EQUINET NEWSLETTER 132 : 01 February 2012

1. Editorial

Alternatives to privatization of services from Africa and beyond
David McDonald, Municipal Services Project

The number of people in the global South without access to adequate basic services is staggering, not least in Africa. For more than two decades, international financial institutions have prescribed private sector participation as the remedy, often with disastrous consequences. Recently, critics of this approach have given new visibility to ‘alternatives to privatization’ to counter this trend.

Although the debate about alternatives to privatization in the water sector has been particularly dynamic, the health sector has been slower to recognize and promote new models. Similarly, Africa has developed fewer alternatives than Asia and Latin America – although the African health sector has seen some innovative community health insurance schemes and reliable non-state provision on a not-for-profit basis.

The Municipal Services Project (www.municipalservicesproject.org) is at the forefront of such research and action, and is releasing a new book this February – Alternatives to Privatization: Public Options for Essential Services in the Global South – in an effort to stimulate further debate and research in this field. The authors who contributed to this book address questions of what constitutes alternatives to privatization, what makes them successful (or not), and what lessons are to be learned for future service delivery debates. The analysis is backed up by a comprehensive examination of initiatives in over 50 countries in Africa, Asia and Latin America, looking at three sectors: electricity, health care and water/sanitation. As the first global survey of its kind, it provides the most rigorous platform to evaluate alternatives to date, and compares them across regions and sectors.

We conceive of alternatives to privatization as those involving public entities that are state-owned and operated, or non-state organizations functioning on a non-profit basis. We propose a normative set of ‘criteria for success’ to make sense of case studies because we believe that some universal claims are necessary if we are going to have a coherent global dialogue about the kinds of service delivery alternatives we want to promote. We have focused on current efforts to make public services more democratic, participatory, equitable, transparent and environmentally sound.

Equity emerges as an important criterion for alternatives because inequity is arguably the single largest concern with privatization, leaving scores of marginalized groups with little or no access to health care and other services. We are particularly interested in equity along class, gender and ethnic lines, and how public services have attempted to overcome these disparities.

Our aim has been to construct a bridge between universal criteria (such as equity) and the particularity of different locations. We recognize the unique realities of each region and the fact that there are no ideal models (in opposition to the neoliberal approach that sweeps away differences and pushes a one-size-fits-all solution). Uganda is not Uruguay is not Ulan Bator, but there are core values and objectives that underscore our definitions of what it means to provide a successful public service and consistent ways to evaluate this success.

Africa may be the weakest region in terms of such successful initiatives, as identified by our researchers, but there is robust popular resistance to privatization and it may play to the continent’s advantage that lessons can be drawn from experiments in other parts of the world.

In the chapter on alternatives to privatization in the African health care sector – African Triage – Yoswa Dambisya and Hyacinth Eme Ichoku identify and evaluate promising models for more equitable health systems. First, they explore community-based health insurance schemes (or mutuelles de santé), which aim to extend benefits to populations excluded from traditional social protection programs and operate on voluntary and non-profit bases, promoting principles of mutual aid, solidarity, and pooling of risk. These systems offer protection from catastrophic health costs and facilitate cross-subsidization. In Rwanda and Tanzania, it appears that such schemes would increase the chances of seeking assistance from formal health care providers rather than opting for self-medication or traditional healers. Ghana also developed an interesting alternative at the community level, sending nurses to live in villages to reduce barriers to geographical access, and setting up local health oversight committees. However, these schemes can also suffer from limited revenue due to low population coverage and can result in a situation where the poorest cross-subsidize the less poor. In short, these types of insurance models can complement, but not substitute, strong government involvement in health system financing.

Second, Dambisya and Ichoku review national health insurance schemes. These are more formal than community-based models but also allow pooling of risk and cross-subsidization of health services, equalizing financial access. Important shortcomings are that they do not erase geographical barriers, leaving rural populations at a disadvantage, and that they cover those in the informal sector last – even though these groups are probably the neediest. Further, such initiatives may not be viable where there is rampant corruption and high mistrust of authorities, as the failure to implement plans for national health insurance in Uganda and Zimbabwe may indicate.

Finally, faith-based organizations emerge as the largest single health care provider outside of government in most of Sub-Saharan Africa. Mission hospitals appear to offer the best quality care, generally operate in an efficient manner, and have stood the test of time. What may be more problematic is the issue of accountability and community participation. Policy makers should look into ways of better integrating these large players into national health systems.

Findings from Latin America and Asia present a very different picture of alternatives to privatization in the health sector, however, and offer some intriguing lessons for Africa, as do lessons from the water and electricity sectors in all regions studied. But despite the differences it is the commonalities that are most encouraging, highlighting a commitment from policy makers, frontline workers, activists and academics to a world that is not dictated by the demands of the market, celebrating public systems that work and pushing for innovative reforms where they don’t.

In the end, the book is just a start and the final chapter concludes with a series of future research and activist priorities, pointing to a long-term and exciting challenge for those committed to a world of social and economic equity.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read the book Alternatives to Privatization: Public Options for Essential Services in the Global South published in Africa by HSRC Press and available at http://www.hsrcpress.ac.za.

2. Latest Equinet Updates

EQUINET Policy brief 28: Implementing the WHO Global code of Practice on the International Recruitment of health Personnel in Africa

The World Health Organisation (WHO) Global Code of practice on the international recruitment of health personnel was adopted by the 63rd World Health Assembly in May 2010 in response to the intensifying movement of health workers, especially from low to high income countries. This movement of health workers aggravates inequity, particularly with regard to the number of health workers relative to health need. The WHO Code is a voluntary ethical framework. This policy brief looks at the developments in Sub-Saharan Africa since the adoption of this code with regards to its implementation. It presents the activities required to monitor its implementation and what actions have so far been implemented.

3. Equity in Health

2011 in review: Key health issues
World Health Organisation: 30 December 2011

In 2011, there was important progress in a number of areas, according to the World Helath Organisation, with reports on AIDS, tuberculosis and malaria all indicating fewer deaths – and fewer new infections. The UN General Assembly met to agree a global agenda for noncommunicable diseases – only the second time (after HIV/AIDS) that a health-related theme was selected as the topic for a UN high-level meeting. Natural disasters and conflict took their toll. The year was marked by the earthquake, tsunami and nuclear power plant damage in Japan. Conflicts disrupted health services and added to health demands in a number of countries, notably in Libya, where WHO contributed to the health response, providing expertise and supplies. 2011 also continued to be marked by the world's financial crisis. This photo feature presents a selection of some of the major health issues in 2011.

Grand strategy and global health: The case of Ethiopia
Bradley EH, Taylor L, Skonieczny M and Curry LA: Global Health Governance V(1) (Fall 2011), 21 November 2011

Despite successes in global health to combat specific diseases, progress remains slow particularly in sub-Saharan Africa. In this paper, researchers discuss two challenges in the global health landscape currently: the changes in global health governance and the recurrent pendulum swing between horizontal (health systems focused) to vertical (single-disease focused) programming by external funders and agencies. Using Ethiopia as a case study, their analysis highlights leadership actions that promoted both vertical and horizontal objectives. These included: clarity and country ownership of purpose, authentic engagement with diverse partners, appropriately focused objectives, and the leveraging of management to mediate policy decisions and front-line action. The authors conclude that effective leadership in global health can reconcile vertical and horizontal objectives.

