HIV services. Speakers included UNAIDS executive director, Michel Sidibe. Before the meeting, four religious leaders had called a press conference to denounce it. Ethiopia's Minister of Health, Tedros Adhanom Ghebreyesus, persuaded them to cancel the press conference. Even at the new venue, there were hundreds of protesters outside for half the day, said one participant, Homosexuality is illegal in Ethiopia and punishable by between three and 10 years in prison. While the government allowed the meeting to go ahead, gay rights activists doubt it will lead to a positive change for MSM in Ethiopia.
This National Strategic Plan (NSP) has four strategic objectives, which will form the basis of the HIV, STI and TB response: address social and structural barriers to HIV, sexually transmitted infection (STI) and TB prevention, care and impact; prevent new HIV, STI and TB infections; sustain health and wellness; and increase protection of human rights and improve access to justice. The NSP is driven by a long-term 20-year vision for the country with respect to the HIV and TB epidemics, adapting the Three Zeros advocated by UNAIDS, and additional one for discrimination: zero new HIV and TB infections; zero new infections due to vertical transmission (mother-to-child); zero preventable deaths associated with HIV and TB; and zero discrimination associated with HIV and TB. In line with this 20-year vision, the NSP has the following broad goals: reduce new HIV infections by at least 50% using combination prevention approaches; initiate at least 80% of eligible patients on antiretroviral treatment (ART), with 70% alive and on treatment five years after initiation; reduce the number of new TB infections as well as deaths from TB by 50%; ensure an enabling and accessible legal framework that protects and promotes human rights to support implementation of the NSP; and reduce self-reported stigma related to HIV and TB by at least 50%.
On 1 December 2011, World AIDS Day, United States (US) President, Barack Obama, pledged to provide antiretroviral treatment to some six million people globally by 2013, an increase of two million on the previous target. However, there will still be no increase in funding from the US President's Emergency Plan for AIDS Relief (PEPFAR), which pledged US$48 billion in 2008 for five years. Consequently, although costs of HIV and AIDS programmes have come down, PEPFAR is having to look at smarter programming and greater efficiencies to increase roll out. PEPFAR noted that the US was also working to persuade other wealthy countries, such as China, Germany and Sweden, to take greater responsibility in the fight against HIV and AIDS. Obama's announcement has been welcomed with cautious optimism in developing countries, who are concerned that the rich countries of the North may not keep their pledges to the Global Fund – the main HIV and AIDS funder for many poor countries – in the current global recession.
On 3 December 2011, a meeting was held at the All-Africa AIDS Conference (ICASA) addressing the health and human rights of African men who have sex with men (MSM) and the lesbian, gay, bi and intersex (LGBTI) community in general. The meeting was attended by global agencies, including UNAIDS and the African Commission on Human Rights, but by few international non government organisations. Speakers from the United States (US) President’s Fund for Emergency AIDS Relief (PEPFAR) and the African Commission outlined the health needs of MSM in Africa regarding their vulnerability to HIV and AIDS. They made commitments to scale up efforts in this area. Participants called for public health and human rights approaches to be more inclusive, to take into account the full spectrum of LGBTI health issues, including violence, victimisation, psychiatric disorders and substance abuse.
12. Governance and participation in health
This paper presents the findings of a systematic literature review of: (a) the evidence of HFCs' effectiveness, and (b) the factors that influence the performance and effectiveness of HFCs. Four electronic databases and the websites of eight key organizations were searched. Out of 341 potentially relevant publications, only four provided reasonable evidence of the effectiveness of HFCs. A further 37 papers were selected and used to draw out data on the factors that influence the functioning of HFCs. The review found some evidence that HFCs can be effective in terms of improving the quality and coverage of health care, as well as impacting on health outcomes. However, the external validity of these studies is inevitably limited. Given the different potential roles and functions of HFCs and the complex and multiple set of factors influencing their functioning, the authors argue that there is no ‘one size fits all’ approach to CPH via HFCs, nor to the evaluation of HFCs. However, there are plenty of experiences and lessons in the literature which decision makers and managers can use to optimize HFCs.
On 1 December 2012, the final day of the Fourth High-level Forum for Aid Effectiveness held in Korea, the International Dialogue on Peace-building and State-building – consisting of the G7+ group of 19 fragile and conflict-affected countries, development partners and international organisations – signed a ‘New Deal’ of development architecture for fragile states. It builds on vision and principles from a range of international agreements, including the Paris Declaration on Aid Effectiveness, the Accra Agenda for Action and the Millennium Development Goals, and will be implemented in a trial period from 2012 to 2015. Signatories have agreed to use five peace-building and state-building goals (PSGs): foster inclusive political settlements and conflict resolution, establish and strengthen people’s security, address injustices and increase people’s access to justice, generate employment and improve livelihoods, and manage revenue and build capacity for accountable and fair service delivery. They further commit to support inclusive country-led and country-owned transitions out of fragility, using the PSGs to monitor progress, and to support inclusive and participatory political dialogue. Mutual trust will be fostered by providing reliable external funding, managing resources more effectively and transparently, and aligning resources for results.
