EQUINET NEWSLETTER 135 : 01 May 2012

1. Editorial

Flying without Pilots: Education Ministers challenged to fill the skills gap to achieve development goals
Africa Public Health Alliance 15% + Campaign

Following meetings of senior African education sector officials, experts and stakeholders on the eve of the Conference of Ministers of Education of the African Union (COMEDAF) in April in Abuja, Nigeria, the Africa Public Health Alliance and 15% plus Campaign called on African Education Ministers to prioritise the development of an African Multi-sectoral Human Resources Development Plan as a pre requisite to meeting Africa's development goals.

In a statement by the organisation, its coordinator Mr Rotimi Sankore stated that "While universal free, or affordable education is a development goal in its own right, the education sector also has a special role in developing the human resources that are a pre-requisite for meeting all of Africa's overall development goals"

Elaborating further he observed that in virtually every key sector of the economy and society, most African countries are operating at between 25 percent to 75 percent of the required human resources capacity, with the health sector particularly affected. Citing the conference host country Nigeria as an example, he noted that Nigeria has only about 25 percent of the doctors it needs, about 45 percent of nurses and midwives, and about 12 percent of pharmacists, a feature linked to poor performance in key areas such as maternal and child health.

With similar or worse gaps in various areas such as the engineering fields, it's no surprise that many African countries are lagging behind in overall human and social development.

Along side this is the crucial matter of overall poor investment in health, human and social development issues, with 33 African countries investing well below $40 per capita in health, compared to Cuba at $642 per capita, or Costa Rica at $413 per capita, both countries closer to African country development levels but with better health outcomes.

As the Africa Public Health Alliance 15% + Campaign we note that even if we suddenly had all the financial resources required for health services tomorrow morning, we would well find that most African countries do not have the human resources capacity to effectively absorb and utilise the financial investment.

No entrepreneur will ever purchase a hundred airplanes for an airline, and then employ only twenty five pilots and expect the other seventy five planes to fly. Yet this is the scenario in most African countries, where there is a strange expectation that we can meet the Millennium Development Goals and other development targets without the pre requisite human resources and infrastructure.

Considering that Africa's population is set to double from current one billion to two billion by 2050, it is imperative that Africa's education ministers work with other sectors of economy and society to prioritise in each country and at reqional level, the development of a Human Resources Development Plan that identifies what level of human resources are required for each sector, what is currently available, and what policy and investment is required to fill the gaps in the shortest possible time.

Public statement of the Africa Public Health Alliance 15% + Campaign 25 April 2012 at the Conference of African Ministers of Education Abuja 26/27 April 2012. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please contact media@africapublichealth.net.

2. Latest Equinet Updates

Bringing evidence on equity to health policy in Africa: Experiences of the Equity Watch
Session at the Global Forum for Health Research, Cape Town, April 2012

Convened by EQUINET, in association with the ECSA Health Community and IDRC Canada, a session was held at Forum 2012 in Cape Town on April 25th to present evidence and experience from work carried out in 2010-2012 in five countries - Mozambique, Zambia, Zimbabwe, Uganda, Kenya - and at regional level in East and Southern Africa to assess progress in key areas of equity in health outcomes, in social determinants of health and in redistributive health systems. The session reviewed the learning from the work, particularly in relation to monitoring policy commitments to equity in health, and discuss the opportunities and the challenges for institutionalising and using equity analysis within health policy and planning. The session explored why equity analysis is important for strategic planning and what has been learned from the Equity Watch; what challenges countries face in implementing equity analysis and what opportunities exist for linking equity analysis to processes within the health system; and recommendations from the work for institutionalizing equity analysis across different sectors of government and with other actors. A concluding PechaKucha (20 images in 20 seconds each) flagged the key messages and continuing debates in taking equity monitoring and analysis from research to institutional practice in health and health systems. A regional meeting to have deeper dialogue on the national and regional Equity Watch work was held after the forum and the report will be made available through the June newsletter and EQUINET website.

Stakeholders meeting on the Zimbabwe Equity Watch Harare, 23 February 2012
Ministry of Health and Child Welfare, Training and Research Support Centre, and EQUINET: 2012

The Ministry of Health and Child Welfare and Training and Research Support Centre with EQUINET hosted a one day meeting in February in Harare to report on and review the findings of the 2011 Zimbabwe Equity Watch; to 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 to 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 universal health coverage, as well as health in all policies and made proposals for short and medium term steps to work towards equity in universal health coverage. They called for strengthened consistent co-ordination of the institutions and agencies that influence the determinants of health and delivery on universal health coverage. It was proposed that the Equity Watch be institutionalised 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

Accounting for Nature's benefits: The dollar value of ecosystem services
Holzman DC: Environmental Health Perspectives 120, 1 April 2012

The value of ecosystem services typically goes unaccounted for in business and policy decisions and in market prices, according to this article. For commercial purposes, if ecosystem services are recognised at all, they are perceived as free goods, like clean air and water. The author considers the work of organisations like the United States President’s Council of Advisors on Science and Technology (PCAST), which are working to build recognition of ecosystem services and, importantly, methods to evaluate them. By calculating specific values for these services, policy makers and resource managers may be able to make better-informed decisions that factor important environmental and human health outcomes into the bottom line.

Green economy, health equity and sustainable development: Converging in Rio?
Neufeld BM: Health Diplomacy Monitor 3(2): 17-19, April 2012

Over the past year, at a range of international conferences, including the Conference on Social Determinants in Rio and COP-17 in Durban, there have been side events introducing work on the link that exists between health and climate change. In the run-up to Rio+20 climate conference in June 2012, the need for a sustainable approach to global health will become even more important, the author of this article argues. It will require a shift in focus away from disease-specific thinking to an approach that more fully considers climate change and environmental degradation as important determinants of health. The author argues that the Istanbul Declaration, which calls on the world community to take bold action jointly against global social inequities and environmental deterioration, is a useful tool to achieve this end. It points to the need to integrate equity within the links made across health, economy and environment, reinforcing similar issues raised at the World Conference on the Social Determinants of Health, held in October 2011.

Patients without borders: Medical tourism and medical migration in Southern Africa
Crush J, Chikanda A and Maswikwa B: Southern African Migration Project, Migration Policy Series No. 57, 2012

In the industrialised North, South Africa is seen as an archetypal medical tourism destination, combining a medical (elective) procedure with related travel and tourism activity. Yet this paper shows that the industry is premised on a highly romanticised and stylised image of South Africa, and most medical tourism to South Africa is not from the North: the Global North generated a total of 281,000 medical travellers between 2009 and 2010, while the Global South was the source of over two million. Most patients were middle-class people from East and West Africa, as well as a growing number of patients from South Africa’s neighbouring countries. In some cases, patients go to South Africa for procedures that are not offered in their own countries. In others, patients are referred by doctors and hospitals to South African facilities. But most of the movement is motivated by lack of access to basic healthcare at home. The total annual spend by medical travellers in South Africa amounts to over R1.5 billion (US$191 million). Of this, over 90% is generated by South-South medical travellers from the rest of Africa, powerfully illustrating the overall economic importance of this form of medical travel. In addition, South Africa has entered into bilateral health agreements with eighteen African countries. The authors call for further research on and policy attention for intra-African medical tourism and migration, which is identified as a growing trend.

Systematic review of diarrhoea duration and severity in children and adults in low- and middle-income countries
Lamberti LM, Fischer-Walker CL and Black RE: BMC Public Health 12(276), 6 April 2012

Diarrhoea is a leading cause of morbidity and mortality globally; yet the overall burden of diarrhoea in terms of duration and severity has not been quantified. This study aims to fill that research gap. The authors estimated that, globally, among children under-five, 64.8% of diarrhoeal episodes are mild, 34.7% are moderate, and 0.5% are severe. On average, mild episodes last 4.3 days, and severe episodes last 8.4 days and cause dehydration in 84.6% of cases. Among older children and adults, 95% of episodes are mild; 4.95% are moderate; and 0.05% are severe. Among individuals ≥16 yrs, severe episodes typically last 2.6 days and cause dehydration in 92.8% of cases. Moderate and severe episodes constitute a substantial portion of the total envelope of diarrhoea among children under-five (35.2%; about 588 million episodes). Among older children and adults, moderate and severe episodes account for a much smaller proportion of the total envelope of diarrhoea (5%), but the absolute number of such episodes is noteworthy (about 21.5 million episodes among individuals ≥16 yrs). Hence, the global burden of diarrhoea consists of significant morbidity, extending beyond episodes progressing to death.

UN World Water Development Report
United Nations Educational, Scientific and Cultural Organisation (UNESCO): 2012

The fourth edition of the World Water Development Report, ‘Managing Water under Uncertainty and Risk’ is a comprehensive review of the world's freshwater resources and seeks to demonstrate, among other messages, that water underpins all aspects of development, and that a coordinated approach to managing and allocating water is critical. The report underlines that in order to meet multiple goals water needs to be an intrinsic element in decision-making across the whole development spectrum. It aims to encourage all stakeholders both in and out of the ‘water box’ - water managers, leaders in government, civil society and businesses – to engage early in decision making processes to improve the quality and acceptance of decisions and the probability of successful implementation. It highlights that more responsible action by all water users has enormous potential to lead to better outcomes - but requires political, social, economic and technical responses at all levels of government, businesses and communities, from local to international.

