Current Issue

EQUINET NEWSLETTER 221 : 01 September 2019

1. Editorial

Home-grown solutions for the evidence to policy conundrum: Reflections on the ECSA HC Best Practices Forum
Yoswa M Dambisya, ECSA Health Community, Tanzania


In June, at the East, Central and Southern Africa Health Community (ECSA HC) 12th Best Practices Forum held under the theme: Innovation and Accountability in Health Towards Achieving Universal Health Coverage, about 130 participants deliberated for three days and proposed recommendations for policy and practice, including to enhance delivery on existing policy commitments. The recommendations covered diverse areas relating to the theme, covering: improving adolescent and young people’s health; equity in access to eye health; innovative approaches for food safety and improved quality of life; addressing harmful substance use and mental health problems; achieving water and sanitation global health targets; tackling emerging and re-emerging health threats and a regional ’One Health Approach’ for managing recurrent outbreaks. The full recommendations can be found on the ECSA HC website. What is also important, however, is the process by which these proposals are made and reviewed.

The East, Central and Southern Africa Health Community (ECSA HC) is a regional inter-governmental organisation. It reports to, and receives guidance from the Conference of Health Ministers (HMC).

Over the years, ECSA HC has held a Best Practices Forum (BPF). The BPF aims to encourage and strengthen policy dialogue among the diverse stakeholders involved in evidence-based policy decision making. The BPF attracts a wide range of health actors, including senior officials from ministries of health of ECSA-HC member states, the constituent health professions colleges of the ECSA College of Health Sciences, health research institutions, collaborating partners, civil society organisations and other health experts and implementers from the region and beyond.

While the HMC is the highest policy organ of ECSA HC, the Directors Joint Consultative Committee (DJCC) is its highest technical organ. The DJCC consists of the directors of health services, the deans or heads of health faculties and training institutions, the heads of health research institutions and senior officials in the constituent colleges within the ECSA College of Health Sciences. The DJCC informs the health ministers through persuasive evidence-based recommendations. The BPF, in turn, is a critical step and an important platform for presenting and interrogating findings from the member states, from the region and beyond. It provides a platform for a free participation and open exchange of ideas by technical people, researchers, civil society, partner organisations and ministry of health senior officials. The experience, evidence and analysis from the region presented and debated in this forum inform the recommendations to the DJCC and from there to the health ministers in the HMC.

As applied in the recent 12th BPF, the main theme and sub-themes are set by the health ministers at their previous HMC. Submissions are then invited from the countries and from ECSA HC partners, stakeholders and researchers within the thematic areas. Suitable abstracts are then selected for presentation to prime the discussions in these areas at the BPF. It is a unique feature of the BPF that at the start of the meeting there are no draft recommendations tabled for discussion. Rather the participants draft them in an open and free spirit of intellectual engagement, drawing on their collective experience and the evidence presented. These recommendations are then submitted to the DJCC for their consideration.

To complete the loop, the recommendations made at the BPF, as validated by the DJCC, are presented to the HMC. For example for the 12th BPF held in June this year followed by the 28th DJCC, the recommendations will be presented to the HMC in October this year. The HMC will be held under the same theme as for the BPF and DJCC, and the recommendations will be tabled for the Ministers to consider as the basis for their resolutions. While the recommendations of the DJCC may be used as a guide to enhance the programming and prioritisation of their activities, until they are affirmed or changed by the HMC, the resolutions of the HMC are binding on member states and on the ECSA HC secretariat.

Most of the follow up work to implement the recommendations happens within the countries. However, there are also regional approaches that are within the mandate of ECSA HC and in association with partners for some priority areas. The action points are thus directed to both the member states and the ECSA HC Secretariat as appropriate.

Over the past twelve years by convening the BPF, ECSA HC has developed and institutionalised a mechanism and processes by which it engages both the ‘consumers’ and ‘producers’ of research evidence in policy dialogue. This is often done in a demand-driven manner, with the HMC and DJCC identifying gaps and calling for evidence in areas that draw presentations at the subsequent BPF. However, some presentations and research findings also emerge ‘bottom-up’ from work by stakeholders in the region that raise new evidence and issues within the broad thematic areas under consideration. Some presentations report on the implementation and findings of work that was mandated in prior DJCCs and HMCs and what it means for the health system. Some also track delivery on prior policy commitments, the outcomes achieved and the barriers faced.

