Walk into many international meetings on health in Africa and you will hear discussion on development aid, and international support for programmes to respond to major diseases. The Global Forum for Health Research (Forum 2012) held in Cape Town had a different focus: it provided a platform for how countries across all income groups could invest in research and development (R&D) as a source of innovation to meet their health needs and as an investment in development and job creation.
Held under the title “Beyond Aid: Research and Innovation as key drivers for Health, Equity and Development”, Forum 2012 was organised by the Coalition on Health Research for Development (COHRED), which merged in 2011 with the Global Forum on Health Research (GFHR).
Dr. Francisco Songane, Chair of the Steering Committee for Forum 2012, reflected “There is a misconception that developing countries rely on international aid. National Governments may find it hard to meet targets for R&D spending, but they remain the major funders of research”.
Naledi Pandor, South African Minister of Science and Technology and co-host of the Forum confirmed this and the power of investment in R&D. She observed that “the ability to cycle between the laboratory, clinic and field site provides a very powerful platform for translational research”. Investing in this link in South Africa gave the country an advantage over countries that focused on the basic sciences or clinical research, but not both. According to Minister Pandor, this positions South Africa to respond to health need and to emerging markets in Africa, to advance African-led innovation in drugs, diagnostics, vaccine development and other product-oriented innovation, including in relation to gene therapy, cell therapies and tissue engineering.
Dr Songane, Dr Carel Ijsselmuiden, executive director of COHRED, and other speakers at the Forum raised that achieving these synergies between innovation and economic and social benefit means that “we, in the health sector, need to open the doors of our community, and actively work with the other sectors”. They proposed that we need to shift from an aid paradigm to negotiating investment in and benefit from R&D in health.
The Pharmaceutical Manufacturing Plan for Africa, adopted by the Summit of the African Union in 2007, was raised as a promising example, with its emphasis on a coordinated approach to local medicines production based on countries needs. The research agenda to support the plan seeks to produce evidence on the productive capacities, intellectual property, political, geographical, economic and financing issues that affect the manufacture of medicines, to inform the necessary interactions across multiple government ministries, regulatory authorities, financial investors and private and public research, development, teaching and healthcare delivery institutions.
The Forum also raised issues of equity, at both global and regional levels.
Firstly there are inequities in the current distribution of both capacities to invest and in the sharing of benefits from investments in R&D. For example, Carel Ijsselmuiden pointed to a recent report on the impact of sequencing of the human genome. This report demonstrated that the potential economic return on the initial investment had gone to the global north, rather than the south, where there was no capacity to build on knowledge produced by the project. "The south has to develop the capacity to compete in this type of domain," he said. "The continuing emphasis on aid may stop us seeing this new picture of the world that is emerging."
‘Beyond aid’ should be taken to not mean ‘beyond solidarity and fairness’. In the past the GFHR has drawn attention to the highly uneven distribution of resources for health research between high and low income countries. At regional level, Forum delegates in various sessions pointed, therefore, to the need for collaboration and pooling of resources and knowledge within and across regions, to avoid a widening gap. The technological possibilities for such collaboration are growing. As stated by Dr Songane, “new communication technologies are making up for a lack of infrastructure and resources. The possibilities are exciting – virtual collaboration, sharing of data, and the use of mobile health technology to reach even remote rural areas”.
At global level, a Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG) established by the World Health Assembly (WHA) has in 2010 been examining the current financing and coordination of R&D globally, particularly in relation to neglected diseases and the needs of developing countries. In its report (www.who.int/phi/CEWG_Report_Exec_Summary.pdf) the CEWG proposed minimum shares of gross domestic product to be set for government funded health research and a global convention to address issues of equity and sustainability in financing for R&D. Minister Pandor welcomed new models, like UNITAID’s patent pool for AIDS medicines, which allows generics producers to make cheaper versions of patented medicines by enabling patent holders to license their technology in exchange for royalties.
Raising a second dimension of equity, young researchers at the Forum raised in a communiqué that work on R&D must be framed as a public responsibility, given that health is a human right, and must thus reach and benefit all communities. Youth and other delegates raised that communities’ local or indigenous knowledge should be respected, protected and integrated within research and knowledge systems, and innovations developed in ways that ensure fair partnerships, sharing of evidence and benefit, and collective, social entrepreneurship.
Further, in a session on the Equity Watch work in EQUINET, presenters from research institutions, Ministries of Health, regional and international agencies in east and southern Africa pointed to the need to overcome inequities in access to already known technologies for health, including the housing, food, water, primary health care and other key social determinants of survival. Their country and regional analysis highlighted economic growth paths that raise inequity in access to these resources, such as through unplanned urbanisation, insecure employment, or poor investment in small holder farming. They also presented evidence of public policies and measures within the health system and in other sectors such as education that close the gap.
Forum 2012 called for a different mindset, for innovation and research to be given more attention, given their role as drivers of health, equity and development. Discussions in the Forum raised that equity in health, while desired, cannot be assumed to be an outcome of research and innovation. It is also not adequately addressed by aid. The policies and measures for ensure equity as an outcome- whether through fair sharing of benefits, solidarity and collaboration on capacities and resources, inclusion of communities and their knowledge, or equitable access to existing technologies for health - need to be explicitly negotiated, implemented and monitored.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: firstname.lastname@example.org. For more information on the issues raised in this op-ed please visit http://www.forum2012.org/presentations/ and www.equinetafrica.org
2. Latest Equinet Updates
This report was commissioned by the Regional Network for Equity in Health in East and Southern Africa (EQUINET). It highlights areas of concern for gender equity in health in East and Southern Africa (ESA), based on a review of published literature. The report provides examples of key areas of gender equity in health drawn from the literature. It raises dimensions of gender equity in health in relation to the contexts for and social determinants of health; in health outcomes; in health systems and options for acting on gender equity in health. The report does not provide a systematic analysis using household data and is not a comprehensive assessment of all dimensions of gender equity. Rather by presenting key dimensions of gender inequity in health in the region, it raises the argument for more systematic audit and mainstreaming of gender within health systems in ESA countries.
Two recent global initiatives – the United Nations Secretary General’s Global Strategy on Women’s and Children’s Health (Every Woman Every Child, EWEC) and the Global Plan for Elimination of new HIV Infections among Children by 2015 and Keeping Mothers Alive (Global Plan) – recognise the importance of strong health workforces and call for additional commitments on human resources to be made. This consultation cohosted by EQUINET seeks to gather stakeholders from within and beyond the region to action-oriented movements to strengthen health workforces and improve access to good practice in addressing barriers to improving the numbers, distribution and quality of the health workers needed for maternal and child health. The meeting will share experiences and best practices in how the health worker needs of the EWEC and the Global Plan fits with the overall human resource planning, the promising practices underway and unresolved issues that need to be addressed. Please email the address below for further information.
Convened by EQUINET, in association with the ECSA Health Community and IDRC Canada, this session presented evidence and experience from work carried out in 2010-2012 in five countries 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. This report summarises the presentations and issues raised at the session.
In 2012 EQUINET is initiating a three-year policy research programme to implement case study research on global health diplomacy in east and southern Africa (ESA). Working with government officials in health and diplomacy, with technical institutions, civil society and other stakeholders in ESA countries, we will examine the role of health diplomacy in addressing selected challenges to health and equitable health systems and use the learning and evidence to inform African policy actors and stakeholders. We will feed into regional processes, including the Strategic Initiative of Global Health Diplomacy co-ordinated by the East Central and Southern Africa Health Community. A review meeting on the case study design is being held in Johannesburg, South Africa on June 4-5 2012.
