Health and development: toward a matrix approach

883Bull World Health Organ 2009;87:883–884 | doi:10.2471/BLT.09.071522 Books & electronic media Integrating gender into HIV/ AIDS programmes in the health sector: tool to improve respon- siveness to women’s needs Publisher: World Health Organization; 2009. ISBN: 978-92-4-1597197 Available from: http://www.who.int/gender/ documents/gender_hiv_guidelines_en.pdf Half of all people living with HIV/ AIDS worldwide are female and in sub-Saharan Africa it is far more than half, especially among those aged 15– 24. Women living with or widowed by HIV/AIDS are commonly spurned by their families, beaten, lose their prop- erty, forced to marry a brother-in-law or cast out of their communities. They are the caretakers in the household and held solely responsible for getting pregnant and protecting the babies they bear. Girls’ and women’s vulner- ability to HIV is fuelled by endemic sexual coercion and violence; early and forced marriage to much older men; and lack of access to HIV information, sexuality education and reproductive health services. Over a period of six years, WHO’s Department of Gender, Women and Health invested in field tests in five countries and painstak- ing reviews by diverse practitioners to produce this manual. As a result, HIV/AIDS programme managers and service providers now have a jargon-free guide, focused on action, with enough information on inequal- ities between women and men to persuade readers to act. Four sections for health-care providers focus on se- lected services that are not addressed in the other 187 resources listed in the excellent reference section: HIV testing and counselling, prevention of mother-to-child transmission, HIV treatment and care, and home- based care and support. An opening section explains the role that gender inequalities play in women’s vulner- ability to HIV, in limiting women’s access to and effective utilization of HIV/AIDS services, and the steps required to deliver and monitor programmes that will reduce these problems. Each section of the manual, even the preface, is a gem, a terrific exposi- tion of the investments that should be, but rarely are, made to produce a user- friendly tool. Although the authors suggest that the first section, on gender equality concepts, is most suitable for programme managers, service provid- ers would also benefit from this clear and succinct clarification of “core” concepts. Each of the four service sec- tions has examples of how to address the particular barriers, fears and chal- lenges that women clients and patients are likely to face: at home, in the community and from health services. Examples from real life and materials from programmes provide additional energy to the already clear language and succinct presentations. Two of the best parts of the manual are presented as annexes but no reader should miss these. Each is constructed as a checklist for manag- ers and service providers, respectively, to assess their progress. These lists are an additional way of presenting and reinforcing the actions needed, broken into useful subactions and presented in sequence. Sprinkled throughout the manual are special jewels, such as a clear and compelling list of reproductive rights interpreted for the HIV/AIDS context. There are also several pages on violence against women, its relationship to HIV exposure, its role in deterring effective HIV prevention, testing, disclosure and treatment, and examples of inter- ventions specific to the health sector. This is also a compelling role-play for negotiating safer sex. Annex 3 invites users of the manual to submit suggestions for the expected revision of the manual in five years. This reviewer has a few sugges- tions, without which HIV/AIDS will persist, especially for girls and women. First, each section needs action steps to assist readers to integrate into their work ways to help women cope with stigma and discrimination outside the health system. Second, each section should emphasize supervision and oth- er means to hold managers and provid- ers accountable for improved perfor- mance. Third, the section on preven- tion of mother-to-child transmission does not include treatment for the woman herself. The reference in the treatment section is brief and phrased in negative terms rather than with the strong affirmation it deserves. Further, while addressing family planning, this section does not address women’s need and right to access safe, legal abortion should they want it. Fourth, refer- ences are inadequate on the impor- tance of identifying and providing the comprehensive services women need, and to “linkages” between sexual and reproductive health services and HIV/ AIDS programmes. All women need comprehensive reproductive health ser- vices. This has been agreed many times by governments since 1994 to include, at a minimum: family planning, safe abortion where legal, maternity care and diagnosis and treatment of sexu- ally transmitted infections including HIV. Especially for women and young people, a paradigm shift is needed in HIV/AIDS programming to address HIV as a sexual and reproductive rights and health concern, including the services listed above as well as com- prehensive sexuality education. This manual should be widely introduced, not simply disseminated, by WHO and all others engaged in the delivery and funding of HIV/AIDS services in the health sector. ■ review by Adrienne Germain a Health and development: toward a matrix approach Editors: Anna Gatti & Andrea Boggio Publisher: Palgrave Macmillan, Basingstoke, 2008 ISBN : 9781403947376; hardcover; 296 pages; £50.00 Interest in global health, the relation- ship between health and economic development, and the impact of glo- balization upon both of these, has risen rapidly up international and national agendas in recent years. This expansion of interest has both formal expression, such as the Millennium Development Goals, the Commission on Macroeco- nomics and Health, and the Framework Convention on Tobacco Control, and a International Women's Health Coalition, New York, NY, United States of America. Correspondence to Adrienne Germain (e-mail: agermain@iwhc.org). 