4. Values, Policies and Rights

Aid, resistance and queer power
Abbas H: Pambazuka News 580, 5 April 2012

Increased persecution of homosexuals in Africa has drawn the attention of international funders recently. Western external funders are reported by the author to be considering making aid to African countries conditional on decriminalising homosexuality and upholding the rights of homosexual communities. While intended to show support for an otherwise vulnerable minority, the author suggests that withholding aid would have adverse effects on all Africans, including homosexual Africans. Threatening to withdraw foreign aid, it is argued, only reinforces the argument that homosexuality is a Western construct and would result in a local backlash. Further aid itself cannot be a tool for social justice given its roots in imequitable power relations. In contrast the author calls for an emerging movement that seeks to locate gender and sexuality, including that of homosexual people, within the broad spectrum of social and economic issues that affect all Africans.

Minerals and Africa's development
International Study Group on Africa’s Mineral Regimes, United Nations Economic Commission for Africa (UNECA): December 2011

This study focuses on the African Mining Vision (AMV), which was adopted by the African Union in 2008, an agreement that seeks to shift mineral policy beyond a focus on extracting minerals and sharing revenue. Instead, it relates mineral policy to the transformation of Africa’s economies and views an industrialisation strategy anchored on minerals and other natural resources as critical for achieving the Millennium Development Goals, eradicating poverty and securing sustainable growth. The study looks at regulation of artisanal and small­scale mining in Africa, the increasing importance of corporate social responsibility initiatives in the mining sector, and perspectives on capturing, managing and sharing mineral revenue for the befit of all. It highlights the fact that policy design works best when instruments are available to carry it out, and for much of Africa, that plan remains part of the rhetoric of official declarations, dissociated from real policy. So far, the policy position of stakeholders, especially government, is limited to short­-term responses to immediate concerns or focused on extracting and exporting unprocessed natural resources. The AMV and this report affirm the need for Africa to transform its mining sector from an enclave of raw material supplies to an integrated industry that will help drive the continent's socio-economic development.

National Strategic Plan on HIV, STIs and TB: 2012—2016
South African Department of Health: 2012

April 2012 marked the start of South Africa's new five-year strategy on HIV, STIs and TB. The plan has several broad goals: to reduce new HIV infections by at least 50%; to start at least 80% of eligible patients on antiretroviral treatment; to reduce the number of new tuberculosis infections and deaths by 50%; to ensure a legal framework that protects and promotes human rights to support implementation of the plan; and to reduce self-reported stigma related to HIV and tuberculosis by at least 50%. Additionally, a major strategic objective of the plan will be to address the social and cultural barriers to HIV, sexually transmitted infection, and tuberculosis prevention and care. The plan states that key vulnerable populations (eg, women between the ages of 15 years and 24 years, people from low socioeconomic groups, and men who have sex with men) will be targeted with different but specific interventions under each goal to achieve maximum impact. The strategy endorses a new focus on tuberculosis (TB), which is much needed, as South Africa has 482,000 TB sufferers, 70% of whom are co-infected with HIV.

Shifting paradigm: How the BRICS are reshaping global health and development
Global Health Strategies Initiatives: March 2012

This report presents findings from a qualitative and quantitative survey of present and future efforts by Brazil, Russia, India, China and South Africa to improve global health. It examines these roles within the broader context of international development and foreign assistance. BRICS foreign assistance spending is still relatively small when compared to overall spending by the US and Western European countries, but in recent years it has been increasing rapidly. Today, among the BRICS, China is by far the largest contributor to foreign assistance, and South Africa is estimated to be the smallest by a significant margin. Brazil and Russia prioritise health within their broader assistance agendas, while China, India and South Africa tend to focus on other issue areas. Though their health commitments vary significantly in both size and scope, each of the BRICS has contributed to global health through financing, capacity building, dramatically improved access to affordable medicines, and development of new tools and strategies. In this context, BRICS policymakers themselves have recognised their potential to have even greater global health impact when they committed in 2011 to ‘support and undertake inclusive global public health cooperation projects, including through South-South and triangular co-operation’.

UN Commission on the Status of Women fails to uphold women’s rights
Asia Pacific Forum on Women, Law and Development: April 2012

At the 56th session of the United Nations Commission on the Status of Women, held in April 2012, the Asia Pacific Forum on Women, Law and Development report that the Commission failed to adopt agreed conclusions protecting women’s rights for reasons of ‘safeguarding traditional values’. This failure comes at the expense of human rights and fundamental freedoms of women, according to this statement of a number of feminist and women's rights organisations in the Forum. These organisations reject any proposed re-opening of negotiations on the already established international agreements on women's human rights and call on all governments to demonstrate their commitment to promote, protect and fulfil human rights and fundamental freedoms of women. Customs, tradition or religious considerations must not be tolerated to justify discrimination and violence against women and girls, whether committed by State authorities or by non-state actors. In particular, the statement urges governments to ensure that the health and human rights of girls and women are secured and reaffirmed at the upcoming 2012 Commission on Population and Development and the International Conference on Sustainable Development (Rio+20). Any future international negotiations must move forward implementation of policies and programmes that secure the human rights of girls and women.

‘Water belongs to everyone’: The role of the private sector in tackling global issues surrounding water
Pambazuka News 579: 29 March

While the sixth World Water Forum took place in Marseille in March 2012, an Alternative World Water Forum (FAME) also took place in parallel in the French city. Promoting a motto of ‘Water belongs to everyone’, the trade unions, corporate watchdog groups and environmentalists behind FAME accused the World Water Forum of failing to adequately address issues of universal water access and sustainability, and of rather promoting expensive private sector technologies for safe water. The World Water Forum declaration did include commitments to speed up access to safe drinking water and sanitation for all, focusing on the most vulnerable. The Alternative Forum argued, however, that the Forum declaration failed to reflect a full commitment to the rights to water and sanitation, according to the United Nations special rapporteur on the human right to safe drinking water and sanitation.

5. Health equity in economic and trade policies

African countries set to reform their mining sector
Social Watch: Pambazuka News 579: 29 March 2012

African ministers of mineral resources resolved, in a conference in Addis Ababa in December 2011, to move into action to reform Africa’s mining sector to benefit the African people. They set a brand new vision apparent in its action plan that includes these six points: Member States should reform the fiscal framework in order to optimise benefits from the mineral sector; Member States should explore the possibility of renegotiating existing contracts to secure a fair share of the rent; Member States should align their development strategies to their long term national development goals; Member States should ensure transparency in the collection and use of mining revenues; Governments could explore the use of equity participation in mineral ventures to capture a greater share of benefits; and Governments in collaboration with partners should build capacity of oversight bodies. Along with the action plan, the ministers reasserted the African Mining Vision (AMV) approved by the February 2009 African Union Summit. The AMV puts development outcomes at the heart of mineral regimes to stimulate the local economy and help prevent mines operating as enclave enterprises.

BRICS increasingly pivotal role in the continent
South African Foreign Policy Initiative: Open Society Foundation for South Africa, 12 April 2012

The fourth annual BRICS summit, held in March 2012 under the theme of "BRICS Partnership for Global Stability, Security and Prosperity", sought to strengthen ties between the five countries (Brazil, Russia, India, China and South Africa) in order to heighten bargaining power. And while the global media is focused on China in Africa, the author of this article argues that they are missing out on the story of trade between Africa and remaining partners Russia, India and Brazil. Outside of China, these countries remain some of the largest players in South-South relations and on the African continent. Trade between Brazil and Africa tripled from 2004-2010, totaling over $20 billion, while Indian trade with Africa reached $60 billion in 2011, with both countries expecting increased trade with the continent. And while Russian activity on the African continent remains low - at $7.3 billion in 2008 - it is also expected to grow.

China and Africa: Taking stock after a decade of advances
Freemantle S and Stevens J: Standard Bank, 19 March 2012

Roughly a decade on from the launch of a new era of commercial and strategic alignment, China-Africa ties continue to mature, substantially altering the make-up of Africa’s political and economic milieu, according to this paper. The authors evaluate the current and potential scale of China’s position in Africa, and, in so doing, pose questions as to the role of Africa’s traditional Western partners in the continent’s ongoing economic progression. Bilateral trade in 2011 reached US$160 bn, up by 28% from the previous year, when China accounted for 18% of Africa’s trade (up from 10% in 2008). African exports to China increased by one-third in 2011, while Africa’s imports from China (23.7%) increased by 4%. Fluctuations in currency and domestic prices have little explanatory role in why China has undermined the position of developed nations in Africa, the authors argue. What counts is China’s foresighted engagement with Africa back at the start of the past decade, allowing Beijing to steal a march on Africa’s other partnerships. Importantly, China is well-positioned to be a significant player in Africa’s next phase of development.

