In the 1990s and early 2000s leaders of African countries persistently called for compensation for the loss of publicly trained health workers from low income African communities to the high income communities of Europe, North America and Australia. A November 2011 British Medical Journal paper by Edward Mills et al reported on the magnitude of the loss to health worker training investments in African countries to be US$2.17bn, ranging from $2.16m for Malawi to $1.41bn for South Africa. At the same time the benefit to destination countries of recruiting trained doctors was estimated at $2.7bn for the United Kingdom and $846 mn for the United States.
Despite acknowledgement that migration is driven by social, political and economic causes, it was deemed justifiable to take actions to more fairly manage these flows and their consequences. African countries made submissions in various international forums for governments of destination countries to notify governments of source countries on the number of health workers employed, their professional status and their contractual rights and obligations, and to provide equal treatment to migrant and local health workers. In addition, the African countries urged for restrictions on unethical recruitment and employment practices and proposed that compensation for losses from permanent migration could be organised through investment and tax remittance arrangements, and through technical and other resource inflows to support health professional training in Africa.
Responding to these pressures in the context of a crisis of health worker shortages in many African countries, in 2004 the World Health Assembly resolved to develop a multilateral response through a non-binding code of practice on the international recruitment of health workers. After consultation and negotiation, the Code of Practice on the International Recruitment of health workers was adopted at the 2010 World Health Assembly, almost 20 years since the World Health Organisation members agreed on such a code, the 1981 International Code of Marketing of Breast Milk Substitutes. Strong compliance by African countries with provisions of this code would advance us towards the diplomatic “finishing line” in the effort to more fairly manage health worker migration.
Regrettably however, by June 2011 (the latest reporting available) only 48 countries had reported even their National Authority for the code to WHO, with only 13 of these from Sub-Saharan Africa and only seven from the 16 in east and southern Africa (Kenya, Mauritius, Swaziland, Uganda, Democratic Republic of Congo, Angola and Namibia). More may have reported since then. The low reporting of even this administrative information raises concern about how far the code is known and implemented, and whether the reporting at the 2012 WHA will be an active tool to raise both its positive impacts and its shortfalls, or a passive bureaucratic ritual.
The 2010 code sets out the responsibilities, rights and ethical responsibilities of stakeholders to ensure fair recruitment and equitable treatment practices for the health workers who would have migrated, including to avoid recruiting health workers within existing domestic contractual obligations. Health workers are also obliged to be transparent about their contractual obligations.
In relation to health workforce development and health systems sustainability, the code discourages active recruitment from countries with critical health workforce shortages; encourages utilization of code norms as a guide when entering into bilateral, regional, and multilateral arrangements to further international cooperation and coordination; identifies the need to develop and support circular migration policies between source and destination countries; encourages countries to develop sustainable health systems that would allow for domestic health services demand to be met by domestic human resources; and places particular focus on the need to develop health workforce policies and incentives in all countries that support the retention of health workers in underserved areas.
The code appears to be a milder instrument than what African countries pushed for given that it is not legally binding. Its voluntary nature makes it a weak instrument as there are no specific commitments to return investments in stabilising the socioeconomic conditions of health workers or supporting training in low income countries. The code has become ‘the response’ to policy discussions on the relative costs and benefits of health worker migration. It does not fully address the African concerns that motivated to its negotiation and final adoption, but its presence has curtailed further discussion of these concerns.
One of the measures to assess the impact of the code is through monitoring its implementation and tracking the action taken by WHO member states. Member states are obliged to report to the WHO Secretariat on their actions on the code every three years, beginning in 2012. Given that the code is not fixed, and that its contents are considered as dynamic and subject to review, monitoring becomes one of the tools for keeping alive issues and concerns that were not fully addressed.
With the WHA only three months away, states, civil society and health worker associations should look for signs of progress, or otherwise, in the areas covered by the code, and ensuring that these are raised at the Assembly. Some of the questions this raises are:
Are there national coordination mechanisms for all relevant stakeholders and partners to facilitate policy dialogue and implementation on health workers?
Has there been any development of policies and practices since 2010 encouraging circular migration (such as migration within countries in east and southern Africa) and return migration from destination countries?
Is there policy or law requiring recruiters to follow ethical recruitment practices that covers state and private and non state actors?
Are there positive developments in collaboration of source countries and destination agencies or countries to sustain health worker development and training? Are there any new bilateral, regional, multilateral arrangements – soft law instruments – on health workers between source and destination countries?
Are there any new development assistance efforts (including mechanisms for compensation) to support coordination and collaboration on health worker migration between destination and source countries?
Are the regional bodies keeping and publicly reporting an annual scorecard of performance in the region against the agreed key indicators?
If the feedback on these questions indicate that the global code, as has been the case for many of its international precursors, is a useful signal of policy intent but not effective for managing costs and benefits, then the initial demand of the African countries for a more fair deal on the migration of health workers fairness still needs to be raised and addressed. African countries should use the forthcoming WHA in May of 2012, to strongly scrutinize developments around the implementation of the code. The results of this first assessment should help point towards concrete action to be taken on the implementation of the code.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: firstname.lastname@example.org. For further information on the code visit http://www.equinetafrica.org/bibl/docs/Polbrief28%20Code.pdf
2. Latest Equinet Updates
This call is for applicants for grants for policy research into global health diplomacy, and particularly in relation to the manner in which African interests around equitable health systems are being advanced through health diplomacy. Applicants are invited to indicate their capacities and proposals for implementing the work in ONE of the three areas:
1. On the reflection of African interests and issues around equitable health systems in the stages of motivating, negotiating, implementing, monitoring and reporting of the WHO Code on international Recruitment of health personnel.
2. On collaborations on access to essential drugs through south- south relationships with China, Brazil and India, particularly in relation to medicines production, distribution and regulation across countries within the ESA region, the alignment with and outcomes for national health systems, regional and global health diplomacy processes and the lessons learned for health diplomacy.
3. On the involvement of African actors in global health governance, particularly in relation to the participation, issues raised, outcomes and thus influence of African state and non-state actors on the decision making processes in the WHO and Global Fund, particularly on universal access to prevention, treatment and care for HIV and AIDS, and the lessons for health diplomacy.
Visit the website for information on the work, the grant call and the necessary information to include in the applications.
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 Kenya'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 towards closing geographical, rural–urban, wealth and other social disparities in some health outcomes, such as in immunisation coverage, access to primary education, contraceptive use, access to antiretrovirals and access to safe sanitation. Nevertheless, other areas are reported on that have made less progress or now have wider differentials. The report suggests that the health care system cannot make progress on its own. It will be difficult to achieve health equity unless we also address the social and economic determinants of health. However the health sector does also play a role. For example, the report shows the progress made in areas where health workers have been capacitated suggesting that the role health workers play in health equity needs more attention and support.
The Health Economics Unit (University of Cape Town, South Africa) has a new Facebook page. The Unit conducts research in health economics, health policy & health systems, offers Master's and PhD training and facilitates regional and international academic and policy networking. The Unit is particularly interested in using their research to influence health policy and practice. You can follow the Unit on Facebook to see their regular updates, post on their wall and communicate with them about health care issues.
3. Equity in Health
Development progress in the world's poorest countries could be halted or even reversed by mid-century unless bold steps are taken now to slow climate change, prevent further environmental damage, and reduce deep inequalities within and among nations, according to projections in the 2011 Human Development Report. In the report the United Nations Development Programme (UNDP) argues that environmental sustainability can be most fairly and effectively achieved by addressing health, education, income and gender disparities together with global action on energy production and ecosystem protection.
The deadline for meeting the Millennium Development Goals (MDGs) is quickly approaching. While progress has been made on a number of the goals, it is already clear that many targets will not be reached. Policy makers have been reluctant to start discussions of what comes after the 2015 deadline, fearing that negotiating a new framework would detract from efforts to meet the Millennium Development Goals (MDGs). While there seems to be broad support for a post- 2015 framework, there is not yet agreement on what this could look like. The United Nations and the World Health Organisation have started discussions on the issue, and it appears that sustainable development goals may be the way forward. In a survey of developing countries by the Institute of Development Studies, respondents overwhelmingly agreed that although the MDG framework has shortcomings, it is desirable to have an internationally agreed framework in place. Eighty percent of the respondents agreed that the post- 2015 arrangement should be target based, in part because it allows monitoring of progress.