ECSA-HC continues to work towards strengthening this approach in the hope that it helps to close the gaps in evidence for policy dialogue from the region and in channels for researchers and implementers to present their experience and findings in a way that influences policy. In doing this, the organisation hopes that relevant research and policy, which are two sides of the same coin, can be increasingly connected. The BPF model is being replicated in West Africa through the West African Health Organisation (WAHO), suggesting that it is perceived as a worthwhile effort.

One major challenge with the BPF approach, however, is in the identification of ‘best practices’. While this is based on an open call for and submission of abstracts, the ECSA HC does not have the capacity to ensure that all the best practices in each area come to the fore and there may be limited publicity of the BPF as the outlet for relevant research findings. It has also become evident that a lot of experience and research evidence that is seen to be relevant and useful by policy actors in the DJCC and HMC does not make its way into formal journals for wider dissemination.

Notwithstanding such challenges, the BPF stands out as a useful and unique home-grown solution to the false divide between researchers and implementers on the one hand, and decision and policy makers on the other. It does so by providing a platform for the free input, exchange of and debate on ideas, embedding this within the policy processes and structures of the organisation. Looking at the journey over the last twelve years, one is justified to suggest that in the next twelve years, the BPF could itself be identified as a ‘best practice’ for the East, Central and Southern African region.

Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the ECSA HC BPF please visit https://ecsahc.org/

Reclaiming African knowledge systems - what does it mean?
Editor, EQUINET Newsletter

There has been growing engagement around the inequitable benefit from the extraction of minerals, genetic and biological resources from the continent. Attention is now also growing on the exploitation of local and indigenous knowledge, and as captured in some of the articles in this newsletter, the injustice of knowledge systems that extract empirical evidence for analysis in other countries, and impose barriers to those most directly exposed to conditions being able to travel and participate in scientific programmes and forums, to bring direct knowledge on those conditions into global health forums. This international context contrasts with the experience described in this month's editorial of a sustained initiative within east, central and southern Africa to facilitate dialogue between researchers, service implementers, civil society and government policy makers in and from the region, to share and review knowledge for health and health systems within the region. How actively do we use, engage in and benefit from such platforms? What do we need to do reclaim, build and assert the knowledge systems in the region - and from the region, globally- to advance health equity? We invite you to share your experiences and perspectives as comments, opeds, or links to relevant papers and reports for our next newsletter.

2. Latest Equinet Updates

EQUINET Discussion paper 118: Comparative review: Implementation of constitutional provisions on the right to healthcare in Kenya and Uganda
Centre for Health, Human Rights and Development (CEHURD): EQUINET, Uganda, 2019

This discussion paper is produced by the Centre for Human Rights and Development (CEHURD) as part of the theme work on health rights and law of the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The paper examines the implementation of constitutional provisions on the right to healthcare in Kenya and Uganda, two countries in East Africa. It aims to identify factors and mechanisms that have facilitated implementation of constitutional provisions on the right to healthcare, including how the constitutions were developed and framed. It compares implementation in Kenya, where the right to healthcare is explicit in their 2010 Constitution, and in Uganda, where the right to healthcare is implicit in the National Objectives and Directive Principles of State Policy. The paper draws on two EQUINET case studies on implementation of constitutional provisions on the right to health, one each in Kenya and Uganda, published in 2018, a 2017 regional workshop that discussed the implementation of constitutional provisions on the right to health, and additional review of published literature. It presents a thematic analysis of the findings from the two case studies in terms of the judicial, political and popular implementation mechanisms, exploring further the factors and mechanisms that have facilitated or blocked their implementation. As the two constitutions address the right to healthcare differently, this analysis of their application provides insights into the factors and mechanisms for practice that may be useful in other settings.

3. Equity in Health

Armed conflicts and national trends in reproductive, maternal, newborn and child health in sub-Saharan Africa: what can national health surveys tell us?
Boerma T, Tappis G; Saad-Haddad G; Das J; et al: BMJ Global Health 4, i161–i168, 2019

This paper seeks to examine data from national surveys in 13 countries in sub-Saharan Africa with major conflicts during 1990–2016, to assess the levels and trends in reproductive, maternal, newborn and child health intervention coverage, nutritional status and mortality in children under 5 years in relation to the trends. The surveys provide substantive evidence of a negative association between these indicators at national level and armed conflict, with some exceptions. Major improvements in these indicators took place post-conflict, except for stunting. The short-term conflict in Congo and the Ethiopian–Eritrea war had limited effects on national trends, even though direct local associations with increased child stunting were
found in Eritrea. The authors findings suggest that armed conflict can have negative consequences on reproductive, maternal, newborn and child health. They argue that surveys are a critical data source which, in combination with further analysis of the distinct features of each conflict as well as programme data collected to measure conflict impact, can provide a better assessment of the national impact of armed conflicts on health.