Mainstreaming Health Equity in the development agenda of Africa countries
UN Economic Commission for Africa

This report presents the findings of a study on “Mainstreaming health equity into the development agenda in Africa”. A steep gradient in health outcomes between rural and urban areas, between better-off households and the less better-off are due in part to inequities in health. Reducing inequities in health is integral to success in reaching the targets of the three health-related MDGs and the other MDGs where health is an important component. The Report shows that policy makes a difference and that success requires that health equity is clearly mainstreamed in the national development plan because it provides the overall strategic direction to ensuring that development is more inclusive; it can infuse the multi-sectoral linkages required in addressing health inequities; and can strengthen the case for increased resources to health. In only a few countries are there identified health equity-focused strategies to
be implemented. Most of the plans outline strategies that are aimed at universal coverage of health services and take the goal of equity as given.

Socioeconomic-related health inequality in South Africa: evidence from General Household Surveys
Ataguba J, Akazili J, McIntyre D: International Journal for Equity in Health 2011, 10:48

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. However, these studies are based on selected disease conditions and only consider a single point in time. Trend analyses have yet to be produced. 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. This 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. The current burden and distribution of ill-health indicates how critical it is for the South African health system to strive for access to and use of health services that is in line with need for such care. Concerted government efforts, within both the health sector and other social and economic sectors are therefore needed to address the significant health inequalities in South Africa.

The Debate: Why is equity in health care crucial for the well being of children?
Victora C, Vega J, Chopra M: Research Watch - the web TV/magazine of the UNICEF Office of Research - 2012

All too often what has been counted falls back into a traditional paradigm of economic inequity – measuring poorest and richest quintiles – not for lack of interest but for lack of agreement on an appropriate measure, let alone what priority measures should be. While we all recognize the need to go further, tested and validated measures bringing attention to geographic, ethnic, age and gender disparities are few, let alone those which truly measure inequities and inequalities in health and the related availability, accessibility, acceptability and quality of services as mandated under the right to health. But this panel argues that this must be the goal, with important implications for the health and well-being of children. Christopher Garimoi Orach from Makerere University School of Public Health, Kampala, gives an insight into research on the unmet needs of new and expectant mothers in displaced populations in Uganda, and Gavin Mooney from the University of Cape Town discusses research on the impact of health care payments on families, and in particular on the well-being of children.

The World Development Report 2012: Gender Equality and Development
World Bank: December 2011

In this report, the World Bank argues that closing persistent gender gaps is important for development, as gender equality is a core development objective in its own right. But it is also smart economics, as greater gender equality can enhance productivity, improve development outcomes for the next generation, and make institutions more representative. Building on a growing body of knowledge on the economics of gender equality and development, the Bank identifies the areas where gender gaps are most significant-both intrinsically and in terms of their potential development payoff-and where growth alone cannot solve the issues. It then sets forth four priorities for public action: Reducing excess female mortality and closing education gaps where they remain; improving access to economic opportunities for women; increasing women's voice and agency in the household and in society; and limiting the reproduction of gender inequality across generations.

4. Values, Policies and Rights

Descriptive Review and Evaluation of the Functioning of the International Health Regulations (IHR) Annex 2
Anema A, Druyts E, Hollmeyer HG, Hardiman MC and Wilson K: Globalization and Health 8(1), 10 January 2012

Annex 2 of the International Health Regulations (IHRs) outlines decision-making criteria for State-appointed National Focal Points (NFP) to report a potential public health emergency of international concern to the World Health Organisation (WHO), and is a critical component to the effective functioning of the IHRs. The aim of this study was to review and evaluate the functioning of Annex 2 across WHO-reporting States Parties. The evaluation found that the IHR's Annex 2 is perceived as useful for guiding decisions about notifiability of potential public health emergency of international concern. There is scope for the WHO to expand training and guidance on application of the IHR's Annex 2 to specific contexts. Continued monitoring and evaluation of the functioning of the IHR is reported to be imperative to promoting global health security.

Protocol to the African Charter on the Rights of women: Implications for access to Abortion at the Regional level
Ngwena C: International Journal of Gynecology and Obstetrics, Vol. 110, pp. 163-166, 2010

Article 14(2)(c) of the Protocol to the African Charter on the Rights of Women enjoins States Parties to take appropriate measures "to protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest, and where continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus." This paper considers the implications of Article 14 for access to safe, legal abortion. It is submitted that Article 14 has the potential to impact positively on regional abortion law, policy and practice in three main areas. First, it takes forward the global consensus on combating abortion as a major public health danger. Second, it provides African countries with not just an incentive, but also an imperative for reforming abortion laws in a transparent manner. Third, if implemented in the context of a treaty that centers on the equality and non-discrimination of women,Article 14 has the potential to contribute towards transforming access to abortion from a crime and punishment model to a reproductive health model.

Reflections on health-care reforms in South Africa
Ruff B, Mzimba M, Hendrie S and Broomberg J: Journal of Public Health Policy 32: S184–S192, July 2011

In this paper, the authors describe an economic framework, including demand- and supply-side factors, for approaching the analysis and planning of health system reform in South Africa, in order to avoid piecemeal debates. They argue that there is an urgent need to re-engineer the way health facilities are internally organised to achieve better productivity and responsiveness. They further argue that funding is not the central problem of the South African public health system but rather the enormous inefficiencies in management and low productivity; and that separating the purchase from the supply side is a critical component of making significant efficiency gains. Finally, they suggest that income inequalities and a divided health system in South Africa are departure points for reform initiatives. The government must build on the strengths of the South African health system in preparation for the eventual achievement of a more homogeneous health-care system across the public and private sectors.

The global governance of bioethics: Negotiating UNESCO’s Universal Declaration on Bioethics and Human Rights (2005)
Langlois A: Global Health Governance V(1) (Fall 2011), 21 November 2011

UNESCO’s Universal Declaration on Bioethics and Human Rights (2005) was drawn up by an independent panel of experts (the International Bioethics Committee) and negotiated by member states. UNESCO aimed for a participatory and transparent drafting process, holding national and regional consultations and seeking the views of various interest groups, including religious and spiritual ones. Furthermore, reflecting UNESCO’s broad interpretation of bioethics, the IBC included medics, scientists, lawyers and philosophers among its membership. Nevertheless, several potential stakeholders - academic scientists and ethicists, government policy-makers and NGO representatives - felt they had not been sufficiently consulted or even represented during the Declaration’s development.