Researchers in this study systematically collected all available data for malaria mortality for the period 1980–2010, correcting for misclassification bias. They found that global malaria deaths increased from 995,000 in 1980 to a peak of 1,817,000 in 2004, decreasing to 1,238,000 in 2010. In Africa, malaria deaths increased from 493,000 in 1980 to 1,613,000 in 2004, decreasing by about 30% to 1,133,000 in 2010. The researchers estimated more deaths in individuals aged 5 years or older than has been estimated in previous studies: 435,000 deaths in Africa and 89,000 deaths outside of Africa in 2010. In conclusion, the researchers assert that the malaria mortality burden is larger than previously estimated, especially in adults. There has been a rapid decrease in malaria mortality in Africa because of the scaling up of control activities supported by international funders. They argue that external funder support needs to be increased if malaria elimination and eradication and broader health and development goals are to be met.
While attention has focused on the rapid pace of urbanisation as the sole or major factor explaining the proliferation of informal settlements in developing countries, this paper argues that there are other factors that may have an effect. The paper accounts for differences in the prevalence of informal settlements among developing countries using data drawn from the recent global assessment undertaken by the United Nations Human Settlements Programme. The empirical analysis identifies substantial inter-country variations in the incidence of these settlements both within and across the regions of Africa, Asia as well as, Latin America and the Caribbean. Further analysis indicates that higher GDP per capita, greater financial depth and increased investment in infrastructure reduces the incidence of slums. Conversely, external debt burden, inequality in the distribution of income, rapid urban growth and the exclusionary nature of the regulatory framework governing the provision planned residential land directly contribute to the prevalence of informal settlements.
This study aimed to examine the longitudinal contributions of four political and socioeconomic factors to the increase in life expectancy in less developed countries (LDCs) between 1970 and 2004. Researchers collected 35 years of annual data for 119 LDCs on life expectancy at birth and on four key socioeconomic indicators: economy, educational environment, nutritional status and political regime. Results showed that the LDCs' increases in life expectancy over time were associated with all four factors. Political regime had the least influence on increased life expectancy in initial years but increased over time, while the impact of the other socioeconomic factors was initially stronger and decreased over time. Though authors argue that socioeconomic factors have strong impact on life expectancy, but the long-term impact of democracy should not be underestimated.
A number of key challenges to reproductive health in Namibia are identified: high fertility, especially among the poorest people and adolescents; an unmet need for contraception at 21%; women not using modern contraceptives because of health concerns or fear of side effects; and an increase in HIV among adults aged 15–49 years from 4% in 1992 to 20% in 2006. Knowledge of HIV prevention methods was found to be high. Key actions to improve reproductive health outcomes in Namibia were identified in this report as strengthening gender equality; reducing high fertility; highlighting the effectiveness of modern contraceptive methods and properly educating women on the health risks and benefits of such methods; and reducing maternal mortality and the prevalence of STIs/HIV/AIDS.
There are limited means to monitor the occurrence of cancer in developing countries and planning for prevention relies largely on estimates. This paper summarises priorities in cancer prevention in developing countries and the underlying evidence base, and addresses some of the challenges. The author concludes that cancer control calls for interventions that are kept logistically simple, integrated within systems and gradually building the infrastructure to bring care to the population at large. Given serious budgetary constraints, cancer control programmes need to maximise the efficacy of their investments. Of all possible interventions to reduce the cancer burden, the author argues that comprehensive programmes to prevent tobacco smoking are the most cost-effective, so that tobacco prevention should be a priority. Immunisation of infants against hepatitis B virus (HBV) is probably the second most cost-effective option in regions where the infection is still endemic. The author further argues that the uncontrolled use of carcinogens in industrial processes need to be addressed any cancer control programmes.
4. Values, Policies and Rights
This brief aims to explain the context of the landmark petition the Centre for Health, Human Rights and Development (CEHURD) on the right to health and maternal mortality. CEHURD and other partners have filed the petition in the Ugandan Constitutional Court to secure a declaration that non-provision of essential maternal health commodities in government health facilities, leading to the death of some expectant mothers, is an infringement on the right to health of the victims. CEHURD argues that these maternal deaths were preventable if the state had taken its human rights obligations seriously and the state should be held accountable. Reproductive health is argued to be a human right protected by both international and domestic law. The petition has generated public debate on maternal health and rallied civil society advocates behind the cause of reproductive health. However, litigation of human rights standards has two significant challenges. First, in situations where the judicial system has a huge case backlog it may take a long time before the case is disposed of. Second, litigation per se may not lead to change, unless followed by deliberate advocacy and lobbying. The authors argue that the case will be useful in identifying other areas of human rights warranting litigation, and lever efforts to build the capacity of various actors to take on litigation as an advocacy strategy.
The authors of this study draw on the experience of a Learning Network for Health and Human Rights (LN) involving collaboration between academic institutions and civil society organisations in the Western Cape, South Africa. The network aimed at identifying and disseminating best practice related to the right to health. The LN's work in materials development, participatory research, training and capacity-building for action, and advocacy for intervention illustrates lessons for human rights practice. Evidence from evaluation of the LN is presented to support the argument that civil society can play a key role in bridging a gap between formal state commitment to creating a human rights culture and realising services and policies that enable the most vulnerable members of society to advance their health. Through access to information, the creation of space for participation and a safe environment for learning to be turned into practice, the agency of those most affected by rights violations can be redressed, supported by civil society.
In this interview with Adrienne Germain, President Emerita of the International Women’s Health Coalition, she talks about her experiences promoting women’s health in developing countries. She argues that there are many reasons why there is widespread resistance to integrating HIV and reproductive health services, including disease control models that emphasise risk, not vulnerability; competition for scarce resources; narrow disciplinary training that encourage health professionals to work separately rather than collaborate across subjects and services; and gender bias. She pointed out that research shows that women’s health has definitely suffered from the separation of HIV information and services from other components of sexual and reproductive health care. For example, in sub-Saharan Africa, most HIV services fail to provide contraceptives, safe abortion, treatment and referral following sexual coercion or violence, or human papillomavirus (HPV) screening to women living with HIV. She also noted that political commitment has improved, but most politicians act only in their own interests or when they are pressed to do so. In most countries, women and children don’t have a strong political voice, although in some they have gained considerable ground over the last decade or so. We must invest in both local and international advocates whose main task today is to persuade those with power and resources to transform their rhetoric into action.
The aim of ths paper was to examine the use of contraception in 13 countries in sub-Saharan Africa; to assess changes in met need for contraception associated with wealth-related inequity; and to describe the relationship between the use of long-term versus short-term contraceptive methods and a woman’s fertility intentions and household wealth. The analysis was conducted with Demographic and Health Survey data from 13 sub-Saharan African countries. Researchers found that the use of contraception has increased substantially between surveys in Ethiopia, Madagascar, Mozambique, Namibia and Zambia but has declined slightly in Kenya, Senegal and Uganda. Wealth-related inequalities in the met need for contraception have decreased in most countries and especially so in Mozambique, but they have increased in Kenya, Uganda and Zambia with regard to spacing births, and in Malawi, Senegal, Uganda, the United Republic of Tanzania and Zambia with regard to limiting childbearing. After adjustment for fertility intention, women in the richest wealth quintile were more likely than those in the poorest quintile to practice long-term contraception. In conclusion, family planning programmes in sub-Saharan Africa show varying success in reaching all social segments, but inequities persist in all countries.