884 Bull World Health Organ 2009;87:883–884 | doi:10.2471/BLT.09.064931 Books & electronic media more informal expressions, through concerns and negotiations focusing upon pandemic influenza, the role of the food industry in nutrition-related chronic disease and the role of pat- ent protection in access to essential medicines. These, and many other in- stances, serve to demonstrate that there is no such thing as national health or a national health system; in today’s world, all health is global health. This has led to a welcome con- comitant increase in funding allo- cated to global health, both through traditional aid routes and increasingly through new initiatives, most notable perhaps being the Global Fund to Fight AIDS, Tuberculosis and Malaria. However, this increase has not been universally applauded and there have been criticisms, mostly focused upon the reinforcement of the “vertical” approach, emphasizing a disease- specific approach to securing health improvement. This has come at a time when many in the international health community were feeling that there had finally been a breakthrough in securing recognition that health improvement can only be achieved through strength- ening of health systems more generally; the so called “horizontal” approach. More recently a consensus may be emerging that both approaches have strengths and weaknesses, and that synergies may be capitalized upon if both are pursued in tandem; simulta- neously strengthening the health sys- tem while focusing upon those diseases that are the major burden to a country. It is this tandem, or “diagonal”, approach that Anna Gatti & Andrea Boggio emphasize in this book. In their introduction they emphasize this perspective and outline a matrix that seeks to combine both vertical and horizontal aspects to aid resource al- location. This is a novel and potentially illuminating means of categorizing in- terventions. The remainder of the book then comprises four sections written by a wide variety of authors internal and external to WHO. Part 1, on the a London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England. Correspondence to Richard Smith (e-mail: Richard.Smith@lshtm.ac.uk). global health arena, considers especial- ly the role of WHO in global health. Part 2, on health and development looks in more detail at various perspec- tives on global health and develop- ment, including those of evolution, economics, law and ethics. Part 3, on global health and vulnerability, focuses on the experiences of the elderly, chil- dren and women. Part 4 considers the interrelation between specific disease and development, then shifts the focus to specific diseases of chronic illness, malaria, HIV/AIDS and tuberculosis. In the main, the book is relatively neutral in its presentation, provides a good deal of evidence – some of it new – and is authored by those with a good knowledge of their subjects. Certainly some of the perspectives by those working in or with international orga- nizations provides interesting insights at times. The book is pervaded by the emphasis on building systems and ca- pacities, rather than new technological discoveries, as the key to future health improvement. It is likely that readers interested in global health will find much that appeals and informs, and it is certainly a welcome addition to my bookshelf. I read the book over a period of several weeks' travelling, something many readers may do, and the edited nature of the book lends itself very well to this style of reading as each chapter stands alone. However, once I had finished the final chapter, I found myself somewhat disappointed that there was no final section or chapter to turn to that deals with the perfor- mance of the matrix approach that was introduced at the beginning of the book. The book begins with the au- thors “propos[ing] a matrix as a tactical tool to be used to define optimal al- location of (scarce) resources” (p.xxiii). However, it is not made clear how the various chapters link to this, or how the analyses are informed by it, and the chapters themselves do not tend to make reference to this matrix. It is therefore disappointing to get to the end and find that there is no chapter to bring the book full circle and reflect upon the material in these chapters from this matrix perspective, or to offer a summary of the research and policy agenda’s arising from them. This lack of emphasis on the matrix makes one wonder at the appropriateness of the subtitle of the book as, apart from a brief discussion in the introduction, the matrix approach does not appear and the book then becomes another collection – albeit an interesting col- lection – of papers with some specific views and opinions on globalization, health and development. A further feature to bear in mind is that 12 of the 16 authors are current or ex-WHO staff and this is reflected in an often uncritical reflection upon the role and activities of WHO (perhaps the best example being the discussion in chapter 2). Although there have clearly been considerable successes achieved by the Organization over the past 60 years, this uncriti- cal reflection of its role in the current global environment is a weakness, as there is considerable debate – internal and external to WHO – about the role the Organization will play in the next 60 years; for example vis-à-vis other international organizations, such as the World Trade Organization, concerning issues of trade and health. This empha- sis of the role WHO does and should play seems critical to any discussion of the links between health and develop- ment. In summary, this is a useful and accessible book that offers much benefit for those interested in global health. This is especially true of those who are active in the field in research and policy but it may also be of some value to graduate students, probably as an optional reading or reading of selective chapters. I only wish that the editors had taken that final step to conclude with something more on their proposed matrix! ■ review by Richard Smith a