MILLENNIUM DEVELOPMENT GOALS - 2012 REPORT HIGHLIGHTS

PREAMBLE: The MDG Report 2012 was launched in New York by UN Secretary-General Ban Ki-moon on July 2, 2012. Several MDG targets have been met well ahead of the 2015 target date. The report states that meeting remaining targets remains possible if Governments keep their commitments made over a decade ago. Clearly this includes both recipient and donor nations.

Highlights of the Report:

Extreme poverty is falling in every region including Sub- Saharan Africa.

The poverty reduction target was met: the global poverty rate at $1.25 a day fell in 2010 to less than half the 1990 rate. If confirmed, the first target of the MDGs— cutting extreme poverty to half its 1990 level—will have been achieved at the global level well ahead of 2015.

The world has met the target of halving the proportion of people without access to improved sources of water: the proportion of people using an improved water source rising from 76 per cent in 1990 to 89 percent in 2010.

Improvements in the lives of 200 million slum dwellers exceeded the slum target: The share of urban residents in the developing world living in slums declined from 39 per cent in 2000 to 33 per cent in 2012. This achievement exceeds the target of significantly improving the lives of at least 100 million slum dwellers, well ahead of the 2020 deadline.

The world has achieved parity in primary education between girls and boys: Many more children are enrolled in primary school, especially since 2000. Girls benefited the most. The gender parity index value of 97 falls within the margin of error for 100.

Many countries facing the greatest challenges have made significant progress towards universal primary education. Enrolment rates of primary school age children increased markedly in sub-Saharan Africa, from 58 to 76 per cent between 1999 and 2010.

Child survival progress is gaining momentum. Despite population growth, the number of under-five deaths worldwide fell from more than 12.0 million in 1990 to 7.6 million in 2010.

Access to treatment for people living with HIV increased in all regions. At the end of 2010, 6.5 million people were receiving antiretroviral therapy for HIV or AIDS in developing regions. This total constitutes an increase of over 1.4 million people from December 2009, the largest one-year increase ever. The 2010 target of universal access, however, was not reached.

The world is on track to achieve the target of halting and beginning to reverse the spread of tuberculosis. Globally, tuberculosis incidence rates have been falling since 2002, and current projections suggest that the 1990 death rate from the disease will be halved by 2015.

Global malaria deaths have declined. The estimated incidence of malaria has decreased globally, by 17 per cent since 2000. Over the same period, malaria-specific mortality rates have decreased by 25 per cent. Reported malaria cases fell by more than 50 per cent between 2000 and 2010 in 43 of 99 countries with ongoing malaria transmission.

These accomplishments notwithstanding, there remain major challenges:

Inequality detracts from these gains, and advances have slowed: Achievements are unequally distributed across and within regions and countries. Moreover, progress has slowed for some MDGs after the 2008-9 economic crisis and related consequences.

Vulnerable employment has decreased only marginally over twenty years. Defined as share of unpaid family workers and own-account workers in total employment, this fell to 58 per cent from 67 per cent two decades earlier. Women and youth remain the most vulnerable.

Decreases in maternal mortality are far from the 2015 target. Despite improvements, progress is still slow. Reductions in adolescent childbearing and expansion of contraceptive use have continued, but at a slower pace since 2000 than over the decade before.

Use of improved sources of water remains lower in rural areas. While 19 per cent of the rural population used unimproved sources of water in 2010, the rate in urban areas was only 4 per cent. Nearly half of the population in developing regions still lack access to improved sanitation.

Hunger remains a global challenge. 850 million people lived in hunger in the 2006-8 period, 15.5 per cent of the world population. This continuing high level reflects lack of progress on hunger in several regions, even as income poverty decreased. Progress is slow in reducing child undernutrition. Close to one third of children in Southern Asia were underweight in 2010.

The number of people living in slums continues to grow. Despite a reduction in the proportion of urban populations living in slums, the absolute number continues to grow from a 1990 baseline of 650 million. An estimated 863 million people now live in slum conditions.

Gender equality and women’s empowerment remain key challenges. Gender inequality persists and women continue to face discrimination in access to education, work and economic assets, and participation in government. Violence against women continues to undermine efforts to reach all goals.

REFERENCE:
United Nations. The Millennium Development Goals Report 2012. New York 2012. http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2012/English2012.pdf

MAJOR PROGRESS IN MALARIA CONTROL: THE ROLE OF THE GLOBAL FUND, ITS DETRACTORS AND SUPPORTERS.