5. Health equity in economic and trade policies
African Heads of States and Governments convened in Addis Ababa, Ethiopia from 23-30 January 2012 to launch a continent-wide free trade agreement (CFTA). The Summit focused on solutions to the numerous impediments that hinder intra-African trade including: trade facilitation, productive capacity, trade related infrastructure and trade policy. In this article, the author calls for greater regional integration given African countries smaller markets. Africa’s regional economic communities are adopting uniform policies among their members but they are expected to trade with the rest of the world under various international trade regimes, which is argued to undermine regional integration and trade diversification. The author observes that trade preferences should be viewed only as a temporary arrangement – what is needed is to extend the period of the current trade regimes (say until 2020) and consolidate their conditions in a manner that supports manufacturing and consolidates regional markets. International partners and African countries should adopt a policy that revolves around access to high-income and emerging market countries linked to progress in integration with neighbouring countries.
In this study, economy-wide and hydrological-crop models are combined to estimate and compare the impacts of current and future climate trends in Zambia. Accounting for uncertainty, simulation results indicate that, on average, the trends may reduce gross domestic product by 4% over a ten-year period and pulls over 2% of the population below the poverty line. Socio-economic impacts are larger during drought years, and climate variability is projected to be a binding constraint on development in Zambia, at least over the next few decades.
In this paper, the authors discuss the various aspects of occupational cancer in developing countries, focusing on the conditions of informal workers and firms. They found that estimating the burden of cancers attributable to occupational exposures is difficult as occupational cancers are usually clinically indistinguishable from those unrelated to occupation. Lack of reliable data is an obstacle to establishing the place for cancer prevention in public policies, particularly in poor regions. Workplaces are argued to be a substantial source of carcinogen exposures, together with psychosocial stressors that mediate exposure to cancer risk factors such as smoking and alcohol consumption. Enforcement of hazard control in workplaces is weak and workers’ organisations are not strong enough to ensure compliance with standards required for healthy and safe work environments. This situation is even more intense in the informal economy, where firms are beyond state control. There are reports of increased risks of cencer among informal workers compared to formal workers.
In this article, the author argues that regional integration and regional agricultural markets are particularly important for African agriculture, since national markets and institutions are too small to bring about the needed transformation of African agriculture. Great opportunities exist, with Africa having 60% of the world's total amount of uncultivated arable land and therefore an immense potential for agricultural productivity growth. However, the author believes more attention should be dedicated to increase the productivity of small-scale farmers, who contribute around 90% of Africa's agricultural production but remain largely locked out of trade dynamics. Regional integration and agriculture development, and in particular intra-African agricultural trade, offer a great potential for food security and pro-poor growth in Africa, if they can work in synergy, especially at the regional level. Various independent processes are under way to promote agricultural development and encourage regional trade in Africa, such as the Comprehensive Africa Agriculture Development Programme (CAADP) and the development of trade corridors. However, weak communication across the agriculture and trade sectors/communities and the parallel - and at times competing - policy frameworks hamper the creation of much needed synergies.
In the lead-up to Free Trade Agreement (FTA) discussions during the European Union-India Summit in New Delhi on 10 February 2012, UNITAID has urged both parties to ensure that access to medicines, and particularly AIDS medicines, is not hampered by trade interests via provisions that could undermine the production, registration and availability of generic medicines. The agreement coincides with a delicate time for access to treatment efforts - the suspension of grants by the Global Fund and diminishing resources for health and development, said UNITAID, calling on the European Union to safeguard the right of millions of people in developing countries to continue accessing affordable life-saving medicines produced by the Indian generic industry. AIDS treatment has experienced startling progress over recent years, with almost seven million people starting treatment between 2003 and 2011, largely due to India's ability to produce low-cost, quality-assured generic medicines and to healthy competition among India's producers. However, such provisions as data exclusivity, patent term extensions and border measures could severely legally restrict manufacturers' ability to produce recently developed medicines and patient adapted formulations at low cost and to export those medicines to other developing countries.
An intellectual property (IP) conference for government ministers, to be held in April 2012 in South Africa, has stirred controversy among civil society advocates. Entitled “Africa Intellectual Property Forum: Intellectual Property, Regional Integration and Economic Growth in Africa”, the event is being organised by the United States government, and is being touted as the first Africa-wide ministerial-level event of its kind. The authors observe that the focus of the conference appears however to be stricter enforcement of IP rights, as most panels are concerned with enforcement and protection, and most speakers originate in developed country governments and industry. Non-governmental organisations who have worked on intellectual property rights have expressed disappointment, as they expected the conference would consider the 2007 World Intellectual Property Organisation Development Agenda, which consisted of 45 agreed recommendations intended to more fully incorporate the development dimension into WIPO activities, including technical assistance. They critique the agenda and an apparent underlying motive of encouraging strong IP legislation in those countries, at the expense of development and universal access to affordable medicines.
The World Health Organisation (WHO) Executive Board has agreed to propose to the May 2012 World Health Assembly the establishment of a mechanism for international collaboration on counterfeit and substandard medical products, but with the exclusion of trade and intellectual property issues. The Executive Board resolution would “establish a new Member State mechanism for international collaboration among Member States, from a public health perspective, excluding trade and intellectual property considerations, regarding substandard/spurious/falsely-labelled/falsified/counterfeit medical products”. The next Assembly in May will decide on this resolution. The mechanism would be reviewed by the World Health Assembly after three years, and countries will submit a progress report after one year. A contentious issue around counterfeits has been the suspicion on the part of some developing countries that concerns about counterfeit and substandard medicines are being purposely confused with trade in legitimate generic medicines from those countries. Removing intellectual property and trade from WHO discussions is intended to minimise the possibility of confusion.
6. Poverty and health
The authors of this paper argue that Tanzania has the potential to substantially increase its maize exports to other countries, if global maize production falls due to supply shocks in major exporting regions. Tanzania may be able to export more maize at higher prices, even if it also experiences below-trend productivity. Future climate predictions suggest that some of Tanzania’s trading partners will experience severe dry conditions that may reduce agricultural production in years when Tanzania is only mildly affected. Tanzania could thus export grain to countries as climate change increases the likelihood of severe precipitation deficits in other countries while simultaneously decreasing the likelihood of severe precipitation deficits in Tanzania. Trade restrictions, like export bans, prevent Tanzania from taking advantage of these opportunities, foregoing significant economic benefits.
As the drought in the Horn of Africa, deepens, Oxfam has extended its famine relief programmes in Somaliland, Ethiopia and Kenya with a mixture of emergency aid, long-term development and prevention, and advocacy to address the root causes of chronic drought. Nearly five million Ethiopians are affected by the crisis. Oxfam is scaling up its response in Ethiopia to reach 700,000 people by helping communities look for more sustainable sources of water, drilling boreholes, developing motorised water schemes and improving traditional water harvesting systems. In the driest and worst affected areas Oxfam has been trucking in emergency water supplies to over 69,000 people, which is treated and used for drinking, cooking, washing and keeping animals alive. Community health workers are also conducting public campaigns to help stop the spread of water-borne diseases such as diarrhoea. In Kenya, 4.3 million people are affected by the crisis – mainly in the southern agricultural areas and the northern pastoralist regions, such as Turkana and Wajir. People in these areas rely on their livestock as their main source of income and nutrition, but the drought has left the animals weak, dying and hard to sell. Oxfam’s “de-stocking” programme buys up some of the weakest goats and, sheep and slaughters the animals to provide meat to the community. About 900,000 vulnerable animals – belonging to 18,000 families – are also benefiting from Oxfam’s veterinarian and de-worming programmes.
European Commissioner for Humanitarian Affairs, Kristalina Georgieva, has endorsed the Charter to End Extreme Hunger, launched by leading agencies to make deadly food crises like the one gripping East Africa a thing of the past, saying “We need to pre-empt crises, rather than reacting when the disaster hits.” The first leader to sign this charter was Kenyan Prime Minister Raila Odinga, and later other leaders including UK Development Minister Andrew Mitchell endorsed it. Georgieva’s public engagement came as part of a debate, held by aid groups Caritas Europa, Oxfam, Polish Humanitarian Action (PAH) and ONE, which took place in December 2011 in Warsaw, Poland. The event organisers are calling on the European Union (EU) as a whole, including the European Commission and EU member states, to take action on three fronts. 1. Launch a pan-European initiative for the Horn Africa, involving all EU member states, that mobilises substantial funds for recovery and longer-term assistance to ensure families can feed themselves now and rebuild their futures. 2. Invest more in building people’s resilience by supporting local food production. Supporting local, small-scale farmers and pastoralists is argued to be one of the best ways to mitigate the effects of climate change and soaring food prices. To do so, the authors observe that the EU must boost these investments within the next seven-year EU budget. 3. Launch a new flexible tool that ensures there is no money gap between emergency aid and long-term assistance when a humanitarian crisis strikes.