EU-India free trade agreement: Implications for global health
Kamradt-Scott A: Health Diplomacy Monitor 3(2): 6-8, April 2012

The European Union (EU) has committed to concluding a new free trade agreement (FTA) with India, known formally as the Bilateral Trade and Investment Agreement (BITA), by the end of 2012, but the BITA may have significant adverse implications for India’s generic pharmaceutical industry that supplies much of the developing world’s antiretroviral (ARV) medications and other drugs. Critics argue that free trade agreements that may create new intellectual property obligations for India can increase ARV prices, impede the development of acceptable dosage forms, and delay access to new and better ARVs. They also state that by pressuring India and other developing countries to accept new intellectual property rules for pharmaceuticals, the EU threatens to undermine the Doha Declaration, a TRIPS-related agreement that is intended to ensure that low- and middle-income countries gain access to affordable medicines. The schedule for the next round of BITA negotiations in September 2012 has yet to be released and preparations are shrouded in secrecy. Neither party has sufficiently acknowledged the impact the FTA may have on millions of the world’s poorest people, who rely on India’s generic pharmaceutical industry to provide them with access to life-saving treatments.

Fourth BRICS Summit: Delhi Declaration
Brazil, Russia, India, China and South Africa (BRICS): 29 March 2012

In this declaration from the fourth annual BRICS summit, held in March 2012, participants call for a more representative international financial architecture, with an increase in the voice and representation of developing countries and the establishment and improvement of a just international monetary system that can serve the interests of all countries and support the development of emerging economies. The declaration expresses BRICS’s concern at the slow pace of quota and governance reforms in the International Monetary Fund (IMF), calling for greater representation of developing countries by January 2013. The declaration reiterates BRICS’ position that that the heads of the IMF and the World Bank be selected through an open and merit-based process, and that Bank leadership must commit to transform the Bank into a multilateral institution that truly reflects the vision of all its members. The declaration also announces BRICS’s intention to set up a new Development Bank for mobilising resources for infrastructure and sustainable development projects in BRICS and other developing countries.

India grants first compulsory licence for patented drug
Estavillo M: Intellectual Property Watch, 12 March 2012

In a move welcomed by many in the international community, India has granted its first compulsory licence to a local generic drug maker to manufacture and sell a cancer drug, Sorafenib tosylate, which is patented by German pharmaceutical giant, Bayer, under the brand name Nexavar. Compulsory licensing is one of the flexibilities on patent protection under the World Trade Organisation’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement, and it allows developing countries to manufacture affordable generic versions of patented medicines needed for public health in developing countries. Natco, the Indian generic producer, has already developed a process to manufacture the drug, expected to be ready for marketing in April 2011. It is anticipated that Bayer will make an appeal against the decision, which requires Natco to pay a quarterly royalty at 6% of the net sales of the drug, far below Bayer’s asking royalty of 15%. Médecins Sans Frontières said the ruling has ended Bayer’s monopoly in India on the drug and could set a precedent for making more expensive patented drugs available for compulsory licensing.

6. Poverty and health

Achieving food security in the face of climate change: Final report from the Commission on Sustainable Agriculture and Climate Change
Beddington J, Asaduzzaman M, Clark M, Fernández A, Guillou M, Jahn M et al: CGIAR Research Programme on Climate Change, Agriculture and Food Security (CCAFS), 2012

This report by the Commission on Sustainable Agriculture and Climate Change contains its recommendations to policy makers on how to achieve food security in the face of climate change. The Commission’s recommendations are designed to be implemented concurrently by a constellation of governments, international institutions, investors, agricultural producers, consumers, food companies and researchers. They call for changes in policy, finance, agriculture, development aid, diet choices and food waste as well as revitalised investment in the knowledge systems to support these changes. The Commission recommends significantly raising the level of global investment in sustainable agriculture and food systems in the next decade; sustainably intensifying agricultural production on the existing land base while reducing greenhouse gas emissions; and reducing losses and waste in the food system. The Commission urges governments attending the Rio+20 Earth Summit in June 2012 to make financial commitments for regionally-based research, implementation, capacity building and monitoring to improve agriculture and food systems.

Brazil to work with South Africa against hunger
Southern African Press Association: 10 April 2012

Brazil has agreed to assist South Africa on social development issues, particularly in fighting against poverty and hunger. Brazil is aiming to help 16.2 million Brazilians out of extreme poverty with its comprehensive national poverty alleviation plan, ‘Brasil Sem Misera’. The plan includes cash transfer initiatives, and increased access to education, health, welfare and sanitation. South Africa has expressed a desire to learn about Brazil’s national alleviation plan and its successful Zero Hunger programme.

Linking migration, food security and development
Crush J (ed): Southern African Migration Project, Migration Policy Series No. 60, 2012

In this report, the authors argue that food security in Southern Africa needs to be "mainstreamed" into the migration and development agenda and migration needs to be "mainstreamed" into the food security agenda. They set out to promote a conversation between the food security and migration agendas in the African context, focusing on the connections in an urban context. Four main issues are singled out for attention: the relationship between internal migration and urban food security; the relationship between international migration and urban food security; the difference in food security between migrant and non-migrant urban households; and the role of rural-urban food transfers in urban food security. Findings indicate that most poor households in Southern African cities either consist entirely of migrants or a mix of migrants and non-migrants. Rapid urbanisation, increased circulation and growing cross-border migration have all meant that the number of migrants and migrant households in the city has grown exponentially. This is likely to continue for several more decades as urbanisation continues. Policymakers cannot simply assume that all poor urban households are alike. While levels of food insecurity are unacceptably high amongst all of them, migrant households do have a greater chance of being food insecure with all of its attendant health and nutritional problems.

Sorting out the what, how, and who for regional action on agriculture in Africa
Afun-Ogidan D: European Centre for Development Policy Management blog, 30 March 2012

Many African countries and regions have programmes to boost their agricultural productivity to ensure food security, with the pan-African Comprehensive Africa Agriculture Development Programme (CAADP) being the most comprehensive. On 5 March 2012 members of the CAADP Development Partners Task Team met in Brussels to discuss and explore how to facilitate and support greater involvement of regional stakeholders that are important for CAADP implementation at the regional level. Participants discussed how to achieve faster progress on implementing the programme and stressed the need to identify concrete regional actions for faster progress. They also emphasised the importance of deciding on roles and responsibilities of different regional actors, and of improving coordination among development partners, and between development partners and Regional Economic Communities. Although these ideas do not represent formal positions, they could be used to guide discussion between development partners, Regional Economic Communities and other actors during the Eighth CAADP Partnership Platform meeting, due to be held 3-4 May 2012.

The association between malnutrition and the incidence of malaria among young HIV-infected and -uninfected Ugandan children: A prospective study
Arinaitwe E, Gasasira A, Verret W, Homsy J, Wanzira H, Kakuru A et al: Malaria Journal 11(90), 27 March 2012

In this study, a cohort of 100 HIV-unexposed, 203 HIV-exposed (HIV negative children born to HIV-infected mothers) and 48 HIV-infected children aged six weeks to one year were recruited from an area of high malaria transmission intensity in rural Uganda and followed until the age of 2.5 years. All children were provided with insecticide-treated bed nets at enrolment and daily trimethoprim-sulphamethoxazole prophylaxis (TS) was prescribed for HIV-exposed breastfeeding and HIV-infected children. Monthly routine assessments, including measurement of height and weight, were conducted at the study clinic. The researchers found overall incidence of malaria was 3.64 cases per person year. Mild stunting and moderate-severe stunting were associated with a similarly increased incidence of malaria compared to non-stunted children. Being mildly underweight and moderate-severe underweight were not associated with a significant difference in the incidence of malaria compared to children who were not underweight. There were no significant interactions between HIV-infected, HIV-exposed children taking TS and the associations between malnutrition and the incidence of malaria. The researchers point out, in conclusion, that they were unable to disentangle the relationship between malnutrition and the incidence of malaria, and their findings do not necessarily indicate any causal connections between malaria and malnutrition.

7. Equitable health services

Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: A cross-sectional study
Crede S, Hoke T, Constant D, Green MS, Moodley J and Harries J: BMC Public Health 12(197), 16 March 2012

This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the intra-uterine device (IUD) and female sterilisation in a high HIV-prevalence setting in Cape Town, South Africa. A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV-positive and 273 HIV-negative postpartum women. Women's knowledge and attitudes towards long-acting and permanent methods (LAPMs), as well as factors that influence their choice in contraception, were examined. Current use of contraception was found to be high, with no difference by HIV status (89.8% HIV-positive and 89% HIV-negative). Most women were using short-acting methods, primarily the three-monthly injectable. Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using LAPMs (all chose sterilisation). The researchers conclude that poor knowledge regarding LAPMs is likely to be contributing to their poor uptake . They recommend improving contraceptive counselling to include LAPMs and strengthening services for these methods. Given that HIV positive women were found to be more favourable to future use of the IUD, it is possible that there may be more uptake of the IUD amongst these women, they argue.