PREAMBLE: Over the past two issues we have taken note of decisions by several European entities (Germany, Ireland, and Sweden and the European Commission itself) to suspend funding to the Global Fund on AIDS, Tuberculosis and Malaria (GFATM). In part, this decision was made ostensibly due to concerns about corruption in recipient countries, even though this was limited to only 4 countries (among over a hundred recipients) and was discovered, investigated and openly reported by the Global Fund itself. This level of corruption, independently analysed, is significantly lower than that of the EURO block.

The truth behind this decision is that Europe has been financially mismanaged, with bank failures in some countries, and problems of corruption and mismanagement. European captains of industry (like their Americans counterparts) walked away with fortunes under their belts in the form of self-awarded bonuses, even as their operations have been bailed out by their taxpayers. Several governments are now at risk of unprecedented financial defaults.

The decisions of these European entities smack of old style colonialism: arrogance from the top down. It damages their hard won (or restored) reputations for being global leaders.

To use developing countries and the Global Fund as a scapegoat for this is unconscionable: at least be honest! Instead, these particular European entities should have had the integrity to own up and say “sorry, we cant afford this now, because we ourselves are in such a mess”.

Thankfully, the Bill and Melinda Gates Foundation, being evidence-based, has stepped in to shore up Global Fund finances due to this donor default. Also, former Japanese prime minister Naoto Kan said his country would contribute $340 million to the fund this year. Two years ago, Japan contributed $200 million, but it gave only $110 million last year because of domestic needs from the earthquake and tsunami. Of course many other countries are honoring their pledges, even as many of them also have financial challenges at this time.

“These are tough economic times, but that is no excuse for cutting aid to the world’s poorest,” Bill Gates said in announcing the $750 million contribution.

We congratulate the Gates Foundation, and the government of Japan, a nation that knows more than most the meaning of hardship and tragedy, and apparently has a high sense of integrity.

We dedicate this issue to the major successes now taking place in malaria control, largely thanks to support from the Global Fund. With this purpose, we have partially extracted verbatim the report below which appeared in the Health and Development Global Update published by the HLSP Institute in June 2011.

Reference: Brown D, Gates Foundation gives $750 million to Global Fund. Washington Post January 27, 2012. http://www.washingtonpost.com/national/health-science/gates-foundation-gives-750-million-to-global-fund/2012/01/26/gIQAHKw5TQ_story.html Accessed February 18, 2012.

MALARIA: A GLOBAL UPDATE
The latest WHO World Malaria Report in April 2011 documents impressive increases in intervention coverage and reductions in malaria morbidity and mortality. WHO estimates that the number of malaria cases has fallen by more than 50% in 43 countries over the past decade. Eleven countries in Africa have shown a reduction of more than 50% in either confirmed malaria cases or malaria admissions and deaths in recent years. In Asia, four countries saw a decrease in the number of malaria cases of more than 50% since 2000.

Africa in particular has seen tremendous progress in increasing access to insecticide-treated nets (ITNs) in past 3 years. However, given an estimated lifespan of three years, nets delivered in 2006 and 2007 are already due for replacement and those delivered between 2008 and 2010 will soon be. The challenge is in ensuring that the high levels of coverage achieved are maintained.

We still have incomplete information on access to treatment in general, and particularly for the significant proportion of patients treated in the private sector. We do know that the number of procured rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs) is increasing globally yet, especially in African countries, most patients are receiving ACTs without confirmatory diagnosis. This continues to represent a significant financial, technical and personal challenge for many patients, health care providers and national malaria control programme managers. One exception is Senegal, which has introduced RDTs on a national scale in public facilities and, with high levels of adherence to diagnostic results, achieved dramatic reductions in ACT consumption . On the other hand, another study in urban Tanzania shows that the introduction of RDTs also had the unintended consequence of increasing inappropriate antibiotic prescription (from 49% to 72%) – a behaviour ascribed to clinicians’ insufficient knowledge and training on other causes of fever. This is why RDTs able to diagnose a range of common illnesses are high on the malaria community’s R&D ‘wish list’.

Coverage with intermittent preventive treatment for pregnant women (IPTp) remains far from target levels – ranging from 2.4% in Angola to 62% in Zambia. No country has yet adopted a national policy of intermittent preventive treatment for infants (IPTi), as recommended by WHO.

In the countries with greatest progress, the decreases are associated with intense malaria control interventions. But this progress is fragile. The resurgence of the disease in 2009 in Rwanda, Sao Tome and Principe, and Zambia shows that control programmes need to be maintained even if numbers of cases have been reduced substantially.

