At the just ended World Health Assembly (WHA 66) member states reviewed progress in implementing the WHO Global Code of Practice on International Recruitment of Health Personnel. This was the first review report since the adoption of the Code three years ago. The Secretariat report tabled at the WHA showed that few African countries had designated authorities for monitoring and reporting on the Code, and that only one African country had submitted a report on implementation. This low response has been commented on in April 2013 EQUINET newsletter (http://www.equinetafrica.org/newsletter/index.php?issue=146)
When the report on the health workforce, which included progress on the Code, was discussed at the WHA, the discussion was somewhat muted. Only fourteen member states commented on the report, and only eleven made reference to the Code. African countries speak as a group on issues through a nominated delegate. Burkina Faso spoke for the 46 WHO-AFRO member states, and Ethiopia spoke in support of Burkina Faso. Those that attended the WHA in 2010 when the Code was adopted observed the contrast to the exciting atmosphere of intense debates and the large number of voices that were heard at that stage.
So what has happened over the last few years? At a side event at the WHA, participants took stock of the progress, or lack thereof, in the implementation of the Code. The side event was organised by Medicus Mundi Internationales together with the Governments of Malawi and Belgium, EQUINET and AMREF. Participants raised various challenges that member states faced in getting the implementation of the code off the ground, including their lack of preparedness, the poor mobilisation of national level stakeholders and limited engagement of civil society since the Code was adopted. Ministries of Health were also reported to be overwhelmed with other issues. WHO and some countries reassured that despite low reporting, work was underway. The fact that many countries had reported was seen as a positive sign, given the voluntary nature of the code, as was the commitment of Northern countries, (USA, EU) and WHO Secretariat to support its implementation.
The muted African member state reaction to the report at the WHA by the Secretariat may, as raised above, be explained by the diplomacy process of the Africa Group, where African ministers reach agreed positions, as they did on this issue, giving little added value in countries making further individual statements. While shared position and voice is an important feature and strength of African diplomacy, it is also common practice for countries to state/restate their position as they “align themselves with the statement made by the delegate for...... region”. This allows countries to give force behind specific areas and for country experiences to add weight to positions raised. African countries may also have been reluctant to raise their voice in the WHA process given lack of input to the Secretariat report, as raised earlier.
Whatever the reason, and this needs to be further explored, the low profile adopted by African member states on this occasion may have sent a message that the Code is not perceived to be a key policy instrument for the region to address its continuing challenges over the production, retention and migration of health workers. If so, then given the energy that went into its adoption, where are the shortfalls?
There are lessons from other processes at the WHA. Voluntary codes may fall out of attention as other issues demand more urgent government attention. If this is the case then the implementation of the only other WHO Code - on breast milk substitutes – provides a lesson on the role of civil society to galvanise countries into action, particularly with technical support of WHO. Civil society has kept the code on breast milk substitutes alive and current and generated pressure within countries to ensure that it is implemented. Is this possible for the Code of Practice on International Recruitment of Health Personnel? In theory it is achievable. The loss of health workers in countries of highest health need is still a concern, and communities and health workers have an interest in the issue, as it affects their rights and services.
Civil society organisation on health worker issues has partly been through the Global Health Worker Alliance (GHWA). The fact that the GHWA currently has no executive director weakens its support for civil society input, and creates uncertainty about its future. The third global forum on health workers organised by WHO and the GHWA will be held in Recife, Brazil in November 2013. It should provide an opportunity to review and give profile to the role of the Code in addressing health worker issues, and give new momentum to the role of civil society in its implementation. This however does need civil society, health worker organisations and academics within countries to ask questions on the implementation of the Code, to ask delegations for feedback from the discussions held at the WHA, and to know, share information on and support implementation of the Code.
It is also a matter of concern that reforms at the WHO Secretariat have diminished the capacity of the unit dealing with health worker issues. Fewer people are now contending with an increasing workload, weakening the capacity of that unit to play a leading role in support of member states and the wider community.
A number of civil society organisations, including MMI/Peoples Health Movement, and the International Federation of Medical Students Associations (IFMSA) spoke as observers at the WHA deliberations on the Code. Most of the presentations raised the weakening of these institutional capacities for supporting its implementation and called for a stronger Health Systems Policies and Workforce unit at WHO Secretariat and a stronger GHWA.
In a world of rapidly shifting policy attention, it seems to be important to organise and secure the resources, institutional roles and capacities for implementation when negotiating new instruments, particularly if they are voluntary as the Code is. The next few years will be a test of whether the slow implementation is a feature of countries preparing for a marathon rather than a sprint, or whether it is a feature of diminishing interest in the race. Issues are also sustained when they have a place in the current focus of policy attention. The focus of this year’s WHA and of much current global engagement in heath was on universal health coverage (UHC). It was thus important that health workers were identified as a central element of that policy.
This then may be the important message that we need to send. Delivering on UHC is not possible without health workers, and one sign of that delivery at global level is the extent to which countries are operationalizing the Code and implementing its intentions. The international agreements negotiated by member states at the WHO are instruments for achieving UHC, whether voluntary or not, as are the global and national capacities in governmental and non-state institutions for leading and being accountable on their implementation.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: email@example.com. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
When I joined the Global Fund in 2003, my main responsibility, as the Manager of Online Communications, was to help the organisation deliver on its commitment to transparency. One of the conditions set forth by donors was the ability to trace every granted dollar to make aid recipients accountable for how it would be spent. This meant, among other things, developing and maintaining a website that quickly became a central repository of all Global Fund data and information. We were praised for the unprecedented level of openness that this made possible. But over time, I realised that something was (and still is) missing.
If you Google “Global Fund” + AIDSfor news stories, the overwhelming majority of results are articles that are reactive (i.e. based on official announcements, press releases and conferences) or that make reference to the Fund only indirectly or anecdotally.
Apart from experts in donor governments and a handful of technical partners, Aidspan and the likes, very few local organisations or people take advantage of Global Fund transparency to trigger open and well-informed discussions on aid effectiveness. How can this be when all the data and documents are “just a mouse click away”? Close to $20 billion were disbursed in a few years. Where did it all go? Who got it? To do what? With what success?
The Fund’s website should be an extraordinary tool to get the facts right on those questions. It should be a gold mine of stories for local journalists, civil society organisations (CSOs), activists and parliamentarians in recipient countries. But, for the most part, they aren’t panning for this gold. What is transparency all about if it doesn’t translate into increased accountability at country level, and if people and communities for whom the Global Fund was created don’t use it to keep pressure on grantees, to voice their concerns and claim their rights?
The reality is that using Global Fund data to make recipients accountable is out of reach to most concerned people because they lack access to the Internet, because they don’t have enough time or the technical skills – and because there are obstacles to freedom of information and speech.
Global Fund transparency, as it is practised today, is more of a barrier to journalists and in-country activists than anything else: intimidating piles of reports filled with obscure language, countless files and downloadable materials that reassure technocrats in donor capitals but that don’t say much about the reality of what happens to the funds when they hit the ground. Understanding, processing and making use of this information requires learning about technical jargon, Global Fund internal processes, and the roles and responsibilities of different local partners. One needs to be familiar with web searching techniques and data processing methods, and to have some basic communication skills to translate often indigestible data into a plain, common language that non-technical audiences can understand.
Last, but not least, trying to make the powerful accountable in countries with no such tradition is a risky game for the few activists and concerned citizens who dare to do so. With the rise of the “Open Government” and “Open Data” movements in Africa and elsewhere, people may fear less for their lives than they used to, but threats and intimidation are still very much a daily reality for local watchdogs.
This leads to a strange paradox. As I heard recently: “That is almost the flip side of transparency. It’s very easy to use transparency if actually you want to drown people in information. I know it’s a tactic for lawyers: just give too much information to people, and it will be difficult for them to really figure out what is important.” Certainly, the Global Fund did not create this complexity consciously and voluntarily, but the result is the same: mountains of data and files that have the effect of shielding grantees and the Fund’s bureaucracy from too much scrutiny.
Today, in the wake of the Global Fund, a growing number of international organizations have committed to making their information on aid spending easier to find, use and compare. More than 120 UN agencies, multilateral banks, bilateral donors and NGOs have already endorsed the IATI (the International Aid Transparency Initiative) and have agreed to convert their data into a common standard. While this is a major step in the right direction, a simple lesson should be drawn from the Global Fund’s experience: Opening up databases is not enough for change to occur in the way local accountability happens. Rather, change requires a real commitment to accompany those for whom this data is made available as they make their first steps in the maze of aid transparency.
