EQUINET NEWSLETTER 145 : 01 March 2013

1. Editorial

A reminder of the local

This month's editorial comes from the lens of a health worker at a rural hospital, with an appeal for policy to test itself against whether it supports and has involved those working at the frontline and reflects ground realities. In a few days time a global meeting will be held in Botswana to review the health dimension of global development goals. In the newsletter is a resolution from a meeting of local governments and communities in Guatemala that urges, as we would, for a reminder of the faces, voices, wisdom and importance of the local in that discussion. As evident from the many reports EQUINET has produced, national averages hide significant subnational and within area inequalities, many of which are growing, and social agency, community systems and frontline health services need to be given significantly greater profile in policies and goals seeking to deliver on rights to health.

How golden policies lead to mud delivery – and how silver should become the new gold
Dr. Karl le Roux, Zithulele Hospital, Eastern Cape, South Africa

There is a general perception amongst academics, government officials, non-governmental organisations (NGOs) and the South African public at large that as a country we have good policies, but that we implement these policies poorly (as reported by the South African Institute of International Affairs in 2011). In fact, one of the fundamental issues that we need to address as a country is to try to understand why, despite good policies, adequate amounts of money and more skilled workers than in most parts of Africa, South Africa performs so badly (especially in health and education) when compared to other African countries. The tendency of policy makers is to blame downstream factors, such as general lack of capacity , “lazy managers” or “obstructive clinicians”, which to some extent is reflected in the research.

But my job today is to describe to you what it is like being at the rural coalface. Though I have loved working in a rural hospital for the past six years, it has also been one of the toughest periods in my life. Working in rural medicine is a bit like sitting on a rollercoaster: a combination of enormous challenge and reward, feeling exhausted and exasperated and then inspired and invigorated, seeing dignity and strength in patients, but also sadness and unnecessary suffering and death. One always feels stretched and one often feels as if one is hanging on by one’s fingertips. The rural idyll is something that might be experienced on weekends off, but the reality of the working week is that on the whole one is extremely busy and constantly rationing care and doing the best one can with the resources available.

It therefore might come as no surprise to the reader that at the coalface “policies” are more often seen as a hindrance than a help to the delivery of health care. Policies or programmes are often imposed from above, with no consultation and with little understanding of realities on the ground. There is usually poor data collection and feedback, lots of time-consuming and unnecessary paperwork and a focus on irrelevant aspects of care with the neglect of critical aspects. I need to make clear that good, realistic and helpful policies are greatly appreciated by most clinicians working at primary care level, as they improve care and the health of our patients (for example the new antiretroviral treatment guidelines).

But there are also many examples of policies and programmes that aim for an unrealistic gold standard (with its unnecessary and unhelpful complexity) and which, as a result, undermine the provision of good healthcare to as large a population as possible.

The first example of this is the new Road to Health Booklet. Although an extremely well-intentioned document, it is completely unrealistic to expect a busy primary care nurse to use this tool properly. It appears as if the designers of the document have never set foot in a packed rural (or township) immunization clinic, or tried to fill in the booklet with 60 screaming babies requiring injections in the waiting room outside. A year after it was introduced in our area, we still find that critical data such as mother’s HIV status and type of prevention-of-mother to child transmission (PMTCT) treatment provided is left out, whilst on the old, much simpler Road to Health Card, this was filled out really well.

Another example of where aiming for gold results in mud delivery is the District Health Information System (DHIS), a tool with so many parameters and different indicators that it is not actually possible to fill it out correctly unless each clinic has several dedicated data capturers with computers and technical support. As a result, much of the data is literally made up (I have seen it happen with my own eyes) and results in very poor quality data. At a recent meeting in my district, for example, several clinics had a higher than 120% coverage for measles vaccination. Yet managers and health planners scratch their heads and wonder why we get such poor quality data and complain that overloaded nurses at the coalface must just fill the data sheets out correctly. The DHIS needs to be simplified drastically, and nurses on the ground must get regular feedback on certain critical indicators that truly reflect improved care.

Many people balk at the idea of not aiming for a “gold standard” at a policy level – surely we must at least aim for the stars even if this isn’t really achievable?

Firstly, I would like to argue that we have ample evidence of how aiming for gold actually undermines the provision of care at grassroots level, and that we instead need to focus on simplicity and doing the basics really well. This would result in the biggest health impact on the greatest number of people.
Secondly, I think that we need to be cognisant of our limitations in terms of both human and financial resources in South Africa and recognise that we do not have the capacity to achieve gold right now, although it may be possible to aim for gold 20-30 years from now.

In the health sector we should be working within a framework of clear, straightforward priorities, aiming for what is achievable (silver?) and doing the basics extremely well, with simple monitoring and clear feedback to all healthcare workers.

I would like to argue that a policy cannot be labelled as “good” unless it is implementable. We need to recognise that putting policy together is the beginning of a long process. Policymakers need to be involved in drawing up implementation strategies, and government must support policy implementation through adequate finances and capacitating and empowering managers to manage the changes that will be required when policy is implemented.

Let me end with a final plea from the coalface that those of you who write policy use the following as your guiding principle: good health policies make things better and easier on the ground and result in improved patient care.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This oped was featured in a paper for the Public Health Association of Southern Africa newsletter at le Roux K. How golden policies lead to mud delivery – and how silver should become the new gold. Newsletter of the Public Health Association of South Africa. November 15, 2012. ). The views expressed are those of the author and do not necessarily represent the views of PHASA.

2. Latest Equinet Updates

Equity Watch: Assessing progress towards equity in health in Tanzania, December 2012
Ifakara Health Institute, Ministry of Health and Social Welfare, Training and Research Support Centre: December 2012

An Equity Watch is a means of monitoring progress on health equity by gathering, organising, analysing, reporting and reviewing evidence on equity in health. Equity Watch work is being implemented in countries in eastern and southern Africa in line with national and regional policy commitments. In February 2010 the Regional Health Ministers' Conference of the ECSA Health Community resolved that countries should 'report on evidence on health equity and progress in addressing inequalities in health'. This report provides an array of evidence on the responsiveness of Tanzania’s health system in promoting and attaining equity in health and health care, using the Equity Watch framework. The report introduces the context and the evidence within four major areas: equity in health, household access to the resources for health, equitable health systems and global justice. It shows past levels (1980–2005), current levels (most current data publicly available) and comments on the level of progress towards health equity.

3. Equity in Health

A literature review of role of obesity in adult health with reference to Africa
Lokuruka MNI: African Journal of Food, Agriculture, Nutrition and Development 13(1), January 2013

This literature review highlights the causes, effects and potential mitigation measures of adult obesity in Africa. The major factors that contribute to obesity include over-nutrition, physical inactivity, change of dietary habits, modernisation, consumption of high-fat, high-carbohydrate foods and increased urbanisation. Despite African women tending to be more obese than men, they are less prone to hypertension, heart disease and type 2 diabetes than men before they reach menopause due to their fat deposition being predominantly sub-cutaneous rather than abdominal. The defining metabolic changes in obesity are decreased glucose tolerance, decreased sensitivity to insulin, hyperinsulinemia and reduced life expectancy. The author highlights that obesity is a controllable behavioural disorder, with regular exercise and sensible eating being the best ways to regulate body fat percentage and maintain a healthy body weight. As it is difficult to treat obesity, efforts in Africa should be directed towards prevention in order to keep it in check.

Climate change and health: What's the problem?
Anstey MH: Globalisation and Health 9(4), 9 February 2013

The corroboration of scientific evidence across disciplines has confirmed that global warming is occurring and that this will have potentially negative consequences for health, such as respiratory diseases from polluted air, the spread of tropical diseases and increased malnutrition due to drought and floods. The author of this paper argues that it is time for public health advocates to draw on their past successes in tackling the health consequences of pollution, and to draw the link between the causes of global warming and pollution. In addition, strategies that link stakeholders and current development goals and provide feedback data from climate change adaptation and mitigation approaches are needed as we move forward to face the health consequences of global warming.

Communique: Meeting of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda in Monrovia, Liberia
High-Level Panel of Eminent Persons on the Post-2015 Development Agenda: 1 February 2013

The High-Level Panel of Eminent Persons on the Post-2015 Development Agenda has been tasked by United Nations Secretary-General Ban Ki-Moon to develop a framework for a post-2015 development agenda. This Communiqué reports on the Panel’s third meeting in Monrovia, Liberia from 30 January to 1 February 2013, where members took stock of the progress achieved so far towards the fulfilment of the Panel’s mandate. Members agreed to make every effort to achieve the Millennium Development Goals by 2015, while also framing a single and cohesive post-2015 development agenda that integrates economic growth, social inclusion and environmental protection. Economic growth alone is not sufficient to ensure social justice, equity and sustained prosperity for all people. The global community must pursue economic and social transformation leading to sustained and inclusive economic growth at the local, national and global levels. The protection and empowerment of people is crucial. Achieving structural transformations through a global development agenda will involve: sustainable growth with equity, creating wealth through sustainable and transparent management of natural resources; and partnerships with many actors, unified behind a common agenda.

