EQUINET NEWSLETTER 147 : 01 May 2013

1. Editorial

Are we bringing African perspective to global health diplomacy?
Rene Loewenson, Moeketsi Modisenyane, Mark Pearcey

Diplomats, officials, civil society and private actors converging in May at the World Health Assembly bring to the spotlight the increasing extent to which decisions on policies and resources for health systems are taking place at global level. Beyond the health sector, global level negotiations on trade, investment, migration and climate have significant impacts on health. Foreign policy has traditionally concerned itself with economic and security issues. Health has been brought to foreign policy when epidemics have threatened trade or economic expansion, or as a way to generate positive relations between countries. Health diplomacy in colonial Africa did both, preventing disease from affecting colonial economic interests and providing medical services to legitimize colonial expansion.

Health has in recent decades assumed a higher profile as a goal of foreign policy at the global level, such as in the negotiation of global responses to treatment rights for people living with HIV, or the negotiation of competing interests around recruitment and migration of health workers. Political attention to health in global policy became more intense and sustained after 2000, with many new global conventions, funds and institutions. This raises twin challenges for African actors in global health diplomacy (GHD), to ensure that the norms and goals of public health are not lost in the differing norms and goals of foreign policy, and to ensure that African interests are advanced and protected within global processes.

With its high share of global mortality and illness, the stakes are high for Africa. Hence, for example, in the context of an HIV pandemic that was ravaging the continent, African countries played a lead role in negotiating the 2001 Doha declaration on the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) and Public Health, which provided for WTO Members’ right to protect public health and access to medicines for all. Africans also provoked the global negotiation on the recruitment of health workers, given that African health systems were losing millions of dollars invested in training of health workers and losing key people for service delivery. Raising such issues at the global level takes diplomacy beyond negotiating economic self-interest, and raises shared risk, and shared responsibility as a basis for collaboration across borders. While this presents new opportunities for addressing Africa’s health challenges, global solidarity is not a dominant feature of diplomacy, and health demands may be diluted or overshadowed in foreign policy processes as states secure their interests in response to financial, climate, resource, food and other threats to security. The transborder nature of GHD also raises caution in the public health community as it may disguise a more direct and influential hand of private interests, including in global health institutions.

New actors are also becoming increasingly influential in global diplomacy. Brazil, China and India, each facing their own health challenges, have become more engaged and influential in GHD, and south-south cooperation has opened up new avenues of influence, including for African countries. Countries in the ‘global south’ bring new perspective to global health: For example China’s principles of peaceful coexistence avoids interference or conditionality in the relations between states, with foreign policy used to widen its access to resources and markets and to speed up its own modernisation. Brazil’s pursuit of ‘structural cooperation in health’ in contrast brings a rights based approach to health, raising the precedence of health in global economic and trade platforms, such as in its negotiations on patents, counterfeits and technology transfer. We discuss other examples of approaches to diplomacy in EQUINET discussion paper 96 ‘Concepts in and perspectives on global health diplomacy’.

This raises the question: Are there uniquely African perspectives or approaches in GHD? This is not easy to answer by reading published materials- much diplomacy on health in Africa appears to be unrecorded in the public domain, or documented by northern or global actors. Across African countries, there is evidence of some principles more commonly informing foreign policy. Reciprocity and interdependence is rooted in traditional norms that give more weight to the interests of the community than those of the individual (‘I am because we are’). These principles informed the unity around struggles for national independence and Africans have continued to build unity in global engagement through alliances across sovereign states, such as in the Africa Group at the World Health Assembly. Liberation and nation building have also been central to recent African history. This ‘liberation ethic’ has continued to inform diplomacy post-independence, from the shared stance against apartheid South Africa to a foreign policy engagement on economic decolonization. As a form of public diplomacy, this foreign policy image has also been used to bolster domestic legitimacy. Many African countries are also explicitly pursuing developmental foreign policies, raising economic justice and seeking to protect the authorities needed for developmental states within international policy, albeit with some diversity of view on what a developmental foreign policy means.

How far have these approaches influenced global diplomacy on health, a sphere that has been more commonly associated with emergency relief and development aid? Africans are increasingly involved in GHD, and initiatives such as the ECSA Health Community Strategic Initiative on GHD seek to strengthen African engagement and influence in global health platforms. There is evidence from examples such as the 2001 Doha declaration, the claims on health worker migration or recent negotiations on technology transfer or on research and development that the liberation ethic, unity and developmental foreign policy are informing diplomacy on health. It is however difficult to read how far these principles are being actively crafted for the 21st century and used for health. For example, how do principles of sovereignty, non-interference and self determination that have been central to nation building accommodate the human rights approaches or concepts of shared risk and shared responsibility that are being used to raise health as a goal of global diplomacy? How effectively are newly emergent south-south alliances, such as BRICS, strengthening the unity (and regional integration) within African countries that is seen to be key to global engagement? What co-ordination across sectors and institutional changes need to take place within African countries to strengthen their hand in advancing a liberation ethic and developmental foreign policy in health negotiations at global level?

Further information on the issues raised in this editorial can be found in EQUINET Discussion paper 96 at http://www.equinetafrica.org/bibl/docs/GHD%20concept%20paper%20Jan2013.pdf. The discussion paper is an interim working paper to draw feedback and EQUINET invites you to send your comments on African approaches to health diplomacy to include in the next edition. Please email your comments and inputs on the questions raised to admin@equinetafrica.org.

2. Latest Equinet Updates

EQUINET Discussion Paper 96: Concepts in and perspectives on global health diplomacy
Loewenson R, Modisenyane M And Pearcey M: EQUINET, January 2013

The Regional Network for Equity in Health in East and Southern Africa (EQUINET) is implementing a three year policy research programme to address selected challenges to health and strengthening health systems within processes of global health diplomacy (GHD). In the June 2012 inception workshop for the programme, delegates called for a paper that explains the concepts and emergence of global health diplomacy, the different approaches being taken in GHD, including African approaches. Given the de facto rise in health diplomacy, this paper explores questions on GHD, to inform debate and dialogue in Africa on raising health within global diplomacy. The authors briefly present the roots and emergence of GHD, and the debates on raising public health within global diplomacy. They outline how the concepts of and approaches to GHD differ across countries and regions. They explore the perspectives that have informed diplomacy in Africa, and ask what this means for African engagement in GHD, and for public health in Africa. At various points in this paper they raise questions on what implications the developments described have for health diplomacy in Africa. Given the limitations of documented evidence on African approaches or analysis of health diplomacy from an African lens, it is difficult to draw conclusions. The authors thus raise questions that they hope will provoke dialogue, debate and response.

Policy Brief 32: Financing universal coverage in east and Southern Africa
Health Economics Unit in EQUINET with ECSA Health Community: April 2013

Financing universal health coverage (UHC) is not only about how to generate funds for health services. It is also about how these funds are pooled and used to purchase services. This policy brief explores options for financing UHC in East and Southern Africa (ESA). It presents learning from countries that have made progress towards UHC, including the need to increase domestic funding and to use mandatory pre-payment (tax and other government revenue, possibly supplemented by mandatory health insurance contributions) as the main mechanism for funding health services. The brief indicates the problems associated with introducing or expanding health insurance to fund UHC. With tax funding often the most equitable and efficient option, there is scope for increasing government revenue and health expenditure in many ESA countries.

3. Equity in Health

Health in the post-2015 agenda: Report of the Global Thematic Consultation on Health
World Health Organisation, UNICEF, Government of Sweden, Government of Botswana and United Nations: April 2013

This report is a synthesis of inputs received during the Global Thematic Consultation on Health, which concluded on 6th March 2013 in Gaborone, Botswana. It highlights lessons learned from the Millennium Development Goals (MDGs), health in the post-2015 agenda, health priorities for 2015-2030, and how to frame the future health agenda in terms of principles, goals, targets and indicators. Participants suggested an overall health development goal: “Maximising health at all stages of life,” and proposed two health sector goals: accelerating progress on the health MDGs and reducing the burden of major non-communicable diseases (NCDs). They also suggested that the post-2015 framework should include more ambitious health targets; emphasise equity; address reproductive health and sexual rights; include differentiated targets and indicators for various life stages; and appreciate the interconnections between health and other goals, while addressing macroeconomic issues that impact on health, inequality and poverty. Further, participants argued that universal health access might be a preferable formulation – and vision – to universal health coverage.