From 26-28 April 2012, EQUINET held a regional methods workshop in Cape Town, South Africa. It gathered the lead institutions of country teams in the Equity Watch work, the EQUINET steering committee, regional and international agencies and networks involved in work on health equity. The workshop aimed to: provide training on equity analysis and discuss future approaches to capacity building on equity analysis; review Equity Watch work at country level and the learning and implications from the work for future monitoring of health equity within countries; and review and discuss the draft regional Equity Watch and the follow up and dissemination. Equity Watch presentations were delivered at the meeting for five of the countries in east, central and southern Africa included in the EQUINET network, namely Kenya, Uganda, Zambia, Zimbabwe and Mozambique. Results were mixed from the various countries, indicating success in improved aggregate health in most countries, some closing of rural-urban disparities in health, but widening social and economic inequalities in health and the social determinants of health. Delegates argued that aggregated data obscured inequities in health in the region. They identified decreases in public health spending as a major problem in giving ministries the leverage over other sources of spending on health. They also called for ‘mainstreaming’ health equity into the national and regional health agendas, as well as for the dissemination of the Equity Watch results at country and regional level to all stakeholders, identifying champions who will take Equity Watch forward, putting effective monitoring and evaluation in place to measure progress in health equity in the region, and conducting district-level analysis (so far Equity Watch analysis has been on regional and national levels only). Presentations were also given on various aspects of equity analysis, such as disaggregating health expenditure, analysing the social determinants of health equity and universal health coverage and linking equity analysis to the Millennium Development Goals.
3. Equity in Health
The aim of this study was to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage. Two nationally representative cross-sectional households surveys conducted in 2003 and 2007 were the main sources of data. A comprehensive analysis of the entire health system was conducted including the public sector, private-not-for-profit and private-for-profit sectors. The three sectors recorded similar levels of pro-rich distribution in 2003, but in 2007, the private-not-for-profit sector was pro-poor, public sector benefits showed an equal distribution, while the private-for-profit sector remained pro-rich. Larger pro-rich disparities were recorded for inpatient compared to outpatient benefits at the hospital level, but primary health care services were pro-poor. Benefits were distributed on the basis of ability to pay and not on need for care. In conclusion, the Kenyan health sector is clearly inequitable and benefits are not distributed on the basis of need.
Previous studies have reported large socioeconomic inequalities in mortality from conditions amenable to medical intervention, but it is unclear whether these can be attributed to inequalities in access or quality of health care, or to confounding influences such as inequalities in background risk of diseases. In this study, researchers hypothesised that, as compared to non-amenable causes, inequalities in mortality from amenable causes are more strongly associated with inequalities in health care use and less strongly with inequalities in common risk factors for disease such as smoking. Cause-specific mortality data for people aged 30-74 years were obtained for 14 countries, and were analysed by calculating age-standardised mortality rates and relative risks comparing a lower with a higher educational group. In most countries and for most amenable causes of death substantial inequalities in mortality were observed, but inequalities in mortality from amenable causes did not vary between countries in patterns that are different from those seen for inequalities in non-amenable mortality. As compared to non-amenable causes, inequalities in mortality from amenable causes are not more strongly associated with inequalities in health care use. Inequalities in mortality from amenable causes are also not less strongly associated with common risk factors such as smoking. The authors call for further research to find the causes of socio-economic inequalities in mortality from amenable conditions.
The 2011 Update identifies and discusses 159 different health equity activities and 79 sets of recommendations from local, state, national, and international reports. It notes that many of the recommendations focus on a wide range of areas, including early childhood investment, education, lifestyle, housing, transportation, the environment, employment and community and interagency collaboration. This breadth of topics reflects the growth in “Health in All Policies” thinking and analysis among community groups and governments at all levels, calling for each sector to contribute to the quality of the nation's health. The Update recommends actions to increase awareness of health inequities and the social determinants of health, as well as advocacy and leadership for health equity and social justice. A health equity-oriented approach should emphasise community empowerment, increasing collaborative partnerships with all sectors and the need to coordinate and utilise research and outcome evaluations more effectively.
The current over-arching development framework of the MDGs expires in 2015. Any plans for SDGs coming out of Rio+20 must be fully integrated into the global overarching post-2015 development framework, argues Beyond 2015. To develop SDGs and the post-MDG development framework in parallel would be both inefficient and short-sighted, and could lead to a number of negative scenarios. Principles of participation, accountability, equality and non-discrimination must cut across any post-2015 framework to ensure outcomes which are effective, just and sustainable. Principles of Agenda 21 should similarly be embedded throughout. To illustrate this, Beyond 2015 have identified four principles which must be the foundation for any guidance coming out of Rio+20 on a future development framework: holistic, inclusive, equitable and universally applicable. Fundamentally, any global development framework must be based on, and fully ensure, equal enjoyment of all human rights for all people.
More than 3,000 delegates from approximately 120 countries assembled at the 13th World Congress on Public Health in Addis Ababa from the 23rd to 27th of April 2012. In this statement, delegates re-affirm their commitment to international agreements enshrining health as a human right. They also pledge to promote innovative research to generate evidence on the social determinants of health and health equity, as well as advocate for: evidence-based policy; making health equity an integral part of policy and development; equitable access to high quality health services; and fair trade in all commodities that affect human health. The Federation further intends to strengthen partnerships and networks to take common action on global public health priorities, share experiences and help build capacity.
World Health Statistics 2012 is the World Health Organisation’s annual compilation of health-related data for its 194 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets. In this edition it also includes highlight summaries on the topics of non-communicable diseases, universal health coverage and civil registration coverage. The report notes a decrease in child mortality, increased vaccination coverage, while worldwide obesity prevalence almost doubled between 1980 and 2008. In the last 20 years, maternal deaths have been reduced by almost half, but the mortality burden is extremely uneven, and remains high in sub-Saharan Africa, where 500 women out of every 10,000 die in childbirth.
4. Values, Policies and Rights
This study aimed to investigate the contribution made by health policy analysis institutes in low- and middle-income countries to health policy agenda setting, formulation, implementation and monitoring and evaluation; and assess which factors, including organisational form and structure, support the role of health policy analysis institutes in low- and middle-income countries in terms of positively contributing to health policy. Six case studies of health policy analysis institutes in Bangladesh, Ghana, India, South Africa, Uganda and Vietnam were conducted including two NGOs, two university and two government-owned policy analysis institutes. Some key messages merged. Under the right conditions, health policy analysis institutes can play a positive role in promoting evidence-informed decision making in government. Factors critical in supporting effective policy engagement include: a supportive policy environment, some degree of independence in governance and financing, and strong links to policy makers that facilitate trust and influence. Motivation and capacity within government to process and apply policy advice developed by a health policy analysis institute was found to be key to the institute’s ultimate success.
The current system for the research and development (R&D) of new medicines does not adequately meet the needs of the majority of the world's population, argue the authors of this paper. There is a lack of new medicines for the “neglected diseases”, namely those that primarily affect populations with little purchasing power, and therefore offer an insufficient incentive for industry to invest in R&D. Despite the emergence of many new approaches to generating R&D that meets the needs of poorer populations, efforts remain ad hoc, fragmented, and insufficient. The authors discuss how an R&D treaty could complement and build on existing initiatives by addressing four areas where the system remains particularly weak: affordability, sustainable financing, efficiency in innovation, and equitable health-centered governance. They argue that effective tools for global governance are required to generate medical R&D as a global public good, based on the understanding that a politically and financially sustainable system will require both fair contributions from all, and fair benefit-sharing for all.
This book focuses on how health policy is developed nationally and globally, clearly explaining the key concepts from political science with examples. This edition is fully updated to reflect new research and ways of thinking about the health policy process. The book covers a range of topics: health policy analysis; power and policy making; public and private sector; agenda setting; government roles in policy; interest groups and policy; policy implementation; globalisation and policy process; policy research and evaluation; and doing policy analysis. It is intended as a resource for students of public health and health policy, public health practitioners and policy makers.
The World Health Organisation's Commission on Social Determinants of Health has stated that health inequities result from inequities in power, money, and resources, which in turn are based on a combination of unfair economic arrangements, poor policies and programmes and bad governance. In other words, a focus on health equity should shift to the causes of the causes. According to this article, putting health equity at the heart of policy making is a perfectly feasible goal. While there is fierce debate over economic policy in the face of huge debts faced by rich countries, with some economists calling for economic growth and others calling for reduced deficit spending, the criterion of success seeming to be a return to growth of gross domestic product (GDP). The author argues here that what is actually required are broader measures of social and economic progress than simply GDP. He calls for examination of the effects of economic policy choices on the lives people are able to lead, and hence the likely effect on health equity. When governments cut social expenditures, the effect is greatest on those at the lower end of the social hierarchy, namely those who are most dependent on cash and in-kind government expenditures. It should be of the highest priority to ensure that government policies do not unfairly increase avoidable health inequalities.