Malawi's maize-growing central and southern regions have not had good rains, prompting concerns about possible shortages of the staple in the coming months. With maize plants still in the early stages of growth, there is concern the crop might not be ready for harvest at the usual time in April-May. Maize meal prices climbed by more than 60% in the last four months of 2011 due to fuel and foreign currency shortages. An input subsidy programme in recent years had helped Malawi become self-sufficient in maize, with 40% funded externally. The government has tried to control the maize price increase by increasing the price of maize sold through the state grain marketer, ADMARC, and to set a controlled price to discourage traders from buying through ADMARC and reselling. United Nations agencies are reported as saying however that ADMARC itself has played a role in price increases.
Endowed with 80 million hectares of arable land (of which only 10% is used), diverse climatic conditions, and abundant water resources, the Democratic Republic of Congo (DRC) has the potential to become the breadbasket of the entire African continent, according to this paper. Instead, the country is one of the most affected by malnutrition. The DRC has the highest number of undernourished persons in Africa and the highest prevalence of malnutrition in the world. As a result, child stunting and infant mortality rates in the DRC are also among the highest in the world. Overall, at least 50% of the population is deficient in vitamin B12, calories, riboflavin, iron, vitamin E, folate, and zinc. In rural areas, strategies to improve nutrition will need to use instruments that attack malnutrition directly rather than relying simply on rising incomes. Overall, the results highlight the paradox of the DRC - a country with huge potential for agricultural development but incapable of feeding itself in terms of both quantity and quality of nutrients.
In the context of rapid urbanisation in Democratic Republic of Congo, increasing population density in Kinshasa is associated with inequalities, poverty, environmental degradation, socio-economic tension, spontaneous settlements and sprawl. Rapid urban growth without planning in some areas and with limited employment underlies negative health outcomes. The author points to sustainable urbanisation as a priority, with a need to reconsider urbanisation processes to stimulate economic growth and mobilise resources at local, national and global levels. In this paper, the author reviews approaches to urban planning that balance development and the transformation of the city. He presents urban renewal as remedial action holding opportunities to improve environmental and social quality.
The number of people living in urban areas is rising rapidly in Southern Africa. By mid-century, the region is expected to be 60% urban. Rapid urbanisation is leading to growing food insecurity in the region’s towns and cities. This paper presents the results of the first ever regional study of the prevalence of food insecurity in Southern Africa. The AFSUN food security household survey was conducted simultaneously in 2008-9 in 11 cities in eight Southern African Development Community countries. The results confirm high levels of food insecurity amongst the urban poor in terms of food availability, accessibility, reliability and dietary diversity. The survey provides important insights into the causes of food insecurity and the kinds of households that are most vulnerable to food insecurity. It also shows the heavy reliance of urban poor people on informal food sources and the growing importance of supermarket chains.
The new international food security agenda focuses almost exclusively on raising food production by small rural farmers (something that has preoccupied rural development ‘experts’ for decades without success). The authors of this paper argue that there is a very real danger that this approach will be transferred uncritically to urban areas in the form of technical inputs for poor urban households to grow more food for themselves and for market. There is already an emerging focus on the “technical” aspects of urban farming and how these can be supported and enhanced through strategic interventions such as the promotion and adoption of innovative and appropriate urban farming technologies. However, as elsewhere, such technocratic ‘solutions’ are likely to fail if they do not first examine why so few poor households in southern Africa currently grow any of their own food. Agriculture is rarely recognised as a legitimate land use activity in urban plans or municipal designs. For urban farmers, this means that land is scarce and they often ruffle the feathers of officials and police by establishing their farming activities wherever they can, and urban farmers are often harassed by municipal authorities. The authors conclude that comprehensive, systematic research into the links between urban agriculture, food security and health/nutrition could go a long way to easing such institutional and political obstacles so that city farming can meet its full potential in Southern Africa.
7. Equitable health services
This report aims to present the evidence that supports the case for expanded access to cancer care and control (CCC) in low and middle income countries (LMICs), and describe innovative models for achieving this goal. The document summarises information from 56 countries. The report emphasises that innovation in delivery systems, increased access to affordable vaccines and medications, innovative financing mechanisms to make care accessible and affordable are of great importance in terms of CCC. The authors call for promoting prevention policies that reduce cancer risk, mobilising all public and private stakeholders in the cancer arena, and expanding training opportunities for researchers in LMICs. They recommend that national cancer control programmes in LMICs must work systematically to adapt global guidelines for national cancer prevention, treatment, and palliation programmes. Also, they must strengthen procurement and distribution systems and ensure regulation of quality and safety. Cancer detection and treatment should be made more accessible and affordable through diagnostic tests and medications that are more easily delivered in remote settings. Governments must expand access across the cancer care control continuum through universal financial protection for health, and efficient use of all levels of care.
For many decades, the cornerstone of malaria management in Africa was to treat all febrile children with chloroquine. With high-level resistance to chloroquine and improved means of malaria diagnosis, recommendations for the management of malaria in Africa have changed in two important ways in the last few years. First, recommended therapy for uncomplicated falciparum malaria has moved to highly effective artemisinin-based combination therapies. Second, it is now recommended that the treatment of malaria be confined to parasitologically confirmed cases. This recommendation requires the availability of reliable diagnostic tests. The gold standard test for the diagnosis of malaria is microscopy. Evaluation of Giemsa-stained thick smears, when performed by expert microscopists, provides accurate diagnosis of malaria, although assuring expert slide preparation and reading can be difficult. Indeed, microscopy is often unavailable, especially in rural settings. In this regard, the advent of rapid diagnostic tests (RDTs) for malaria is an important advance. Multiple immunochromatographic tests, incorporating a number of different parasite antigens and produced by many different manufacturers, are now available. At best, these tests offer a simple, fairly inexpensive, and reliable means of diagnosis that can be performed by healthcare workers with limited training. However, concerns with RDTs include potential unreliability because of inconsistent manufacture or poor storage, uncertain supply, and potential misreading of results by unskilled health workers. An additional, generally unappreciated concern when considering RDTs is differences between available tests.
Cases of occupational disease, solvent encephalopathy and occupational asthma are used to exemplify failings of the workers’ compensation system in South Africa, that include delays in processing claims, non-response to requests for information, and inadequate assessment of disability. These and other systemic deficiencies in administration of the Compensation for Occupational Injuries and Diseases Act of 1993 (COIDA) reduce access by workers with occupational disease to private medical care, and shift costs to workers and to public sector medical care. Another unintended effect is to promote underreporting of occupational disease by employers and medical practitioners. Reforms have been tried or proposed over the years, including decentralisation of medical assessment to specialised units, which showed promise but were closed. Improved annual performance reporting by the Compensation Commissioner on the processing of occupational disease claims would promote greater public accountability. Given the perennial failings of the system, a debate on outsourcing or partial privatisation of COIDA’s functions is due, the author concludes.
Medicins Sans Frontieres will be the first global medical humanitarian organisation to adopt South Africa's Triage Score (Sats) emergency response system in several countries where their teams provide emergency medical care. Triage systems were introduced worldwide to reduce the waiting time for patients who need critical care when they arrive at emergency rooms. Without the system, patients who seek medical attention in understaffed and overcrowded emergency rooms often can't get the help they need in time. With Sats, patients are categorised according to need, decreasing the waiting time for critically ill patients. The triage scoring system has been found to improve patient flow in accident and emergency units, as well as lower mortality rates and improved the delivery of time-critical treatment for patients with life-threatening conditions. The South African system is designed to deal with the unique challenges of emergency rooms in developing countries, where more patients suffer trauma than in developed countries. MSF has already piloted Sats in some district hospitals in Botswana, Malawi and Ghana.