Post-2015: framing a new approach to sustainable development
Independent Research Forum on a Post-2015 Sustainable Development Agenda: March 2013

This briefing note offers principles and approaches for integrating economic, social and environmental sustainability and equity in a new post-2015 development agenda. It offers guidance on how development processes can help create a foundation for human wellbeing based on economic progress, equitable prosperity and opportunity, a healthy and productive environment and participatory governance. The Independent Research Forum argues that sustainable development can only be achieved when these dimensions of development are all present and mutually reinforcing. But first, eight shifts will be essential: from ‘development assistance’ to a universal global compact; from top-down to multi-stakeholder decision-making processes; from economic models that increase inequalities and risks to ones that reduce them; from business models based on shareholder value to those based on stakeholder value; from meeting ‘easy’ development targets to tackling systemic barriers to progress; from damage control to investing in resilience; from concepts and testing to scaled up interventions; and from multiple discrete actions to cross-scale coordination.

4. Values, Policies and Rights

Ensuring access to essential medicines through the inclusion of the right to health in the Mauritian Constitution
Budoo A: AfricLaw, 5 March 2013

Mauritius is signatory to the 2001 Doha Declaration, which ensures that government can access generic medicines for use in the public sector and without the patent holder’s approval and is an important tool to ensure universal access to medicines. Although the state has been compliant with the Doha Declaration, the Constitution of Mauritius has no provisions for the protection of the right to health. Furthermore, the National Human Rights Commission has no specific mandate to deal with economic, social and cultural rights and there is no National Medicines Policy document. The author calls on government to give effect to the recommendation of the CESCR and bring about a constitutional amendment that will include economic, social and cultural rights in the Constitution thus making the right to health justiciable. After including the right to health in the Constitution, the government should adopt a new legislation to protect the right to health of all the citizens and enshrine access to medicines as a component of the right to health. To avoid any foreseeable problem, the use of generic medicines should be included in the act and there should be a clear demarcation between generic drugs and counterfeiting so that it does not limit the access to medicines of Mauritians.

Prevalence and correlates of being bullied among in-school adolescents in Malawi: results from the 2009 Global School-Based Health Survey
Kubwalo HW, Muula AS, Siziya S, Pasupulati S and Rudatsikira E: Malawi Medical Journal 25(1): 12-14, 2013

This study was conducted to estimate the prevalence of self-reported bullying and its personal and social correlates through a secondary analysis of the 2009 Malawi School-Based Student Health Survey. A total of 2,264 in-school adolescents participated. Just under half (44.5%) reported having been bullied in the previous month to the survey (44.1% among boys versus 44.9% among girls). Compared to adolescents of age 16 years or older, those who were 12 years old or younger and those who were 14 years of age were more likely to be bullied. The other risk factors that were identified in the analysis were loneliness and being worried. Adolescents who had no close friends were 14% more likely to be reporting bullied compared to adolescents who reported having close friends. Adolescents who smoked cigarettes were more than three times more likely to reporting be bullied compared to non-smokers, while those who drank alcohol were more than twice as likely to be bullied as adolescents who did not take alcohol. Health workers caring for adolescents should be sensitised to the frequent occurrence of bullying and to its correlates and consequences.

5. Health equity in economic and trade policies

'BRICS without straw'? A systematic literature review of newly emerging economies' influence in global health
Harmer A, Xiao Y, Missoni E and Tediosi F: Globalization and Health 9(15), 15 April 2013

What influence, if any, do the BRICS (Brazil, India, Russia, China and South Africa) wield in global health, and, if they do wield influence, how has that influence been conceptualised and recorded in the literature? To answer these questions, researchers conducted a systematic international literature review, finding 887 documents, of which only seven met inclusion criteria and only one provided sustained analysis of the BRICS’ collective influence; the overwhelming tendency was to describe individual BRICS countries’ influence. Although influence was predominantly framed by BRICS countries’ material capability, there were examples of institutional and ideological influence, particularly from Brazil. Individual BRICS countries were primarily ‘opportunity seekers’ and regional mobilisers but with potential to become ‘issue leaders’ and regional organisers. Whilst it may still be too early for newly emerging economies in global health to have matured, the authors argue that there is scope to further develop the concept of influence in global health and to better understand the working of groups of countries such as BRICS. The BRICS have made a number of important commitments towards reforming global health, but they need to start putting those collective commitments into action, the authors conclude.

A call for more equitable economies and some ideas on how to get them
Chang C: CAFOD, April 2013

What can we do collectively to tackle inequality? The author of this article argues that first we need to ensure that governments are providing proper support to the livelihoods of poor men and women. At present, governments are a very long way from knowing if the money that they are spending on economic development is having an impact on poor entrepreneurs. Second, we need to ensure that the rules of the game governing our economies are not stacked against the poorest, resulting in distorted and unfair markets. These issues need to be addressed collectively by governments and included in an international setting. For example, taxing companies that operate across borders requires governments in different tax jurisdictions to cooperate. However, on these difficult, structural issues, promising first steps have been made. George Osborne led the call for a crack-down on tax-dodging multinationals at a G20 meeting last month, while in 2012 governments agreed to rethink investment rules at a United Nations conference in Doha.

BRICS and the SA government sell out to international capital
Bond P: Pambazuka News 622, 20 March 2013

According to this article, the BRICS Durban summit in March 2013 marks the point at which the five BRICS powers have carved up the African continent with one common objective: efficient resource extraction through export-oriented infrastructure. The new ‘BRICS Bank’ has cost US$50 billion in start-up capital and comes nine months after $75 billion was wasted by the BRICS powers by bailing out the International Monetary Fund in a manner that shrunk both Africa’s voting share and prospects for world economic recovery. BRICS countries aimed to set up a ‘Bank of the South’. This was dreamt of by the late Hugo Chavez although repeatedly sabotaged by more conservative Brasilia bureaucrats and opposed by Pretoria. the author asks, however, whether this will be any different than Washington’s twin banks? He argues that it will not, if one considers South Africa’s precedent, the Development Bank of Southern Africa (DBSA), which lost R370 million ($41 million) in 2012, promoted privatisation of water and toll roads, and turned a blind eye to construction industry collusion. The author warns that Africa could become an even more violent battleground for conflicts between BRICS firms intent on oil, gas and minerals extraction.

How to overcome the EPA stalemate?
Dieye CT: Bridges Africa Review 2(1): 18 March 2013

In this article, the author considers why the Economic Partnership Agreement (EPA) negotiations between the European Union (EU) and the African, Caribbean and Pacific (ACP) countries have reached a ‘technical’ stalemate. He proposes three reasons: the configuration of the regions and the great difficulty of states to agree on common interests; the sometimes aggressive nature of European demands; and the evolution of the Europe-Africa partnership in the context of global geopolitical changes. Least-developed countries in Africa already enjoy a number of trade-related flexibilities and advantages and stand nothing to gain from the EPAs, which may explain their reluctance to sign the agreements, the author argues. At the same time, major trading powers are engaged in a low-level trade war aimed at implanting themselves in Africa or consolidating positions they have already acquired. Africa may have understood that such a development could be beneficial provided that it puts into place good policies and strategies, and develops appropriate partnerships. In addition, the emergence of Southern trading powers has widened Africa’s policy space. This could explain the continent’s cautious approach to the trade liberalisation required by the EPAs. The author concludes that the solutions that could unblock the stalemate are no longer technical but political in nature.