Health in the Post-2015 Development Agenda: Report of the Global Thematic Consultation on Health: Draft for public comment
Task Team of the Global Thematic Consultation on Health: 1 February 2013

Placing health at the heart of the post-2015 development agenda will not only save lives and advance economic development, it will also protect environmental sustainability, and advance wellbeing, equity and social justice, according to this report. It makes a number of recommendations. Health goals should be equitable, holistic and people-centred. The post-2015 development agenda should be direct explicit attention to reducing health inequities between and within all countries, especially when considering the needs of the poor, marginalised, and those whom the efforts of the Millennium Development Goals (MDGs) have not reached. The right to health means that governments must generate conditions in which everyone can be as healthy as possible. A hierarchy of goals is needed to capture the increasing complexity of priority health challenges and the reality that efforts to prevent disease and disability and improve health and well-being require policies and actions both within the health sector and across many other sectors. Indicators need to measure impact, coverage of health services and health systems. Some qualitative indicators may be needed to measure quality of life and well-being, while assessing quality of health services may require qualitative as well as quantitative indicators. The MDG targets and indicators as well as those in other internationally agreed agendas should be revised for the post-2015 era and included under the relevant goals.

Results of the Consultation with Representatives of Local Governments, Indigenous Communities, Afro-Communities, and Civil Society Organizations about the Post 2015 Development Agenda on the topic of Health
PAHO, Antigua Guatemala, 12 to 14 February 2013

The commitment toward achieving universal coverage understood as access to quality, individualized healthcare for all, in a human rights framework, has been profiled as the Goal of the Post 2015 Development Agenda on the topic of Health. For this reason, the Pan American Health Organization proposed a consultation of the key social actors in this process and to hear their voices. The present document summarizes the debate and the agreements assumed by the representatives of civil society organizations, municipal authorities or mayors, indigenous authorities, afro descendants, and other civil society representatives.

Further details: /newsletter/id/37689

4. Values, Policies and Rights

Colonising African Values: How the US Christian Right is Transforming Sexual Politics in Africa
Kaoma KJ: Political Research Associates, 2012

This report reports on the impact of Christian conservatism from United States on human rights policies in Africa. A number of churches are reported in this paper to be working in Africa to promote US ‘family values’, campaigning against condom use to prevent HIV transmission, claiming that family planning is a Western conspiracy to reduce African development, and supporting campaigns to pursue the death penalty for gays and lesbians. The author argues that government and civil society should confront the myths of human rights advocacy being western neocolonialism, noting indigenous African human rights agendas and support African advocacy to respect human rights for all.

How do national strategic plans for HIV and AIDS in Southern and Eastern Africa address gender-based violence? A women’s rights perspective
Gibbs A, Mushinga M, Crone ET, Willan S and Mannell J: Health and Human Rights 14(2), 2012

Gender-based violence (GBV) is a significant human rights violation and a key driver of the HIV epidemic in southern and eastern Africa. In this study, the authors frame GBV from a broad human rights approach that includes intimate partner violence and structural violence. They use this broader definition to review how National Strategic Plans for HIV and AIDS (NSPs) in southern and eastern Africa address GBV. NSPs for HIV and AIDS provide the national-level framework that shapes government, business, external funder, and non-governmental responses to HIV within a country. They authors’ review suggests that attention to GBV is poorly integrated, and few recognise GBV and programme around GBV. The programming, policies and interventions that do exist privilege responses that support survivors of violence, rather than seeking to prevent it. Furthermore, the subject who is targeted is narrowly constructed as a heterosexual woman in a monogamous relationship. There is little consideration of GBV targeting women who have non-conforming sexual or gender identities, or of the need to tackle structural violence in the response to HIV and AIDS.

Integrating interventions on maternal mortality and morbidity and HIV: A human rights-based framework and approach
Fried S, Harrison B, Starcevich K, Whitaker C and O’Konek T: Health and Human Rights 14(2), 2012

In sub-Saharan Africa, HIV and maternal mortality and morbidity (MMM) are connected in both outcomes and solutions: HIV is the leading cause of maternal death, while prevention of unintended pregnancy and access to contraception are considered two of the most important HIV-related prevention efforts. Both are central to reducing unsafe abortion, another leading cause of maternal death in Africa. A human rights-based framework helps to identify shared structural drivers include gender inequality; gender-based violence (including sexual violence); economic disempowerment; and stigma and discrimination in access to services or opportunities based on gender and HIV. Therefore the authors call for a human rights-based and integrated response to the two health issues. Governments should establish the health-related human rights standards to which all women are entitled and provide remedy for human rights violations related to HIV and maternal mortality and morbidity. No single goal, such as those addressing HIV and MMM, can be achieved without progress on all development goals.

Mental health in Ghana: A rights violation in action
Asokan I: Consultancy Africa Intelligence, 24 January 2013

This report argues that Ghana is reported to be violating the African Charter on Human and Peoples’ Rights when people with mental disorders are subjected to prayer camps that advocate complete isolation, being chained to trees, and forced exorcism for demonic possession, and fails to provide services for mentally illness. The author suggests that mental health problems often stem from poor nutrition, depressed socioeconomic status, and elevated, persistent violence. Despite the widespread presence of these factors mental heath problems like depression or undiagnosed schizophrenia are often ignored in health policy agendas in Africa. The author proposes that mental health be recognised as a human right, coupled with de-stigmatisation of mental health disorders, and resource allocation for treatment.

New avenue for Litigating the Right to Health: Optional Protocol to the ICESCR comes into force
Cabrera OA Friedman E and HonermannB: O’Neill Institute, February 2013

On 5 February, 2013, Uruguay became the tenth country to ratify the Optional Protocol to the International Covenant on Economic, Social and Cultural Rights (ICESCR), which means the Optional Protocol will come into force on 5 May, 2013. Until now, the CESCR has been limited to issuing concluding observations and recommendations to member countries as part of semi-regular country reporting requirements in the ICESCR and to issuing broad general comments on rights under the Convention. The opportunity will now exist at the global level to litigate and begin to develop more concrete standards around the rights in the ICESCR – including the right to of everyone to the enjoyment of the highest attainable standard of physical and mental health (Article 12 of the ICESCR). The authors of this paper highlight emerging opportunities within the framework of the ICESCR and the Optional Protocol to begin serious investigations into the social determinants of health, such as access to sufficient food, water, sanitation, and education. They call for an approach that goes beyond the typical and narrower construction of the right to health based in access to health care services to include the determinants discussed in Article 12.

Universal health coverage should be anchored in the right to health
Ooms G, Brolan C, Eggermont N, Eide A, Flores W, Forman L et al: Bulletin of the World Health Organisation 91(1): 2-2A, January 2013

In this article, the authors propose that the right to health and its imperative of narrowing health inequities should be central to the post-2015 international health agenda. However, they argue that universal health coverage - as defined by the World health Organisation and typically conceived - is not enough to ensure the right to health. Policy-makers will need to address the social determinants of health such as safe drinking water and good sanitation, adequate nutrition and housing, safe and healthy occupational and environmental conditions and gender equality. The post-2015 health agenda should also explicitly describe the accountability mechanisms that will make it possible for people to claim – not beg for – additional national public resources and international assistance, if needed. Furthermore, it must specify how citizens will participate in the decision-making processes surrounding their health services and their physical and social environment. Participation must be genuine and built on a continuing relationship among researchers, governments and those communities, otherwise goals may end up being formulated by policy elites after token and superficial consultations, undermining the rights of the very communities they serve.

5. Health equity in economic and trade policies

A cross-sectional survey on knowledge and perceptions of health risks associated with arsenic and mercury contamination from artisanal gold mining in Tanzania
Charles E, Thomas DS, Dewey D, Davey M, Ngallaba SE and Konje E: BMC Public Health 13(74), 25 January 2013

An estimated 0.5 to 1.5 million informal miners, of whom 30-50% are women, rely on artisanal mining for their livelihood in Tanzania, and are exposed daily to mercury and arsenic. The primary objective of this study was to assess community risk knowledge and perception of potential mercury and arsenic toxicity in Rwamagasa in northwestern Tanzania, an area with a long history of artisanal gold mining. A total of 160 individuals over 18 years of age completed a structured interview. These interviews revealed wide variations in knowledge and risk perceptions concerning mercury and arsenic exposure, with 40.6% and 89.4% not aware of the health effects of mercury and arsenic exposure respectively. Males were significantly more knowledgeable (36.9%) than females (22.5%) with regard to mercury poisoning. An individual’s occupation category was associated with level of knowledge, and individuals involved in mining (73.2%) were more knowledgeable about the negative health effects of mercury than individuals in other occupations. Of the few individuals (10.6%) who knew about arsenic toxicity, most (58.8%) were miners. Overall lack of knowledge, combined with minimal environmental monitoring and controlled waste management practices, highlights the need for health education, surveillance, and policy changes, the authors conclude.