The purpose of this paper is to present a global update of drug-resistant tuberculosis (TB) and explore trends in 1994–2010. Data on drug resistance among new and previously treated TB patients, as reported by countries to the World Health Organization, were analysed. In 2007–2010, 80 countries and eight territories reported surveillance data. In South Africa, more than 10% of the cases of multi-drug resistant (MDR) TB were extensively drug-resistant. Globally, in 1994 to 2010 multidrug resistance was observed in 3.4% of all new TB cases and in 19.8% of previously treated TB cases. No overall associations between MDR-TB and HIV infection or sex were found. Between 1994 and 2010, MDR-TB rates in the general population increased in various countries, including Botswana. In conclusion, the highest global rates of MDR-TB ever reported were documented in 2009 and 2010. Trends in MDR-TB are still unclear in most settings. Better surveillance or survey data are required, especially from Africa and India.
In this study, 2010-2011 data are reported from public facilities in Kenya where alarming stock-outs were revealed in 2008. Data were collected between January 2010 and June 2011 as part of 18 monthly cross-sectional surveys undertaken at nationally representative samples of public health facilities. The primary monitoring indicator was total stock-out of all four weight-specific artemether-lumefantrine (AL) packs. The secondary indicators were stock-outs of at least one AL pack and individual stock-outs for each AL pack. The number of surveyed facilities across 18 time points ranged between 162 and 176 facilities. The stock-out means of the proportion of health facilities were 11.6% for total AL stock-out, 40.6% for stock-out of at least one AL pack, and between 20.5% and 27.4% for stock-outs of individual AL packs. Despite lower levels of AL stock-outs compared to the reports in 2008, the stock-outs at Kenyan facilities during 2010-2011 are still substantial and of particular concern. Only a minor decrease was observed in the stock-outs of individual AL packs. Recently launched interventions to eliminate AL stock-outs in Kenya are fully justified, the authors argue.
This study was conducted in Chitungwiza, a high density dormitory town outside Harare, to determine in adults registered with recurrent TB how treatment outcomes were affected by type of recurrence and HIV status. Data were abstracted from the Chitungwiza district TB register for all 225 adult TB patients who had previously been on anti-TB treatment and who were registered as recurrent TB from January to December 2009. Results indicated that of 225 registered TB patients with recurrent TB, 159 (71%) were HIV tested, 135 (85%) were HIV-positive and 20 (15%) were known to be on antiretroviral treatment (ART). More females were HIV-tested (75/90, 83%) compared with males (84/135, 62%). Overall, treatment success was 73% with transfer-outs at 14% being the most common adverse outcome. TB treatment outcomes did not differ by HIV status. However those with relapse TB had better treatment success compared to “retreatment other” TB patients. In conclusion, no differences in treatment outcomes by HIV status were established in patients with recurrent TB. Important lessons from this study include increasing HIV testing uptake, a better understanding of what constitutes “retreatment other” TB, improved follow-up of true outcomes in patients who transfer-out and better recording practices related to HIV care and treatment especially for ART.
This report describes the work of two four-wheel drive mobile clinics launched in 2008 to fill an identified service gap in the remote areas of Mulanje District, Malawi. The clinics provide basic HIV, TB STI and pre-natal services. The researchers found that in the project, the implementation process and schedule can be affected by medication, supply chain and infrastructural issues, as well as governmental and non-governmental requirements. Timelines should be sufficiently flexible to accommodate unexpected delays. Once established, service scheduling should be flexible and responsive; for instance, malaria treatment rather than HIV testing was most urgently needed in the season when these services were launched. The mobile clinics provide services for people who otherwise may not have attended a health centre. Strong relationships have been forged with local community leaders and with Malawi Ministry of Health officers as the foundation for long-term sustainable engagement and eventual integration of services into Health Ministry programmes.
8. Human Resources
The human resource crisis affects developed and developing countries, but the global poor suffer disproportionately, not only because they have a much smaller workforce but also because their needs are so much greater, according to this paper. Of the 57 countries with critical shortages, 36 are in Africa. Africa has 25% of the world’s disease burden, but only 3% of the world’s health workers and 1% of the economic resources. The causes of the human resource shortages are multifaceted and complex, but not so complex that they cannot be understood and acted upon, the authors argue. They make several recommendations. The United States (US) administration, using an “all-of-government” approach, should develop a strategic plan to address the global health worker shortage. The US government should also reform US global health assistance programmes to increase health workforce capacity in partner countries, as well as increase financial assistance for global health workforce capacity development. Finally, Congress should empower the Department of Health and Human Services or another appropriate agency to regulate the recruiters of foreign-trained health workers.
Lesotho faces a severe human resource shortage as it attempts to manage its HIV pandemic, with more than 25% of the population infected with HIV. This paper reports on a programme that provided HIV services in seven rural clinics in Lesotho. LHWs played an important role in the provision of HIV services that ranged from translation, adherence counseling, voluntary counseling and testing (VCT) for HIV and patient triage, to medication distribution and laboratory specimen processing. Training the LHWs was part of the clinic physicians' responsibilities and thus required no additional funding beyond regular clinic operations. This lent sustainability to the training of the LHWs. This paper describes the recruitment, training, activities, and perceptions of the LHW work between June 2006 and December 2008. LHWs participated successfully in the care of thousands of people with HIV in Lesotho and their experience can serve as a model for other countries facing the disease, the authors conclude.
The objective of this study was to determine the percentage of South African nurses initiating new HIV-positive patients on therapy within two months of attending the Nurse Initiation and Maintenance of Antiretroviral Therapy (NIMART) course, and to identify possible barriers to nurse initiation. A brief telephonic interview using a structured questionnaire of a randomly selected sample (126/1736) of primary care nurses who had attended the NIMART course between October 2010 and 31 March 2011 at primary care clinics in seven provinces. Outcome measures were the number of nurses initiating ART within two months of attending the FPD-facilitated NIMART course. Results showed that, of the nurses surveyed, 62% (79/126) had started initiating new adult patients on ART, but only 7% (9/126) were initiating ART in children. The main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages. In conclusion, despite numerous challenges, many primary care nurses working in the seven provinces surveyed have taken on the responsibility of sharing the task of initiating HIV-positive patients on ART. The barriers preventing more nurses initiating ART include the shortage of primary care nurses and the lack of sufficient consulting rooms. Expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating a further 1.2 million HIV-positive patients on ART by 2012.
In this study, researchers examined the performance of community antiretroviral therapy and tuberculosis treatment supporters (CATTS) in scaling up antiretroviral therapy (ART) in Reach Out, a community-based ART program in Uganda. Retrospective data on home visits made by CATTS were analysed to examine the CATTS ability to perform home visits to patients based on the model's standard procedures. Qualitative interviews conducted with 347 randomly selected patients and 47 CATTS explored their satisfaction with the model. The CATTS ability to follow-up with patients worsened from patients requiring daily, weekly, monthly, to three-monthly home visits. Only 26% and 15% of them correctly home visited patients with drug side effects and a missed clinic appointment, respectively. Additionally, 83% visited stable pre-ART and ART patients (96%) more frequently than required. Six hundred eighty of the 3,650 (18%) patients were lost to follow-up (LTFU) during the study period. Ninety-two percent of the CATTS felt the model could be improved by reducing the workload. In conclusion, the Reach-Out CHW model may be too labour-intensive. Triaged home visits could improve performance and allow CATTS time to focus on patients requiring more intensive follow-up.
The aim of this study was to identify workforce ratios in nine allied health professions and to identify whether these measures are useful for planning allied health workforce requirements. A systematic literature search using relevant MeSH headings of business, medical and allied health databases and relevant grey literature for the period 2000-2008 was undertaken. Twelve articles were identified which described the use of workforce ratios in allied health services. Only one of these was a staffing ratio linked to clinical outcomes. The most comprehensive measures were identified in rehabilitation medicine. The authors conclude that evidence for use of staffing ratios for allied health practitioners is scarce and lags behind the fields of nursing and medicine.