5. Health equity in economic and trade policies

African Union to focus on trade, peace and governance in 2012
Africa Review: 17 January 2012

Inter-African trade, which is high on the agenda at the upcoming African Union (AU) summit, will not remain the AU’s only priority in 2012. According to this report in Africa Review, the ambitious list of priorities consists of efforts to boost the continent’s global role, and plans to review the AU’s international partnerships in order to ensure they bring greater benefits to Africa. Peace and security continue to be a major concern, and AU intends to push its member states to strengthen democracy and good governance, an area closely linked to security concerns. The AU will take steps to establish food reserves and to secure access to markets and competitive prices for farmers. A free trade zone across the continent is envisaged to boost commerce between countries. At present, less than 15% of African trade stays on the continent - the rest is sold abroad.

Confronting uneven and combined development theory
Bond P, Desai A, Ngwane T: 17 January 2012

This paper describes the contemporary contours of protest in South Africa, and the dominance of the Tripartite Alliance and its embrace of neoliberal policies. It discusses the development of a strategic impasse among South African social movements. The authors present and critique several theoretically informed alternative routes out of or around the apparent cul-de-sac. They pose the strategic questions for an agency-centred South African left.

EPA not a priority for Africa says AU
Ghana Business News: 5 December 2011

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.

Future of India’s generic medicines industry uncertain
Khor M: Third World Network, 14 January 2012

India has one of the best patent laws in the world that still gives some space to its producers to make generic drugs. But international health organisations such as UNAIDS, UNITAID and Medicins Sans Frontieres have raised serious concerns that recent trends may threaten India’s role as the chief supplier of affordable medicines to Africa and other developing countries. The old policy space has been eroded because many new drugs since 2005 have been patented by multinational companies which are selling them at exorbitant prices. Indian companies can no longer make their own generic versions of these new medicines unless they successfully apply to the government for compulsory licences, and that is quite cumbersome; or unless they obtain a licence from the patent-owning multinational, and that usually comes with stringent conditions, especially for export. Another worry is that India is negotiating a free trade agreement with the European Union. Such agreements usually contain provisions such as data exclusivity and extension of the patent term, which prevents or hinders generic production. Finally, six Indian companies have recently been bought up by large foreign firms. If this trend continues, the Indian drug market may be dominated by multinationals again. It is uncertain whether they will continue to supply the developing world with cheap generic medicines when this may be in conflict with their own branded products.

Implementation of TRIPS and Access to Medicines for HIV after January 2016: Strategies and Options for Least Developed Countries
UNAIDS: November 2011

Least developed countries (LDCs) have used the 2016 transition period for TRIPS and have demonstrated the value of the flexibility provided by the extension. There remains opportunity to further enhance the benefits of this transition period through the end of the period in 2016. LDCs and other stakeholders, like civil society, can all play a role in maximising opportunities to improve access to HIV-related medicines in least developed countries during this period. By January 2016, the patenting situation of HIV-related medicines, particularly second and third-line treatments, as well as diagnostics, will be even more complex than it was in 2001 when the Doha Declaration was adopted. Therefore LDCs will continue to need maximum flexibility beyond January 2016 with respect to their TRIPS obligations in order to address their public health needs. There are clear parameters and rationale for granting LDCs further extension before full pharmaceutical patenting is required. The case for extension should be made clearly and in timely manner by LDCs with the support of other WTO Members and international organisations, such as UNAIDS. It is key that a coherent legal, political and practical case is presented, complying with TRIPS procedures, in order to ensure success.

Inequality overshadows tenth anniversary of Doha Round of trade talks
International Trade Union Confederation: 14 December 2011

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. 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.

Interpreting TRIPS: Globalisation of Intellectual Property Rights and Access to Medicines
Yamane H: Hart Publishing, March 2011

This book examines various views of the role of intellectual property rights (IPRs) as incentives for innovation against the backdrop of development and the transfer of technology between globalised, knowledge-based, high technology economies. The book retraces the origins, content and interpretations of the TRIPS Agreement, including its interpretations by WTO dispute settlement organs. It also analyses sources of controversy over IPRs, examining pharmaceutical industry strategies of emerging countries with different IPR policies. The continuing international debate over IPRs is examined in depth, as are TRIPS rules and the controversy about implementing the 'flexibilities' of the Agreement in the light of national policy objectives. The author concludes that for governments in developing countries, as well as for their business and scientific communities, a great deal depends on domestic policy objectives and their implementation. IPR protection should be supporting domestic policies for innovation and investment. This, in turn requires a re-casting of the debate about TRIPS, to place cooperation in global and efficient research and development at the heart of concerns over IPR protection.

US-sponsored risky research may affect global flu virus framework
Hammond E: Third World Network, 17 January 2012

The fallout from United States-sponsored experiments with pandemic influenza strains has raised strong biosafety concerns and raised dilemmas for implementing the World Health Organization's Pandemic Influenza Preparedness (PIP) Framework. Scientists in the United States (US) have created a new, potent virus, and as a result of outbreak fears, US officials have imposed a de facto moratorium on publication of the studies and are debating proposals to censor public versions of the papers, while restricting access to the scientific details to laboratories that have a "legitimate" need to know. The situation raises significant issues for the PIP Framework, which emphasises that significant research results with pandemic implications should be reported to the international laboratory system, and that novel potentially pandemic strains should be provided to the WHO System for characterisation by its laboratory network. In this case, however, it appears that the US will not be willing to share its viruses and research results with WHO Member States, contradicting its pro-sharing position taken in the negotiation of the PIP Framework.

‘Big Think’, disjointed incrementalism: Chinese economic success and policy lessons for Africa, or the case for pan-Africanism
Gros J: African Journal Of International Affairs 11(2): 55–87, 2008

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

Biofuels and food security: Green economy in sub-Saharan Africa
Chinweze C, Abiola-Oloke G, Kennedy-Echetebu C And Jideani C: United Nations Research Institute For Social Development, 22 November 2011

In Africa, agricultural land covers less than 15% of the land area, yet demand from transnational companies is increasing for arable terrain. This demand is 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.

Effect of nutritional supplementation of breastfeeding HIV positive mothers on maternal and child health: findings from a randomised controlled clinical trial
Kindra G, Coutsoudis A and Esposito F: BMC Public Health 11(946), 22 December 2011

This study aimed to assess the effect of nutritional supplementation to HIV infected lactating mothers on nutritional and health status of mothers and their infants. It took the form of a randomised controlled clinical trial to study the impact of nutritional supplementation on breastfeeding mothers. Measurements included anthropometry; body composition indicators; CD4 count, haemoglobin and albumin; as well as incidence rates of opportunistic infections; depression and quality of life scores. Infant measurements included anthropometry, development and rates of infections.c The researchers found that the supplement made no significant impact on any maternal or infant outcomes. However in the small group of mothers with low BMI, the intake of supplement was significantly associated with preventing loss of lean body mass. There was no significant impact of supplementation on the infants.

Kenya climate hearings 2011: Communities speak out
Oxfam: 11 November, 2011

In the run up to the 2011 United Nations climate conference – hosted in Durban, South Africa, from 28 November to 1 December – Oxfam supported communities to speak out about the impact that climate change is having on their lives. In drought-prone areas of Kenya, Oxfam 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 were 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 painted 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 were 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.