Source: HLSP Institute. Health and Development Global Update. July 2011. http://www.hlsp.org/LinkClick.aspx?fileticket=VxUphqNpW_w%3D&tabid=1575

Envoie: The prevention and control of AIDS, Tuberculosis and Malaria represent moving targets. Only with sustained international support from both public and private sectors, and perseverance by the countries mostly affected, will eventual success be achieved. The results as reported in the above extract are extremely encouraging and should be taken into account by the European entities mentioned in our preamble, when they eventually reconsider their support: which they surely will.

EUROPEAN COUNTRIES RENEGE ON COMMITMENTS TO THE GLOBAL FUND

PREAMBLE:
The track record of developed countries honoring their aid commitments is not impressive (especially the G8 nations)[1]. However, until recently, there was optimism that most would honor their commitments to support the Millennium Development Goals (MDGs).

To briefly revisit the MDGs for those readers who may not recall what they were about, here is a thumbnail sketch: at a United Nations conference in 2000, governments around the world pronounced the MDGs, to be achieved by 2015. Eight goals were constructed (listed below), reflecting the world's main development challenges and responding to the calls of civil society.[2] Within these goals there are 18 targets, complemented by 48 measurable indicators to measure progress towards the MDGs.

Goal 1: Halve Proportion of People in Extreme Poverty and Hunger
Goal 2: Achieve Universal Primary Education
Goal 3: Promote Gender Equality and Empower Women
Goal 4: Reduce Child Mortality by 2/3
Goal 5: Reduce Maternal Mortality by 3/4
Goal 6: Combat HIV/AIDS, Malaria and other diseases
Goal 7: Ensure Environmental Sustainability
Goal 8: Develop a Global Partnership of Development

Last year’s UN Special Session on MDG outcomes provided an important reminder: in relation to Goal 8 (Develop a Global Partnership of Development) there was a message for all donor countries, namely that, without more reliable support from developed countries, several Goals are likely to be missed in many developing ones.[3]

However there is now serious concern regarding the 6th goal, which comes within the remit of a “Global Fund to fight AIDS, Tuberculosis and Malaria”. Tragically, in November 2011, several European entities (Germany, Ireland, Sweden and the European Commission itself), ostensibly in response to fraud in a small number of developing nations (4 out of >120 recipient countries), have frozen or drastically cut back on their funding support to the Global Fund as a whole with the effect that it will not be able to take on any new commitments for a 3 year period.

Although it is understood around the world that the entire European Union is now under existential threat, and therefore unable to make good on their commitments, in our view it is a “bit rich” (to use the vernacular, no pun intended) that these rich nations, whose own financial mismanagement and fraud in some instances led to their own current morass, feel free to tar recipient countries with the same brush.

The documented fraud amounts to $34 million, which represents 0.03% of the Fund’s whole portfolio, and all of the evidence of fraud that was cited in the press was uncovered by the Fund itself after it undertook investigations. Furthermore, the Fund had publicly announced these findings as they were uncovered. There was never any duplicity or attempts to cover up the losses. It would be interesting indeed to see how this compares with the extent and impact of fraud in the European Community itself, especially on the heels of various banking collapses, and national defaults. Pot calls kettle black?

For this issue of PacificSci Global Perspectives, we extract from an objectively critical situation analysis as presented by Results UK, an NGO registered in England, Wales and Scotland.[4]

NOTE: This is our last issue for 2011. Our Year in Review will appear as the first issue for 2012.

References:
1. White F. Development assistance for health – donor commitment as a critical success factor. Can J Public Health (2011)102,6:421-3
2. United Nations Development Programme. About the MDGs: Basics - What are the Millennium Development Goals? http://www.undp.org/mdg/basics.shtml Accessed December 15, 2011.
3. UN General Assembly. 65th Session Agenda Items 115. Special Session on the MDGs. Outcome Document: New York. September, 2010.
4. Supporting the Global Fund – making the case for immediate intervention. Background Sheet 1: RESULTS – the power to end poverty. December 11, 2011. http://results.org.uk/sites/default/files/December%202011%20Background%20Sheet%201%20Supporting%20the%20Global%20Fund.pdf Accessed December 15, 2011.

THE GLOBAL FUND TO FIGHT AIDS, TB AND MALARIA (GF)
Note: This report is extracted verbatim from the work of Results-UK (citation #4 above). While we fully endorse what they have stated, the originality of this analysis belongs entirely to them. We recognize that it was written for a primarily UK audience, but we feel that it deserves global recognition and readership.

