SHAREMBABANE, 29 January 2013 (IRIN) – The relief felt by health officials and activists several months ago at the apparent outlawing of child marriages now appears to have been premature, with Swaziland’s traditional leadership recently declaring that such unions are acceptable under customary law.
“I have not received any instructions that [‘kwendzisa’] [the custom of a man marrying an underage girl] should be abolished,” Velebantfu Mtetwa, the country’s top traditional leader, told the Swazi press. As governor of Ludzidzini royal village, where the traditional seat of government is located, Mtetwa is known as Swaziland’s traditional prime minister.
Little attention was paid to the country’s traditional leadership last year when the powerful royal counsellors to King Mswati III said they would review the Child Protection and Welfare Act of 2012 and, if need be, raise objections.
Instead, attention was focused on Deputy Prime Minister Themba Masuku’s declaration that any man found to contravene the act by marrying a girl under the age of 18 faced arrest and prosecution. The marriages would be annulled and the former husband could be fined R10,000 (US$1,100). A man guilty of raping a girl faces a R20,000 (US$2,200) fine and prison term of up to 20 years. King Mswati, a strict traditionalist, approved the law in September 2012.
Damaging to girls
UNICEF estimates that, globally, about 70 million women aged 20-24 were married before reaching 18 years old. Of these, some 23 million were been married before turning 15. The consequences of child marriage can be life threatening: 50,000 girls aged 15-19 die of pregnancy- and childbirth-related causes each year.
The child protection act notes that children forced into marriage face serious psychological and social damage, and that girls’ educations tend to cease as they take up household duties.
Activists have welcomed the law, which is seen as a means of curbing HIV transmission. “The longer young women put off childbirth, the more likely they are to stay in school and, of course, avoid HIV,” said Sophia Mukasa Monico, country representative for UNAIDS.
“Such practices spread AIDS and contribute to Swaziland having the highest HIV prevalence in the world. It’s unfortunate that AIDS activists appear to be ‘anti-culture’ because, as Swazis, we love our culture. But some practices need reforming, and this seems impossible to do,” said Sylvia Dube, director of an AIDS testing and counselling centre.
Law made powerless
But the new statutory law, originating in the cabinet and passed by parliament, has been rendered powerless by the superiority of Swazi Law and Custom if a man chooses to marry in a traditional ceremony. The law appears now to apply only to “Westernised” Swazis who wed in civil ceremonies before a magistrate after having acquired a marriage license.
Swazi Law and Custom has never been written down but is interpreted by traditional leaders whose primary authority is Mtetwa. Cabinet officials, including Deputy Prime Minister Masuku, are appointed from the recommendations of royal counsellors, and these politicians are aware of their power relative to the country’s traditional authorities.
Mtetwa came out with the traditionalists’ stance on child brides following the arrest of a local soccer star for the rape of a 14 year-old girl. The accused stated that the girl was his bride, and that their families had agreed to the marriage. “If the parents and the girl have agreed, the authorities never penalize anyone,” Mtetwa said.
In terms of modern law, an underage girl cannot make such a decision. But in terms of tradition, she also has no say because marriages are arranged between families by the girls’ parents or older relatives. In addition, official records for traditional marriages can be incomplete because many go unreported.
With no national awareness campaign to educate Swazis about the Child Protection and Welfare Act, it remains unclear whether Swazi girls are aware of their rights. People who choose to challenge such unions have nowhere to go to lodge a complaint.
“What is most disturbing is the fact that most of these ‘marriages’ are forced, with the young girls having little or no say in being married to much older man,” said Maureen Littlejohn, communications officer for the Swaziland Action Group Against Abuse, an NGO that counsels survivors of gender-based and child violence. Littlejohn noted that poor families are often influenced by gifts of cattle and money to give up their daughters.
Has HIV funding revived lagging health systems?
JOHANNESBURG, 6 March 2013 (IRIN) – The HIV/AIDS epidemic arrived in sub-Saharan Africa after decades of neglect had left healthcare systems dangerously weak, barely able to cope with the onslaught of patients. Then the money started pouring in – funding for HIV programmes rose from 5.5 percent of health aid in 1998 to nearly half of it almost 10 years later.
But the jury is still out on whether the large sums of AIDS funding have made healthcare systems more resilient, whether ” the capacity gains conferred over the past decade will be durable as donors pull out [and whether] previous, pre-aid boom fragilities in service delivery and volatility in public spending would be reduced in the post-donor period,” noted Amanda Glassman, director of global health policy and research at the Washington-based Center for Global Development.
Some have argued that the AIDS epidemic has helped generate an overall increase in health funding and mobilized an international push for more equitable healthcare access. But others maintain that the billions of donor dollars spent fighting HIV/AIDS in the last decade have done little to strengthen fragile national health systems.
