Monthly Archives: November 2013

Africa: Does Democracy Improve Your Health?

18 Nov 2013

Back in the 1990s, the Nobel-prize winning economist Amartya Sen famously wrote that “no famine has ever taken place in a functioning democracy”, coining an argument has shaped thinking across countless sectors – and none more so than healthcare.

If governments face open criticism and are under pressure to win elections, we assume, they are incentivised to improve the health of their populations. Dictators are not.

“Democracy is correlated with improved health and healthcare access … Democracies have lower infant mortality rates than non-democracies, and the same holds true for life expectancy and maternal mortality,” Karen Grépin, assistant professor of global health policy at New York University, wrote in a 2013 paper. “Dictatorship, on the other hand, depresses public health provision.”

She argues that democracies entrench longer-term reforms than their dictatorial counterparts – often involving universal healthcare or health insurance schemes.

“The effects of democracy are more than a short-term initiative, such as an immunisation programme, which don’t always have lasting effects,” she said in a telephone interview. “Democracy can bring larger-scale reforms that create new things or radically transform institutions.”

But does that theory hold water in Africa?

Ghana, one of the continent’s deepest democracies, is doing well. According to Gallup data, 75 percent of its population consider its elections to be honest, compared to a median of 41 percent over 19 sub-Saharan countries. Correspondingly, it was also one of the first countries in Africa to enact universal health coverage laws.

In 2003, roughly a decade after entering a multi-party democratic system, the west African country hiked VAT by 2.5 percent to fund a national health insurance programme.

Voters who had been overstretched by the previous ‘cash-and-carry’ system happily swallowed the tax increases, and the scheme was so popular that when the government unexpectedly changed in 2008, it survived the transition.

The country still has a way to go to attain universal coverage. According to the National Health Insurance Authority, by the end of 2010 34 percent of the Ghanaian population actively subscribed to the scheme. But the institutions are now in place, laying the foundations for the future.

Similar schemes are being rolled out in other democracies like South Africa. But this isn’t a simple equation. There are plenty more multi-party systems which have failed to enact meaningful reform – think of the pitiful performance in Kenya, where the government changed earlier this year – while some more autocratic regimes are performing well.

“Several of the countries that are seen as the big success stories in public health are not very democratic,” argued Peter Berman, a health economist at the Harvard School of Public Health.

Take Rwanda. Led by Paul-Kagame’s decidedly authoritarian Rwandan Patriotic Front, the country is considered “not free” by Freedom House. In the run up to 2010 presidential elections Human Rights Watch alleged political repression and intimidation of opposition party members against the leadership.

Yet the government has a strong developmental track record. “Rwanda started out with somebody who is autocratic, but who genuinely wants to see these indicators change,” Grépin said.

Over the last decade, Rwanda has registered some of the world’s steepest healthcare improvements. After the 1994 genocide – when national health facilities were destroyed and disease was running rampant – life expectancy stood at 30 years.

Today, citizens live to an average of almost double that. Deaths from HIV, tuberculosis and malaria have each dropped by roughly 80 percent over the last 10 years, while maternal and child mortality rates have fallen by around 60 percent.

Part of its success stems from the fact that its healthcare services reach rural citizens. The leadership hands responsibility to local government and authorities and holds them accountable for their efficiency; and almost 50,000 community health workers have been trained to deploy services to marginal populations.

Like Ghana, Rwanda runs a universal health insurance scheme, though it has fared better in its roll out. Upwards of 90 percent of the population is covered by the community-based Mutuelles de Santé programme, which has more than halved average annual out-of-pocket health spending.

“By decreasing the impact of catastrophic expenditure for health care we increase the access,” explained Agnes Binagwaho, minister of health, from her Kigali office.

The benefits of that programme are clear to see at the bustling Kimironko Health Centre, which is a 20-minute drive from central Kigali and deals with most of the suburb’s non-life threatening medical complaints.

As dozens of men, women and children queue to hand over their health cards, a young nurse named Francine Nyiramugisha explains that “Ever since the Mutuelles de Santé was introduced, there has been a huge difference. You pay 3,000 RwF ($4.50) per year and then you get treatment.”

In the reception, thirty-year-old Margaret Yamuragiye, a slender sociology student who has been diagnosed with malaria, waits patiently for her prescription. “Before I got my Mutuelles card I would fear that I could not go to the clinic because it would be too expensive. Today if I have simple cough or flu, I come to the doctor, I don’t wait to see if it gets worse,” she said.