4. Values, Policies and Rights

Launch of the EAC Regional Contingency Plan for Public Health Emergencies
East, Central and Southern African Health Community (ECSA HC): Arusha, July 2019

In 2014, the EAC regional Technical Working Group for Communicable and Non-Communicable Diseases conceived the idea of developing a regional plan for preparedness and response to public health emergencies. ECSA-HC, through the World Bank-funded East Africa Public Health Laboratory Networking Project, supported the drafting and development of the initial version of the plan. This is a multi-hazard preparedness and response plan whose scope includes epidemic prone diseases, and other known and unknown hazards that may have overwhelmed individual countries or are spreading across international border(s) in the EAC region. The Incident Command System describes teams of stakeholders involved in triggering and managing the preparedness, response and recovery phases of public health emergencies, all implemented in a One Health context. The command system is triggered by the national disease surveillance system at a point they determine to be in need of regional assistance. The plan was launched on June 11th 2019 at a ceremony in Namanga at the inauguration of the field simulation exercise for a fictitious Rift Valley fever outbreak spreading across the border between Kenya and Tanzania. ECSA-HC provided technical support in the planning and execution of the World Health Organization-led exercise.

Realizing Universal Health Coverage in East Africa: the relevance of human rights
Yamin A; Maleche A: BMC International Health and Human Rights 17(21) 1-10, 2019

The authors propose that applying a robust human rights framework would change thinking and decision-making in efforts to achieve Universal Health Coverage (UHC), and advance efforts to promote women’s, children’s, and adolescents’ health in East Africa, a priority under the Sustainable Development Agenda. Nevertheless, they point to a gap between global rhetoric of human rights and ongoing health reform efforts. This article seeks to fill part of that gap by setting out principles of human rights-based approaches and then applying those principles to questions that countries face in undertaking efforts toward UHC and promoting women’s, children’s and adolescents’ health, particularly to ensure enabling legal and policy frameworks, establish fair financing and priority-setting and provide meaningful oversight and accountability mechanisms. In a region where democratic institutions are weak, the authors argue that the explicit application of a human rights framework could enhance equity, participation and accountability, and in turn the democratic legitimacy of UHC reforms being undertaken in the region.

5. Health equity in economic and trade policies

Urban Health Initiative in Accra: Workshop on planning for climate action, improved air quality and health
Accra Metropolitan Assembly: Ghana, May 2019

The World Health Organisation, Accra Metropolitan Assembly, Ghana Health Service, Environmental Protection Agency, UN-Habitat and ICLEI hosted a two-day workshop with the Accra Metropolitan Assembly in May 2019 to support action towards healthier urban environments and to engage other municipalities to jointly act on air quality, public health and the reduction of short-lived climate pollutants. With representatives from several assemblies and municipalities, ministries and other relevant institutions, the workshop took participants through working sessions to discuss the health and economic impacts of sectoral policies, to inform the development of Accra’s Climate Action Plan and control of air pollution.

6. Poverty and health

Remembering women’s struggles against destructive mining
Mugari T: Centre for Natural Resource Governance, Zimbabwe, 2019

In 1972, disaster struck the coal mining town of Hwange killing 427 workers following an underground explosion at the No.2 Colliery, also known as Kamandama Mine, part of Hwange Colliery. Forty-seven years later, the author reports that the widows of the victims of the Kamandama mine disaster live in neglect and abject poverty. Following the death of their husbands, they were forced out of colliery houses to pave way for new workers and their families. Many who had no relatives in town moved to rural areas. In a commemoration to remember the women’s struggles, convened by Centre for Natural Resource Governance (CNRG) and Greater Hwange Residents Trust, with the support from Open Society Initiative for Southern Africa, the surviving widows said that they are only remembered once per year, in June, when the mining town commemorate the Kamandama mine disaster. The widows called on the government and Hwange Colliery Company to compensate them and ensure they get improved access to health care. The CNRG called on the government of Zimbabwe, as the majority shareholder in Hwange Colliery Company Limited, to compensate the widows and ensure decent housing in the villages for them.