Overcoming the barriers: How to ensure future food production under climate change in Southern Africa
Vincent K, Joubert A, Cull T, Magrath J and Johnston P: Oxfam, 9 November 2011

Farmers in Southern Africa are experiencing changes to their climate that are different in magnitude to what they have experienced in the past. Farmers interviewed for this report say that these changes are increasing the risk of poor yields or crop failure. The observations of farmers are largely borne out by meteorological data, particularly on rising temperatures – ongoing climate change, bringing increasing temperatures and changes to precipitation patterns, is projected to make food production more difficult. Southern African farmers are already actively experimenting with changing agricultural practices, and looking for ways to diversify their livelihoods in response climate and other stresses, within their resource constraints. But where large-scale farmers, in the main, can access the resources needed to adapt, small-scale farmers face major obstacles. The authors argue that policy makers need to identify the barriers for farmers, particularly smallholder farmers, as they attempt to adapt to the new climate and other environmental, economic and political pressures.

The World Trade Organisation and the post-global food crisis agenda: Putting food security first in the international trade system
De Schutter O: November 2011

In this briefing note, the United Nations Special Rapporteur on Food Security argues that existing World Trade Organisation (WTO) rules do include certain flexibilities for States to pursue food security-related measures but many of these modifications to the original Agreement on Agriculture (AoA) are relatively modest and even these are by no means assured with the outcome of the Doha Round highly uncertain. Many elements of the AoA and the draft modalities continue to fall short of offering a favourable policy framework for the realisation of the right to food, such as the narrow range of policy measures that could be used to potentially establish national and regional food reserves and domestic institutions to manage price and income volatility for poor rural households. The report sets out a number of recommendations, such as: ensuring that future criteria of the AoA do not impede the development of policies and programmes to support food security and that they are tailored to the specific national circumstances of developing countries; avoiding defining the establishment and management of food reserves as trade-distorting support; adapting the provisions of the AoA and other WTO agreements (in particular, in the area of public procurement) to ensure compatibility with the establishment of food reserves at national, regional and international level; and allowing marketing boards and supply management schemes to be established.

7. Equitable health services

A national audit of home and community-based care (HCBC) organisations in South Africa
Ogunmefun C, Friedman I, Mothibe N and Mbatha T: AIDS Care, October 2011

The main objective of the study was to conduct an audit of home and community-based care (HCBC) organisations in South Africa in order to provide the Government with empirical information on their existence, distribution, services and challenges. Of the 2,001 HCBC organisations that participated in the audit, most were situated in Limpopo and KwaZulu-Natal Provinces. More than half of all the organisations were located in the rural areas. Most of the organisations were faced with challenges such as lack of access to water, electricity and computer equipment and a formal office space. In addition, some organisations were in need of funds for stipends for their community caregivers. Non-availability of funds for stipends and necessary assets might affect the quality of HCBC services rendered. The findings of the study therefore suggest the need for more financial assistance from the Government and other stakeholders for organisations rendering HCBC services, in order for them to afford necessary assets and provide sustainable, high-quality services that can help in reducing HIV impacts in South Africa.

Changes in malaria morbidity and mortality in Mpumalanga Province, South Africa (2001-2009): a retrospective study
Ngomane L and de Jager C: Malaria Journal 11(19), 13 January 2012

This study aimed to assess the changes in the burden of malaria in Mpumalanga Province during the past eight malaria seasons (2001/02 to 2008/09) and whether indoor residual spraying (IRS) and climate variability had an effect on these changes. This is a descriptive retrospective study based on the analysis of secondary malaria surveillance data (cases and deaths) in Mpumalanga Province. Within the study period, a total of 35,191 cases and 164 deaths due to malaria were notified in Mpumalanga Province. There was a significant decrease in the incidence of malaria from 385 in 2001/02 to 50 cases per 100,000 population in 2008/09. The incidence and case fatality (CFR) rates for the study period were 134 cases per 100,000 and 0.54%, respectively. Mortality due to malaria was lower in infants and children and higher in those >65 years, with the mean CFR of 2.1% as compared to the national target of 0.5%. Mpumalanga Province has achieved the goal of reducing malaria morbidity and mortality by over 70%, partly as a result of scale-up of IRS intervention in combination with other control strategies. These results highlight the need to continue with IRS together with other control strategies until interruption in local malaria transmission is completely achieved. However, the goal to eliminate malaria as a public health problem requires efforts to be directed towards the control of imported malaria cases; development of strategies to interrupt local transmission; and maintaining high quality surveillance and reporting system.

Clinical practice guidelines within the Southern African Development Community: a descriptive study of the quality of guideline development and concordance with best evidence for five priority diseases
Kredo T, Gerritsen A, van Heerden J, Conway S and Siegfried N: Health Research Policy and Systems 10(1), 5 January 2012

There is limited data on availability, quality and content of guidelines within the Southern African Development Community (SADC). This evaluation aimed to address this gap in knowledge and provide recommendations for regional guideline development. The authors prioritised five diseases: HIV in adults, malaria in children and adults, pre-eclampsia, diarrhoea in children and hypertension in primary care. A comprehensive electronic search to locate guidelines was conducted between June and October 2010 and augmented with email contact with SADC Ministries of Health. The authors identified 30 guidelines from 13 countries, publication dates ranging from 2003-2010. Overall the 'scope and purpose' and 'clarity and presentation' domains of the AGREE II instrument scored highest, with a median of 58% and 83% respectively. 'Stakeholder involvement' followed with median 39%. The authors recommend that future guideline development processes within SADC should better adhere to global reporting norms requiring broader consultation of stakeholders and transparency of process. A regional guideline support committee could harness local capacity to support context appropriate guideline development.

Diabetes, HIV and other health determinants associated with absenteeism among formal sector workers in Namibia
Guariguata L, de Beer I, Hough R, Bindels E, Weimers-Maasdorp D, Feeley FG and Rinke de Wit TF: BMC Public Health 12(44), 18 January 2012

While previous studies have assessed the impact of single conditions on absenteeism, the current study evaluates multiple health factors associated with absenteeism in a large worker population across several sectors in Namibia. From March 2009 to June 2010, a series of cross-sectional surveys of 7,666 employees in seven sectors of industry were conducted in Namibia. Results indicated that, controlling for demographic and job-related factors, high blood glucose and diabetes had the largest effect on absenteeism, followed by anemia and being HIV positive. In addition, working in the fishing or services sectors was associated with an increased incidence of sick days. The highest prevalence of diabetes was in the services sector, with the highest prevalence of HIV in the fishing sector. The authors conclude that both non-communicable disease risk factors and infectious diseases are associated with increased rates of short-term absenteeism of formal sector employees in Namibia. Programmes to manage these conditions could help employers avoid costs associated with absenteeism, they recommend, which could include basic health care insurance including regular wellness screenings.

