This newsletter includes the Istanbul Declaration, adopted by delegates to the first Global Human Development Forum in Istanbul in March 2012. The Declaration calls on the world community, gathering soon at the United Nations Conference on Sustainable Development (Rio+20) in June 2012, to set and implement global and national development strategies that emphasise social inclusion, social protection, and equity. This is in recognition of the fact that economic development has too often gone hand in hand with environmental degradation and increased inequality. Who sets those development strategies matters. One paper in this newsletter points, for example, to the disproportionate power over the global economy of just over 100 transnational corporations. Another questions the influence of private wealth in the underfunded global 'protector' of public health, the World Health Organisation. Within such asymmetries of power and influence the work at Rio+20 cannot end with aspirations. It also needs to tackle how institutions and processes need to change to deliver on these aspirations.
Pneumonia is one of the top five deadly diseases for children in Malawi. It causes more deaths than measles, malaria and AIDS combined. Infection with Streptococcus pneumonia and can cause a range of illness, from relatively mild ear infections to fatal pneumonia, meningitis and sepsis. It was estimated by Ministry of Health in 2011 that childhood pneumonia accounted for 18 percent of deaths of children under five years.
This death is avoidable and unnecessary. Childhood pneumonia is preventable through living in a well ventilated housing, avoiding indoor pollution through using improved stoves, pot lids and clean fuels among other factors. It can also be prevented with a simple vaccine.
In November 2011, World Pneumonia Day, Malawi launched and added the new pneumonia vaccine (Pneumococcal Conjugate Vaccine (PCV 13) to its routine immunization chart. Bright Masangwi Chisale (male) was the first child to receive the new oral vaccine in Lilongwe-Malawi. His immunization was presided by Malawi’s Minister of health Hon Dr Jean Kalirani. In 2012, 1.2 million Malawian children under the age of one will be vaccinated against pneumonia. This is being co-financed by the Government of Malawi, with government putting in $0.20c per dose and the Global Alliance for Vaccine and Immunization(GAVI Alliance) putting in $11.17 over three years for each of the 1.2 million children immunized to cover the systems, vaccine and outreach costs. These are huge investments and their effectiveness will need to be tracked in the expected improvements in child mortality.
Vaccines are one of the best technical options for disease prevention. Many vaccines, not all, protect a child for a lifetime. As they are one of the most cost effective interventions to prevent illness, they should be given priority in the allocation of resources, particularly in a low income country like ours with many competing health priorities.
However without GAVI support the introduction of the vaccine would not have been possible as the cost would have been too high. It is encouraging that in 2011 vaccine manufactures gradually reduced vaccine prices. However the costs remain high. Malawi pays 15 cents to 20 cents per dose for its vaccines. But it is estimated that the vaccine for pneumonia cost $2.50 to $3.50 per dose. With Malawi’s total government expenditure on health at $22.00, this cost would be unaffordable. Unless there are further reductions in vaccine price it will be difficult for countries like Malawi to afford these effective technologies to prevent childhood and adult mortality, without depending on external funders.
Even the most effective vaccines will only have an impact if they are actually made available to the children who need them. The need is clearly higher in low income countries like Malawi. So should the funding of vaccines be a matter of ad hoc external funding? Or should vaccines rather be considered a global public good, to be funded more predictably at global level, and equitably allocated to countries based on their populations and need.
It will then be up to the country to ensure vaccine outreach. Low income countries like Malawi are able to achieve high vaccination coverage rates through primary care services and outreach campaigns. Malawi has achieved such high coverage as immunization services are administered by the cadre closest to communities, the Health Surveillance Assistants (HSA), who are trained to administer the vaccine. These cadres are found in the most hard to reach areas, and are given support from Ministry of Health. While the programme has support from World Health Organisation, UNICEF, the GAVI Alliance and civil society, the delivery system through primary care cadres is a primary responsibility of the government.
It is possible to ensure that no child dies from a vaccine preventable disease. However this needs the vaccine industry to continue to make vaccines cheaper and more accessible. It needs global level funding for vaccines with a mechanism for predictable and equitable collection and allocation of global funding of vaccines as a public good. It needs governments to resource a health system that ensures a chain of delivery of the vaccines to the community level cadres and facilities, and to all the adults and children who need them. It needs communities to take up the vaccines.
While the discussion today is on the vaccine for childhood pneumonia, tomorrow it may be other vaccines, such as those for malaria, typhoid or dengue fevers. It is a welcome development to hear that malaria vaccine trials are showing positive results in the sites where they have been tested. A vaccine for malaria will be a major contribution to public health in Africa.
Vaccines alone are not enough to solve all of our persistent health problems. We still need to focus on the deeper causes such as improving indoor air quality, improved nutrition, improved case management/ treatment and strengthening health systems, as this will produce much wider and long term health gain than vaccinations. However, ensuring access to pneumococcal vaccines should be something we do today to protect children’s right to life.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: firstname.lastname@example.org
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 below
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.
This report was commissioned by EQUINET to look at the characteristics and extent of private sector involvement in health financing and provision in East and Southern African countries. It synthesises available information on the private health sector in the following ESA countries: Angola, Botswana, the Democratic Republic of the Congo (DRC), Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, the United Republic of Tanzania, Uganda, Zambia and Zimbabwe. For each country the core health financing issues, including available NHA data, are briefly discussed. As external financial resources play a key role in the funding of private sector initiatives (both for-profit and not-for-profit), the extent of external funding is also considered. Thereafter, an overview is provided of the presence (or not) of private health insurance, and different types of private providers. A trend observed in this review is the expansion of South African private health care organisations into other African countries.
The Ministry of Health and Child Welfare and Training and Research Support Centre/ EQUINET hosted a one day meeting on Thursday 23rd February in Harare to report on and review the findings of the 2011 Zimbabwe Equity Watch; involve health and non health sector actors in identifying priorities and actions to strengthen equity in universal health coverage and action on the social determinants of health; and propose how to institutionalise health equity monitoring. The meeting involved 52 delegates from different sectors of government, parliament, civil society, private sector, technical institutions and international organisations. The meeting identified a number of recommendations and areas of follow up action flowing from the discussions on the Equity Watch report and the presentations in the plenary and parallel sessions that are presented in the report. Stakeholders endorsed equity as a guiding principle for UHC, as well as health in all policies. They called for strengthened consistent co-ordination of the institutions and agencies that influence the determinants of health and delivery on UHC. It was proposed that the Equity Watch be institutionalized and repeated in future with the involvement of other sectors, with indicators also identified for annual monitoring in the routine information system. Specific additional areas for equity analysis were identified.
3. Equity in Health
A cholera epidemic has spread to nine out of 11 provinces in the Democratic Republic of the Congo, according to the United Nations. The UN said the spread was "worrisome" as the epidemic had so far killed 644 people and infected 26,000 since January 2011. Lack of access to potable water remains the single most important cause of the recurrent cholera outbreaks, according to the United Nations Office for the Co-ordination of Humanitarian Affairs (UN OCHA). UN OCHA cited the example of the north-eastern city of Bunia, where over a third of the residents - more than 100,000 people - have been cut off from drinking water since the start of 2012. In neighbouring Republic of Congo, an official announced that there have been more than 340 cholera cases reported in recent months, and several people have died from the water-borne disease.