In the initial, emergency phase of the epidemic, donors bypassed weak areas of national health systems to set up structures that would yield faster results. On the ground, this meant modern HIV/AIDS clinics, fully staffed and equipped, offering free services in one corner of a public hospital, while the rest of the hospital limped along with inadequate infrastructure, high user fees and staff shortages.
“It was appropriate and inevitable at the time. We had to react the way we did. Now, we need to be responsive to the current situation and what we learned,” said Alan Whiteside, executive director of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal.
It is difficult to assess whether donor funding has increased resilience, but gains in health status and HIV/AIDS service coverage – such as the number of eligible people receiving antiretrovirals (ARV) and the number of pregnant women receiving services to prevent mother-to-child transmission of the virus – suggest that health-system capacity has been strengthened, Glassman told IRIN.
Even with its health sector crippled by tuberculosis (TB) and HIV epidemics, South Africa’s antiretroviral programme is now the biggest in the world – over 1.7 million HIV-positive people are treated by the government. And in this year’s budget speech, Finance Minister Pravin Gordhan announced plans to put an additional 500,000 people on treatment each year.
“The [treatment programme] has added staff and resources to the base of the health system, brought in a whole lot of technical assistance from the outside, and, in an intangible way, it has raised hope amongst [healthcare] providers,” said Helen Schneider of the School of the Public Health at the University of the Western Cape.
HIV treatment programmes have created new regiments of healthcare workers, including lay counsellors and patients with good ARV adherence who assist with adherence counselling through clinics and community outreach. The community outreach approach has been extended to home-based care for patients with extensively drug-resistant TB. In addition, to deal with the scarcity of doctors, nurses have been certified to initiate HIV treatment and to expand access to HIV treatment.
Community health has been positively affected. A recent study conducted in South Africa’s KwaZulu-Natal Province – one of the regions hardest hit by the HIV epidemic – found that increased access to ARV therapy has raised adult life expectancy by more than 11 years since 2004. The observed increase in life expectancy was one of the most rapid in the history of public health, noted the authors of the study, released in the February edition of the journal Science.
But major challenges remain – particularly for countries that are over-reliant on international funding and that still don’t spend enough of their domestic budgets on health.
The real test
As AIDS becomes a chronic and manageable condition, donors are turning their attention to strengthening health systems. The Global Fund to Fight AIDS, TB and Malaria has acknowledged that weak health systems have limited the performance potential of its projects. The US President’s Emergency Plan for AIDS Relief (PEPFAR) is looking at a “deeper integration of HIV services into existing national programs and systems”.
And the real test to measure the resilience of health systems is yet to come. “We won’t really know if that strengthening can be sustained until donors phase out,” Glassman told IRIN.
Savvy recipient countries that have used donor funds earmarked for specific diseases to build their health systems will fare better. Rwanda, for example, used its Global Fund and PEPFAR monies to fund insurance coverage for the poor, including benefits related to HIV, TB and malaria.
“Governments that allowed all the donor spending off-budget on AIDS will have a major problem building resilience, and the transition arrangements [for when donors pull out] in those settings are still vague,” Glassman warned.
For more stories on resilience, please visit the In-Depth
SHAREMAPUTO, 19 March 2013 (IRIN) – Mozambique has become the latest African country to implement a financial transaction tax (FTT) and airplane levy to fund health services in developing countries, part of the UNITAID initiative. Philippe Douste-Blazy, board chairman of the international financing mechanism, spoke to IRIN about the state of play in innovative health financing.
Q: We’ve heard a lot about innovative financing since HIV funding began to flat-line in 2009. What’s happened since?
A: We began with a levy on plane tickets in 2006 in France and 13 countries. In the last two months, we’ve added Morocco. This week, we have been told Mozambique will also join. We’ve also added Chad, and I hope that discussions with Japan are going to continue.
It’s very important to understand why we do innovative financing… We are living through one of the biggest economic crises in history. You cannot ask members of parliament in Europe or the United States for money. We should continue to try, but it is impossible. We have to ask Brazil, India, China, South Africa, Russia to give more – but they don’t do that. So we have to create innovative financing mechanisms.
The idea is very simple: to take a micro, painless, tiny solidarity contribution from activities that benefit from globalization – that’s mobile, internet, and financial transactions, plane tickets, etc. We proved that innovative financing can help achieve the Millennium Development Goals. In five years, we’ve raised US$2 billion from the small levy or tax on plane tickets. We’ve treated eight out of 10 children with HIV, 322 million people with malaria and one million people with tuberculosis. UNITAID is the first laboratory of innovative financing in the world.
