This week, while South Africa united to celebrate Mandela’s 95th birthday, the Abuja +12 Special Summit on HIV/AIDS, TB and Malaria was kicked off by a Statement from President Goodluck Jonathan who launched a new HIV/AIDS Response Plan targeted at achieving universal access to the prevention, treatment, care and support for all Nigerians living with HIV/AIDS. The Summit intended to evaluate the efforts made since the 2001 Abuja Declaration urged governments to spend fifteen percent of their annual budgets to improve the health sector, renewing commitment to scaling-up actions to fight the three epidemics and increase domestic spending.
Whether the Summit will result in improved outcomes remains, of course, a matter of debate. The fact that Sudanese President al-Bashir reportedly fled the country under heavy international pressure could not preclude Abuja +12 from discussing important lessons and keeping ambitions high on the political agenda. Although the MDGs will not be met by 2015, and no targets for increased domestic spending have been set, the principles that underlie the successful AIDS response over the last decade can surely be leveraged for the post-2015 agenda, while the continued work of the AIDS Watch Africa Champions clearly point to the strong political commitment to moving forward the African Union Roadmap for Shared Responsibility & Global Solidarity for AIDS, TB and Malaria.
As usual, the details are provided in this newsletter, as well as a summary of the most interesting articles and highlights of this week’s global health agenda. Attention is paid to the discussion of NTD and evidence-based policy, the new UN framework on HIV/AIDS, and an editorial from EV Emma Chademana who recounts her experience of attending the health system track of the 6th SA AIDS Conference in Durban.
Enjoy your reading (and the holidays 😉
Peter Delobelle, Kristof Decoster, Ildikó Bokros, Basile Keugoung & Wim Van Damme
Building on Successes: Insight in the Health Systems’ Track of the 6th South African AIDS Conference, 2013
“As a country, we have made significant inroads in our response and have begun to see the impact of our policies and strategies” remarked Deputy President Kgalema Motlanthe at the closing session of the 6th South Africa (SA) AIDS Conference. The Conference, which took place from 18-21 June in Durban, was centred around the theme “Building on Successes: Integrating Systems”.
The theme resonated throughout the track on Health Systems, Programmes, Human Rights and Ethics as the overall tone was largely positive, acknowledging the successes achieved in the fight against HIV/AIDS. A broad range of interventions were presented, some specific to HIV/AIDS and others more general to health system strengthening. Some interesting discussions of the use of antiretroviral treatment (ART) adherence clubs as a model of decentralisation; new technologies improving service delivery; South Africa’s new Integrated School Health Policy and the ART drug stock-out crisis in the Eastern Cape Province.
In particular, there were presentations and discussions of how decentralisation of care has helped the country’s health system cope with the increased patient load. Currently South Africa has over two million people on ART and the National Strategic Plan 2012-2016 targets to have 80% of all people eligible to be placed on ART by 2016, which is estimated to be more than three million people; this growing number puts an increasing pressure on the already stretched human resource capacity. An ART delivery model was presented at the conference using adherence clubs to provide ART in Gugulethu, Cape Town. An adherence club consists of a group of patients who meet regularly with a lay health worker, such as a community care worker, and receive their pre-packed medication, rapid clinical assessments, referrals and peer support services. This is a long-term retention model of care catering for stable ART patients. Adherence clubs offer the potential to reduce pressure on facilities by reducing patient load and hence reducing waiting times, in turn contributing to increased long-term patient retention.
The presentations also showed how the use of technology has helped strengthen system performance in line with the WHO Health Systems Framework, which advocates the use of new technologies as a building block for a well-functioning health system. . For example, the use of GeneXpert for active TB case detection has significantly increased TB case findings and decreased the time to treatment in Sisonke district, KwaZulu-Natal. The GeneXpert MTB/RIF test diagnoses both TB and rifampicin-resistance in under two hours, which means that people presenting with a case of multiple drug resistance (MDR) TB can be put on treatment much earlier. In the TB Reach project, the average time from sputum collection to treatment for drug-resistant TB decreased from 136 days to 15 days. This project also used mobile phone technology to link patients to Community Health Facilitators (CHFs), as the CHFs use cell phones to contact patients directly once results from the lab arrive. South Africa is also leading the way in mobile health technology (mHealth) with the use of cell phone messaging for CD4 count results, and adherence and appointment reminders. mHealth has shown to be a viable option in increasing patient entry and retention in care and it provides a promising solution for ensuring health systems strengthening. Discussions of mHealth, however, centred largely around its sustainability in the SA public health sector, as it requires IT infrastructure and governmental resourcing.
