A review of global progress toward the Millennium Development Goal 1 Hunger Target.

BACKGROUND: The hunger component of the first Millennium Development Goal (MDG) aims to reduce the proportion of people who suffer from hunger by half between 1990 and 2015. In low- and middle-income countries, progress has been mixed, with approximately 925 million people hungry and 125 million and 195 million children underweight and stunted, respectively. OBJECTIVE: To assess global progress on the hunger component of MDG1 and evaluate the success of interventions and country programs in reducing undernutrition. METHODS: We review global progress on the hunger component of MDG1, examining experience from 40 community-based programs as well as national efforts to move interventions to scale drawn from the published and gray literature, alongside personal interviews with representatives of governments and development agencies. RESULTS: Based on this review, most strategies being implemented and scaled are focusing on treatment of malnutrition and rooted within the health sector. While critical, these programs generally address disease-related effects and emphasize the immediate determinants of undernutrition. Other major strategies to tackle undernutrition rely on the production of staple grains within the agriculture sector. These programs address hunger, as opposed to improving the quality of diets within communities. Strategies that adopt multisectoral programming as crucial to address longer-term determinants of undernutrition, such as poverty, gender equality, and functioning food and health systems, remain underdeveloped and under-researched. CONCLUSIONS: This review suggests that accelerating progress toward the MDG1 targets is less about the development of novel innovations and new technologies and more about putting what is already known into practice. Success will hinge on linking clear policies with effective delivery systems in working towards an evidence-based and contextually relevant multisectoral package of interventions that can rapidly be taken to scale.

Socioeconomic disparities in access to HIV/AIDS treatment programs in resource-limited settings.

This study employs data from rural South Africa to determine whether there were socioeconomic differences in the profile of HIV-infected persons living in the community and HIV-infected patients presenting for hospital-based outpatient HIV/AIDS care and related services. There were 776 HIV-infected persons aged 18-35 years in Limpopo Province, South Africa who were included in the study, including 534 consecutive patients who presented for care at a hospital-based outpatient HIV clinic, and 242 persons living in the community. Persons seen in clinic had a higher overall socioeconomic profile compared to the community sample. They were more likely to have completed matric or tertiary education (P=0.04), less likely to be unemployed (P<0.001), and more likely to live in households with access to a private tap water supply (P<0.001). These differences persisted after multivariable adjustment. Our findings demonstrate that important socioeconomic differences in uptake of hospital-based HIV/AIDS care were identified among HIV-infected adults living in a rural region of South Africa. This suggests an important limitation in hospital-based HIV/AIDS care and underscores the need to monitor the equity implications of highly active antiretroviral therapy scale-up in resource-limited settings.

Can social capital be intentionally generated? a randomized trial from rural South Africa.

While much descriptive research has documented positive associations between social capital and a range of economic, social and health outcomes, there have been few intervention studies to assess whether social capital can be intentionally generated. We conducted an intervention in rural South Africa that combined group-based microfinance with participatory gender and HIV training in an attempt to catalyze changes in solidarity, reciprocity and social group membership as a means to reduce women's vulnerability to intimate partner violence and HIV. A cluster randomized trial was used to assess intervention effects among eight study villages. In this paper, we examined effects on structural and cognitive social capital among 845 participants and age and wealth matched women from households in comparison villages. This was supported by a diverse portfolio of qualitative research. After two years, adjusted effect estimates indicated higher levels of structural and cognitive social capital in the intervention group than the comparison group, although confidence intervals were wide. Qualitative research illustrated the ways in which economic and social gains enhanced participation in social groups, and the positive and negative dynamics that emerged within the program. There were numerous instances where individuals and village loan centres worked to address community concerns, both working through existing social networks, and through the establishment of new partnerships with local leadership structures, police, the health sector and NGOs. This is among the first experimental trials suggesting that social capital can be exogenously strengthened. The implications for community interventions in public health are further explored.

Does accessibility to antiretroviral care improve after down-referral of patients from hospitals to health centres in rural South Africa?

We conducted an evaluation of healthcare accessibility among patients taking antiretroviral treatment (ART) after they were 'down-referred' from hospital-based programmes to primary healthcare (PHC) centres in a rural South African setting. A cross-sectional design was used to study 109 PHC users compared to a randomly selected control group of 220 hospital-based users. Both groups were matched for a minimum duration on ART of six months. Using a comprehensive healthcare-accessibility framework, the participants were asked about availability, affordability and acceptability of their ART care in structured exit interviews that were linked to their ART-clinic record reviews. Unadjusted and adjusted regression models were used. Down-referral was associated with reduced transportation and meal costs (p = 0.001) and travel time to an ART facility (p =0.043). The down-referred users were less likely to complain of long queues (adjusted odds ratio [AOR] 0.06; 95% confidence interval [95% CI]: 0.01-0.29), were more likely to feel respected by health providers (AOR 4.43; 95% CI: 1.07-18.02), perceived lower stigma (AOR 0.25; 95% CI: 0.07-0.91), and showed a higher level of ART adherence (AOR 8.71; 95% CI: 1.16-65.22) than the hospital-based users. However, the down-referred users preferred to consult with doctors rather than nurses (AOR 3.43; 95% CI: 1.22-9.55) and they were more likely to visit private physicians (AOR 7.09; 95% CI: 3.86-13.04) and practice self-care (AOR 4.91; 95% CI: 2.37-10.17), resulting in increased health-related expenditure (p = 0.001). Therefore, the results indicate both gains and losses in ART care for the patients, and suggest that down-referred patients save time and money, feel more respected, perceive lower stigma and show better adherence levels. However, unintended consequences include increased costs of using private physicians and self-care, highlighting the need to further promote the potential gains of down-referral interventions in resource-poor settings.