The Istanbul Declaration was adopted by consensus at the conclusion of the two-day Global Human Development Forum, a gathering of more than 200 leading development experts, civil society activists, government ministers, private sector representatives and UN officials from all regions of the world. The Declaration stresses the need for global and national development strategies to put “strong emphasis on social inclusion, social protection, and equity, in recognition of the fact that economic development has too often gone hand in hand with environmental degradation and increased inequality.” Achieving those goals will require better-coordinated “mobilization of global capital and local resources,” good governance on the local and global level, and full empowerment of women “through access to education, health care, basic services and their participation in the labour force.” The declaration calls for a post 2015 MDG framework that addresses all three dimensions of sustainable development (social, economic and environmental), and their interconnections.
The theme of the Prince Mahidol Award Conference – held in Bangkok, Thailand on on 24-28 January 2012 – was “Moving towards universal health coverage: health financing matters”. At the close of the meeting, a 10-point declaration recognised universal health coverage (UHC) as fundamental to the right to health, and marked the commitment by more than 800 delegates to translate the rhetoric of UHC into better, more equitable health outcomes. Similar endorsements of UHC have been made before, including at the World Health Assembly in 2011. What makes the Bangkok Statement any more likely to hasten and widen the implementation of UHC? One answer may be the power of the Prince Mahidol Award Conference and its sponsors to draw global health enthusiasts from a wide variety of disciplines and health systems. Delegates from 68 countries included external funders and recipients of aid, managers and front-line health workers, ministers, economists, and consumers. From these many perspectives came the realisation that whether one seeks to provide access to health care for the one billion people who lack it, or to protect the 100 million people who end up in poverty every year as a result of medical costs, or to accelerate progress towards the Millennium Development Goals: UHC provides a common mechanism – and common cause.
Despite a high disease burden, mental illness has thus far not achieved commensurate visibility, policy attention, or funding, the authors of this study note. They found that, while significant progress has been made in terms of prioritising mental health globally, debates around the definition of mental illness, and the continued impact of stigma, remain. The authors make five recommendations to increase the visibility and policy priority of mental health as a global issue. 1. Greater community cohesion and international governance structures need to be developed to contribute to a more unified voice regarding global mental health. 2. A common framework of integrated innovation is needed to ensure that global mental health speaks in the language of national and international policy makers. 3. For global mental health to gain significant attention, a coherent evidence base for scalable interventions that can be shown to have an impact at the structural level - on economic development and human well-being - is central. 4. A social justice and human rights approach is important. 5. Current innovative strategies for addressing stigma need to be evaluated and expanded.
4. Values, Policies and Rights
The author of this article hails the 2012 World Development Report (WDR) as a watershed moment: it is the first time that the World Bank has devoted its flagship publication to gender. But she argues that the report leaves the Bank failing to face up to its role in perpetuating policies that harm women, and is seriously limited in its approach to women’s movements, markets and households. Although the report cites self-identified feminist work liberally, its own understanding of feminism as a transnational social movement is poor. The report also fails to mention the historical background of the Bank in gender and development, a convenient oversight given its inconsistent role in the struggle for gender equality in the past. Another key omission in the WDR argued by the author is any sustained analysis of gender and the current financial crisis, and the author casts doubt on the Bank’s assumption that free market capitalism brings about gender transformation. While the report advocates for women’s social networks and for women’s independent control of income, it defines gender equality as ideally achieved within sharing partnerships in nuclear male-headed families. This leads to serious tension over the meaning of gender empowerment.
According to this article, recent studies suggest that women stuck in financially dependent relationships are at greatest risk for HIV infection in African countries. Women afraid of violence and abuse, stigmatisation, being labelled adulterous or being abandoned may be too frightened or intimidated to pursue testing and treatment. Also, the extra costs - US$2 or more - to travel to clinics are prohibitive. In effect, poor and unemployed women have been forced by men to forfeit their reproductive rights in issues pertaining to sex and protection from HIV. Women who are dependent on men for their livelihood are forced to have unprotected sex with their husbands or partners, even if they know they have cheated on them. Sex workers allege that married men especially from the middle class and the upper classes are willing to pay more for sex without a condom. The author concludes that silence on this topic in the media and the research community is a powerful ally in male domination of women economically and socially, and a driver in the spread of HIV.
Uganda’s notorious 'Anti-Homosexuality' Bill - proposed first in 2009 – has been re-tabled at a parliamentary session in Kampala. The Bill contains harsh provisions arguing for the death penalty for homosexuals and stiff prison sentences for their supporters which, if introduced, would threaten the safety of lesbian, gay, bisexual, transgender and intersex (LGBTI) people and human rights activists in the country. It is reported that both government and opposition members of parliament clapped in support of reintroduction of the Bill, which comes a few days after the first anniversary of the murder of prominent LGBTI rights defender David Kato, killed on 26 January 2011. Front Line Defenders reiterates its grave concern in this article that the passing of the Bill would further hamper the work of public health workers and human rights defenders who work with LGBTI people. the article also raises concern that rhetoric and media coverage around the Bill could incite further violence against human rights defenders working on LGBTI issues.
The World Health Organisation (WHO) has denied claims that partial guidelines for the implementation of Articles 9 and 10 of the Framework Convention on Tobacco Control (FCTC) on Regulation of the contents of tobacco products and tobacco product disclosures will have a negative effect on burley tobacco producers. The International Tobacco Growers Association (ITGA), has fought against the adoption of the guidelines, arguing that reducing the demand for burley tobacco could shrink economies, employment and incomes, such as in Malawi where tobacco contributes about 13% to the Malawi economy and accounts for 60% of foreign currency earnings. [Contrary to tobacco industry claims, the guidelines do not recommend a ban on burley tobacco or any other type of tobacco but do regulate flavourings that would attract target grioups such as young people to smoke. Cigarettes containing burley continue to be sold in jurisdictions where strong restrictions on flavourings are in place].
5. Health equity in economic and trade policies
In this update to Medicins Sans Frontieres’ (MSF) November 2010 report on the Anti-Counterfeiting Trade Agreement (ACTA) - which has so far been signed by most developed nations - the impact of ACTA on access to medicines is investigated. Although a number of provisions that were harmful to access to medicines in developing countries were removed during the negotiations, the final text remains problematic, according to MSF. The agreement, for example, will undermine the ability of developing country governments to apply the Doha Declaration to protect public health. It puts medical distributors, non-governmental organisations and public health authorities at risk of severe penalties, while allowing for continued border detention of in-transit medicines destined for developing countries. ACTA undermines the role of the judiciary in protecting the right to health and balance private intellectual property rights with the larger public interest, and acts as a deterrent to the production and trade in generic medicines, as it provides for excessive punishment, shifts the risks entirely on to the generic manufacturer, and grants few protections against abuse. MSF states that it does not recognise the legitimacy of ACTA because it has been negotiated in secret with little room for public engagement. The authors conclud that ACTA is a cynical exploitation of concerns around unsafe medicines and is not a legitimate response to the problem of counterfeiting.
Non-communicable diseases (NCDs) are the leading cause of death globally, killing more people each year than all other causes combined. Furthermore, behavioural risk factors for NCDs fall increasingly on poorer people within all countries, mirroring the underlying socio-economic determinants. The need for prevention efforts through well-planned, cost-effective and feasible interventions across all levels of society is therefore obvious, the authors of this paper argue. The workplace is argued to provide an important setting for ecological models that ensure the both the policies and the environments that enable health.