Another focus was on intersectoral collaboration, which is a guiding principle of the Ouagadougou declaration on Primary Health Care and Health Systems in Africa. It recognizes the need for coordinated intersectoral action in order to improve health determinants. This principle was echoed at the conference in a discussion of South Africa’s new Integrated School Health Programme (ISHP), where the Departments of Health (DOH), Basic Education (DBE) and Social Development (DSD) have taken joint responsibility for ensuring that health services reach all learners across the education system. The programme aims to build on and strengthen existing school health services for learners by offering a comprehensive package of health education and promotion, learner assessment and screening, on site health care services, and environmental assessments. The ISHP is rooted within the Primary Healthcare Re-engineering approach in the department of Health and the Care and Support Learning Programme in the Department of Basic Education.
Lastly, the drug supply challenge was a very prominent topic at the conference, as the Eastern Cape has been experiencing on-going interruptions of ART and TB drug supply. This drug supply crisis stretches across SA for ART and various other chronic medications. A coalition consisting of the Rural Health Advocacy Project (RHAP), Doctors Without Borders (MSF), the Treatment Action Campaign (TAC) and SECTION 27 released a report on the catastrophic drug supply crisis in the Eastern Cape and other provinces in the country at the conference. The report, “The Chronic Crisis: Essential drug stock-outs risk unnecessary death and drug resistance in South Africa” is a follow-up to an earlier report released in January that outlined the history of the Mthatha Medical Depot crisis and the intervention by TAC and MSF. The follow-up report discusses results from their survey where 40% of 70 facilities in Eastern Cape experienced HIV and TB drug shortages with stock-outs lasting on average 45 days and forcing thousands of people to interrupt their treatment. The Mthatha crisis dates back to October 2012 and has still not been addressed. In response to the problem, the coalition has set up a civil society monitoring group that will focus on solving the drug supply problems and continue monitoring drug supply across the country. The coalition called for urgent action from the National Department of Health and the Eastern Cape Department of Health and stresses that “any durable solution to the supply problems in the Mthatha region must make the Depot and health system as a whole more accountable to the patients that it serves.”
The fight against HIV/AIDS in South Africa can be largely attributed to an integrated response, focused leadership and dedicated funding, through conditional grants and donor programs. However, the country still faces challenges in its health system, notably in its drug supply management.
Recommendations and lessons from the SA AIDS Conference health systems’ track hence include:
- building a health workforce capacity requires a combination of approaches such as training, mentoring, increasing staff numbers and building positive attitudes;
- intersectoral collaboration is vital for a well-functioning health system;
- sharing and distilling health system strengthening experience and innovations is required for more systematic scaling up and
- there is need to strengthen community systems and civil society engagement.
From these recommendations, it is evident that health system strengthening involves reinforcing many complex and interlinked systems as well as using an intersectoral approach, and that there is no magic bullet.
Global Health News
1. Abuja +12 Special Summit on HIV/AIDS, TB and Malaria
The Abuja +12 Special AU Summit on HIV/AIDS, TB and Malaria, which took place in the Nigerian capital from 15-16 July, served as a follow-up to the 2001 Summit of AU Member States, which culminated in the Abuja Declaration of commitment on HIV/AIDS by which leaders pledged to allocate 15 percent of their annual budgets to improvement of the health sector. Until now, however, only a few countries managed to achieve this target.
In addition to reviewing past achievements and mapping the road ahead, Abuja +12 called for improved access to HIV/AIDS, TB and malaria treatment, care and support, including for MDR-TB, while implementing the African Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, and building capacity and adequate facilities for the detection and monitoring of XDR-TB.
A Report, Abuja +12: Shaping the future of health in Africa, was also launched at the Summit, emphasizing increased targeted health spending as the essential foundation to greater economic growth and development in Africa. The Report is published jointly by AU/UNAIDS, reviews the progress made since the AU’s 2001 Abuja Declaration, highlights remaining gaps, and prioritizes the next steps.
