Zambia has one of the highest HIV seroprevalence rates in the world, estimated in 1995 at 17%. Rural Monze district in the Southern province, the site of the study, has high rates of HIV, estimated at 10-12% in 1991. During the study, the district was affected not only by AIDS but also by the 1991-92 drought and by a bovine epidemic of East Coast Fever. This study documents the impact of HIV and AIDS on the health services and on the district economy, and draws some long term implications for the national economy. At the district hospital, approximately 44% of inpatients and 30% of outpatients were HIV seropositive as were 18% of rural health centre patients. Tuberculosis, other respiratory infections, and diarrhoea accounted for the majority of days in hospital. The HIV epidemic was found to be affecting the hospital staff as well, with mortality at Monze and neighbouring Choma hospitals rising from 2 per 1,000 nurse years in 1980 to 27 in 1991 - a 13-fold increase. Measures to increase supply, reduce losses, and make better use of existing staff are proposed. The household survey found that while patients were better off overall than the district population, there was no appreciable difference in wealth between patients with HIV infection and those without. HIV-positive patients were younger than HIV-negative patients, and had fewer children. The loss of a member with HIV would cause a rise in the average household's dependency ratio of 16-17%. Production was affected by HIV disease, with an average of 94 days' loss of labour (patients plus carers) in the final year of life. Implications for policy include the need to decentralize care of patients with HIV disease to health centres, and to protect and make better use of the health human resources. The impact of HIV/AIDS on rural production, with approximately 1 in 3 district households having a member with AIDS, combined with external factors such as removal of subsidies, changes in marketing processes under structural adjustment, and long term drought, makes it increasingly difficult to eke out a living from farming. Combined with the lure of apparent employment opportunities in urban areas created by deaths due to AIDS, these factors may contribute to increased urbanization, making it difficult for Zambia to replace declining copper revenues with increased yields from agricultural production.

Wits Business School University of Witwatersrand Johannesburg, South Africa Master in Finance and Investment (2014) / Following decades of under-investment, gaps in Africa’s healthcare infrastructure are becoming disturbingly obvious. The interplay of governments’ fiscal policies of budget imbalance reduction and other political considerations present a seemingly insurmountable obstacle to overcoming the backlog in Africa’s healthcare infrastructure. The two main objectives of this study were to understand the sources of financing and the best way to structure the financing of healthcare infrastructure in Africa. Looking at financing arrangements in various industries; and how healthcare sectors in developed countries have been financed, the report draws on perspectives from the financiers on how the healthcare infrastructure gap should be filled in Africa. This study, which utilised survey questionnaires and in-depth interviews, identified government revenues, regional development banks, private equity and donor financing numbers as dominant funding sources for the financing of healthcare infrastructure in Africa. Further, the study explored various ways in which finance could be structured and found that within those various models of financing, donor financing and government revenue were statistically significant on structuring the finance, especially within public-private partnership arrangements. These include sale and lease back arrangements (p=0.0022), complete ownership of projects by the private sector (p=0.003), management operation contracts (p=0.00034) and other forms of PPPs. More perspectives were obtained on enablers and barriers to improving investability of the healthcare sector. Africa’s economic growth and the improving ease of doing business were major enablers for healthcare sector’s investability. However, the role played by government as both a financier and a regulator seemed a barrier. Some structural models that would need government back-up include subordinated debt; with pricing at marginal cost and matching risk and return recovered through the taxation system. The latter continues to characterise much of Africa’s publicly provided healthcare infrastructure. In conclusion, investments in healthcare may not be separated from a country’s level of financial deepening. As the sector develops, it then becomes possible to utilise the models aforementioned. It is recommended that any governments’ investments in healthcare be more catalytic, to unlock value that allows the private sector to compete, both as financiers and innovators in healthcare. Furthermore clear strategies on PPPs are urgently needed for healthcare in Africa including policy consistency in financing and regulating healthcare.