China has asserted that its aid to Africa has no strings attached. The author of this article argues that in contrast China's activities in Africa, like those of other major external funders have conditionalities attached. There is an oft-repeated Western view that China's only interest in Africa is to extract its natural resources. However in Mozambique China's investments are more targetted at the industrial sector, and there are numerous infrastructure and development projects across the continent attesting to the effectiveness of Chinese investment. The author notes that African governments would be foolish to believe that their relationship with China will avoid all the political wrangling inherent in aid and trade relationships. He warns that rather than casting aspersions on China's role in Africa. Western governments should acknowledge their own mixed record in African relations, and build a more balanced analysis of the costs and benefits of China's growing engagement in international development.
According to this article, Africa has much to gain from China’s growing presence on the continent, though it is not without some negative impacts. Increased trade and investment links are particularly promising, as they have the potential to support poverty alleviation and sustain recent economic gains. However, African countries must exercise their bargaining power more effectively to ensure that they benefit from the growing relationship, including in areas such as modern technology transfer. It is also the continent’s responsibility to make sure that, as it takes advantage of Chinese investments, competition is preserved and encouraged and regulatory frameworks are improved, including mining codes, by increasing transparency and accountability of contracts. In addition, large flows of Chinese investment and aid should not be allowed to delay much-needed domestic reforms, such as strengthening economic management and improving the business environment. These are needed to attract foreign direct investment from Western countries, which in turn would help to counterbalance potential overdependence on China’s investment. Africa does not have to choose between the West and China – it can have both.
A growing concern among those interested in economic development is the realisation that hundreds of billions of dollars are illicitly flowing out of developing countries to tax havens and other financial centres in the developed world. This new book by the World Bank assesses the dynamics of these flows, much of which is from corruption and tax evasion. What causes them, what are their consequences and how might they be controlled? The chapters by authors from a variety of backgrounds, including criminologists and practicing lawyers as well as economists, examine many dimensions of the phenomenon. Some chapters examine major illegal markets (drug trafficking and human smuggling) to assess how they contribute to these flows, while others are concerned with the corporate role in the phenomenon, particularly the possibility that transfer pricing (in which firms set prices for international trade among wholly owned affiliates) might play a major role in moving money illicitly.
In this UNRISD paper, the author reviews research on the employment impacts of neoliberalism, specifically on women’s employment. She considers a number of aspects that are central to employment issues: the slowdown in economic growth and the decline in the responsiveness of employment to growth; the impact of trade and investment liberalisation, informalisation and inflation targeting on employment; the consequences of increasingly frequent economic crises; and the public sector. The author contends that the Washington consensus’ macroeconomic policy conventions – liberalisation, privatisation and macro stability – have become so globally entrenched that they are rarely questioned by the academic and policy establishment. To this effect, she points to numerous, wide gaps in research into the employment impacts of neoliberal macroeconomic development policy.
Increased demand for seafood and its functional by-products has been associated with a concomitant rise in fishing and aquaculture activities. This increased consumption and processing of seafood is associated with more frequent allergic health problems among seafood processors, according to this overview of occupational allergies and asthma in seafood-exposed workers. It illustrates the changing nature of the fishing and seafood processing industry in the midst of ecological degradation and globalisation. It provides detailed insights into the major and minor allergens that have been identified and other pathophysiological mechanisms that have been ¬implicated in airway inflammation. More refined exposure assessment studies in recent times have enabled detailed characterisation of allergen exposure response relationships, which confirm the increased risk associated with elevated allergen exposures. Directions for future research and preventive strategies are outlined.
According to the Southern Africa Development Community’s (SADC) latest financial report, the region recorded an average real GDP growth of 4.7% in 2011, which is 0.8% below the 2010 growth rate of 5.5%. Inflation pressures gathered in most SADC Member States; however, regional inflation averaged 8.3%, almost the same level as in 2010. The average fiscal deficit deteriorated to 4.8% of GDP in 2011 compared to 3.2% of GDP in 2010. However, general government debt remained at 2010 level of 39% of GDP. The current account deficit of the balance of payments improved marginally from 8.8% of GDP in 2010 to 8.3% of GDP in 2011. Medium-term prospects are good but downward risks are high partly as a result of the sovereign debt crisis in the European Union.
This article refers to a forthcoming analysis of the relationships between 43,000 transnational corporations. The analysis identified a relatively small group of companies, mainly banks, with disproportionate power over the global economy. The work, to be published later in 2012 in PLoS One, revealed a core of 1,318 companies with interlocking ownerships, each of which had ties to two or more other companies, and on average connections to 20 companies. Although they represented only 20% of global operating revenues, the 1,318 appeared to collectively own through their shares most of the world’s large blue chip and manufacturing firms – referred to by the authors as the “real” economy – representing a further 60% of global revenues. Further analysis of the web of ownership revealed that much of it tracked back to a “super-entity” of 147 even more tightly knit companies that control 40% of the total wealth in the network – these companies include financial giants like Barclays Bank, JPMorgan Chase & Co and Goldman Sachs. Crucially, by identifying the architecture of global economic power, the analysis could help make the global economy more stable, the author argues, adding that we may need global anti-trust rules, which now exist only at national level. The author argues that firms should be taxed for excess interconnectivity to prevent power being concentrated in the hands of a few.
The concept of ‘green growth’ implies that a wide range of developmental objectives, such as job creation, economic prosperity and poverty alleviation, can be easily reconciled with environmental sustainability. The authors of this study, however, argue that rather than being win-win, green growth is similar to most types of policy reforms that advocate the acceptance of short-term adjustment costs in the expectation of long-term gains. In particular, green growth policies often encourage developing countries to redesign their national strategies in ways that might be inconsistent with natural comparative advantages and past investments. In turn, there are often sizeable anti-reform coalitions whose interests may conflict with a green growth agenda. The authors illustrate this argument using case studies of Malawi, Mozambique, and South Africa, which are engaged in development strategies that involve inorganic fertilisers, biofuels production, and coal-based energy, respectively. Each of these countries is pursuing an environmentally suboptimal strategy but nonetheless addressing critical development needs, including food security, fuel and electricity. The study’s results show that adopting a green growth approach would not only be economically costly but also generate substantial domestic resistance, especially amongst the poor.
6. Poverty and health
The World Bank is preparing a new agriculture action plan to cover 2013-2015. This paper argues that its market liberalisation focus has been criticised, pointing to strongly critical reports on World Bank agriculture projects such as in Peru and Papua New Guinea, and crtique of its lack of gender focus. Critics argue that the Bank is too narrowly focused on private equity investment in agriculture, instead of taking an approach that includes local communities and smallholder farmers. At the same time, the Bank has failed to acknowledge the impact of financial speculation on volatility in food prices, despite many analysts suggesting this is a major contributor to food insecurity. By promoting investor access to land, the authors argue that Bank threaten rather than improve food security and local livelihoods in developing countries.
In 2003 the Comprehensive Africa Agriculture Development Programme (CAADP) was established by the assembly of the African Union (AU) aiming to raise agricultural productivity by at least 6% per year and increasing public investment in agriculture to 10% of national budgets per year. This paper evaluates progress in CAADP negotiations in the Common Market for Eastern and Southern Africa (COMESA) region. There is in general full support in the region for an effectively multidimensional regional CAADP, anchored in ongoing programmes implemented by COMESA. But so far, there has not been enough consultation with relevant non-state stakeholders, like farmers’ organisations, and the authors urge government to include them in the process, as well as to address past failures to communicate effectively and timeously with regional stakeholders about CAADP. They also call for greater integration between regional and national stakeholders and development partners to help mainstream CAADP into ongoing regional programmes and other sectors relevant to food security. More regular dialogue is needed between COMESA, AUC-NPCA and DPs around the implementation of regional CAADP plans. The authors argue that it is very important to ensure coherence between regional policies and investments in food security and in other sectors of regional cooperation.