Letter to the Uganda Minister of Justice on the revision of the IP bill
CEHURD, HEPS Uganda, SEATINI, People’s Health Movement et al: 22 March 2013

In this open letter to the Minister of Justice, Ugandan civil society organisations (CSOs) working in areas of intellectual property (IP) and access to medicines argue that the country’s intellectual property (IP) Bill does not make full and maximum use of the TRIPS flexibilities and therefore poses a threat to public health. Almost 90% of drugs in Uganda are imports, most of which are generic versions that need protection from patent owners who may want to stop their sale in a bid to sell their expensive brand name drugs instead; this would be a disadvantage to Ugandans as they will not be able to access cheap drugs. The CSOs call on government to reaffirm its 2001 Doha commitment to ensure that the TRIPS Agreement does not and should not prevent World Trade Organisation members like Uganda from taking measures to protect public health. The Industrial Properties Bill should take maximum advantage of the flexibilities detailed under the TRIPS Agreement and as provided by the Doha Declaration.

Publication and invitation to comment on the Draft Protection of Traditional Knowledge Bill
James WG: March 2013

An alternative South African bill on the protection of traditional knowledge (TK) has been published in the official Government Gazette that would create a new system of intellectual property right specific to TK. The Wilmot Bill aims to provide adequate, financially viable, legally enforceable protection for traditional knowledge (TK) that will provide sui generis protection for TK, comply with South Africa’s international obligations, give effect to the principles for the protection of indigenous knowledge advocated by the World Intellectual Property Organisation, safeguard South Africa’s existing IP statutes from irreparable harm, and establish a more sophisticated system for the protection of traditional knowledge in South Africa. The Stellenbosch Chair of Intellectual Property (CIP) is asking for support in their call on the government to reject the old TK Bill, open the matter for public comment from all traditional communities and support the Wilmot Bill. If the current TK bill is to become law, CIP argues that South Africa will face numerous financial, legal and practical difficulties and it further condemns the dismissive attitude of the Portfolio Committee on Trade and Industry toward legitimate concerns of the public.

6. Poverty and health

Access to Land is Critical for the Poor
World Bank Group: 8 April 2013

At the Annual World Bank Conference on Land and Poverty convened in early April 2013 in Washington, DC, the World Bank Group issued this statement. In the light of land grabs by multinationals that displace smallholder farmers, the Group argues that modern, efficient and transparent policies on land rights are vital to reducing poverty and promoting growth, agriculture production, better nutrition and sustainable development. It supports and endorses the Voluntary Guidelines on the Responsible Governance of Tenure of Land, Fisheries and Forests in the Context of National Food Security (the VGs). These guidelines are a major international instrument to inform specific policy reforms, and inform Bank procedures and guidance to clients. The World Bank Group is already working with countries to implement the VGs, with a special focus on Africa. With its partners, it has also developed the Land Governance Assessment Framework (LGAF) as a diagnostic tool to assess the status of land governance at the country level. LGAF assessments have been carried out - or are underway - in 18 countries, 10 of them in Africa.

Building from the ground up: How the foundations of a post-2015 framework should translate into change for people in poverty
Frecheville N and Fischler B: CAFOD, 2013

In this paper, the authors call for a post-2015 framework to support a vision of the world where poor women and men have dignity and are able to flourish through participating in enabling societies and equitable economies that operate within safe ecological boundaries nationally and globally. The framework will: prioritise global issues that support and facilitate transformational change; keep issues that matter most to people in poverty on the international agenda; secure national action that drives progress on the ground; and enable better accountability, data collection, and monitoring and evaluation. CAFOD has identified three areas for action: empowering governance, which enables people to participate in the decision-making which affects their lives; the need for poor women and men to be able to participate in equitable economies and get a fair return for their contribution; and, resilient livelihoods, so that people’s dignity and flourishing are not undermined by environmental shocks and stresses, and development pathways are within ecological limits. These have the potential to transform the lives of people in poverty through addressing the underlying causes of poverty that prevent people from achieving their own aspirations.

Building resilient and inclusive food markets: Analysis of trends and actors in food and nutrition security
Quak E: The Broker Online 17 April 2013

To achieve maximum impact on food and nutrition security, knowledge and research policy should focus on local agriculture and food sectors - this means including small-scale farmers in regional food chains as well as making investments in the food system work for the rural poor by taking into account local environmental and cultural values. This article focuses on what a knowledge agenda on food and nutrition security should look like and what actors should be involved. The author argues that one of the main causes of current economic growth without food security is that small-scale farmers are not included in the formal food system and do not benefit from investments in agriculture and food, especially in sub-Saharan African. They also lack access to knowledge to improve their situation. To help create resilient and inclusive food markets, the author recommends strengthening cooperatives and producer organisations, developing comprehensive business models, designing a framework for public-private partnerships that include small-scale farmers and takes into account local cultural and environmental values, taking away the constraints to access knowledge by farmers, and pursuing coherent policies.

Community concepts of poverty: an application to premium exemptions in Ghana’s National Health Insurance Scheme
Aryeetey GC, Jehu-Appiah C, Kotoh AM, Spaan E, Arhinful DK, Baltussen R, van der Geest S and Agyepong IA: Globalization and Health 9(12), 14 March 2013

In 2009, researchers in Ghana commenced a study to explored the social and relativist dimension of poverty in five communities in the South of Ghana with differing socio-economic characteristics. This research was meant to inform the development and implementation of policies and programmes to identify and target the poor for premium exemptions under Ghana’s National Health Insurance Scheme (NHIS). They employed participatory wealth ranking (PWR) as a qualitative tool for the exploration of community concepts, identification and ranking of households into socio-economic groups. Key informants within the community ranked households into wealth categories after discussing in detail concepts and indicators of poverty. Results showed that community-defined indicators of poverty covered themes related to type of employment, educational attainment of children, food availability, physical appearance, housing conditions, asset ownership, health seeking behaviour, social exclusion and marginalisation. In conclusion, the in-depth nature of the PWR process precludes it from being used in a large national-scale programme such as the NHIS. However, the authors argue that it can provide valuable qualitative input to inform policy and programmes exempting health payments for poor people.

From local to global: prioritising food security
Quak E: The Broker Online 17 April 2013

To feed the world’s growing population in a sustainable and inclusive way with good quality food is one of the main challenges facing the world in the 21st Century. The author of this article argues that the solution lies partly at the local level: the livelihoods, and the cultural, socioeconomic and environmental circumstances in which food is produced, processed and distributed. This means that the debate around food security should move to the local level and how small-scale farmers can be part of (formal) food markets, mainly regionally, in a sustainable way. Building resilient and inclusive local food markets also requires policies that take the macro-level players into account, that link the local to the global. More comprehensive knowledge and research into food security is needed, and the role of civil society and local governments should also be studied. This implies participation and a bottom-up approach. Currently, investments in food security are mainly channelled through national policies and centralised negotiations; however, these decisions should be made within a participatory local democracy.

Nutrition status and associated factors among children in public primary schools in Dagoretti, Nairobi, Kenya
Mwaniki EW and Makokha AN: African Health Sciences 13(1): 39-46, March 2013

Interventions for school age children can supplement efforts to reduce levels of stunting in the preschool years. In this study, researchers aimed to assess the nutrition status and associated risk factors of children in selected public primary schools in Dagoretti Division, Nairobi. They randomly selected 208 students aged 4-11years of both gender from four public primary schools in Dagoretti Division. Data was collected from school registers and directly questioning the students, parents /guardians. Among the children surveyed, 24.5% were stunted, 14.9% underweight and 9.7% were wasted. There were more boys than girls who were stunted. Breakfast contributed 10.2% of the daily energy intake. Few children consumed foods from more than four food groups. Incidence of diarrhoea, colds/coughs increased the risk of stunting and underweight. Overall, the most important predictors of malnutrition were consumption of food that is inadequate in required calories and from less than four varieties of food groups.

7. Equitable health services

Current integration of tuberculosis (TB) and HIV services in South Africa, 2011
Chehab JC, Vilakazi-Nhlapo AK, Vranken P, Peters A and Klausner JD: PLoS One 8(3), 4 March 2013

The objective of this study was to assess the current integration of TB and HIV services in South Africa, using data from 2011. Forty-nine randomly selected health facilities were included, at which interviewers administered a standardised questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to TB clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centres.