Global crises not only impact the economy and people's livelihoods, they also unsettle basic ideas and assumptions about the meaning and drivers of development. This collection of theoretical and empirical studies contributes to the global debate about the substance and politics of policy change three years into the 2007-2008 crisis. The authors examine the challenges and dynamics involved from the perspective of development and developing countries, engaging with some of the most pressing and contested issues. To what extent does the crisis provide an opportunity for moving away from the doctrines and policies that reinforced inequality and vulnerability? What new directions in policy, especially social policy, are required, and are developing countries moving in such directions? Are social forces and political coalitions supportive of transformative change able to mobilise? While the political underpinnings of policy change conducive to social reform - contestation, social mobilisation and coalition politics - are energised in the context of crises, the book shows that the nature of demands and the responsiveness of elites can vary considerably.
Member states at the World Health Assembly (WHA) was held from 21-26 May 2012 in Switzerland supported the concept of universal health coverage as an indispensable precondition for sustainable human development and a fair society. Some of them presented their experiences in implementing universal access to healthcare. Among the tools suggested were mainstreaming health in all national policies, sharing costs between public and private sectors, and offering subsidies and health insurance. Member States expressed their support for a stronger WHO as the organisation has a critical role to play in prevention, equitable access and efficiency in public health.
5. Health equity in economic and trade policies
According to this report, Africa’s economic outlook is positive in some respects, as the continent is home to seven of the world’s fastest-growing economies, with 70% of Africa’s population living in countries that have averaged economic growth rates in excess of 4% over the past decade. However, the report also records that most countries are not on track to achieve the Millennium Development Goals by 2015, flagging slow progress in areas such as child nutrition, child survival, maternal health, and education. The need for equitable growth is all the more critical, the report states, because of Africa’s profound demographic shift towards youth, as well as high levels of population growth. It calls for a greater focus by policymakers on jobs, justice and equity to ensure sustainable, shared growth that benefits all Africans. Failure to generate equitable growth could result in rising levels of youth unemployment, social dislocation and hunger. Africa’s governments and development partners must urgently draw up plans for a big push towards the 2015 Millennium Development Goals, the report says.
According to this booklet, media has a crucial role to play in shaping the intellectual property (IP) rights reform agenda in East Africa. As far as IP issues are concerned, CEHURD makes a number of recommendations. Media should aim to build their own capacity to understand IP issues, which tend to be technical and dynamic. It is important to understand the World Trade Organisation system and how it functions, as well as the ongoing negotiations, and to assess which position is in the best interest of Uganda and the region. The media should also follow ongoing policy and legislative processes and report and evaluate them at every stage. They should show support for progressive decisions by government actors in the negotiations, generate community support to promote social and economic change, and persuade the public and Parliament to demand that the president and Cabinet act in public and national interest. Media can further play a role in empowering ordinary citizens through civic education, information and mobilisation to participate more directly in the discussion and debate of ongoing IP reforms and their impact the different aspects of social life.
Health activists working in Kenya have welcomed the April 2012 decision by the Kenyan High Court, which ruled that that the country’s Anti-Counterfeit Act 2008 was ‘vague’ and could undermine access to affordable generic medicines. The ruling means that Parliament will now have to review the Act and amend sections that confuse generic medicines with counterfeits and remove ambiguities that may result in arbitrary seizures of generic medicines under the guise of fighting counterfeits. The organisations signing this joint statement have vowed to press for those changes to protect access to generic medicines. They hope this ruling will set a positive precedent for the East Africa region as other countries in the region are considering anti-counterfeiting laws that may threaten generics.
The High Court of Kenya has ruled that the country’s 2008 Anti-Counterfeit Act was too ‘broad’ and could interfere with the flow of legal generic medicines to patients. The landmark ruling stated that ‘the Act is vague and could undermine access to affordable generic medicines since the Act had failed to clearly distinguish between counterfeit and generic medicines.’ High Court Judge Mumbi Ngugi called on Kenya’s Parliament to review the Act and remove ambiguities that could result in arbitrary seizures of generic medicines under the pretext of fighting counterfeit drugs. She also said that intellectual property rights should not override the right to life and health. She specifically found that Section 2 (definition of counterfeiting), section 32 (offenses) and Section 34 (Powers of the Commissioner to seize suspected counterfeit Goods) could severely limit or threaten access to affordable and essential drugs including generic medicines for HIV and AIDS and therefore infringed the right to life, dignity and health of the three Petitioners (all people living with HIV/AIDS) under the Constitution of Kenya, 2010.
In this brief, the Centre for Health Human Rights and Development (CEHURD) argues that anti-counterfeit measures are not an appropriate policy measure for curtailing the spread of substandard and falsified products, including medicines. The likely impact of the draft EAC Anti-Counterfeit Bill (2010) will be huge implementation costs through monitoring and settling international trade disputes. In addition, intellectual property rights (IPR) border controls and criminalising possession and trade in IPR infringing goods deters overall trade, in both IPR infringing goods and non-infringing goods. CEHURD notes that IPR-related “anticounterfeiting” action in the form of confiscated shipments of generic medicines reveals a pro-IPR bias and is being used to disrupt the flow of generics to developing countries instead of addressing more important issues of quality, safety and efficacy of generic medicines. The brief highlights the importance of distinguishing between generics, substandard medicines and counterfeit medicines. The TRIPS Agreement uses the term “counterfeit” only in the context of criminal trademark infringements that are wilful and on a commercial scale. CEHURD argues that there is a critical need to find legislative and policy approaches that would reduce the spread of such illicit, unregistered, and unsafe products without hindering access to good quality, safe and efficacious medicines - particularly legitimate and affordable generics of assured quality.
This article provides a local legal analysis of the ruling from the Kenyan High Court case in April 2012, where the judge found the Kenya Anti-Counterfeit Act was unconstitutional in hindering access to generic medicines, thereby undermining public health needs and the right to health of all Kenyans. The judge recommended the State reconsider and appropriately amend section 2 of the Anti-Counterfeit Act in a manner that ensures that the State fulfils its obligations to ensure that Kenyans have access to the highest attainable standard of health. The author of this article questions the usefulness of the Anti-Counterfeit law, arguing that the existing legal framework in Kenya was sufficient for enforcing intellectual property rights. He asks why Kenyan taxpayers should be paying for the implementation of this law as well as for the costs of running the Anti-Counterfeit Agency.
Uganda’s 2009 Industrial Property Bill needs to be reviewed before it is enacted into law, according to this brief by the Centre for Health Human Rights and Development (CEHURD). The review is needed to make full and maximum use of the flexibilities available in the TRIPS Agreement in order to guarantee public health, particularly access to essential medicines, for all Ugandans. CEHURD argues that, since Uganda is classified as a less-developed country, it is free to exploit all the flexibilities the TRIPS Agreement offers, and is required to adopt only the minimum levels of intellectual property rights (IPR) protection. The current bill contains unnecessary IPR protection over and above the minimum required by the TRIPS Agreement, and does not fully utilise flexibilities, CEHURD argues. A revised Industrial Property Act should promote Uganda’s public health interests by aiming to: develop the capacity at national level for production of generic medicines; allow the widest possible scope for parallel importation; adopt a simple and expeditious procedure for compulsory licensing and government use order; and allow extensive flexibility for scientific research and regulatory approval exceptions.
In this brief, the Centre for Health Human Rights and Development (CEHURD) outlines the current legislative environment affecting intellectual property (IP) rights in Uganda. The brief also considers the implications of the Industrial Properties Bill on the right to access essential medicines, a proposed piece of legislation that CEHURD argues will undermine efforts to manufacture generics in Uganda. It unnecessarily requires Government to consult the patent owner before producing generics for the public sector. It further requires applicants for a “compulsory license” to go through the lengthy court processes, yet procedures for granting such a licence should be simple and expeditious. Due to a lack of sufficient knowledge at the population level as well as Uganda’s weak negotiating position vis-à-vis other countries and negotiating blocs, CEHURD argues that the current laws and draft laws are not taking advantage of the TRIPS flexibilities, which would allow Uganda to fast track the supply essential medicines to the public sector.