The UN has launched a new framework to give fifteen million people with HIV/AIDS access to antiretroviral treatment by the year 2015. ‘The framework, named Treatment 2015, offers countries and stakeholders practical and innovative ways to increase the number of people accessing ART that will enable those living with HIV to live longer and healthier lives, as well as help prevent new infections’ the UN news centre writes.
Treatment 2015 also takes into account the new and consolidated WHO guidelines on the use of ART for treating and preventing HIV released last month. These guidelines recommend that people living with HIV start ART at a much earlier stage, which has important public health consequences, as outlined in NPR’s Shots blog and ‘Morning Edition’ program for South Africa: “If the country ends up adopting the latest WHO recommendations more than a million additional South Africans could be put on ART at public expense” the blog states, and “the new WHO treatment guidelines are widely praised in the country by physicians and activists as a step forward,” but some in the country have “been opposed to the new global guidelines.” NPR quotes a number of public health experts and policymakers on both sides of the argument, highlighting the issues of drug toxicity and stock outs in the country.
3. Plos – Has the NTD Community Neglected Evidence-Based Policy?
In this viewpoint, members of the Cochrane Infectious Diseases’ Group express their concern about the slow uptake of evidence-based policy and debate among neglected tropical disease (NTD) researchers, and present the available evidence in the field.
In a reply to this viewpoint, Montresor et al. of the WHO Department of NTD Control point out the limitations of RCTs and consider long-term monitoring of the impact of a disease control or elimination programme to be the best way to evaluate the benefits of preventive chemotherapy interventions in communities. WHO has also named three NTD drugs to be included on the list of essential drugs, which is a major victory for a 10-year old program to develop drugs in this area of the Drugs for Neglected Diseases Initiative.
The End the Neglect website has also posted an interview with an NTD expert.
4. Lancet – Burden and aetiology of diarrhoeal disease in infants and young children in developing countries
In this three year, prospective, case-control study in children younger than five years in low-income countries in Africa and Asia, four pathogens were found to be the most attributable causes of moderate-to-severe diarrhea, leading to increased odds of dying during the first life years. Interventions targeting these pathogens could substantially reduce the population-based burden of diarrhoeal disease in sub-Saharan Africa and South Asia.
5. PLOS Medicine: Global Burden of Sickle Cell Anemia
Piel and colleagues, using modeling based on demographics, excess mortality and interventions, report that the global burden of sickle cell anemia (SCA), a hereditary blood disorder, is increasing, and that universal screening programs could save the lives of almost ten million newborns with SCA globally, in particular in sub-Saharan Africa (the story is covered by NPR in its blog and morning edition for less academic savvy readers).
In an accompanying perspective article, Osrin and Fottrell comment on how, as child mortality from SCA decreases, the relative burden of child morbidity and disability will increase and require changing policies and health services.
6. UN – additional emergency funding, but humanitarian aid lacking for children and elderly
The UN humanitarian chief has announced the allocation of some $72 million from an emergency fund to assist people in neglected crises in 12 countries worldwide, which brings the total amount provided by the UN Response Fund to $172 million a year.
Meantime a new report from HelpAge International — endorsed by Save the Children UK revealed that only about two percent of UN/NGO project proposals targeted older people, and about four percent were specifically aimed at children under five, thereby pointing to the neglect of the needs of older people and young children in emergencies around the world.
Inter Press Service reports that the United Nations is unleashing an army of Women Protection Advisers (WPAs) to specifically curb sexual violence in war zones, who will be deployed with peacekeeping missions in South Sudan, the Central African Republic, Côte d’Ivoire, [Democratic Republic of Congo (DRC)], Mali and Somalia.
8. UN Conference of States Parties to the Convention on the Rights of Persons with Disabilities
The largest meeting on disability has started in New York to discuss implementation of the UN Convention on the Rights of Persons with Disabilities.
You can check here if your country has ratified the convention.
9. Pathfinder – Strengthening community and health systems for quality PMTCT: Applications in 4 African countries
This report discusses the experiences and recommendations of PMTCT programmes, attributing the barriers to implementing programmes for PMTCT in resource-limited settings to common biomedical, behavioural, and structural categories. In addition to a lack of access to quality PMTCT services at the clinic level, community-level factors such as stigma, adverse gender dynamics, low support for HIV testing, antenatal care (ANC) and skilled birth attendance, and poor linkages between communities and their facilities all pose challenges to improving PMTCT outcomes.