9. Public-Private Mix
According to this article, February 2012 is a key month for the future of the life-saving Indian generic industry, because fights on all three fronts (EU-India FTA, TPPA, and Novartis v. India) are occurring simultaneously - all with the same objective of using intellectual property rules that will significantly reduce the ability of Indian suppliers to produce and export low cost generic medicines. The European Union (EU) has put great pressure on India to conclude a trade agreement that includes TRIPS-plus IP protections, particularly in terms of investor-versus-state claims, general IP enforcement measures, and data exclusivity. In sum, the EU wants to enshrine IP-right holders and other investors rights to bring private arbitration claims directly against India when their investment-return expectations are upset by government regulations or other actions. February is also a key month in the ongoing TPPA negotiations, with side meeting on IPRs scheduled in Hollywood as a precursor to major negotiation in early May in Melbourne. The United States (US) attack on India-style protections against patent monopoly evergreening is quite explicit in its leaked TPPA demands. Contrary to the direct rule of Sec. 3(d) of the India Amended Patents Act (2005), the US is trying to mandate that patent be granted on minor changes in the form, new uses, and dosages, formulations, and combinations of known chemical entities. It also seeks mandatory patent term extensions, disallows the kind of pre-grant oppositions used so effectively by activists in India, and insists on data exclusivity and patent-registration linkage. Moreover, the US seeks to limit price control mechanisms like those currently used in India and seeks enforcement rights even more onerous than those pursued by the EU.
In 2006 the drug company Novartis took the Indian government to court over its patent law, in a move that threatened access to affordable medicines produced in India for millions of people across the developing world. The company wanted to get the law changed so that they could more easily extend the patents on their products, and stop generic companies producing the same medicines at a fraction of the price. MSF’s Drop the Case campaign, launched in response to this move, gathered nearly half a million signatures calling on the company to drop its case. But six years later, the legal battle continues. India’s Supreme Court is now due to give the final judgement on the case this year. In August 2007, the Madras High Court in August 2007 ruled against Novartis. Undeterred, the company has continued to appeal against each legal reversal, with the result that India’s final court – the Supreme Court - is now due to hear the case. To add your voice to the discussion, visit: http://www.msfaccess.org/STOPnovartis/
10. Resource allocation and health financing
External funders are concerned about how their aid is used, especially how it affects fiscal behaviour by recipient governments. This study reviews the recent evidence on the effects of aid on government spending and tax effort in recipient countries, concluding with a discussion of when (general) budget support is a fiscally efficient aid modality. Severe data limitations restrict inferences on the relationship between aid and spending, especially as the government is not aware of all the aid available to finance the provision of public goods. Three generalisations are permitted by the evidence: aid finances government spending; the extent to which aid is fungible (can be substituted with other resources) is over-stated and even where it is fungible this does not appear to make the aid less effective; and there is no systematic effect of aid on tax effort. Beyond these conclusions the fiscal effects of aid are country specific.
In 2010, vast humanitarian crises from Haiti to Pakistan almost overwhelmed the international system’s ability to respond. Despite years of reform, United Nations (UN) agencies, external funders, and international NGOs (INGOs) struggled to cope. In 2011, Somalia yet again saw a response too little and too late, driven by media attention, not a timely, impartial assessment of human needs. At the same time, humanitarian action is needed now more than ever, Oxfam argues. The growing number of vulnerable people, the rise in disasters, and the failure to put most fragile states on the path to development, will significantly increase needs. Western-based external funders, INGOs and the UN provide only part of the answer. Already, new external funders and NGOs from around the world provide a significant share of humanitarian aid. Future humanitarian action will rely on them, and on the governments and civil society of crisis-affected countries even more. The UN and INGOs will be vital, but the author argues that their contribution will increasingly be measured by how well they complement and support the efforts of others and uphold humanitarian principles.
As aid diminishes in importance, the authors argue that governments need to improve the quality of their public spending. This paper suggests three organisational tools - independent ratings of spending systems, independent public service agencies, and sovereign development funds- as a means of assessing public spending.
With global funding for HIV/AIDS on the decline, Zimbabwe's innovative AIDS levy - a 3% tax on income - has become a promising source of funding for the country, with a dramatic increase in revenue collected in the past two years. For the year ending 31 December 2010, a total of US$20.5 million was collected in 2010 against $5.7 million the previous year. The National AIDS Council Board attributed the increase to improved revenue flows owing to improved political and economic stability in the country, which has created more jobs in the formal sector and improved tax remittances. Zimbabwe's economy has witnessed steady growth following the formation of the coalition government of Prime Minister Morgan Tsvangirai and President Robert Mugabe in 2009. Although the revenue figures for 2011 have not yet been audited, the National AIDS Council estimates it collected about $25 million.
Following the ARV roll out in South Africa, people living with HIV (PLHIV) experienced improved health that, in turn, affected their grant eligibility. The aim of this paper was to explore whether PLHIV reduced or stopped treatment to remain eligible for the disability grant from the perspectives of both PLHIV and their doctors. Researchers conducted interviews with 29 PLHIV and eight medical doctors working in the public sector, as well as three focus group discussions with programme managers, stakeholders and community workers, and a panel survey of 216 PLHIV receiving anti-retrovirals (ARVs). They found that unemployment and poverty were the primary concerns for PLHIV and the disability grant was viewed as a temporary way out of this vicious cycle. Although loss of the disability grant significantly affected the well-being of PLHIV, they did not discontinue ARVs. However, in a number of subtle ways, PLHIV "tipped the scales" to lower the CD4 count without stopping ARVs completely. Grant criteria were deemed ad hoc, and doctors struggled to balance economic and physical welfare when assessing eligibility. The researchers call on government to ensure that it provides sustainable economic support in conjunction with ARVs in order to make "positive living" a reality for PLHIV. A chronic illness grant, a basic income grant or an unemployment grant could provide viable alternatives when the PLHIV are no longer eligible for a disability grant.
11. Equity and HIV/AIDS
In this study, researchers evaluated the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting in western Kenya. The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High risk express care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of [less than or equal to]100 cells/mm3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of [less than or equal to]100 cells/mm3 were eligible for enrolment into HREC and for analysis. Between March 2007 and March 2009, 4,958 patients initiated cART. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality, and reduced loss to follow up compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up. The researchers conclude that frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.
This study reports on HIV-free survival among nine- to 24-month-old children born to HIV-positive mothers in the national prevention of mother-to-child transmission (PMTCT) programme in Rwanda. Researchers conducted a national representative household survey between February and May 2009. Participants were mothers who had attended antenatal care at least once during their most recent pregnancy, and whose children were aged nine to 24 months. They found that out of 1,448 HIV-exposed children surveyed, 44 (3%) were reported dead by nine months of age. Of the 1340 children alive, 53 (4%) tested HIV positive. HIV-free survival was estimated at 91.9 % at nine to 24 months. Adjusting for maternal, child and health system factors, being a member of an association of people living with HIV improved by 30% HIV-free survival among children, whereas the maternal use of a highly active antiretroviral therapy (HAART) regimen for PMTCT had a borderline effect. HIV-free survival among HIV-exposed children aged nine to 24 months is estimated at 91.9% in Rwanda. The national PMTCT programme could achieve greater impact on child survival by ensuring access to HAART for all HIV-positive pregnant women in need, improving the quality of the programme in rural areas, and strengthening links with community-based support systems, including associations of people living with HIV.
As external funders retreat from funding HIV prevention and treatment, national programmes reliant on external funding have become exceedingly vulnerable. Activists from East and Southern Africa are calling on governments to take increased ownership of these programmes to ensure treatment continues after donor funds have gone. According to Dr Mbulawa Mugabe, UNAIDS deputy regional director for East and Southern Africa, the region has made considerable progress towards reaching the universal HIV treatment access target of 80% coverage among those in need of antiretrovirals (ARVs). He added that the region is performing above average for low and middle-income countries. However, he indicated that hardly any of the region’s governments are contributing financially to the treatment response. “We cannot leave the lives of nationals to development partners," he emphasised. According to researchers, governments need to bridge the gap between domestic and external spending for ARVs but, without accurate country-level data, this gap is difficult to estimate.