There is a pressing need for Africa to bolster its pharmaceuticals industry, but it also requires the right policy framework, argues the author of this article. With limited initial capacity, countries need to be prudent about which drugs are developed. Different countries have different needs, and selection must be made through dialogue between government ministries, pharmaceutical companies, and local drug regulatory authorities. Good regulation is crucial, yet could prove most challenging. Many African states have patchy regulatory systems for quality assurance and little means to ensure drugs testing follows ethical guidelines. They will need to create and enforce watertight regulations to ensure that substandard or ineffective medicines don’t flood the market. But the development of a robust pharmaceutical industry in Africa can’t, and shouldn’t be, uniform, the author argues. States are extremely varied in their scientific ability, level of manufacturing regulation, and financial capacity to invest. She proposes that some countries could first set up a system to simply manufacture drugs based on existing formulations, before progressing to research and development. Others with more advanced biotech industries, such as South Africa, will have the know-how to innovate in drug development.
6. Poverty and health
Exposure to household air pollutants released during cooking has been linked to numerous adverse health outcomes among residents of rural areas in low-income countries. This study describes the roles of local vendors, behaviour change, promotional incentives, and integration of cookstoves with household water treatment interventions to motivate adoption of locally-produced, ceramic cookstoves (upesi jiko) in an impoverished, rural African population. The project was conducted in 60 rural Kenyan villages in 2008 and 2009. During an initial, eight-month assessment period in 10 villages, 159 (75%) of 213 upesi jiko sales occurred in five villages where vendors received behaviour change training. The combined strategy was found to effectively motivate the adoption of cookstoves into a large number of households. The mobilisation and training of local vendors as well as appropriate promotion and pricing incentives created opportunities to reinforce health messages and promote the sale and installation of cookstoves. The authors conclude that additional applications of similar strategies will be needed to determine whether the strategy can be exported equitably and whether reductions in fuel use, household air pollution, and the incidence of respiratory diseases will follow.
Health experts have pointed out that African countries with good maternal health statistics are generally those that have long-term political stability, like Botswana, arguing that this shows that stability is a fundamental basis for development. Generally, maternal health is neglected in public health, as most African countries focus on the eradication of poverty and hunger, according to a spokesperson from the United Nations Development Programme (UNDP) in Ivory Coast. The UNDP spokesperson added that few governments seem to be aware of the close link between maternal health and poverty. It takes strong leadership at the country level to shift priorities and spend more on maternal and child health, as well as more effectively implement existing policies and international agreements, he added. One example is the right to family planning, which has not yet been included in public health care provision in many African countries.
The campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) was launched at Osindisweni Hospital in Ethekwini District, KwaZulu-Natal Province on 4 May 2012. CARMMA aims to accelerate the implementation of activities to stem maternal and child mortality and meet Africa’s targets for Millennium Development Goals four and five - to reduce by three quarters the maternal mortality rate and to reduce by two thirds the child mortality rate between 1990 and 2015. South Africa has a rising maternal mortality rate, yet it is one of the last countries in southern Africa to implement the campaign since it was started in 2009. In many of the countries, the national champions of CARMMA or the national authorities have committed to follow-up activities to intensify the reduction of maternal mortality in their countries, including Malawi, Zambia, Rwanda and Swaziland.
In this article, Global Health Watch provides an analysis of WHO’s ‘Draft implementation plan on maternal infant and young child nutrition’ (shown also in this section of the newsletter) . While it welcomes the evidence-based approach adopted in the draft, it argues that the plan fails to deal with the intersection of trade relations and nutrition, and steers clear of the challenges to be faced in building a regulatory framework to regulate transnational agribusiness and food corporations at global and country level. This is especially problematic at the moment, as new provisions are being inserted into preferential trade agreements to provide transnational corporations with powerful new defences against regulation at both the national and international levels. Global Health Watch argues that that nutrition needs to be understood in the context of food security (and insecurity). Food security in Africa is jeopardised by speculation in food commodities, which was the main contributor to a 50% rise in food prices in 2008, as well as the diversion of land growing food to growing biofuels. Global Health Watch argue that WHO cannot address the issues of trade and the regulation of transnational industry alone but it can take a pro-active stance in working with other competent intergovernmental bodies.
Before his death in April 2012, Malawi's former president Bingu wa Mutharika resisted calls by the International Monetary Fund (IMF) to devalue the Malawian kwacha as a way to boost exports, arguing that poor people would be negatively impacted. His decision alienated external funders, who withdrew support. Malawi's new president, Joyce Banda, has moved quickly to restore relations with funders, in part by meeting the IMF's conditions for a support package. On 7 May 2012, she devalued the kwacha by nearly 50% and untied the currency from the dollar. External funders have started responding, with the World Bank reportedly working on a package to help poor Malawians cope with the effects of devaluation and the United Kingdom (UK) agreeing to unlock aid frozen in 2011. The UK's International Department for International Development (DFID) are reported to have pledged to release an initial £30 million (US$47.3 million) tranche of urgent funding, of which £10 million ($15.8 million) will be used to support Malawi's healthcare system, and £20 million will go to towards stabilising the economy. The implications for household poverty of the measures funded are as yet not reported.
In this study, researchers aimed to determine short- and long-term trends in child malnutrition in Eastern and Southern Africa and how these are affected by drought and HIV. An analysis was conducted of data from national surveys, generally from the mid-1990s to the mid-2000s. Results indicated that overall trends in child nutrition are improving as national averages; the improvement is slowed but not stopped by the effects of intermittent droughts. In Southern Africa, the prevalence rates of underweight showed signs of recovery from the 2001–03 crisis. As expected, food production and price indicators were related (although weakly) to changes in malnutrition prevalence; the association was strongest between changes in food production and price indicators and changes in malnutrition prevalence in the following year. Despite severe intermittent droughts and the HIV and AIDS epidemic (now declining but still with very high prevalence rates), underlying trends in child underweight are improving when drought is absent. Preventing effects of drought and HIV could release potential for improvement and, when supported by national nutrition programmes, help to accelerate the rates of improvement, now generally averaging around 0.3% per year, to those needed to meet Millennium Development Goals (0.4 to 0.9% per year).
Malaria is commonly considered a disease of the poor, but there is very little evidence of a possible two-way causality in the association between malaria and poverty. This study aimed to address this gap. In the study, results show that households with a child who tested positive for malaria at the time of the survey had a wealth index that was, on average, 1.9 units lower. If malaria is indeed a cause of poverty, as the findings of this study suggest, then malaria control activities, and particularly the current efforts to eliminate/eradicate malaria, are much more than just a public health policy, but also a poverty alleviation strategy, the authors argue.
According to this draft comprehensive implementation plan, the World Health Organisation acknowledges that nutrition challenges are multi-faceted, effective nutrition actions exist but are not expanded sufficiently and new initiatives have been launched to address nutrition, such as the Scaling Up nutrition movement. The plan sets five global targets and a time frame. The plan aims to alleviate the double burden of malnutrition in children, starting from the earliest stages in development. It contains five key actions. 1. To create a supportive environment for the implementation of comprehensive food and nutrition policies. 2. To include all required effective health interventions with an impact on nutrition in national nutrition pans. 3. To stimulate development policies and programmes outside the health sector that recognise and include nutrition. 4. To provide sufficient financial resources and staff for the implementation of nutrition interventions, 5. To monitor and evaluate the implementation of policies and programmes.
7. Equitable health services
In this study, researchers consider the contribution by non government organisations (NGOs) towards the control of onchocerciasis (river blindness) in Cameroon, Mali, Nigeria and Uganda. The four case studies presented here illustrate some key contributions the NGOs made to the development of "community directed treatment with ivermectin" -CDTI, in Africa, which became the approved methodology within the African Programme for Onchocerciasis Control (APOC). The partnership between the international, multilateral, government institutions and the NGDO Coordination Group was the backbone of the APOC programme's structure and facilitated progress and scale-up of treatment programmes. Contributions included piloting community-based methodology in Mali and Nigeria; research, collaboration and coordination on treatment strategies and policies, coalition building, capacity building of national health workforce and advocacy at the national and international level. The NGOs used a community-based methodology which was also aimed at strengthening community health systems. The researchers argue that similar partnerships may be useful in other countries affected by onchocerciasis.