7. Equitable health services

Breaking down the silos of Universal Health Coverage: towards systems for the primary prevention of non-communicable diseases in Africa
Oni T; Mogo E; Ahmed A; Davies J: BMJ Global Health 4(4), doi: http://dx.doi.org/10.1136/bmjgh-2019-001717, 2019

The third sustainable development goal (SDG), ensuring healthy lives and well-being for all at all ages, although comprising multiple components, is often strongly linked with the concept of universal health coverage (UHC) and its underlying principles of equity, quality and financial protection. While addressing the upstream determinants of health is seen as a vital accelerator of progress in achieving the SDGs, in practice, UHC has often been focused on a disease-fighting, healthcare-centric approach. African countries are not on track to achieve global targets for non-communicable disease (NCD) prevention, driven by an insufficient focus on ecological drivers of NCD risk factors, including poor urban development and the unbridled proliferation of the commercial determinants of health. As the risk factors for NCDs are largely shaped outside the healthcare sector, an emphasis on downstream healthcare service provision to the exclusion of upstream population-level prevention limits the goals of UHC and its potential for optimal improvements in (achieving) health and well-being outcomes in Africa. The author argues for a systems for health rather than a solely healthcare-centric approach, that proactively incorporates wider health determinants (sectors)—housing, planning, waste management, education, governance and finance, among others—in strategies to improve health. This includes aligning governance and accountability mechanisms and strategic objectives of all ‘health determinant’ sectors for health creation and long-term cost savings. Researchers are seen to have a vital role to play, collaborating with policy makers to provide evidence to support implementation and to facilitate knowledge sharing between African countries.

Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya
McCollum R; Taegtmeyer M; Otiso L; Mireku M; et al: International Journal for Equity in Health volume 18(65) 1-12, 2019

The authors applied Tanahashi’s equity model to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. A qualitative study was implemented between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. The findings revealed that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, and limited efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. The authors suggest that if Kenya is to achieve universal health coverage, then county governments must address all aspects of equity, including quality, including through community health services.

8. Human Resources

Health workers’ strikes in low-income countries: the available evidence
Russo G; Xu L; McIsaac M; Matsika-Claquin M; et al: Bulletin of the World Health Organisation 97(7) 460–467H, 2019

In this paper, the authors analysed the characteristics, frequency, drivers, outcomes and stakeholders of health workers’ strikes in low-income countries, using published and grey online sources for 2009 to 2018. They identified 70 unique health workers’ strikes in 23 low-income countries during the period, accounting for 875 strike days. 2018 had the highest number of events, with 170 work days lost. Strikes involving more than one professional category were more frequent, followed by strikes by physicians only. The most commonly reported cause was complaints about pay, followed by protest against the sector’s governance or policies and safety of working conditions. Positive resolution was achieved more often when collective bargaining institutions and higher levels of government were involved in the negotiations.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation
Ormel H; Kok M; Kane S; Ahmed R; et al: Human Resources for Health 17(59) 1-12, 2019

This paper aims to critically analyse how using incentives affected community health worker motivation in six countries was undertaken. The motivational factors were defined as financial, material, non-material and intrinsic and semi-structured interviews and focus group discussions with community health workers, supervisors, health managers and selected community members were used. The authors found that incentives influence motivation in similar and sometimes different way across contexts. Motivation was negatively influenced by gaps between incentives and expectations, including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of community health workers. Furthermore, it was found that incentives could cause friction in the interface between community health workers, communities and the health sector. Whether they are employed or volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of community health workers, yet for many who are salaried, payment does not compensate for the demotivation derived from the perceived low level of financial reward. The authors suggest that managing expectations and consistency in payments may be as important as the absolute level of incentives.

9. Public-Private Mix

African Governments Urged to move with Speed to Address Over-Dependence on Imported Medicines
United Nations Economic Commission for Africa: UNECA Addis Ababa, 2019

At the two-day Horn of Africa trade forum in Addis Ababa, organized by the ECA, the Government of Ethiopia, the African Union Commission (AUC), and the European Union, participants agreed that with the African Continental Trade Agreement (AfCFTA) in force, it was time for the continent to increase domestic production of pharmaceutical products and end over-dependence on imported medicines. The AfCFTA, they agreed, provides an opportunity for economies of scale necessary for African pharmaceutical production. The Economic Commission for Africa's (ECA) Director for Regional Integration and Trade, Stephen Karingi, in closing the forum said that domestic policies that can be used to support the industry, including through investment assurances, grants, fiscal incentives and local content requirements. Regional centers of excellence could be used to overcome constraints in human capacities and resources for research and development and testing. The forum also agreed on the need to strengthen regulatory frameworks to develop the pharmaceutical sector; to encourage domestic production with a regional focus; and to ensure efficient and safe logistic chains that can bring down the cost of medicines.

