In 2013, the fifth Tokyo International Conference on African Development (TICAD V) will be hosted by the Japanese government. TICAD, which has been held every five years, has played a catalytic role in African policy dialogue and a leading role in promoting the human security approach (HSA). We review the development of the HSA in the TICAD dialogue on health agendas and recommend TICAD’s role in the integration of the HSA beyond the 2015 agenda. While health was not the main agenda in TICAD I and II, the importance of primary health care, and the development of regional health systems was noted in TICAD III. In 2008, when Japan hosted both the G8 summit and TICAD IV, the Takemi Working Group developed strong momentum for health in Africa. Their policy dialogues on global health in Sub-Saharan Africa incubated several recommendations highlighting HSA and health system strengthening (HSS). HSA is relevant to HSS because it focuses on individuals and communities. It has two mutually reinforcing strategies, a top-down approach by central or local governments (protection) and a bottom-up approach by individuals and communities (empowerment). The “Yokohama Action Plan,” which promotes HSA was welcomed by the TICAD IV member countries. Universal health coverage (UHC) is a major candidate for the post-2015 agenda recommended by the World Health Organization. We expect UHC to provide a more balanced approach between specific disease focus and system-based solutions. Japan’s global health policy is coherent with HSA because human security can be the basis of UHC-compatible HSS.

Background
Female Genital Mutilation (FGM), which can be considered as one of the harmful effects for the health of pregnant women and violence to women, is performed widely as a social custom in some African countries. Therefore, this study aims to clarify the situation of FGM prevalence and a recent trend of African countries by using published health statistics.
Method
Demographic and Health Survey (DHS) full reports in African countries written in English in which topic of FGM is included and whose comparison was possible between the latest report and the one about ten years ago were obtained. And, indicators regarding FGM were compared by countries and years.
Results
Of six countries, the prevalence of FGM in five countries had a trend of decline, and their FGM prevalence rates were higher in rural areas than urban. In these countries, wider decline was seen in younger population. For example, in Tanzania, the prevalence changed from 13.5% to 7.1% in 15-19 years old, and from 22.2% to 21.5% in 45-49 years old between 1996 and 2010, respectively. On the other hand, the FGM prevalence of Nigeria was higher in urban areas than rural, and increased in younger women. Some DHS reported the variety of FGM prevalence by places and ethnic groups even in a country.
Conclusions
In many countries, the decline of FGM prevalence in young women could lead us to expectation of more decreased prevalence in the future. The health education to the young, who will become mothers, could be effective. However, since some countries have different characteristic features in the trend of FGM prevalence, it was suggested that sociocultural background should be individually considered for effective interventions.

Objectives
The objective of this study is to identify barriers and facilitators of anti-retroviral treatment (ART) continuation among ART patients in Zambia. It also aims to explore ART scale-up approach while reducing defaulters.
Methods
In October 2009, we obtained ART statistics, interviewed District Health Management Team (DHMT) in Livingstone, Zambia, and conducted Focus Group Discussion (FGD) with 27 ART defaulters who were traceable, where participants shared experience in relation to why they gave up and how they resumed treatment.
Results
Although ART facilities have been increased in Livingstone, half of the facilities are not equipped with CD4 count machine, which affects timely commencement of treatment. Anti-retrovirals (ARV) and consultation are basically offered free of charge to ART patients, yet patients have to pay X-ray and co-morbidity treatment. On average, 22.7% of ART patients stopped visiting ART facilities. Especially in large-scale ART centre, defaulters were not followed up. FGD revealed the process of how defaulters developed hopelessness and pill burden, which were triggered and influenced by several factors including hunger, poverty, stigma, side-effects and co-morbidities. Some stopped medication as they thought being cured after condition recovered. Others attributed discontinuation to the accessibility of service and the attitude of ART centre staff. Default was attributed by internal (inadequate knowledge, weak motivation) and also external (hunger, medical service system) factors. It is inevitable to empower patients with adherence management by strong motivation to treatment and supportive environment.
Conclusion
Financial empowerment of patients, free-service of co-morbidity treatment and side effect mitigation are desirable for sustainable ART scale-up. Defaulter follow-up, continuous regular adherence counseling and ART roll-out to small-scale clinics are inevitable to reduce defaulters.