Fighting syphilis and HIV in women and children: Lessons from Uganda and Zambia
Bitarakwate E, Strasser S, Sripipatana T and Pollakusky J: Global Health (Winter 2012), January 2012

According to this article, in sub-Saharan Africa, co-infection of syphilis and HIV is a serious public health challenge, with women and young children among the most vulnerable groups. Unfortunately, although HIV testing has become more accessible for pregnant women in sub-Saharan Africa as part of routine antenatal care, in many countries, including Uganda and Zambia, syphilis testing must still be accessed at separate sites. The researchers in this study identified high rates of syphilis and HIV co-infection in pregnant women in both countries: in Uganda 14.3% of syphilis-positive pregnant women also tested positive for HIV, and the rate was 24.2% in Zambia. But newly devised rapid syphilis testing has made it easier to integrate syphilis screening into services provided at antenatal clinics to prevent mother-to-child transmission (PMTCT) of HIV. As a result, there has been swift and direct policy change in Uganda and Zambia to further the goal of eliminating congenital syphilis and pediatric HIV and AIDS, as the Ministries of Health in Uganda and Zambia, are incorporating rapid syphilis testing into their standard package of PMTCT services and antenatal care.

Patient- and provider-level risk factors associated with default from tuberculosis treatment, South Africa, 2002: A case-control study
Finlay A, Lancaster J, Holtz TH, Weyer K, Miranda A and van der Walt M: BMC Public Health 12(56), 20 January 2012

The authors of this study conducted a national retrospective case control study to identify factors associated with tuberculosis treatment default in South Africa using programme data from 2002 and a standardised patient questionnaire. The sample included 3,165 TB patients from eight provinces; 1,164 were traceable and interviewed. Significant risk factors associated with default among both groups included poor health care worker attitude and changing residence during TB treatment. New TB patients that defaulted were more likely to report having no formal education, feeling ashamed to have TB, not receiving adequate counseling about their treatment, drinking any alcohol during TB treatment, and seeing a traditional healer during TB treatment. Among retreatment patients, risk factors included stopping TB treatment because they felt better, having a previous history of TB treatment default, and feeling that food provisions might have helped them finish treatment. In conclusion, risk factors for default differ between new and re-treatment TB patients in South Africa. Addressing default in both populations with targeted interventions is critical to overall programme success.

Service availability and utilisation and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries
Lora A, Kohn R, Levav I, McBain R, Morris J and Saxena S: Bulletin of the World Health Organisation 90(1): 47-54B, January 2012

In this study, researchers set out to outline mental health service accessibility, estimate the treatment gap and describe service utilisation for people with schizophrenic disorders in 50 low- and middle-income countries. They found that the median annual rate of treatment for schizophrenic disorders in mental health services was 128 cases per 100,000 population. The median treatment gap was 69% and was higher in participating low-income countries (89%) than in lower-middle-income and upper-middle-income countries (69% and 63%, respectively). Of the people with schizophrenic disorders, 80% were treated in outpatient facilities. The availability of psychiatrists and nurses in mental health facilities was found to be a significant predictor of service accessibility and treatment gap. In conclusion, the treatment gap for schizophrenic disorders in the 50 low- and middle-income countries in this study is disconcertingly large and outpatient facilities bear the major burden of care. The significant predictors found suggest an avenue for improving care in these countries.

8. Human Resources

Evaluating a streamlined clinical tool and educational outreach intervention for health care workers in Malawi: the PALM PLUS case study
Sodhi S, Banda H, Kathyola D, Burciul B, Thompson S, Joshua M et al: BMC International Health and Human Rights 11(Suppl 2):S11, 8 November 2011

PALM PLUS (Practical Approach to Lung Health and HIV/AIDS in Malawi) is an intervention designed to simplify and integrate existing Malawian national guidelines into a single, simple, user-friendly guideline for mid-level health care workers. Training utilises a peer-to-peer educational outreach approach. Research is being undertaken to evaluate this intervention to generate evidence that will guide future decision-making for consideration of roll out in Malawi. In the first phase of qualitative inquiry respondents from intervention sites demonstrated in-depth knowledge of PALM PLUS compared to those from control sites. Participants in intervention sites felt that the PALM PLUS tool empowered them to provide better health services to patients. Interim staff retention data shows that there were, on average, three to four staff departing from the control and intervention sites per month. Additional qualitative, quantitative and economic analyses are planned. This initiative is an example of South-South knowledge translation between South Africa and Malawi, mediated by a Canadian academic-NGO hybrid. Success in developing and rolling out PALM PLUS in Malawi suggests that it is possible to adapt and implement this intervention for use in other resource-limited settings.

Health workers at the core of the health system: Framework and research issues
Anand S, Bärnighausen T Health Policy (2011), 25 October 2011

This paper presents a framework for the health system with health workers at the core. The authors reviewed existing health-system frameworks and the role they assign to health workers, finding that earlier frameworks either do not include health workers as a central feature of system functioning or treat them as one among several components of equal importance. As every function of the health system is either undertaken by or mediated through the health worker, the authors argue that the health worker should be placed at the centr of the health system. They describe six research issues on the health workforce: metrics to measure the capacity of a health system to deliver healthcare; the contribution of public- vs private-sector health workers in meeting healthcare needs and demands; the appropriate size, composition and distribution of the health workforce; approaches to achieving health-worker requirements; the adoption and adaption of treatments by health workers; and the training of health workers for horizontally vs vertically structured health systems.

Keeping health workers and facilities safe in war
Serle J and Fleck F: Bulletin of the World Health Organisation 90(1): 8-9, January 2012

The nature of armed conflict is changing, putting health workers increasingly in harm’s way. A new campaign by the Red Cross, the Health Care in Danger strategy, aims to raise awareness and improve conditions on the ground for health workers and facilities in conflict zones. The harm done when health workers are attacked is not limited to the assault itself, but has a knock on effect that can deprive patients of treatment. The intensity of attacks on health care workers has increased, according to Physicians for Human Rights, but they acknowledge there is a lack of reliable data. Because of the blurred nature of contemporary war, health facilities find themselves providing services to both sides of a conflict and exposing themselves in doing so. According to this article, it has become more common for soldiers to enter a hospital to settle scores, for example, or indeed for government forces to come looking for insurgents and prevent doctors from treating opponents. Médecins Sans Frontières (MSF), recommends negotiating what may be called the “parameters of intervention” before starting operations, which requires communicating and negotiating with all the relevant military and paramilitary actors to create the neutral space in which medical services can be offered.

The human resource for health situation in Zambia: Deficit and maldistribution
Ferrinho P, Siziya S, Goma F and Dussault G: Human Resources for Health 9(30), 19 December 2011

In this paper, the authors describe the way the human resources for health (HRH) establishment is distributed in the different provinces of Zambia, with a view to assess the dimension of shortages and of imbalances in the distribution of health workers by province and by level of care. They used secondary data from the "March 2008 payroll data base", which lists all the public servants on the payroll of the Ministry of Health and of the National Health Service facilities. Results indicate that workers are maldistributed across Zambia. This case study documents how a peaceful, politically stable African country with a longstanding tradition of strategic management of the health sector and with a track record of innovative approaches dealt with its health worker issues, but still remains with absolute and relative shortages of health workers. The Zambia case reinforces the idea that training more staff is necessary to address the health worker crisis, but it is not sufficient and has to be completed with measures to mitigate attrition and to increase productivity.