African Union to Proceed With controversial Pan-African IP Office
New W: Intellectual Property Watch, 6 February 2013

The African Union (AU) has announced it will proceed with the establishment of a Pan-African Intellectual Property Office (PAIPO), despite misgivings from civil society and development economists about the potential impact on local economies. There is currently no intellectual property (IP) office for Africa. The AU has requested a meeting of all stakeholders dealing with intellectual property before the May 2013 AU Summit. According to the author of this article, public information is difficult to obtain from the African Union, and nothing further is known at this time. He argues that signing up to the global IP system, in which nearly all of the IP rights are owned by non-African entities, clashes with the development objectives of the African Union, which are to promote African sovereignty and equitable development.

Aid for trade: An opportunity to increase fruit and vegetable supply
Thow AM: Bulletin of the World Health Organisation (early online version), 16 November 2012

Low fruit and vegetable consumption is an important contributor to the global burden of disease. In the wake of the United Nations High-level Meeting on Non-Communicable Diseases (NCDs), held in September 2011, a rise in the consumption of fruits and vegetables is foreseeable and this increased demand will have to be met through improved supply. The World Health Organisation, the Food and Agriculture Organisation and the World Bank have highlighted the potential for developing countries to benefit nutritionally and economically from the increased production and export of fruit and vegetables. Aid for Trade, launched in 2005 as an initiative designed to link development aid and trade holistically, offers an opportunity for the health and trade sectors to work jointly to enhance health and development. It is one of the few sources of aid for development that is stable and experiencing growth, according to this paper. At present the health sector has very little input into how Aid for Trade funds are allocated. This is an opportune moment to investigate opportunities for collaboration, since more than half of the reporting external funders are planning to revise their Aid for Trade strategies in 2013. Health departments should make central planning and finance departments aware of the potential health and economic benefits, for both developed and developing countries, of directing Aid for Trade to fresh produce markets.

Global Wage Report 2012/13: Wages and Equitable Growth
International Labour Organisation: 7 December 2012

The 2012/13 edition of the Global Wage Report looks at the macroeconomic effects of wages, and in particular at how current trends are linked to equitable growth. Among the major findings of the report are that the gap between wage growth and labour productivity growth is widening, the difference between the top and bottom earners is increasing, and the labour income share is declining. Workers are receiving a smaller slice of the economic pie than before. These worrying changes affect the key components of aggregate demand – particularly consumption, investment and net exports – that are necessary for recovery and growth. The report looks at the reasons for these trends, which range from the increasing financial and trade globalization to advances in technology and the decline in the power of trade unions and reduced union density. Raising average labour productivity remains a key challenge which must involve efforts to raise the level of education and the capabilities that are required for productive transformation and economic development. The development of well-designed social protection systems would allow workers and their families to reduce the amounts of precautionary savings, to invest in the education of their children, and to contribute towards stronger domestic consumption demand and raise living standards. The report calls for internal and external “rebalancing” to achieve more socially and economically sustainable outcomes within and across countries, proposing policy actions beyond labour markets and national borders.

LDCs seek indefinite extension of transition period under TRIPS
Raja K: Third World Network, 9 November 2012

The Least Developed Countries (LDCs) have submitted a "duly motivated" request to the WTO TRIPS Council for an extension of the transition period for them to comply with the TRIPS Agreement "for as long as the WTO Member remains a least developed country". The request was submitted by Haiti, on behalf of the LDCs, at a meeting of the TRIPS Council on 6-7 November 2012. The exemption will continue to allow LDCs to access affordable medicines without the risk of violating patents on the medicines. Haiti argued that because of their extreme poverty, LDCs need the policy space to access various technologies, educational resources, and other tools necessary for development. Furthermore, LDCs have such small economies that they do not represent a significant loss of profits for pharmaceutical patent owners. Most intellectual property-protected commodities are simply priced beyond the purchasing power of these countries’ governments and their nationals, the spokesperson for Haiti added. Haiti has asked for this issue to be put on the agenda of the next TRIPS Council meeting, scheduled to take place in March 2013.

Pharmaceutical industry targets Africa's growing middle class
Berton E: Mail and Guardian, 12 February 2013

Pharmaceutical spending in Africa is expected to reach US$30 billion by 2016, driven by increases in incomes and the shifting nature of its disease burden, according to this article. Non-communicable diseases (NCDs) are expected to account for 46% of all deaths in sub-Saharan Africa by 2030, up from 28% in 2008. As a result, big pharmaceutical companies are now expressing interest in new opportunities opening up for treating chronic, non-communicable diseases (NCDs), particularly in African middle classes. The author projects that the pharmaceutical market in Africa will grow in the next decade.

Protection of populations from exposure to second-hand smoke in Africa: Policy Implementation challenges
Piotie PN: Consultancy Africa Intelligence, 22 January 2013

Economists have predicted that tobacco consumption will double in the next 12 to 13 years in Sub-Saharan Africa unless anti-smoking policies are adopted. Besides impoverishing families, an increase in the consumption rate will result in an increase in disease burden that will generate unaffordable health costs. Implementing smoke-free policies in Africa remains a problem, however, largely due to tobacco industry interference, insufficient financial and human resources, lack of support from government officials and legislators and poor involvement of civil society. However, the author argues that poor compliance, as well as poor, often non-existent enforcement and monitoring and surveillance systems are the real threats to smoke-free laws in Africa. Therefore, there is a crucial need for efficient implementation strategies, along with proper monitoring and surveillance systems on the one hand; and on the other, a need for scientific research in order to evaluate the effectiveness of smoke-free policies in Africa.

The Slate is Clean: What’s Next? An evaluation of debt relief in the Democratic Republic of Congo, 2003-2010
De Crombrugghe D, de Looringhe D and Ruben R: GREAT Insights 2(1), January 2013

In this report, the authors provide an in-depth evaluation of debt cancellation measures the Democratic Republic of Congo (DRC) that took place at the beginning of the 21st century. As a proxy for the effect of debt relief, the authors of this report looked into the education sector for evidence of improvements following the debt cancellation. Some positive changes, notably in the payment of wages, were found that correlated with the debt relief, but these changes did not reach further than the headquarters of the ministry of education in Kinshasa. They identified two new issues: the growing need to question the legitimacy of ‘odious debt’ incurred during a dictatorship without the population ever having received any benefits from it; and the ongoing fight against vulture funds and other rogue creditors, which buy up the debt of poor developing countries at very low prices and then sue them to enforce payment of the nominal value, including arrears of interest. Legislation outlawing the seizure of Overseas Development Assistance (ODA) funds and state-to-state loans would be an important step in that direction, the authors argue. Belgium has already passed a law to protect its ODA grants against seizure and also intends to audit the ethical basis of all sovereign credits on developing countries. (Please note that this report has only been issued in French – the English version is forthcoming.)

6. Poverty and health

A cross sectional study: latrine coverage and associated factors among rural communities in the District of Bahir Dar Zuria, Ethiopia
Awoke W and Muche S: BMC Public Health 13(99), 4 February 2013

The aim of this study was to assess latrine coverage and the associated factors among the rural communities in district of Bahir Dar Zuria, Ethiopia. A community-based cross-sectional study was conducted on 608 households in district of Bahir Dar Zuria. Data were collected by means of a pretested, standardised questionnaire and observation checklist. Of the 608 households, 355 (58.4%) had pit latrines and only 220 (62%) were functional (providing services during data collection). One hundred and eighty-seven (52.7%) had been constructed two or more years prior to the time of the study and 202 (56.9%) latrines required maintenance. Latrine coverage in District of Bahir Dar Zuria was far from the national target of 100%. The availability of latrines was found to be affected by income level, frequency of visits by health workers, walking time from local health institutions, and distance from the urban area of Bahir Dar. Therefore, it is recommended that the frequency of supportive visits be increased and that special attention be given to households in inaccessible areas.

Health in the post-2015 development agenda: The need for a social determinants of health approach
Joint statement of the UN Platform on Social Determinants of Health International Labour Organisation, United Nations Development Programme, United Nations Population Fund, United Nations Children’s Fund, World Health Organisation and UNAIDS: 2013

In order to reduce health inequities, there is a need to address the wider socioeconomic and structural factors that influence how people become sick, what risk factors they are exposed to, how they access services, and how they use those services. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. This joint statement argues that integrated policy approaches are necessary in order to address the complexity of health inequities, including through national social protection floors, which address income security and the goal to establish universal access to health care simultaneously. Health policy generally, and health equity in particular, to a large extent depend on decisions made in sectors other than health, and are fundamentally linked to several interrelated issues such as governance, environment, education, employment, social security, food, housing, water, transport and energy. It means that health outcomes cannot be achieved by taking action in the health sector alone, and that actions in other sectors are critical. Failing to address the social determinants of health has held back progress on existing global health and development goals, including the Millennium Development Goals. The joint statement outlines the actions to be taken to address the social determinants of health, sector by sector.

Poor Governance, Good Business: How land investors target countries with weak governance
Oxfam: 7 February 2013

In this media briefing, Oxfam reveals that investors are targeting the world’s weakest-governed countries to buy land, and it calls on the World Bank to lead the fight against land grabs. It argues that the Bank is in a unique position to act because it sets international standards for land investments, provides finance for land deals and advises developing countries on land investments. Oxfam’s analysis reveals that over three quarters of the 56 countries where land deals were agreed between 2000 and 2011 scored below average on four key governance indicators. The 23 least developed countries account for more than half of the recorded land deals over this period. Researchers assessed a range of factors including voice and accountability (e.g. whether citizens participate in selecting their government), rule of law, the quality of private sector regulation, and control of corruption. They found poor governance is good business for investors looking to secure land quickly and cheaply. Investors seem to be cherry-picking countries with weak rules and regulations. This can spell disaster for communities if these deals result in their homes and livelihoods being snatched away without consent or compensation.

Rural areas in the Eastern Cape Province, South Africa: The right to access safe drinking water and sanitation denied?
Fobosi S: Consultancy Africa Intelligence, 24 January 2013

This paper critically analyses the denial of the right of access to safe drinking water and sanitation. In so doing, it engages with the debate about whether access to water is a human right, using the situation in the rural areas of the Eastern Cape Province as a case study. Water in rural areas of the Eastern Cape continues to be regarded as a scarce resource, while at the same time the Constitution asserts that everyone has a right to access sufficient water and sanitation. The author argues that it is the duty of SA’s Government to work effectively for the progressive realisation of the right to access sufficient water and sanitation in rural areas. It should prioritise improvement of access to water in those areas where there is greatest need. Water sources must be as close as possible to households and water should be available on a daily basis. It should be as accessible and affordable as possible, particularly for the most marginalised and vulnerable members of SA society. An adequate policy should also be developed and monitored to prevent pollution of water resources and encourage water conservation.

South African government drops willing buyer-willing seller option to accelerate land reform
Magudulela M: SABC News, 14 February 2013

The South African government has announced it will no longer pursue the willing buyer-willing seller option for land redistribution, citing the process as slowing down the speed of land reform. President Jacob Zuma listed land reform as a priority area for 2013 in his State of the Nation address on 14 February 2013. June 2013 will mark the centenary of the 1913 Land Act, whereby the British dispossessed African people of their land. He argued that the legacy of the Native Land Act still lives, and as a result many native families are still working for white farmers only for their food. Zuma said the land question needs to be resolved amicably within the framework of the Constitution and the law. But he called for the time it takes to finalise a claim to be shortened. In this regard, Government will now pursue the ‘just and equitable’ principle for compensation as set out in the Constitution instead of the willing buyer- willing seller principle, which forces the State to pay more for land than the actual value. Government’s mid-term review in 2012 revealed a number of shortcomings in the land reform implementation programme, which Zuma says will be used to improve implementation. He also pointed out that better incentives need to be provided for commercial farmers that are willing and capable of mentoring smallholder farmers.

7. Equitable health services

Access to health care in Mozambique
Ravenscroft J: Global Health Check, 4 February 2013

This film examines the barriers that people face in accessing healthcare in rural Mozambique, specifically the rural area of Tsangano in the province of Tete, a huge region in the centre of the country. In the film, you can see how the examples of Tsangano and Tete clearly show that all parts of a health system need to come together in order for the system as a whole to function. The film advocates for an end to out-of-pocket payments by health service users. To ensure this, the ‘key ingredients’ that will make user fee removal a success must also be addressed – the financing for the system as a whole and ensuring increased investment in transport and infrastructure – particularly in rural areas – a bigger, stronger health workforce, universal access to medicines and better information for the population to demand their right to health.

Hypertension in Northern Angola: prevalence, associated factors, awareness, treatment and control
Pires JE, Sebastião YV, Langa AJ and Nery SV: BMC Public Health 13(90), 31 January 2013

In this study, researchers aimed to estimate the prevalence, awareness, management and control of hypertension and associated factors in an adult population in Dande, Northern Angola. They conducted a community-based survey of 1,464 adults, following the World Health Organisation's Stepwise Approach to Chronic Disease Risk Factor Surveillance, and selected a representative sample of subjects, stratified by sex and age (18–40 and 41–64 years old). Prevalence of hypertension was 23% in the sample. A follow-up consultation confirmed the hypertensive status in 82% of the subjects who had a second measurement on average 23 days after the first. Amongst hypertensive individuals, 21.6% were aware of their status. Only 13.9% of those who were aware of their condition were under pharmacological treatment, of which approximately one-third were controlled. Greater age, lower level of education, higher body mass index and abdominal obesity were found to be significantly associated with hypertension. The authors conclude that there is an urgent need for strategies to improve prevention, diagnosis and access to adequate treatment in Angola, where massive economic growth and its consequent impact on lifestyle risk factors could lead to an increase in the prevalence of hypertension and cardiovascular disease.

Knowledge of tuberculosis (TB) and human immunodeficiency virus (HIV) and perception about provider initiated HIV testing and counseling among TB patients attending health facilities in Harar town, Eastern Ethiopia
Seyoum A and Legesse M: BMC Public Health 13(124), 8 February 2013

In this study, researchers assessed knowledge of tuberculosis (TB) and HIV, and perceptions about provider-initiated testing and counselling (PITC) among TB patients attending health facilities in Harar town, Eastern Ethiopia. Using a semi-structured questionnaire, a total of 415 study participants were interviewed about their knowledge of TB and HIV as well as the impact of HIV testing on their treatment-seeking behaviour. Results showed that living more than 10 km from a health facility was associated with low knowledge of TB and low knowledge of HIV testing. Delay in treatment was more likely among female participants, single participants and those living more than 10 km from a health facility. Most of the study participants (70%) believed that there was no association between TB and HIV and AIDS, while most (81.6%) of the study participants who were 21 years old or younger believed that fear of PITC could cause delay in treatment seeking. The authors recommend that emphasis should be given to improving knowledge of TB and HIV among residents living far from a health facility, as well as to improving the negative perceptions of PITC among young adults.

Quality of antenatal care in Zambia: a national assessment
Kyei NAN, Chansa C and Gabrysch S: BMC Pregnancy and Childbirth 12(151), 13 December 2012

Little conceptual or empirical work exists on the measurement of antenatal care (ANC) quality at health facilities in low-income countries. To address this gap, researchers in this study developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers. They included 1,299 antenatal facilities in the study and compared the quality of ANC received by 4,148 mothers between 2002 and 2007. Results showed that only 45 antenatal facilities (3%) fulfilled the study’s developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester. The authors argue that these results indicate missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect the “quality gap” where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress.

Rapid case-based mapping of seasonal malaria transmission risk for strategic elimination planning in Swaziland
Cohen JM, Dlamini S, Novotny JM, Kandula D, Kunene S and Tatem AJ: Malaria Journal 12(61), 11 February 2013

Commonly available malaria maps are based on parasite rate, a poor metric for measuring malaria at extremely low prevalence. New approaches are required to provide case-based risk maps to countries seeking to identify remaining hotspots of transmission while managing the risk of transmission from imported cases. In this study, household locations and travel histories of confirmed malaria patients during 2011 were recorded for the higher transmission months of January to April and the lower transmission months of May to December. Data was gathered and used to generate maps predicting the probability of a locally acquired case at 100 m resolution across Swaziland for each season. Results indicated that case households during the high transmission season tended to be located in areas of lower elevation, closer to bodies of water, in more sparsely populated areas, with lower rainfall and warmer temperatures, and closer to imported cases. The high-resolution mapping approaches described here can help elimination programmes understand the epidemiology of a disappearing disease. The authors argue that generating case-based risk maps at high spatial and temporal resolution will allow control programmes to direct interventions proactively according to evidence-based measures of risk and ensure that the impact of limited resources is maximised to achieve and maintain malaria elimination.

Why do women not use antenatal services in low- and middle-income countries? A metasynthesis of qualitative studies
Finlayson K and Downe S: PLoS Medicine 10(1), 22 January

The authors of this study synthesised the findings of all relevant qualitative studies reporting on the views and experiences of women in low- and middle-income countries (LMICs) who received inadequate antenatal care. The synthesis revealed that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services. These findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings.

Why some women fail to give birth at health facilities: a qualitative study of women's perceptions of perinatal care from rural Southern Malawi
Kumbani L, Bjune G, Chirwa E, Malata A and Odland JØ: Reproductive Health 10(9), 8 February 2013

Despite Malawi government’s policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care. This study explored the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. Results indicated that onset of labour at night, rainy season, rapid labour, socio-cultural factors and health workers’ attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbours. Most women went to the health facility the same day after delivery. This study reveals beliefs about labour and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. There is a need for further exploration of barriers that prevent women from accessing health care.

