Transiting from MDGs to SDGs and Post-2015 Developmental Agenda: Continuity or Transformation?
Dr. Palesa Sekhejane, Research Specialist in the Africa Institute of South Africa, Sustainable Development Programme, Human Sciences Research Council. Research interests: health biosciences, health technology, systems and innovation.
Many health policy commitments have come and gone like the Alma Ata Declaration of 1978, Health for all in the 21st century, the Abuja and Ouagadougou Declarations. Another epoch of post-2000, known as the Millennium Development Goals (MDGs) has passed; and the post-2015 has dawned upon us whereby we have to renew and rename our developmental goal’s vows. The vows of the current era, as we have come to know them, are referred to as the Sustainable Development Goals (SDGs) and Post-2015 developmental agenda. The 2000 United Nations (UN) MDG declaration was agreed on by 189 heads of state to achieve eight set goals by the year 2015. Given the progress made in the developed nations such as North America and Europe, Africa still lags behind in achieving envisaged developmental goals, particularly health related developmental goals.
Africa’s healthcare status
Let’s reduce the focus to Africa’s health care status, since the majority of data suggests that the continent is failing to rise to the occasion. In Africa important developmental matters have been marginalised for material wealth. Human life and health have become an ideal notion, rather than a practical reality. Instead of prioritizing meaningful sustainable quality of life, Africa is romantically imagining what could potentially be, and not what ought to be. Of course the distasteful interventions and physical destructions of the West continue to linger and cause hangover across the continent. However, it is time that Africa’s renewal of the developmental agenda recognises health as a subterranean state-building path. Health is classified as a human right, but it is appalling how the majority of people in the African continent do not have the privilege to enjoy this “scarce commodity”. Healthcare in many of the African countries is a service provided by the state and thus is supposed to be a priority in the national budgets. The hurdle is that many African states are, to a certain extent, unable to provide this social service precisely because this would have to source funding from the government revenue. Therefore, if it is a matter of solely pressurising the finance part of things, then it is important to find means to curb the implications in order to reach the envisaged “sustainable development”. In the current economic models states are not supposed to compete in the economic activities, however, it has to play an interventionist role (1). The states generally accrues the revenue from taxation and the fiscus. This accumulation of the state’s revenue is heavily reliant on the public servants, which places burden on them. This inevitably results in the frustration of the general population if the fiscus is not utilised equitably, prosperously and reasonably; as essentially is a betrayal of human rights. If the economic models are to continue in the current form, health will remain the bottleneck of the state, while the private sector is siphoning billions which could be channelled to the achievement of this social value.
As we learn that sustainable development ties together economic, environmental and social development, it is critically vital to understand for who and by whom is the development undertaken. The question of development in Africa has been lingering and daunting for decades. However, reality is that development or a developmental agenda that marginalizes people should not be recognized at any cost, because healthy human beings are central to development. Uroh (2) and Osia (3) in their seminal works eloquently provided a distinction between development and economic growth:
Public health and the climate: addressing the challenges for Southern Africa
Rajen Nithiseelan Naidoo, Associate Professor in Occupational Medicine/Head of Discipline of Occupational and Environmental Health, School of Nursing and Public Health, University of KwaZulu-Natal. Areas of research interest: occupational and environmental respiratory diseases.
The Lancet has declared that the changing climate and its impact on health is the most serious health threat of the 21st century (1). When an institution such as The Lancet makes such a declaration, it is incumbent on us as health professionals to take notice. By placing health on the climate change agenda, we, as public health professionals, have the opportunity of focusing the
climate challenge on human impacts as compared to the other broader environmental impact that have dominated the agenda to date. According to the best available science, the impact of climate on the global population is likely to develop to castastrophic proportions over the next 4-5 decades. Addressing risks that our children and their children will face can no longer be left to the politicians or international agencies – the outcomes of COP17 were nowhere near the drastic and urgent solutions that are needed to resolve the crisis. If we are to address global population health, it must become the task of health professionals to provide the lead.