Eastern and southern Africa, a region that is home to a twentieth of the world’s population, accounts for half the number of people living with HIV globally, including an increasingly drug resistant Tuberculosis epidemic. The high mortality and untold human suffering associated with HIV in the region during the late 1990s and early 2000s has mostly been mitigated by a rapid scale up of national HIV treatment programmes over the past decade, largely made possible by generic competition from Indian pharmaceutical manufacturers. The sustainability of treatment programmes in the region depends on various factors. National HIV treatment programmes are largely financed by multilateral donor mechanisms which are facing a decline in funding for the first time in the history of the AIDS response. Indian pharmaceutical manufacturers are increasingly encountering patent barriers stemming from the country’s implementation of its intellectual property obligations under the World Trade Organisation’s TRIPS Agreement. As eastern and southern African countries increasingly focus on local pharmaceutical production and south-south co-operation as vehicles for treatment sustainability, this thesis examines the extent to which public health related flexibilities present in the TRIPS Agreement can be used to as enablers of affordable treatment, both in domestic intellectual property legislation, and relevant regional platforms. The thesis undertakes case studies of the policy and legislative environment in two countries with very different profiles: The United Republic of Tanzania as a least developed country with a nascent local pharmaceutical manufacturing industry and South Africa, as the country with the largest pharmaceutical industry on the continent present the full range of country profiles in the region. Conclusions are drawn regarding the optimization of legislative and policy frameworks to facilitate both the importation and local production of health technologies. Finally, the thesis explores challenges and opportunities facing various south-south co-operation initiatives in the region.

No description available.

The purpose of this thesis is to show through a chain of events how the Lutheran Mission societies in their quest to provide health care through biomedicine to indigenous people in Southern Africa ended up co-operating with the South African government in the implementation of the policy of apartheid. The question that this thesis will thus seek to answer is the following: If foreign missionaries were motivated to the extent that they left their homes in Europe and North America, why did they allow their hospitals to be subjected to government takeovers without offering much by the way of resistance? Biomedicine was not introduced to supplement the existing traditional health systems but to replace them. Black people had ways and means to attend to their sick through traditional health systems such as izinyanga, izangoma, and izanusi among the Zulu, and dingaka and didupe among the Sotho-Tswana. In Southern Africa, the missionaries saw suffering and great need, and worked as lay medical practitioners to alleviate health problems long before apartheid was formally introduced after the National Party came to power in 1948. Subsequently, they worked with trained medical missionary nurses and doctors. The Lutheran missionaries saw biomedicine as being not far-removed from advancing their mission work of converting the indigenous people to Christianity. In their provision of basic biomedicine from small structures, the Lutheran missionaries developed their health centres into hospitals by means of assistance from home societies before apartheid became the policy of the government. Financial assistance was also received from the South African government especially in the 1960s to combat the tuberculosis epidemic. However dedicated the missionaries were, they were condemned to see their influence gradually reduced because they were forced to rely on government subsidies in the running of the hospitals. In the 1970s, the apartheid government nationalized Lutheran and other mission hospitals. The hospitals were taken over and handed to the newly-established homelands and self-governing states to run. Under this new management, the mission hospitals’ quality of service was compromised. The question is: why did the Lutheran missions allow their hospitals to be nationalized? Overall, one can see that the Lutheran missions were influenced by race when they excluded black people from participating in the running of the mission hospitals, despite Blacks having taken over the running of the former mission churches since the 1960s. In Botswana, nationalization occurred differently. There was no total take-over of mission hospitals and the attendant exodus of white medical missionaries. From the time of independence in 1966, the Botswana government decided to work with mission societies in health care. The government formulated health policies and provided part of the financial needs of the hospitals, while the mission societies provided personnel and ran the hospitals. For example, the Bamalete Lutheran Hospital (BLH) in Ramotswa continues to be run by the Hermannsburg Mission Society. The national Lutheran Church played an important role in the hospital as the Church was part of the governing board. This thesis has attempted to show that, while the Lutheran missionaries were motivated to develop a health care system for the indigenous people through the introduction of biomedicine and the building of hospitals, they were so dependent on the assistance of the apartheid government, especially in the 1960s and the 1970s, that they could not see that their collaboration with the government in the nationalization of mission hospitals was in fact a collaboration with apartheid. Some individual mission doctors and nurses, especially in the Charles Johnson Memorial Hospital in Nquthu, resisted the nationalization programme, but not the Lutherans. These were paralysed in the face of the pseudo-nationalization programme of the apartheid regime. The interpretation of the Lutheran doctrine of the ‘Two Kingdoms’, which dissuades Christians from interfering in the sphere of secular governance, may have had bearing on their reluctance to challenge the apartheid regime to provide better health care. / Thesis (Ph.D.)-University of KwaZulu-Natal, Pietermaritzburg, 2012.