8. Human Resources

E-learning in medical education in resource constrained low- and middle-income countries
Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H et al: Human Resources for Health 11(4), 4 February 2013

This paper summarises the literature on e-learning in low- and middle-income countries (LMIC), and presents the spectrum of tools and strategies used. Using standard decision criteria, reviewers narrowed the article suggestions to a final 124 relevant articles. Of the relevant articles found, most referred to e-learning in Brazil (14 articles), India (14), Egypt (10) and South Africa (10). While e-learning has been used by a variety of health workers in LMICs, most (58%) reported on physician training, while 24% focused on nursing, pharmacy and dentistry training. Blended learning approaches were the most common methodology presented (49 articles) of which computer-assisted learning (CAL) comprised the majority (45 articles). Other approaches included simulations and the use of multimedia software (20 articles), web-based learning (14 articles), and eTutor/eMentor programmes (3 articles). The authors conclude that e-learning in medical education is a means to an end, rather than the end in itself. Utilising e-learning can result in greater educational opportunities for students while simultaneously enhancing faculty effectiveness and efficiency. However, this potential of e-learning assumes a certain level of institutional readiness in human and infrastructural resources that is not always present in LMICs.

Human resource governance: what does governance mean for the health workforce in low- and middle-income countries?
Kaplan AD, Dominis S, Palen JGH and Quain EE: Human Resources for Health 11(6), 15 February 2013

This study was conducted to determine how 20 low- and middle-income countries are operationalising health governance to improve health workforce performance. The 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalising the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses included difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers. Further research is warranted into the effectiveness of specific interventions that enhance the links between the health workforce and governance to determine approaches to strengthening the health system.

New academy to address hospital CEO shortages
Magubane K: Business Day, 4 February 2013

The South African government wants to use the newly launched Academy for Leadership and Management in Healthcare to set benchmarks, norms and standards for the leadership and management of hospitals in South Africa. The academy was launched in November 2012 to provide leadership and management skills to hospital CEOs. Just over a hundred CEOs started orientation week on 4 February 2013. At the start of orientation week, Minister of Health Aaron Motsoaledi argued that hospital CEOs were key to addressing problems such as staff constraints and fraud. In the future, he expected that no person would become a hospital CEO or manager without first having attended the academy. He added that problems in South African hospitals often related to leadership and management, rather than staffing.

Policy implementation and financial incentives for nurses in South Africa: a case study on the occupation specific dispensation
Ditlopo P, Blaauw D, Rispel LC, Thomas S and Bidwell P: Global Health Action 6: 19289, 24 January 2013

In 2007, the South African government introduced the occupation-specific dispensation (OSD), a financial incentive strategy to attract, motivate, and retain health professionals in the public sector. Implementation commenced with the nursing sector. In this paper, researchers examine implementation of the OSD for nurses and highlight the conditions for the successful implementation of financial incentives. They conducted a qualitative case study design using a combination of a document review and in-depth interviews with 42 key informants, finding several implementation weaknesses. Only a few of the pre-conditions were met for OSD policy implementation. The information systems required for successful policy implementation, such as the public sector human resource data base and the South African Nursing Council register of specialised nurses, were incomplete and inaccurate, thus undermining the process. Insufficient attention was paid to time and resources, dependency relationships and task specification. In conclusion, the implementation of financial incentives requires careful planning and management in order to avoid loss of morale and staff grievances.

Restructuring the brain drain: strengthening governance and financing for health worker migration
Mackey TK and Liang BA: Global Health Action 6: 19923, 15 January 2013

For this study, researchers analysed health worker policies in developing countries to assess current strategies aimed at alleviating the ‘brain drain’ of medical professionals from these countries. Although governments and private organisations have tried to address this policy challenge, the researchers found that brain drain continues to destabilise public health systems and their populations globally. Most importantly, lack of adequate financing and binding governance solutions continue to fail to prevent health worker brain drain. In response to these challenges, the establishment of a Global Health Resource Fund in conjunction with an international framework for health worker migration could create global governance for stable funding mechanisms encourage equitable migration pathways, and provide data collection that is desperately needed.

9. Public-Private Mix

Conflicts of interest within philanthrocapitalism
Global Health Watch: 2012

This chapter from Global Health Watch 3 explores the origins of philanthrocapitalism and addresses its increasing influence on global health governance and decision-making. It examines the functioning and priorities of the Bill and Melinda Gates Foundation in order to explore how the alignment of corporate interests and philanthropic investment may be having adverse effects on health policy. It looks at the efforts of the proponents of philanthrocapitalism to challenge progressive tax measures that could generate government revenues earmarked for global health. Finally, the chapter suggests that a focus on conflicts of interest could be a useful starting point for the mobilisation of health specialists who are concerned about the influence of the Gates Foundation on health policy, but who have thus far had difficulty, as a result of the immense scale of the Foundation’s influence, in highlighting some of its controversial policies. Global Health Watch cautions against the new philanthropy’s core idea that private-sector investment fills the void left by cash-strapped governments. A key objective for health activists could be highlighting the ways in which government revenues are strapped through private-sector support and through a reluctance to embrace tax measures that are disparaged by philanthropists who purport to be operating outside the realm of politics.

Global Health Philanthropy and Institutional Relationships: How Should Conflicts of Interest Be Addressed?
Stuckler D, Basu S and McKee M: PLoS Medicine 8(4), 12 April 2011

In recent years, tax-exempt private foundations and for-profit corporations have increasingly engaged in relationships that can influence global health. Using a case study of five of the largest private global health foundations, the authors of this study identified the scope of relationships between tax-exempt foundations and for-profit corporations. They found that many public health foundations have associations with private food and pharmaceutical corporations. In some instances, these corporations directly benefit from foundation grants, and foundations in turn are invested in the corporations to which they award these grants. Personnel move between food and drug industries and public health foundations. Foundation board members and decision-makers also sit on the boards of some for-profit corporations benefitting from their grants. While private foundations adopt standard disclosure protocols for employees to mitigate potential conflicts of interests, these do not always apply to the overall endowment investments of the foundations or to board membership appointments. Transparency or grant-making recusal of employees alone may not be preventing potential conflicts of interests between global health programmes and their financing, the authors conclude.

Is the timing right for an International Code of Marketing of Food and Non-Alcoholic Beverages to Children?
Irwin R: Global Health Governance VI(1), 31 December 2012

This article addresses recent calls for the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) to develop a Code of Practice on the Marketing of Unhealthy Food and Beverages to Children. The author argues that such suggestions ignore the development of WHO’s Set of Recommendations on the Marketing of Food and Non-Alcoholic Beverages to Children and misrepresent its scope. The recommendations, adopted by the World Health Assembly in 2010, aim ‘to reduce the impact on children of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt.’ In light of the current WHO reform process and financial constraints, the fact that WHO member states explicitly chose to develop a Set of Recommendations instead of a Code, the author questions the feasibility and value of re-opening the issue. Instead he recommends that the Secretariat be supported in their mandate to provide assistance to member states in implementing the existing WHO Set of Recommendations.

Salt, sugar, and malaria pills: How the Affordable Medicine Facility–malaria endangers public health
Kamal-Yanni M: Oxfam Briefing Paper 163, 24 October 2012

This paper argues that the Affordable Medicine Facility–malaria, a global subsidy for malaria could skew investment away from more effective solutions to the disease. The AMFm advocates selling artemisinin-based combination therapy (ACT) medicines through the private sector, such as small shops. But selling ACT drugs, even at a small cost, is argued to exclude poor people who cannot afford to pay for a full course of treatment. Furthermore, the informal private sector does not have the ability or incentive to provide correct diagnosis and treatment, which may contribute to worsening drug resistance. The authors raise that getting malaria medicines from informal private providers is not a sound public health approach and not a substitute for investment in public service provision.

The Gates Foundation and Coca-Cola: At odds or legitimate bedfellows?
Shumate M: Non-Profit Quarterly, 31 January 2013

In this article, the author argues that there is a conflict of interest regarding public and nonprofit leaders who sit on the corporate boards of major commercial softdrink companies and their role on non profit foundations. The author reports in the paper that 7% of the Gates Foundation’s corporate stock endowment (more than 15 million shares) is in the form of shares of Coca-Cola, and questions whether Gates should be invested so heavily in sweetened soft-drinks given its health focus.

10. Resource allocation and health financing

An online debate about the UN General Assembly vote in favour of Universal Health Coverage
Ngabire E: Harmonisation for Health in Africa blogs, 4 February 2013

On 12 December 2012, a resolution called “Global health and foreign policy” was voted at the United Nations. This declaration, whose main focus is universal health coverage (UHC), triggered a debate on the online discussion forum of the Performance-Based Financing Community of Practice. This blog post summarises the main points of the discussion.