There continues to be a grouping of denialists who question the phenomenon of the changing climate, supported by prominent scientists, and arguing questionable science. The former US National Academy of Sciences president Dr. Frederick Seitz, stated in the 1980s that "Global warming is far more a matter of politics than of climate" (2). In 1998, Seitz endorsed the “Oregon Petition” (3), a document drafted in opposition to the Kyoto protocol, boasting the signatures of over 9000 scientists with doctoral qualifications! The petition and its accompanying scientific documentation claimed: “The proposed limits on greenhouse gases would harm the environment, hinder the advance of science and technology, and damage the health and welfare of mankind. There is no convincing scientific evidence that human release of carbon dioxide, methane, or other greenhouse gases is causing or will, in the foreseeable future, cause catastrophic heating of the Earth's atmosphere and disruption of the Earth's climate." (3) It went on to say: We are living in an increasingly lush environment of plants and animals as a result of the carbon dioxide increase. Our children will enjoy an Earth with far more plant and animal life than that with which we now are blessed.” (3)
While the denialists are in retreat, particularly at the substantial scientific burden of proof, they are no less deterred. As recently as last year, the Heartland Institute, a conservative think-tank organisation, supported by industry and the conservative elite in the US has promoted a 2011 publication called “Climate Change Reconsidered” (4). According to this report “natural causes are very likely to be (the) dominant cause of climate change that took place in the twentieth and at the start of the twenty-first centuries”. The authors of the latest report go on to say “the net effect of continued warming and rising carbon dioxide concentrations in the atmosphere is most likely to be beneficial to humans, plants, and wildlife.” (4)
The determination with which these denialists approach their mission, the seemingly rational arguments that they present to the politicians and broader public and the funding that they have access to, to achieve their goals, implies that we cannot be simply dismissive of them.
How golden policies lead to mud delivery – and how silver should become the new gold.
Dr. Karl le Roux, Principal Medical Officer at Zithulele Hospital (Eastern Cape). He is passionate about maternal and child health, breastfeeding and rural medicine. He is running a research project following up 500 mothers and their children for 1 year from January 2013. He served as Chairperson of RuDASA from September 2008 to September 2012.
There is a general perception amongst academics, government officials, non- governmental organisations (NGOs) and the South African public at large that as a country we have good policies, but that we implement these policies poorly (1). In fact, one of the fundamental issues that we need to address as a country is to try to understand why, despite good policies, adequate amounts of money and more skilled workers than in most parts of Africa, South Africa performs so badly (especially in health and education) when compared to other African countries. The tendency of policy makers is to blame downstream factors, such as general lack of capacity , “lazy managers” or “obstructive clinicians”, which to some extent is reflected in the research (2).
But my job today is to describe to you what it is like being at the rural coalface. Though I have loved working in a rural hospital for the past six years, it has also been one of the toughest periods in my life. Working in rural medicine is a bit like sitting on a roller coaster: a combination of enormous challenge and reward, feeling exhausted and exasperated and then inspired and invigorated, seeing dignity and strength in patients, but also sadness and unnecessary suffering and death. One always feels stretched and one often feels as if one is hanging on by one’s fingertips. The rural idyll is something that might be experienced on weekends off, but the reality of the working week is that on the whole one is extremely busy and constantly rationing care and doing the best one can with the resources available.
It therefore might come as no surprise to the reader that at the coalface “policies” are more often seen as a hindrance than a help to the delivery of health care. Policies or programmes are often imposed from above, with no consultation and with little understanding of realities on the ground. There is usually poor data collection and feedback, lots of time-consuming and unnecessary paperwork and a focus on irrelevant aspects of care with the neglect of critical aspects. I need to make clear that good, realistic and helpful policies are greatly appreciated by most clinicians working at primary care level, as they improve care and the health of our patients (for example the new antiretroviral treatment guidelines).
Addressing staff shortages in public hospitals: a role for clinical associates?
Jane Doherty, independent researcher and part-time lecturer at the School of Public Health, University of the Witwatersrand. Formerly Deputy Director of the Centre for Health Policy in the same School. Research interests: health systems and policy research.