10. Resource allocation and health financing

Even Larry Summers Denounces World Bank’s “PEF” Ebola Bonds that Enriched Investors at the Expense of the sick in the Congo
Smith. Y: Naked Capitalism, USA, August 2019

The author reports that Larry Summers, a former World Bank chief economist, viewed the Banks Ebola financing scheme as a problem. As recounted by another former World Bank economist, Olga Jonas, the World Bank involvement of the private sector in funding countries affected by Ebola in the wake of the 2014-2016 outbreak led to the Pandemic Emergency Financing Facility (PEF) as a form of investor scheme for private financing. However, as Jonas points out, the PEF stipulates a payout of $45 million for Ebola if the officially confirmed death toll reaches 250 (which occurred in the DRC [Democratic Republic of the Congo] by mid-December 2018), but only if at least 20 deaths occurred in a second country. Given that the WHO lists only one multi-country outbreak amid more than 30 that occurred in a single country, this requirement is viewed as inappropriate. Rather than a lack of funds, the author argues that vigilance and public-health capacity have been the main deficiencies. When governments and the World Bank are prepared to respond to infectious-disease threats, money flows within days. The World Bank has said that the PEF is working as intended by offering the potential of ‘surge’ financing. However its triggers are said to guarantee that payouts will be too little because they kick in only after outbreaks grow large. The author concludes that the best investment of funds and attention is in ensuring adequate and stable financing for core public-health capacities, that the PEF has failed. It should end early — and that IDA funds should go to poor countries, not investors.

We are called the et cetera: experiences of the poor with health financing reforms that target them in Kenya
Kabia E; Mbau R; Oyando R; Oduor C; et al: International Journal for Equity in Health 18(98) 1-14, 2019

This study examined the experiences of poor people with health financing reforms that target them. The authors conducted a qualitative cross-sectional study in two purposively selected counties in Kenya, using focus group discussions and in-depth interviews with people in the lowest wealth quintile and health insurance subsidy programme beneficiaries. Health financing reforms reduced financial barriers and improved access to health services for poor people in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that health insurance subsidy programme beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among poor people.

When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi
Pot H; de Kok B; Finyiza G: Reproductive Health Matters, 26(54) 126-136, 2018

This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world’s highest burdens of maternal mortality. The authors analysed Malawi’s recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of external funding, a shift in political leadership and priorities and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. The authors report that different actors are frustrated about user fees and their impact on poor people, especially because in Malawi non-institutional deliveries have become strongly associated with maternal deaths. This especially affects women in rural areas, where access to care is already minimal. In addition, the poorest rural women struggle most to pay user-fees, and would have to travel to the district hospital. User-fees eroded trust between women and health workers. The authors indicate that the fact that local maternity services excluded of the most vulnerable rural women from care rather than address higher level sources reflect the power dynamics involved in this issue.

11. Equity and HIV/AIDS

Integrating community health assistant-driven sexual and reproductive health services in the community health system in Nyimba district in Zambia: mapping key actors, points of integration, and conditions shaping the process
Zulu J; Kinsman J; Hurtig A; Michelo C; et al: Reproductive Health 16(122) 1-11, 2019

This study aimed to identify the conditions and strategies through which Community Health Assistants gained entry and acceptability into community health systems to provide sexual and reproductive health services services to youth in Nyimba district, Zambia. Community Health Assistants worked with a range of community actors, including other health workers, safe motherhood action groups, community health workers, neighborhood health committees, teachers, as well as political, traditional and religious leaders and took services to health facilities, schools, police stations, home settings, and community spaces. They used their health facility service delivery role to gain trust and entry into the community, and built relationships with other community level actors by holding regular joint meetings, and acting as brokers between the volunteer health workers and the Ministry of Health. They used their existing social networks to deliver sexual and reproductive health services to adolescents, and embedded this into general life skills at community level, the improving its acceptability. Support from community leaders also promoted their legitimacy. The acceptability of their services was limited by a taboo of discussing sexuality issues, a gender discriminatory environment, competition with other providers, and challenges in conducting household visits.

