What we do matters: Supporting anti-racism and decolonisation of public health teaching and practice through the development of Maori public health competencies.

OBJECTIVE: This research sought to expand on a set of core Maori hauora a-iwi/public health competencies initially designed for teaching and to enable their use in workplaces. METHODS: The research used a kaupapa Maori methodology in four stages including the development of draft levels of competence for all core competencies, consultation hui (meetings), analysis of feedback and redrafting, and respondent validation. RESULTS: Key themes elicited in relation to the content of the competencies included increasing language expectations, the importance of strength-based approaches and self-determination, and the need for individual responsibility to address structural racism. Reflective practice was identified as a fundamental cross-cutting competency. Participants suggested planetary health and political ideologies be included as additional socio-political determinants of health with equity impacts. Key concerns related to the application of the competency document included the need for cultural safety and ensuring that all public health practitioners are 'seen'. CONCLUSIONS: The Maori hauora a-iwi/public health competencies have been published under a Creative Commons licence. IMPLICATIONS FOR PUBLIC HEALTH: The process of drafting a set of Maori public health competencies elicited key themes potentially relevant for public health practice in other countries and resulted in a competency document for use by universities and workplaces.

Unplanned antiretroviral treatment interruptions in southern Africa: how should we be managing these?

Adherence to antiretroviral therapy is essential for maximising individual treatment outcomes and preventing the development of drug resistance. It is, however, frequently compromised due to predictable, but adverse, scenarios in the countries most severely affected by HIV/AIDS. This paper looks at lessons from three specific crises in southern Africa: the 2008 floods in Mozambique, the ongoing political and economic crisis in Zimbabwe, and the 2007 public sector strike in South Africa. It considers how these crises impacted on the delivery of antiretroviral therapy and looks at some of the strategies employed to mitigate any adverse effects. Based on this it makes recommendations for keeping patients on treatment and limiting the development of drug resistance where treatment interruptions are inevitable.

The impact of ART (anti-retroviral treatment) scale-up on health systems de-strengthening in sub-Saharan Africa: justice and justification.

The scale-up ofanti-retroviral treatment (ART) in sub-Saharan Africa (sSA) is unquestionably a positive development. To be successful, however, scale-up must be understood as more than the technical delivery of pills. A central dimension of the challenge involves the health systems through which services are delivered. Part 1 of this article explores how the scale-up of ART could impact on health systems in sSA. We conclude that the current expansion of access to ART potentially involves an approach to health delivery that runs counter to many aims of health system strengthening. Part 2 addresses the question of whether this impact is justified. We argue that the potential erosion of health systems strengthening in the region is justified, provided simultaneous efforts are undertaken to optimize the possibility for realizing the "AIDS transition". We discuss these simultaneous efforts, drawing on recent research to illustrate the emerging scenario in sSA. In Part 3, we identify lessons that may inform scale-up of ART in sSA in ways that, at least, minimize detrimental effects and, ideally, serve to strengthen health systems in the region. We discuss the value of solidarity as a guiding principle for ART scale-up, followed by concrete lessons for moving forward.

The evolving impact of HIV/AIDS on outpatient health services in Kwazulu-Natal, South Africa.

UNLABELLED: BACKGROUND AND OBJECTIVE; The high HIV prevalence in KwaZulu-Natal (KZN) places immense pressure on the health system. The burden of HIV/AIDS on health services is evolving as the epidemic progresses and as antiretroviral treatment becomes more widely available. For health policy makers and managers, timely and appropriate information is needed to facilitate adaptive management of health services. Through longitudinal research covering outpatient health services in KZN we examined the dynamics of the evolving HIV/AIDS burden and the resource implications of this burden, necessary for resource allocation decisions. METHODS: Data were collected between 2004 and 2005 in outpatient services across six health facilities in the province. The burden of HIV/AIDS was measured by assessing the proportion of outpatients presenting as HIV positive, determined by a clinical diagnosis (and test result where available). The burden was also measured by looking at the types of diseases presenting at outpatient facilities. Moreover, the study assessed the burden experienced by health care workers and financial implications for health facilities. RESULTS AND CONCLUSIONS: The study demonstrates that the burden on outpatient services is significant but has not been increasing over time, suggesting that people are not accessing care if and when they need it. However, in terms of resources, this burden has been increasing and shifting from tertiary services to more primary services. In order to accommodate the demands of HIV/AIDS, our focus therefore needs to turn towards outpatient services, in particular at the primary care level.

Comparative health systems research in a context of HIV/AIDS: lessons from a multi-country study in South Africa, Tanzania and Zambia.

Comparative, multi-country research has been underutilised as a means to inform health system development. South-south collaboration has been particularly poor, even though there have been clearly identified benefits of such endeavours. This commentary argues that in a context of HIV/AIDS, the need for regional learning has become even greater. This is because of the regional nature of the problem and the unique challenges that it creates for health systems. We draw on the experience of doing comparative research in South Africa, Tanzania and Zambia, to demonstrate that it can be useful for determining preconditions for the success of health care reforms, for affirming common issues faced by countries in the region, and for developing research capacity. Furthermore, these benefits can be derived by all countries participating in such research, irrespective of differences in capacity or socio-economic development.