The WHO Global Code of Practice on the International Recruitment of Health Personnel: The Evolution of Global Health Diplomacy
Taylor AL and Dhillon IS: Global Health Governance V(1) (Fall 2011), 21 November 2011

The May 2010 adoption of the World Health Organisation 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 organisations. The article emphasises the importance of political leadership, appropriate sequencing, and support for capacity building of developing countries’ negotiating skills to successful global health negotiations. It also reflects on how the dynamics of the Code negotiation process evidence an evolution in global health negotiations amongst the WHO Secretariat, civil society, and WHO Member States.

9. Public-Private Mix

Competition Commission may probe healthcare
Visser A: Business Day, 30 December 2011

South Africa’s Competition Commission is considering initiating a market inquiry into the private healthcare industry reminiscent of its probe into the banking sector a few years ago, which recommended lower banking costs. Health Minister Aaron Motsoaledi has condemned high healthcare costs and accused the private health sector of engaging in "uncontrolled commercialism" and "destructive, unsustainable practices". Tembinkosi Bonakele, deputy commissioner of the Competition Commission, said that the commission was "likely" to commence with an inquiry because of growing concern about the high cost of private healthcare and the effect this had on the public healthcare system.

GAVI money welcome but could it be more wisely spent?
Medicins Sans Frontiers: 14 June 2011

Medicins Sans Frontiers (MSF) argues in this article that big pharmaceutical companies are charging too much for their vaccines used in the developing world. Price disclosures by GlaxoSmithKline (GSK) and Johnson & Johnson show that these companies have been selling some vaccines at premiums of up to 180%. According to MSF, GSK and Pfizer are selling 30 million doses of pneumococcal vaccines annually to GAVI at a reduced price of US$3.20 through a scheme called Advance Market Commitment, but are also each getting a subsidy of US$215 million. Emerging country suppliers like India’s Serum Institute have said they could sell similar pneumococcal vaccine products for US$2 a dose – a 40% reduction on the GSK and Pfizer price. Serum Institute said recently that if they had not faced patent restrictions, the vaccine could have been available by 2012 – now it is not expected until 2015. Technology transfer and product development grants to low-cost suppliers are being supported by the Bill and Melinda Gates Foundation, but these sums are dwarfed by the Advance Market Commitment subsidy to Big Pharma. MSF calls on GAVI to start thinking about more affordable vaccines and calls on government donors to pressurise GAVI to foster competition and to push for products especially adapted for developing countries.

Global Fund collusion with liquor giant is a clear conflict of interest
Matzopoulos R, Parry CDH, Corrigall J, Myers J, Goldstein S and London L: Bulletin of the World Health Organisation 90(1): 67-69, January 2012

Alcohol is the third leading contributor to death and disability in South Africa, where SABMiller is the major supplier of malt beer, the most popular beverage consumed. The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) has recently included SABMiller as a recipient of funding for an education intervention aimed at minimizing alcohol-related harm, including HIV prevention, among men in drinking establishments. Global Fund support for this initiative is cause for concern, according to the authors of this article. They argue that it is debatable whether these men are the best target group for the intervention, whether a drinking establishment is the best location, and whether the educational intervention itself is effective. The authors argue that the industry supports interventions that will not affect drinking rates at a population level. These interventions allow the industry to fulfil social and legal obligations to address the harmful use of alcohol while ensuring that sales and profits are maintained. Providing funding for an industry that could afford to fund its own interventions also reduces the funds available for less well-resourced organisations.

10. Resource allocation and health financing

Geographical distribution of financial flows to developing countries 2011: Disbursements, commitments, country indicators
Organisation for Economic Co-operation and Development: February 2011

This book provides comprehensive data on the volume, origin and types of aid and other resource flows to around 150 developing countries. The data show each country's intake of official development assistance and well as other official and private funds from members of the Development Assistance Committee of the OECD, multilateral agencies and other key external funders. Key development indicators are given for reference. The data cover net and gross disbursements, commitments, terms and the sector/purpose allocation of bilateral Official Development Assistance commitments. The aim of the book is to present a comprehensive record of the external financing of each country shown. The data show the transactions of each recipient country with: DAC member countries (individually or as a group); multilateral agencies (individually or as a group); and other major external funders.

The Commission on Macroeconomics and Health: 10 years on
Das P And Samarasekera U: The Lancet,378(9807): 1907-1908, 3 December 2011

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.

The human cost of cutting global health funding
Spitzer M: Huffington Post, 17 November 2011

With recent threats by the United states (US) Congress for extensive cuts to the federal government's budget for global health programmes, the author of ths paper argues that there could not be a worse time to pull back from long-standing American commitments to the health of people around the world. The cuts are argued to be particularly brutal at a time when medical science and field research shows the potential to achieve huge advances in the quality and scope of actions in global health. Major progress has been made in terms of providing care to malaria- and HIV-infected individuals. Rather than slashing global health funding, which represents less than 1% of the federal budget, the author argues that the US should be ensuring funding of successful international health initiatives and exploring new ways of generating predictable revenue for vital lifesaving programmes.

11. Equity and HIV/AIDS

Antiretrovirals and the use of traditional, complementary and alternative medicine by HIV patients in KwaZulu-Natal, South Africa: a longitudinal study
Peltzer K, Friend-du Preez N, Ramlagan S, Fomundam H, Anderson J and Chanetsa L: African Journal of Traditional, Complementary and Alternative Medicines. 8(4):337-345, 2011

The aim of this prospective study (20 months) was to assess HIV patients' use of Traditional, Complementary and Alternative Medicine (TCAM) and its effect on anti-retroviral (ARV) adherence at three public hospitals in KwaZulu-Natal, South Africa. Seven hundred and thirty-five (29.8% male and 70.2% female) patients who consecutively attended three HIV clinics completed assessments prior to ARV initiation, 519 after 6 months, 557 after 12 and 499 after 20 months on antiretroviral therapy (ART). Results indicate that following initiation of ARV therapy the use of herbal therapies for HIV declined significantly from 36.6% prior to ARV therapy to 8% after 6 months, 4.1% after 12 months and 0.6% after 20 months on ARVs. Faith healing methods (including spiritual practices and prayer) declined from 35.8% to 22.1%, 20.8% and 15.5%, respectively. In contrast, the use of micronutrients, such as vitamin supplements, significantly increased from 42.6% to 78.2%. Herbal remedies were mainly used for pain relief, as immune booster and for stopping diarrhea. As herbal treatment for HIV was associated with reduced ARV adherence, patient's use of TCAM should be considered in ARV adherence management, the authors conclude.