While all stakeholders acknowledge the importance of regional food security, most agree that introducing the Comprehensive Africa Agriculture Development Programme (CAADP) at the regional level has not been a priority for East African Community (EAC) countries in the past. Institutional capacity and financial resources are argued to have placed limits on the role of the EAC Secretariat in driving the CAADP process. Most external funders have concentrated on national efforts at food security, overlooking the role of regional support and integration. The EAC Secretariat’s relations with development partners is perceived as good, but this has not yet translated into visible improvement in regional agriculture, largely, the authors argue, because implementation remains a challenge. Slow progress in regional trade, infrastructure and other related regional initiatives have impacted negatively on regional food security and agricultural development, and national interests tend to take precedence over regional ones. The authors also call for greater consultation with all stakeholders if CAADP is to succeed.
Countries in the Southern African Development Community (SADC) have never formally launched a regional Comprehensive Africa Agriculture Development Programme (CAADP) process as they are currently developing their own Regional Agricultural Policy (RAP). The authors argue that SADC governments should mainstream CAADP principles into the RAP by, for example, enlarging the range of stakeholders regularly involved in the regional preparations (especially non-state actors like farmers), as well as including accountability mechanisms governing regional food security, and ensuring policy coherence at national and regional levels. So far the major criticism of the RAP process is lack of multi-stakeholder consultation. In addition, SADC development partners are reported as not having adequately supported regional food security measures. The authors argue for more institutional support for the SADC Secretariat, given its key role in the CAADP process.
7. Equitable health services
The authors of this study conducted an external quality assessment of laboratories in Africa that routinely investigate epidemic-prone diseases. Since 2002, three surveys comprising specimens and questionnaires associated with bacterial enteric diseases, bacterial meningitis, plague, tuberculosis and malaria have been sent annually to test participants’ diagnostic proficiency. Identical surveys were sent to referee laboratories for quality control. The authors found that between 2002 and 2009, participation increased from 30 to 48 Member States of the World Health Organisation and from 39 to 78 laboratories. Results of performance evaluations were mixed. Laboratories correctly identified bacterial enteric diseases and meningitis components 65% and 69% of the time, respectively, but their serotyping and antibiotic susceptibility testing and reporting were frequently unacceptable. Microscopy was acceptable for 73%, with tuberculosis microscopy excelling, as 87% of responses received acceptable scores. In the malaria component, 82% of responses received acceptable scores for species identification but only 51% of parasite quantitation scores were acceptable.
Eye injuries that occur in the workplace are more common in developing countries like South Africa where appropriate eye protection might be lacking. The purpose of this paper is to assist the occupational health care provider to correctly assess damage to the eye and interpret the findings to make a diagnosis and appropriate decisions for primary care. The authors argue that examination of the eyes by health-care doctors and nurses should be systematic, assessing all the structures in order to determine appropriate treatment and referral. The most urgent condition is a chemical burn in which minutes matter and immediate irrigation can prevent long-term vision loss. Lid lacerations are usually easy to identify but penetrating globe injuries or intraocular foreign bodies may be missed and result in permanent loss of vision and disability. Many injuries can be adequately managed by primary care health workers, either medical doctors or nurses, and do not require referral, the authors conclude.
The main goal of this study was to provide robust empirical evidence on the causal link from national levels of health system coverage to population outcomes. The authors assembled annual data for the period 1995-2008 encompassing 153 developing and developed countries. Taken together, the results strongly indicate that expansions in health system coverage lead, on average, to improved general population health. Higher government health spending per capita is consistently found to reduce both child and adult mortality rates, the authors argue. The estimated gains are the largest when under-five mortality is examined and are larger for low- and middle-income countries than in the full sample. Based on the results for under-five mortality and public health spending, the implied marginal cost of saving a year of life is just around US$1,000 in the full sample of countries. For the average country, pre-paid public spending seems more effective in reducing mortality than prepaid private insurance funds. Higher immunisation coverage was also found to decrease mortality rates.
In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. In this literature review, researchers conducted a systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. Social class was determined by patient's income, education or occupation. Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour. The researchers found that the literature on the social gradient in doctor-patient communication that was published in the last decade addresses new issues and themes. Firstly, most of the found studies emphasise the importance of the reciprocity of communication. Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication. By increasing the doctors' awareness of differences in communication and by empowering patients to express concerns and preferences, a more effective communication could be established, the researchers conclude.
This article reports on health centres in Arua district, at Entebbe hospital and Jinja referral hospital in Uganda that were paralyzed after the facility ran short of water, displacing patients to other services. The author argues that frequent load shedding and water shortages have had devastating effects on health service ability to deliver adequate care. The author argues that government should reconstruct wrecked health facilities, and construct more new bore holes and water storage tanks, and provide standard by power sources like solar energy and generators for emergencies cases.
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 United States (US), with its high salaries and technological innovation, is the world’s most powerful magnet for doctors, according to this article, attracting more every year than Britain, Canada and Australia combined. Some of the responsibility for the migration of health care workers lies with the immigration laws in the host countries. For example, in the US, some states may grant waivers to foreign doctors if they agree to practice in communities where doctors are in short supply. The author compares Zambia and the US, acknowledging that salaries and working conditions in a country like Zambia are never going to match those in the US, and considers some of the factors that influence a person’s decision to emigrate, such as family ties, the cost of living and home language. There are signs of change, as doctors from Ghana, who used to mass emigrate to the US, now prefer to stay home as salaries rose enough to weigh the scales in favour of staying. Although there are foreign-funded initiatives to train and recruit doctors, such as a project funded by the Global Fund to help Zambia recruit and retain doctors, these solutions can create further problems. For example, many of the doctors hired by aid agencies are doing research and don’t see patients so they don’t contribute to improving health services. Frustrated public health officials in Zambia and other developing countries call this the “internal brain drain”.
Over the past half decade South Africa has been developing, implementing and redeveloping its lay health worker (LHW) policies. The aim of this study was to explore contemporary LHW policy development processes and the extent to which issues of gender are taken up within this process. Eleven policy actors (policy makers and policy commentators) were interviewed individually. From the interviews it seems that gender as an issue never reached the policy making agenda. Although there was strong recognition that the working conditions of LHWs needed to be improved, poor working conditions were not necessarily seen as a gender concern. On the positive side, the authors note that LHW policy redevelopment was focused on resolving issues of LHW working conditions through an active process involving many actors and strong debates. But, within this process the issue of gender had no champion and never reached the LHW policy agenda.
Healthcare workers in South African healthcare facilities work in environments with a high density of tuberculosis patients due to the dual burden of tuberculosis and human immunodeficiency virus in the population, thus predisposing them to contracting tuberculosis. Despite the knowledge of the high tuberculosis incidence and the likelihood of tuberculosis transmission to both health care workers and patients, and the availability of basic infection control measures in our healthcare facilities, there is still inadequate implementation of infection control measures in healthcare facilities, according to this paper. The authors review the knowledge base, instruments for tuberculosis control, the implementation of these tools and the knowledge gaps within the healthcare system in South Africa. A comprehensive review of scholarly literature was conducted based on Internet search engines. The review revealed the availability of adequate knowledge and tools for the control of tuberculosis in healthcare facilities, but inadequate implementation of infection control measures.