Magister Public Health - MPH / The purpose of this study is to gain a greater understanding of the perceptions and barriers that influence condom use amongst male and female students at the Polytechnic of Namibia (Technical Vocational Education & Training Department). The specific objectives of this study include the following: To obtain a better understanding of knowledge amongst students about the correct use of condoms. To identify some of the problems students have in accessing condoms. To identify the common sources of information regarding condoms, the common perceptions that exist about condoms, and the extent to which students discuss condoms with others. / South Africa

RESUME<p>La Trypanosomiase Humain Africaine (THA) demeure un problème de santé publique pour plusieurs pays en Afrique subsaharienne. Le contrôle de la THA est basé essentiellement sur la stratégie de dépistage actif suivi du traitement des personnes infectées. Le dépistage actif est réalisé par des unités mobiles spécialisées, bien que les services de santé fixes jouent un rôle important en détectant « passivement » des cas. Le dépistage reposait jadis sur la palpation ganglionnaire mais, depuis le développement du test d’agglutination sur carte (CATT), trois possibilités se sont offertes aux programmes de contrôle à savoir: i) continuer avec la palpation ganglionnaire ii) combiner la palpation ganglionnaire avec le CATT iii) recourir au CATT seul. Certains programmes comme celui de la République Démocratique du Congo (RDC) ont opté pour la combinaison en parallèle de la palpation ganglionnaire avec le CATT. Toute personne ayant une hypertrophie ganglionnaire cervicale et/ou un CATT positif est considéré comme suspecte de la THA. Elle sera soumise aux tests parasitologiques de confirmation à cause de la toxicité des médicaments anti-THA. Les tests parasitologiques classiques sont l’examen du suc ganglionnaire (PG), l’examen du sang à l’état frais (SF), la goutte épaisse colorée (GE). La sensibilité de cette séquence a été estimée insuffisante par plusieurs auteurs et serait à la base d’une grande perte de l’efficacité de la stratégie dépistage-traitement. D’autres techniques de concentration ont été développées comme la mini-Anion Exchange Concentration Technique (mAECT), la Centrifugation en Tube Capillaire (CTC) et le Quantitative Buffy Coat (QBC), mais ces techniques de concentration ne sont pas utilisées en routine. <p>En RDC, une interruption des activités de contrôle en 1990 a eu comme conséquence une réémergence importante de la maladie du sommeil. Depuis 1998 les activités de contrôle ont été refinancées de manière structurée. <p>Ce travail vise deux buts à savoir le plaidoyer pour la continuité des activités de contrôle et la rationalisation des stratégies de contrôle. Nous avons évalué l’évolution de la maladie du sommeil en rapport avec le financement, son impact sur les ménages ainsi que la communauté. L’exercice de rationalisation a porté sur les outils de dépistage et de confirmation. Nous avons d’abord évalué la validité des tests, leur faisabilité ainsi que les coûts et ensuite nous avons effectué une analyse décisionnelle formelle pour comparer les algorithmes de dépistage et pour les tests de confirmation.<p>Pendant la période de refinancement structurel de la lutte contre la THA en RDC (1998-2003), le budget alloué aux activités a été doublé lorsqu’on le compare à la période précédente (1993-1997). Le nombre des personnes examinées a aussi doublé mais par contre le nombre des nouveaux cas de THA est passé d’un pic de 26 000 cas en 1998 à 11 000 en 2003. Le coût par personne examinée a été de 1,5 US$ et celui d’un cas détecté et sauvé à 300 US$. Pendant cette période, les activités ont été financées par l’aide extérieure à plus de 95%. Cette subvention pourrait laisser supposer que l’impact de la THA au niveau des ménages et des communautés est réduit mais lorsque nous avons abordé cet aspect, il s’est avéré que le coût de la THA au niveau des ménages équivaut à un mois de leur revenu et que la THA fait perdre 2145 DALYs dans la communauté. L’intervention par la stratégie de dépistage-traitement a permis de sauver 1408 DALYs à un coût de 17 US$ par DALYs sauvé. Ce coût classe l’intervention comme « good value for money ».<p>Le recours au CATT seul s’est avéré comme la stratégie la plus efficiente pour le dépistage actif. Le gain marginal lorsque l’on ajoute la palpation ganglionnaire en parallèle est minime et n’est pas compensé par le coût élevé lié à un nombre important des suspects soumis aux tests parasitologiques. Les techniques de concentration ont une bonne sensibilité et leur faisabilité est acceptable. Leur ajout à l’arbre classique améliore la sensibilité de 29 % pour la CTC et de 42% pour la mAECT. Le coût de la CTC a été de 0,76 € et celui de la mAECT de 2,82 €. Le SF a été estimé très peu sensible. L’algorithme PG- GE-CTC-mAECT a été le plus efficient avec 277 € par vie sauvée et un ratio de coût-efficacité marginal de 125 € par unité de vie supplémentaire sauvée. L’algorithme PG-GE-CATT titration avec traitement des personnes avec une parasitologie négative mais un CATT positif à un seuil de 1/8 devient compétitif lorsque la prévalence de la THA est élevée.