Here is what I think needs to happen.
Build capacity to use Global Fund data. Local watchdogs need help to stay afloat in the aid data deluge, to learn how to use the tools of transparency to have impact. While their work may not require the same level of technical sophistication as global watchdogs, they need training. They need to be able to understand who does what and where to find the information. They need to acquire watchdogging skills, using real-life case studies and guidance based on local needs. Watchdogs usually don’t focus on one single aid provider; no organisation would be justified in developing such a programme in isolation. Therefore, the capacity building should be a shared responsibility, and a combined and coordinated effort, by all concerned parties, such as the IATI signatories and some global or regional players in the field of transparency. The Global Fund has the credibility to take the lead on this. It should sit down with IATI partners to explore how a step-by-step, scalable, replicable and carefully targeted capacity-building programme could be implemented. As a critical side effect, such an initiative could provide some recognition to participating local aid monitors, thus breaking their isolation and protecting them in the exercise of their democratic rights.
Declare war on gobbledygook. Besides data, transparency is first and foremost about communicating in plain language. How much sense does it make for thousands of people, including the Secretariat’s own staff, to have to turn to a newsletter like the GFO to understand the rules of the game of a multi-billion dollar transparent organisation? The Global Fund should elevate proper communications with implementers (and others) to a top priority. The Fund should stop relying on technical staff to draft documents that are meant for wide distribution. It should reinforce the capacity of its Communication Department by adding writers who can translate complex policies and procedures into plain language.
If the Global Fund were to support and encourage local watchdogs, this would constitute a valuable early warning system for the Fund – one that complements the work of the local fund agents and the Office of the Inspector General. Building the capacity of local watchdogs to use transparency could greatly reinforce the Fund’s own risk management and fraud prevention efforts, at little cost. The Global Fund should also tackle its poor communications with implementing countries by addressing the Secretariat’s capacity issues in this field. With the 2015 MDG deadline on the horizon and the development community bracing for what comes next, with pressure on the Fund to improve its oversight mechanisms, and with the need for the Fund to position itself for a possible redefinition of its mandate, these measures could reassure donors about its capacity to be a truly different business model in international development.
The Global Fund should renew its commitment to transparency and take bold steps to promote wide use of its transparency in recipient countries. Information is power. It’s time to give power to those for whom the Global Fund was created so that transparency can fully achieve what it is meant for.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: firstname.lastname@example.org. Robert Bourgoing joined the Global Fund in its early days, in 2003, and was a senior member of its communications team until last year. He is a trained lawyer and an experienced journalist, and currently works as an independent consultant. This commentary was originally published in Global Fund Observer (GFO) Issue No. 215 on 23 April 2013, produced by Aidspan.
2. Latest Equinet Updates
This report documents the proceedings of a skills workshop on financing incidence analysis (FIA) that was held to review international experience on the social distribution of burdens of various financing sources and the methods used for assessing financing incidence, drawing on work that has been carried out in Africa. Specifically the workshop sought to: explore ways to realise additional funding from different progressive financing sources; draw input from the Health Economics Unit, University of Cape Town, on methodologies for analysing the progressivity and regressivity of different financing sources; draw lessons from international and local experiences on FIA of different financing sources; and answer questions on how to address challenges with data collection and analysis, review of tools, preliminary results and reporting.
Financing universal health coverage (UHC) is not only about how to generate funds for health services. It is also about how these funds are pooled and used to purchase services. This policy brief explores options for financing UHC in East and Southern Africa (ESA). It presents learning from countries that have made progress towards UHC, including the need to increase domestic funding and to use mandatory pre-payment (tax and other government revenue, possibly supplemented by mandatory health insurance contributions) as the main mechanism for funding health services. The brief indicates the problems associated with introducing or expanding health insurance to fund UHC. With tax funding often the most equitable and efficient option, there is scope for increasing government revenue and health expenditure in many ESA countries.
This policy brief reviews how far the promises of fair globalisation, rights to sustainable development, equity and global solidarity in the 2000 UN Millennium Declaration were delivered for East and Southern Africa. It raises key issues for the post 2015 agenda: There is an unfinished agenda in the MDGS, with wide inequalities in some areas, and monitoring of progress must be socially disaggregated. An agenda for universal health coverage should explicitly address equity in access and investment in strong primary health care services. Thirdly, economic growth is not enough, and public policies should also close wide gaps in access to resources for health, Finally, beyond development aid, global solidarity needs to more explicitly accelerate measures for wider benefit from markets, innovation and wealth in globalisation.
Access to essential medicines is one of the key requirements for achieving equitable health systems and better population health. The number of people with regular access to essential medicines increased from 2.1 billion to about 4 billion between 1997 and 2002. However, access to medicines in sub-Saharan Africa remains low. One reason for this is the low level of domestic production on the continent. This brief outlines the factors that affect medicines production in East and Southern Africa, drawing on the African Union, Southern Africa Development Community (SADC) and East African Community (EAC) pharmaceutical plans. It identifies the barriers to local production as: lack of supportive policies, capital and skills constraints, gaps in regulatory framework, small market size and weak research and development capacities. There are potential opportunities available through south-south cooperation in medicines production. Negotiations on such south-south arrangements would need to look not only at the immediate production investment, but at strengthening capacities for research and development, for regulation, medicines price and quality monitoring, prequalification, infrastructure and human resource development.
This report documents discussions at a regional review meeting held in April 2013, eight months after the start of the 2012 Health Literacy (HL) Programme in Uganda and Zambia. The meeting reported on and reviewed the programme to date and identified progress markers for the outcomes, and identify issues to address, as well as develop future actions for HL in the year ahead. Participatory sessions covered a range of themes, such as to review a protocol for the participatory work for health literacy on sexual and reproductive health (SRH) and to review and plan the next phase of work.
3. Equity in Health
A major outcome of the United Conference for Sustainable Development, better known as Rio+20, held in Rio de Janeiro in June 2012, was the decision to establish a universal, intergovernmental high-level political forum (HLPF) on sustainable development. In this article, the author argues that argued that the proposed HLPF needs to truly be a forum on sustainable development, both in their work on the next set of global development goals and in their broader mandate, rather than a forum on environmental sustainability. The forum will need to make particular effort to engage on economic and social issues so that each of the three pillars of sustainable development is comprehensively addressed. The HLPF must also connect with human rights and peace and security communities to ensure support and legitimacy. The author advocates that the post-2015 development goals be structured as global goals, with national targets. This would make the goals actionable and relevant in different country contexts, and ideally, allow for the goals to be linked more directly to domestic policy priorities.
The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) proposes a cohesive approach to ending preventable pneumonia and diarrhoea deaths. It brings together critical services and interventions to create healthy environments, promotes practices known to protect children from disease and ensures that every child has access to proven and appropriate preventive and treatment measures. The solutions to tackling pneumonia and diarrhoea do not require major advances in technology. Proven interventions exist. Children are dying because services are provided piece- meal and those most at risk are not being reached. Use of effective interventions remains too low; for instance, only 39% of infants less than 6 months are exclusively breastfed while only 60% of children with suspected pneumonia access appropriate care. Moreover, children are not receiving life-saving treatment; only 31% of children with suspected pneumonia receive antibiotics and only 35% of children with diarrhoea receive oral rehydration therapy WHO recommends: exclusive breastfeeding for six months and continued breastfeeding with appropriate complementary feeding; use of vaccines; use of simple, standardised guidelines; use of oral rehydration salts; and proper water, sanitation and hygiene interventions.
In this paper, the authors argue that addressing inequality should be central to the post-2015 development framework. They say inequality must be approached on multiple levels: within countries, among nations, and between generations. Tracking inequalities – for example, the progress of the poorest quintile of the population – is important, but to actually reduce inequality, we must reduce the structural inequalities that cause poverty, they add. Their paper highlights some of the many examples of severe inequalities that can be found both among and within countries today. Inequalities are caused by structural barriers, and new as well as old deprivations. A post-2015 development framework must find ways to build on the progress that has already been made and identify policies that can break down some of the barriers faced by the disadvantaged. While the world might be ready to set ambitious targets in areas such as sustainable energy, water, sanitation, and access to knowledge and technology, the authors point out that other areas like migration and trade should also be taken into account. They demand an agenda that pays more attention to social cohesion and social justice, and emphasise that getting the metrics right is critical to improving the reach and effectiveness as of public services.