NEPAD and the East African Community (EAC) launched the EAC Medicines Registration Harmonisation (MRH) Project on 30 March 2012 in Arusha, Tanzania. The EAC MRH Project will promote the harmonisation of medicines registration in the region, which is expected to allow the public health sector to rapidly access good quality, safe and effective medicines for priority diseases. The EAC Secretariat, working in close collaboration with representatives from the National Medicines Regulatory Authorities (NMRAs) of all five partner states, will implement the project. Partner states agreed to co-operate in the initial stages of the project, including drawing up the draft implementation work plan and budgets, and the draft operational manual. Stakeholders hope that successful implementation of the EAC project will serve as a model for other countries and regions considering harmonised regulations for their populations.
With two decades of research behind it, the "invisible economy" of care is a critical area of scientific enquiry and policy action. However, far from being global, much of the public debate has been limited to advanced industrialised countries. Meanwhile, governments in developing countries - where economic restructuring raises perennial concerns about social reproduction, and women's increasing burdens of unpaid care work - are experimenting with new ways of responding to care needs in their societies. In this book, contributors from a wide range of backgrounds discuss and debate the care economy in the developing world at a moment when existing systems are under strain and new ideas are coming into focus. Empirically grounded case studies of countries as diverse as China, Nicaragua, India and South Africa shed new light both on existing care arrangements and changing policies.
In 2007 Madagascar implemented a sentinel surveillance system for influenza-like illness (ILI) based on data collected from sentinel general practitioners, launching an innovative case reporting system based on the use of cell phones. Encrypted short message service (SMS), which costs less than US$2 per month per health centre, is now being used by sentinel general practitioners for the daily reporting of cases of fever and ILI seen in their practices. To validate the daily data, practitioners also report epidemiological and clinical data (e.g. new febrile patient’s sex, age, visit date, symptoms) weekly to the epidemiologists on the research team using special patient forms. Madagascar’s sentinel ILI surveillance system represents the country’s first nationwide ‘real-time’ surveillance system. The authors of this paper argue that it has proved the feasibility of improving disease surveillance capacity through innovative systems despite resource constraints. They recommend this type of syndromic surveillance for detecting unexpected increases in the incidence of ILI and other syndromic illnesses.
This study was conducted working with community-owned resource persons to provide early diagnosis and treatment of malaria, and collect data for estimation of malaria burden in four villages of Korogwe district, north-eastern Tanzania. Reduction in anti-malarial consumption was determined by comparing the number of cases that would have been presumptively treated and those that were actually treated. the study found that with basic training and supervision, community-owned resource persons successfully provided early diagnosis and treatment and reduced unnecessary consumption of anti-malarials. Progressively declining malaria incidence and slide positivity rates suggest that all fever cases should be tested before treatment.
8. Human Resources
The objective of this study was to assess the extent to which the Health Economics Unit (HEU) has contributed to the development of health economics capacity in sub-Saharan Africa through the provision of Master’s and PhD programmes since the 1990s. The evaluation was based on a document review and 25 key informant interviews – with Master’s and PhD graduates, HEU staff members with management roles, beneficiaries of HEU’s internal capacity-building initiatives and international experts. The programmes have so far graduated 115 Master’s and 15 PhD graduates in health economics. Feedback from graduates indicated they are largely satisfied with the programmes. Most graduates are retained in the region if not in their home countries and find employment in a post that uses at least some of the skills gained during the programme, although not necessarily strictly in health economics. In terms of overall financial sustainability of HEU’s post-graduate programmes, SIDA funding has come to an end, which means there is a need to pursue financial support from the University in line with the usual funding of post-graduate training. The policy brief also makes some recommendations for improving future programmes.
With much smaller numbers relative to their counterparts in developed countries, pharmacists in developing countries tend to keep to the confines of dispensing roles mainly in community pharmacies. In this article the authors challenge these pharmacists to move away from the dispensing window and to demonstrate the value of the years invested in pharmacy schools to improve the well-being of communities. In Africa, another reason why pharmacy must be proactive in assuming service- and systems-based roles is the fact that physicians are often overloaded with clinical duties. By demonstrating that they can competently assume these roles and complement physicians in providing quality healthcare services, pharmacists have ready-made opportunities to enhance their role in the community. To arrest the waning image of the profession in Africa, there is need to identify service opportunities that would perpetuate the continued relevance of the profession to health systems and communities. Even though new opportunities in the areas of public health, pharmaceutical supply chain management, pharmacovigilance, regulation, management, rational drug use and others are emerging in different forms and designs, pharmacists appear slow to seize these opportunities. Changes in mind sets, perceptions, curricula and teaching methodologies are required, the article concludes.
A workshop on enhancing the global workforce for vaccine manufacturing was organised by the World Health Organisation from the 30 November to 2 December 2011, in Cape Town, South Africa. This workshop was attended by representatives from academia, pharmaceutical industries, research institutions, non-governmental organisations and regulatory agencies. A recurring theme during the discussions was the notion that international support for establishing or strengthening vaccine production capacity in developing and emerging economy countries must also include appropriate efforts to train and retain a skilled local workforce. A highly skilled workforce will support long term sustainability and viability of the operations of developing country vaccine manufacturers. Due to the synergies/similarities between the vaccine production workforce and the workforce producing other biological drugs, participants at the workshop argued that the two labour forces could complement each other during times of critical need. The management model of the biological drug manufacturing workforce could also serve as a benchmark for training, recruitment and retention policies.
9. Public-Private Mix
In the run up to the 65th World Health Assembly (21-26 May 2012) the NCD Alliance, a major international alliance of organisations working in the field of non-communicable diseases (NCDs) revised its statement calling on its Member States to support the creation of a Global Platform on NCDs. After the Conflict of Interest Coalition expressed its concerns to the Alliance over private sector involvement in health policy and planning in such a platform, the Alliance added the clause ‘with appropriate safeguards for public interest over private profit’ and issued a new statement in May 2012. Rundall argues that this amendment does not adequately address the need for a clear differentiation between policy, norms and standards development and involvement in implementation. She warns that lack of clarity will play into the hands of those who favour slow, industry-friendly, voluntary approaches rather than legally binding measures that hold the private sector accountable for their practices.
In this Statement of Concern, the Conflict of Interest Coalition calls for the development of a Code of Conduct and Ethical Framework to guide private sector involvement in public health policy development. The Coalition seeks clarity on the nature of recent government ‘partnerships’ with the private sector, and argues that public-private partnerships run the risk of counteracting efforts to protect and improve public health. The proposed framework should help protect the integrity of the United Nations’ public policy decision-making, to ensure it is transparent and to identify, safeguard against and manage potential conflicts of interest. The Statement argues that a clear distinction must be made between business-interest not-for-profit organisations (BINGOs) and public interest non-governmental organisations (PINGOs) and a clear differentiation between policy and norms and standards development and appropriate involvement in implementation. The Coalition calls on the World Health Organisation (WHO) to develop guidance for Member States to identify conflicts and eliminate those that are not permissible. WHO should perform thorough risk/benefit analyses on partnerships and provide surveillance on those considered acceptable.
On 6 December 2011, the East African Community Regional Pharmaceutical Manufacturing Plan of Action was launched in Arusha, Tanzania. The Plan of Action will guide the region towards evolving an efficient and effective pharmaceutical manufacturing industry that can supply national, regional and international markets with quality efficacious medicines. A number of recommendations were made at the end of the meeting. Participants agreed that, following discussion on the baseline survey, the draft report and the relevant questionnaire will be sent to national associations and regulatory authorities for corrections and further input, and then to national pharmaceutical manufacturers associations for input. They called on EAC Partner States to mobilise the necessary resources to ensure successful implementation of the Plan of Action. It was resolved that the EAC Secretariat will be responsible for putting in place clear coordination and management structures for the implementation, monitoring and evaluation of the plan.
Governments around the world argue that there is no money for badly needed public services. But the author of this briefing note disagrees, pointing to evidence that large pools of public monies exist for investment in public infrastructure, with public pension funds and sovereign wealth funds being two examples. Currently, these funds are being directed toward large-scale, capital-intensive, high-return projects aimed primarily at well-off urban residents and the private sector. Lessons from the financial crisis show that such funds could actually realise greater long-term returns from investment in public service provision, the authors argue, while avoiding the politically controversial and contradictory practice of using public sector funds to support privatisation. They make the case for using public pension funds and sovereign wealth funds for socially responsible investments in the global South, in support of essential public services.