<p>Il est donc possible dans le contexte actuel de réduire la prévalence de la THA mais à condition que les activités ne soient pas interrompues. Le recours à un algorithme recourant au CATT dans le dépistage actif et à la séquence PG-GE-CTC-mAECT est le plus efficient et une efficacité de 80%. La faisabilité et l’efficacité peut être différent d’un endroit à l’autre à cause de la focalisation de la THA. Il est donc nécessaire de réévaluer cet algorithme dans un autre foyer de THA en étude pilote avant de décider d’un changement de politique. Le recours à cet algorithme implique un financement supplémentaire et une volonté politique. <p><p><p>SUMMARY<p>Human African Trypanosomiasis (HAT) remains a major public health problem affecting several countries in sub-Saharan Africa. HAT control is essentially based on active case finding conducted by specialized mobile teams. In the past the population screening was based on neck gland palpation, but since the development of the Card Agglutination Test for Trypanosomiasis (CATT) three control options are available to the control program: i) neck gland palpation ii) CATT iii) neck gland palpation and CATT done in parallel .Certain programs such as the one in DRC opted for the latter, combining CATT and neck gland palpation. All persons having hypertrophy of the neck gland and/or a positive CATT test are considered to be a HAT suspect. Confirmation tests are necessary because the screening algorithms are not 100 % specific and HAT drugs are very toxic. The classic parasitological confirmation tests are lymph node puncture (LNP), fresh blood examination (FBE) and thick blood film (TBF). The sensitivity of this combination is considered insufficient by several authors and causes important losses of efficacy of the screening-treatment strategy. More sensitive concentration methods were developed such as the mini Anion Exchange Concentration Techniques (mAECT), Capillary Tube Centrifugation (CTC) and the Quantitative Buffy Coat (QBC), but they are not used on a routine basis. Main reasons put forward are low feasibility, high cost and long time of execution. <p>In the Democratic Republic of Congo, HAT control activities were suddenly interrupted in 1990 and this led to an important re-emergence or the epidemic. Since 1998 onwards, control activities were financed again in a structured way.<p>This works aims to be both a plea for the continuation of HAT control as well as a contribution to the rationalization of the control strategies. We analyzed the evolution of sleeping sickness in the light of its financing, and we studied its impact on the household and the community. We aimed at a rationalization of the use of the screening and confirmation tools. We first evaluated the validity of the tests, their feasibility and the cost and we did a formal decision analysis to compare screening and confirmation algorithms. <p>The budget allocated to control activities was doubled during the period when structural aid funding was again granted (1998-2003) compared with the period before (1993-1997). The number of persons examined per year doubled as well but the number of cases found peaked at 26 000 in 1998 and dropped to 11 000 in the period afterwards. The cost per person examined was 1.5 US$ and per case detected and saved was 300 US$. The activities were financed for 95 % by external donors during this period. This subvention could give the impression that the impact of HAT on the household and the household was limited but when we took a closer look at this aspect we found that the cost at household level amounted to one month of income and that HAT caused the loss of 2145 DALYs in the community. The intervention consisting of active case finding and treatment allowed to save 1408 DALY’s at a cost of 17 US$ per DALY, putting the intervention in the class of “good value for money”. <p>The use of CATT alone as screening test emerged as the most efficient strategy for active case finding. The marginal gain when neck gland palpation is added is minor and is not compensated by the high cost of doing the parasitological confirmation test on a high number of suspected cases. The concentration methods have a good sensitivity and acceptable feasibility. Adding them to the classical tree improves its sensitivity with 29 % for CTC and with 42 % for mAECT. The cost of CTC was 0.76 US$ and of mAECT was 2.82 US$. Sensitivity of fresh blood examination was poor. The algorithm LNP-TBF-CTC-mAECT was the most efficient costing 277 Euro per life saved and a marginal cost effectiveness ratio of 125 Euro per supplementary life saved. The algorithm LNP-TBF-CATT titration with treatment of persons with a negative parasitology but a CATT positive at a dilution of 1/8 and more becomes competitive when HAT prevalence is high. <p>We conclude that it is possible in the current RDC context to reduce HAT prevalence on condition that control activities are not interrupted. Using an algorithm that includes CATT in active case finding and the combination LNP-TBF-CTC-mAECT is the most efficient with an efficacy of 80 %. Feasibility and efficacy may differ from one place to another because HAT is very focalized, so it is necessary to test this novel algorithm in another HAT focus on a pilot basis, before deciding on a policy change. Implementation of this algorithm will require additional financial resources and political commitment.<p><p> / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished