EQUINET NEWSLETTER 151 : 01 September 2013

1. Editorial

Health literate populations are the core of effective health systems
Rene Loewenson, Barbara Kaim TARSC, Clara Mbwili Muleya, Adah Zulu Lishandu Lusaka District Health Management Team, Rosette Mutambi, Pelagia Tusiime HEPS Uganda

As she walks away from the clinic Sarah’s back is straight and she has a smile on her face. She has heard confirmation from the nurse that there have been no cases of cholera in her area this year, unlike in previous years, when many died of the disease. She can’t wait to get back to tell the others - “we did it!”

This is not a fiction. It was achieved, for example, in parts of Lusaka district, Zambia, after the joint activities of health literacy facilitators, communities and health workers. At a time of scarce resources and mounting disease we may overlook that our health systems have one of the most critical resources in abundance - people.

The power and ability that people and social groups have to know, act on and direct resources towards promoting health and addressing their health needs are key contributors to health. Health systems that are organised around social participation and empowerment create powerful constituencies to protect and advance public interests in health. Aware and organised communities support early detection of and response to problems and uptake of services, reducing the need for costly treatment of advanced disease. Despite high levels of poverty, East and Southern Africans have high literacy levels and strong social capabilities and social networks that are all assets for health.

But do we effectively tap these assets? We praise the benefits of social participation in health, but do we really practice it? Are there national scale programmes for ensuring that the population is not only literate but ‘health literate’? Do we recognize in law and invest in the capacities and functioning of mechanisms for dialogue and joint planning by health workers and communities as a core part of health systems? Do we ‘lecture’ to and ‘mobilise’ communities, or work in a way that builds on their experience and facilitates their own learning, reflection and collective action?

Studies carried out in the pra4equity network in EQUINET over the last decade suggest that our health systems don’t have strong or sustained investment in these social roles and mechanisms, give limited incentives for health workers to put time into them, have top down planning and weakly address barriers and facilitators to health service uptake and adherence, leading to resource inefficiencies.

Investing in health literacy should, however, be as central to our health systems in the region as supplying medicines or training health workers. Health literacy is a process that empowers people to understand and act on health information to advance their health and improve their health systems. It isn’t only about sharing information, however. Literacy implies functional capacity. Health literacy draws on local experience, encourages reflection on that experience, identifies shared problems, and draws in new information on those problems for community level diagnosis and action on health.

Work on health literacy (HL), co-ordinated through TARSC, has been implemented in the pra4equity network in EQUINET over the past five years. HL addresses the major health issues faced at all stages of life, and includes information on how the health and other sectors are (or should be) organized to address these issues and on social rights and organization. Health literacy was initiated in Zimbabwe, where the Community Working Group on Health now covers nearly half of all districts with the programme. It then spread to Malawi, Botswana, Zambia and Uganda. After pilot work in Uganda in 2011, with Cordaid support, five civil society organisations formed a network co-ordinated by HEPS Uganda to extend health literacy into new areas and communities. Organisations such as the National Forum for People Living with HIV and AIDS (NAFOPHANU) are building health literacy onto work on treatment literacy, with actions taking place on prevention of malaria, typhoid and brucellosis. In Zambia, the Lusaka District Health Office first implemented health literacy in selected communities in the city, building on participatory work strengthening communication between health workers and communities. After realizing the impact the programme had achieved in reducing diseases such as cholera, the Ministry of Health officially adopted the programme for national scale up in 2012.

The work in the past year has highlighted the potentials of scaling up HL and the challenges to be addressed.

HL brings together a wide range of stakeholders, including health workers, community leaders and members, youth and vulnerable groups. This demands facilitation that is sensitive to inequalities in voice and power in these groups. However the discussion and analysis of health problems and their causes across these groups can lead to a deepening understanding of the different experiences and views in communities, and build shared decision making that leads to more inclusive action. CEHURD HL sessions with youth and health workers in Uganda revealed for example a perception amongst students that health workers only interact with students when the school administration wants to identify those who are pregnant for expulsion. Dialogue between health workers and youth in the HL sessions helped to strengthen their mutual relations and opened discussion of ideas from each on how to strengthen youth friendly health services. In Zambia, the HL programme has overcome past suspicions and built communication between communities and health workers, with both working together and with local authorities to clear waste dumps that had grown over years, to improve safe water and sanitation, food hygiene and other public health issues. Healthy environments are often identified as high priority by communities.

From the work in Zambia and Uganda we have seen features of HL programmes that would seem to be essential for any efforts to scale HL to national level. They include national political and technical support; a core of experience and capacities in participatory reflection and action; HL materials that integrate regional good practice with national content; and a co-ordinating group that is able to plan, review and support the horizontal roll out of HL activities, mentor and evaluate the work and share learning. Perhaps the most central feature are young, old, male, female, urban and rural HL facilitators that recognize local knowledge and creativity, are able to use participatory methods to support people to explore, discuss and plan their health actions, and that are evidently passionate about health! The work in Zambia has shown that the best way of scaling up is through a bottom up and horizontal roll out, where communities can take leadership and facilitators in existing areas can mentor in new areas. This can take time, but it also yields more sustainable results.

Like any element of a functioning health system, building a health literate population calls for policy support, planning, resources, organization and capacities to be applied. Surely an informed, active and organized population is too valuable an element of the health system to leave to ad hoc inputs and external funding? Its time all countries in the region followed Zambia’s example and adopt health literacy as a core activity of national health systems!

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org

2. Latest Equinet Updates

EQUINET Discussion Paper 99: Legislation on the for-profit private health sector in east and southern Africa
Doherty J: EQUINET, August 2013

International evidence shows that, if left unregulated, the for-profit health sector may lead to distortions in the quantity, distribution and quality of health services, as well as anti-competitive behaviour. As the for-profit private sector appears to be expanding in east and southern African (ESA) countries, governments need to strengthen regulations to ensure that the for-profit sector does not undermine national health system objectives. This report examines how existing regulation provides for objectives such as the quantity, quality, distribution and price of health care services and suggests priorities for strengthening legal frameworks in 16 countries in east and southern Africa. It draws on a desk-based review of legislation accessed through the internet or from in-country researchers and interviews with in-country experts.

Regional training workshop on participatory methods for a people-centred health system: 7–11 October 2013: Call for applicants
Closing date: 3 September 2013

TARSC, through COPASAH and EQUINET, are holding a regional workshop on Participatory Approaches to Strengthening People Centred Health Systems in the east and southern African region. The workshop will explore how to raise community voice in strengthening the resourcing and functioning of primary health care systems through the use of participatory approaches to build community roles in accountability and action. The workshop is targeted at civil society organisations, NGOs, community leaders, health workers, academics, researchers and others involved in work with communities and health workers in the east and southern African region. Applications to be mailed to info@tarsc.org by 3 September.

Further details: /newsletter/id/38579

3. Equity in Health

Neonatal mortality in South Africa: How are we doing and can we do better?
Editorial: South African Medical Journal 103(8): 518-519, August 2013

This editorial considers the neonatal deaths occurring in South Africa that are due to limited availability of intensive care beds or inadequate referral systems and problematic transport systems. The editor proposes simple, cost-effective preventative measures to decrease the mortality rate outside of tertiary care centres, including resuscitation training of primary health care providers, breastfeeding and kangaroo mother care (KMC) programmes, using polyethylene wrappings for neonates less than 1200g and increasing the number of neonatal beds available and the number of staff to care for these patients. Community education programmes on healthy pregnancies are proposed to improve help-seeking behaviour, improve clinic attendance and increase awareness of the benefits of free interventions, such as breastfeeding and KMC. While many other countries in the region have reduced their maternal mortality, South Africa has made limited progress. The authors call on government to prioritise the implementation of sustainable measures to improve neonatal mortality, and ultimately reducing under-5 mortality.