Integrating pneumonia prevention and treatment interventions with immunisation services in resource-poor countries
Cohen AL, Hyde TB, Verani J and Watkins M: Bulletin of the World Health Organisation 90(4): 289-294, April 2012

Pneumonia is a leading cause of morbidity and mortality worldwide. Effective vaccine and non-vaccine interventions to prevent and control pneumonia are urgently needed to reduce the global burden of the disease. In this paper, researchers explore practical strategies and policies for integrating interventions to prevent and treat pneumonia with routine immunisation services, and investigate the challenges involved in such integration. They identify three primary pneumonia prevention and treatment strategies that should be implemented during routine childhood immunisation visits: vaccination of children against the disease, caretaker education and referral of children to medical services when necessary.

Linking global HIV/AIDS treatments with national programmes for the control and elimination of the neglected tropical diseases
Noblick J, Skolnik R and Hotez PJ: PLoS Neglected Tropical Diseases 5(7), 26 July 2011

The authors of this article argue that a high prevalence of neglected tropical diseases (NTDs) in sub-Saharan Africa promotes susceptibility to the HIV virus and can worsen the clinical course and progression of AIDS. They highlight emerging evidence to provide a scientific rationale for combining treatment programmes for NTDs with programmes for the treatment of HIV andAIDS. They argue that improved NTD control could both decrease susceptibility to HIV infection and improve morbidity levels in seropositive individuals. Improved efficiency and cost- effectiveness of integrating NTD programmes into a wider framework to provide HIV care would require careful co-ordination and collaboration among concerned NGOs, private entities and Ministries of Health. Major stakeholders should be encouraged to establish operational links between HIV and AIDS and NTD activities.

Neglected tropical disease (NTD) control in health systems: the interface between programmes and general health services
Marchal B, Dormael MV and Pirard M: Acta Tropica 120(Suppl 1): S177–S185, September 2011

The aim of this paper is to examine the interactions of neglected tropical disease (NTD) control programmes and general health services, focusing particularly on sub-Saharan African countries and reviewing related studies. The authors found that NTDs affect the poorest communities, which are served by the weakest health systems. Further findings suggest that the strategy of integrated control at the community level offers opportunities for enhanced cost-effectiveness and feasibility in low-resource settings, with managers of disease control programmes playing a crucial role in assessing progress. Co-ordinated efforts based on a coherent overall policy, managerial and administrative vision, and a long-term view are required. The article concludes that NTD campaigns have the potential to enhance some elements of the general health services. These may include the health information system, the drug procurement system, the health workforce and the community volunteers. On the other hand, NTD campaigns are at risk of inducing negative effects on health systems. These can be categorised as duplications, distortions and interruptions. As a result, detailed follow-up and documentation of how NTD campaigns and general health services interact is essential, the paper concludes.

Stress-reducing effects of real and artificial nature in a hospital waiting room
Beukeboom CJ, Langeveld D and Tanja-Dijkstra K: Journal of Alternative and Complementary Medicine (Online Ahead of Print), 10 April 2012

This field study investigated the potential stress-reducing effects of exposure to real or artificial nature on patients in a hospital waiting room. Additionally, it was investigated whether perceived attractiveness of the room could explain these effects. In this between-patients experimental design, patients were exposed to one of the following: real plants, posters of plants, or no nature (control). These conditions were alternately applied to two waiting rooms. The subjects consisted of 457 patients (60% female and 40% male) who were scheduled for various health services, such as echocardiogram and x-ray. Patients exposed to real plants, as well as patients exposed to posters of plants, report lower levels of experienced stress compared to the control condition. Further analyses show that these small but significant effects of exposure to nature are partially mediated by the perceived attractiveness of the waiting room. In conclusion, natural elements in hospital environments have the potential to reduce patients' feelings of stress. By increasing the attractiveness of the waiting room by adding either real plants or posters of plants, hospitals can create a pleasant atmosphere that positively influences patients' well-being.

8. Human Resources

A survey of Sub-Saharan African medical schools
Chen C, Buch E, Wassermann T, Frehywot S, Mullan F, Omaswa F et al: Human Resources for Health 10(4), 24 February 2012

The Sub-Saharan African Medical Schools Study (SAMSS) survey is a descriptive survey study of sub-Saharan African medical schools. Surveys were distributed to 146 medical schools in 40 of 48 sub-Saharan African countries. One hundred and five responses were received (72% response rate). Enrolments for medical schools ranged from 2 to 1,800 and graduates ranged from 4 to 384. Seventy-three percent of respondents increased first-year enrolments in the past five years. On average, 26% of respondents’ graduates were reported to migrate out of the country within five years of graduation. The most significant reported barriers to increasing the number of graduates and improving quality were related to infrastructure and faculty limitations, respectively. Significant correlations were seen between schools implementing increased faculty salaries and bonuses, and lower levels of loss of faculty staff. Strengthened institutional research tools and funded faculty research time were also linked to greater faculty involvement in research. The results of the SAMSS survey are intended to serve as a baseline for future research, policies and investment in the health care workforce in the region.

Africa's neglected area of human resources for health research: The way forward
IJsselmuiden C, Marais DL, Becerra-Posada F, Ghannem H: South African Medical Journal 102(4): 228-233, April 2012

Africa lacks a system for defining, co-ordinating and growing the human resources for health research (HRHR) needed to support its health systems development, according to this review. The authors found that research consists of unco-ordinated, small-scale activities, primarily driven from outside Africa. They present examples of ongoing HRHR capacity building initiatives in Africa. There is no overarching framework, strategy or body for African countries to optimise research support and capacity in HRHR. A simple model is presented to help countries plan and strategise for a comprehensive approach to research capacity strengthening. Everyone engaged with global, regional and national research for health enterprises must proactively address human resource planning for health research in Africa, the authors argue. Unless this is made explicit in global and national agendas, Africa will remain only an interested spectator in the decisions, prioritisation, funding allocations, conduct and interpretation, and in the institutional, economic and social benefits of health research, rather than owning and driving its own health research agendas.

The disengagement of the South African medical diaspora
Crush J and Chikanda A: Southern African Migration Project, Migration Policy Series No. 58, 2012

This paper reports on a survey of 415 South African doctors in Canada conducted in 2009-2010, representing almost 20% of the total number working in Canada. The researchers found that, while this group of South African professionals are proud to think of themselves as South African and take a relatively keen interest in events in that country, they are largely disengaged from any serious diasporic interest in and commitment (beyond contact with and some limited support for family members who remain). Amounts remitted by South African physicians are small in comparison to their incomes and remitting is infrequent, differing markedly in their remitting behaviour from physicians from other African countries and from African diasporas in general, where remittances are significant. More than half expressed no interest in returning to South Africa to help with nation building. Only 7% said they are likely to return within the next two years and another 10% within the next five years. Almost without exception, the respondents painted a very negative picture of life in South Africa and they do not see any role for themselves in helping address the country’s deep social and economic inequalities and needs. The findings of this study challenge assertions by neo-liberal economists that the negative impacts of the ‘medical brain drain’ in Africa are highly exaggerated and there is adequate compensation in the form of remittances, direct investment, knowledge and skills transfer, return migration and involvement in diaspora associations.

9. Public-Private Mix

Private funding: An emerging trend in humanitarian donorship
Stoianova V: Global Humanitarian Assistance, April 2012

Private external funders (donors) are growing steadily more important to global aid, contributing one-quarter of the estimated US$73.9 billion spent on emergency assistance from 2006 to 2010, according to this report. Trusts, foundations, businesses and individuals are the main sources of private funding, with non-governmental organisations (NGOs) depend on these sources for 57% of their financial support, while UN agencies depend on it for only 8%. There are also wide variations: for example, Médecins Sans Frontières (MSF) gets roughly 90% of its funding from private sources but the Norwegian Refugee Council receives only 2%. While many agencies are courting private funders, the lack of tracking creates a significant information gap in both co-ordinating and evaluating this source of funds.

South African Health Department seeks private sector engagement in NHI
Mkhwanazi A: Heath-e News, 19 March 2012

South Africa’s National Health Department is courting the private sector to build public-private partnerships in the development of the country’s new National Health Insurance (NHI) system. The Department has announced that it considers the issue of improving working relations and trust between the private and public health sectors an important step towards the establishment of the NHI, calling for greater transparency and accountability. Olive Shisana of the Human Sciences Research Council (HSRC) echoed government’s position, arguing that the reluctance of the private sector to work with government on the NHI ‘fails to recognise the long-term benefits for health care’ in the country. The private sector has so far been reluctant to work with government, fearing profit losses if NHI is implemented.

TB vaccine receives Gates boost
Thom A: Health-e News, 15 March 2012

The Bill and Melinda Gates Foundation has pledged US$220 million over the next five years for the search for a tuberculosis (TB) vaccine. The money will be channeled via Aeras, a non-profit organisation developing vaccines to combat TB against the backdrop of a significant increase in drug-resistant strains. A large portion of their proposed TB vaccine work will take place in South Africa, where research partners have been promised they will benefit from the grant. The grant will allow Aeras to advance several vaccine candidates into pivotal large-scale efficacy trials in South Africa and elsewhere. Aeras estimates a total of $400-500 million will be needed over the next five years to fund activities. The Gates grant will provide approximately half of the estimated cost of meeting 2012 to 2016 milestone targets.

The difficult relationship between faith-based healthcare organisations and the public sector in sub-Saharan Africa
Boulenger D and Criel B: Studies in Health Services Organisation and Policy 29, ITG Press, 2012

In this book, the authors present the principal findings of a study conducted between September 2007 and March 2009 on contractual arrangements between faith-based hospitals and public health authorities in four sub-Saharan African countries: Cameroon, Tanzania, Chad and Uganda. In Tanzania, Christian faith-based organisations were found to be well represented, particularly the Catholic Church. The study focused on the Nyakahanga District Designated Hospital (NDDH), a rural Lutheran hospital located in the north-west of the country. Researchers found that monitoring of the contractual relationship between church and state is not properly done and supervision remains erratic, with frequent stock-outs and lack of capital investment, leading to a negative perception of the relationship by both parties. In Uganda, the faith-based health sector owns about 30% of the country’s health facilities. Field research for the study focused on two faith-based hospitals in Uganda that were involved in contracting agreements with PEPFAR recipients. Restrictive and demanding agreements between PEPFAR recipients and hospitals were identified as problematic, but this was mitigated by the reliability of PEPFAR funding. The authors observe that where the relationship between public and faith-based sectors is not satisfactory, faith-based organisations may opt for more predictable agreements that they can rely on with external organisations like PEPFAR.

10. Resource allocation and health financing

Aid transparency important as EU aid budgets slashed
Publish What You Fund: 5 April 2012

European civil society organisations have expressed dismay at new Organisation for Economic Co-operation and Development data revealing the cuts made to almost all European countries’ aid programmes in 2011. Twelve European countries slashed their aid budgets in 2011 – with the biggest cuts seen in Greece (-39.3%), Spain (-32.7%), and Austria (-14.3%) – and only three European countries increased their aid spending: Italy (33%), Sweden (10.5%) and Germany (5.9%). Publish What You Fund urges the development community to focus on maximising the impact of aid by ensuring external funders provide more accessible, timely, and comparable information about the aid they give. All European funders should implement the commitments they made in the EU Transparency Guarantee by publishing their aid information to the International Aid Transparency Initiative (IATI), so that other European countries and funders around the world can co-ordinate their aid spending more effectively. It is also crucial that information on European Union (EU) aid is made available through the common standard so that recipient countries can see what is coming to them and plan their own spending in relation to this.

Expanding coverage to the formal and informal sectors in Kenya
Sealy S: UHC Forward, 4 April 2012

The National Health Insurance Fund (NHIF)’s new partnership with the Kenya National Union of Teachers – one of the largest unions in Kenya – has meant that NHIF will be able to provide an affordable and comprehensive package of in and out-patient benefits to more than 1,300,000 teachers and their family members. In addition, NHIF is offering unlimited out and in-patient benefits for approximately 1,100,000 civil servants and their family members beginning on 1 January 2012. The NHIF is also seeking to extend the unlimited in and out-patient care benefits to the informal sector in a phased-out manner. In this interview with Richard Kerich, CEO of Kenya's NHIF, he identifies a number of obstacles to expanding coverage in Kenya, such as weak and outdated policies, a low ratio of health workers to the population, a lack of modern equipment and political interference. Kerich has advice for other countries wishing to achieve universal health care (UHC): their governments must draw up strong governing documents and the population must be compelled in some way to contribute, and all systems must be made to support the introduction of UHC, including facilities, human resources, roads and information technology. He calls on Kenya’s policymakers to develop new policies that will serve the best interests of Kenya’s citizens.

From high to low aid: A proposal to classify countries by aid receipt
Glennie J and Prizzon A: Overseas Development Institute, March 2012

The authors of this paper argue that a classification of countries according to their aid receipts could contribute to a more effective aid agenda and help external funders (donors) and aid recipients monitor changes. High aid levels do not equal aid dependence, which is more complex, they argue, but can be a critical factor in aid dependence. They offer the ratio of recipient aid to Gross National Income (GNI) as a relevant measure complementing the traditional focus on aid as a proportion of donor GNI, symbolised by the 0.7% target. Recipient economies may be classified in four categories: high aid countries (HACs), middle aid countries (MACs), low aid countries (LACs) and very low aid countries (VLACs), on the basis of their net aid to GNI ratio above 10%, between 2% and 10%, between 1% and 2%, and below 1%, respectively. While much effort is made to follow trends in aid levels as a proportion of donor GNI, the analysis presented here underlines the importance of looking at aid from the recipient point of view. While external funders aim to reach the 0.7% target, recipients could also aim to reduce their aid to GNI ratio to become LACs or VLACs. This raises the debate on what is sustainable and fair in relation to aid levels.

Global health funding and economic development
Martin G, Grant A and D'Agostino M: Globalization and Health 8(8), 10 April 2012

In this study, researchers investigate the relationship between improvements in health and the growth of an economy. The negative effects of ill health on the economy are clear, as high levels of sickness decrease the size and capabilities of the workforce through impeding access to education and suppressing foreign direct investment (FDI). The researchers present evidence that investing in health improvements can result in a significant increase in GDP per capita in four ways: Firstly, healthier populations are more economically productive; secondly, proactive healthcare leads to decrease in many of the additive healthcare costs associated with lack of care (treating opportunistic infections in the case of HIV for example); thirdly, improved health represents a real economic and developmental outcome in-and-of itself and finally, healthcare spending capitalises on the Keynesian 'economic multiplier' effect. The paper ends with a call for the recognition of health as a major engine of economic growth and for commensurate investment in public health, particularly in poor countries.

Kenya increases national health insurance contributions
Juma V: Business Daily, 29 March 2012

Kenya’s Central Organisation of Trade Unions (Cotu) has launched an appeal after it lost a High Court case seeking to block public health insurer, the national Health Insurance Fund (NHIF), from raising member contributions. NHIF plans to raise monthly contributions for high-income earners by more than 600% to help the government offer universal access to health services, as stipulated in the Constitution. It plans to raise monthly contributions for those earning a gross salary of Sh100,000 and above from Sh320 to Sh2,000, which represents 2% or less of total income. Lowest-paid formal sector workers earning a salary of less than Sh5,999 will contribute Sh150. Cotu’s main argument against the new charges is that the NHIF has in the past not managed the funds to the best interest of members and should not be entrusted with more money until it demonstrates that it has the capacity to improve the quality of services offered.

Malawi’s fight to achieve universal coverage
Rachel Lander: UHC Forward, 19 March 2012

This article charts Malawi's progress in achieving universal health coverage (UHC) and the problems it has experienced since external funding was cut in 2011. Between 2004 and 2008, offering specific healthcare services without charge (in maternal and child health) resulted in a 75% increase in live births in facilities and a 13% reduction in mother and baby deaths, with knock-on effects on society. In 2009, the government announced new commitments to extend this to an additional 860,000 Malawians over the next four years, including 80,000 more women delivering safely. Malawi – like Sierra Leone, Gabon and Rwanda – offered proof that UHC in this area was feasible in low-income settings. However, in July 2011, in response to evidence of the government's mismanagement of aid and violation of human rights, the United Kingdom (UK) and the United States announced they would be cutting aid. The impact on health has been devastating, with regular drug stock-outs and a lack of essential medical supplies and a shortage of anti-retrovirals. The UK International Development Committee is currently conducting an enquiry into the development situation in Malawi, but in the meantime external funders are turning to civil society organisations to deliver for their communities.

Modelling the affordability and distributional implications of future health care financing options in South Africa
McIntyre D and Ataguba JE: Health Policy and Planning 27(Suppl 1), March 2012

South Africa is considering introducing a universal health care system. A key concern for policy-makers and the general public is whether or not this reform is affordable. In this paper, the authors consider three reform scenarios: universal coverage funded by increased allocations to health from general tax and additional dedicated taxes; an alternative reform option of extending private health insurance coverage to all formal sector workers and their dependants with the remainder using tax-funded services; and maintaining the status quo. Findings suggest that universal coverage is affordable and sustainable in the South African context, but would require substantial increases in public funding for health care. Universal coverage, if funded through general tax allocations and a dedicated surcharge on taxable income, would result in the most progressive financing incidence when compared with the status quo and an alternative financing reform of extending private insurance to all formal sector workers and their dependants. Such an approach to financing universal coverage would also achieve the most equal distribution of benefits from using health services across socio-economic groups when compared with other reform options.

Modelling the implications of moving towards universal coverage in Tanzania
Borghi J, Mtei G and Ally M: Health Policy and Planning 27(Suppl 1), March 2012

In this study, researchers developed a model to assess the impact of possible moves towards universal coverage in Tanzania over a 15-year time frame. The model estimated the costs of delivering public health services and all health services to the population as a proportion of Gross Domestic Product (GDP), and forecast revenue from user fees and insurance premiums. Findings indicated that expanded financial protection in Tanzania will have a significant effect on utilisation levels, especially for public outpatient care. Universal coverage, offering a minimum benefit package to the population through the two largest health insurance schemes, would require the share of government allocation to health to increase to 18% initially (driven largely by the health system strengthening costs required to support additional demand, combined with costs of expanding cover among the informal sector). Reserve funds from the National Health Insurance Fund (NHIF) could be used to finance universal coverage or additional resources could be generated through increases in the rate of value-added tax (VAT) or expanding the income tax base. The authors emphasise the fact that regulation of health care to control costs is paramount to the feasibility of universal coverage, as this affects the overall cost of expanding coverage as well as the extent of the revenue surplus available from the NHIF.