10. Resource allocation and health financing
This study measured out-of-pocket costs for caesarean section and neonatal care at an urban tertiary public hospital in Madagascar, assessed affordability in relation to household expenditure and investigated where families found the money to cover these costs. Data were collected for 103 women and 73 newborns at the Centre Hospitalier Universitaire de Mahajanga in the Boeny region of Madagascar between September 2007 and January 2008. Out-of-pocket costs for caesarean section were catastrophic for middle and lower socio-economic households, and treatment for neonatal complications also created a big financial burden, with geographical and other financial barriers further limiting access to hospital care. This study identified 12 possible cases where the mother required an emergency caesarean section and her newborn required emergency care, placing a double burden on the household. In an effort to make emergency obstetric and neonatal care affordable and available to all, well-designed financial risk protection mechanisms and a strong commitment by the government to mobilise resources to finance the country's health system are necessary, the authors conclude.
Many national hospitals in the Democratic Republic of Congo (DRC) are no longer accepting new HIV-positive patients for antiretroviral treatment (ART), largely due to lack of capacity and funding shortfalls. According to Medicins Sans Frontiers, urban areas are poorly covered by ART (30% for Kinshasa), but rural areas are much more severely underserved. Funding remains uncertain. A major World Bank project recently closed after six years, while UNITAID, which provides funding for paediatric and second-line antiretrovirals, will end its funding to the DRC in December 2012. The cancellation of Round 11 funding by the Global Fund to fight AIDS, Tuberculosis and Malaria is likely to worsen the situation. Réseau National d'Organisations Assises Communautaire (RNOAC), a national network of community-based organisations, has called on government to supply funding for HIV programmes instead of relying exclusively on external funding.
The Global Fund to fight AIDS, Tuberculosis (TB) and Malaria has announced an increase in US$1.6 billion in funding to invest between 2012 and 2014. The new funds are a result of strategic decisions made by the Board, freeing up funds that can be invested in countries where there is the most pressing demand, according to this statement. Organisational changes have brought improved financial supervision and overall efficiency’: for instance, the Fund has cut its staff by 7.4%. In addition, it has received new donations recently, including $750 million from the Bill and Melinda Gates Foundation and $340 million from Japan. Poor funding in 2011 forced the Fund to make an unprecedented decision to cancel its 11th round of funding, raising fears that gains made in the fight HIV would be lost. Some $616 million in grant requests is now being considered by the Technical Review Panel. UNAIDS said the money would allow countries and communities to take the lead in determining their priorities to meet the targets of the 2011 UN Political Declaration on AIDS.
This review examines the role and impact of co-payments in the context of a National Health Insurance system. The application of co-payments, which is a demand-side mechanism, attempts to play a dual role in health care: they primarily serve as a mechanism to avert moral hazard and secondly they add a small amount to the pool of health care funding. Available evidence shows that co-payments are applied in a large variety of health care settings. Across all settings and in different health care and country contexts, co-payments reduce utilisation, disproportionately so for those who are more vulnerable and more disadvantaged. They thereby increase the likelihood of higher health care costs in the long term, as necessary health care is deferred and increasing hospitalisation and more complications arise accordingly. There is, however, no clear evidence to suggest that co-payments address moral hazard and neither is there evidence of any substantial cost savings. A co-payment does, however, shift the burden of cost from health care funders onto users. The review also examines alternate supply-side mechanisms that can contribute to decreased health care costs and address potential over-utilisation, one being gate-keeping. The author concludes that, before co-payments are introduced, other mechanisms should be explored as alternative cost- and utilisation-control interventions.
Every year the Ugandan government spends at least Shs377 billion (about US$150 million) on medical procedures for mostly top government officials abroad, according to the Ugandan newspaper, Sunday Monitor. This amount is similar to the total amount of foreign funding flowing into the country’s health sector. Ministry of Health permanent secretary Asuman Lukwago agreed that the amount should be reduced and that the money would be better spent on ongoing efforts to rejuvenate health facilities, including upgrading all referral hospitals. The secretary added that Uganda had the capacity to perform most procedures, arguing that there was minimal need for government officials to travel abroad to get treatment.
11. Equity and HIV/AIDS
This study describes the design, implementation and evaluation of Project Mwana, a pilot project in Zambia’s rural Southern Province. The main aim of this project was to reduce the time between blood sampling for the detection of infant HIV infection and notification of the test results to the relevant point-of-care health facility by using an SMS-based system. Ten public health facilities within two districts in Zambia’s Southern Province were purposively selected for inclusion in the pilot SMS project. Results from this study suggest that in Zambia, particularly in rural areas, mobile phone texting can overcome the logistical and distance barriers that can impede the early diagnosis of HIV infection in infants. An automated SMS allowed the results of PCR testing of infant dried blood samples to be reported to the relevant point-of-care health facility or infant caregivers much faster than would have been possible by using a courier to deliver the results on paper to the relevant health facility. In addition, the results delivered through SMS texting were highly accurate by comparison with the results recorded on paper.
Increased fertility rates in HIV-infected women receiving antiretroviral therapy (ART) have been attributed to improved immunological function; it is unknown to what extent the rise in pregnancy rates is due to unintended pregnancies. In this study, non-pregnant women ages 18–35 from four public-sector ART clinics in Johannesburg, South Africa, were enrolled into a prospective cohort and followed from August 2009 to March 2011. Fertility intentions, contraception and pregnancy status were measured at participants' routine ART clinic visits. Of the 850 women enrolled, 170 pregnancies were detected, of which 105 (62%) were unplanned. Unmet need for contraception was 50% higher in women initiating ART in the past year as compared to women on ART for longer than one year. Eight hormonal contraceptive failures were detected. Overall 47% (80/170) of pregnancies were not carried to term. The researchers conclude that integration of contraceptive services and counselling into ART care is necessary to reduce maternal and child health risks related to mistimed and unwanted pregnancies. Further research into injectable contraceptive failures on ART is warranted.
In this study, researchers explored the lessons learnt by health workers involved in the provision of prevention of mother-to-child transmission (PMTCT) services in eastern Uganda to better understand what more needs to be done to strengthen the PMTCT programme. A qualitative study was conducted at Mbale Regional Referral Hospital, The AIDS Support Organisation (TASO) Mbale and at eight neighbouring health centres in eastern Uganda, between January and May 2010. Data were collected through 24 individual interviews with the health workers involved in the PMTCT programme and four key informants (two district officials and two officials from TASO). Study themes and sub-themes were identified following multiple reading of interview transcripts. The key lessons for programme improvement were: ensuring constant availability of critical PMTCT supplies, such as HIV testing kits, antiretroviral drugs (ARVs) for mothers and their babies, regular in-service training of health workers to keep them abreast with the rapidly changing knowledge and guidelines for PMTCT, ensuring that lower level health centres provide maternity services and ARVs for women in the PMTCT programme and provision of adequate facilities for effective follow-up and support for mothers.
Three countries in Southern Africa have the highest adult HIV prevalence in the world: Swaziland (25.9%), Botswana (24.8%), and Lesotho (23.6%). Fiscal policy is crucial for addressing this HIV and AIDS crisis, according to the African Development Bank (ADB). Utilising a calibrated model, this paper investigates the impact of fiscal policy on reducing the HIV and AIDS incidence rates in these countries. In particular, ADB studied the welfare impact of different taxation and debt paths in these countries in reducing the HIV and AIDS prevalence rates. Results showed that tax policies that were associated with reduced HIV rates not only had positive societal effect but also positive fiscal effects.
12. Governance and participation in health
A group of leading international humanitarian, development, social justice, environmental, and workers' organisations have warned that June 2012’s UN Conference on Sustainable Development (Rio+20) looks set to add almost nothing to global efforts to deliver sustainable development. The warning from Development Alternatives, Greenpeace, the Forum of Brazilian NGOs and Social Movements for Environment and Development (FBOMS), International Trades Union Confederation (ITUC), Oxfam, and Vitae Civilis comes at the end of two weeks of negotiations between governments on the conference outcomes, with less than 50 days before the summit in Rio de Janeiro, Brazil, from 20 - 22 June. The group warns that the current negotiating text does not adequately capture human rights and principles of equity, precaution, and 'polluter pays', despite the urgency provided by the current financial crises, growing inequalities, broken food As a benchmark against which to assess the outcome of Rio+20, the organisations have set out a 10-point agenda that includes global goals for sustainable development, designed to eradicate poverty, reduce inequality and realise justice and human rights, while respecting the finite limits of Earth's natural resources.