This study aimed to assess the policy and programmatic implications of task shifting in Uganda. This was a qualitative, descriptive study through 34 key informant interviews and eight focus group discussions, with participants from various levels of the health system. Policy makers understood task shifting, but front-line health workers had misconceptions on the meaning and intention(s) of task shifting. There was apparently high acceptance of task shifting in HIV and AIDS service delivery, with involvement of community health workers (CHW) and people living with HIV and AIDS (PLWHAs) in care and support of AIDS patients. There was no written policy or guidelines on task shifting, but the policy environment was reportedly conducive with plans to develop a policy and guidelines on task shifting. The study identifies a number of factors favouring task shifting and barriers. There were widespread examples of task in Uganda, and task shifting was mainly attributed to HRH shortages coupled with the high demand for healthcare services. The authors emphasise a need for clear policy and guidelines to regulate task shifting and protect those who undertake delegated tasks.
The aim of this study was to estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States. Researchers included nine sub-Saharan African countries with an HIV prevalence of 5% or greater or with more than one million people with HIV/AIDS and with at least one medical school (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), and data available on the number of doctors practising in destination countries. In the nine source countries the estimated government subsidised cost of a doctor’s education ranged from US$21 000 in Uganda to $58 700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn, with costs for each country ranging from $2.16m for Malawi to $1.41bn for South Africa. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m). Destination countries should consider investing in measurable training for source countries and strengthening of their health systems, the authors conclude.
9. Public-Private Mix
This book assesses the achievements and limitations of a new set of non-state or multi-stakeholder institutions that are concerned with improving the social and environmental record of business, and holding corporations to account. It does so from a perspective that aims to address two limitations that often characterise this field of inquiry. First, fragmentation: articles or books typically focus on one or a handful of cases. Second, the development dimension: what does such regulation imply for developing countries in terms of well-being, empowerment and sustainability? This volume examines more than 20 initiatives or institutions associated with different regulatory and development approaches, including the business-friendly corporate social responsibility (CSR) agenda, 'corporate accountability' and 'fair trade' or social economy. Several chapters deal specifically with the mining sector in Africa.
Commercial production of Tanzania's first locally manufactured antiretroviral drugs (ARVs) will start later in 2012 and it is hoped the country will eventually provide medicines for half of all HIV-positive Tanzanians. A pharmaceutical plant has been built near the northern city of Arusha using a grant from the European Union of about US$6.6 million, as well as about $1.5 million in funding from the private sector. Co-operation with a generic licence-holder on a fixed-dose combination ARV is also being considered as this would shorten the registration period significantly. Under the World Trade Organisation's Trade-related Aspects of Intellectual Property Rights (TRIPS) agreement, low income countries like Tanzania are permitted to produce essential drugs without requiring the permission of patent holders until 2016. The plant's current capacity is designed to serve a minimum of 100,000 patients with a reserve to triple the output if required - its minimum output is 100 million tablets a year.
This author argues that Zimbabwe is ripe for private waste sanitation companies (“toilet capitalists”). In 2008, cholera swept through the country due to aging and absent water and waste sanitation systems. The author argues that private systems cannot replace public investment and that what happens in the political terrain will be critical for determining whether revenue will flow in the direction of the public good.
Transnet has launched its second health train in South Africa, the Phelophepa II, costing R82m (US$10.8). The first Phelophepa train has served more than six million in rural communities over the past 18 years. The trains, crewed by medical specialists including a number of final year students, provide primary healthcare, dental, psychological and optical services. Transnet’s rail engineering division, TRE, was responsible for the development of the new train with the Swiss-based pharmaceutical group F Hoffman La Roche a major sponsor of both trains. The trains operate from January to September every year and cover vast areas of South Africa where primary healthcare facilities are under pressure.
The World Health Organisation (WHO) is under siege by private sector forces using their financial leverage to gain undue influence in the financially beleaguered United Nations agency, according to the author. He makes this assertion from observing developments such as the presence of Microsoft Chairman Bill Gates sharing the stage with WHO Director General Margaret Chan at the World Health Assembly in 2011, in the presence of industry interests at a civil society meeting before the 2011 UN summit on non-communicable diseases or from the private-sector influence in the increasingly powerful global foundations in health. Many corporate giants are noted to have been adopted by WHO since 2010, as private sector partners working together for ‘better global health’.
The origins of this public-private sector partnership process can be traced to WHO’s chronic funding problems and in the search for extra resources, the private sector funding of foundations has become more influential. The author points to concerns of industry influence in the reform proposals of WHO and asks the question whether the Director General's actions in promoting public-private partnerships have been at odds with her speeches on defending the basic mandate of WHO to promote the public health interest on the global stage?
10. Resource allocation and health financing
Flows of development financing from the BRICs (Brazil, Russia, India, and China) to low-income countries (LICs) have surged in recent years. The authors of this paper found that, though there are some differences across BRICs, the philosophies of most BRICs for development financing differ from traditional external funders (donors) in three main ways: BRICs, with the exception of Russia, provide financial assistance based on the principle of ‘mutual benefits’ in the spirit of South-South cooperation, while Russia and traditional funders emphasise the role of aid in poverty reduction. Second, BRICs, particularly China, view policy conditionality as interfering with recipients’ sovereignty and tend to provide noncash financing as a means to circumvent corruption, whilst traditional funders view policy conditionality as a means to ensure efficient use of aid. Third, different emphasis is placed on how to ensure debt sustainability, with some BRICs giving a greater weight to microsustainability and growth while traditional funders paying more attention to long-run macrosustainability. This difference is, however, narrowing with BRICs increasingly appreciating the importance of overall debt sustainability and traditional funders the need for investing in physical capital and seeing results.
In this interview with Irene Agyepong, Regional Director of Health for Greater Accra, she attributes Ghana’s success in rolling out universal coverage to genuine political commitment as well as demand from society for change. She identifies three major challenges facing Ghana: poor capacity, loss of health workers who migrate overseas and lack of financing. She gives advice to other countries wishing to implement universal coverage. First, they should build a strong health system as well as technical and administrative capacity and make sure that they retain that capacity to support universal coverage. Second, governments and external funders must realise that leadership has to come from within the country – externally motivated change is unlikely to work. Third, context and history matter. Countries need to tailor their systems to fit their context and history. Overall, stakeholders should bear in mind that universal coverage is a long-term goal.
As the need for anti-retroviral therapy (ART) grows without commensurate increase in the amount of available resources, it is critical to assess the health and economic gains being realised from increasingly large investments in ART. This study estimates total programme costs and compares them with selected economic benefits of ART for an estimated 3.5 million ART patients in low-and middle-income countries whose treatment is co-financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Using 2009 anti-retroviral prices and ART programme costs, the authors estimate that the cost of maintaining these patients is US$14.2 billion for the period 2011–2020. This investment is expected to save 18.5 million life-years and return $12 to $34 billion to the economy through increased labour productivity, averted orphan care and deferred medical treatment for opportunistic infections and end-of-life care. These results suggest that, in addition to the large health gains generated, the economic benefits of treatment will substantially offset, and likely exceed, programme costs within 10 years of investment.
In this study, the authors argue that, in Ghana, Tanzania and South Africa, the regressivity of voluntary health insurance and out-of-pocket payments results from charging flat insurance premiums, ineffective systems to exempt poor groups and insufficient prepayment funding to cover the health care costs of the poor. The cost of health care is not the only barrier to health care access, as the authors found a wide range of affordability, availability and acceptability barriers, which affect poorer groups most severely. Changing the way in which health services are funded, particularly moving away from out-of-pocket payments and towards a greater reliance on prepayment funding mechanisms, will be necessary to address these inequities, they argue. However, explicit measures to address the full range of access barriers are also required.