Social solidarity and willingness to tolerate risk- and income-related cross-subsidies within health insurance: Experiences from Ghana, Tanzania and South Africa
Goudge J, Akazili J, Ataguba J, Kuwawenaruwa A, Borghi J, Harris Band Mills A: Health Policy and Planning 27(Suppl 1), March 2012

In this paper, the authors examined individual preferences for willingness to pre-pay for health care and willingness to cross-subsidise the sick and the poor in Ghana, South Africa and Tanzania. Household surveys in the three countries elicited views on cross-subsidisation within health care financing. In South Africa and Ghana, 62% and 55% of total respondents, respectively, were in favour of a progressive financing system in which richer groups would pay a higher proportion of income than poorer groups, rather than a system where individuals pay the same proportion of income irrespective of their wealth (proportional). In Tanzania, 45% of the total sample were willing to pay for the health care of the poor. However, in all three countries, a progressive system was favoured by a smaller proportion of the most well off than of less well off groups. The three countries had different experiences of health insurance and this may have contributed to the above differences in expressed willingness to pay between countries. Building and ‘living with’ institutions that provide affordable universal coverage is likely to be an essential part of the learning process which supports the development of social solidarity.

Will increased funding for neglected tropical diseases really make poverty history?
Allen T and Parker M: The Lancet 379(9821): 1097-1098, 24 March 2012

In January 2012, The UK’s Department for International Development announced a fivefold increase in its support for programmes to control neglected tropical diseases (NTDs). However, the authors of this paper point to a growing body of research that highlights hazards associated with current modes of implementing NTD control strategies, including undermining already-fragile health care systems, facing serious logistical problems and medical risks, and contributing in administrative failure. They draw on fieldwork in Uganda and Tanzania to shows that the specific political, economic, and social contexts in which mass drug administration (MDA) programmes are rolled out profoundly affects the uptake of drugs for the treatment of some NTDs. Average drug uptake in 2010 was well below 50%, an issue which remains unaddressed. The authors call for governments to deal with NTDs in a sustainable way that will involve a range of factors, including behavioural change, and promote an integrated bio-social approach, with more adequate monitoring and surveillance.

11. Equity and HIV/AIDS

AIDS dependency crisis: Sourcing African solutions
Joint United Nations Programme on HIV/AIDS (UNAIDS): 2012

In this paper, UNAIDS argues that enhancing African ownership of the AIDS response will further the health gains made so far and will also further enhance economic growth. UNAIDS points out that only half of Africans living with HIV who are eligible for treatment are able to access it currently. African governments invest less on AIDS than would be expected, while external assistance dominates HIV investment in most countries in Africa, which destabilises the AIDS response. Africa should pursue a more balanced partnership with international partners in the AIDS response, according to the paper, using health insurance as a mechanism to channel health spending more efficiently and equitably. UNAIDS urges African governments to set up new industrial policies that can support local pharmaceutical industries. It argues that Africa can bridge the resource gap with strong political leadership, leveraging the strong economic growth, and by adopting innovative funding opportunities.

Antiretroviral outcomes in South African prisoners: A retrospective cohort analysis
Davies NECG and Karstaedt AS: PloS One 7(3), 7 February 2012

Little is known about antiretroviral therapy (ART) outcomes in prisoners in Africa. To address this gap, researchers conducted a retrospective review of outcomes of a large cohort of prisoners referred to a public sector, urban HIV clinic. A total of 148 inmates (133 male) initiated on ART were included in the study. By week 96 on ART, 73% of all inmates enrolled in the study and 92% of those still accessing care had an undetectable viral load. By study end, 96 (65%) inmates had ever received tuberculosis (TB) therapy with 63 (43%) receiving therapy during the study: 28% had a history of TB prior to ART initiation, 33% were on TB therapy at ART initiation and 22% developed TB whilst on ART. Nine (6%) inmates died, seven in the second year on ART. While inmates responded well to ART, there was a high frequency of TB/HIV co-infection. The authors recommend that attention should be directed towards ensuring eligible prisoners access ART programmes promptly and that inter-facility transfers and release procedures facilitate continuity of care. Institutional TB control measures should remain a priority.

Debating the World Bank Report on Fiscal Constraints: A return of the 90s?
Baker B: Global Health Check, 28 March 2012

In March 2012, the World Bank issued a report: ‘The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda’. The report, the author of this article argues, is not new because it represents a recurrent theme in the World Bank approach from the earliest days of the global AIDS pandemic – it’s not fiscally sustainable to treat people living with HIV in high-impact, low-resource countries – instead the world must focus on prevention measures. The author disagrees, and points out a number of significant flaws in the report. First, the report is already out of date since it relies almost exclusively on pre-2009 data and fails to take into account increased efficiencies in AIDS programming, which have been significant in the past several years. The World Bank has also ignored the exciting new research that shows that suppressive anti-retroviral therapy reduces the risk of onward transmission of HIV by at least 96%. Second, there is growing evidence, again ignored by the Bank, that even a moderate expansion of investments now in treatment scale-up and in diffusion of scaleable prevention methods like condoms and needle-exchange can have significant impacts on new infections and thus future treatment costs. Third, the Bank fails to use evidence to rally support for (unspecified) “prevention” activities and does not call for innovative global financing, like a financial transaction tax. Fourth, the report appears to neglect the economic and social benefits of a healthier population and to ignore some of the costs of premature deaths by focusing on fiscal costs of treatment, while ignoring the huge social and economic benefits of the survival of the vital age 25-45 cohort.

Don’t stop now: How underfunding the Global Fund to fight Aids, Tuberculosis and Malaria impacts on the HIV response
Podmore M, Mburu G and Nieuwenhuys BJ: International HIV/AIDS Alliance, 2012

In November 2011, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) announced that its next scheduled funding round was cancelled. This report draws on recently collected field data from numerous countries where the International HIV/AIDS Alliance operates to explain why AIDS funding crisis requires urgent action. The authors note that countries like Zambia and Zimbabwe have so far been making strong progress towards reducing HIV infections and AIDS-related deaths but this progress is now under threat. The cancellation of funds will seriously affect the scale-up of the worldwide HIV response and important existing services will be reduced or eliminated in the absence of urgent measures. They argue that the Global Fund is the best mechanism the world has for realising the possibility of a world without AIDS but can only do so with sufficient investment. They recommend that external funders and other stakeholders must act very quickly to maintain and scale up critical HIV services so that lives are not put at risk, particularly ensuring that interventions with the highest impact on the epidemic are supported. In addition, national governments must increase investment in their own HIV responses and in the implementation of national AIDS strategies.

Sexual behaviour of HIV-positive adults not accessing HIV treatment in Mombasa, Kenya: Defining their prevention needs
Sarna A, Luchters S, Pickett M, Chersich M, Okal J, Geibel S, Kingola N and Temmerman M: AIDS Research and Therapy 9(9), 19 March 2012

This study in Mombasa Kenya explored sexual behaviours of people living with HIV (PLHIV) who are not receiving any HIV treatment. Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships. Main risk factors associated with unsafe sex were found to be non-disclosure of HIV status, stigma and the belief that condoms reduce sexual pleasure. In conclusion, high-risk sexual behaviours were found to be common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. The authors urge government to identify and reach this population to provide health services.

The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland and Uganda
Lule E and Haacker M: World Bank, March 2012

In this report, the authors calculate and analyse the fiscal costs of HIV and AIDS for Botswana, South Africa, Swaziland and Uganda, interpreting the HIV and AIDS response as a long-term fiscal commitment, and including certain costs such as specific social grants that are not normally included in HIV and AIDS costing studies. From a microeconomic perspective, the authors calculate, for each country, the fiscal commitment that, under the parameters of the national HIV and AIDS programme, is incurred by a single HIV infection. Similarly, they calculate costs and savings associated with HIV and AIDS-related interventions, concluding that these costs can be substantial, nearly equal to GDP per capita (South Africa) up to 12 times GDP per capita (Uganda). On the macroeconomic level, they aggregate the costs incurred by new infections to track the evolving fiscal burden of HIV and AIDS over time. They found that newly incurred costs are generally lower than current spending, and that the fiscal burden of HIV and AIDS is declining over the projection period, perhaps reflecting a projected decline in HIV incidence. At the same time, the fiscal costs remain large, and increasingly reflect the success or failure of the HIV and AIDS programme in preventing new infections.

Uganda’s HIV rate increases from 6.4% to 6.7%
Plus News: 21 March 2012

Uganda's HIV and AIDS prevalence rate has risen slightly from 6.4% to 6.7% among adults aged between 15 and 49, according to the government’s recently released national AIDS Indicator Survey. HIV prevalence for women stands at 7.7%, with men at 5.6%. The Ministry of Health argues that the increase is small and is due to HIV-positive children growing up and entering the age bracket of 15 to 19 years old. However, activists are concerned that the lack of progress indicated by the new statistics is the result of gaps in the government's HIV prevention programmes, such as lack of supplies like condoms. They are also becoming increasingly concerned about risk compensation as a result of failing HIV prevention messages, especially since the survey found that just 28.1% of women and 31.4% of men aged between 15 and 19 used a condom during their last sexual encounter, dropping to 6.7% and 12.2% respectively among 30- to 39-year-olds. The full report is due for release in June 2012.