This fact sheet outlines trends in key dimensions of socio-economic inequality in the BRICS countries (Brazil, Russia, India, China and South Africa), looking especially at education, gender, health, social expenditure and environmental sustainability. The BRICS countries have growing influence in the global economy, but face challenges in reducing inequality. For instance, growth in the informal jobs sector is associated with deepening inequality, and working women are particularly affected. In South Africa, India and China, rural dwellers are increasingly poorer than their urban counterparts; 50.3% of China’s rural population is excluded from public benefits such as health insurance and higher levels of education. In all the BRICS, girls are disadvantaged in levels of access to education, especially in rural areas. Gaps in women’s and men’s economic participation are high, although the number of women in political leadership in Brazil and South Africa has increased. Regressive taxation systems, dependent on consumption rather than income, and subscription-based social security schemes, mean that the poorest are disproportionately taxed and lack security nets such as health insurance. And with climate change disproportionately impacting poor and vulnerable populations, strategies for ‘green growth’ must also address inequalities in people’s exposure to environmental risks.
This statistical release presents information on mortality and causes of death in South Africa for deaths that occurred in 2010. It also provides information on death occurrences from 1997 to 2009 to show trends in mortality and causes of death. It is based on data collected through the South African civil registration system that is maintained by the Department of Home Affairs. The information on causes of death provided is as recorded on death notification forms completed by medical practitioners and other certifying officials. The results generally showed that mortality continues to decline in the count ry. A total of 543,856 deaths occurred in 2010, which was a 6,2% decline from 579,711 deaths that occurred in 2009. Decreases in the overall number of deaths from the civil registration system have been observed since 2007. The National Population Register, which is maintained by the Department of Home Affairs, also showed annual declines in the number of deaths since 2007. Furthermore, median ages at deaths showed that mortality occurs later in life, which is also an indication of declining mortality. In 2010, the median age at death was estimated at around 48 years, which has increased by about five years since 2004. Tuberculosis maintained its rank as the number one leading cause of death in South Africa (12% of all mortalities).
4. Values, Policies and Rights
This paper reports on an analysis of 11 African Union (AU) policy documents to ascertain the frequency and the extent of mention of 13 core concepts in relation to 12 vulnerable groups, with a specific focus on people with disabilities. The researchers applied the EquiFrame analytical framework to the 11 AU policy documents. The 11 documents were analysed in terms of how many times a core concept was mentioned and the extent of information on how the core concept should be addressed at the implementation level. The analysis of regional AU policies highlighted the broad nature of the reference made to vulnerable groups, with a lack of detailed specifications of different needs of different groups. This is confirmed in the highest vulnerable group mention being for ‘universal’. The reading of the documents suggests that vulnerable groups are homogeneous in their needs, which is not the case. There is a lack of recognition of different needs of different vulnerable groups in accessing health care. The authors conclude that the need for more information and knowledge on the needs of all vulnerable groups is evident. The current lack of mention and of any detail on how to address needs of vulnerable groups will significantly impair the access to equitable health care for all.
Attention to women’s and children’s health is increasing in AU policy making, according to this report. The AU has provided a platform for leaders to debate issues of women’s and children’s health and to make commitments to their improvement. In an environment where different priorities compete for funding, women and children's health could be given greater profile by providing evidence of their contribution to overall development. Improving the health of women and children requires a cross sectoral approach and evidence on collective impact.
Delivering health services to vulnerable populations is a significant challenge in many countries. Groups vulnerable to social, economic, and environmental challenges may not be considered or may be impacted adversely by the health policies that guide such services. In this study, the authors report on the application of EquiFrame, a policy analysis framework, to ten Namibian health policies, representing the top ten health conditions in Namibia identified by the World Health Organisation. Health policies were assessed with respect to their commitment to 21 Core Concepts of human rights and their inclusion of 12 Vulnerable Groups. Substantial variation was identified in the extent to which Core Concepts of human rights and Vulnerable Groups are explicitly mentioned and addressed in these health policies. Four health policies received an Overall Summary Ranking of High quality; three policies were scored as having Moderate quality; while three were assessed to be of Low quality. Health service provision that is equitable, universal, and accessible is instigated by policy content of the same. EquiFrame may provide a tool for health policy appraisal, revision, and development.
Refugees and asylum seekers face a host of challenges when crossing borders, but the obstacles are particularly pronounced for lesbian, gay, bisexual, transgender, or intersex (LGBTI) persons, according to this article. LGBTI asylum seekers and refugees face a range of threats, risks and vulnerabilities throughout the displacement cycle, said the UN Refugee Agency (UNHCR). In situations of upheaval or conflict, sexual and gender minorities have become targets for scapegoating or “moral cleansing” campaigns, compounding the inherent vulnerability created by unrest. Activists say that security in refugee camps is complicated and contingent on numerous, unpredictable factors, which are exacerbated for LGBTI persons. Sexual abuse is common, but often goes unreported because the right questions are not being asked, and because survivors of sexual violence are reluctant to report events that will “out” them to legal authorities. This discrimination impacts negatively on LGBTI’s ability to access basic health services for fear of exposure and discrimination.
With over-consumption of alcohol on the rise, governments are struggling to find suitable legislation to control the marketing of alcohol. The increase in the market for branded alcohol in Africa has been attributed to demographic shifts, including the growth of the middle-class and an increase in self-dependent women. Both law and education are needed to avert the risk of alcohol related disease, injury and death, for both illegally produced local liquor and the big brands of beverage giants. Among the major concerns are the impact of prolific advertising campaigns on young people, particularly in new markets where attitudes. Unethical advertising is also a major concern, with companies suggesting alcohol consumption is a timeless part of African culture, or could lead to a better life and or even sporting achievements.
While gender equality is enshrined in the 1948 UN Declaration of Human Rights, in the Convention on the Elimination of All Forms of Discrimination against Women and in legislation in most countries, women’s conditions of participation in markets and their rewards from that participation, still remain woefully unequal to men’s. Many women work in temporary or informal positions and are therefore “invisible” to laws and regulations. Women also currently bear a disproportionate share of household and domestic labour performing 80% of unpaid care work. Business can’t solve all these problems alone, but corporate practice can either, aggravate and perpetuate gender inequality, or it can help lead the way to for equality among men and women. This article discusses the Women’s Empowerment Principles, which are a set of Principles for business offering guidance on how to empower women in the workplace, marketplace and community. The seven principles are: 1. Establish high-level corporate leadership for gender equality. 2. Treat all women and men fairly at work – respect and support human rights and non-discrimination. 3. Ensure the health, safety and well-being of all women and men workers. 4. Promote education, training and professional development for women. 5. Implement enterprise development, supply chain and marketing practices that empower women. 6. Promote equality through community initiatives and advocacy. 7. Measure and publicly report on progress to achieve gender equality.
5. Health equity in economic and trade policies
This paper highlights the importance of bridging the gap between the extractive sector and productive value chains in Africa in order to foster sustainable transformation and development. In particular, the author stresses the importance of and industrial policy that promotes links between the extractive sector and agriculture and that identifies areas where extractive industries can contribute to value added production.
The inequality debate, the idea of ’trickle-down’ – that the poor can be made less poor if the rich become richer, as this will increase demand for goods produced by the poor – is argued by the author to have failed at the global level, just as it failed at the country level. The current model of globalization is creating a global economy which systematically excludes most of the global poor. The author raises that to accelerate progress in reducing poverty after 2015 – and especially to have some hope of eradicating poverty in a meaningful sense in a period of decades rather than centuries – this needs to change. We need to shift from a model premised on the unrealistic assumption that the economic benefits of growth will automatically trickle down to the poor to one where the considerable economic benefits of poverty reduction and eradication will bubble up to the rest of the economy. This means focusing economic policy on poverty reduction, not growth, particularly in rural areas, where poverty is greatest. The author suggests options for doing this, in public works, cash transfers, income generation, rural electrification and public health and educational services. In most countries, this would require substantial improvements in tax systems, and an increase in tax collection capacity, which would itself be costly.