12. Governance and participation in health
Commonwealth Good Governance 2011/12 is a comprehensive guide to public sector reform in the Commonwealth. Articles in this edition examine: the link between democracy and development; political-administrative relations; leadership in the public sector; strengthening local government; aid and governance; and building capacity in national assemblies. The report also contains governance profiles of the 54 Commonwealth member countries.
The author of this paper 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.
This article evaluates progress in governance of Namibia since independence in 1990. Unemployment is high – estimated at 50% - and pass rates at schools are dropping, while the promised fruits of independence have not yet reached the broad spectrum of the population, and the government’s success in attracting investment has not paid much in terms of long-term dividends. However, there have been plenty of immediate and valuable gains, such as regular elections, much wider access to schooling, and government benefits that are available for ex-combatants and war orphans, and other vulnerable groups. While the courts are at times outspoken, they remain visibly understaffed. Despite the fact that democratic commitment remains fragile in the country, the so-called ‘born-frees’ (those people born after independence) are becoming increasingly vocal and more active in the debate over the country’s future, free speech is now more deeply entrenched and there are a number of vibrant public discussion platforms, including social media.
This paper examines the changing perceptions of Frelimo's nationalist project amongst members of the middle class in Maputo, Mozambique's capital. The author argues that nationalism in Mozambique has created a system of meaning and new forms of identity that are especially relevant for more privileged urbanites. However, growing urban poverty and inequality has had an effect throughout the social spectrum in Mozambique. and everyday life conflicts with the government's message of unity and progress for all.
Large-scale social mobilisation, including street protests and parallel activities, is the only thing can save the United Nations Conference on Sustainable Development (Rio+20) from ending in nothing but frustration, according to activists and analysts. A repeat of the failure of recent conferences to negotiate an international climate change pact seems inevitable, said Cândido Grzybowski, the director general of the Brazilian Institute of Social and Economic Analysis (IBASE) and one of the founders of the World Social Forum, the largest global civil society gathering. Grzybowski based his pessimistic outlook on a number of factors, such as the economic/financial crisis in the wealthy nations, combined with the fact that this a year of elections in many of them, including France and the United States, moving international commitments to the bottom of their leaders’ agendas. He also blamed what he calls the limited convening power of Brazilian President Dilma Rousseff, particularly when it comes to environmental issues. Civil society actions must not be limited to Rio de Janeiro, say activists. The Brazilian Forum of NGOs and Social Movements for the Environment and Development (FBOMS) is planning to promote demonstrations in many other cities around the world, with the aid of the internet and social networks. The Thematic Social Forum in Porto Alegre will help to coordinate these initiatives, with the participation of representatives of civil society movements like the Indignados (Indignant) movement in Spain and the Occupy movement in the United States.
13. Monitoring equity and research policy
This study describes implementation of South Africa’s HIV monitoring and evaluation (M&E) system, determines the extent to which it is integrated with the district health information system (DHIS), and evaluates factors influencing the extent of HIV M&E integration. The study was conducted in one health district in South Africa. Data were collected through key informant interviews with programme and health facility managers and review of M&E records at health facilities providing HIV services. Results indicated that the HIV M&E system is top-down, over-sized, and captures a significant amount of energy and resources to primarily generate antiretroviral treatment (ART) indicators. Processes for producing HIV prevention indicators are integrated with the district health information system. However, processes for the production of HIV treatment indicators by-pass the DHIS and ART indicators are not disseminated to district health managers. Specific reporting requirements linked to ear-marked funding, politically-driven imperatives, and mistrust of DHIS capacity are key drivers of this silo approach. In conclusion, parallel systems that bypass the DHIS represent a missed opportunity to strengthen system-wide M&E capacity. Integrating HIV M&E (staff, systems and process) into the health system M&E function would mobilise ear-marked HIV funding towards improving DHIS capacity to produce quality and timely HIV indicators that would benefit both programme and health system M&E functions.
According to this reader, health policy and systems research (HPSR) is often criticised for lacking rigour, providing a weak basis for generalisation of its findings and, therefore, offering limited value for policy-makers. This reader aims to address these concerns through supporting action to strengthen the quality of HPSR. It is primarily intended for researchers and research users, teachers and students, particularly those working in low- and middle-income countries. It provides guidance on the defining features of HPSR and the critical steps in conducting research in this field. It showcases the diverse range of research strategies and methods encompassed by HPSR, and it provides examples of good quality and innovative HPSR papers.
The World Health Organisation’s (WHO) Consultative Expert Working Group on Research and Development (CEWG) has proposed the adoption of a convention which would incorporate a mechanism for resource distribution, pooling of funds and global coordination to help developing countries with the research and development for their public health systems. In its draft report to WHO, it argued that intellectual property rights and other incentives, such as financial mechanisms and coordination among stakeholders, are needed to ensure research and development lead to relevant and affordable medical innovations for poor patients. Responses to the report have been typically polarised among WHO Member States, with developing countries expressing strong support and industrial nations taking a more cautious approach. Before the formal negotiations of a convention can start, though, a number of variables are still to be considered, such as the need to table a procedural resolution to take note of the report and to request time before engaging in further negotiations.
This research aimed to elaborate a theory of knowledge translation (KT) in Uganda that could also serve as a reference for other low- and middle income countries. The researchers employed qualitative approaches to examine the principal barriers and facilitating factors to KT. A review of the literature revealed that the most common factors facilitating knowledge uptake included institutional strengthening, research characteristics, dissemination processes, partnerships and political context. The analysis of interviews conducted by the researchers, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. Respondents rasied the importance of mainstreamed structures within the Ministry of Health to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of communities and civil society in KT. The study tests a framework that can be more widely used in empirical research on the process of KT on specific policy issues.
In September 2011, it was announced that Dutch, Japanese and American scientists had independently genetically altered the H5N1 avian influenza virus, transforming it into a highly lethal, airborne strain that could conceivably spread easily between humans. The studies were funded by the United States (US) and the US National Science Advisory Board for Biosecurity (NSABB) then prevented the researchers from releasing their findings on the grounds that the experiment could be replicated by terrorists. The scientists involved in the H5N1 research have questioned the need for redacting the studies’ findings, arguing that “there is already enough information publicly available” to reproduce their experiments and that withholding the information only serves to disadvantage legitimate scientific research. The incident has sparked intense international public debate, clearly dividing much of the scientific and policy-making community. Some commentators have argued that an international consensus on appropriate approaches is needed, as national governments can only control matters in their own jurisdiction and this is an international question. The World Health Organisation, which has maintained a relatively low profile regarding the controversial H5N1 studies so far, agreed to host a technical meeting on 16-17 February 2012 to discuss the issues.
In this analysis of participatory civil society assessments, the authors make a number of important points. A new generation of country-led civil society assessments is now required, which will address important fundamental issues of philosophy, principle and methods and should be tailored to national and historical contexts. New approaches to civil society assessment need to shift from mapping and reporting to forecasting and foresight to be more relevant to civil society and policymakers. Diminishing returns of international comparative civil society assessments means that the time has come to expand and disaggregate assessment tools to make them progressively more meaningful and valid locally. The range of tools should be versatile to satisfy different stakeholders and stakeholders should question the applicability of “Western‟ theories and approaches to non-western societies. When conducting assessments in restrictive and culturally sensitive environments, certain factors, such as collective work, mutual trust and self-criticism, are needed to achieve positive results. A multi-stakeholder approach should be taken that represents government, business and the organised citizenry. It is also time to go beyond NGOs and public formal organisations to include informal organisations, which often have greater importance for the health of society. Final recommendations include going beyond a sectoral approach, using a domain approach to civil society assessments, adopting a clearer multi-centred theory of governance and recognising norm-free assessment as a fallacy.