12. Governance and participation in health

Effects of household heads training on long-lasting insecticide-treated bed nets utilisation: A cluster randomised controlled trial in Ethiopia
Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M et al: Malaria Journal 11(99), 30 March 2012

Utilisation of long-lasting insecticide-treated bed nets (LLITNs) by under-five children has been reported as unsatisfactory in many sub-Saharan African countries due to behavioural barriers. Previous studies have focused exclusively on coverage and ownership of LLITNs, so to address this research gap, researchers examined the effect of skill-based training for household heads on net utilisation. The study included 22 villages in southwest Ethiopia, with totals of 21,673, 14,735 and 13,758 individuals at baseline, sixth and twelfth months of the project period. At the baseline survey, 47.9% of individuals in the intervention villages (which received training) and 68.4% in the control villages (which did not) reported that they had utilised a LLITN the night before the survey. At six months, 81% of individuals in the intervention villages and 79.3% in the control villages had utilised LLITNs. Among under-five children, net utilisation increased by 31.6% at six months and 38.4% at twelve months. The researchers conclude that household level skill-based training demonstrated a marked positive effect in the utilisation of LLITNs. The effect of the intervention steadily increased overtime. Therefore, distribution of LLITNs should be accompanied by a skill-based training of household heads to improve its utilisation.

Maternal and child health: Implementing the recommendations of the Commission on Information and Accountability
Munoz F and Seiter E: Health Diplomacy Monitor 3(2): 9-11, April 2012

This article evaluates progress in implementing the United Nation’s Global Strategy on Women and Children’s Health since it was released in September 2010. The Commission on Information and Accountability for Women’s and Children’s Health was created in December 2010 to oversee the implementation of the Global Strategy. Since then it has met with stakeholders twice and developed a strategic plan of action. Feedback from those meetings indicate that developing countries – in particular, African countries – face major obstacles in gathering birth and maternal mortality data. The future of the Commission remains uncertain, however, with stakeholders expressing skepticism about whether or not external funders will meet their commitments. In order to succeed in reducing maternal mortality, a combination of interventions is needed, including education on reproductive health issues; access to effective birth control and safe abortion; universal prenatal care; diagnosis and referral of high-risk pregnancies; a high percentage of births overseen by skilled attendants; and safe motherhood protocols for managing normal and high-risk births. However, reaching a consensus on which interventions should be funded is complicated, the article concludes, given the sensitive nature of maternal health issues, specifically family planning and safe abortion, which are opposed by conservatives.

Slippery slope in Southern Africa
Tiwana M: CIVICUS, 12 April 2012

Civicus argue that the Southern African Development Community (SADC) region is experiencing a major backslide in democratic freedoms. Recent restrictions on civil society in the region, whether through regressive laws, policies or vigorous persecution of activists, are argued to fly in face of the SADC treaty which calls upon its 14 members to uphold human rights and the rule of law and promote common political values through democratic, legitimate and effective institutions. The article cites examples from countries in the region, including from Zimbabwe, Malawi, Swaziland, Angola, DRC and South Africa.

State of civil society report 2011
CIVICUS: April 2012

According to CIVICUS, in 2011, the existing institutions of global governance failed to provide people-centred responses to the current global economic, social, political and environmental crises. Too often in key multilateral meetings and processes, the narrow national interests of states prevailed. The Durban climate change summit of 2011 (COP17) fell short of the decisive action required, as did the 2011 G20 meeting of the world’s most powerful economies. On the positive side was the launch of the new United Nations body, UN Women, as well as the Busan High-Level Forum on Aid Effectiveness, and many of the stances adopted by the UN Human Rights Council in Geneva, particularly during the Universal Periodic Review, its peer-reviewed assessment of human rights in UN member states. In Busan and in Geneva, the space guaranteed to civil society enhanced the credibility and quality of the process, and these procedures should be regarded as minimal standards that should be extended to other arenas. A predicament for both states and civil society alike is the fact that disconnected summits purport to address intertwined issues such as economic growth, development effectiveness, climate change and human rights in silos. Civil society organisations must combine to advocate for a multilateral system that has the reach and ambition to tackle connected challenges and the imagination to put global interests first.

The Global Health Security Initiative: Opportunities and challenges
Martinez MEC: Health Diplomacy Monitor 3(2): 11-13, April 2012

In December 2011, the Global Health Security Initiative (GHSI) celebrated its 10th anniversary with a ministerial meeting in Paris, France. This article chronicles the achievements of the Initiative in global health security, namely the development of globally common methods for the assessment of global health threats and risks, such as the H1N1 flu virus, and the mainstreaming of a multidisciplinary approach on health security. The Initiative has been involved in: setting up information-sharing networks, such as a contact emergency network for communication among health officials; the establishment of general guidelines for risk communications; the design of a ‘risk incident scale’ for global health emergencies; and the development of evidence-based research for policy making related to human decontamination. Although the Initiative is limited to only the eight countries, the network is working with the World Health Organisation to share the best practices with the broader global health community.

Using stakeholder analysis to support moves towards universal coverage: Lessons from the SHIELD project
Gilson L, Erasmus E, Borghi J, Macha J, Kamuzora P and Mtei G: Health Policy and Planning 27(Suppl 1), March 2012

The aim of this paper is to support all stakeholders who are developing or researching universal health care (UHC) reforms and who wish to conduct stakeholder analysis to support evidence-informed pro-poor health policy development. It presents practical lessons and ideas drawn from experience conducting stakeholder analysis around UHC reforms in South Africa and Tanzania, revealing that differences in context and in reform proposals generate differences in the particular interests of stakeholders and their likely positioning on reform proposals, as well as in their relative balance of power. It is, therefore, difficult to draw cross-national policy comparisons around these specific issues, the authors caution. Nonetheless, they argue that cross-national policy learning is possible with regard to choosing approaches to policy analysis and management of policy processes, but stakeholders should avoid generalisations when comparing UHC reform packages and should rather focus on how to manage the reform process within a particular context. The authors emphasise that stakeholder analyses can be used both to think through the political viability of new policy proposals and to develop broader political management strategies to support policy change.

13. Monitoring equity and research policy

Estimates of child deaths prevented from malaria prevention scale-up in Africa 2001-2010
Eisele TP, Larsen DA, Walker N, Cibulskis RE, Yukich JO, Zikusooka CM: Malaria Journal 11(93), 28 March 2012

In this study, the Lives Saved Tool (LiST) model was used to quantify the likely impact that malaria prevention intervention scale-up has had on malaria mortality over the past decade (2001-2010) across 43 malaria endemic countries in sub-Saharan African. The likely impact of insecticide-treated nets (ITNs) and malaria prevention interventions in pregnancy (intermittent preventive treatment [IPTp] and ITNs used during pregnancy) over this period was assessed. Results indicated that malaria prevention intervention scale-up over the past decade has prevented 842,800 child deaths due to malaria in the 43 countries, compared to a baseline of the year 2000. Over the entire decade, this represents an 8.2% decrease in the number of malaria-caused child deaths that would have occurred over this period had malaria prevention coverage remained unchanged since 2000. The biggest impact occurred in 2010 with a 24.4% decrease in malaria-caused child deaths compared to what would have happened had malaria prevention interventions not been scaled-up beyond 2000 coverage levels. ITNs accounted for 99% of the lives saved. The results suggest that funding for malaria prevention in Africa over the past decade has had a substantial impact on decreasing child deaths due to malaria. Rapidly achieving and then maintaining universal coverage of these interventions should be an urgent priority for malaria control programmes in the future, the authors argue. Successful scale-up in many African countries will likely contribute substantially to meeting Millennium Development Goal (MDG) 4 to reduce child mortality, as well as succeed in meeting MDG 6 (Target 1) to halt and reverse malaria incidence by 2015.

Improving influenza surveillance in sub-Saharan Africa
C Steffen, F Debellut, BD Gessner, FC Kasolo, AA Yahaya, N Ayebazibwe et al: Bulletin of the World Health Organisation 90(4): 301-305, April 2012

Little is known about the burden of influenza in sub-Saharan Africa. Routine influenza surveillance is key to getting a better understanding of the impact of acute respiratory infections on sub-Saharan African populations. To address this gap, a project called Strengthening Influenza Sentinel Surveillance in Africa (SISA) was launched in Angola, Cameroon, Ghana, Nigeria, Rwanda, Senegal, Sierra Leone and Zambia. It aimed to help improve influenza sentinel surveillance, including both epidemiological and virological data collection, and to develop routine national, regional and international reporting mechanisms. These countries received technical support through remote supervision and onsite visits. Consultants worked closely with health ministries, the World Health Organization, national influenza laboratories and other stakeholders involved in influenza surveillance. Working documents such as national surveillance protocols and procedures were developed or updated and training for sentinel site staff and data managers was organised. The main lesson emerging from SISA is that targeted support to countries can help them strengthen national influenza surveillance, but long-term sustainability can only be achieved with external funding and strong national government leadership.