The landmark decision by the Indian Supreme Court in Delhi to uphold India's Patents Act in the face of a seven-year challenge by Swiss pharmaceutical company Novartis is a major victory for patients' access to affordable medicines in developing countries, according to Médecins Sans Frontières (MSF). The court ruling was made on 1 April 2013 in the face of a seven-year legal battle with the pharmaceutical manufacturer. Novartis first took the Indian government to court in 2006 over its 2005 Patents Act because it wanted a more extensive granting of patent protection for its products than what was offered by Indian law. In a first case before the High Court in Chennai, Novartis claimed that the act did not meet rules set down by the World Trade Organisation and was in violation of the Indian constitution. Novartis lost this case in 2007, but launched a subsequent appeal before the Supreme Court in a bid to weaken the interpretation of the law and empty it of substance. Instead of seeking to abuse the patent system by bending the rules and claiming ever-longer patent protection on older medicines, MSF calls on the pharmaceutical industry to focus on real innovation, and governments should develop a framework that allows for medicines to be developed in a way that also allows for affordable access.
Much has been said in the media about the health innovation and access to medicines impact of the recent decision of the Indian Supreme Court (SC) in the Novartis case. But there are broader implications, argues the author of this article. The ruling is also a revealing tale about the changing role of developing countries in the global intellectual property landscape and the growing influence of the judiciary in these countries in the implementation of international intellectual property rules. The worldwide attention received by the Indian SC ruling and its global implications could represent a turning point, as the Novartis judgment marks the first time that a decision by a judicial authority from a developing country in the area of intellectual property has been so closely scrutinised and so extensively commented upon internationally. The Novartis decision might be spearheading a world where judicial decisions from countries such as China, India and Brazil have an increasing global reach and contribute to shaping global approaches to intellectual property. It is also more generally reflective of the growing assertiveness of developing countries, particularly emerging economies, in the current global intellectual property landscape. However, the author cautions that only the future will tell us is if such a choice is ‘exceptional’ as it touches the highly sensitive issue of drugs affordability – which is of great political and social concern in India – or if it is signalling a broader trend.
The request by least developed countries (LDCs) to push back the date on which they would have to enforce intellectual property rules under the World Trade Organisation (WTO) is the subject of ongoing informal consultations between delegations, as the deadline is fast approaching. Particularly at stake is the time period of the extension, which developed countries would prefer to be limited. Although a large consensus has emerged to grant an extension to LDCs for complying with TRIPS, developed countries voiced their preference for a time-limited extension at the WTO’s March 2013 meeting. Another problem for developing countries is the so-called “no roll-back clause,” which seeks to ensure that if LDCs have granted intellectual property protection to some products, they cannot go back on this decision. LDCs consider this clause as a hindrance to their ability to use policy space. A delegate from an LDC country said that it is important that the extension be awarded as long as a country remains an LDC because many LDCs do not have a technological base. Without that technological base, LDCs would not be able to benefit from intellectual property protection, which might actually hinder their development.
South Africa plans to overhaul its intellectual property laws to improve access to cheaper medicines by making it harder for pharmaceutical firms to register and roll-over patents for drugs, according to the Department of Trade and Industry (DTI). Central to the reforms is closing a loophole known as "ever-greening", whereby drug companies slightly modify an existing drug whose patent is about to expire and then claim it is a new drug, thereby extending its patent protection and their profits. If approved by parliament, the changes should mean cheaper medication for cancer and HIV and AIDS in South Africa. DTI said its policy position was to ensure a strong system that will not grant easy patents, arguing that granting easy patents would open the door for extensions on the original patent. South Africa's position was supported this month by a ruling from India's top court that dismissed an application by Swiss drugmaker Novartis to win patent protection for its Glivec cancer drug. Lobby groups such as Doctors Without Borders (MSF) want South Africa to follow India's example and add a specific clause preventing companies from gaining patents on existing drugs, in a move that would help generic drug manufacturers.
With the support of the Government of South Africa, the World Economic Forum on Africa was held in Cape Town, South Africa, from 8 to 10 May. Over 1,000 participants from more than 80 countries took part. Under the theme ‘Delivering on Africa’s Promise’, the meeting’s agenda integrated three pillars: accelerating economic diversification; boosting strategic infrastructure; and unlocking Africa’s talent. The main message to emerge from the event was the need for investment to consolidate and make more inclusive recent African growth. Participants called for greater regional integration, as well as investments in social entrepreneurship and industry to promote inclusive growth and fight poverty, while others argued that Africa needs to offer better enabling environments for industrialisation to capitalise on opportunities, like the fact that China’s workforce will shed 85 million jobs in the near term. Another participant said that leaders needed to realise that Africa’s true wealth lay in its people, not in its mineral deposits.
6. Poverty and health
This informal document aims at informing policymakers how best to consider the social determinants of health in the post-2015 global thematic consultations organised under the United Nations Development Group. It illustrates the concept of the social determinants of health as applied to the thematic groups, gives examples of why health is important to each theme and shows how each theme could contribute to health. In order to reduce health inequities, the UN Platform argues that there is a need to address the wider socioeconomic and structural factors that influence how people become sick, what risk factors they are exposed to, how they access services, and how they use those services. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. Integrated policy approaches are necessary in order to address the complexity of health inequities, including through national social protection floors, which address income security and the goal to establish universal access to health care simultaneously.
Concepts of ‘what constitutes mental illness’, the presumed aetiology and preferred treatment options, vary considerably from one cultural context to another. In this study, participants from four locations in Burundi, South Sudan and the Democratic Republic of the Congo, were invited to describe ‘problems they knew of that related to thinking, feeling and behaviour?’ Data were collected over 31 focus groups discussions (251 participants) and key informant interviews with traditional healers and health workers. While remarkable similarities occurred across all settings, there were also striking differences. In all areas, participants were able to describe localised syndromes characterised by severe behavioural and cognitive disturbances with considerable resemblance to psychotic disorders. Additionally, respondents throughout all settings described local syndromes that included sadness and social withdrawal as core features. However, attributed causes varied from supernatural to psychosocial and natural. The authors conclude that local conceptualisations have significant implications for the planning of mental-health interventions in resource-poor settings recovering from conflict.
The aim of this study was to examine growth indicators and dietary intake patterns of orphans and vulnerable children aged 4-18 years residing in state-run residential care facilities in Durban, South Africa. Thirty-three girls and 110 boys, aged 5-18 years, in three different children’s homes participated in the study. The results showed that stunting and overweight were prevalent in this group: 4.7% of the boys aged 4-8 years and 3.3% of the boys aged 14-18 years were severely stunted, while 13.3% of the girls aged 9-13 years and 20% of the girls aged 14-18 years were stunted. A small number were wasted. At the same time, 33.3% of the girls aged 4-8 years and 33.4% of the girls aged 9-13 years were at risk of being overweight, while 26.7% of the girls aged 14-18 years were overweight. One hundred per cent or more of the dietary reference intakes for energy, protein, carbohydrate and most of the micronutrients were met, except for calcium and iodine. A low intake of vitamin C among older boys and girls was reported. None of the groups met the recommended fibre intake. The authors call for the development and implementation of a comprehensive nutrition education programme for both child care workers and children.
Wealthy states are currently purchasing millions of hectares of land in poor states throughout Africa. This is a problem for many reasons, including increasing rural poverty and driving millions of people off land that they have been farming for generations. These land purchases also have environmental effects and are resulting in food shortages and food insecurity across Africa. In this paper, the author discusses this controversial practice and concludes that these land purchases should be considered land grabs. He focuses on the environmental effects that such land grabs have and also discusses the social effects of these land grabs on the communities in which they are taking place. The author concludes that African states must immediately recognise that these deals have environmental repercussions that harm not only the natural resources, but their citizens as well; and should thus put measures in place to curb the incidences and conclusion of these deals. African governments should instead sell such land to African entities, or at the very least, entities that will be required to keep a portion of all grown food in the host state to feed the populace. They must also reform land tenure and land registration laws to ensure that their citizens are not forced off land that they have farmed for generations. Only when African states control their land can they ensure that their citizens do not go hungry.