Nearby in Ethiopia, another autocratic regime registered by Freedom House as “not free” is also clocking significant health improvements. Like Rwanda, leaders in Addis Ababa have little time for political opposition, but are registering impressive developmental gains.

“They’re not very democratic but they have the power and authority to allocate resources towards population health needs,” Harvard’s Berman said.

There’s no universal coverage scheme in Ethiopia, but government has opted to focus on deploying basic healthcare services across hard-to-reach rural areas.

Starting from a pitifully low base, it has spent a decade training a network of around 40,000 extension workers to bring care to rural communities. Over ten years, the nation registered a more than 25 percent decline in HIV prevalence, according to a 2012 progress report. Under-five mortality has declined to 101 deaths per 1,000 live births in 2009/10, from 167 in 2001/2. Infant mortality halved in the same period.

Those examples should be evidence enough that the relationship between democracy and improved healthcare isn’t a simple one. “There are autocratic governments that care about the people and there are autocratic governments who don’t. There are democracies where politicians respond to a broad public demand, and then there are democracies where the politicians respond to narrower interest groups,” Berman said.

“There is no simple equation between democracy and caring about public health.”
[Courtesy of This is Africa]

Uganda: Mothers in New HIV Campaign

16 November 2013
Uganda’s first lady, Janet Museveni will join the Kampala Capital City Authority (KCCA) to launch a new campaign to end mother-to-child transmission of HIV/Aids.

The campaign is coordinated by the Uganda Aids Commission. UAC Director General David Kihumuro Apuuli said last week, over 1.5 million people in Uganda were living with HIV/Aids, most of them the result of the mother-to-child transmission.

He told journalists in Kampala the campaign was critical to inform HIV-positive women that they could give birth to HIV-negative children. According to 2012 national HIV/Aids indicator survey, at least 16,000 babies were born with HIV in 2011 alone.

Kihumuro hopes that with the campaign, this number will reduce, in the next year. According to the commission, 140,000 people were infected with HIV between 2011 and 2012, down from 160,000 in 2010/2011, a 13 per cent reduction.

Dr Sarah Zalwango, the HIV/Aids focal person at KCCA, said a number of activities such as male circumcision, cancer screening and counselling would take place on that day and urged people to come in huge numbers.
[Courtesy of AllAfrica News]]

Africa: Mental Health Update

September 2013:
As African countries strive to meet the UN Millennium Development Goals (MDGs) by 2015 and plot a new development agenda thereafter, health experts are gathering evidence across the continent to make a case for a greater focus on its millions of mentally ill.

Experts say investing in mental health treatment for African countries would bolster development across the continent, but national health priorities have been overtaken by the existing MDG structure, which has specific targets for diseases like malaria and HIV, placing them higher on countries’ agendas than other health issues.

“Everyone is putting their money in HIV, reproductive health, malaria,” says Sheila Ndyanabangi, director of mental health at Uganda’s Ministry of Health. “They need also to remember these unfunded priorities like mental health are cross-cutting, and are also affecting the performance of those other programmes like HIV and the rest.”

Global experts celebrated the passing of a World Health Assembly action plan on World Mental Health Day in May, calling it a landmark step in addressing a staggering global disparity: The World Health Organization (WHO) estimates 75-85 percent of people with severe mental disorders receive no treatment in low- and middle-income countries, compared to 35-50 percent in high-income countries. The action plan outlines four broad targets, for member states to: update their policies and laws on mental health; integrate mental health care into community-based settings; integrate awareness and prevention of mental health disorders; and strengthen evidence-based research.

In order for the plan to be implemented, both governments and donors will need to increase their focus on mental health issues. As it stands, the US Agency for International Development (USAID), the world’s biggest bilateral donor, will only support mental health if it is under another MDG health priority such as HIV/AIDS. Meanwhile, mental health receives on average 1 percent of health budgets in sub-Saharan Africa despite the WHO estimate that it carries 13 percent of the global burden of disease.

“Mental health hasn’t found its way into the core programmes [in developing countries], so the NGOs continue to rely on scraping together funds to be able to respond,” Harry Minas, a psychiatrist on the WHO International Expert Panel on Mental Health and Substance Abuse and director of the expert coalition Movement for Global Mental Health, told IRIN. “Unless we collectively do something much more effective about NCDs [non-communicable diseases], national economies are going to be bankrupted by the health budgets.”