Malaria control aimed at the entire population in KwaZulu-Natal negates the need for policies to prevent malaria in pregnancy
Tsoka-Gwegweni JM and Kleinschmidt I: South African Medical Journal 103(3), March 2013

South Africa has no policy to prevent malaria in pregnancy, despite the adverse effects of the disease in pregnancy. However, malaria control measures consisting of indoor residual spraying and specific antimalarial treatment have been in place since the 1970s. This study was conducted to determine if the country needs a specific policy for malaria prevention in pregnancy, by determining the burden of malaria in pregnancy in KwaZulu-Natal (KZN) province, South Africa. Pregnant women were enrolled at their first antenatal care visit to three health facilities in Umkhanyakude health district in northern KZN during May 2004-September 2005 and followed up until delivery. Of the 1,406 study participants, 33.2% of the women were anaemic, but this was not related to malaria. The prevalence and incidence of malaria were very low, and low birth weight was only weakly associated with malaria (1:10). In conclusion, the low burden of malaria in these pregnant women suggests that they have benefited from malaria control strategies in the study area. The implication is that additional measures specific for malaria prevention in pregnancy are not required. However, ongoing monitoring is needed to ensure that malaria prevalence remains low.

Measles vaccination coverage in high-incidence areas of the Western Cape, following the mass vaccination campaign
Bernhardt GL, Cameron NA, Willems B, Boulle A and Coetzee D: South African Medical Journal 103(3), March 2013

This community survey was conducted in measles high-incidence areas in the Western Cape, South Africa, to assess measles vaccination coverage attained by routine and campaign services among children aged 6 months to 59 months at the time of a mass campaign in the areas. Of 8,332 households visited, there was no response at 3,435 (41.2%); 95.1% of eligible households participated; and 91.2% of children received a campaign vaccination. Before the campaign, 33% of 917-month-olds had not received a measles vaccination, and this was reduced to 4.5% after the campaign. Of a total of 1,587 children, 61.5% were estimated to have measles immunity before the campaign, and this increased to 94% after the campaign. It appears that routine services had failed to achieve adequate herd immunity in areas with suspected highly mobile populations. This study shows that mass campaigns in such areas in the Western Cape significantly increased coverage. The authors conclude that extra vigilance is required to monitor and sustain adequate coverage in these areas.

Netting barriers to prevent mosquito entry into houses in southern Mozambique: a pilot study
Kampango A, Bragança M, Sousa B and Charlwood JD: Malaria Journal 12(99), 16 March 2013

This pilot study was conducted to investigate the protective effect of three types of Mosquito netting material against the entry of malarial mosquitoes into village houses in Mozambique. A two-step intervention was implemented in which the gable ends of houses (the largest opening) were covered with one of three materials (four year old mosquito bed nets; locally purchased untreated shade cloth or deltamethrin-impregnated shade cloth) followed by covering both gable ends and eaves with material. Mosquito entry rates were assessed by light-trap collection and the efficacy of the different materials was determined. Results showed that houses treated with mosquito netting or the untreated shade cloth had 61.3% and 70% fewer Anostopheles. funestus in relation to untreated houses, but there was no difference in An. funestus in houses treated with the deltamethrin-impregnated shade cloth compared to untreated houses. Houses treated with mosquito netting reduced entry rates of An. gambiae by 84%, whilst untreated shade cloth reduced entry rates by 69% and entry rates were reduced by 76% in houses fitted with deltamethrin-impregnated shade cloth.

Physical activity and health promotion strategies among physiotherapists in Rwanda
Frantz JM and Ngambare R: African Health Sciences 13 (1): 17-23, March 2013

In this study from Rwanda, researchers aimed to establish the relationship between physical activity levels of physiotherapists and their physical activity promotion strategies. They drew data from 92 self-administered questionnaires and a focus group discussion of 10 purposively selected physiotherapists. The findings revealed that 64% of the participants were physically active both within the work and recreation domains and 65% of the participants had good physical activity promoting practices. Discussing physical activity and giving out information regarding physical activity were most common methods used in promotion of physical activity. Policies on physical activity, cultural influence, and nature of work, time management as well as the environment were the barriers highlighted. In conclusion, although physiotherapists experience barriers to promoting physical activity, they have good physical activity promoting practices.

Psychological distress among adults admitted to medical and surgical wards of a Regional Referral Hospital, Uganda
Rukundo ZG, Nakasujja N and Musisi S: African Health Sciences 13(1): 82-86, March 2013

Little is known about psychological distress of patients on general wards in developing countries. This study aimed to determine the extent and associations of psychological distress among adult in-patients on medical and surgical wards of Mbarara hospital in Uganda. Researchers conducted a cross-sectional descriptive study among 258 adult in-patients. They used the WHO endorsed self report questionnaire (SRQ-25) to assess psychological distress with a cut off of 5/6, as well as the MINI International Neuropsychiatric Interview (MINI) to identify specific psychiatric disorders. Results indicated that 158 individuals (61%) had psychological distress. One hundred and nine (42%) met criteria for at least one major psychiatric diagnosis. Only 6% of these were recognised by the attending health workers. Psychological distress was significantly associated with previous hospitalisations, ward of admission and marital status. The authors conclude that despite high levels of psychological distress among the physically ill, it is often unrecognised and untreated.

Risks and Challenges in Medical Tourism: Understanding the Global Market for Health Services
Hodges JR, Kimball AM and Turner L: Praeger, July 2012

This book provides an in-depth, comprehensive assessment of the benefits and risks when health care becomes a global commodity. The collection includes contributions from leading scholars in law and public policy, medicine and public health, bioethics, anthropology, health geography, and economics. Contributors examine how government agencies, medical tourism companies, international hospital chains, and other organisations promote medical tourism and the globalisation of health care. The topics explored include the legal remedies available to medical tourists when procedures go awry; potential consequences when patients cross borders for medical procedures that are illegal in their home countries; the relationship of medical tourism to international spread of infectious disease; and the lack of adequate transnational policies and regulations governing the global market for health services.

The politics of delivery: Our findings so far
Foresti M, O’Neil T and Wild L: Overseas Development Institute, April 2013

Based on research in education, health, water and sanitation, the authors of this paper sought to identify how politics and governance can constrain or enable equitable and efficient service delivery in developing countries, including Malawi, Rwanda and Uganda. Some of these constraints reflect the nature of the wider governance system, and may have similar effects across sectors, for example in how financial resources are used or how human resources are allocated. The authors’ focus was on the interactions at regional, district and community level between local government officials, service providers and users – the ‘missing middle’ of the service delivery chain. Their analysis of four aid programmes suggests that aid-funded activities can facilitate government efforts to address governance constraints in public service delivery. However, it also indicates that the way in which programmes are designed and implemented matters to whether they are able to gain domestic traction and support institutional change. The authors advocate for ‘arm’s length’ aid models, which work through organisations that offer advisory services directly to governments and other public bodies in developing countries and have had some success as brokers of collective action and facilitators of change.

Wits launches Institute for Malaria
Health-e News: 18 March 2013

The University of the Witwatersrand in South Africa has announced the formation of the Wits Research Institute for Malaria, (WRIM), strengthening research into one of Africa’s deadliest diseases. The Institute combines three existing research groups from the School of Public Health who are working on malaria vectors, parasites and pharmacology. Africa has very few research institutes that have the capacity to address a host of issues and make an impact on the disease. The WRIM aims to produce leading research and researchers to benefit malaria control in Africa.