Comparing antiretroviral treatment outcomes between a prospective community-based and hospital-based cohort of HIV patients in rural Uganda
Kipp W, Konde-Lule J, Rubaale T, Okech-Ojony J, Alibhai A, Saunders DL: BMC International Health and Human Rights 11(Suppl 2):S12, 8 November 2011

This intervention study aimed to assess the effectiveness of a rural community-based anti-retroviral therapy (ART) programme in a subcounty (Rwimi) of Uganda and compare treatment outcomes and mortality in a rural community-based ART programme with a well-established hospital-based programme. Successful treatment outcomes after two years in both the community and hospital cohorts were high. All-cause mortality was similar in both cohorts. However, community-based patients were more likely to achieve viral suppression and had good adherence to treatment. The community-based programme was slightly more cost-effective. The unpaid community volunteers showed high participation and low attrition rates for the two years that this programme was evaluated. Key successes of this study include the demonstration that ART can be provided in a rural setting, the creation of a research infrastructure and culture within Kabarole’s health system, and the establishment of a research collaboration capable of enriching the global health graduate programme at the University of Alberta.

Missing the Target 9: The Long Walk: Ensuring comprehensive care for women and families to end vertical transmission of HIV
International Treatment Preparedness Coalition: December 2011

Most prevention of mother-to-child transmission (PMTCT) programmes in Africa are still not following a comprehensive approach around the four pillars as recommended by the UN strategy, according to this paper, despite the evidence on how critical interventions such as improving access to family planning and HIV prevention knowledge and tools support the goal of ending vertical transmission of HIV. Many women in the developing world continue to receive sub-optimal drugs and confusing messages about infant feeding, undermining even the slow ‘progress’ made on pillar three. And far too many women and infants in need of treatment are leaving prevention of vertical transmission programmes without any follow-up treatment, care and support. Research conducted in a number of African countries has revealed several barriers to care, such as lack of involvement of men in PMTCT services, lack of implementation of WHO guidelines on prevention of vertical transmission and infant feeding, prohibitive costs of ANC, delivery, diagnostic tests, OI and STI treatment, and transportation to distant clinics, and stigma, combined with a shortage of trained health care workers, long waiting times and lack of integrated services under one roof.

Swaziland: No money, no CD4 tests
Plus News: 23 January 2012

Swaziland is still short of lab reagents needed for CD4 count testing, used to initiate and monitor patients on antiretroviral treatment. Shortages of HIV programme supplies in Swaziland were first reported in mid-2011. Although the stock-outs have been largely blamed on reduced revenues from the Southern African Customs Union (SACU), the country also opted not to apply for funding in Round 10 from the Global Fund to Fight AIDS, TB and Malaria. Instead, it chose to assume financial responsibility for HIV treatment itself, at a time when SACU revenues were already expected to decline. Health Minister Themba Xaba said in a statement that the government needed US$875,000 to purchase the CD4 machine reagents.

The report of the UNAIDS Advisory Group on HIV and Sex Work
UNAIDS Advisory Group: December 2011

In this report, the UNAIDS Advisory Group strongly affirms that sex workers and their organisations play a crucial role in confronting HIV and in many places have an outstanding record in helping to achieve universal access. However, sex workers usually face human rights violations and struggle to access HIV and other health and social services. Stigma and discrimination within society results in repressive laws, policies and practices against sex work, as well as their economic disempowerment. Violence against sex workers is too often committed with impunity by state and civilian actors, exacerbating sex workers’ HIV vulnerability. They are often excluded from access to benefits and financial services available to the general population and prevented from forming organisations that enable economic empowerment and social inclusion. In this report, the Advisory Group argues it it necessary for sex workers to enjoy universal access to HIV services, highlighting good practices that enhance human rights protections for sex workers in the hope that the information presented here will help shape programmes and policies on HIV and sex work that are truly human rights-based.

Uptake of prevention of mother to child transmission interventions in Kenya: health systems are more influential than stigma
Kinuthia J, Kiariie JN, Farquhar C, Richardson BA, Nduati R, Mbori-Ngacha D and John-Stewart G: Journal of the International AIDS Society 14(61), 28 December 2011

The authors of this study set out to determine the relative roles of stigma versus health systems in non-uptake of prevention of mother to child transmission of HIV-1 interventions by conducting a cross-sectional assessment of all consenting mothers accompanying infants for six-week immunisations. Between September 2008 and March 2009, mothers at six maternal and child health clinics in Kenya's Nairobi and Nyanza provinces were interviewed regarding PMTCT intervention uptake during recent pregnancy. Among 2,663 mothers, 2,453 (92.1%) reported antenatal HIV-1 testing. Although internal or external stigma indicators were reported by between 12% and 59% of women, stigma was not associated with lower HIV-1 testing or infant HIV-1 infection rates; internal stigma was associated with modestly decreased antiretroviral uptake. Health system factors contributed to about 60% of non-testing among mothers who attended antenatal clinics and to missed opportunities in offering antiretrovirals and utilisation of facility delivery.

12. Governance and participation in health

African Awakenings: The Emerging Revolutions
Manji F, Ekine S (Editors), Fahamu publishers

The tumultuous uprisings of citizens in Tunisia, Egypt and Libya have seized the attention of media analysts who have characterised these
as 'Arab revolutions', a perspective given weight by popular demonstrations in Yemen, Bahrain, Syria and elsewhere. However, what have been given less attention are the concurrent uprisings in other parts of the African continent. The uprisings across Africa and in the Middle East, the book argues, are the result of common experiences of decades of declining living standards, mass unemployment, land dispossessions and impoverishment of the majority, while a few have engorged themselves with riches. Through incisive contributions from analysts and activists across the continent, the essays in ‘African Awakening’ provide an overview of the struggle for democratisation which goes beyond calls merely for transparent electoral processes and constitutes a reawakening of the spirit of freedom and justice for the majority.

An approach to addressing governance from a health system framework perspective
Mikkelsen-Lopez I, Wyss K and de Savigny D: BMC International Health and Human Rights 11(13), 2 December 2011

In this paper, researchers reviewed contemporary health sector frameworks which have focused on defining and developing indicators to assess governance in the health sector. Based on these, they propose a simplified approach to look at governance within a common health system framework which encourages stewards to take a systematic perspective when assessing governance. Although systems thinking is not unique to health, examples of its application within health systems has been limited. This approach is built largely on prior literature, but is original in that it is problem-driven and promotes an outward application taking into consideration the major health system building blocks at various levels in order to ensure a more complete assessment of a governance issue rather than a simple input-output approach. Based on an assessment of contemporary literature the authors propose a practical approach which we believe will facilitate a more comprehensive assessment of governance in health systems leading to the development of governance interventions to strengthen system performance and improve health as a basic human right.

Global health governance as shared health governance
Ruger JP: Journal of Epidemiology and Community Health (2011), 14 December 2011

The author of this article develops select components of an alternative model of shared health governance (SHG), which aims to provide a ‘road map,’ ‘focal points’ and ‘the glue’ among various global health actors to better effectuate cooperation on universal ethical principles for an alternative global health equilibrium. Key features of SHG include public moral norms as shared authoritative standards; ethical commitments, shared goals and role allocation; shared sovereignty and constitutional commitments; legitimacy and accountability; country-level attention to international health relations. A framework of social agreement based on ‘overlapping consensus’ is contrasted against one based on self-interested political bargaining. A global health constitution delineating duties and obligations of global health actors and a global institute of health and medicine for holding actors responsible are proposed. Indicators for empirical assessment of select SHG principles are described. The author concludes that global health actors, including states, must work together to correct and avert global health injustices through a framework of SHG based on shared ethical commitments.