Brazil-Africa technical cooperation in health: what's its relevance to the post-Busan debate on aid effectiveness?
Russo G, Cabral LV and Ferrinho P: Globalisation and Health 9(2), 22 January 2013

This paper explores the issue of emerging external funders' contribution to the post-Busan debate on aid effectiveness by looking at Brazil's health cooperation projects in Portuguese-speaking Africa. The authors consider Brazil's health technical cooperation within the country's wider cooperation programme, aiming to identify its key characteristics, claimed principles and values, and analysing how these translate into concrete projects in Portuguese-speaking African countries. They found that, by adopting new concepts on health cooperation and challenging established paradigms - in particular on health systems and HIV and AIDS - the Brazilian health experience has already contributed to shape the emerging consensus on development effectiveness. However, its impact on the field is still largely unscrutinised, and its projects seem to only selectively comply with some of the shared principles agreed upon in Busan. Although Brazilian cooperation is still a model in the making, not immune from contradictions and shortcomings, it should be seen as enriching the debate on development principles, thus offering alternative solutions to advance the discourse on cooperation effectiveness in health.

Cost–effectiveness analysis of pandemic influenza preparedness: what’s missing?
Drake TL, Chalabi Z and Coker R: Bulletin of the World Health Organisation 90(10): 940-941, 10 October 2012

Pandemic influenza presents the greatest risk in low- and middle-income countries. The objective of this paper is to suggest improvements to the methods and scope of economic evaluations surrounding pandemic influenza and other epidemic or pandemic events in these countries. The evidence base for the cost-effectiveness of pandemic influenza preparedness policy options is small but growing rapidly. Modelling methods vary considerably between studies and the literature is limited in scope. To contribute to improving quality and consistency in this emerging study area, the authors recommend: greater focus on low-resource settings; inclusion of non-pharmaceutical interventions; incorporation of health system capacity; and more robust analysis and presentation of pandemic event uncertainty. So, what’s missing from pandemic influenza preparedness cost-effectiveness analysis and research? In the final analysis, the authors identify some crucial research gaps: poor countries, non-pharmaceutical interventions, health system capacity and pandemic uncertainty.

Reviewing the evidence: how well does the European Development Fund perform?
Gavas M: Overseas Development Institute, 31 January 2012

The European Union (EU) is currently negotiating the budget for the European Development Fund (EDF) for 2014-2020. The EDF is the EU’s main instrument for delivering development aid to the 78 African, Caribbean and Pacific (ACP) countries under the ACP–EU Cotonou Partnership Agreement. This paper reviews the EDF’s performance against three critiques made by some Member States: the EDF targets middle-income countries (MICs) at the expense of a focus on poor countries; the EDF is inflexible in its procedures and unable to adapt quickly to changing circumstances; and the EDF suffers from weak forecasting and slow disbursement of funds. The author argues that the EDF has a strong focus on poor countries and takes into account other criteria beyond income, like vulnerability and fragility. This focus will become stronger with further differentiation in aid allocation. In terms of flexibility, the EDF continues to face the challenge of being flexible enough to re-programme funds and to respond to crises, whilst at the same time ensuring long-term funding to strengthen security, development and humanitarian links. In terms of slow disbursement, the EU has started to address some of the weaknesses regarding disbursement by boosting staff levels and expertise.

The Impact of Universal Coverage UHC Schemes in the Developing World: A Review of the Existing Evidence
Giedion U, Alfonso EA and Díaz Y: The World Bank, Washington DC, January 2013

In this review, overall evidence indicates that universal health coverage (UHC) interventions in low- and middle-income countries have improved access to health care. However, the effect of UHC schemes on access, financial protection, and health status varies across contexts, UHC scheme design, and UHC scheme implementation processes. The authors highlight four lessons from the research, which have implications for both policy and future UHC research. First, affordability is important but will not reach those who cannot afford to pay at all. Second, interventions should target the poor but also keep an eye on the non-poor, as the most common UHC scheme designs are generally less effective for the non-poor. Third, benefits should be closely linked to target populations’ needs. Fourth, highly focused interventions can be a useful initial step toward UHC, as they have clearly defined targets and generate positive effects on access, financial protection, and even on health status outcomes. Finally, in terms of future UHC research, the review shows that most of the studies fail to involve evaluators from the start, which has led to weak evaluation designs to assess the impact of UHC schemes.

World Bank must decide if it stands for development or business as usual
Kwakkenbos J: Eurodad, 31 January 2013

The first round of consultations for the World Bank’s review of its procurement policy has been completed. Clear areas of contention between external funders, developing countries, and their private sector have arisen in the process on issues of domestic preferences and the use of developing countries’ procurement systems. The Bank has to decide whether it stands on the side of development and developing countries, or whether it stands for market orthodoxy and “business as usual,” argues the author of this article. For the most part developing countries and their domestic private sector argued that managing multiple external funding procurement systems with already limited capacity could be overwhelming. If the Bank wishes to demonstrate its commitment to development, it should support the use of domestic preferences, and live up to its international commitments by using country procurement systems as the default option. Furthermore, it should support developing countries in building transparent end effective country procurement systems and not undermine the policy space that these countries need to implement their development strategies and industrial policies. Eurodad supports calls from civil society organisations to initiate an independent review assessing barriers and how to effectively support small and medium-sized businesses.

11. Equity and HIV/AIDS

Fertility desire and intention of people living with HIV/AIDS in Tanzania: a call for restructuring care and treatment services
Mmbaga EJ, Leyna GH, Ezekiel MJ and Kakoko DC: BMC Public Health 13(86), 30 January 2013

Health programmes that serve people living with HIV/AIDS (PLWHA) pay little attention to PLWHA’s reproductive health needs. In this study, researchers collected data on fertility desire and intention to assist in the integration of sexual and reproductive health in routine care and treatment clinics. They conducted a cross-sectional study of 410 PLWHAs aged 15-49 residing in Kahe ward in rural Kilimanjaro, Tanzania. Fifty-one per cent reported they were married or cohabiting, 73.9% lived with their partners and 60.5% were sexually active. The rate of unprotected sex was 69%, with 12.5% of women reporting to be pregnant at the time of the survey. Further biological children were desired by 37.1% of the participants and lifetime fertility intention was 2.4 children. Increased fertility desire was associated with living and having sex with a partner, HIV disclosure, good perceived health status and CD4 count ≥200 cells for both sexes. These results showed that fertility desire and intention of PLWHA was relatively high, although lower than that of the general population in Tanzania. With increasing antiretroviral coverage and subsequent improved quality of life of PLWHA, these findings underscore the importance of integrating reproductive health services in the routine care and treatment of HIV and AIDS.

Neoliberal plague: AIDS, Africa and global capitalism
Hickel J: Pambazuka News 616, 13 February 2013

Aids in Africa is a symptom of an unjust global order, argues the author of this article. Mass poverty leaves people with no option other than labour migration and transactional sex, which he identifies as the key drivers of HIV transmission in southern Africa. Old approaches to rolling back AIDS don’t work any longer – what is needed is a new, more systematic approach in which poor African countries are released from structural adjustment programmes so they can rebuild their economies using tariffs, subsidies, state spending and low interest rates – the very policies that rich countries use. The author also calls for the cancellation of odious debts so African countries can spend money on health services instead of interest payments. Furthermore, governments need to amend TRIPS to decommoditise life-saving drugs and amend the World Trade Organisation’s (WTO) Agreement on Agriculture to ban the dumping of subsidised farm products in Africa and elsewhere. This means reforming the World Bank, the International Monetary Fund and the WTO, where voting power is monopolised by rich nations and special interests. The World Bank and the Gates Foundation – the biggest funders of AIDS prevention – cannot be entrusted with these tasks, as they have clear interests in the very policies (debt service, structural adjustment and patent laws) that have created the problem in the first place.

Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: A qualitative study
Ware NC, Wyatt MA, Geng EH, Kaaya SF, Agbaji OO, Muyindike WR et al: PLoS Medicine 10(1), 8 January 2013

Despite the successes in rolling out antiretroviral therapy in sub-Saharan Africa, treatment remains lifelong and systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programmes. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programmes in Africa. They interviewed 890 patients enrolled in HIV treatment programmes in Jos in Nigeria, Dar es Salaam in Tanzania and Mbarara in Uganda who had extended absences from care. Two-hundred-eighty-seven were located, and 91 took part in the study. Findings revealed unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Through the process of disengagement, patients who missed visits and felt reluctant to return over time lost their subjective sense of connectedness to care. The authors conclude that efforts to prevent missed clinic visits combined with moves to minimise barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.