8. Human Resources

Effect of brief training on reliability and applicability of Global Assessment of functioning scale by Psychiatric clinical officers in Uganda
Abbo C, Okello ES and Nakku J: African Health Sciences 13(1): 78-81, March 2013

The Global Assessment of Functioning (GAF) is the standard method and an essential tool for representing a clinician’s judgment of a patient’s overall level of psychological, social and occupational functioning. It is probably the single most widely used method for assessing impairment among the patients with psychiatric illnesses. The authors of this study set out to assess the effects of one-hour training on application of the GAF by Psychiatric Clinical Officers’ in a Ugandan setting. They randomly selected five psychiatrists and five psychiatric clinical officers (PCOs) or assistant medical officers who hold a two-year diploma in clinical psychiatry to take part. Before receiving an hour of training on how to rate the GAF scale, they were asked to rate a video-recorded psychiatric interview, and they assessed the video again after training. The PCOs were then offered and asked to rate the video case interview again. Results showed that the interclass correlations (ICCs) between the psychiatrists and the PCOs before training in the past one year, at admission and current functioning were +0.48, +0.51 and +0.59 respectively. After training, the ICC coefficients were +0.60, +0.82 and +0.83. The findings of this study indicate that brief training given to PCOs improved the applications of their ratings of GAF scale to acceptable levels. There is need for formal training to this cadre of psychiatric practitioners in the use of the GAF.

Motivation and job satisfaction of Health Surveillance Assistants in Mwanza, Malawi: an explorative study
Kok MC and Muula S: Malawi Medical Journal 25(1): 5-11, 2013

This qualitative assessment was undertaken to identify factors that influence motivation and job satisfaction of health surveillance assistants (HSAs) in Mwanza district, Malawi, in order to inform development of strategies to influence staff motivation for better performance. Seven key informant interviews, six focus group discussions with HSAs and one group discussion with HSAs supervisors were conducted in 2009. Data were supplemented by a district wide survey involving 410 households, which included views of the community on HSAs performance. The main satisfiers identified were team spirit and coordination, the type of work to be performed by an HSA and the fact that an HSA works in the local environment. Dissatisfiers were low salary and position, poor access to training, heavy workload and extensive job description, low recognition, lack of supervision, communication and transport. Managers and had a negative opinion of HSA perfomance, while the community was much more positive: 72.9% of all respondents had a positive view on the performance of their HSA. Activities associated with worker appreciation, such as performance management were not optimally implemented. The district level can launch different measures to improve HSAs motivation, including human resource management and other measures relating to coordination of and support to the work of HSAs.

Rwanda’s revolutionary prescription for health
Paulson T: Humanosphere, 26 March 2013

Rwanda is widely celebrated for having demonstrated that major improvements in health can be achieved in a poor country, at relatively low cost per capita, by good strategy, innovation and focusing on the best value for money. Rwandan health officials have installed well-trained, compensated health workers into every community to make sure that community members get to access the primary health care services they need, including routine prenatal care, immunisation and malaria diagnosis – early treatment significantly reduces health costs. The authors argue that the lesson learned from Rwanda’s success in health is that the country’s 45,000 community health workers (CHWs) are not viewed as complementary components to the public health system, but central to it.

Strategic Plan for Nursing Education, Training and Practice 2012/13 – 2016/17
Ministry of Health, South Africa: March 2013

South Africa launched its National Strategic Plan for Nurse Education, Training and Practice for 2012/13 - 2016/17 in March 2013. The plan aims to revitalise the ailing public health sector. According to the plan, nursing colleges will be declared higher education institutions in compliance with the provisions of the Higher Education Act (as amended in 2008). This will help to address provincial inequalities, norms and standards, quality, decrease fragmentation, eliminate fly-by-night nursing education institutions (NEIs), improve clinical training and enhance social accountability. Nursing students will also have the status of full students (rather than employees) while undergoing training. They should receive funding support paid monthly for tuition books and study materials, as well as living costs, medical aid and indemnity insurance, while tuition fees should be paid directly to the NEIs. The plan also addresses the need to emphasise modules that focus on caring, and these should be compulsory at all levels of nursing and midwifery. This should help address the issue of compassion in the profession. The plan also significantly proposes that an office for the chief nursing officer be established, which will then take responsibility for the implementation of the strategy over the next five years.

9. Public-Private Mix

A literature review: the role of the private sector in the production of nurses in India, Kenya, South Africa and Thailand
Reynolds J, Wisaijohn T, Pudpong N, Watthayu N, Dalliston A, Suphanchaimat R et al: Human Resources for Health 11(14), 12 April 2013

This scoping systematic review was undertaken to assess the evidence for the role of private sector involvement in the production of nurses in India, Kenya, South Africa, and Thailand. The authors performed an electronic database search and also captured grey literature from the websites of relevant human resources organisations and networks. The review revealed that despite very different ratios of nurses to population ratios and differing degrees of international migration, there was a nursing shortage in all four countries, which were struggling to meet growing demand. All four countries saw the private sector play an increasing role in nurse production. Policy responses varied from modifying regulation and accreditation schemes in Thailand, to easing regulation to speed up nurse production and recruitment in India. There were concerns about the quality of nurses being produced in private institutions. The authors recommend that strategies must be devised to ensure that private nursing graduates serve public health needs of their populations. They call for policy coherence between producing nurses for export and ensuring sufficient supply to meet domestic needs, in particular in under-served areas. Further research is needed to assess the contributions made by the private sector to nurse production and to examine the variance in quality of nurses produced.

Private medical aid membership: What is the impact on health care use and out-of-pocket payments in South Africa?
Health Economics Unit, University of Cape Town: Policy brief, January 2013

This policy brief examines the extent to which private medical scheme membership shields South African members from out-of-pocket payments. This is important for the design of the National Health Insurance system in the country. The Health Economics Unit (HEU) found that medical scheme members have significantly more private health care visits and pay substantial out-of-pocket payments to use health services, in addition to their contributions to the medical schemes. Consequently, there is a need to move away from fee-for-service payments, which often leads to over-servicing, cost escalation, and assessment and regulation of less effective medications and interventions. There is also a need to limit, as much as possible, out-of-pocket payments that adversely affect scheme members and also address the rising contribution rates. A form of insurance that ensures adequate use of health services is needed. Ideally, this should be a form that ensures universal access to health care, for example, the proposed National Health Insurance, the policy brief concludes.

South Africa’s NHI seeks GPs
Health-e News: 18 March 2013

South Africa’s National Department of Health (DoH) has embarked on an initiative to improve and expand access to healthcare services through the contracting of private General Medical Practitioners (GPs) to render sessional service in Primary Healthcare facilities. This initiative is in support of the National Health Insurance (NHl) pilot that aims to improve access to high quality public sector health care services. The initial phase of GP contracting for sessional services will take place in the 10 NHI pilot districts across the country. The DoH embarked on a consultation process started by the Minister of Health in his visits and road shows to the various districts; this was then followed by a letter from the Director-General of Health to GPs to test their levels of interest to participate in this project. Government has advertised for candidates and will soon begin the selection process.

10. Resource allocation and health financing

Comparative analysis of the Busan common standard implementation schedules
Publish What You Fund: 2013

Since committing to a common standard for publishing aid information at the Fourth High Level Forum on Aid Effectiveness at Busan in 2011, 42 governments and external funders have released implementation schedules outlining their plans to meet this commitment. In this short paper, Publish What You Fund analyses the schedules. It notes that some external funders are planning a substantial increase in the quality of their data, but most have failed to commit to publishing timely, comparable and forward-looking information. It appears that some of the most important data are only going to be delivered by a small number of funders, particularly data on results and conditions. This needs to be addressed. A small group of external funders are planning no IATI-compatible publication at all: this paper recommends they should reflect on their Busan commitment to ‘implement a common, open standard for electronic publication of timely, comprehensive and forward-looking information’. Finally, Publish What You Fund says implementation needs to start soon, so that external funders can learn lessons (both from their own experience and that of their peers), and achieve their aim of fully implementing the schedules by the end of 2015.

Moving towards universal coverage in South Africa? Lessons from a voluntary government insurance scheme
Govender V, Chersich MF, Harris B, Alaba O, Ataguba JE, Nxumalo N and Goudge J: Global Health Action 6, 24 January 2013

The authors of this study analysed coverage of the South African government health insurance scheme for civil servants, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. They selected and interviewed 1,329 civil servants from the health and education sectors. Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. The authors argue that achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.