Health policy & financing
10. BMJ News – India must respect intellectual property rights
An analysis of healthcare in India by the UCL School of Pharmacy warned that failure to respect IP rights risks ‘undermining future development of new and more effective medicines for conditions such as cancers and dementia,’ the BMJ reports. The report also said that reducing the price of drugs for conditions such as cancer, which are only effective in high technology settings, would not help the majority of people in India, 400 million to 600 million of whom do not have access to essential medicines.
A similar viewpoint if found in this blog on the India page of the Wall Street Journal.
11. BMJ (Editorial) – The Vienna Declaration on nutrition and non-communicable diseases
This editorial points out the weaknesses of the recently launched Vienna Declaration on Nutrition and Non-Communicable Diseases, which highlights the need for a multi-agency approach and high level political support, but turns towards a lifestyle drift by emphasizing (yet again) the downstream (individual) determinants of lifestyle change.
12. HHA – Micro-Health Insurance: Chronicle of a Death Foretold
In this blog, a meeting of researchers affiliated with the Health Working Group of the Microinsurance Network is reported, as well as some reflections on the role of micro-health insurance in the transition to universal health coverage.
Aid & development
13. Guardian – ‘Pool development aid to stamp out poverty’ says EU
The European commission has adopted a communication proposing that all types of development aid in the post-2015 period be considered as a whole, with resources streamlined according to well-defined policy objectives. The commission proposes to bind current international efforts and use all their financial resources in the post-2015 period in “a new, innovative way,” reports the Guardian development network.
14. Euractiv – As disease rates fall in Africa, EU urged to maintain health aid
While Africa has made inroads in combating TB and HIV, according to the Abuja+12 Report, malaria deaths continue to rise and progress on infectious diseases, as backed up by the EU ‘programme for action’ could slow if the EU and other donors skimp on their aid, Global Fund’s Mark Dybul has told the EU Development Committee, urging the EU and other donors to sustain their commitments to fight these diseases – despite the fiscal challenges at home.
15. GF – New Funding Model – All Systems Go
This News Flash covers the successful grant application from the first three countries participating in the new funding model, including sharing the lessons learnt between neighbouring African countries through generation of a concept note, and a regional initiative to fight malaria in Central America.
16. Aidspan – New Issue Of ‘Global Fund Observer’
This GFO issue includes an article on France’s announcement that it will contribute nearly $500 million per year to the Global Fund for the period 2014-2016; an article examining the Grant Management Assurance Framework, and an article about a new report from Open Society Foundations which highlights the role of local civil society in the development of concept notes in Myanmar and Zimbabwe.
17. WHO-EURO Pharmaceutical innovation must align with patient needs
This new WHO report calls for pharmaceutical researchers to adjust their research and development work to take account of the global demographic transition. The report focuses on pharmaceutical gaps (where treatments do not exist are may soon become ineffective), and identifies a number of other important topics for future research.
18. COHRED – guidance document
The Council on Health Research for Development (COHRED) has recently published a guidance document on fair research contracting to support contract negotiation skills in LMIC institutions to improve distribution benefits of collaborative research, such as overhead costs, data ownership, institutional capacity, technology transfer, and IP rights. The guidance highlights issues for consideration when entering into formalised research partnerships and provides tools and resources for negotiating fairer research contracts.
19. HPP – Access to subsidized ACT and malaria treatment – evidence from the first year of the AMFm program in Uganda
This study suggest that, during its first year of implementation in Uganda, the AMFm achieved its main objective of increasing the availability and use of ACTs. Estimates of the impact of the AMFm on ACT use for children under 5 imply that the program should be considered highly cost-effective under current WHO guidelines.
20. HPP – Factors associated with maternal healthcare service utilization in nine high focus states in India
This study highlights the role of strengthening public health infrastructure at district level in the study area, promoting awareness about available healthcare services and subsidized schemes in the community.
21. WHO-EURO MERS-CoV not yet a public health emergency
The emergency committee convened to assess the situation of Middle East respiratory syndrome coronavirus (MERS-CoV) unanimously decided that the situation does not meet the conditions for a public health emergency, but offered some technical advice for consideration by WHO and Member States on a broad range of issues.