12. Governance and participation in health

Decision-making in district health planning in Uganda: does use of district-specific evidence matter?
Henriksson D; Peterson S; Waiswa P; Fredriksson M: Health Research Policy and Systems 17(57), 1-11, 2019

This study investigated how evidence used in the planning process affects decision-making and how stakeholders involved in planning perceived the use of evidence. Quantitative data was collected from district health annual work plans for 2012-2016 and from 'bottleneck analysis reports' for these years. Qualitative data was collected through semi-structured interviews with key informants from the two study districts. District managers reported that they were able to produce more robust district annual work plans when they used district-specific evidence. Approximately half of the prioritised activities in the annual work plans were evidence based. Procurement and logistics, training, and support supervision activities were the most prioritised activities. District-specific evidence and a structured process for its use to prioritise activities and make decisions in the planning process at the district level helped to systematise the planning process. However, the districts also reported having limited decision and fiscal space, inadequate funding and high dependency on external funding that did not always allow for the use of their own district evidence in planning .

The ghost battalion: On the Sudanese Professionals Association (SPA) the organized force behind the revolutionary uprising in Sudan
Majdoub S: Africa is a Country, August 2019

In Sudan, the Tajamoo al-mihanyin al-sudaniyin or the Sudanese Professionals Association (SPA) is an alliance of independent professionals shrouded in mystery. Described as the “ghost battalion” by the now-deposed president Omar al-Bashir, the contemporary movement led by the SPA exerted influence on mobilizations and protest movements through sustained appeals, and built broad appeal and demonstrated a know-how of protests, applied within the social movement across the country. They initiated civil disobedience, rallies and marches in all parts of the country, focusing on women, displaced and exiled people, and on social justice and life on the margins. Moreover, they have taken the call to protest beyond the limits of major cities like Khartoum and across sectors—from resignation marches in outlying towns and provinces to the mobilization of dock workers in Port Sudan. The For a movement like the SPA there are challenges. Will its spirit remain strong or be exhausted? Will it be the guardian of this transition or its watchdog?

The visa conundrum in global health
Vervoort D: The BMJ Opinion, June 2019

There is a growing push to include local voices in global health initiatives and policies to promote ownership of downstream implementation, but also to get a proper sense of the realities on the ground. Many governments gladly jump on the bandwagon. Yet when it comes to it, visa applications are often rejected on feeble grounds. Physicians and medical students with booked return flights, domestic hospital affiliations, formal invitation letters and even proof that they will not be a financial liability are rejected. Academia increasingly understands the need for local authorship and ownership of global health programmes, and rightfully so. However, a colonial trend persists in the wider community. Policies and resolutions are driven by high income country actors or government officials who are, by definition, detached from what is happening on the ground. Civil society actors who live among the realities of poverty are left behind.

‘Prejudiced’ Home Office refusing visas to African researchers
Grant H: The Guardian, June 2019

The UK Home Office is reported to be accused of institutional racism and to be damaging British research projects through increasingly arbitrary and “insulting” visa refusals for African academics. In April, a team of six Ebola researchers from Sierra Leone were unable to attend vital training in the UK, funded by the Wellcome Trust as part of a £1.5m flagship pandemic preparedness programme. At the LSE Africa summit, also in April, 24 out of 25 researchers were missing from a single workshop. Shortly afterwards, the Save the Children centenary events were marred by multiple visa refusals of key guests. The article refers to a parliamentary inquiry into visa refusals hearing evidence that there is “an element of systemic prejudice against applicants”. In a letter in the Observer, 70 senior leaders from universities and research institutes across the UK warn that “visa refusals for African cultural, development and academic leaders … [are] undermining ‘Global Britain’s’ reputation as well as efforts to tackle global challenges”. The system is reported to be so difficult to predict or navigate that meetings, including conferences funded with British government money, are now being held in other countries.

13. Monitoring equity and research policy

Regional Research–Policy Partnerships for Health Equity and Inclusive Development: Reflections on Opportunities and Challenges from a Southern African Perspective
Yeates N; Moeti T; Luwabelwa M: Institute for Development Studies Bulletin 50(1) 121-142, 2019

This article critically reflects on the experience and lessons from a health-focused social policy research project involving a partnership spanning multiple countries across southern Africa and Europe. It asks what factors condition the efficacy of the partnership–policy nexus. The policy research project Southern African Development Community partnership case study used participatory action research to create a regional indicators-based monitoring toolkit of pro poor health policy and change for the region. The article addresses the partnership drivers, features, methodological context, and process of the project, and the wider implications for constructing partnerships for social change impact. Lessons drawn from this case study underscore the importance of participatory action research -inspired partnership structures and working methods while querying assumptions that the relationship between participatory action research and policy change is seamless. The authors argue that greater focus is needed on the wider institutional context conditioning the work of partnerships when considering the efficacy of a nexus between partnerships and policy.