Encouraged by the growing number of social protection mechanisms in the Africa region delegates from the 1st Pan-African Congress on Universal Health Coverage (15-17 November 2011) have drafted and adopted a declaration to create a “Movement for Universal Coverage for Health in Africa” or MUCH in Africa. The MUCH in Africa delegation consists of representatives from ministries of health, directors general, chief executives of health insurance schemes, chief directors, principal secretaries, academics, policy experts and researchers from twenty-seven (27) African countries and multilateral, bilateral, regional, development partner and civil society organisations. In consultation with countries and development partners, the new organisation will advocate for and catalyse action through constructive engagement and advocacy and push for universal health coverage as a reform agenda in African countries. They made a number of resolutions to improve health financing, health systems and collaborative research in Africa.
Total health care financing in South Africa is progressive, as richer socio-economic groups spend more of their consumption expenditure on health care than poorer groups. In contrast, the overall distribution of both public and private sector health care benefits in South Africa is pro-rich, as poorer socio-economic groups are benefiting less from the use of health services than richer groups. The overall distribution of health care benefits is also not in line with the need for care: poorer groups that indicate poorer self-assessed health status receive fewer health care benefits compared with richer groups with higher self-assessed health status. In their final analysis the authors argue that the South African health system, considering both the delivery and financing of health care, is inequitable.
In this study, researchers developed two practical methods for measuring the affordability of medicines in developing countries. The proposed methods – catastrophic and impoverishment methods – rely on easily accessible aggregated expenditure data and take into account a country’s income distribution and absolute level of income. The catastrophic method quantifies the proportion of the population whose resources would be catastrophically reduced by spending on a given medicine; the impoverishment method estimates the proportion of the population that would be pushed below the poverty line by procuring a given medicine. The authors found that, when accurate aggregate data are available, the proposed methods offer a practical way to obtain informative and accurate estimates of affordability. Their results are very similar to those obtained with household micro-data analysis and are easily compared across countries.
This paper is the first in a special issue which presents a body of research whose overall aim was to critically evaluate existing inequities in health care financing and provision in Ghana, South Africa and Tanzania, and the extent to which health insurance mechanisms (broadly defined) could address financial protection and equity of access challenges. The authors found that insufficient emphasis has been given to analysis of equity of health care financing at the systems level. They argue that studies are needed which explore how financial protection can best be expanded by building on the mix of financing mechanisms currently found in many low- and middle-income countries. Key issues are how to reduce the share of out-of-pocket payments, provide financial protection to the informal sector, reduce the fragmentation of financing arrangements and allocate public resources more equitably.
According to the findings of this study, the current Ghanaian health care financing system is progressive, but the benefits from health services are pro-rich. Out-of-pocket payments are the most regressive component of the health financing system, yet still account for the single largest share of health care financing. National health insurance scheme contributions from those outside the formal employment sector are very regressive. The authors conclude that, if Ghana is to achieve universal coverage, it is essential to reduce out-of-pocket payments, to identify ways of providing financial protection for those outside the formal sector within the national health insurance framework, and to address actively the many access barriers to health services.
The aim of this study was to understand the trajectory of health expenditure in developing countries. The authors used panel data from 143 countries over 14 years, from 1995 to 2008 to explore the factors associated with the growth of total health expenditure as well as its main components namely, government health expenditure and out-of-pocket payments. The data show great variation across countries in health expenditure as a share of GDP, which ranges from less than 5% to 15%. Apart from income, many factors contribute to this variation, ranging from demographic factors to health system characteristics. The results suggest that health expenditure in general does not grow faster than GDP after taking other factors into consideration. The authors also found no difference in health expenditure between tax-based and insurance-based health financing mechanisms, and noted that external aid for health reduces government health spending from domestic sources.
11. Equity and HIV/AIDS
This book tracks the progress and pitfalls of the global fight against HIV and AIDS over the past 30 years. The book's strength lies in its methodical documenting of the medical community's response to the virus. Harden also seeks to explain how political and cultural ideas influenced the science of AIDS. In specific instances, such as explaining how stigma about a sexually transmitted disease initially associated with the gay community hampered early research in the United States, she succeeds. But she does not make the same effort to explain later shifts in political perceptions. There is very little discussion of former President George W Bush's decision to launch the President's Emergency Plan for AIDS Relief, for instance, or what impact it had. At a time when the US is projecting a vision of an AIDS-free generation, Harden's history shows that constant monitoring and new perspectives remain critical. She reminds us that the world only arrived at the idea of an AIDS-free generation through constant trial-and-error: first, in determining the causes and later in producing effective therapies to prolong the lives of infected people.
Zimbabwe's ambitious plan to offer an HIV test to every household in the country is not yet under way but is already being met with scepticism by activists who feel this is not a priority for the country, especially with global HIV and AIDS funding on the decline. Zimbabwe Lawyers for Human Rights has warned of the possibility of compromising on informed consent and confidentiality when testing is done on a large scale. If not properly executed, ostracism, violence, stigma and abuse in the home can result from status disclosure. Door-to-door testing was successfully conducted in Uganda between 2005 and 2007, but Lesotho’s proposed door-to-door testing campaign has been criticised by researchers as substandard. Activists ask where additional funding will be found for the campaign, arguing that resources should instead be used for those who have already been identified as HIV positive and who need treatment now. They have also raised concerns about whether the testing campaign will go beyond merely testing people, and whether it will motivate them to change their sexual behaviours and also refer those testing positive to treatment facilities.
Paediatric antiretroviral adherence is difficult to assess, the authors of this paper argue, and subjective measures are affected by reporting bias, which in turn may depend on psychosocial factors such as alcohol use and depression. In this study, they enrolled 56 child caregiver dyads from Cape Town, South Africa, and followed their adherence over one month via various methods. The Alcohol Use Disorder Inventory Tool and Beck Depression Inventory 1 were used to assess participants’ alcohol use and levels of depression and their effect on drug adherence. The median age of the children was four years, and median time on antiretroviral therapy (ART) was 20 months. Increased time on ART was associated with poorer adherence via three-day recall. Alcohol use was inversely associated with adherence. Having a mother as a caregiver and shorter time on highly active antiretroviral therapy (HAART) were significantly associated with better adherence. The authors conclude that paediatric adherence is affected by caregiver alcohol use, but the caregiver’s relationship to the child is most important. This small study suggests that interventions should aim to keep mothers healthy and alive, as well as alcohol-free.
The objective of this study was to report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal, South Africa. Mothers with infants aged ≤16 weeks and fathers or legal guardians with infants aged 4–8 weeks who, between May 2008 and April 2009, attended immunisation clinics in six districts of KwaZulu-Natal were included. Findings indicated that, of the 19,494 mothers investigated, 89•9% reported having had an HIV test in their recent pregnancy. Of the 19,138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7,981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission and suggest that the elimination of paediatric HIV infections is feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.
Published data on adherence to antiretroviral therapy (ART) in Kenya is limited. This study assessed adherence to ART and identified factors responsible for non-adherence in Nairobi. This is a multiple facility-based cross-sectional study, where 416 patients aged over 18 years were systematically selected and interviewed using a structured questionnaire about their experience taking ART. Additional data was extracted from hospital records. Overall, 403 patients responded: 35% males and 65% females, of whom 18% were non-adherent, and the main (38%) reasons for missing therapy were being busy and forgetting. Accessing ART in a clinic within walking distance from home and difficulty with dosing schedule predicted non-adherence. The study found better adherence to HAART in Nairobi compared to previous studies in Kenya. However, the authors argue that adherence can be improved further by employing fitting strategies to improve patients' ability to fit therapy into their lifestyles and implementing cue-dose training to impact forgetfulness. Further work to determine why patients accessing therapy from ART clinics within walking distance from their residence did not adhere is recommended.
