Academic journal article Bulletin of the World Health Organization

The Role of the Law in Reducing Tuberculosis Transmission in Botswana, South Africa and Zambia/Role De la Legislation Dans la Reduction De la Transmission De la Tuberculose En Afrique Du Sud, Au Botswana et En Zambie/ El Papel De la Legislacion a la Hora De Reducir la Transmision De la Tuberculosis En Botswana, Sudafrica Y Zambia

Academic journal article Bulletin of the World Health Organization

The Role of the Law in Reducing Tuberculosis Transmission in Botswana, South Africa and Zambia/Role De la Legislation Dans la Reduction De la Transmission De la Tuberculose En Afrique Du Sud, Au Botswana et En Zambie/ El Papel De la Legislacion a la Hora De Reducir la Transmision De la Tuberculosis En Botswana, Sudafrica Y Zambia

Article excerpt

Introduction

Tuberculosis is the leading cause of death among human immunodeficiency virus (HIV)-infected people in Africa, (1,2) where 80% of HIV-positive tuberculosis cases and deaths occur. (3) In sub-Saharan Africa, transmission of tuberculosis in health facilities (i.e. nosocomial transmission) has been identified as a major contributor to high tuberculosis rates. (4) Although all health-care workers and patients are at risk of exposure to, and the acquisition of, tuberculosis, (5,6) those with an HIV infection are at a particularly high risk. Substantial nosocomial transmission of multidrug-resistant and extensively drug-resistant tuberculosis has also been documented in Africa--these forms of the disease are far more costly and difficult to treat. (3,7) Fortunately, the risk of nosocomial transmission can be minimized by a combination of managerial, administrative, environmental and personal protection measures, collectively referred to as tuberculosis infection control. (8,9) Political commitment is critical for tuberculosis infection control and that commitment can be demonstrated by a country's legislation, (8) which may influence the practice of infection control. However, if we are to discern the impact of legislation on tuberculosis infection control, or on any other area of public health, we must first have information about the relevant laws--this may require a cross-disciplinary approach involving legal research and policy analysis.

Law, which has been defined as a government's system of binding rules that order, permit, reward, forbid and punish behaviour, (10) has been proven to have a positive effect on health in a wide range of public health areas, such as tobacco control, injury prevention and encouraging increased physical activity through urban design. (11) The hierarchy of laws differs between countries but typically includes various types of legal instruments (Box 1). A country's highest law--the constitution--sets out the broad structure of government as well as fundamental rights and duties. Legislation is a specific act or statute passed by the legislative or parliamentary branch of government to help implement the broad mandates of the constitution. For example, legislation can create a ministry of health to realize a constitutional right to health. A further step in operationalizing the law is the issuance of regulations by executive branch officials: for instance, ministers of health are often authorized by legislation to issue regulations. Law has long been central to public health, so much so that the Constitution of the World Health Organization (WHO) requires that: "Each Member shall communicate promptly to the Organization important laws, regulations, official reports and statistics pertaining to health which have been published in the State concerned". (12) However, in important areas of public health, such as tuberculosis infection control, the global health community lacks a sound understanding of the law's effect on population health. As observed in the literature, "little national research, and even less cross-national comparative research, has been conducted to describe and analyse legislative approaches to tuberculosis control". (13) The discontinuation of WHO's International Digest of Health Legislation makes it even more important that public health practitioners research, describe and analyse relevant public health laws. (14)

Box 1. Hierarchy of laws and their relationship to public health
practice The constitution:

* sets out rights, such as the right to health or health-care
services;

* sets out duties, such as a state's obligation to realize the
right to health;

* sets out civil liberties, which at times may conflict with public
health objectives.

Legislation:

* builds on broader constitutional principles and aims by creating
public health structures;

* creates entities such as a ministry of health and positions such
as a minister of health;

* establishes requirements, objectives and processes and prohibits
practices. … 
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