What is ‘global health diplomacy’? A conceptual review
Lee K and Smith R: Global Health Governance V(1) (Fall 2011), 21 November 2011

While global health diplomacy (GHD) has attracted growing attention, accompanied by hopes of its potential to progress global health and/or foreign policy goals, the concept remains imprecise. This paper finds the term has largely been used normatively to describe its expected purpose rather than distinct features. This paper distinguishes between traditional and “new diplomacy”, with the latter defined by its global context, diverse actors and innovative processes. The authors point to need to strengthen the evidence base in this rapidly evolving area.

13. Monitoring equity and research policy

Collaboration between infection control and occupational health in three continents: a success story with international impact
Yassi A, Bryce EA, Breilh J, Lavoie M, Ndelu L, Lockhart K and Spiegel J: BMC International Health and Human Rights 11(Suppl 2):S8, 8 November 2011

Canadian occupational health and infection control researchers have found that training is key to a positive safety culture, leading them to develop information and communication technology (ICT) tools to promote occupational health and infection control. The South African government invited the Canadian team to work with local colleagues, resulting in an improved web-based health information system to track incidents, exposures, and occupational injury and diseases, just in time for the H1N1 pandemic. Research from these experiences led to strengthened focus on building capacity of health and safety committees, and new modules are thus being created, informed by that work. The international collaboration between occupational health and infection control researchers in Canada, Ecuador and South Africa led to the improvement of the research framework and development of tools, guidelines and information systems. Furthermore, the research and knowledge-transfer experience highlighted the value of partnership amongst Northern and Southern researchers in terms of sharing resources, experiences and knowledge.

Global health research, partnership, and equity: no more business-as-usual
Zarowsky C: BMC International Health and Human Rights 11(Suppl 2):S1, November 2011

This supplement of BMC International Health and Human Rights consists of a collection of 10 case studies showcasing effective global health research. The collection provides practical, transferable lessons for research partnerships working to address health inequities. In the context of increasing competition for individual or institutional "leadership" of the field (and business) of global health, these papers instead speak of active and sustained collaboration - listening, responsiveness, flexibility, willingness and capacity to follow as well as to lead - in learning what to transform or sustain, and how, in order to move towards greater equity in both health and health research. In addition, they challenge conventional models of research focused on narrowly defined research questions and a narrow range of pre-specified research methods, documenting instead how both the research questions and the methods most appropriate to address them change over time. Finally, they challenge both the idea of "pure" science undertaken by independent researchers on behalf of science and specific communities, and the conventional wisdom that North-South and research-research user-community partnerships are necessarily either North and researcher-driven, or scientifically dubious.

The importance of research in a University
Mamdani M: CODESRIA Bulletin 3:4, 2011

This paper explores the current situation in universities with respect to research practice. The author observes that the market-driven model is dominant in African universities. The consultancy culture it has nurtured has had negative consequences for postgraduate education and research. Consultants presume that research is all about finding answers to problems defined by a client. They think of research as finding answers, not as formulating a problem. The consultancy culture is institutionalized
through short courses in research methodology, courses that teach students
a set of tools to gather and process quantitative information, from which
to cull answers. The author calls in contrast for an intellectual environment strong enough to sustain a meaningful intellectual culture.

14. Useful Resources

Database of medical journals: African Index Medicus

The African Region of the World Health Organisation (WHO/AFRO) manages this database of medical journals, which has recently increased its share of African medical journals to 156, some with open access. For the full list of these journals, visit the website. Other documents such as medical dissertations/theses and grey literature are also available.

International Statistical Classification of Diseases and Health Related Problems (The) ICD-10. 2010 Edition
World Health Organisation: 2010

The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines. It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States.

New blog on South Africa’s health system
Health Policy SA

In this new blog, Jane Doherty, a researcher and lecturer at the Wits University School of Public Health in South Africa, takes the view that South Africa must move towards a health system that is fair and functional. She discusses the proposed national health insurance (NHI) scheme for South Africa, introducing readers to a range of issues relevant to the new NHI. For example, relevant legislation, in the form of the government’s Green Paper on the NHI is presented, and Doherty discusses the motivations behind the NHI, such as the urgent need to reduce South Africa’s high levels of maternal mortality, and she also considers the employment impact of the NHI, contending that claims that the NHI will cause job losses are unfounded. There are links to Doherty’s research, as well as to other interesting and relevant research.

15. Jobs and Announcements

Health Policy Action Fund (HPAF) - Call for Proposals
Closing date 28 February 2012.

The Health Policy Action Fund (HPAF) invites Civil Society Organisations from 30 IHP+ countries to submit proposals for funding of health policy work at national level. The grants will fund work over an 18-month period starting in April 2012, and have a maximum of US$ 30,000 per grantee. Interested applicants are requested to visit the HPAF website at www.healthpolicyactionfund.org for the detailed Criteria for Selection and the proposal application forms. The HPAF aims to support southern civil society organizations, networks and coalitions to become more effectively engaged in national health policy processes. Supported by the grants, recipients engage in health policy and implementation monitoring and analysis, policy dialogue with key national health stakeholders, and hold governments and aid donors accountable to work towards achieving universal and equitable access to health care and the health-related Millennium Development Goals.

Call for nominations for the 2012 Red Ribbon Award
Closing Date: 29 February 2012

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).

Call for post-doctoral fellowship applications: The Achieve Research Partnership ‘Action For Health Equity Interventions’
Application Deadline: 13 February 2012

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.

Healthcare In Africa Conference: 6-7 March 2012, Cape Town, South Africa
Registration Dates Not Announced

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?

Register for the Thirteenth World Congress On Public Health: 23-27 April 2011, Addis Ababa, Ethiopia
Registration deadline: 14 April 2012

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.

Registration now open for Forum 2012: 24-26 April 2012, Cape Town, South Africa
COHRED And The Global Forum

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.

Registration open for SEYCOHAIDS 2012
8-10 June 2012: Lilongwe, Malawi

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.

Third People’s Health Assembly
6-11 July 2012 in Cape Town, South Africa

The People’s Health Assembly (PHA), organised by the People's Health Movement (PHM), is a global event bringing together health activists from across the world to share experiences, analyse global health situation, develop civil society positions and to develop strategies which promote health for all. It will look at forms of action to address identified challenges and build capacity among health activists to act. It is an opportunity for PHM as a whole to reflect on the global struggle, to review and reassess, to redirect and re-inspire. This through analysing PHM’s situation, reflecting on pathways, barriers and strategies, sharing of experiences and crystallising out new directions, slogans, commitments for the movement. PHA3 is not just about developing our movement. It is also about impacting directly in the struggle for social change: for health for all, decent living conditions for all, work in dignity for all, equity and environmental justice.

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