7. Equitable health services
Timely access within 24 hours to an authorised artemisinin-based combination treatment (ACT) outlet is one of the determinants of effective malaria treatment coverage. In this study, timely access was assessed in two district health systems in rural Tanzania: Kilombero-Ulanga and Rufiji. Members of randomly pre-selected households that had experienced a fever episode in the previous two weeks were eligible for a structured interview. Data was collected on timely access from a total of 2,112 interviews in relation to demographics, seasonality, and socio economic status. In Kilombero-Ulanga 41.8% and in Rufiji 36.8% of fever cases had access to an authorised ACT provider within 24 hours of fever onset. In neither site was age, sex, socio-economic status or seasonality of malaria found to be significantly correlated with timely access. The poor results fly in the face of government interventions intended to improve access such as social marketing and accreditation of private dispensing outlets. The authors call for more innovative interventions to raise effective coverage of malaria treatment in Tanzania.
The objective of this study was to investigate factors, including uptake of the offer of HIV testing, associated with availability and utilisation of healthcare by TB patients in a rural programme devolved to primary care in Hlabisa sub-district, KwaZulu-Natal. Three hundred TB patients at primary healthcare clinics (PHC) were randomly selected for the study. Most patients (75.2%) received care for a first episode of TB, mainly pulmonary. Nearly all (94.3%) were offered an HIV test during their current TB treatment episode, patients using their closest clinic being substantially more likely to have been offered HIV testing than those not using their closest clinic. About one-fifth (20.3%) of patients did not take medication under observation, and 3.4% reported missing taking their tablets at some stage. Average travelling time to the clinic and back was 2 hours, most patients (56.8%) using minibus taxis. The study demonstrates high HIV testing rates among TB patients and the authors suggest appropriate management of HIV-TB co-infected patients.
Timely tuberculosis treatment initiation and compliance are the two key factors for a successful tuberculosis control programme. However, studies to understand patents’ perspective on tuberculosis treatment initiation and compliance have been limited in Ethiopia. In this qualitative, phenomenological study, researchers conducted 26 in-depth interviews with tuberculosis patients. Results indicated that a lack of geographic access to health facilities, financial burdens, use of traditional healing systems and delay in diagnosis by health care providers were the main reasons for not initiating tuberculosis treatment timely. Lack of geographic access to health facilities, financial burdens, quality of health services provided and social support were also identified as the main reasons for failing to fully comply with tuberculosis treatments. The authors argue that decentralisation of tuberculosis diagnosis and treatment services to peripheral health facilities, including health posts, is of vital importance to make progress toward achieving tuberculosis control targets in Ethiopia.
8. Human Resources
To mark International Day of the Midwife (5 May), AMREF is calling on African governments to accelerate implementation of Human Resources for Health (HRH) strategies to increase the number of midwives trained and upgraded in the country, to fast track the attainment of MDG 5 (maternal mortality) in all countries where targets have not been achieved and to adopt innovative mechanisms to support the training, recruitment, deployment and retention of midwives across rural and remote areas. Governments should ensure that midwives access to the UN Commission’s 13 lifesaving commodities for women and children, including long-term family planning methods and other commodities for reproductive health, for them to be able to provide appropriate quality health services. At the same time, AMREF recommends that development partners should adopt and support innovative mechanisms for training, recruitment, deployment and retention of midwives in Africa within the post MDG priority setting processes.
According to this article, health worker density/100,000 population is substantially lower in South Africa compared to the vast majority of countries against which South Africa is benchmarked, including the BRIC (Brazil, Russia, India and China) countries. The existing higher education sector is unable to meet the graduate output required by the health sector while foreign recruitment is constrained by current legislation on the registration and practice of foreign healthcare professionals by the Professional Councils and the WHO Global Code of Practice on the International Recruitment of Health Personnel. Existing and future health workforce production is not commensurate with the healthcare needs of the country. A number of challenges are identified: health challenges have outpaced curriculum reform; fragmented, outdated, static curricula produce ill-equipped health graduates; there are episodic encounters as opposed to a continuum of care; healthcare is hospi-centric as opposed to primary healthcare based; there is narrow technical focus without contextual understanding; there exists a mismatch of competencies and patient/population needs; and there is poor teamwork. Solutions to barriers related to the quantitative aspect of health workforce production in South Africa are presented in the article.
The South African government plans to increase the number of new medical students by 10% over the three to four years, raising the total from 1,800 to 2,395 by 2016. According to the Department of Health’s chief operating officer, the department’s plan to ensure more medical students at South African universities is part of its health systems strengthening strategy and aims to address the critical shortage of public health workers in the country, particularly in rural areas.
The African Union has announced its strong support for the new One Million Community Health Workers Campaign that was launched by Rwanda’s President Paul Kagame, Professor Jeffrey Sachs and Novartis CEO Joseph Jimenez at the World Economic Forum early in January 2013. The new campaign will work closely with governments and aid agencies to finance and train the health workers, each of whom would serve an average of around 500 rural inhabitants. The incremental costs for full coverage might sum to around US$2.5 billion per year, or $5 per person per year covered by the expanded CHW programme. The campaign will work to mobilise these additional funds from existing and new external funders, as well as from the host countries consistent with their budgetary means. The campaign aims to boost the ongoing community health worker programmes and policies of many leading institutions.
9. Public-Private Mix
A high-level roundtable on Building Private Equity and Private Capital Markets in Africa met on 8 May 2013 to explore the promise and obstacles facing private capital investments in Africa. The report of this meeting highlights a discussion on the growth of private equity markets in Africa given rapid urbanisation and a growing middle-class, but questions whether the growth of Africa’s private equity will be based on a model that benefits local people.
South African competition authorities will launch an investigation into the private healthcare industry, where early evidence showed high prices and market distortions, according to Economic Development Minister Ebrahim Patel. Various stakeholders have raised concerns about pricing, costs and the state of competition and innovation in private healthcare. Patel said competition authorities had ruled previously that the practice of setting up common tariffs for medical procedures was uncompetitive. Instead he pointed to a growing trend of increasing healthcare costs and a massive asymmetry of power health markets. Patel said preliminary evidence showed that some that in some cases competition was "prevented, distorted or restricted." Private health providers in Africa's largest economy include Life Healthcare, Mediclinic International and Netcare Ltd, all of whom have benefitted from the growth of the middle classes. The Competition Commission, which can impose administrative fines, is expected to launch the "market inquiry" before September 2013.
10. Resource allocation and health financing
The 2005 Paris Declaration on Aid Effectiveness sets targets for increased use by external funders (donors) of recipient country systems for managing aid. This study investigates the degree to which external funders ' use of country systems is in fact positively related to their quality, using indicators explicitly endorsed for this purpose by the Paris Declaration and covering the 2005-2010 period. The author shows that external funders
appear to have modified their aid practices in ways that build rather than undermine administrative capacity and accountability in recipient country governments.
The Global Fund to Fight AIDS, Tuberculosis and Malaria announced a goal of raising US$15 billion so that it can effectively support countries in fighting these three infectious diseases in the 2014-2016 period. The Fund aims to help turn these three high-transmission epidemics into low-level endemics, essentially making them manageable health problems instead of global emergencies. It said that together with other funding, including an estimated US$37 billion from domestic sources in implementing countries and US$24 billion from other international sources, a US$15 billion contribution would allow the Fund to address close to 90% of the global resource needs to fight these three diseases, estimated at a total of US$87 billion. This aggregate level of funding would mean that 17 million patients with tuberculosis and with multidrug-resistant tuberculosis could receive treatment, saving almost 6 million lives over this three-year period.
This report analyses equity and financial protection in the health sector of Malawi. In particular, it examines inequalities in health outcomes, health behaviour and health care utilisation; benefit incidence analysis; and financial protection. It found that ill health is more concentrated among the poor, who use health services significantly less often than the rich. The distribution of government spending on health is mildly pro-rich, while the effect of out-of-pocket payments on household financial well-being is not too severe. In 2003, only about 11.5% of households spent more than 10% of total household consumption on out-of-pocket health payments and only 3% spent more than 40%.
This report analyses equity and financial protection in the health sector of Zambia. In particular, it examines inequalities in health outcomes, health behaviour and health care utilisation; benefit incidence analysis; financial protection; and the progressivity of health care financing. It found that ill health is more concentrated among the poor, who use health services slightly less often than the rich but who do not experience major financial shocks form out of pocket payments. Overall, health care financing in Zambia in 2006 was fairly progressive, i.e. the better off spent a larger fraction of their consumption on health care than the poor. The financing sources that contribute to the overall progressivity of health care finance are general taxation, which finances 42% of domestic spending on health, and contributions made by private employers, which finance 9% of spending. An additional contribution to overall progressivity is made through pre-payment mechanisms, but this remains fairly limited given that they only represent 1% of total health finance. Out-of-pocket health payments, which account for 47% total health financing, appear to be proportional to income, with only slight and not statistically significant evidence of progressivity.