Recent news headlines have highlighted the shortage of doctors in public hospitals, especially in disadvantaged areas. There is no doubt that more doctors need to be trained and recruited into the public sector. But are these strategies sufficient to solve the shortage of hospital staff with skills to diagnose patients’ problems and implement treatment? How long will it take to fill all the public sector’s vacant posts, especially in disadvantaged areas? And how much will it cost?
Developing mid-level health professionals who can complement existing staff is an additional strategy that has been debated since 1994 and incorporated into the government’s recent human resources policy (1). Yet progress in the production of mid-level health workers has been slow. Reasons for this are likely to include competing priorities, the practical difficulties associated with setting up and implementing new training programmes, constraints on absorbing new cadres into the existing health system, tensions between different cadres over role definition and working conditions, and the brain drain into the private sector. More fundamentally, concerns remain about whether mid-level workers are the correct choice for our health system (2,3): Will they be supervised adequately?; Will they be able to work well with other professionals?; Will they become a second-best health care option for poor communities?
Drawing on a rapid assessment that has been published in more detail elsewhere (3,4), it is discussed here how the design and early implementation of a new programme to develop South Africa’s first mid-level medical health professionals took account of these concerns and realities. Also highlighted are the issues that need to be addressed by government in order to ensure that this new programme has a substantial impact on the quality of care delivered in public hospitals.
Capacity of the SA public health sector to deliver rehabilitation services: an institutional analysis
Ms. Harsha Dayal is a chief researcher at the Human Sciences Research Council (HSRC). As an Occupational Therapist by profession, her research experience is in health, disability, gender and poverty reduction as programmatic work, but also has an interest in producing and communicating evidence to inform policy and practice.
International and national discourses on disability conclude that rehabilitation is a fundamental concept in disability policies and is seen as the process without which many people with health problems leading to impairment and/or disability would not be able to participate fully in society (1). While successful health outcomes for doctors and nurses are measured in how many lives are saved and how many people remain healthy, successful rehabilitation outcomes are judged by the level of integration into mainstream society of people with residual impairments. Social integration is impossible to achieve without effective rehabilitation service delivery. Despite a progressive and enabling legislative framework in South Africa (SA), services for people with disabilities (PwD) somehow are not meeting the needs of both adults and children with disabilities in SA, as demonstrated through continued poor socio-economic status. Emerging evidence that the public health sector is struggling to provide effective, efficient and equitable rehabilitation services, requires due attention to be paid to understanding what these capacity constraints are from a provider perspective.
To NHI or not? And if so, what, when, why and how?
Di McIntyre, holds the NRF funded South African Research Chair in Health and Wealth at UCT. Her present focus is on conceptual and empirical research around how to achieve universal coverage in low- and middle- income countries and how to promote health system equity. This includes research on strategic purchasing as part of the RESYST consortium.
It has been almost four years since the Green Paper on the proposed National Health Insurance (NHI) was gazetted. With no White Paper in sight, many are questioning whether the NHI policy will be taken forward or whether there has been a change of heart. There remains considerable confusion about the nature of the proposed reforms and I believe that it will not be possible to overcome the inevitable contestation around a policy of this magnitude until a clear vision is presented. This ‘thought-piece’ outlines my own understanding of the proposed health system reforms.
What are the proposed NHI reforms all about?
The term National Health Insurance is an unfortunate one. It immediately makes people think that what is being proposed is the creation of an insurance scheme, in the mould of private medical schemes. One of the connotations that goes along with this misconception is that government will need to pay for everyone to become a member of this ‘mega-medical scheme’, which is patently unaffordable given that medical schemes account for nearly half of all health care expenditure in South Africa yet cover less than a fifth of the population. An associated misconception is that the proposed NHI is all (and only) about how to raise more money for health services.
Quality healthcare for all children – where are we in achieving the MDGs for maternal and child health?
Micky Chopra, Chief of Health and Associate Director of Programmes at UNICEF’s New York Headquarters. Research interests: maternal, newborn and child health, immunization, paediatric HIV/AIDS, and health systems strengthening, policy and research.