This research explored communities’ views on the elements of public health services that they find particularly problematic. It aimed to quantify the priority placed on each of these aspects of public service delivery that requires attention. Communities view the routine availability of effective medicines as the greatest priority for improved public sector health services; the least important priority is treatment by doctors. Routine availability of medicines is ten times more important than treatment by doctors. A thorough examination and clear explanation of a patient’s diagnosis and treatment by health professionals are also highly valued community priorities. Communities tolerate poor quality public sector service characteristics such as long waiting times, poor staff attitudes and the lack of direct access to doctors if they receive the medicine they need and a thorough examination and if a clear explanation of their diagnosis and treatment is provided.
The aim of this study was to examine the relationship between health systems outcomes and equity, and governance as a part of a process to extend the range of indicators used to assess health systems performance. Using cross sectional data from 46 countries in the African region of the World Health Organisation, an ecological analysis was conducted to examine the relationship between governance and health systems performance. Governance was found to be strongly associated with under-five mortality rate (U5MR) and moderately associated with the U5MR quintile ratio. After controlling for possible confounding by healthcare, finance, education, and water and sanitation, governance remained significantly associated with U5MR. Governance was not, however, significantly associated with equity in U5MR outcomes. This study suggests that the quality of governance may be an important structural determinant of health systems performance, and could be an indicator to be monitored. The association suggests there might be a causal relationship. However, the cross-sectional design, the level of missing data, and the small sample size, forces tentative conclusions. Further research will be needed to assess the causal relationship, and its generalisability beyond U5MR as a health outcome measure, as well as the geographical generalisability of the results.
The NCD Alliance is calling for a global coordinating platform for non-communicable diseases (NCDs), housed within a United Nations agency, driven by Member State champions, with an independent Board and Secretariat, to be a catalyst for coordinated action on NCDs. The Alliance argues that key gaps in the current global and national response to NCDs are a result of a lack of multisectoral action, a problem which could be addressed by the proposed platform. In this paper, the Alliance lays out various partnership options for a global coordinating platform (GCP) on NCDs: simple affiliations, lead partners, secretariats and joint ventures. The Alliance recommends a secretariat structure, similar to platforms like the Partnership for Maternal, Newborn and Child Health and the Global Health Workforce Alliance. It argues that an effective GCP on NCDs should be based on a set of best practice principles in order to effectively catalyse action on NCDs and coordinate the multisectoral response needed to reduce preventable NCD deaths by 25% by 2025.
A conference on Migration and Social Policy: Comparing European and African Regional Integration Policies and Practices was held on 19-20 April 2012 in Pretoria, South Africa. It brought together participants from the South African government, UN organisations, national research centres and NGOs to underscore the potentials to develop more effective regional social policy, improve policies for social protection and meet the social protection needs of cross-border migrants. Three main themes emerged. First, lessons can be drawn from cross-regional research experiences, in particular new directions of regionalism and its implications for migration and socioeconomic and political rights. Second, stakeholders should consider going beyond "migration management", toward more coherent governance systems that advance the social dimensions of migration. This approach could lead to more positive development outcomes of migratory processes. Third, looking at regional integration through the lens of the free movement concept was considered a useful approach to map out the advantages of advancing free movement in a regional context, for example with regard to already existing institutions and common regulations. Other issues raised during the conference included challenges presented by informal labour markets, irregular migration and insufficient formal social protection mechanisms; the lack of political will to promote free movement; and the need to construct a regional identity, in particular among civil society.
The single most important message of this paper is that development outcomes in poor countries depend fundamentally on the political incentives facing political elites and leaders. Political will has usually been treated as an inexplicable ‘black box’. The authors seek in this paper open up the black box, to say some definite things about the specific contexts in which political ambitions are shaped and policy choices are made in different parts of the world and at different stages of countries’ development processes. They argue that economic growth without economic transformation is limited. The authors raise the case that democracy depends on the formation of social classes, including productive capitalists, and organised professional groups and wage-earning workers. This only happens as a result of economic diversification and the accumulation of technological capacities. If the formal sector cannot generate adequate incomes and taxes for state revenues, the ruling elites draw resources to meet the demands of crucial coalition groups from various kinds of off-budget transfers and informal sharing of rents. The paper explores country contexts in Africa where there is evidence of diversity in the relationship between ruling elites and state bureaucracies, to better understand the reasons for this diversity and its implications for development aid.
The International Baby Food Action Network and the Third World Network review the World Health Organisation’s (WHO) reform process from a civil society perspective. (The WHO DG report on the reform is also included in this newsletter). The organisations argue that the reform process has not been transparent, as the Secretariat has withheld vital documents, such as the reports by consultants used to develop the reform agenda. With regard to stakeholders, they argue that it is important that WHO identifies the different types of social, political and economic actors with which it interacts and clearly distinguishes those that are related to commercial interests. The organisations refer to the WHO 12th General Programme of Work (GPW) as a sign of its direction, noting the unclear includion of work on the right to health, social determinants of health, primary health care and gender equality.
This report covering all aspects of World Health Organisation (WHO) reform was commissioned by the WHO for submission to the 65th World Health Assembly in May 2012. It addresses the three substantive areas of WHO reform: programmes and priority setting, governance and management. First,with regard to programmes and priority setting, the draft general programme of work, as it is developed over coming months, will demonstrate: how agreed criteria have been used to identify priorities; how high-level goals have been set; and how WHO’s core functions, comparative advantage and organisational position have been used to focus its the work. Guidance from Member States will influence the development of a first full draft for discussion by the regional committees later in 2012. Next, the section on governance consolidates proposals under four main headings: more rational scheduling, alignment and harmonisation of governance processes; strengthening oversight; more strategic decision- making by governing bodies; and more effective engagement with other stakeholders. The focus of recent work has been the internal governance of WHO by Member States. More detailed work and consultation is called for in relation to the streamlining of national reporting to WHO as well as engagement with other stakeholders. Finally, the management chapter has been reorganised to reflect the fact that stronger technical, normative and policy support for all Member States should be a key outcome of reform.
This independent evaluation of the World Health Organisation’s (WHO) proposed reform package found that WHO had responded adequately to challenges pointed out by stakeholders in the area of internal governance by using a Member State-driven consultative process to re-set its priorities and programme areas. Issues regarding resource allocation and the strengthening of governing bodies, however, need further amplification. A number of recommendations were made. As the proposed reform has highly interdependent components, the report calls on WHO to establish and maintain links among governing bodies at headquarters and regional offices to promote coherence and strategic focus, and adopt an approach that recognises this interdependence. Accountability and responsibility structures for three layers of governance would need to be redesigned, with results-based management and effective performance management and development. To generate acceptance at various levels, an advocacy plan should be developed, and regular communication should be maintained with all stakeholders. The report also calls for desired outputs, outcomes and impact to be identified, the designing of indicators to measure these, and a monitoring and feedback mechanism. As the reform programme is comprehensive and involves action on a large number of fronts, the report recommends that WHO develop a prioritisation plan to allow a smooth and gradual shift.
13. Monitoring equity and research policy
CEWG, the expert working group advising the World Health Organisation (WHO) on research and development, has recommended that the May 2012 World Health Assembly adopt an international convention on research and development (R&D) that will bind member states to action and catalyse new knowledge for diseases that primarily affect the global poor but for which patents provide insufficient market incentives. In this editorial, the chairpersons of the expert group summarise the recommendations and report of CEWG, which they say constitute a transformative change for achieving access to medicines. They argue that financial contributions should be determined based on the concept that both the costs and benefits of R&D should be shared. They recommend a role for WHO in the stronger coordination of R&D and suggest pooling of financial investments to secure efficient allocations to where demands and opportunities are identified through active participation of developing countries. An international convention, the authors argue, is a way to secure a systemic and sustainable solution since it creates a formalised platform for the future where countries can be held accountable.