The non-profit Universities Allied for Essential Medicines (UAEM) is a student-driven movement to promote equitable global access and innovation in publicly funded medical research. Through UAEM’s advocacy, universities that license medical research to industry have now begun to include requirements for generic production or “at cost” provisions for low- and middle-income countries. These “global access” provisions lower the price of the final products for poor patients, and have been adopted by leading institutions including Harvard, Yale, the University of British Columbia, and the US National Institutes for Health (NIH). While over 30 research institutions worldwide have endorsed a “Statement of Principles and Strategies” supporting global access to their medical discoveries, the students of UAEM want to ensure that this translates into real-world impact. They argue that the statement itself should be strengthened, and individual universities can adopt more robust policies. Most importantly, however, universities must demonstrate that they are regularly including global access provisions in their licensing negotiations with pharmaceutical companies. Improving the transparency of universities and their licensing practices is critical. Not only do universities need to ensure affordable access to their medical breakthroughs, but they also need to show that they are committing resources, both human and financial, to research on neglected diseases.
14. Useful Resources
This highly illustrated guide helps health promoters, development workers, environmental activists, and community leaders take charge of their environmental health. The book contains activities to stimulate critical thinking and discussion, inspirational stories, and instructions for simple health technologies such as water purification methods, safe toilets, and non-toxic cleaning products. 23 chapters cover topics including: preventing and reducing harm from toxic pollution; forestry, restoring land, and planting trees; protecting community water and watersheds; food security and sustainable farming; environmental health at home; solid waste and health care waste; and how to reduce harm from mining, oil, and energy production. With dozens of activities to stimulate critical thinking and discussion, instructions for simple health technologies such as safe toilets, safe cleaning methods, and water purification methods, and hundreds of drawings to make the messages clear, the guide should be useful for people just beginning to address environmental health threats, as well as people with many years’ experience in the field.
This is the first of six films in the series "Bringing the Social to Rio+20". The film uses footage from recordings and interviews from the 2011 UNRISD conference, "Green Economy and Sustainable Development: Bringing Back the Social Dimension". It explores the green economy's potential as a path to inclusive, sustainable development and poverty eradication.
These six right-to-health pamphlets contain basic, easy to read information and can be placed in any South African public health service facility or distributed to patients and organisations working in public health. Topics include: community involvement; the Patients’ Rights Charter; individual and collective rights; access to information; and rights and resource allocation.
Existing guidelines for management of diarrhoea are often ignored in public and private practice, possibly because of a perception that the guidelines are too simple, or because of expectations of the need to give ‘real’ drug therapy to stop diarrhoea. This guideline provides a problem-based approach to the basics of present-day management of acute gastroenteritis, and discusses the evidence for the recommendations. The guidelines recommend that each episode of diarrhoea must be seen as an opportunity for caregiver education in the prevention of the illness, in the ‘what’ and ‘how’ of oral rehydration and re-feeding, and in the recognition of when to seek help. The vast majority of patients recover rapidly, but serious complications do occur, and must be recognised and managed correctly. The guidelines are endorsed by the Paediatric Management Group (PMG) in South Africa.
This toolkit was designed in response to the need for a practical tool to empower communities on what the right to health means, how to identify violations of health rights and how to respond to these violations. The toolkit can be used as a stand-alone source of information or as training tool for workshops on the right to health. Each section uses practical examples to illustrate ideas, and has a number of exercises and case studies that could be used for training purposes. At the end of each chapter is a set of workshop handouts that can be photocopied for participants. Many of these examples are actual cases that emerged from the work of the Learning Network for Health and Human Rights over the past few years. The toolkit is designed for use by civil society organisations (CSOs) such as health committees, NGOs working with health issues, educational institutions, community members or anyone with an interest in health rights.
15. Jobs and Announcements
Also referred to as the Earth Summit or Rio+20 due to the initial conference held in Rio in 1992, the objectives of the Summit are: to secure renewed political commitment to sustainable development; to assess progress towards internationally agreed goals on sustainable development and to address new and emerging challenges. The Summit will also focus on two specific themes: a green economy in the context of poverty eradication and sustainable development, and an institutional framework for sustainable development.
As part of its national research capacity-strengthening mandate, the Consortium for National Health Research (CNHR) invites applications for research career development grants (RCDGs) from qualified Kenyan researchers (currently based in Kenya or working within the Diaspora) who wish to further develop their careers while undertaking research and training programmes in Kenya. The grants aim at enabling successful applicants to obtain high-quality research training that will lay the foundation for a successful independent research career. CNHR is planning to award 12 RCDGs commencing in October 2012. The grants will be competitively offered to support the development of research ideas, or acquisition of specialised research/training skills as a step towards a productive independent research career in areas of national health priority currently focused on the attainment of Millennium Development Goals (MDGs) 4 (child health); 5 (maternal health); 6 (infectious diseases); emerging and non-communicable diseases, with improvement of health systems as an overarching theme.
Organisers of the Global Symposium on Health Systems Research (HSR) are calling on all interested parties to submit abstracts for the Second Global Symposium. Abstracts may be in one of three main themes: Knowledge translation; state-of-the-art health systems research; and health systems research methodologies. There are also three cross-cutting themes: Innovations in health systems research; neglected priorities or populations in health systems research; and financing and capacity building for health systems research. The overall goal of this call is to enhance health policy and management decision-making processes in low- and middle-income countries (particularly for the implementation and scale-up of effective interventions for MDGs 4, 5, and 6) through the identification and testing models of leadership development to strengthen the capacity of decision-makers to demand, access and use research.
The East, Central and Southern Africa College of Nursing (ECSACON) is calling for abstracts for the 10th ECSACON Scientific Conference. The theme is “Acceleration towards attainment of Millennium Development Goals (MDGs) through revitalising primary health care: nurses and midwives sharing high impact interventions”. Sub-themes: Improving maternal and child health: Moving towards achieving the MDGs; Health systems strengthening; Innovations and excellence in nursing and midwifery; Evidence-based primary health care practices/approaches.
As part of its national research capacity-strengthening mandate, the Consortium for National Health Research (CNHR) invites applications for Research Career Development Grants (RCDGs) from qualified Kenyan researchers (currently based in Kenya or working within the Diaspora) who wish to further develop their careers while undertaking research and training programmes in Kenya. The grants aim at enabling successful applicants to obtain high-quality research training that will lay the foundation for a successful independent research career. In the long term, the aim is to build a critical mass of researchers undertaking relevant research-for-health for the betterment of Kenyans. CNHR is planning to award 12 RCDGs commencing in October 2012. The RCDGs will offer research career development opportunities for periods of not more than 18 months (from 1st October 2012), and will be offered to successful applicants who apply for consideration either as: postdoctoral research fellow; mid-career research fellow; or mid-career clinical research fellow.
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.
Forum 2012 will bring together key actors to make research and innovation work for health, equity and development: governments, industry, social enterprise, non-governmental organisations, researchers, media, funders , international organisations and others. Partipcipants will explore who will explore ways to go ‘beyond aid’ by building on the rapidly expanding research and innovation capacity of low- and middle-income countries as basis for development. The Forum has three main themes: improving and increasing investments in research and innovation; networking and partnerships in research, technological innovations, social innovations and delivery of better health care; and improvement of health, equity and development of low-income countries by creating a supportive environment, including priority setting in research for health, fair research contracting, research cooperation and ethics, nanotechnologies, technological and social innovations, and using the web as a tool for planning research.
SEYCOHAIDS 2012 is the largest international gathering for young people on HIV and AIDS in the Eastern and Southern Africa region, where young researchers, policy makers, activists, educators and people living with HIV will be able to link with people in other countries and meet to share and learn about HIV prevention methods, treatments, care policies and programmes relating to HIV and AIDS in Africa. The broad objectives for the Conference are to: ensure effective and meaningful youth participation in international AIDS response; identify gaps and challenges in government policies in providing youth-friendly HIV and AIDS services; develop regional and country-level strategic programmes for youth and HIV and AIDS; identify and build the capacity of new and emerging youth leaders for the AIDS response to ensure sustainability of youth initiatives at the national, regional and international levels; sustain adult-youth partnerships and dialogue; develop the Southern and Eastern Africa youth network on HIV and AIDS; develop country specific youth networks on HIV and AIDS; establish funding mechanisms for regional and country youth networks; and monitor government and donor commitments to youth and HIV and AIDS. Applicants must be no older than 35 years old at the time of the application.
Registration is open for participation in the People’s Health Assembly (PHA), organised by the People's Health Movement (PHM). The PHA 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. PHA3 aims to impact 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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