This report is the first ever to track what developing countries are spending on the Millennium Development Goals (MDGs). It finds that recent spending increases explain the rapid progress on the MDGs, but the vast majority of countries are spending much less than they have promised, or than is needed to achieve the MDGs or their potential successor post-2015 goals. Aid cuts, low implementation rates and low recurrent spending all threaten to reverse existing progress. The report suggests that developing countries need to make data on MDG spending more accessible to their citizens; to strengthen policies for revenue mobilisation (notably combating tax avoidance and tax havens), debt and aid management; and to spend more on agriculture, water, sanitation and hygiene, and social protection. External funders need to report and repatriate illicit outflows; end laws and investment treaties which reduce poor countries’ revenues; increase innovative financing such as financial transaction and carbon taxes; put more aid through developing country budgets; maximise budget and sector support to make spending more accountable; and report planned disbursements to developing countries. Finally, the International Monetary Fund needs to sharply increase space for sustainable spending in its programmes.
Members of Parliament have called for health insurance coverage for all Tanzanians, noting that the government should find ways of making the National Health Insurance Fund (NHIF) accessible to every Tanzanian, regardless of whether they are in the formal sector or not. Debating budget estimates for the Ministry of Health and Social Welfare, the legislators decried weaknesses in the current distribution system of drugs and medical equipment and the scarcity of health workers, and claimed that enrolling all people in the NHIF would support wider access to quality health services, particularly for mothers and children.
11. Equity and HIV/AIDS
To investigate the claim that widespread availability of antiretroviral therapy (ART) may result in sexual disinhibition, including practice of high-risk sexual behaviour, the authors of this study determined the correlates of sexual activity and high-risk sexual behaviour in an ART-treated population in rural and urban Uganda. They studied 329 ART-treated adult patients at two hospitals in western Uganda, collecting data on sexual activity, frequency of condom use, pregnancy, viral load and CD4 counts. Younger age, higher monthly income and being married were associated with being sexually active. Among the sexually active, alcohol consumption and unknown serostatus of partner were significant predictors of high-risk sexual behaviour. The frequency of unprotected sex at the last intercourse was 25.9% and 22.1% among the men and women respectively and was not significantly different. The authors recommend that counselling on alcohol use and disclosure of sero-status may be useful in reducing high-risk sexual behaviour.
In April 2013, the South African government announced that it will offer all HIV-infected pregnant and breastfeeding women antiretroviral (ARV) treatment, regardless of the state of their health. Previously, only pregnant women with significantly weakened immune systems qualified for the drugs. The government is also now supplying HIV-infected pregnant women with a convenient once-a-day tablet. A department of health spokesperson said an increase in access to ARVs will lead to a decline in maternal mortality. Almost half of all maternal deaths in South Africa are caused by HIV-related complications. However, the former director of maternal health at the department of health, Eddie Mhlanga, disagreed, arguing that there is no evidence yet that the government's antiretroviral drug programme has led to a lower chance of pregnant women infected with the virus dying during pregnancy, childbirth or within 42 days thereafter. He said negligence, substandard care and mismanagement in maternal wards would first need to be addressed.
This study reports on a ten-step Nurse Initiation Management of Antiretroviral Treatment (NIMART) rollout intervention in which 45 nurses from 17 primary healthcare centres (PHCs) in Johannesburg, South Africa, were trained and mentored in NIMART to commence patients on antiretroviral treatment (ART). A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. By the end of September 2011, all 17 PHCs were initiating patients on ART. Total initiations significantly increased by 99 patients immediately after NIMART rollout and continued to increase by an average of 9 every month, while referral facility initiations decreased by 12 immediately after NIMART and then decreased by an average of 18 every month. In conclusion, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, the authors argue that it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients.
In a study of prevention of mother-to-child transmission of HIV (PMTCT) by triple antiretroviral therapy (ART) in Dar es Salaam, Tanzania (the Mitra Plus study), retrospective viral load testing revealed a high and increasing frequency of detectable viral load during follow-up for two years postnatally in women given continuous ART for their own health suggesting poor adherence. This study explored women’s own perceived barriers to adherence to ART post-delivery so as to identify ways to facilitate better drug adherence. Semi-structured interviews were conducted with 23 of the 48 women who had detectable viral load at 24 months postnatally. Most women in the study did not acknowledge poor adherence until confronted with the viral load figures. Then they revealed multiple reasons for failing to adhere to ART, which included lack of motivation to continue ART after weaning the child, poverty and stigma. PMTCT and ART projects need to address these issues, as well as women’s lack of empowerment. The authors argue that the new World Health Organisation’s proposal to start all HIV-infected pregnant women on lifelong ART regardless of CD4 cell count needs to address the challenging realities of women in resource-poor contexts if it is to be successful.
12. Governance and participation in health
Governments across Africa are clamping down on dissent, hiding their secrets and attacking the funding base of their critics. In this article the author points out that political movements that once fought for freedom and prosperity, having assumed power, are now undermining both by trying to restrict civil society. He argues that what these governments ignore at their peril is that debate and dissent are vital to both vibrant democracy and economic prosperity. Rather than seeing civil society as a threat, they should see it as a building block of a stable democracy; one that needs to be nurtured, not over-regulated. Community-based organisations can deliver grounded and cost-effective services, helping to educate and skill-up people to take advantage of economic opportunities. They are also big employers in their own right, and a new generation of social entrepreneurs across the continent is emerging with innovative and profitable ways of tackling intractable social problems.
In late 2012, the board of the Global Fund to Fight Malaria, Tuberculosis and AIDS approved a new funding model (NFM), which significantly changes the manner in which funds are allocated, applied for, awarded, disbursed, and monitored. The NFM was formally launched on 28 February 2013, though it will remain in a transitional phase until 2014. While there is much promise in the NFM, there are many questions, some of which are raised in this report. The Fund has established a framework for the core aspects of grant funding under the NFM, but there remain countless details to be uncovered through real-world experience and regulated by Fund policy and protocol. This report reviews the key components of the NFM from a civil society and key population perspective, with a focus on its impact on AIDS programmes. Incorporating the views of leaders from key populations and civil society around the world, the report provides a summary of some current top-level concerns related to the roll-out of the NFM and offers recommendations on how to implement the NFM in a manner which is responsive to and inclusive of civil society and key populations, and ultimately which has the greatest impact on ending the AIDS epidemic globally.
Civil rights groups and communities have expressed concern about the failure of South Africa's Department of Health to release the National Aids Vaccine Strategic Plan (NAVSP) for 2013-2017. In 2012, the Department of Health requested the South African Aids Vaccine Initiative (SAAVI) to develop the NAVSP in collaboration with researchers all over the world and communities and Community Advisory Groups in South Africa. However, since its development the document has been embargoed for public scrutiny without any reason given. At a recent community roundtable on Aids Vaccine Research and Development indicated their dissatisfaction with the embargo on the document as they believe it contains clear objectives on community involvement in AIDS vaccine research that is happening in the country. Researchers from various organisation, including the Perinatal HIV Research Unit, the Aurum Institute for Health Research and the Desmond Tutu HIV Foundation agreed that the embargo creates suspicion about the department’s activities to reduce HIV infections through vaccines and ARVs prevention research.
The role of multilateral external funding agencies in global health is a new area of research, with limited research on how these agencies differ in terms of their governance arrangements, especially in relation to transparency, inclusiveness, accountability, and responsiveness to civil society. In this paper, the authors argue that historical analysis of the origins of these agencies and their coalition formation processes can help to explain these differences. They propose an analytical approach that links the theoretical literature discussing institutional origins to path dependency and institutional theory relating to proto institutions in order to illustrate the differences in coalition formation processes that shape governance within four multilateral agencies involved in global health. Two new multilateral donor agencies that were created by a diverse coalition of state and non-state actors, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and GAVI (‘proto-institutions’), were more adaptive in strengthening their governance processes. This contrasts with two well-established multilateral external funding agencies, such as the World Bank and the Asian Development Bank, what we call Bretton Woods (BW) institutions, which were created by nation states alone; and hence, have different origins and consequently different path dependent processes.