Inside the black box: Modelling health care financing reform in data-poor contexts
McIntyre D and Borghi J: Health Policy and Planning 27(Suppl 1), March 2012

In this paper, the authors outline the process of developing country-specific spreadsheet-based models to explore the financial resource requirements of health system reform options in South Africa and Tanzania. Their intention is to provide guidance for analysts who wish to develop their own models, and to illustrate, with reference to the South African and Tanzanian modelling experience, how one has to adapt to data constraints and context-specific modelling requirements. They found that using modelling to assess the financial feasibility and implications of alternative health system reform paths can be of great value in supporting evidence-informed policy-making. Developing one's own spreadsheet model has a number of advantages, including allowing greater flexibility to reflect specific country circumstances and requiring the analyst to carefully evaluate the assumptions built into the model. A pragmatic approach should be adopted in data scarce contexts, but all assumptions should be made explicit and justified. A major advantage of the modelling process is that it can highlight priority areas for improved data collection.

Lives saved from malaria prevention in Africa: Evidence to sustain cost-effective gains
Korenromp EL: Malaria Journal 11(94), 28 March 2012

Recent estimates of malaria-attributable under-five deaths prevented using the Lives Saved Tool (LiST) confirm the substantial impact and good cost-effectiveness that insecticide-treated nets (ITNs) and indoor residual spraying have achieved in high-endemic sub-Saharan Africa. ITNs, the author argues, have an additional indirect mortality impact by preventing deaths from other common child illnesses, to which malaria contributes as a risk factor. As conventional ITNs are being replaced by long-lasting insecticidal nets and scale-up is expanded, additional lives may be saved, and these figures may be calculated using LiST. LiSt combines key indicators for time trend analysis with dynamic transmission models, fitted to long-term trend data on vector, parasite and human populations over successive phases of malaria control and elimination. The author argues that policy makers and programme planners should use LiST as a planning tool, but notes that this will require enhanced monitoring and evaluation of the national programme and its impact.

The time is right for a global genomic database for micro-organisms
Schlundt J: Health Diplomacy Monitor 3(2): 2-3, April 2012

Because of increased global trade and travel, micro-organisms now travel globally faster than before. To track these microorganisms, whole genome sequence analysis is the ideal instrument, but to make effective use of the results a global genomic database for microorganisms is needed. In this editorial, the author argues that the introduction of genomic testing represents a giant step forward for developing countries in the fight against infectious diseases. He compares the introduction of this new technology to the spread of cellphones, which made expensive and exclusive landlines unnecessary and made communication possible for everybody. Similarly, identification and typing of microorganisms will suddenly become technically and economically feasible, enabling control and prevention efforts previously missing in many regions. At the same time, developing countries moving to use this technology will not need to develop expensive, specialised lab systems, since microbiological lab work will basically be the same for TB, enterobacteria, viruses, etc. The author calls on developing countries to participate in this process from the start.

14. Useful Resources

A guide to using the Protocol on the Rights of Women in Africa
Equality Now and the Movement for Solidarity for African Women's Rights (SOAWR): 2012

The Protocol on the Rights of Women in Africa is renowned for its strong and comprehensive provisions on women’s rights. For the first time in international law, it explicitly sets forth the reproductive right of women to medical abortion when pregnancy results from rape or incest or when the continuation of pregnancy endangers the health or life of the mother. This Guide provides step-by-step guidance for using the Protocol at local, national, and regional levels. It explains how to bring women’s rights abuses that violate the Protocol before domestic courts and regional justice mechanisms like the African Court on Human and Peoples’ Rights and analyses key cases related to women’s rights decided by the African Commission. The Guide also provides activists with more general strategies for the popularisation and domestication of the Protocol to protect the rights of African women and girls and ensure they have complete access to justice.

Community photography: Picha Mtaani national peace building initiative and exhibition tour
Kenya: 2008-2012

The Picha Mtaani national peace building initiative and exhibition tour contains photographs of Kenya’s 2007/8 post election violence, which have been displayed throughout Kenya since 2008. The exhibition has enjoyed tremendous support from the Kenyan public, as evidenced by the participation of over 700,000 young people, the submission of 30,000 completed questionnaires and the subsequent signing of more than 61,000 peace pledges during the exhibition series. This project involving community photography may be of interest to community photographers looking for ideas. Visit the address given above, as well as the following flickr site: http://www.flickr.com/photos/pichamtaani/6440573085/in/photostream/lightbox/

Health Policy & Systems Resources
Consortium for Health Policy & Systems Analysis in Africa (CHEPSAA)

The official website for the EU-funded Consortium for Health Policy & Systems Analysis in Africa (CHEPSAA) has just been launched. CHEPSAA is working with universities in Africa and Europe to strengthen teaching, research & policy networking activities for the rapidly emerging field of health policy and systems research and analysis. The new website collates resources and information on health policy and systems research for teachers, researchers, students, policy-makers & decision-makers, including recommended readings selected by experts; open access teaching materials; course & event news and more.

Launch of new Asia Pacific health equity website: HealthGAEN

The Asia Pacific network of HealthGAEN has just launched its new website. It is intended to function as a tool for information sharing and helping to keep people connected around issues affecting health inequities, particularly in the Asia Pacific region, rather like EQUINET in east, central and southern Africa. AP-HealthGAEN is a partnership of researchers, policymakers and non-government organisations across Asia Pacific - a region that stretches from Mongolia in the north to New Zealand in the south and from Kiribati in the east to India in the west. The network analyses the various ways in which health equity is impacted through the intersection of the social, environmental, health-care and development agendas, drawing on a range of disciplinary expertise and aims to build action on four fronts: collaborative learning and action; cross border action; cross sectoral action; collaborative learning and action.

15. Jobs and Announcements

Call for submissions: African writing competition: Kwani Trust
Deadline: 12 August 2012

To celebrate the African novel and its adaptability and resilience, Kwani Trust announces a one-off new literary prize for African writing. The Kwani Manuscript Project calls for the submission of unpublished fiction manuscripts from African writers across the continent and in the Diaspora. The top three manuscripts will be awarded cash prizes. In addition Kwani will publish manuscripts from across the shortlist and longlist, including the three winning manuscripts, as well as partnering with regional and global agents and publishing houses to create high-profile international publication opportunities. The word count for submissions is 60,000-120,000 words, and submissions should be adult literary or genre fiction and written in English or variants of the language. The manuscript must be unpublished, although Kwani will accept previously published submissions if circulation has been under 500 copies and limited to one national territory. Eligible participants should have at least one parent born in an African country who holds citizenship of that country.

People’s Health Assembly programme information
6-11 July 2012, Cape Town

The People’s Health Assembly (PHA), organised by the People's Health Movement (PHM), is a global event bringing together health activists from across the world to share experiences, analyse global health situation, develop civil society positions and to develop strategies which promote health for all. It will look at forms of action to address identified challenges and build capacity among health activists to act. It is an opportunity for PHM as a whole to reflect on the global struggle, to review and reassess, to redirect and re-inspire. 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. The programme is now available at http://www.phmovement.org/en/pha3/programme

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

SEYCOHAIDS 2012 is the largest international gathering for young people on HIV and AIDS in the Eastern and Southern Africa region, where young researchers, policy makers, activists, educators and people living with HIV will be able to link with people in other countries and meet to share and learn about HIV prevention methods, treatments, care policies and programmes relating to HIV and AIDS in Africa. The broad objectives for the Conference are to: ensure effective and meaningful youth participation in international AIDS response; identify gaps and challenges in government policies in providing youth-friendly HIV and AIDS services; develop regional and country-level strategic programmes for youth and HIV and AIDS; identify and build the capacity of new and emerging youth leaders for the AIDS response to ensure sustainability of youth initiatives at the national, regional and international levels; sustain adult-youth partnerships and dialogue; develop the Southern and Eastern Africa youth network on HIV and AIDS; develop country specific youth networks on HIV and AIDS; establish funding mechanisms for regional and country youth networks; and monitor government and donor commitments to youth and HIV and AIDS. Applicants must be no older than 35 years old at the time of the application.

Second Global Symposium on Health Systems Research: Beijing, China: 31 October-3 November 2012
Registration opens: 1 May 2012

The Symposium will focus on the science to accelerate universal health coverage around the world. It will cover three main themes: knowledge translation; state-of-the-art health systems research; and health systems research methodologies. There will also be three cross-cutting themes: innovations in health systems research; neglected priorities or populations in health systems research; financing and capacity building for health systems research.

Third South African Tuberculosis Conference: 12-15 June 2012, Durban, South Africa
Registration deadline: 18 May 2012

The Third South African Tuberculosis Conference will build on the momentum of the previous TB conferences and give communities an opportunity to assess progress towards reaching TB/HIV targets. The theme for the Conference is “Reaching the target”.

United Nations Conference on Sustainable Development 2012 (Rio+20)
20-22 June 2012: Rio De Janeiro, Brazil

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.

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