Strengthening ethical community engagement in contemporary Malawi
Nyirenda D; Gooding K; Sambakunsi R; et al: Wellcome Open Research, Lilongwe, 2019

Although community engagement is increasingly promoted in global health research to improve ethical research practice, the authors observe that there is sometimes a disconnect between the broader moral ambitions for community engagement in the literature and guidelines on the one hand and its rather narrower practical application in health research on the other. In practice, less attention is said to be paid to engaging communities for the ‘intrinsic’ value of showing respect and ensuring inclusive participation of community partners in research design. Rather, more attention is paid to the use of community engagement for ‘instrumental’ purposes to improve community understanding of research and ensure successful study implementation. Against this backdrop, the authors reviewed the literature and engaged various research stakeholders at a workshop to discuss ways of strengthening ethical engagement of communities and to develop context-relevant guidelines for community engagement in health research in Malawi. They concluded by proposing a model with three elements that would increase participatory community engagement in health research namely: collaboration, consultation and communication from the onset of research.

The problem of ‘trickle-down science’ from the Global North to the Global South
Reidpath D; Allotey P: BMJ Global Health 4(4), doi: http://dx.doi.org/10.1136/bmjgh-2019-001719, 2019

Ten years ago, Nigel Crisp observed, with respect to the healthcare workforce that ‘the global health system is characterised by an import–export business in which rich countries export the ideology of Western scientific medicine and aid predicated on this ideology to poor countries. In return, the poor countries export a portion of their preciously limited pool of trained health workers back to the rich countries’. The authors of the paper suggest that a similar situation holds in scientific research. Many of the very brightest minds from the Global South go to institutions of higher learning in the Global North, either as graduate students or as fully fledged researchers. They are attracted by better pay, resources, engagement and prestige. There are then three broad outcomes: If the move is a permanent one (which is the case 70% of the time) many turn their focus away from the concerns of the south towards the research priorities in the north, where the funding is. Others remain in the north but keep their focus on the issues of the south, albeit often with limited impact, and sometimes compromising their career progression in the north. The third outcome is the return of the researcher to the south, and frustration over the lack of an enabling environment to apply their skills. Trickle-down science as a strategy for advancing knowledge for current and future challenges has enabled an inequity in the distribution of scientific capacities. However the authors observe that there are ways to engage more effectively with the growing, if disempowered, talent in the south to build of enabling environments, leadership and a quality and volume of home grown, contextually driven knowledge.

14. Useful Resources

The toll of the cobalt mining industry on health and the environment
CBS News: March 6 2018

This CBS News video reports an investigation of child labour in cobalt mines in the Democratic Republic of Congo, revealing that tens of thousands of children are growing up without a childhood today – two years after a damning Amnesty report about human rights abuses in the cobalt trade was published. The Amnesty report first revealed that cobalt mined by children was ending up in products from prominent tech companies including Apple, Microsoft, Tesla and Samsung. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious lung disease called 'hard metal lung disease'" – a kind of pneumoconiosis, meaning a lung disease caused by inhaling dust particles. Inhalation of cobalt particles can cause respiratory sensitization, asthma, decreased pulmonary function and shortness of breath, the CDC says. An estimated two-thirds of children in the region of the DRC that CBS News visited recently are not in school. They're working in mines instead. CBS News' Debora Patta spoke with an 11-year-old boy, Ziki Swaze, who has no idea how to read or write but is an expert in washing cobalt. Every evening, he returns home with a dollar or two to provide for his family.

Free online course on Health Systems Strengthening
The University of Melbourne, The Nossal Institute for Global Health, UNICEF: FutureLearn.

The Nossal Institute, in collaboration with UNICEF and FutureLearn, has developed a free online course in health systems strengthening. This course aims to develop skills and confidence in policy makers, managers and clinicians working in health systems to analyse system problems and take decisive, evidence-based actions to strengthen their system. It covers health system structures, functions and components, and how they interact. How to use evidence, and analysis of inequity, to drive interventions to strengthen health systems. It also addresses strengthening health systems through action in areas such as health policy, financing, human resources, supply chain management, quality of care and private sector engagement and using complex systems thinking to address health system problems.