12. Governance and participation in health

CIVICUS World Assembly Report 2012: Montreal Civil Society Commitments for a New Social Contract
Delegates of the Eleventh CIVICUS World Assembly: November 2012

At the end of the Eleventh CIVICUS World Assembly, held in September 2012, the various recommendations made by delegates were analysed and distilled into 15 key commitments for civil society to implement as it seeks to work more effectively to promote equity and to challenge and change the rules of engagement between citizens, the state and other holders of power. Some of these commitments call for greater networking and smarter partnerships between formal civil society organisations and new social movements and social media technologies. The significance of encouraging local and voluntary participation, maintaining community connections and addressing marginalisation was highlighted. Other commitments argued for work within an equity and human rights based framework that includes sustainability and demands accountability to citizens, not external funders. Civil society also needs to be less dependent on governments and seek alternative financing models, like social and crowd-sourced funding. The commitments further call for civil society organisations (CSOs) to be innovative, strategic and have an assets-based approach, develop a better understanding of private sector involvement as well as develop CSO capacities for negotiation and analysis of power.

Civil society has the potential of finding new solutions to global challenges which are based on the principles of equity, participation and sustainability: An Interview with CIVICUS Secretary General, Dhananjayan Sriskandarajah
CIVICUS: 11 February 2013

In this interview, CIVICUS Secretary General, Dhananjayan Sriskandarajah argues that civil society has the potential to find solutions to our greatest global challenges based on equity, participation and sustainability. Civil society participation is now of greater significance as the development paradigm is changing faster than the key players realise. Official aid flows are becoming less important, new actors such as China and India are blurring the boundaries between development and business, and Big Business has moved in to take advantage of potential profits to be made from the 'aid industry'. He identifies two key mechanisms for responding to these changes and to ensuring progress on the development agenda: global commitments that involve all key actors and set real targets, and local action that finds new ways of involving citizens in shaping the development process. He also criticises current multilateral processes where the negotiating positions taken by diplomats do not reflect the wishes of their citizens. At these meetings, principles of human rights, democracy and environmental sustainability disappear from the agenda and narrow interests emerge that do not arise out of any popular mandate. He calls for new ways of holding governments to account for the positions they take on the international stage.

Constitution empowers Kenyans to take part in budgeting
Jaramba G and Changani S: Pambazuka News 615, 7 February 2013

Despite being some of the most taxed citizens of the world, Kenyans have so far had little say in how their economy is managed. The Constitution of Kenya (2010) has, however, given much impetus to ordinary citizens participate in the management and decision-making process in governance socially, economically and politically. Participatory budgeting is a mechanism that civil society can use to decide how to allocate part of a municipal or public budget. In collaboration with Fahamu, in September 2012, the Kwale community engaged in a needs assessment process after which the priority areas were identified before electing budget delegates at the ward level. Kwale County currently has 20 wards following the recent boundary demarcations by the Andrew Ligale-led Interim Independent Boundaries Commission. The 20 wards are in Matuga, Msambweni, Kinango and the newly created Lunga-Lunga constituencies. The ward delegates are charged with developing specific spending proposals which will later be presented to the community for validation. If the community approves of the proposals, the same are to be forwarded to the county government for consideration of implementation. If implemented, participatory budgeting is expected to raise the social and economic well-being of the two counties. Areas that are expected to benefit significantly include education, health, agriculture, roads and energy sectors.

ONE launches campaign for transparency in post-2015 framework
ONE: February 2013

The aim of the “Open for Development” campaign – and the global petition – is to persuade the High-Level Panel on the post-2015 Millennium Development Goals to ensure that openness forms the basis of the next global development framework. In this petition, ONE is calling for three things: 1. Openness in the design of the post-2015 framework to ensure that the post-2015 goals reflect people’s needs and priorities. 2. Openness in the monitoring of investments and outcomes so both funding and recipient governments collect information about what they spend and what they achieve in pursuit of the goals. 3. Openness in terms of making that information widely available and accessible so citizens, parliaments and the media can use it hold governments to account. The global petition urges world leaders to make sure the plan to end extreme poverty is specific, measurable and accountable.

The flip side to Bill Gates’ charity billions
Bowman A: New Internationalist Magazine 451, 1 April 2012

The author raises questions in this paper about the operations of the Gates Foundation in public health and the impact of its work. These relate to the mechanisms for accountability and the considerable power in shaping health policy priorities and intellectual norms, in a context of a significant focus on technocratic solutions for the world’s health challenges and a demand for greater private sector influence in global health policy. Many health rights campaigners argue in contrast for a loosening of private interests, such as in intellectual property laws to increase access to technologies such as medicines - both in lowering prices through generic competition and in enabling innovation outside patent-hoarding companies.

The World Bank’s private sector financing arm doesn’t know the environmental and social impacts of nearly half its portfolio
Oxfam: 8 February 2013

Oxfam is calling for a fundamental overhaul of World Bank lending to financial markets actors, following the publication of an Ombudsman audit that revealed the International Finance Corporation (IFC), the Bank’s private lending arm, “knows very little” about the environmental or social impacts of its financial market lending. Oxfam is calling on the IFC to improve transparency and ensure its loans do not put poor people at risk of land grabs. The fact that many projects technically meet IFC policies ignores the finding that the policies themselves are fundamentally and fatally flawed, the article says, calling for a commitment by the IFC to review its approach to lending to the financial market. The audit shows that the World Bank must not adopt the IFC model, which fosters a culture of client self-monitoring, self-assessment and zero oversight. This would leave communities and the environment vulnerable to harm. The CAO audit also reveals that IFC policies are not industry best practice and that IFC is not above using legal loopholes in financial intermediary policies that other financiers would consider ethically dubious.

WHO’s engagement with non-state actors: the challenge of maintaining integrity and independence
Sangiorgio M: Health Diplomacy Monitor 4(1): 6-8

of the major challenges with regard to the World Health Organisation’s (WHO) engagement with non-state actors is maintaining the independence and intergovernmental nature of the WHO by protecting it from the influence of vested interests. This proved to be one of the major issues raised at the 132nd WHO Executive Board (EB) session held from 21-29 January in Geneva, Switzerland. Participants called for a more flexible accreditation mechanism to authorise non-state actor participation in WHO meetings and argued that WHO’s policy of engagement should be driven by its own interests and needs, and limited to those entities with which mutually beneficial cooperation is possible. Some countries called for a single policy of engagement, while others preferred two separate policies for NGOs and private commercial entities respectively. WHO’s Secretary General supported the single policy option. Participants called for further analysis, particularly concerning the implications of differentiation, a procedure that is perceived to risk exclusion. The Executive Board requested that the director-general conduct public web-based consultations, and convene two separate consultations - one with member states and NGOs, and the other one with member states and the private commercial sector - to support the development of the respective draft policies.

13. Monitoring equity and research policy

CAO audit of a sample of IFC investments in third-party financial intermediaries
Office of the Compliance Advisor Ombudsman (CAO): 10 October 2012

In this audit of the International Finance Corporation (IFC), the World Bank’s private lending arm, the CAO found that the IFC has processed most of its investments in compliance with the organisation’s own environmental and social policy requirements, but it was difficult to make an accurate assessment of the actual impact of the projects it invested in. Despite outward appearances, the CAO argues that many Social and Environmental Management Systems (SEMSs) for development projects have become mere window dressing, rather than a genuine means to improved environmental and social (E&S) outcomes on the ground. At the same time, the IFC’s E&S procedures and impact assessment measurements are not optimally designed to support broader environmental and social outcomes. To achieve those broader objectives, the IFC would need to focus on facilitating a self-sustaining cultural change within client organisations, raising their level of understanding and management of environmental and social risk. This implies a more sophisticated approach to the analysis of client commitment, and interventions that align E&S issues with relevant business and socioeconomic drivers of change, rather than focusing on systems compliance. It would also require a systematic methodology for measuring impact at the subclient level.

Harnessing the power of the grassroots to conduct public health research in sub-Saharan Africa: a case study from western Kenya in the adaptation of community-based participatory research (CBPR) approaches
Kamanda A, Embleton L, Ayuku D, Atwoli L, Gisore P, Ayaya S et al: BMC Public Health 13(91), 31 January 2013

The Orphaned and Separated Children's Assessments Related to their Health and Well-Being (OSCAR) project is a longitudinal cohort of orphaned and non-orphaned children in Kenya. To date the study has enrolled 3,130 orphaned and separated children. In this paper, the authors use this project to describe how community-based participatory research (CBPR) approaches and principles can be incorporated and adapted into study design and methods. Preliminary results suggest that community engagement and participation was integral in refining the study design and identifying research questions that were impacting the community. Through the participation of village chiefs and elders, researchers were able to successfully identify eligible households and randomise the selection of participants. The on-going contribution of the community in the research process was also vital to participant retention and data validation while ensuring cultural and community relevance and equity in the research agenda. In conclusion, the authors argue that CBPR methods can strengthen epidemiological and public health research in sub-Saharan Africa within the social, political, economic and cultural contexts of the diverse communities on the continent, provided that the methods are adapted to the local context.