12. Governance and participation in health
In response to the announcement that World Bank President Robert Zoellick will step down at the end of his term on 30 June 2012, a global coalition of campaigners has called for an open and merit-based process to elect the next World Bank leader, and for developing countries to determine the selection. The campaigners, including many major development organisations, have also asked the United States to announce that it will no longer seek to monopolise the Presidential position. A “gentlemen’s agreement” between Europe and the US dating back to World War II has so far ensured that the President of the World Bank is always an American, and the International Monetary Fund’s Managing Director is European. In this open letter, the campaigners demand that the new President is selected by a majority of World Bank member countries, not just a majority of voting shares, as most members are low- and middle-income countries. They also demand that the selection process be opened to anyone to apply, with interviews held in public and with open voting procedures. A clear job description and necessary qualifications should be set out, requiring candidates to have a strong understanding and experience of the particular problems facing developing countries.
China’s growing involvement in countries where peace is fragile brings new responsibilities and policy choices for Beijing, as well as a new reality for Western funders and policy makers, according to this brief. This increased involvement brings risks and opportunities for peace and stability in conflict-affected states, SAFERWORLD argues. The brief summarises the impacts of China’s growing economic, diplomatic and military engagement in conflict-affected states and analyses the implications for peacebuilding. The briefing also offers recommendations for policy makers in China and the West focused on fostering a culture of dialogue, bridging the current policy gap regarding conflict-affected states, and creating an enabling international architecture. A key conclusion is that as Beijing’s approach towards conflict-affected countries evolves, there is an unprecedented opportunity for China and the West to develop more complementary approaches in support of peace and equitable development.
In this article, the author analyses China’s trade and diplomatic relations with Africa in terms of Joseph Nye’s concept of soft power. He argues that examining China's Africa Policy, there is a motivation to change cultural perceptions about China and to influence agenda's through co-option rather than economic or military coercion. Although Chinese leaders often refer to the importance of its soft power in the world, China's policy for engagement with African countries does not mention soft power directly. Instead, it speaks in very general terms of mutual cooperation and win-win strategies. The author argues that China’s well-disguised soft power approach is not very different from the soft power component of US foreign policy.
The Fourth High Level Forum on Aid Effectiveness, held in Busan, South Korea in November 2011 again promised an opportunity for a new consensus on development cooperation to emerge. This paper reviews the recent evolution of the concept of coordination for development assistance in health as the basis from which to understand current discourses. Four distinct transitions in the understanding, orientation and application of coordination were identified: coordination within the sector, involving geographical zoning, sub-sector specialisation, external funder (donor) consortia, project co-financing, sector aid, harmonisation of procedures, ear-marked budgetary support, external funding agency reform and inter-agency intelligence gathering; sector-wide coordination, expressed particularly through the Sector-Wide Approach; coordination across sectors at national level, expressed in the evolution of Poverty Strategy Reduction Papers and the national monitoring of the Millennium Development Goals; and, most recently, global-level coordination, embodied in the Paris Principles, and the emergence of agencies such as the International Health Partnerships Plus. The transitions are largely but not strictly chronological, and each draws on earlier elements, in ways that are redefined in the new context. With the increasing complexity of both the territory of global health and its governance, and increasing stakeholders and networks, current imaginings of coordination are again being challenged. The High Level Forum in Busan may have been successful in recognising a much more complex landscape for development than previously conceived, but the challenges to coordination remain.
On 9 February 2012, 16 prominent human rights activists were arrested in Dar es Salaam, Tanzania, on the grounds of unlawful assembly. The human rights defenders, who included the executive directors of the Legal and Human Rights Centre and the Tanzania Media Women's Association, were arrested at the Muhimbili National Hospital following a doctor’s strike that had paralysed the provision of health services. The police authorities allege the small group had gathered illegally and were intending to hold an illegal demonstration, although the group maintains that they were not there to protest but to observe the dialogue between the government and health officials. The activists were detained and then later released on bail, pending confirmation of charges. The question is, did the 16 activists cause a breach of the peace, or prejudice public safety and the maintenance of public order? Crucially, were the police, by prohibiting the alleged assembly and subsequently arresting the activists, using their discretion appropriately? The authors’ answer is “No”. A public assembly held to observe (or allegedly protest) negotiations about health sector issues is unlikely to breach public order or public safety. The authors call on the Tanzanian government and police to use their discretion to limit public assemblies wisely and ensure that public assemblies called for a political purpose, which are a common and indeed vital aspect of a healthy democracy, are not arbitrarily restricted or prohibited.
As World Bank projects fail to reduce corruption in the mining sector in the Democratic Republic of Congo (DRC), International Finance Corporation (IFC) investments in extractive industries are provoking complaints and protests around the world, according to this article. In 2012 the Bank will launch its new extractives for development (E4D) initiative, a “knowledge sharing platform” aimed at transforming extractives into a force for development, but critics argue that the Bank needs to first take action against corruption and unethical behaviour in the mining projects it funds. In late 2010, the Bank suspended all new programmes in the DRC after allegations of corruption but resumed lending in June 2011 when it judged the government to be in compliance with the economic governance matrix (EGM), a new transparency framework agreed by the government and the Bank. However, only a month later it came to light that state-owned mining companies had again been secretly selling stakes in mining operations, in one case at a sixteenth of their market price. The author notes that the ombudsman set up by the IFC has been inundated with complaints of irregularities, lack of local consultation, mistreatment of miners, environmental degradation and illusory promises of job creation. Critics argue that the Bank and the IFC should take greater ownership of projects they fund and demand more accountability.
In this interview the Assistant Secretary-General and Executive Coordinator for the United Nations Conference on Sustainable Development discusses issues related to the upcoming conference to be held in Rio de Jainero, Brazil on 20-22 June 2012 (Rio+). She identifies major sustainability challenges facing the world including economic sustainability, indicating that the global financial and economic system should not be characterised by boom and bust cycles, global, regional and local inequities, poor accountability and decreased civil society engagement, and the continuation of poverty, particularly among women and girls. She reported feeling positive about the potential for Rio+ to provide a platform for countries to evaluate environmental problems and craft solutions tailor-made for different countries. She argued that civil society’s role is invaluable in working at every level of society and educating companies and communities on the importance of sustainable development. Civil society needs to play a role in helping to develop new initiatives which will deliver on sustainability and most of all, civil society needs to be vigilant in ensuring that countries commit to sustainability and continue along the pathway they have defined to achieve it.
13. Monitoring equity and research policy
The main aim of this study was to determine how data on water source quality affect assessments of progress towards the 2015 Millennium Development Goal (MDG) target on access to safe drinking-water. Data was collected from five countries on whether drinking-water sources complied with World Health Organisation water quality guidelines on contamination with thermotolerant coliform bacteria, arsenic, fluoride and nitrates in 2004 and 2005. Taking account of data on water source quality resulted in substantially lower estimates of the percentage of the population with access to safe drinking-water in 2008 in four of the five study countries: the absolute reduction was 11% in Ethiopia, 16% in Nicaragua, 15% in Nigeria and 7% in Tajikistan. There was only a slight reduction in Jordan. Microbial contamination was more common than chemical contamination. The authors warn that the WHO criteria used to determine whether a water source is safe can lead to substantial overestimates of the population with access to safe drinking-water and, consequently, also overestimates the progress made towards the 2015 MDG target. Monitoring drinking-water supplies by recording both access to water sources and their safety would be a substantial improvement.