Between 26 April and 5 May 2011, 1,000 people were surveyed in Mozambique by Transparency International. The data were weighted by age, gender and region to represent the population of 5,852,280 Mozambicans. The study found that 68% of people reported having paid a bribe in the past year. Fifty-six percent of respondents believed that corruption had got worse, with the remainder evenly divided in their perceptions of corruption having improved or remained the same. More than a third of those using health services or education reported that they had to pay a bribe in the 12 months before the survey was conducted. Of these about 60% had to pay a bribe to ‘speed things up’, 20% had to pay a bribe to avoid problems with authorities, and the remainder had to pay to receive a service to which they were already entitled. Thirty-seven percent paid a bribie less than US$30, while 42% paid a bribe between $30-99. The minimum annual wage ranges from $54 for farm workers to $173 for financial sector employees.
In recent years, the transparency of foreign aid has received substantial attention among aid practitioners. This analysis shows the impact of political transparency in donor countries on those countries’ formal promotion of aid transparency and on their concrete aid allocation patterns. Political transparency as measured by standard corruption indices not only impacts on the engagement of bilateral external funders (donors) in the International Aid Transparency Initiative. Differences in political transparency in donor countries also explain a large part of their varying aid selectivity patterns. External funders with higher levels of political transparency allocate aid more according to recipients’ neediness and institutional performance.
The International Aid Transparency Initiative (IATI) Steering Committee has approved the creation of a CSO-led working group to discuss application of the IATI standard to the work of civil society organisations (CSOs) and non-governmental organisations (NGOs) or not-for-profit organisations. Building on the Accra Agenda for Action and IATI outcomes to date, the working group will examine the IATI standard in the light of existing CSO and NGO accountability frameworks and self-regulatory mechanisms. It will take into account the particular characteristics of CSOs and NGOs as development and humanitarian assistance actors, as well as the different operating environments that shape CSO responses to demands for greater accountability and transparency. The working group’s primary objective is to encourage the participation of civil society and not-for-profit actors in IATI by developing practical proposals on guidelines and tools to assist CSOs who wish to publish IATI-compatible data. Early priorities include the identification of information that is already being shared or could be reported by CSOs in the short- and medium-term and the development of protocols for exclusions of data where appropriate on privacy or security grounds.
With a range of new development actors at hand, such as China and Brazil, Africa’s position has been strengthened, according to this paper. Africans must decide which partner can best serve their various interests. The authors argue that the European Union (EU) is a good candidate to support capacity in financial administration, regional integration, good governance, and peace and security. To be recognised as such, the EU should stand by its partnership approach and avoid unilateral initiatives towards the continent. However, Africans may perceive EU support as coming at too high a price in terms of values conditionality. In that case, it may choose other partners to rely on. Some applaud an EU move to increase conditionality in its overseas development assistance (ODA). The depth of the euro crisis suggests that after a decade of rising European ODA, the world is now entering a period in which EU ODA will stagnate, though some member states may still manage increases. Further details regarding the Green Climate Fund to cover the costs of climate change also need to be clarified. At some stage Europe, along with other developed parts of the world, will need to meet that obligation. Funding requirements for environmental and other global public goods remains high, but the EU is unlikely to be able to contribute as much as in the past. Old certainties therefore are changing and those who have relied on European support will have little choice but to look elsewhere.
The May 2010 adoption of the World Health Organization Global Code of Practice on the International Recruitment of Health Personnel created a global architecture, including ethical norms and institutional and legal arrangements, to guide international cooperation and serve as a platform for continuing dialogue on the critical problem of health worker migration. Highlighting the contribution of non-binding instruments to global health governance, this article describes the Code negotiation process from its early stages to the formal adoption of the final text of the Code. Detailed are the vigorous negotiations amongst key stakeholders, including the active role of non-governmental organizations. The article emphasizes the importance of political leadership, appropriate sequencing, and support for capacity building of developing countries¹ negotiating skills to successful global health negotiations. It also reflects on how the dynamics of the Code negotiation process is evidence of an evolution in global health negotiations amongst the WHO Secretariat, civil society, and WHO Member States.
13. Monitoring equity and research policy
Unless African governments increase their funding for and engagement in HIV research, the continent cannot hope to attain equal status in determining its research agenda and priorities, speakers said at the 16th International Conference on AIDS and Sexually Transmitted Infections (STIs) in Africa, held in December 2011 in Ethiopia. Most African health research is driven by external funders, which often means that research starts and ends on the say-so of the funders, rather than being based on a country's needs. Prof Nelson Sewankambo, principal of the College of Health Sciences at Uganda's Makerere University, said heavy external funder involvement in local research can actually harm existing national institutions, which may lose strategic direction and become retarded by the loss of key staff to research projects and distortion of institutional structures and governance. He argued that inequities in collaboration can lead to lack of transparency in the decision-making process, as well as disputes over publication rights, ownership of data, specimens and equipment. Other speakers also noted that inadequate community engagement was common when partnerships were skewed in favour of funders’ priorities and ethical violations occurred in research projects, such as the use of placebos in studies on mother-to-child HIV transmission. They called for new, more equitable partnership models and expansion of local capacity to sustain research activities once externally funded projects ended.