The impact of official development aid on maternal and reproductive health outcomes: A systematic review
Taylor EM, Hayman R, Crawford F, Jeffery P and Smith J: PLoS One 8(2), 22 February 2013

The 2005 Paris Declaration on Aid Effectiveness represented a global commitment to reform aid practices. In this study, researchers conducted a systematic review of the evidence of the impact on maternal-health-related Millennium Development Goal 5 (MDG 5) of official development aid delivered in line with Paris aid effectiveness principles. They compared with this aid delivered in the usual manner. While aid interventions appeared to be associated with small improvements in the MDG indicators, it was not clear whether changes are happening because of the manner in which aid is delivered. The researchers note that existing data do not allow for a meaningful comparison between Paris style and general aid. They identified discernible gaps in the evidence base on aid interventions targeting MDG 5, notably on indicators MDG 5.4 (adolescent birth rate) and 5.6 (unmet need for family planning). The findings of this review point to major gaps in the evidence base and should be used to inform new approaches and methodologies aimed at measuring the impact of official development aid.

11. Equity and HIV/AIDS

A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa
Musheke M, Ntalasha H, Gari S, Mckenzie O, Bond V, Martin-Hilber A and Merten S: BMC Public Health 13:220, 11 March 2013

While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing in sub-Saharan Africa (SSA), systematic reviews to provide a more comprehensive understanding are lacking. In this study, researchers synthesised 42 papers from 13 countries to investigate these factors. They found that predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as ‘opt-out’ provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers’ inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women’s decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing.

Assessment of voluntary counseling and testing service utilisation and associated factors among Debre Markos University Students, North West Ethiopia: a cross-sectional survey in 2011
Tsegay G, Edris M and Meseret S: BMC Public Health 13(243), 19 March 2013

This cross-sectional study design was conducted among 753 students drawn from selected departments in Debre Markos University, Ethiopia, using multi-stage sampling technique. A self-administered questionnaire was used to estimate the prevalence of voluntary counseling and testing (VCT) service utilisation and to assess associated factors. A total of 711 students participated in the study, of whom 81.4% had heard about the government’s confidential VCT service, identifying their major sources of information as mass media (73.3%) and health workers (71.1%). Just over half (58.5%) of the study participants had undergone VCT. The researchers identified the major factors for increased VCT service utilisation as knowledge about the availability of antiretrovirals in the VCT site, information about confidentiality, absence of perceived stigma, higher risk perception and knowledge about HIV. Therefore, they argue, actions targeting on these predictors are necessary to effectively enhance the use of the VCT services utilisation.

Consuming sex: the association between modern goods, lifestyles and sexual behaviour among youth in Madagascar
Stoebenau K, Nair RC, Rambeloson V, Rakotoarison PG, Razafintsalama V and Labonté R: Globalization and Health 9(3), 19 March 2013

The authors of this study examined the association between young people's interests in the consumption of modern goods and their sexual behaviour in Antananarivo and Antsiranana, Madagascar. Their survey included 2, 255 youth ages 15-24. Overall, 7.3% of women and 30.7% of men reported having had multiple partners in the last year; and 5.9% of women reported ever practising transactional sex. This was associated with perceptions concerning the importance of fashion and a series of activities associated with modern lifestyles. For transactional sex, results suggested perceptions around fashion, nightclub attendance and getting to know a foreigner were key determinants. The authors found that peri-urban residence was more associated with transactional sex than urban residence; and ethnic origin was the strongest predictor of both outcomes for women. While they found some evidence of an association between sexual behaviour and interest in modern goods, or modern lifestyles, they caution that such processes did not single-handedly explain risky sexual behaviour among youth: these behaviours were also shaped by culture and conditions of economic uncertainty. These determinants must all be accounted for when developing interventions to reduce risky transactional sex and vulnerability to HIV.

Increasing transfers-out from an antiretroviral treatment service in South Africa: patient characteristics and rates of virological non-suppression
Nglazi MD, Kaplan R, Orrell C, Myer L, Wood R et al:. PLoS One 8(3), 5 March 2013

The aim of this study was to determine the proportion, characteristics and outcomes of patients who transfer-out from an antiretroviral therapy (ART) service in a South African township. Researchers included all patients aged &#8805;15 years who enrolled between September 2002 and December 2009. Follow-up data were censored in December 2010. A total of 4,511 patients received ART during the study period. Overall, 597 (13.2%) transferred out. The probability of transferring out by one year of ART steadily increased from 1.4% in 2002/2004 cohort to 8.9% for the 2009 cohort. Independent risk factors for transfer-out were more recent calendar year of enrolment, younger age (&#8804;25 years) and being ART non-naïve at baseline (i.e., having previously transferred into this clinic from another facility). The proportions of patients transferred out who had a CD4 cell count <200 cells/µL and/or a viral load &#8805;1000 copies/mL were 19% and 20%, respectively. With scale-up of ART over time, an increasing proportion of patients are transferring between ART services and the authors argue that information systems are needed to track patients. Approximately one-fifth of these have viral loads >1000 copies/mL around the time of transfer, suggesting the need for careful adherence counselling and assessment of medication supplies among those planning transfer.

Street children’s vulnerability to HIV and sexually transmitted infections in Malawian cities
Mandalazi P, Banda C and Umar E: Malawi Medical Journal 25(1): 1-4, 2013

The objective for this study was to explore street children’s vulnerability to HIV and STIs infection. Researchers employed In-depth interviews with street children in the two main cities of Malawi, Blantyre and Lilongwe. A total of 23 street children were interviewed. Results of the study strongly suggest that street children could be vulnerable to HIV and other sexually transmitted infections (STIs). This is due to various factors which include low knowledge levels of STIs and HIV, high risk sexual practices, lack of safer place to spend their nights for both boys and girls rendering them vulnerable to sexual abuses and the use of sex as a tool to secure protection and to be accepted especially for the newcomers on the street. This study highlights street children’s vulnerability to sexual exploitation which predisposes them to risk of HIV and AIDS as well as STIs. Furthermore, the street environment offers no protection against such vulnerability. There is need to explore potential and context sensitive strategies that could be used to protect street children from sexual exploitation and HIV and STIs.

12. Governance and participation in health

Civil society in Ghana to contribute to new local governance policy
Ghana Business News: 7 March 2013

Non-governmental organisations and civil society organisations in Ghana are being called upon to contribute to the drafting of the country’s new local governance policy, which is intended at deepening local governance through appropriate social accountability. The new policy will consider the views of ordinary Ghanaians to clarify the status, roles and relationships between levels of government and the different actors and strengthen their participation and contribution to local governance. The Institute of Local Government Studies has received funding from the European Union to implement an action on “A Social Accountability Platform for Local Governance Performance in Ghana” with the objective to provide a harmonised approach to promoting comprehensive and coherent social accountability at the sub-national level.

Community knowledge, attitude and practice about malaria in a low endemic setting of Shewa Robit Town, northeastern Ethiopia
Abate A, Degarege A and Erko B: BMC Public Health 13(312), 8 April 2013

The aim of this study was to assess malaria prevalence and knowledge, attitude and practice (KAP) about malaria in the ShewaRobit Town community in northeastern Ethiopia. In October and November 2011, 425 individuals were examined for malaria using thin and thick Giemsa stained blood film, and 284 of the participants were interviewed to assess their KAP about malaria. All respondents had heard of malaria. Most of the respondents (85.2%) attributed the cause of malaria to mosquito bite. However, some of the respondents (>20%) identified the causes of malaria as a lack of personal hygiene, exposure to cold weather, hunger, chewing maize stalks, body contact with a malaria patient and flies. Sleeping under mosquito nets, draining stagnant water and indoor residual spraying were the most frequently mentioned malaria preventive measures perceived and practiced by the respondents. Of the individuals examined for malaria, only 2.8% were positive for Plasmodium parasites. Although a respondents had a high level of knowledge about the cause, transmission and preventive methods of malaria, a considerable proportion of them had misconceptions about the cause and transmission of malaria, suggesting the necessity of health education to raise the community’s awareness about the disease.