This presentation, delivered at Forum 2012 in April 2012, describes a partnership between the Dutch Council on Health Research for Development (COHRED), the African Union (AU) and the NEPAD Agency (a technical arm of the AU) to help African countries develop their national health research agendas. The partnership aims to support Africans’ ownership and optimal utilisation of research for health to achieve health and health equity, reduce poverty, and contribute to the socio-economic development of countries, regions and the continent. It is also intended to strengthen the existing capacity of African institutions and networks to support the process of capacity building at the governance and policy levels of national research systems. At the initial phase, three countries have been identified and selected to participate in the programme: Mozambique, Senegal and Tanzania. In Mozambique, a national priority setting process is being carried out, while in Tanzania, national research priorities and agenda have been set and the partnership has developed a ‘research ethics ‘management’ platform, as well as a national research for health management information system.
Participants at Forum 2012, held in Cape Town in April 2012, have argued that it is a misconception that developing countries rely purely on international aid, as they remain the major funders of research in their countries, despite finding it difficult to meet recommended targets for research and development spending. They called for greater collaboration with neighbouring countries, such as pooling resources and knowledge, as well as better cooperation between different sectors within countries to drive improved health outcomes. Innovation was also identified as a key factor in compensating for the lack of infrastructure and resources, especially in the form of new information and communication technologies (ICTs), with virtual collaboration, sharing of data and mobile health technology to reach rural areas, being some of the exciting possibilities. At the Forum, participants had the opportunity to share experiences on how to set their own priorities for research, build capacities and provide incentives for innovation, with the need to always ensure the involvement of communities in setting the priorities for health research being a strong and recurring theme. Also high on the Forum 2012 agenda was the issue of women’s health, although it was stressed that the focus should be on sexual and reproductive health and not simply on maternal health.
In Tanzania, as in many developing countries, the national Health Management Information System (HMIS) is stuck in a vicious cycle: national health data are used little because they are of poor quality, and their relative lack of use, in turn, makes their quality remain poor. In this study, an action research approach was applied to strengthen the use of information and improve data quality in Zanzibar. The underlying premise was that encouraging use in small incremental steps could help to break the vicious cycle and improve the HMIS. To test the hypothesis at the national and district levels a project to strengthen the HMIS was established in Zanzibar. The project included quarterly data-use workshops during which district staff assessed their own routine data and critiqued their colleagues’ data. The data-use workshops generated inputs that were used by District Health Information Software developers to improve the tool. The HMIS, which initially covered only primary care outpatients and antenatal care, eventually grew to encompass all major health programmes and district and referral hospitals. The workshops directly contributed to improvements in data coverage, data set quality and rationalisation, and local use of target indicators. The authors conclude that data-use workshops with active engagement of data users themselves can improve health information systems overall and enhance staff capacity for information use, presentation and analysis for decision-making.
At Forum 2012, held in Cape Town in April 2012, a session was convened to explore the current roles and future potential of international partnerships in advancing African development through health research. Attendees sought to identify the elements of partnerships that would bring the greatest benefits to research and capacity development in Africa and, at the same time strengthen health and development systems on the continent. COHRED said that funders and research programmes must consciously build systems and capacity in their areas that can extend beyond silos and support other campaigns. Participants developed a number of specific and general recommendations. Most crucially, perhaps, research for health programmes must design capacity building for development and health systems into their programmes from the earliest stages, i.e., this must be a goal and not merely an incidental, even unexpected collateral benefit. Partnering organisations should be selected with attention to their commitment to ensuring that the infrastructure and human expertise which will be developed for the programme is sustainable and transferable. Country ownership will benefit from locally anchored partners, such as national universities, who will still be there when a particular research programme is concluded.
In this global review, researchers aimed to determine which countries are experiencing gaps in health research, identifying Chad, Angola, DRC, Sudan, Lesotho, Rwanda, Madagascar, Algeria, and the Central African Republic as African countries with the lowest levels of health research. Efforts to strengthen capacity in health research have, so far, concentrated on countries where there is existing capacity rather than those where it is almost completely lacking. Judged by absolute numbers of scientific papers, those with the fewest are mainly small islands and a few countries that are politically isolated. Judged by papers per capita, the lowest include countries in the former Soviet Union and Africa, both regions experiencing declines in life expectancy in recent years, and states experiencing conflict. Although there is a positive association between economic development and research output, some relatively wealthy countries seriously underperform. There are many examples of good practice, including regional networks and international partnerships. The authors present a strong argument for external funders to look to the long term and consider how best to build health research capacity where it is virtually absent.
14. Useful Resources
This Reader aims to support the development of the field of health policy and systems research (HPSR), particularly in low- and middle-income countries (LMICs). It provides a particular focus on methodological issues for primary empirical health policy and systems research. More specifically, it aims to support the practice of, and training in, HPSR by: encouraging researchers to value a multidisciplinary approach, recognising its importance in addressing the complexity of health policy and systems challenges; stimulating wider discussion about the field and relevant research questions; demonstrating the breadth of the field in terms of study approaches, disciplinary perspectives, analytical approaches and methods; and highlighting newer or relatively little-used methods and approaches that could be further developed. The Reader is mainly for use by researchers and health system managers, teachers and facilitators involved in HPSR training, and students, from any discipline or background, who are new to the field of HPSR.
The official website for the European Union-funded Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA) has just been launched. CHEPSAA is working with universities in Africa and Europe to strengthen teaching, research and policy networking activities for the rapidly emerging field of health policy and systems research and analysis (HPSR+A). CHEPSAA’s aim is to build the field of HPSA through: assessing the capacity development needs of the African members and national policy networks; supporting the development of African researchers and educators; strengthening the development of HPSA courses; strengthening networking among the health policy and systems education, research and policy communities; and strengthening the process of getting research into policy and practice. The new website gathers HPSR+A resources, pooling information from sources far wider than CHEPSAA for teachers, researchers, students, policy-makers and decision-makers. The website contains a number of resources: classic texts, recommended reading, teaching materials, links to core HPSA journals and material by CHEPSAA.
15. Jobs and Announcements
The World Health Organisation’s Alliance for Health Policy and Systems Research is calling for expressions of interest in the topic of access to medicines in low- and middle-income countries. Proposed research should explore the connections between medicines and three other functions of health systems: health financing, governance and health information. Three core questions have been identified for this call: 1. In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of quality medicines, sustainability of the scheme, and financial impact on beneficiaries? 2. How do policies and other interventions into private markets impact on access to and appropriate use of quality medicines? 3. How can stakeholders use information and data routinely collected and available in the system in a transparent way towards improving access to and use of quality medicines?
Healthcare around the world is unaffordable for millions of people. However, states are responsible for delivering universal access to health systems according to their legal commitments to the Right to Health. This is only possible if they develop sustainable health financing mechanisms to support strong and equitable national health systems. To make Universal Health Coverage (UHC) a reality, there is still the need for greater political will both at national level - to put in practice the reforms needed - and at international level to promote and revitalise a general consensus towards ‘health for all’, facilitating technical support and additional resources. Making progress towards UHC will accelerate social and economic growth, is fundamental to sustainable development and is fair. For these reasons, a group of NGOs has been working on a common statement for UHC, asking for greater political support and promoting a joint movement for UHC. If your organisation wants to strengthen this global movement for UHC and endorse this document, please contact Action for Global Health at the email address given.
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.
The theme of this year’s conference is ‘Turning the tide together’. Policy makers, persons living with HIV and other individuals committed to ending the HIV/AIDS pandemic will meet to assess global progress, evaluate recent scientific developments and lessons learnt, and collectively chart a course forward. The programme will present new scientific knowledge and offer many opportunities for structured dialogue on the major issues facing the global response to HIV. Sessions will focus on the latest issues in HIV science, policy and practice and will also seek to share key research findings, lessons learned, best practices, as well as identify gaps in knowledge. The conference will feature abstract-driven sessions, a daily plenary session, a variety of symposia sessions, professional development workshops, and independently organised satellite meetings. In addition, the conference programme will include a number of programme activities, such as the Global Village and the Youth Programme, which are an integral aspect of the International AIDS Conference.
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
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.
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.
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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