Profits Over People: Mining in Malawi
Human Rights Watch: Malawi, 2016

New mining activities are playing an increasing role in Malawi's economy. This video reports on the situation of families in Malawi affected by new mining activities , and the health problems of families living near coal and uranium mining operations. It reports on the gap in health system capacities to diagnose and address these challenges. While the mining company indicates that they test the water used by these communities and provides the results to government, people in the community are not aware of the results.

15. Jobs and Announcements

2nd Global Symposium on Community Health Workers Evolving Health Systems to Achieve University Health Coverage through Community Health Workers
22-24 Nov 2019, Dhaka, Bangladesh

The 2nd International Symposium on Community Health Workers, hosted by the International Centre for Diarrhoeal Disease Research, Bangladesh, in collaboration with Directorate General of Health Services, Government of Bangladesh; James P. Grant School of Public Health, BRAC University, Bangladesh; and Save the Children, Bangladesh; will be held during November 22 – 24, 2019 at Pan Pacific Sonargaon, Dhaka, Bangladesh. The organisers invite the local and international community engaged in research or policy making on Community Health Workers to attend the Symposium on Community Health Workers to discuss past successes and challenges with Community Health Workers in order to formulate strategic pathways for better community based health programme for prevention and control of Non Communicable Diseases further to attain Universal Health Coverage and Sustainable Development Goals targets.

Call for Papers: Innovations in implementation research in low- and middle-income countries
Deadline for manuscripts: 15 October 2019

This journal of Health Policy and Planning, and the Alliance for Health Policy and Systems Research are calling for papers on the theme of: “Innovations in Implementation Research in Low- and Middle-Income Countries (LMICs)”. This journal supplement will discuss the concept and usefulness of implementation research in the context of LMICs, and invite contributions to illustrate some of the innovations on this. It will outline trajectories of the development of the field and help to chart the way forward for the further application of implementation research to maximise its impact on policies and programmes in the real world. Articles are sought which speak to innovations in the methods, approaches and governance of research on the implementation of public health policies and programmes in LMICs, including but not limited to the following sub-themes: quantitative assessment of public health policy and programme implementation; multidisciplinary and qualitative approaches and mixed methods assessments of public health policy and programme implementation; health policy implementation analysis, including policy process and power; process evaluation of public health programme implementation; systematic reviews of public health policy and programme implementation; embedding and participatory approaches in implementation research; and governance and ethics of implementation research in LMICs. All papers should clearly identify the specific innovation that it is presenting or illustrating and situate it in the literature. Papers that receive positive reviews but are not deemed suitable for this supplement may be considered for individual publication in Health Policy and Planning. This supplement will be launched to coincide with the Sixth Global Symposium on Health Systems Research, taking place in Dubai from 8-12 November 2020.

Kader Asmal Fellowship Programme
Deadline for applications: 11 September 2019

The Embassy of Ireland in South Africa in partnership with Canon Collins Trust invites applications for scholarships for postgraduate study in Ireland commencing in September 2020. In 2020 fellowships will be offered for postgraduate study in: Agriculture, Environmental Science, Conservation, Rural Development; Food Science, Food Engineering and related; Pharmacy and Biotechnology; Health, Medicine and Health Economics; Development Studies, Peace Studies, Conflict Resolution and Humanitarian Action; Social Policy, Social Research, Community Development and Sociology; Law, Human Rights, Women’s Studies, Gender Studies, Equality Studies; Engineering, Hydrology, Sustainable Technology; Economics, Finance, Accounting, Management and Business; Information Systems and Communications Technology and Tourism. Applicants must be a resident national of South Africa and have a minimum of two years relevant work experience. Applicants already in possession of a Masters degree are not eligible.

Public Health Association of South Africa Conference 2019: the Right to Health – 25 years into a Constitutional Democracy
16-18 September 2019, College of Cape Town, Athlone, Cape Town

The 2019 Public Health Association of South Africa conference will reflect on the intersections between democracy and health, and the progressive realisation of health care in South Africa. Despite the legislative, economic, social and cultural accomplishments since 1994, South Africa is facing a quadruple burden of diseases; increasing corruption; the grossly inequitable distribution of access between public and private health care sectors and governance crises in provincial health departments. These have seriously compromised the right to health care and many South Africans remain desperately deprived. This year’s conference will focus on the status of health care since 1994 in South Africa and what can be done to move closer to achieving the targets of the National Development Plan and equity in universal health coverage.

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