In the context of recent global calls for strengthening the field of health policy and systems research (HPSR) as a critical input to strengthening health systems, the authors of this paper assessed the extent to which progress has been achieved in this regard. Two sources of data were used: a bibliometric analysis to assess growth in production of HPSR between 2003 and 2009, and a 2010 survey of 96 research institutions to assess capacity and funding availability to undertake HPSR. Both analyses focused on HPSR relevant to low-income and middle-income countries (LMICs). Overall, the authors found an increasing trend of publications on HPSR in LMICs, although only 4% were led by authors from low-income countries (LICs). Improvements were noted in infrastructure of research institutions in LICs, but more limited gains in the level of experience of researchers within institutions. There has been only a modest increase in availability of funding for LICs.
14. Useful Resources
This tool is a portal that is intended to provide public health practitioners with all the necessary information they need on the social determinants of health (SDH). ACTION:SDH houses knowledge on the SDH and provides a platform for discussion of action on the SDH. The World Health Organisation (WHO) invites everyone in the SDH community to register on ACTION:SDH. WHO is also actively seeking partners interested in collaborating in building up the tool, together with its users. There are three main features: embedded web-pages pages on SDH knowledge relevant to the five action areas for SDH that were identified in the Rio Declaration of October 2011; discussion forums that can be used to share tacit knowledge from practice - either by invitation only, or open to all members; and a document repository that initially is housing selected WHO materials on SDH. Other standard website features also exist, such as an area for advertising upcoming training (Campus) and upcoming meetings (Events).
This document guides policy makers through complex policy options. It looks at access to medicines, trade and innovation together and the effect they have on each other over time and the challenges in the light of a number of developments over the past decade. In terms of manufacturing and product development, public-private partnerships are increasingly emphasised and partnerships for developing health products are ‘coming of age’. More attention is being paid to strengthening national health systems, with more funding for vaccine development and for immunisation. The relationship between public health, the intellectual property system, innovation and access to medical technologies are now better understood. Discussions on international public policy are better informed, and more soundly evidence based, allowing for more coherence across policies in health, trade and intellectual property.
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 United Nations (UN) Trust Fund for 2011 invites proposals in the following areas of action: closing the gap on the implementation of national and local laws, policies and action plans that address violence against women; and addressing violence against women in conflict, post‐conflict and transitional settings. For large civil society organisations, governments and UN Country Teams, budget requests should be US$300,000-1 million for the duration of two to three years. For small civil society organisations, especially grassroots women’s organisations and networks, budget requests will be considered for a minimum of US$100,000. Applicants must be from, or working in, countries in the Organisation for Economic Co-operation and Development’s list of eligible countries (see www.oecd.org/dac/stats/daclist). The proposal must indicate how the proposed interventions will contribute to national capacity development and ownership of national and local organisations in the implementation. Only one application per country is permitted.
The Red Ribbon Award honours and recognises exceptional grassroots leadership in responding to the AIDS epidemic. Ten community-based organisations will be selected through a community-led process and invited to attend the 19th International AIDS Conference in Washington DC, United States, from 22 to 27 July 2012 where they will have the opportunity to showcase their work. All 10 organisations will receive US$10,000 each. Eligible organisations include grassroots initiatives, community-based organisations, faith-based organisations, small non-governmental organisations and organisations of people living with HIV. Themes include: prevention of sexual transmission; prevention among people who use drugs; treatment, care and support; advocacy and human rights; and stopping new HIV infections in children and keeping mothers alive (women’s health).
ACHIEVE is aimed to equip new researchers with the competencies necessary for closing the gap between measuring inner city health inequities and reducing them. The program has two main foci: Population Health and Health Services Interventions Research; and Community Engagement, Partnerships, and Knowledge Translation. Three to five Fellows may be accepted for the 2012-2014 term. To be eligible, you must have a PhD completed within the past three years or a health professional degree plus Master’s level degree (Master’s degree completed within the past three years). If you are currently completing your PhD/ Master’s degree, you must expect to complete all requirements of this degree by 1 September 2012. Acceptance to the programme cannot be deferred.
The Africa Initiative announces a call for applications for the 2012 graduate research grant programme. 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?
The Ethiopian Public Health Association and the World Federation of Public Health Associations invite public health professionals from around the world to participate in the Thirteen World Congress on Public Health 2012. The theme of the conference is ‘Towards global health equity: Opportunities and threats’. The conference has four main objectives. It is intended to serve as an international forum for the exchange of knowledge and experiences on key public health issues, as well as contribute towards protecting and promoting public health at global, continental and national levels. It is also intended to help create a better understanding of Africa’s major public health challenges within the global public health community and to facilitate and support the formation of the African Federation of Public Health Associations.
Contact EQUINET at firstname.lastname@example.org and visit our website at www.equinetafrica.org
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to email@example.com Please forward this to others. SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to firstname.lastname@example.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact email@example.com immediately regarding any issues arising.