According to a May report from the UN Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, the MDGs have overseen the fastest reduction of poverty in human history.

Yet it also acknowledges that they have done little to reach the world’s most vulnerable. The report says the MDGs were “silent on the devastating effects of conflict and violence on development” and focused too heavily on individual programmes instead of collaborating between sectors, resulting in a largely disjointed approach to health. Experts say without a more holistic approach to global health in the new development era, the world’s most vulnerable will only be trapped in that cycle.

“The MDGs were essentially a set of vertical programmes which were essentially in competition with each other for resources and for attention,” said Minas. “We’ve gone beyond that, and now understand we’re dealing with complex systems, where all of the important issues are very closely interrelated.”

In Africa, where many countries are dealing with current or recent emergencies, WHO sees opportunities to build better mental health care.

“The surge of aid [that usually follows an emergency]combined with sudden, focused attention on the mental health of the population, creates unparalleled opportunities to transform mental health care for the long term,” say the authors of the report Building Back Better: Sustainable Mental Health Care after Emergencies, released earlier this month.

In a study published in the Journal of Affective Disorders in July, researchers in northern Uganda – which, starting in the late 1980s suffered a two-decade long war between the government and the rebel Lords’ Resistance Army – monitored the impact of group counselling on vulnerable groups such as victims of sexual and domestic violence, HIV-infected populations, and former abductees of the civil war. It found that those groups who engaged in group counselling were able to return and function markedly faster than those who did not receive counselling, while reducing their risks of developing long-term psychiatric conditions.

“We need to be mentally healthy to get out of poverty,” Ethel Mpungu, the study’s lead researcher, told IRIN.

The link between mental illness and persisting poverty is being made the world over. According to a 2011 World Economic Forum report, NCDs will cost the global economy more than US$30 trillion by 2030, with mental health conditions alone costing an additional $16 trillion over the same time span.

“It really is around issues of development and economics – those things can no longer be ignored,” says Minas. “They are now so clear that ministries of health all around the place are starting to think about how they are going to develop their mental health programmes.”

As mental health legislation is hard to come by in most African countries, Uganda is ahead of most on the continent with its comprehensive National Policy on Mental, Neurological and Substance Use Services, drafted in 2010. The bill would update its colonial era Mental Treatment Act, which has not been revised since 1964, and bring the country in line with international standards, but is still waiting to be reviewed by cabinet and be voted into law.

Uganda is also part of a consortium of research institutions and health ministries (alongside Ethiopia, India, Nepal and South Africa) leading the developing world on mental health care. PRIME – the programme for improving mental health care – was formed in 2011 to support the scale-up of mental health services in developing countries, and is currently running a series of pilot projects to measure their impact on primary healthcare systems in low-income settings.

Research shows that low- and middle-income countries can successfully provide mental health services at a lower cost through, among other strategies, easing detection and diagnosis procedures, the use of non-specialist health workers and the integration of mental healthcare into primary healthcare systems.

Although a number of projects have shown success in working with existing government structures to ultimately integrate mental health into primary health care, the scaling up of such initiatives is being hindered by a lack of investment, as the funding of African health systems is still largely seen through donor priorities, which have been focused elsewhere.

“Billions of philanthropic dollars are being spent on things like HIV/AIDS or water or malaria,” said Liz Alderman, co-founder of the Peter C. Alderman Foundation (PCAF), which works with survivors of terrorism and mass violence. “But if people don’t care whether they live or die, they’re not going to be able to take advantage of these things that are offered.”

[Courtesy pf IRIN]

South Africa: HIV/Aids Vaccine Research Hope

13 November 2013

South Africa is the only country in the world where a large AIDS vaccine trial is being planned, as the global scientific community struggles to find a way to eradicate HIV.

Announced at this week’s international AIDS Vaccine Conference in Barcelona, the South African trial will involve the only vaccine shown to have some effect on the virus when it was tested among 16,000 people in Thailand. Released in 2009, the Thai trial’s results showed that HIV infection rates were 31 percent lower in participants who had received the vaccine than those who had not.

“On the eve of some of the most important vaccine trials, I am proud of the critical role that the people of South Africa will play,” said Ntando Yalo from the Networking AIDS Community Of South Africa, speaking at conference opening.

But the trial’s researchers are cautious.

Glenda Gray is the South African trial’s lead researcher and executive director of the Perinatal HIV Research at the University of the Witwatersrand. She told conference delegates that trial would begin by testing the Thai vaccine on a small group of people to confirm the vaccine worked as well in South African populations as it did in Thai participants.