The burden of HIV-related illness on outpatient health services in KwaZulu-Natal, South Africa.

Health services in sub-Saharan Africa will be faced with increasing numbers of AIDS patients for many years to come. Where there is good availability of drugs and other resources, the costs of treating HIV/AIDS is likely to be higher than those of treating other types of illness. This will put services under strain and potentially jeopardise health system reform, depending on the vulnerability of the system. Whereas previous research has focussed on inpatients, this paper looks at the impact of HIV/AIDS on outpatient services in a district of South Africa. Through facility visits at various levels of care, data concerning HIV status and the costs of care was collected for all patients presenting over a set period of time. The proportion of patients presenting for HIV-related care ranged from 20.2 to 24.5%. The average costs of treating HIV-positive patients were significantly higher than those for non HIV patients at hospitals, with clinics not experiencing this difference due to the limited service provided. District hospitals spent the greatest proportion of direct patient care resources on treating HIV-related illness. In terms of outpatient care, this data suggests that district hospitals may require the most support in dealing with a rising number of AIDS patients.

Economic impact of HIV.

Economics affects everyone and the economic impact of HIV/AIDS will take generations to unfold. Recent macroeconomic predictions have emphasized the concept of human capital, and predicted that much higher costs will be associated with the epidemic than earlier suggestions that economies might simply grow more slowly implied. At a firm or sector level AIDS increases the costs of doing business; impact studies at this level are therefore more important for planning. Impacts at household level are some of the most immediate and devastating, owing to the close relationship between households being affected by HIV/AIDS and subsequent impoverishment. The economic impacts of HIV/AIDS at each level will be modified through prevention and treatment interventions. The potential savings to governments through implementation of a programme to prevent mother-to-child transmission provide some of the most compelling evidence for action. However, health services are suffering under a dual burden of increased demand and reduced capacity to deliver, which contributes to a cycle of poor health and economic decline.

The importance of cultural factors in the planning of rehabilitation services in a remote area of Papua New Guinea.

PURPOSE: The aim of this study in the Middle Ramu, Papua New Guinea, was to gain a better understanding of how cultural factors work to influence the lives of persons with disability in a remote area. The study also explores how this information can be used for the planning of rehabilitation services. METHOD: Two phase screening identified persons with disability in the study area and questionnaires were completed for all those identified. Information documented included the nature of the disability, a biomedical cause (where appropriate), the perceived cause of the disability, as well as some indication as to where help had been sought for the disability. In depth interviews were later done with disabled individuals and their families, to determine how they explained their disability. RESULTS: Thirty-two per cent of persons with disability and their families attributed disability to sorcery or other supernatural causes, a greater proportion than for any other category of perceived aetiology. There was widespread acceptance of Western medicine, although help was more likely to be sought from sources in the community for disabilities believed to have a supernatural origin. CONCLUSIONS: This study demonstrates that an understanding of cultural factors is fundamental to implementing rehabilitation services that are culturally appropriate and address the social dimension of disability.

Using an undertaker's data to assess changing patterns of mortality and their consequences in Swaziland.

This paper measures AIDS mortality using routinely collected data from one of two nationally operating undertakers in Swaziland. The business recorded a marked increase in the number of deaths it handled between 1998 and 2002, most obvious in the 0-4 and 20-49 age categories. Cost data reflects this increase in mortality. Prices for funerals and coffins have declined in real terms. Recorded causes of death were of little use in determining the extent of AIDS mortality. This was due to stigma and denial, the relatively small number of people dying in hospitals and lack of accurate reporting of medical diagnoses. Key informant interviews were done to support the undertaker's data and determine how families bear the burden of burying deceased relatives. Despite a disproportionate increase in deaths in certain age categories and evidence of worsening poverty, funerals remain large and elaborate affairs.

Towards a method for informing the planning of community-based rehabilitation in Papua New Guinea.

Disability is a major public health problem, particularly in developing countries, where there is a close link between poverty and disability. The complex nature of disability allows it to be addressed from a number of different perspectives. Community-based rehabilitation (CBR) is a holistic approach towards disability which is currently being supported in many parts of the world, including Papua New Guinea (PNG). Unfortunately CBR is frequently implemented in resource-poor contexts, which limits the scope for research. As a result little effort is put into determining a need before CBR programs are established, or into evaluating CBR programs following implementation. This research in the Middle Ramu, Madang Province, tested a method for acquiring information for the purposes of CBR planning in PNG. The method used an adapted form of the Ten Questions Screen for Childhood Disability. Quantitative and qualitative methods were further utilized to determine the types of disability presenting, the biomedical and perceived causes of the various disabilities, help-seeking behaviours, the disabled individual's participation in village activities, and the needs of both disabled individuals and their caregivers. A total of 158 disabled individuals were identified in a population of 4946 people and 20 in-depth interviews were conducted. The data obtained were analyzed to formulate an appropriate 'CBR package' that would cater for the specific needs of this population in the Middle Ramu. Evaluation of the basic survey method revealed that it was more sensitive than other methods previously tried in PNG, with an overall disability prevalence of 3.2% obtained. Qualitative methods allowed the fieldworkers to get a much deeper insight into the feelings and perceptions of disabled individuals. The methods tested for this research in the Middle Ramu could have application for CBR workers in other parts of PNG.