To inform policy makers about the feasibility of facility-based SMS interventions, this national, cross-sectional, cluster sample survey was undertaken in 2012 at 172 public health facilities in Kenya. Outpatient health workers and caregivers of sick children and adult patients were interviewed about personal ownership of mobile phones and use of SMS. The analysis included 219 health workers and 1,177 patients’ respondents (767 caregivers and 410 adult patients). All health workers possessed personal mobile phones and 98.6% used SMS. Among patients’ respondents, 61.2% owned phones and 71.4% of phone owners used SMS. The phone ownership and SMS use was similar between caregivers of sick children and adult patients. Wealthier respondents who were male, more educated, literate and living in urban area were significantly more likely to own a phone and use SMS. Mobile phone ownership and SMS use is ubiquitous among Kenyan health workers in the public sector, the researchers conclude. Some of the disparities on SMS use can be addressed through the modalities of m-Health interventions and enhanced implementation processes while further growth in mobile phone penetration is needed to reduce the ownership gap.
PHM WHO watchers developed statements on many of the 2013 World Health Assembly WHA66 agenda items. This website provides statements read out by PHM during the WHA66 and links to daily reports prepared by the PHM WHO watchers. The statements are on WHO Reform; WHO General Program of Work; Social Determinants of Health; MDG's and Post 2015 Agenda; Universal Health Coverage and the Consultative Expert Working Group on Research and Development.
The South African government plans to launch a National Recordal System (NRS) to catalogue its indigenous knowledge. According to the South African Department of Science and Technology (CSIR) benefits could include community recognition, sustainable livelihood, economic value and improved quality of life. Most of the traditional knowledge in South Africa is oral, passed down from one generation to the next, and with older generations passing away, the need to record that knowledge is urgent. Much of this knowledge is medical and is based on traditional remedies and treatments for illnesses. The NRS includes the establishment of indigenous knowledge networks, provincial Indigenous Knowledge Systems Documentation Centers (IKSDCs) and an Information Communication Technology (ICT) knowledge platform. The NRS aims to enable and maintain a secure, accessible national repository for the management, dissemination and promotion of indigenous traditional knowledge, and achieve national intellectual property objectives for the protection of indigenous traditional knowledge.
The State of Civil Society 2013 Report presents insights from over 50 civil society experts from around the world. Alongside the report, CIVICUS is publishing a draft methodology for an Enabling Environment Index (EEI) that seeks to measure how well countries around the world are doing on creating positive conditions for civil society. Amidst the challenges facing civil society, the 2013 report highlights good practices around the world and challenges on the horizon for citizens and civil society around the world, such as: rising fundamentalism threatening women's and sexual minorities rights movements; challenges to democracy in Africa, with case studies from Burkina Faso, Central African Republic, Democratic Republic of Congo and Uganda; the state of the internet and access to information; threats to writers, journalists and trade unionists; and civil society successes.
This paper is aimed at those who work as health facilitators and activists at community level, civil society organisations, government personnel and anyone else interested in the rights of ordinary citizens to participate in decisions and have access to the resources that determine the way their country’s health system functions. The paper is divided into three sections: The first focuses on how the interaction between people’s participation, knowledge and power effects the functioning of health systems. The following section pays particular attention to approaches we can use to build a more just and equitable health system. The final section concludes by asking a series of questions to provoke and deepen our thinking on ways we can overcome obstacles to achieving this goal, at both community level and as we move from the local to the global as a strategy for change. Each section blends discussion on concepts and issues with descriptions of experiences and case studies from around the globe, especially from countries in Latin America, Asia and east and southern Africa, where a wealth of material describes the impact of neoliberalism and globalisation on health systems, and attempts to build alternatives.
The Sixty-fifth World Health Assembly requested the Director-General to report, through the Executive Board at its 132nd session, to the Sixty-sixth World Health Assembly, on progress in the implementation of WHO reform, on the basis of a monitoring and implementation framework. This report provides a comprehensive overview of progress up to the end of the first quarter of 2013 in the three broad areas of WHO reform: programmes and priority-setting; governance; and management, as well as a high-level implementation plan for reform. A comprehensive, detailed and budgeted implementation plan is the basis for managing change, monitoring progress, and mobilising resources to finance the proposed reform activities. The plan and report are structured around the 12 elements of reform that were identified in the monitoring and implementation framework considered by the Sixty-fifth World Health Assembly, and include an additional element on change management. The report provides a narrative describing action taken in each area, and a status update on the outputs and key deliverables.
13. Monitoring equity and research policy
The challenge of improving healthcare information in countries with meagre resources will require more than just highlighting insufficiencies, according to this editorial. The right to access health information is a key component of a strong health system, but to be effective it requires evaluation and synthesis of evidence, translation of evidence into educational materials, and implementation and dissemination. Health information is key to improving weak health systems. If governments are legally obliged to support the right to access reliable health information, what can be done to ensure that they do so? It is suggested that a legal approach may not work, but that locating access to reliable health information within the broader human rights framework may generate benefit from the momentum of human rights advocacy.
In this study, the authors aim to provide a comprehensive description of available data sources, propose a set of indicators for monitoring the global landscape of health research and development (R&D), and present a sample of country indicators on research inputs (investments), processes (clinical trials), and outputs (publications), based on data from international databases. Total global investments in health R&D (both public and private sector) in 2009 reached US$240 billion. Only about 1% of all health R&D investments were allocated to neglected diseases in 2010. Diseases of relevance to high-income countries were investigated in clinical trials seven-to-eight-times more often than were diseases whose burden lies mainly in low-income and middle-income countries. This report confirms that substantial gaps in the global landscape of health R&D remain, especially for and in low-income and middle-income countries. Too few investments are targeted towards the health needs of these countries. Better data are needed to improve priority setting and coordination for health R&D, the authors argue, ultimately to ensure that resources are allocated to diseases and regions where they are needed the most. The establishment of a global observatory on health R&D, which is being discussed at WHO, could address the absence of a comprehensive and sustainable mechanism for regular global monitoring of health R&D.
Tackling health inequalities must be a central plank of public policy for any Government, and this report is intended to help to shape the policy direction, and inﬂuence the targeting and delivery of services, in tackling inequalities. The evidence base about “what works” is still fairly weak, but there is now a commitment to address this. Resources are going into research and development to advance our knowledge and understanding of what works. This report works in parallel to that research, in terms of measuring inequalities in order to plan, set targets, monitor and evaluate. The authors recommend establishing mechanisms to monitor inequalities in health and to evaluate the effectiveness of measures taken to reduce them. This report is relevant to anyone involved in addressing health inequalities, as it presents the complicated science of the measurement of inequalities in a rigorous but accessible way.
In 2007, the 60th World Health Assembly endorsed a Global Plan of Action on Workers’ Health for 2008-2017 and urged WHO member states to devise national policies and plans for its implementation. To establish a baseline for measuring progress, information was collected in 2008-2009 from Member States – this report presents the findings of that survey. While most countries have introduced ways of addressing risks at the workplace such as integrated management of chemicals and tobacco smoking bans, enforcement of regulations for workplace health protection remains insufficient. Less than half of countries surveyed have endorsed or drafted a national plan of action on workers’ health. Only one third of countries cover more than 30% of their workers with occupational health services. Although half the countries have national workers’ health profiles with data on occupational diseases, injuries, and legislation, information about communicable and non-communicable diseases among workers and about lifestyle risks are the least-covered topics. Workers’ health issues feature in policies concerning management of chemicals, emergency preparedness and response, employment strategies, and vocational training. However, workers’ health is seldom considered in policies regarding climate change, trade, economic development, poverty reduction, and general education.
14. Useful Resources
This monitoring and evaluation framework is a guide for project implementers to help them develop national monitoring and evaluation plans to monitor and report on progress when implementing mobile messaging programmes for mothers. The key objective of this framework is to ensure that MAMA programme outputs meet the needs of the target population. The indicators presented in this framework can be used to monitor and report on progress in the implementation of the various MAMA initiative components in countries.