The GF is a multilateral agency founded in 2002 and is the world’s largest financer of anti-AIDS, TB and Malaria programs. It operates as a partnership between governments, civil society, the private sector and affected communities. It draws its funding from donor governments, trusts and foundations and distributes that money to implementing agencies. To ensure that GF money goes to where it is needed most, it prioritises countries with low incomes and high disease burdens. Importantly the GF is guided by the principles of accountability and transparency. It focuses explicitly on results and has an outstanding track record for delivering real impacts on the ground.

At the end of 2010 the GF has approved funding of $22 billion for more than 600 programs in 150 countries. Because it has such clear monitoring mechanisms the Fund states that it has distributed 190 million insecticide treated nets to treat malaria, provided TB treatment for 8.2 million people and provided antiretroviral drugs and holistic care for some 3.2 million people, saving 7.7 million lives.

How funding works: the replenishment process
The fund is predominantly bankrolled by contributions from the governments of developed nations. Since it was created in 2002, 95% of pledges have been from these governments (totalling $28.3bn), with the other 5% coming from private sector and philanthropic givers like the Gates Foundation. From 2001-2010 by far the largest contributor to the fund has been the USA, followed by France, Japan, Germany and the UK. In terms of giving as per cent of GNI, Sweden gives the largest proportion, followed by France, Norway, Holland and Spain.

After the initial funding it received for 2002-2004 the GF has gone through a replenishment cycle every three years, with the last of these events taking place in 2010 in New York. The GF went into the New York conference seeking $20 billion to fully fund the fight against the three diseases. Whilst this represented a doubling of contributions from the 2007 replenishment, it was considered as absolutely vital to avoid losing ground to the diseases. Unfortunately, pledges and projections at the conference only ended up totalling $11.68 billion. The result was that the GF needed to seek new funding, could not fund certain high cost programs and had to slow the pace of scale up.

The UK contribution
The UK government has been a strong historic supporter of the Fund. In 2001 the Labour government made a pledge to give £1.36 billion between 2001-2015 and has delivered £1.06bn thus far. After coming to power the new coalition undertook a review of all UK giving to multilaterals and the Fund came out very well, rated in the highest category as providing ‘Very Good’ value for money, which was only given to 9 organisations. In giving the Global Fund a top score, the Multilateral Aid Review (MAR) found its “quality and depth of reporting” were very high, and reported that “standards for financial management and audit” were very high as well. Overall it found the Global Fund to be critically important in the delivery of the MDGs.

As such, the new government has committed to continued giving to the fund at the same levels as the previous administration. The UK has not made a new pledge recently, however, our historically strong stance puts us ahead of many European countries. Civil society organisations across the UK and Europe have been calling on the UK to make a contribution of £840 million between 2011-2013, a figure that would represent a ‘fair share’ of the $20 billion that the GF requested to fill financing needs of partner countries.

What went wrong?
There have been several competing factors that have led to countries withdrawing or withholding their payments to the Global Fund.

1. The financial crisis: The global economic downturn of 2008 has severely hit the GF. With aid budgets being squeezed more tightly than ever before, many countries have chosen to hold back or renege on their commitments to the Fund, citing a variety of causes. As the crisis has continued the ratio of pledges to money actually delivered has steadily worsened, with countries including Spain, Holland, Denmark, Italy, Belgium and the US seriously behind on their commitments. Countries are finding the crisis a convenient excuse not to meet their commitments.

2. Global Fund Corruption: In January this year, corruption in GF programmes was inaccurately and sensationally reported by the Associated Press. Citing losses of $34 million dollars across several countries, the media created a situation in which Germany, Ireland, the European Commission and Sweden all announced that they were withholding funding until investigations into the causes of the losses and how they occurred were carried out.

3. A victim of its own success: Ironically, the Fund’s success up until 2010 has partly led to these problems. The Fund introduced new paradigms in the global health and international development arenas. It established a mechanism which channels resources to fund demand through the submission of evidence based, technically sound TB/Malaria/HIV proposals, and as a result has regularly met and exceeded its targets. As such, scale up in demand has been steep, leaving the Fund needing increasingly more and more funding. When global economics were good, this was a curve that could continue. Now this is clearly no longer the case.

The issue of corruption
Stories began to circulate in January 2011 about money going missing from GF supported programs in nine different countries. The total sums that were misappropriated or unaccounted for totalled around $34 million dollars. As a reaction, Germany, Ireland, Sweden and the E.C all stated that they were withholding money to support pledges. They all cited slightly different reasons – and had slightly different motivations – but all called for the Fund to conduct an investigation into its activities.