From Better “Stuff” To More “Power”: Why transparency matters
O’Brien P: Oxfam blogs, 21 March 2013

In 2011, Publish What You Fund, the world’s biggest funding transparency monitoring body, ranked USAID in the bottom 36% of most transparent external funders, but by 2012 it had climbed into the top 37% . In the light of this improvement, the author of this article calls on USAID Administrator Raj Shah to commit USAID to joining the top 10% by the time he leaves his post in four years. He predicts, though, that it is more likely that “technological innovation” will continue to win out over “governance” issues like transparency in Shah’s priorities. Poverty, he argues, is a function of power imbalances as much as innovation deficits, which requires USAID’s leadership to start talking about governance, incentives and democratising “power” as much as helping people to get more and better “stuff”. Shah should explain why transparency is so important, and explicitly link transparency to making local institutions more politically accountable to their own citizens. Functioning, inclusive domestic institutions in developing countries are the indispensable foundation for innovations to take hold, the author concludes.

Improving governance in healthcare systems in Africa
Mugo J: Consultancy Africa Intelligence, 17 February 2013

In this paper, the author analyses governance gaps in healthcare systems in sub-Saharan Africa and how they could be overcome, with a particular focus on the areas of budget and resource management, individual provider performance, health facility performance and corruption. She attributes poor governance to the effects of a range of factors. Budget leaks, which refer to the discrepancy between the authorised health budget and the amount of funds received by intended recipients such as frontline providers, undermine service provision, as do high levels of health worker absenteeism. Job purchasing, which refers to payments made by job-seekers in exchange for employment in the public sector, a practice that often bypasses appointing on merit, is another common practice, which results in poor quality staff. On the financial side, chronic underfunding of health facilities and corruption at management levels are the other dimensions of poor governance in the health sector. The author urges governments and external funders to not only focus on the input and outputs, but also to ensure that these resources are used effectively to ensure maximum impact on health outcomes.

South African AIDS Activism and Global Health Politics
Mbali M: Palgrave Macmillan, March 2013

What did South African AIDS activists contribute, politically, to early international advocacy for free HIV medicines for the world's poor? Mandisa Mbali demonstrates that South Africa's Treatment Action Campaign (TAC) gave moral legitimacy to the international movement, which enabled it to effectively push for new models of global health diplomacy and governance. The TAC rapidly acquired moral credibility, she argues, because of its leaders' anti-apartheid political backgrounds, its successful human rights-based litigation and its effective popularisation of AIDS-related science. The country's arresting democratic transition in 1994 enabled South African activists to form transnational alliances. Its new Constitution provided novel opportunities for legal activism, such as the TAC's advocacy against multinational pharmaceutical companies for blocking access to affordable generics and the South African government when it failed to provided antiretrovirals. Mbali's history of the TAC sheds light on its evolution into an influential force for global health justice.

13. Monitoring equity and research policy

Assessing hunger: what do the FAO’s revised undernourishment figures tell us?
Svedberg P: Bridges Africa Review 2(1): 18 March 2013

For the first time since 1996, the United Nations Food and Agriculture Organisation (FAO) has significantly revised how estimates the number of hungry people in the world. When the new methodology is used to generate estimates for the past 20 years, the figures show a steady decline, running counter to previous estimates, which showed a continual increase in the number of undernourished people from the mid-1990s up to the late 2000s. What lies behind the FAO’s revised prevalence of undernourishment estimates are changes in the methodology used to arrive at the estimate and newer, more complete data used for the building blocks of the FAO model. The methodological innovations may be found in the assumed distribution of dietary energy consumption, and the way in which variations in habitual food consumption are estimated. The most important data change is that estimates of food losses at the retail distribution level, not only at the production and storage levels, are taken into account. The FAO is in the process of developing a range of additional food security indicators, intended to reflect changes in ‘determinants of (or inputs to) food security’ and to capture how food prices evolve in relation to consumer prices in general in developing countries.

EDCTP regional networks of excellence: Initial merits for planned clinical trials in Africa
Miiro GM, Oukem-Boyer OOM, Sarr O, Rahmani M, Ntoumi F, Dheda K et al: BMC Public Health 13(258), 22 March 2013

In this study, researchers conducted a quasi-formative evaluation between October and December 2011 on four regional-led African research networks: Central Africa Network on Tuberculosis, HIV/AIDS and Malaria (CANTAM); East African Consortium for Clinical Research (EACCR); West African Network of Excellence for TB, AIDS and Malaria (WANETAM), and the Trials of Excellence for Southern Africa (TESA) launched between 2009 and 2010. They shared a participatory appraisal of field reports, progress reports and presentations from each network to jointly outline the initial experiences of the merits, outputs and lessons learnt. Results showed that the self-regulating democratic networks, with 64 institutions in 21 African countries, have trained over 1, 000 African scientists, upgraded 36 sites for clinical trials, leveraged additional € 24 million and generated 38 peer-reviewed publications through networking and partnerships. The shared initial merits and lessons learnt portray in part the strengthened capacity of these networks for improved research coordination and conduct of planned multi-centre clinical trials in Africa. Increased funding by African agencies, governments and international health partners will ensure sustainability of these networks for research capacity development and demonstrate their commitment to achieving the Millennium Development Goals in Africa.

Forget GDP: The Social Progress Index Measures National Well-Being
Schwartz A: Fast Co-exist, 2013

For many years, economic indicators were considered the ultimate measure of a country’s well-being. But the general happiness of a country doesn’t always correlate with its wealth. In fact, economic indicators don’t match up with a number of important indicators about well-being. Hence the Social Progress Index, an initiative from the Social Progress Imperative and Harvard Business School Professor Michael Porter that examines how 50 countries perform on 52 indicators related to basic human needs, the foundations of well-being, and opportunity. The index looks at social and environmental outcomes directly rather than proxies of economic indicators. These social and environmental components include personal safety, ecosystem sustainability, health and wellness, shelter, sanitation, equity and inclusion, and personal freedom and choice. Each component is calculated based on specific outcomes: health and wellness, for example, is determined by life expectancy, obesity, cancer death rate, and other factors. The author argues that the index will allow businesses to better articulate the purpose they serve, and how business can collectively shape, influence and be a co-collaborator in some of the bigger social progress issues.

Health Research Colloquium Calls On Countries To Invest More In R&D
Hermann RM: Intellectual Property Watch, 9 April 2013

During the March 2013 Council on Health Research for Development (COHRED) Colloquium, participants highlighted the value of research and development in supporting public health in developing countries and the importance of building self-reliance for countries through government investment. Although the meeting was not aiming at consensus, a few key themes emerged. Participants widely agreed that countries should increase their own investments in research for health to attract external funding and ensure fairer collaboration. And in the context of the global economic crisis, participants also took note of an emerging trend among external funders toward implementation research, which looks at how to effectively translate findings into practice, and suggested that governments should do the same. With less funding available, governments increasingly have to justify additional spending on health research, show the value of investment and increase efficiency. Participants called on countries to look at the knowledge and technology interventions they already have, invest in research to examine why they are or not working, and focus on optimising them.

The National Health Care Facilities Baseline Audit: National Summary Report
Health Systems Trust: 2013

From May 2011 to May 2012, with funding from the South Africa’s national Department of Health, an audit of every health facility in the public health sector was conducted by a consortium of partners. The audit assessed infrastructure, classification of facilities, compliance to priority areas of quality and function, human resources, access and range of services offered, and geographic positioning (GPS) for location of facilities and photographs. The overall objective of the audit was to collect baseline data from all public health facilities in the country using standardised and existing measurement tools provided by the national Department of Health. The data collected were captured into the National Core Standards database established by the national Department of Health. Data collected from each of the facilities were aggregated to sub-district, district and national averages that are presented by theme in a variety of dashboards and can be accessed centrally from the web-based reporting database. This national summary report provides a succinct and high level interpretation of the results and summary of the findings of the audit. This information is essential to identify health system strengths and gaps, to assess current and future needs and for planning investments and future services such as the National Health Insurance.