Introduction
The economic situation of the Republic of Indonesia has been good with 6% economic growth in 2010. The health provision was affected by the decentralization after 2001, which has caused the prominent diversity in health condition. The health system and health situation in Indonesia are overviewed.
Health situation
The health indicators of Indonesia have been improving in general though maternal and child health (MCH) indicators are still not good enough compared to the surrounding ASEAN countries. The health budget has been increasing though up to 2% of GDP. The efforts by the Government have increased the number of health facilities as well as health workforce through it is yet to be improved. The Public Health Security Fund has extended its coverage with the target of universal health coverage. The health strategic plan 2010-2014 shows us the master plan of health development, whose vision is to encourage autonomous efforts by the community for health and the equity of health.
Conclusions
Indonesia is now on the epidemiological and populational transition with double burden of diseases. With the target of universal health coverage, it is urgent need to enhance the health service provision with development of health workforce in order to meet the demand along with enhancement of the health insurance coverage.

 Zambia is one of the HIV high burden countries in Sub Saharan Africa. Government of Zambia has been expanding Antiretroviral Therapy (ART) service nationwide at district level. However, it is still hard to access to ART service for PLHIVs who live in rural. In terms of accessibility, the service must be expanded to rural health centre level, but there are many challenges to expand the quality services into such resource limited setting, especially in the shortage of health providers.
 JICA's “Integrated HIV and AIDS Care Implementation Project at District Level” launched at April 2006 to improve the quality and accessibility of HIV and AIDS care services in rural Zambia. Two districts in rural area, namely Mumbwa and Chongwe, were selected as project sites. The Project introduced the “mobile ART service” at rural health centre level using the existing health system. Mobile ART services enable a rural health centre that cannot offer ART by itself to provide ART services through the human resource and technical support/assistance of the District Hospital. Mumbwa and Chongwe District Health Management Team (DHMT) started mobile ART services in the first Quarter of 2007, therefore access to ART service in districts has been improved and contributed to increase of ART clients and reduce the defaulter rate within first 6 months of treatment. The project also tried to introduce the community involvement to overcome the shortage of human resources.
 We found that Mobile ART services involving the community are beneficial and effective, and help ART services expansion to rural health facilities where resources are limited, and as close as possible to places where clients live. The strategies we experienced were cited in “the National Mobile HIV Services Guidelines” published by the MoH and will be able to be duplicated in other resource-limited areas of not only Zambia but also other developing countries.

Objective
 In recent years, antiretroviral therapy (ART) has been significantly expanded in developing countries, while drug resistance to HIV caused by low adherence is becoming a grave concern. As a member of the international community, Japan is expected to expand its cooperation for supporting the expansion of ART. However, the evaluation of ART adherence remains a challenge since the definition and the methods of its measurement are not standardized. In this regard, the articles of studies on ART adherence are reviewed to investigate available methodologies that can be used for measurement.
Method
 Articles were searched and extracted through Ovid Full Text database for the period between Jan. 2002 and Aug. 2006 by using keywords of “adherence” and “HIV”. Among 81 extracted original articles, 50 articles were selected based on the inventory and clear identification of the methodologies used to measure adherence.
Result
 The studies were conducted in the US (28 articles: 56%), Canada (5 articles: 10%), UK (3 articles: 6%), Africa and South America (10 articles: 20%) and no articles were extracted from Asia. The mean sample size of the studies was 581.2 (range: 24-6288). Measurements of adherence that were used in the articles as follows; patient's self-report (31 articles: 62%), electric drug monitoring (14 articles: 28%), pharmacy's refill record (12 articles: 24%), pill-count (9 articles: 18%), laboratory testing (6 articles: 12%) and combination of these (14 articles: 28%). Of the 31 articles using patient's self-report, 25 articles asked for the participant's frequency of missed dose.
Conclusion
 Studies concerned with ART adherence have been mainly undertaken in industrialized countries, and it was found that inquiries on missed doses were the most frequently used method to measure ART adherence. We strongly suggest the development of more simplified methods for measuring ART adherence, especially for resource-limited settings.