The media reports of corruption have been very damaging to the Fund, but it’s important to look at this in detail and put the figures into perspective. All of the evidence of fraud that was cited in the press was uncovered by the Fund itself after it undertook investigations. Corruption was found in 9 out of 33 investigated programs (of 145 the fund administers). In Mali, the country with the greatest losses, the Fund has reclaimed a large amount of that money and secured the convictions of nine civil servants involved in its theft. The Office of the Inspectorate General (OIG) is a completely independent body within the Fund that carries out these investigations. What’s more, the Fund had publicly announced these findings as they were uncovered. There was never any duplicity or attempts to cover up the losses. Joe Liden, a spokesman for the Fund stated that they felt they had been “treated very badly by the media.”

Within the whole of the Fund’s portfolio, the $34 million represents 0.03% of the Fund’s whole portfolio (although only 33 countries were investigated). However, these 9 programs were investigated for the very reason that they were some of the riskiest grants the Global Fund provided. Looking at the most recent set of reviews from the OIG, which analysed over $1b of grants, indicates that across the whole portfolio, no more than 1% of funds have been lost to fraud. This is substantially less than is lost by the UK’s DWP every year.2 However, the sensationalist language used by the media has stuck and the Fund’s reputation as been damaged. The Fund has been through a process of self-evaluation and produced a High Level panel report discussing the problems it faced around fiscal accountability, auditing and investigation practices and has addressed many of the criticisms made by concerned donors.

OUR COMMENT: The ethics of the European Community need to be called into question. It appears that they have held the Global Fund to a higher standard than they themselves could meet, especially given the evidence of everything from bank fraud to gross mismanagement of national finances in several of their own members (Ireland is one of the countries that have reneged on their GF commitments, but isnt this also one of the so-called “PIGS” that have exhibited financial mismanagement?), leading to the current crisis in the Euro. At least one should expect Europe to be honest about this and not play “bully in the pulpit”. Why not lay the blame for reneging on commitments on their own mismanagement, and by extension accept responsibility for any reversals that will result from funding shortfalls in global efforts to combat these diseases over the next 3 years?

We wish all readers the very best for the Holiday Season, and a Happy New Year.

CELEBRATING THE AFRICAN MEDICAL AND RESEARCH FOUNDATION (AMREF)

PREAMBLE: On cloudless nights in 1957, children lay on their backs searching for a small red object traversing the sky: the Soviets had launched “sputnik”, the world’s first satellite. Although this also led to accelerating the “space race” and intensifying the “cold war”, imaginations everywhere were captivated by our common primordial fantasy: reaching for the stars. In the same year, three surgeons in Kenya, Michael Wood, Archibald McIndoe and Thomas Rees had a vision that could revolutionize health care in Africa. Sharing in the romance of Africa, its needs, its potential and sense of destiny, they launched a Flying Doctor Service. Over the next 5 decades, men set foot on the moon, satellites explored our solar system, the universe probed was probed with powerful orbital telescopes, robots explored the surface of Mars, and shuttles began servicing an international space station. In the meantime, what began as the Flying Doctor Service became Africa’s largest indigenous health organization: the African Medical and Research Foundation.

Yet, even as we make progress in solving the riddles of the universe, there remains extreme poverty and ill-health throughout Africa, and injustice throughout the world. In this, its 50th anniversary year, we celebrate the AMREF story which continues to unfold. In doing so we have drawn from our opportunity to view the organization at work during a joint donor evaluation in 2005-6, and from their anniversary book A Very African Journey (URL at foot of this article).

THE AMREF STORY
AMREF’s Vision is to seek “better health for Africa”. Its Mission states… “In creating vibrant networks of informed communities that work with empowered health workers in stronger health systems, we aim to ensure every African has access to the good health which is theirs by right.”

Over the past half century, AMREF has truly evolved. Prior to the 1970s, most of its work was service delivery. Under then-chairman, Dunstan Omari (former secretary to the East African Community), the concept of community-based health care was promoted. Advocated by then-lecturers at Nairobi University, Roy Shaffer and Miram Were (now Chair of AMREF), and implemented by Revi Tuluhungwa, Chris Wood and others, a strategy of working more closely with Ministries of Health took root. Since then, AMREF has trained Africans to staff the organization, relying steadily less on foreigners to carry out its work, just as it has been training community health workers for many African governments. Its Flying Doctor Service is now a self-sustaining entity, while AMREF itself still delivers an outreach programme to support essential care and training to rural hospitals. AMREF initiated and now runs community-based programmes in Kenya, Tanzania, Uganda, Ethiopia, Somalia, Sudan and South Africa. Increasingly it has emphasized education, innovation and research, working in partnership with communities, grassroots organizations, governments and donors. It concentrates on finding ways to improve health through projects that address Africa’s unique problems, taking into account: culture, attitudes, economies, politics and environment as critical factors. Based on evidence supported by its operational research, AMREF’s programmes serve as implementation models for Africa, influencing policies and practices by sharing its interventions across the continent.

For decades, AMREF has applied ecosystems principles in the identification of health risks and piloting appropriate health system solutions in rural areas. On the dry plains, trachoma (leading infectious cause of blindness) persists among the Masaai in an environment of little water and swarms of flies; this contrasts with a farming community nestled between two rivers only 15 kilometres away: here trachoma is absent and malaria hyperendemic (where water is plentiful, mosquitoes breed more readily). Clearly, differing environments in conjunction with human behaviour combine to determine health risks. Overlaid on a traditional culture in which each wife shares a one-room home with her children and newborn animals, preparing meals on a contaminated floor, it is in these settings that conditions such as trachoma must be tackled. The WHO “SAFE” protocol was adopted: surgery, antibiotics, face-washing, and environmental improvements. From a primary prevention perspective, the underlying priority is the reverse of this, but one must deal with the most seriously affected first, as this gains immediate attention and promotes the credibility of an integrated approach. Attending to environmental and personal hygiene are also prerequisites to the prevention of a much wider range of conditions. Simple interventions like “leaky tin technology” (a large can of water with a small hole at its base plugged by a thorn), so that clean water can remain uncontaminated and used sparingly, have made the difference in reducing exposure and transmission of such diseases. Two decades ago AMREF realized that episodic clinical teams weres neither effective nor efficient, and that a community approach was needed, emphasizing the role of women. Adopting the WHO “PHASE” campaign (personal hygiene and sanitation education) in 1995, and in partnership with Glaxo Smith Kline, AMREF pioneered this approach in Kenya and Uganda; this has been replicated elsewhere in the world eg., Peru, Tajikistan, Nicaragua, Bangladesh.

AMREF’s operational activities reflect Africa’s disease burdens at the grassroots, including malaria and HIV. For example, the Malaria Partnership Programme in Uganda involves AMREF, Ministries of Health and local NGOs with funding from Glaxo, Smith, Kline. In Kiboga, Kanungu and Kumi districts, AMREF has trained over 1,000 “community medicine distributors” (CMDs) to promote insecticide-treated bednet use and home-based fever management in children who previously would have been treated with ineffective drugs purchased from roadside vendors. Population Services International has underwritten the distribution of nets, using a revolving fund. Within 3 years, 80% of children with malaria in these districts benefited from CMD interventions, supported by AMREF-trained clinical officers, nurses and laboratory technicians, and a marketing effort using radio broadcasts, drama and music, as well as posters in shops, schools and churches. In response to the HIV epidemic, the “Angaza Project” (Swahili: “shed a light”) in Tanzania has implemented 47 counseling and testing sites (more in development), and almost 1,000 counselors trained, supported by a marketing effort using peer educators, music and sports: 0.5 million people have already been tested.

AMREF is intimately involved in health systems development in difficult urban settings. As stated by Director-General Dr Michael Smalley: “If health systems are robust then everything else works”. For example, in the Kibera slum nearby Nairobi, a squatter community of some 850,000 live in extreme poverty and overcrowding, in grossly deficient housing and poor environmental conditions. This situation is found in many cities throughout Africa, due to the rural to urban shift of populations. Such shanty-towns are becoming home to 2nd and 3rd generations, and are virtually a permanent feature of these cities. As migrants come from differing backgrounds and cultures, there is ethnic tension and little community solidarity. Nonetheless, it is precisely in this setting that AMREF has been working in close collaboration with the community-based organization Mradi ya Afya Msingi na Maendeleo (MRAMMA), to develop Primary Health Care (PHC), in a manner that reflects the spirit of the Alma Ata Declaration (1978), the most enduring set of principles for PHC development. In partnership for 11 years, the project has reached 100,000 slum dwellers, including such interventions as community organization and leadership development, stimulation of small enterprises, provision of safe water and sanitation, a core package of PHC interventions emphasizing maternal and child health, and a health centre to deal with a range of conditions responsible for the bulk of the disease burden. This community-based effort has succeeded so well that the City of Nairobi, the Ministry of Health and other partners have now joined to uplift the conditions of Kibera.

Among AMREF’s most important roles is the management of knowledge: building capacity through training, and introducing new learning systems. Since 1987, AMREF has run a 1-year diploma in community health, now offered in affiliation with Kenya’s Moi University. Through this rigorous programme have passed almost 500 students from 35 African countries. Innovative ways have also been found to exercise this role in a distributed manner, eg., almost 10,000 students have taken AMREFs correspondence courses. In 1998 the Maridi National Health Institute was started in southern Sudan with AMREF funding and support: this is a 3 year” clinical officer” course, through which over 130 graduates have been trained to become first line practitioners. New learning methods and technologies are being utilized: increasingly teaching is based on the PBL approach (problem-based learning), and an e-learning initiative has been launched in collaboration with the Nursing Council of Kenya with support (funding and technical) from Accenture: to upgrade 22,000 nurses from certificate to diploma level.

Much more could be told about the work of AMREF than is possible in the space of this short report. In South Africa, where the Ministry of Health accepts traditional practitioners within the formal health system (>60% of South Africans consult sangomas), AMREF is working to help determine “best practices”, and to promote the integration of sangomas within health priorities such as HIV counseling, TB treatment, oral rehydration therapy, and checking on immunization status, while also supporting safe and more effective traditional practices. Elsewhere in Africa eg., Kechene District, Ethiopia, AMREF is supporting microcredit schemes for families, simultaneously addressing poverty and health: helping women to develop economically viable small enterprises and to take care of their familes at the same time. In conflict zones eg., northern Uganda and southern Sudan, AMREF is working “to have health systems and informed communities ready to take control of their own lives and… health, once the fighting is over”.

Conclusion: AMREF recognizes far better than most health organizations around the world that 80% of health is made in households and communities; perhaps only 20% is repaired in hospitals and clinics. Redressing the imbalance in Africa requires empowering communities, teaching preventive measures in a way that can be understood, and narrowing the gap between health systems and communities. Priority must be given to operational and applied research: AMREF’s own priorities are development driven, and a research question embodied within all proposals to donors. From this research comes policy making: AMREF sees itself at the interface in this critical process. AMREF’s current 5 year strategy (2006-11) is to strengthen health systems and to provide the evidence. As stated by AMREF Chair, Professor Miriam Were: “In the past we just assumed that people would see how passionate and experienced we were and follow. Now we know it takes hard-nosed science to persuade others… we are beginning to produce the evidence to influence policy-makers”.

Reference: A Very African Journey is available on-line at: http://64.176.64.243/A%20Very%20African%20Journey.pdf
For more about AMREF, visit their website: http://www.amref.org/

OFFICIAL DEVELOPMENT ASSISTANCE AND GLOBAL HEALTH TRENDS

PREAMBLE: During our first 6 months, this report addressed the following global issues: climate change, child development, colonized minorities, food security, human rights, and other news and reviews. In most instances we also addressed the relevance of these issues to Canada, our home base. To locate these issues you may either scan down this issue to earlier issues, or Google search by combining the keywords just noted with the term pacificsci.

This June 2007 issue reviews the vexing issue of official development assistance from wealthy developed countries such as Canada, makes reference to a report on global social and economic trends, then selects reports from a discipline that is essential to understanding global health trends: Health Situation Analysis. This refers to information on health conditions, supported by vital and health statistics critical to strategic and operational development planning. Our selected examples include Africa, the State of the World Children, and Projections of Mortality and Burden of Disease to 2030.

Our sidebar addresses the emergence of “corporate hybrids”, freedom of speech and tolerance for intellectual opinions.

 G7 OFFICIAL DEVELOPMENT ASSISTANCE (ODA)
The most recent confirmed OECD data for ODA (2005) reveal that, although absolute amounts are higher, G7 countries allocate proportionally less Gross National Income (GNI) for international development: 0.30%, compared with .50% for non-G7 nations. Of 22 OECD nations only 5 met the UN target of at least 0.7%: Norway, Sweden, Denmark, the Netherlands, and Luxembourg, none of which are G7 countries. The lowest G7 allocation is made by the USA (0.22%; among 15 non- G7 nations, only Portugal and Greece give less than this), while Canada comes in slightly above the G7 mean at 0.34%. Clearly, both individually and collectively, the G7 should show more leadership.

Note: OECD rankings do not include Russia, a G8 country (G7 + 1).
Reference: Final ODA Data for 2005. http://www.oecd.org/dataoecd/52/18/37790990.pdf

 SERIOUS QUESTIONS ABOUT CANADA’s ODA
Questions are being raised about Canada’s ODA priorities eg., $30 million in 2006 to China, an emerging political and economic powerhouse. Parliamentarians urging increased aid to truly poor nations say the government’s refusal to support proposed new legislation to guide ODA reveals lack of commitment. “Canada used to be a leader and is now a… laggard” said Alexa McDonough, NDP foreign affairs critic. According to McDonough, the planned 2006 ODA of just over $3 billion represents 0.32 % of GNI, down from 0.34% last year and far off the 0.7% target that Canada helped set. Josee Verner, Minister for international aid, replied “spending in 2007-08 will increase by 8%, in line with the goal of doubling by 2011 the amount spent on ODA in 2001”.
Source: Sue Bailey. The Canadian Press. March 27, 2007
EDITORIAL: an annual increase in absolute expenditures in the order of 8% will simply maintain the status quo with little movement towards the target of 0.7% GNI

 REPORT FROM 8TH GLOBAL DEVELOPMENT CONFERENCE, Beijing. For up-to-date social and economic trends, visit the Global Development Network April 2007 newsletter. Topics include: the rise of Asia in the global economy; growth and poverty in Latin America; structural transformation opportunities in Africa and the Middle East. http://www.gdnet.org/pdf2/research_monitor/2007-April_conference%20edition_Research%20Monitor.pdf

 HEALTH SITUATION OF SUB-SAHARAN AFRICA

The health situation of Sub-Saharan Africa (SSA) is the least favourable of all regions. Following steady declines until the mid-1990s, adult mortality sharply reversed, with the disease burden increasingly dominated by HIV/AIDS superimposed on already heavy burdens from endemic malaria, water-borne diseases, vaccine-preventable diseases, nutritional deficiencies, and other preventable conditions. In some settings, this was compounded by war and civil strife, with consequent increases in violent death, food shortages, poverty and displacement of people, further fueling a rural to urban migration for economic survival. In parts of SSA, adult mortality rates are at their highest in 3 decades; a rapid drop in life expectancy (LE) is seen in 38 countries (LE age 40 or less in 8 of these). Without HIV/AIDS, LE at birth would have been almost 6.1 years higher in 2002. The slippage is not only due to HIV/AIDS: for example, despite major gains in immunization coverage during the 1980s, these have reversed since, reflecting a loss of capacity to deliver primary health care. In the meantime, the health profiles of Africa and the world are not standing still: the pattern is shifting with a steady increase in Non-Communicable Diseases and injuries. Even given Africa’s preoccupation with infectious diseases, which still dominate the disease burden, planners must now be alert to this emerging and future disease burden.
Source: The foregoing brief report is a paraphrased extract from a health situation analysis carried out by PacificSci for an assignment in East Africa completed in 2006.

 THE HEALTH OF THE PEOPLE: THE AFRICAN REGIONAL HEALTH REPORT: A fully comprehensive situation analysis has recently been published by the WHO Regional Office for Africa. http://www.who.int/bulletin/africanhealth/en/index.html

 THE STATE OF THE WORLD’s CHILDREN 2007

This UNICEF report focuses on the discrimination and disempowerment experienced by women and girls. It discusses how gender equality will move the UN Millennium Development Goals forward, and how investment in women’s rights will ultimately produce a dual dividend: advancing the rights of women and children. Seven interventions are advocated:

1. Abolish school fees and invest in girls' education
2. Invest government funding in gender equality
3. Enact legislation to create a level playing field for women and to address domestic as well as gender-based violence
4. Ensure women's participation in politics
5. Involve women's grassroots organizations in policy development
6. Engage men and boys on the importance of gender equality
7. Improve research and data on gender issues.
For the full report as a PDF document: http://www.unicef.org/sowc07/report/report.php

 PROJECTIONS OF MORTALITY & DISEASE BURDEN TO 2030

Revised global and regional projections of mortality and burden of disease by cause for 2005, 2015 and 2030 are now available from the World Health Organization. Principal investigators (CD Mathers & D Loncar) applied separate projection models for males and females, stratified into 7 age groups. The website below offers online access to the article, a working paper, and references to papers on data sources and methods. Detailed results for projected deaths and DALYs can be downloaded as Excel spreadsheets. The analyses were carried out at country level with aggregation into regional or income groups. The investigators used socio-economic projections to model future mortality and morbidity patterns, assuming slower and faster rates of development and population growth, taking into account independent variables: income, education, time, and tobacco use. The results suggest that, from 2002 to 2030, life expectancy will increase throughout the world, with an upward shift in the age of deaths, with considerably fewer younger children dying, while deaths due to cancer and heart disease will increase. Deaths from infectious diseases will decline overall, while mortality from HIV/AIDS will continue to increase. http://www.who.int/healthinfo/statistics/bodprojections2030/en/index.html

Acknowledgment: In constructing our summary, a review by Robert Goldberg on ProCOR (Recommended link in sidebar) was helpful, including his note of caution regarding the quality of data used to develop the predictive models and assumptions utilized.

THANKS FOR VISITING PacificSci GLOBAL PERSPECTIVES!