Q: Does innovative financing look different in developed countries such as France than it does in resource-poor countries like Mozambique?
A: No. The strength of the concept is that we are all part of a global community. When a person buys a plane ticket, it is the same price in Paris, Bamako or Maputo. If you can buy a plane ticket, you can pay one dollar more; you have no difference between [the contributions of] developed and developing countries. The strength of this concept is [it fosters not only] North-South solidarity but also South-South solidarity.
Q: Why haven’t more countries joined UNITAID?
A: Each time I speak to a head of state, he says, “This is fantastic. We are going to do this.” After that, he speaks to his minister of finance, and his minister of finance says it’s not possible.
In the case of FTTs, ministers of finance are afraid their stock exchanges will be bypassed. It’s false argument. In 1984, British Prime Minister Margaret Thatcher [imposed] a 0.5 percent levy per share [transacted]. This FTT didn’t change anything. Nicholas Sarkozy did it in March 2011… Now, I believe that I have convinced President Dilma Vana Rousseff of Brazil to do that as well.
So often head of states forget 1.5 billion people are living in the South… If you are a head of state, you should have a vision for your country, of course, but also about your country in the world. That vision cannot continue to be selfish.
Q: You are hoping the US government will join UNITAID. Explain the US government’s reluctance.
A: The American people are the most generous people in the world. There is a culture of giving in that country… but when it is obligatory – and this is cultural – the answer is no. The word “tax” is very difficult for Americans. We have to explain to them that this is an absolutely painless, micro contribution and that it is managed by the public and private sector and civil society – not only by some big United Nations agency with the American government at the table.
I think it is possible to get an agreement. We are a long way from convincing, them but some members of Congress are becoming convinced.
Q: What is your top priority at the moment?
A: When we see this gap between rich and poor grow, you can do two things: Revolution – although in history, revolution is not always success. It’s often a failure, with a lot of civil wars. The other thing to do is… use the momentum of capitalism to take innovative financing further. Say that the more traders who are going to do financial transactions, the more I am going to take 0.0001 percent of that transaction for the poor.
The answer is to create a UNITAID movement, to take micro solidarity contribution from globalized activities. We live in a global village. It’s as true for Apple and Google as it is for the rich and the poor.
SHARENAIROBI, 31 March 2013 (IRIN) – The British government has announced a major new programme aimed at providing essential healthcare to six million people in the Democratic Republic of Congo (DRC). The five-year, US$270.7 million project will focus on rebuilding health facilities, training health workers, and supplying drugs and equipment.
Civil war has destroyed much of the country’s health infrastructure, as well as the road networks and vital services such as electricity, meaning patients often have to travel long distances to health centres that may not be equipped to handle their complications.
IRIN has put together a list of five health issues in DRC that require urgent attention:
Maternal and Child Health – DRC’s maternal mortality ratio is 670 deaths per 100,000 live births, with an estimated 19,000 maternal deaths annually. The country has a severe shortage of health workers – less than one health professional is available per 1,000 people.
With 170 out of every 1,000 children dying before they reach the age of five and 10 percent of infants underweight, DRC has one of the worst child health indicators in the world. It is one of five countries in the world in which about half of under-five deaths occur. Some of the biggest killers of children are diarrhoea, malaria, malnutrition and pneumonia.
Sexual violence – Several studies report high levels of sexual violence perpetrated against women, children and men in DRC, both by armed groups and within the home; one study, conducted in the North and South Kivu and Ituri in 2010, found that 40 percent of women and 24 percent of men had experienced sexual violence.
Between the stigma of rape and the dearth of decent health services in DRC, sexual violence often leaves survivors injured, infected with sexually transmitted illnesses and severely traumatized. Some of the main requirements are first aid and trauma services, counselling, diagnosis and treatment of sexually transmitted infections, HIV post-exposure prophylaxis and access to contraception.
During a recent visit to eastern DRC, UK Foreign Secretary William Hague announced $312,110 in new funding to support the NGO Physicians for Human Rights, which works at Panzi Hospital in South Kivu Province, “to help efforts to develop local and national capacity to document and collect evidence of sexual violence”.
Diarrhoeal diseases – The consumption of unsafe water is one of the main causes of the diarrhoeal diseases – such as cholera – that infect and kill children and adults in DRC. A cholera epidemic that started in June 2011 has infected tens of thousands and killed more than 200 people. In the capital, Kinshasa, which has been hit by the epidemic, less than 40 percent of people have no access to piped water. According to the UN Children’s Fund, UNICEF, 36 million people in DRC live without improved drinking water, and 50 million without improved sanitation.