Since the World Conference on Social Determinants of Health in Rio de Janeiro last 2011, there has been a surge of interest and commitment among different stakeholders, especially WHO Member States, to addressing the social determinants of health to achieve health equity. In order to support this growing global movement, the Secretariat now launches a newly-revitalised website that captures the considerable body of work done since the launch of the report of the WHO Commission on Social Determinants of Health in 2008. The website’s contents are more accessible and better organised, and include useful information in three areas. 1. Evidence established by WHO and its partners on the various themes covered by the Commission’s work. 2. Action in terms of WHO programmes and activities that implement the five action areas of the Rio Political Declaration on Social Determinants of Health. 3. Global commitments, including key documents, resolutions, and declarations that express the political commitment of WHO, its Member States, and the global community to the social determinants of health approach.
This guide was developed by amfAR’s MSM Initiative to provide fundraising assistance to community-based organisations that provide HIV-related programs and services for gay men, transgender individuals, and other men who sex with men (MSM) in low- and middle-income countries. In this guide, a number of key questions are answered about external funders, grants, programmes and projects The guide offers information about who is funding MSM/LGBT groups, snapshots of what those grant programmes look like, how to approach funders, and what projects those grant makers have supported in the past. This toolkit goes beyond traditional funders, such as private foundations, and offers information and ideas about other organisations that provide funding to, or partner with, MSM/LGBT groups. Finally, the guide offers general tips on fundraising, from networking to proposal writing, and includes templates to help organisations and activists get started.
Embassies play a vital role in the co-ordination of bilateral and multilateral development efforts. Certain embassies organise and directly implement a funding country bilateral aid (such as the Dutch Embassies). Other external funder countries, such as Germany, manage grant schemes through their diplomatic offices abroad. Embassies could also provide crucial training schemes to support the managerial and administrative capacity of NGO workers (such as the British Embassy) and serve as platforms to get in contact with other local and international NGOs working in the same field of action. This guide takes in account programmes and strategies of five embassies working in developing countries. It illustrates what strategies have been so far implemented, offers ideas on how to engage local embassies on collaborative projects.
15. Jobs and Announcements
This conference will bring together researchers, activists, labour representatives, development practitioners and policy makers from around the world working to promote progressive public services, with an emphasis on health, water and electricity. It will showcase promising alternatives to private provision, as well as those which push forward our conceptual and methodological understandings of how public attitudes and practices arise, how they are constituted, and how they might be sustained. Papers can have a regional (Africa, Asia, Latin America) and/or sectoral focus (water, electricity, health) and should represent original work. All topics will be considered, as long as they meet the central conference theme of researching and promoting progressive public services.
The ICASA conference is held every year in sub-Saharan Africa and aims to contribute towards overcoming the HIV and TB epidemics that grip the region. The theme for 2013 is ‘Now more than Ever: Targeting Zero’. Abstracts may be according to one of several tracks: basic science; clinical science, treatment and care; epidemiology and prevention science; social science, human rights and political science; and health systems, implementation science and economics. ICASA 2013 will present a Young Investigator Award in each track. To be eligible, the presenting author of an abstract must be no older than 35 years of age on 7 December 2013. The Young Investigator Prize: Women, Girls and HIV/AIDS will be awarded to a young woman investigator from a resource-limited setting whose abstract most demonstrates excellence in research and/or practice that address women, girls and gender issues related to HIV and AIDS.
This call goes out to all African health economists and health policy analysts or those working in Africa or on research of relevance to Africa to submit abstracts for the Second Conference of the African Health Economics and Policy Association (AfHEA), which will be held in Nairobi, Kenya, from 11 to 13 March 2014. The overall theme of this conference is "The Post-2015 African Health Agenda and UHC: Opportunities and Challenges". Researchers and other actors are encouraged to submit abstracts on this broad theme or indeed on any other interesting, innovative or topical African health sector or systems research that may be presented orally or in poster format at the conference. Proposals for organised sessions are also invited from interested individuals or institutions.
The Economics of Tobacco Control Project at the University of Cape Town is soliciting expressions of interest from potential participants in an Emerging Tobacco Control Researcher Programme to be held in Cape Town, South Africa in 2013. The programme is to be held in partnership with the International Tobacco Control Research Program at the American Cancer Society and funded through a grant by the Bill & Melinda Gates Foundation as part of the African Tobacco Control Consortium. The programme is expected to take place in October 2013 and participants will spend a week in residence in Cape Town participating in workshops on tobacco control research. This year the programme will focus on the economics of tobacco control, with a particular interest in poverty and tobacco use, and will explore the use of existing survey instruments including expenditure surveys and demographic and health surveys.
The next Emerging Voices venture will take place on 7-11 December 2013 at the ICASA Conference in Cape Town, South Africa. Emerging Voices for Global Health (EV4GH) is a blended training programme for young researchers on health research and scientific communication. EV4GH trains “Emerging Voices” to participate actively in international conferences and to raise their voice in the scientific debate. There are three thematic tracks: Track 1 (clinical track). Theme: HIV co-infection: clinical challenges anno 2013. Track 2 (prevention track). Theme: Combination prevention for HIV. Track 3 (health systems track). Theme: HIV & Health Systems Strengthening. Applicants must be under 40 years of age (born after 1 January 1973), a researcher, a decision maker, or a practitioner involved in HIV and AIDS in Africa.
The Human Rights Scholarship (HRS) is awarded to local or international applicants wishing to undertake graduate research studies at the University of Melbourne in the human rights field and who are able to demonstrate their commitment to the peaceful advancement of respect for human rights. Each year the University offers two HRSs. Applicants must be able to demonstrate that their commitment to the peaceful advancement of respect for human rights extends beyond their academic studies (such as voluntary work and/or work experience). Applicants must have applied for, or be currently enrolled in a graduate research degree in the human rights field at the University of Melbourne. Applicants who have commenced their graduate research degree must have at least 12 months full-time or equivalent candidature remaining. International students must have an unconditional course offer at the University of Melbourne for the course for which they seek the support of a HRS.
The Global Network for Health Equity (GNHE) has launched its Scholarships Programme for 2013–2014. The programme aims to build capacity in low and middle-income countries for health systems research into issues of health systems equity and universal health coverage, by supporting junior researchers from those countries undertaking research on any of the following topics: equity in health systems financing and financial protection; equity in health systems delivery, including access and utilisation; equity in health outcomes at the population level; and universal health coverage. Applications from health economics and all other relevant research fields will be considered as well as inter-disciplinary proposals.
These two events will be held jointly in South Africa. The target audience is policy makers, public health academics and students, health professionals, health service managers and individuals from non-governmental and community-based health organisations. The joint conference will have as its focus, a scientific debate and discussion on strategies and action needed to move beyond the MDGs and on the public health legacy that we should leave, or want to, leave behind for the future generation. Speakers will include policy-makers, leading local and international academics and representatives of international organisations, such as the World Health Organisation (WHO) and the World Federation of Public Health Associations. Parallel workshops will precede the main conference, with wide-ranging topics to suit diverse interests.
These two events will be held jointly in South Africa. The target audience is policy makers, public health academics and students, health professionals, health service managers and individuals from non-governmental and community-based health organisations. The joint conference will have as its focus, a scientific debate and discussion on strategies and action needed to move beyond the MDGs and on the public health legacy that we should leave, or want to, leave behind for the future generation. Speakers will include policy-makers, leading local and international academics and representatives of international organisations, such as the World Health Organisation (WHO) and the World Federation of Public Health Associations. Parallel workshops will precede the main conference, with wide-ranging topics to suit diverse interests.
A total of four postdoctoral fellowships are available in the area of Health Policy and Systems Research (HPSR) for the Collaboration for Health Systems and Policy Analysis and Innovation (CHESAI) project, which is based at the School of Public Health and Family Medicine, University of Cape Town (UCT) and the School of Public Health, University of Western Cape (UWC), both in Cape Town, South Africa. The fellowships are for the period 2012-2016. Applicants must have citizenship of a sub-Saharan African country, be an expatriate African, or demonstrate commitment to future work in African health systems. They must have achieved a PhD in the last five years in any suitable field, such as health sciences or social sciences and not have previously held any permanent academic positions. Their work must show clear evidence of robust scholarly performance including a relevant publications record and have some relevant experience, specifically a track record of interest in health policy and systems issues, preferably including research. Applicants will be asked to propose an area of work relevant to one or more of the CHESAI themes, and to show how their past research provides a basis for this proposed work and/or what additional activities are proposed to contribute to the CHESAI community of practice. Please contact Jill Oliver and Thubelihle Mathole at the email address given.
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