The authors of this study assessed the feasibility of using birth attendants instead of bereaved mothers as perinatal verbal autopsy respondents in low- and middle-income countries. Verbal autopsy interviews for early neonatal deaths and stillbirths were conducted separately among mothers (reference standard) and birth attendants in 38 communities in four developing countries, including the Democratic Republic of Congo and Zambia. For early neonatal deaths, concordance between maternal and attendant responses across all questions was 94%. Concordance was at least 95% for more than half the questions on maternal medical history, birth attendance and neonate characteristics. Concordance on any given question was never less than 80%. For stillbirths, concordance across all questions was 93%. Concordance was 95% or greater more than half the time for questions on birth attendance, site of delivery and stillborn characteristics. Overall, the causes of death established through verbal autopsy were similar, regardless of respondent. In conclusion, birth attendants can substitute for bereaved mothers as verbal autopsy respondents.
Incidence is a better measure than prevalence for monitoring AIDS, but it is not often used because longitudinal HIV data from which incidence can be computed is scarce. The objective of this study was to estimate the force of infection and incidence of HIV in Malawi using crosssectional HIV sero-prevalence data from the Malawi Demographic and Health Survey conducted in 2004. The researchers estimated population incidence from the force of infection by accounting for the prevalence, as the force of infection applies only to the HIV-negative part of the population. The estimated HIV population incidence per 100,000 person-years among men is 610 for the 15–24 year age range, 2,700 for the 25–34 group and 1,320 for 35–49 year olds. For females, the estimates are 2,030 for 15–24 year olds, 1,710 for 25–34 year olds and 1,730 for 35–49 year olds. In conclusion, the researchers assert that their method provides a simple way of simultaneously estimating the incidence rate of HIV and the age-specific population prevalence for single ages using population-based crosssectional sero-prevalence data. The estimated incidence rates depend on the HIV and natural mortalities used in the estimation process.
In this study, researchers evaluated the effect of an intervention to improve the quality of data used to monitor the prevention of mother-to-child transmission (PMTCT) of HIV in South Africa. The study involved 58 antenatal clinics and 20 delivery wards (37 urban, 21 rural and 20 semi-urban) in KwaZulu-Natal province that provided PMTCT services and reported data to the District Health Information System. The data improvement intervention, which was implemented between May 2008 and March 2009, involved training on data collection and feedback for health information personnel and programme managers, monthly data reviews and data audits at health-care facilities. Data on six data elements used to monitor PMTCT services and recorded in the information system were compared with source data from health facility registers before, during and after the intervention. Findings suggested that the level of data completeness increased from 26% before to 64% after the intervention. Similarly, the proportion of data in the information system considered accurate increased from 37% to 65%. Moreover, the correlation between data in the information system and those from facility registers rose from 0.54 to 0.92.
RESYST is a new international research consortium funded by the United Kingdom’s Department for International Development. It aims to enhance the resilience and responsiveness of health systems globally to promote health and health equity and reduce poverty. RESYST conducts research in a variety of countries in Africa and Asia, including low- and middle-income countries, seeking to identify lessons that are transferable across contexts. Research is conducted in three areas: financing (focusing on how best to finance universal health coverage in low and middle-income countries); health workforce (identifying effective, practical interventions to address human resource constraints); and governance (studying the relationships among frontline actors and mid-level management, and leadership in health policy implementation processes).
14. Useful Resources
Originally published in 2009, this updated version of Setting Up Community Health Programmes covers all the basic principles of community-based health care, setting up specific programmes, and managing them, while reflecting post-millennium realities. Topics covered include: health awareness and motivation; learning about the community; setting up a community health clinic; setting up community programmes for TB, maternal health and family planning; a community development approach to HIV/AIDS; setting up environmental health improvements; and managing personnel and finance. Designed for both urban and rural locations, this manual addresses the needs of health workers, programme managers, doctors, nurses, health planners and all those who seek an evidence-based and practical approach to health care in the developing world.
Some of the main reasons for occupational health and safety deficiencies in small-scale mining are unawareness of risks of chronic occupational diseases and inadequately implemented education and training. The key needs of the sector is to provide access to knowledge and tools that will raise awareness and disseminate affordable, best practice methods for use by small-scale mines. With this in mind, the CSIR Occupational Health and Ergonomics research group have developed the OREOHS tool, which is a comprehensive model for hazard identification and risk assessment of occupational health stressors that can be applied to mining operations of various types and sizes but in particular by small-scale enterprises. A scoring system was included in the checklists to facilitate a quantifying of the risk which would further enable a risk rating and ranking of health hazards in the workplace. Guidelines for the use of the organisational evaluation of risks associated with exposure to health stressors and guidelines for the use of each checklist are included. The OREOHS can be transposed onto a spreadsheet that will facilitate the automatic calculation of the risk rating and ranking of health hazards in a small mine.
15. Jobs and Announcements
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.
HEARD's first workshop for 2012 offers particpants the opportunity to learn the skills and the contributions that health economics can bring to resource planning, allocation and evaluation in the health care sector. The application of concepts will be directed toward understanding and interpreting the HIV and AIDS epidemic in southern and eastern Africa.
Objectives of the course are to: Give participants an understanding of the conceptual basis of economics; Enable participants to converse in the language of economics; Examine practical examples of the application of key concepts of economics; Give participants an awareness of the strengths and weaknesses of economics; Understand the key organisational impacts of ill health and its amelioration; Equity in health care and economics; Understand the theoretical underpinnings of economic evaluation; Appreciate the value of the techniques of economic evaluation and Examine applications of the various techniques. This workshop is aimed at health service staff who seek to understand how and why economics is applied to health care.
In April 1992 a group of visionaries – most now leading figures in the country – saw the need for an organisation to support the transformation of South Africa’s health system in the new democracy ushered in by the non race-based elections in 1994. The resultant organisation, Health Systems Trust, has grown from strength to strength over the intervening two decades, with work to strengthen health systems in South Africa and in southern Africa. Extensive health systems research (see the HST website), many innovative implementation programmes (including the early Initiative for Sub-district Support; District Strengthening and Community Development; SA SURE), relevant reporting and analysis (South African Health Review, District Health Barometer) and global collaborations advocating for equity (Global Equity Gauge - GEGA, early editions of Global Health Watch) have been implemented towards a vision of “Health systems supporting Health for All in southern Africa”. In May a 20-year celebration is planned. Developments in the South African health system over the past two decades will be explored in a one-day seminar. Then, acknowledging the involvement of the South African communities in sustaining the organisation, HST staff, some partners and dignitaries, will don overalls and participate in a social responsibility exercise in two clinics. HST steps into the next 20 years with confidence and excitement.
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.
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.
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.
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.
Applications are invited for the post of Dean and Professor, Faculty of Health Sciences at the University of Cape Town (UCT). This post will become vacant at the end of 2012, when the current Dean retires. UCT is looking for a candidate of high academic standing with proven leadership and managerial ability in the health and higher education sectors, who is registered, or eligible for registration, as a health professional in South Africa. A sound understanding of the South African health system is crucial. The Dean is responsible for health care and academic partnerships, including managing the agreements with the Western Cape Government and the National Health Laboratory Services. At a university-wide level, the Dean will be a member of the Senior Leadership Group of the University and will be expected to contribute to furthering the strategic goals of UCT, including transformation.
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