Human Rights Indicators: A Guide to Measurement and Implementation
United Nations Office of the High Commissioner for Human Rights: 2012

Qualitative and quantitative indicators are useful tools for promoting and monitoring the implementation of human rights. International human rights treaties and jurisprudence of the human rights treaty bodies call for the development of statistical indicators in compliance with international human rights norms and principles. The Office of the High Commissioner for Human Rights (OHCHR) has published this guide to assist in developing quantitative and qualitative indicators to measure progress in the implementation of international human rights norms and principles. The Guide describes the conceptual and methodological framework for human rights indicators recommended by international and national human rights mechanisms and used by a growing number of governmental and non-governmental actors. It provides concrete examples of indicators identified for a number of human rights - all originating from the Universal Declaration of Human Rights - and other practical tools and illustrations, to support the realization of human rights at all levels. It will be of interest to human rights advocates as well as policymakers, development practitioners, statisticians and others who are working to make human rights a reality for all.

14. Useful Resources

African Partnerships for Patient Safety

The World Health Organisation (WHO) has released a resource package of practical tools specifically aimed at improving patient safety in hospitals in developing countries. African Partnerships for Patient Safety (APPS) is a WHO Patient Safety Programme building sustainable patient safety partnerships between hospitals in countries of the WHO African Region and hospitals in other regions. African Partnerships for Patient Safety (APPS) is a WHO Patient Safety Programme building sustainable patient safety partnerships between hospitals in countries of the WHO African Region and hospitals in other regions. APPS is concerned with advocating for patient safety as a precondition of health care in the African Region and catalysing a range of actions that will strengthen health systems, assist in building local capacity and help reduce medical error and patient harm. The programme acts as a channel for patient safety improvements that can spread across countries, uniting patient safety efforts.

Legal, ethical and counselling issues related to HIV counselling and testing of children: Implementation guidelines
Human Sciences Research Council: 2013

These guidelines dealing with the legal, ethical and counselling issues related to HIV testing of children are intended for HIV and AIDS practitioners working with children. They were developed through an extensive consultative process with key staff from the South African Department of Health, the United States Centres for Disease Control and Prevention (CDC), civil society, non-governmental organisations, academics, policy makers and practitioners working with children. The guidelines cover a range of topics: counselling of children of different ages and developmental levels and assessing a child’s capacity to give informed consent; pre- and post-test counselling for children and for parents and caregivers of children unable to consent independently; follow-up and referral of children and/or parents or caregivers; client-initiated or voluntary counselling and testing and provider-initiated counselling and testing as applied to children; counselling guidelines relative to disclosure of HIV status by and to children; key qualities and competencies required for HIV counselling of children; and the physical environment and use of appropriate materials in work with children and young people.

Resource offers monthly updates on communicable diseases in South Africa

The National Institute for Communicable Diseases (NICD) monitors communicable diseases in South Africa. It is a resource of knowledge and expertise in regionally relevant communicable diseases to the South African Government, to SADC countries and the African continent. The NICD assists in the planning of policies and programmes and supports appropriate responses to communicable disease problems and issues. Every month, NICD publishes its Communiqué for the purpose of providing up-to-date information on communicable diseases in South Africa.

15. Jobs and Announcements

Call for applications: 2013 MILEAD Fellowship
Deadline: 15 March 2013

The Moremi Initiative for Women's Leadership in Africa (Moremi Initiative) is calling for applications for the 2013 Moremi Leadership Empowerment and Development (MILEAD) Fellows Programme. The Programme is a long-term leadership development programme designed to identify, develop and promote emerging young African women leaders to attain and thrive in leadership roles in their community and Africa as a whole. The programme targets young women interested in developing transformational leadership skills that help them address issues facing women and girls across communities in Africa. It aims to equip Fellows with the requisite knowledge, skills, values and networks they need to succeed as 21st century women leaders. Applications are welcome from young African women ages 19-25, living in Africa and the Diaspora. Specific requirements of the programme and related dates are outlined in the application package.

Fifth Annual HIV-In-Context Research Symposium: Urbanisation, Inequality And HIV
13 March 2013 - 15 March 2013: Cape Town, South Africa

From its base in the University of the Western Cape’s School of Public Health, this year’s HIV in Context Research Symposium looks beyond biomedicine at some of the social determinants of HIV, and of responses to HIV, within and outside the health sector. The Symposium will examine the links between HIV, inequality and the dynamics and impacts of urbanisation – dynamics that play out between settings as people move permanently or temporarily to urban centres, and within the highly unequal spaces constituting South African cities. The particular experience of Cape Town as a destination and transit point on migration trajectories will be examined in relation to other cities in South Africa and beyond. Through diverse disciplinary and sectoral lenses, practitioners, researchers, policy makers and civil society activists will examine the many ways in which urbanisation, inequality and HIV interact and affect people’s lives.

HIV Capacity Building Partners Summit
19 -21 March 2013: Johannesburg, South Africa

The Capacity Summit 2013 will bring together leading organisations, capacity building experts, policy-makers and the HIV-affected community to translate the emerging consensus on defining and developing capacity building interventions that are institutionalised, country-owned, evidence based and sustainable to attain the HIV and health targets towards achieving the Millennium Development Goals. The Capacity Summit 2013 is designed to contribute to the good practice within the HIV and health service delivery in the east and southern African region. The Summit’s objectives are: to catalyse and advance knowledge about how to make capacity building work for HIV response and achieve health targets at community, country and regional levels; to address skills and capacity gaps and overcome barriers that limit capacity building interventions to achieve results that are community driven; to promote and enhance collaboration in order to effectively translate and expand on the successes achieved so far in capacity building for HIV and better health services delivery; to influence leaders, including key policy makers and external funders, to increase their commitment to gender-sensitive, country-owned and evidence-based capacity building interventions, including targeted interventions for the most at-risk communities and individuals; and to promote accountability among all stakeholders engaged at various levels of capacity building.

Human resources for universal health coverage: a call for papers
Sheikh M, Boerma T, Cometto G and Duvivier R: Bulletin of the World Health Organisation 91(2): 84, February 2013

The Third Global Forum’s programme will position health workforce development as a critical requirement for effective universal health care (UHC) and will be designed around one overarching theme – “human resources for health: foundation for universal health coverage and the post- 2015 development agenda” – as well as five sub-themes and their corresponding tracks: (i) leadership, partnerships and accountability for health for human resources (HRH) development; (ii) impact-driven HRH investments towards UHC; (iii) a supportive HRH legal and regulatory landscape for UHC; (iv) empowerment of health workers by overcoming policy, social and cultural barriers; and (v) the harnessing of HRH innovation and research through new management models and technologies. To provide a solid evidence base and background to the Third Global Forum’s proceedings, the theme issue will feature commissioned as well as independently submitted articles that will set the scene for and generate innovative thinking on HRH for UHC. The World Health Organisation is looking for contributions on the Forum’s general theme, five sub-themes and tracks, especially those emphasising aspects of HRH directly related to achieving UHC. Submission of relevant country experiences is particularly encouraged. The deadline for submissions is 10 March 2013.

Sixth South African AIDS Conference
18-21 June 2013: Durban, South Africa

The Sixth South African AIDS Conference will be held in Durban from 18-21 June 2013. The conference theme is "Building on our successes: Integrating responses". As South Africa enters the fourth decade of HIV and AIDS, the conference aims to look back at lessons learnt and reflect, celebrate the gains made, and find ways to build on past successes by integrating HIV with other health responses. The conference will bring together various members of the HIV research community, including clinicians, academics, civil society and government.

TB Vaccines Third Global Forum
25-27 March 2013: Cape Town, South Africa

Third Global Forum on TB Vaccines will bring together researchers, policymakers, donors, civil society and other stakeholders interested in the development of new TB vaccines that will contribute to global efforts to eliminate TB. The main goals of the Forum are to: review progress in the field, with a particular focus on the key issues and challenges outlined in the Blueprint for TB Vaccine Development, and discuss strategies to continue to advance and sustain the field; share the latest data and findings on key issues in TB vaccine research; and promote partnerships and collaboration amongst multiple stakeholders across sectors to accelerate and streamline TB vaccine research.

Third Global Forum On Human Resources For Health
Recife, Brazil: 10–13 November 2013

The World Health Organisation’s Workforce Alliance convened the First and the Second Global Forums on Human Resources for Health, in 2008 in Uganda, and 2011 in Thailand respectively. The Global Forums brought together key experts, fellow champions as well as frontline health workers around the common goal of improving the human resources for health to achieve the health-related Millennium Development Goals. Both Forums concluded with the adoption from committed participants of ambitious agendas suitable to translate political will, leadership and partnership into sustainable and effective actions. The Third Global Forum will be held in Recife, Brazil, from 10–13 November 2013.

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