Some of the measures to boost access to safe water and sanitation include hygiene awareness campaigns, rehabilitation of water supply and of sanitation facilities, disinfection of contaminated environments, chlorination of water, and distribution of soap.
Immunization - Despite the existence of an effective vaccine for measles at a cost of roughly $1 per vaccine, the disease is one of the leading killers of children in DRC. According to the Global Alliance for Vaccines, 20-30 percent of children in DRC do not have access to immunization. Some challenges to universal vaccine coverage include the poor road network, the size of the country (DRC is Africa’s second largest country), unreliable electricity for vaccines that require refrigeration, and low awareness within the population.
HIV – More than one million people in DRC are living with HIV; 350,000 of these qualify for life-prolonging antiretroviral drugs, but only 44,000 – or 15 percent – are actually on treatment. Just 9 percent of the population knows of their HIV status, largely because of low awareness, but also because of a shortage of facilities – for instance, only one laboratory in the country is equipped to carry out polymerase chain reaction tests for early infant diagnosis.
Just 5.6 percent of HIV-positive pregnant Congolese women receive ARVs to prevent transmission of HIV to their babies; according to government figures, the mother-to-child transmission rate is about 37 percent.
Humanitarian agencies have called on the government and donors to urgently boost funding for HIV prevention, treatment and care.
SHARETETE, 11 April 2013 (IRIN) – It is 15.45 and two young women are already sitting outside the Night Clinic in Moatize, a small town in Mozambique’s northern Tete Province, near one of the largest coal mines in the southern hemisphere, owned by Brazilian mining giant, Vale. The national 123 road cuts through the town, and the clinic lies just off it, intentionally located to bring its services as close as possible to its target patients: miners, truck drivers and sex workers.
“When the big mining companies were established here, people started moving in from neighbouring countries: Zimbabwe, Malawi and Zambia. Tete became a window of hope, but when people don’t find the jobs they hoped to find, many of them end up involved in prostitution or criminality,” said Oswaldo Inacio Jossiteala, a programme officer at the International Centre for Reproductive Health (ICRH).
Every mining boom brings the fear of a rising HIV infection rate, particularly in a country like Mozambique, where the estimated prevalence is already 11.3 percent.
Although the incidence of infection in Tete has been stable at 7 percent, officials are concerned that this could be changing. In an interview with Radio Mozambique, Domingos Viola, the coordinator of the provincial working group for the fight against HIV/AIDS, noted that in 2012, 35,000 cases of sexually transmitted infections (STIs) were registered in the area, 10,000 of them in Moatize, at the centre of the coal boom, which has just 40,000 residents.
The recently opened Night Clinic is part of a project called the Improved Sexual and Reproductive Health and Rights Services for Most at Risk Populations (MARP) in Tete, set up with the goal of reducing STIs and HIV in Tete and Moatize.
Most of the patients are between 16 and 35 years old, and 30 to 35 receive medical attention every evening. According to Jossiteala, “The target group are often stigmatized when they go to ordinary clinics – we believe they find it easier to come here, and that the new clinic will attract more patients.”
The project is a collaboration between Mozambican health authorities, the International Centre for Reproductive Health, USAID, and the Flemish International Cooperation Agency (FICA). Vale has contributed $200,000 for the infrastructure, while the local health authority is paying for staff and medicines.
The Night Clinic has activists working in local communities, at trucks stops and guesthouses, trying to convince target groups to visit and make use of the services. They also lobby for the rights of sex workers in the province.
“If a sex worker is beaten by a customer, or if a customer doesn’t pay, the women have the right to take the case to court. But since most of them are here illegally, that is very difficult. The women are afraid that the authorities will turn against them, but now we see small changes in the attitudes.”
The Mozambican media last year reported cases of policemen abusing foreign sex workers in Tete and soliciting bribes from them, but Jossiteala noted that since clinic staff began educating sex workers about their rights, this is slowly changing.
As mining companies flourish in the province, residents are growing increasingly unhappy with the inadequate contribution of the firms to the wellbeing of surrounding communities. Most of the people working in the mines are men under 40 years old, many of them living alone. Américo Conceicão, acting Permanent Secretary of Tete Province, has urged the mining companies to do more.
“They have internal HIV-programmes, but how their employees act affects the whole community, not just the mining company. They need to work together with the health authorities concerning these issues,” he said.
Carla Mosse, the provincial director of health in Tete, hopes that with the worrying rise in the incidence of STIs and HIV, mining companies will step up and play a bigger role.
“We are too disorganized. We need to elaborate a provincial plan for social responsibility where we, together with the companies, have decided what they will contribute each year. Now, if we need something we send a letter asking for help, and the answer is always, ‘No, no, no’.”