Sanjana Bhardwaj, Chief of Health and Nutrition, UNICEF. Research area of interest: public health systems and policy, implementation science.
At the United Nations General Assembly in 2000 more than 150 global leaders, including the President of South Africa, signed the Millennium Declaration. In doing so they committed their countries to achieving a set of goals known as the Millennium Development Goals (MDGs). Child health is represented by MDG 4 that states that all countries will reduce the under 5 mortality rate (U5MR) by two thirds by 2015 from the base year of 1990. For South Africa this would mean bringing it down to a rate of 20/1,000 live births by 2015. For maternal health MDG 5 states that all countries will reduce by three quarter the maternal mortality ratio (MMR). For South Africa this means reaching a MMR of 38/100,000 live births by 2015.
What public health actions are needed in African countries to confront health inequalities?
Dr Tewabech Bishaw, President of the Ethiopian Public Health Association (EPHA).
In this article, which is based on the keynote address at the 7th PHASA conference 2011, I will discuss with you the progress that African countries have made in meeting the Millennium Development Goals (MDGs). We will also be able to see the gaps that need to be addressed.
Finally, I share my thoughts on public health actions that I believe could contribute to redress existing gaps and inequalities.
Developing African Countries’ Status Towards Achieving the MDGs
We all know that as recent as September 2010, ten years after the MGDs targets have been established, the world leaders met at the United Nations headquarters to assess progress made towards achieving the MDGs. At this meeting many leaders from African countries reported on the efforts they were making, but also on the challenges they are faced with and the sad unlikelihood of meeting many of the targets. On the other hand, leaders from other regions reported on their progress made, on their successes and the likelihood of meeting the set targets within the time frame.
Using the Pan African Clinical Trials Registry to monitor TB-related research on the African continent
Amber Abrams, project manager of the Pan African Clinical Trials Registry based at the The South African Cochrane Centre, based at the South African Medical Research Council. Research interests: clinical trial activity on the African continent, with a special interest in understanding the experiences of clinical trial participants.
Tamara Kredo, principal investigator of the Pan African Clinical Trials Registry, senior specialist scientist and acting manager at the South African Cochrane Centre, based at the South African Medical Research Council.
Research interests: training and conduct of systematic reviews related to HIV/AIDS and other priority areas.
The Pan African Clinical Trials Registry
In 2004, the World Health Assembly called for the development of a network of clinical trial registers to feed data to a single point of access thereby pooling information and creating a system for unambiguous identification of trials (1). The World Health Organization (WHO) developed the International Clinical Trial Registry Platform (ICTRP), as this single point of access, which collects data from the members of the WHO Network of Primary Registries.
Clinical trial registries can curb publication bias or selective reporting by ensuring that trial protocols are transparent and freely available to stakeholders. The registry collects a standard 20-item data set on registered trials before the inception of the trial and recruitment of the first participant. When trials are prospectively registered the outcomes as stated in the protocol can be tracked all the way through the course of the trial thereby ensuring that objectives cannot be changed without a public record of those changes
Multidrug-resistant tuberculosis: patients in KwaZulu-Natal have better cure rates than patients in the Eastern Cape (PETTS Cohort).
South Africa has the third highest tuberculosis (TB) and the fifth highest drug-resistant tuberculosis (DR-TB) burden in the world. The number of new multidrug-resistant tuberculosis (MDR-TB) cases, defined as TB resistant to the two most important anti-TB drugs (isoniazid and rifampicin) as well as the number of extensively drug-resistant tuberculosis (XDR-TB) cases, defined as MDR-TB with additional resistance to any fluoroquinolone and injectable second-line TB drug, is rapidly increasing in South Africa. The increase of DR-TB is largely due to the HIV epidemic and the challenges that are faced with the management of the disease (1).
KwaZulu-Natal (KZN) and the Eastern Cape (EC) have the highest burden of DR-TB cases in South Africa. For example, the number of MDR-TB cases diagnosed in KZN and EC in 2010 was 2032 and 1782 respectively and the number of XDR-TB cases 201 and 320 respectively (1).
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