“It might not show the same efficacy as in Thailand,” Gray said. “For example, South African women are bigger, and have different (levels of) exposure to the virus.”

With a national HIV prevalence rate of about 17 percent, South Africans are likely to have had much more exposure to the HIV than people in Thailand, where just one percent of the population is HIV-positive. The modest protection offered by the Thai vaccine might be too weak for South Africa, Gray added.

If the vaccine is effective within this smaller group, researchers will modify it for use against the predominant strain of HIV found in South Africa. This modified vaccine would be tested on about 240 people and, if successful, move to a larger trial involving about 5,400 people.

Chasing a “Machiavellian” virus

But the virus, described as “Machiavellian” by scientist Dr Scott Hammer at the start of the conference, continues to evade almost all attempts to eradicate it.

Johnson & Johnson Head of Research Dr Jerry Sadoff said he had been involved in creating 11 vaccines, none of which had taken more than seven years to develop. HIV was the exception, he said.

“You can make a career out of the AIDS vaccine – I have been researching it for almost 30 years,” he joked.

Most vaccines train the body to recognise and kill viruses by injecting people with small, non-toxic “deactivated” parts of the virus.

The body learns to make antibodies to fight the deactivated virus, so that when it is faced with infection from the live, dangerous virus, it is able to recognise and fight it.

But HIV’s constant mutation once it is the body makes it a moving target that is hard to pin down.

About two percent of people infected with HIV are able to contain the virus so that they don’t get sick. Scientists have been studying these “elite controllers,” including sex workers in South Africa, for years but still don’t yet know how their immune systems manage to do this.

Unlocking how our immune systems can produce “broadly neutralising antibodies” to fight HIV is “one of the holy grails of vaccine design,” according to Hammer.

But as scientists struggle to unlock the secrets of our immune systems and HIV, AIDS Vaccine Conference organisers have decided to move away from narrow focus on vaccines.

About 13 years after the first AIDS Vaccine Conference was held, the Global HIV Vaccine Enterprise will open next year’s conference to a wider range of scientists working on HIV prevention methods, including antiretroviral (ARV)-based vaginal or rectal gels – or microbicides – as well as other forms of ARV-based prevention and medical male circumcision.

This much larger gathering of HIV prevention experts will convene in Cape Town next year.

Organisers also raised the issue of a therapeutic HIV vaccine for the first time. Unlike the vaccine being tested in South Africa, a therapeutic HIV vaccine would aim to treat HV infections, not prevent them. A small therapeutic HIV vaccine trial is currently underway in the United States.

[Courtesy AllArica News]

Syria: Mass Polio Immunization Campaign

Syrian children receive vaccination against polio at a Syrian refugee camp in Lebanon, Nov. 7, 2013.

 

Syria 13 Nov 2013:
The The largest-ever immunization campaign in the Middle East is under-way to stop an outbreak of polio in Syria from spreading throughout the region.

 
In mid-October, 22 suspected cases of polio were detected in north east Syria.  The virus has left 10 children paralysed.  But U.N. health agencies warn hundreds of thousands of children across the region are at risk of contracting this crippling disease. 
 
Now, The World Health Organization and U.N. children’s agency are joining forces to immunize more than 20 million children in seven countries and territories during the coming six months.
 
WHO Polio Eradication Program Spokeswoman Sona Bari notes the virus has been circulating in the region for some time, notably in Egypt, Israel and the West Bank and Gaza.  But she says the outbreak in Syria, a country that had been polio-free for 14 years, has accelerated this emergency response in the region.
 
Bari says emergency immunization campaigns to prevent transmission of polio and other preventable diseases have vaccinated more than 650,000 children in Syria.  She says this includes 116,000 in the highly contested north-east Deir-ez Zor province where the polio outbreak was confirmed a week ago. 
 
According to Bari the campaigns fanning out throughout the region aim to vaccinate 22 million children.
 
“This is a sustained six-month effort.  There will be repeated campaigns over this period of time.  It is going to need quite an intense period of activity to raise the immunity in a region that has been ravaged both by conflict in some parts, but also by large population movements.  So, the virus is moving throughout the region,” she said.
 
The WHO reports in the past few days, nearly 19,000 children under age five in Jordan’s Zaatari refugee camp have been vaccinated against polio.  And, it says a nationwide campaign is currently under way to reach 3.5 million people with polio, measles, and rubella.  It says a vaccination campaign has started in western Iraq and soon will begin in the Kurdistan region. Lebanon, Turkey and Egypt also plan campaigns this month. 
 