14. Useful Resources

Haki Zetu: ESC Rights in Practice (Part 1)
Amnesty International: 2010

The Haki Zetu handbook is a practical toolkit for local non-governmental organisations (NGOs) and community-based organisations (CBOs) working with local communities to realise their economic, social and cultural rights. The main target group is rural or local activists and development workers who would like to use a rights-based approach to tackle economic and social problems. The handbook can be used immediately on the ground, to help NGO/CBO workers in their jobs to assist communities secure access to economic, social and cultural rights. It will assist them to better study laws and policies and promote citizens to use them and monitor where they are not being used effectively. This is part 1 of the book.

Haki Zetu: ESC Rights in Practice (Part 2)
Amnesty International: 2010

The Haki Zetu handbook is a practical toolkit for local non-governmental organisations (NGOs) and community-based organisations (CBOs) working with local communities to realise their economic, social and cultural rights. The main target group is rural or local activists and development workers who would like to use a rights-based approach to tackle economic and social problems. The handbook can be used immediately on the ground, to help NGO/CBO workers in their jobs to assist communities secure access to economic, social and cultural rights. It will assist them to better study laws and policies and promote citizens to use them and monitor where they are not being used effectively. This is Part 2 of the handbook.

Haki Zetu: The Right to Health
Amnesty International: 2012

The right to the highest attainable standard of health is a fundamental human right. However, millions of people in Africa do not receive adequate health care. Putting the right to health into practice would allow everyone, regardless of who they are or what health problems they have, to be able to receive help and treatment. Better health would also benefit the economy and society as a whole, argues Amnesty International. Non-governmental organisations (NGOs) and civil society organisations (CSOs) can make a significant difference by promoting the right to the highest attainable standard of health. NGOs and CSOs have already encouraged governments to realise the right to health and they should continue to do so by monitoring government policies, calling attention to violations of the right to health and empowering communities to participate in realising their right to health. In conjunction with the main handbook (included in this newsletter), this booklet explains how this can be done. The booklet is divided into three sections: Section 1 gives a brief introduction to the right to health and the main issues facing CSOs working on the right to health; Section 2 gives advice on preparing to work on the right to health; and Section 3 is about realising rights in practice.

Ushahidi Platform: A free, web-based mapping platform

One of the most powerful ways to visualise information is to display it on a map. You can use the Ushahidi Platform for information collection, visualisation and interactive mapping. It is free for you to download and use and is aimed at activists, news organisations and every-day citizens. It provides information mapping tools that allow you to track your reports on the map and over time. You can filter your data by time and then see when things happened and where, as it's also tied to the map. With multiple data streams, the Ushahidi Platform allows you to easily collect information via text messages, email, twitter and web-forms.

15. Jobs and Announcements

Africa Urban Infrastructure Summit
Cape, South Africa: 22- 23 April 2013

The Africa Urban Infrastructure Summit will seek to bridge the information gap in African urban infrastructure and create a platform to develop the market for African urban infrastructure and real estate investment. The aim of the summit is to bring together national and local government officials, urban planners, designers, developers, facility managers and potential investors to share ideas, develop business opportunities and discuss current projects, case-studies, lessons learned, future challenges and new opportunities. Participants will be able to network with other participants and presenters; and discover the opportunities behind key industries: "smart and green" solutions; renewable energy; construction; ICT; water management; sanitation; and healthcare.

Call for abstracts: ECSA Health Community: Seventh Best Practices Forum (BPF)
Deadline: 20 May 2013

The East, Central and Southern Africa (ECSA) Health Community in collaboration with the International Best Practices (IBP) Consortium will host the Seventh Best Practices Forum (BPF), which will precede the 23rd Director’s Joint Consultative Committee (DJCC) Meeting. The two events will be held from 12 to 14 August 2013. The BPF and the DJCC will bring together Senior Officials (who include health experts, health researchers and heads of health training institutions) from Ministries of Health of the ECSA Health Community member states and diverse collaborating partners from the region and beyond. Their aim will be to identify best practices and key policy issues, approaches and making recommendations to strengthen the response to emerging and re-emerging health concerns in the ECSA Region. Individuals and institutions are invited to submit abstracts for presentation of papers under the BPF. The sub-themes are: integration of non-communicable and communicable disease programmes; addressing adolescent health issues; and strengthening global health diplomacy for equity in public health delivery.

Call for abstracts: Ninth Public Health Association of South Africa (PHASA) conference and the inaugural conference of the African Federation of Public Health Associations (AFPHA)
Deadline: 21 May 2013

PHASA and AFPHA are calling for abstracts for their two conferences, which will run jointly in South Africa. Contributors may write on any of the following six themes: leadership for a lasting legacy; social determinants of health; burden of disease, disability and population health; improving the performance of the health system; policy advocacy and community action for health; and public health education, teaching and training.

Call for applications: CODESRIA Institute on Health, Politics and Society in Africa: Dakar, Senegal: 7-25 October 2013
15 June 2013

The theme of the 2013 session of the Institute on Health, Politics and Society in Africa is “Health, Environment and Development in Africa”. The interface between health and the environment is an overriding challenge for development in Africa today. In many African countries, health is often the source of the slow pace of development processes. On the other hand, with their integration in the global market, African economies have become highly dependent on the environment and the exploitation of natural resources, both renewable and non-renewable. But the environment is not only physical; it also takes into account the socio-cultural aspects of the populations living there, in terms of norms, values and social practices which also pose health problems. African Social Science researchers are therefore invited to reflect, taking into account the gender dimension, on the interface between health and the environment, an important issue for the development of the continent. For every session, CODESRIA will appoint a director from the academic and research community to provide intellectual leadership for the Institute, as well as resource persons and laureates. Applications are now open for all three types of positions.

Call for participants in open session on UHC indicators
World Health Organisation: 23 May 2013

To move forward the debate around universal health care (UHC) there is an urgent need to define a way to measure progress towards UHC, both at global and country level. The World Health Organisation (WHO) has been working with the World Bank to define a set of possible indicators that member states can use to monitor their own progress. A subset of these indicators could be used if UHC is accepted as part of the post-2015 development framework. All non-governmental organisations working in the health sector are invited to join the open discussion on how to measure UHC on 23 May at 13.30. Its aim is to open spaces for civil society organisations to feed into the process. Please confirm your participation as soon as possible. If you have any inquiries or need any further information, contact WHO at jeanteta@who.int or the email given below.

Ninth Public Health Association of South Africa (PHASA) conference and the inaugural conference of the African Federation of Public Health Associations (AFPHA): Cape Town, South Africa: 24 -27 September 2013
Early registration ends 30 July; Late registration ends 13 September 2013

These two events will be held jointly in South Africa. The target audience is policy makers, public health academics and students, health professionals, health service managers and individuals from non-governmental and community-based health organisations. The joint conference will have as its focus, a scientific debate and discussion on strategies and action needed to move beyond the MDGs and on the public health legacy that we should leave, or want to, leave behind for the future generation. Speakers will include policy-makers, leading local and international academics and representatives of international organisations, such as the World Health Organisation (WHO) and the World Federation of Public Health Associations. Parallel workshops will precede the main conference, with wide-ranging topics to suit diverse interests.

Postdoctoral Research Fellowships in Health Policy and Systems Research
No closing date

A total of four postdoctoral fellowships are available in the area of Health Policy and Systems Research (HPSR) for the Collaboration for Health Systems and Policy Analysis and Innovation (CHESAI) project, which is based at the School of Public Health and Family Medicine, University of Cape Town (UCT) and the School of Public Health, University of Western Cape (UWC), both in Cape Town, South Africa. The fellowships are for the period 2012-2016. Applicants must have citizenship of a sub-Saharan African country, be an expatriate African, or demonstrate commitment to future work in African health systems. They must have achieved a PhD in the last five years in any suitable field, such as health sciences or social sciences and not have previously held any permanent academic positions. Their work must show clear evidence of robust scholarly performance including a relevant publications record and have some relevant experience, specifically a track record of interest in health policy and systems issues, preferably including research. Applicants will be asked to propose an area of work relevant to one or more of the CHESAI themes, and to show how their past research provides a basis for this proposed work and/or what additional activities are proposed to contribute to the CHESAI community of practice. Please contact Jill Oliver and Thubelihle Mathole at the email address given.

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