The polio virus usually infects children in unsanitary conditions through faecal-oral transmission.  It attacks the nerves and can kill or cause paralysis.  There is no cure for polio, but it can be prevented through immunization.
 
Bari says 12 suspected cases of polio are under investigation.  She says preliminary evidence indicates the polio virus circulating in the region is of Pakistani origin. 
 
There have been media reports that Pakistani fighters brought the polio virus into Syria but the WHO spokeswoman said that is unlikely. 
 
“We are never going to know exactly how it arrived in Syria.  What we do know is that we have seen a virus that is very similar in Egypt, in the West Bank and Gaza, and in Israel over the past 12 months.  We also know that adults tend to have a much higher level of immunity already developed.  So, it is unlikely that adults brought this in.  It is probably more likely some other route.  But, we will never really know for sure.  All we can say for certain is that it is of Pakistani origin and that it has been in this region for a little while,” she said.
 
Pakistan, Nigeria and Afghanistan are the last three endemic countries in the world, so it is from there that polio will continue to spread.  Since WHO began its polio eradication campaign in 1988, vaccination has reduced this crippling disease by more than 99 percent globally.
 
Despite this setback, Bari says the World Health Organization remains optimistic the outbreak can be stopped and polio, eventually, will be eradicated.

[Courtesy of VOA]

Uganda:HIV Study Reveal Rampant Stigma

061511 Health Aids News

Last year, a primary school teacher in Masaka, Florence Najjumba, lost her job after she declared that she was HIV-positive.

Had the media and Uganda Human Rights Commission not intervened, Najjumba would have lost her livelihood. Yet she is only one of the luckier ones. According to the People Living with HIV Stigma Index, 2013, most HIV-positive people are still discriminated against at work.

The study, released last week by the National Forum of People Living with HIV Networks in Uganda (Nafophanu), surveyed 1,110 people living with HIV.

“[Some] 255 of the people living with HIV reported losing jobs or incomes within the past year preceding the survey and 27 per cent of these attributed it to [their] HIV status,” reads the study report.

Among those that reported losing their jobs, more than half were men. Some 288 reported that their job descriptions had changed due to a combination of factors, including poor health.

Some were discriminated against at work by either co-workers or employers. Eight percent of the respondents reported that they had been barred from work in the previous 12 months.

Supported by UNAIDS and Uganda Aids Commission, Nafophanu conducted the survey in 18 districts.

“This stigma prevents people from getting tested for HIV, seeking medical care and adherence to treatment and follow-up. A biased attitude towards people living with HIV must be stopped,” said Stella Kentusi, Nafophanu executive director.

Consequently, the study states that income levels among people living with HIV are relatively low, with 60 per cent of those surveyed earning less than Shs 250,000 every month.

Home, work

Gossiping, according to the survey, was the most prevalent form of stigma, with 60 per cent (666) of people living with HIV, convinced that they had been gossiped about at least once within the previous year. Also, nearly one in five of the surveyed people said they had been subjected to psychological pressure or manipulation by their husband or wife at least once.

Some 21 percent said they had experienced sexual rejection at least once in the last 12 months before the survey. About 10 per cent had been excluded from family activities such as eating together or sharing rooms.

The study suggests fear of stigma and discrimination are major reasons why people are unlikely to declare their status in public, let alone taking an HIV test.

“This means that disclosure is done selectively or not done at all. People are not free to seek and take up treatment,” Kentusi says, adding that victims of stigma soon develop internal stigma – negative feelings about oneself.

UNAIDS Country Director Musa Bungudu says to reduce such stigma and discrimination, people living with HIV should enjoy economic empowerment and receive updated education about HIV.

Bungudu proposes “a cascade of training of trainers workshops” not only to address attitudes and practices but also to meet information needs and HIV-related supplies.

On his part, the acting programme manager, Aids Control Programme, Dr Joshua Musinguzi, wants more resources dedicated towards access to anti-retroviral drugs for all HIV-positive people.

Today, 566,000 people have access to ARVs out of the 745,000 expected to be put on treatment by the end of this year.

“We need to disseminate the findings to the lowest level so that the health ministry and stakeholders may roll out programmes, reducing new infections and fighting for the rights of people living with HIV effectively, efficiently and transparently,” Musinguzi says.