Outcome Document of the Regional Consultations on the Post-2015 Development Agenda
United Nations Economic Commission for Africa: 2013

This outcome statement summarises views from stakeholders from a total of 53 African countries, represented by governments, Regional Economic Communities, civil society organisations including youth and women’s organisations, parliamentarians, academic institutions and the private sector. Noting the relatively slow progress made by African countries towards the Millennium Development Goals (MDGs) and recognising the capacity deficits and disabling initial conditions prevailing in a number of countries, participants unanimously agreed that the post-2015 development agenda should: 1. Emphasise inclusive economic growth and structural transformation. 2. Re-orient the development paradigm away from externally-driven initiatives toward domestically- inspired and funded initiatives that are grounded in national ownership. 3. Prioritise equity and social inclusion and measure progress in terms of both the availability and quality of service delivery. 4. Pay greater attention to vulnerable groups such as women, children, youth, the elderly, people with disabilities, displaced persons 5. Take into account the initial conditions of nation states and recognise the efforts countries have made towards achieving the goals as opposed to exclusively measuring how far they fall short of global targets. 6. Incorporate the Rio+20 outcomes and the outcomes of Africa-wide initiatives, national and regional consultations as well as UN forums such as ICPD +20. 7. Focus on development enablers as well as development outcomes.

Review of causes of maternal deaths in Botswana in 2010
Ray S, Madzimbamuto FD, Ramagola-Masire D, Phillips R, Mogobe KD et al: South African Medical Journal 103(8): 537-542, August 2013

The objective of this study was to investigate the underlying circumstances of maternal deaths in Botswana. Fifty-six case notes from the 80 reported maternal deaths in 2010 were reviewed. Five clinicians reviewed each case independently and then together to achieve a consensus on diagnosis and underlying cause(s) of death. Results indicated that 60% of deaths occurred in Botswana’s two referral hospitals. Cases in which death had direct obstetric causes were fewer than cases in which cause of death was indirect. The main direct causes were haemorrhage (39%), hypertension (22%), and pregnancy-related sepsis (13%). Thirty-six (64%) deaths were in HIV-positive women, of whom 21 (58%) were receiving antiretroviral (ARV) therapy. Nineteen (34%) deaths were attributable to HIV, including 4 from complications of ARVs. Twenty-nine (52%) deaths were in the postnatal period, 19 (66%) of these in the first week. Case-note review revealed several opportunities for improved quality of care, such as: better teamwork, communication and supportive supervision of health professionals; better supply management; and joint management between HIV and obstetric clinicians. The authors argue that integrating HIV management into maternal healthcare is essential to reduce maternal deaths in the region, alongside greater efforts to improve quality of care to avoid direct and indirect causes of death.

The epidemiology of child homicides in South Africa
Mathews S, Abrahams N, Jewkes R, Martin LJ and Lombard C: Bulletin of the World Health Organisation 91(8): 562-568, August 2013

In this paper the author described age- and sex-specific rates of child homicide in South Africa. A cross-sectional mortuary-based study was conducted in a sample of 38 medico-legal laboratories operating in 2009. Child homicide data were collected from mortuary files, autopsy reports and police interviews. Findings showed an estimated 1,018 child homicides occurred in 2009, or 5.5 homicides per 100,000 children under 18 years. The homicide rate was much higher in boys than in girls. Child abuse and neglect had preceded nearly half of all homicides, but three times more often among girls than among boys. In children aged 15 to 17 years, the homicide rate among boys was nearly five times higher than among girls. South Africa’s child homicide rate is more than twice the global estimate. Since a background of child abuse and neglect is common, the authors recommend that parenting skills should be a key part of primary prevention efforts.

Universal health coverage and universal access
Evans DB, Hsu J and Boerma T: Bulletin of the World Health Organisation 91(8): 546-547, August 2013

Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda. In this editorial, the authors discuss the relationship between universal coverage and universal access. They argue that addressing the broader social determinants of health will also improve access to health services; differences in access in particular will be ameliorated by reducing poverty and income inequalities. These actions alone, however, will not guarantee that all people obtain the health services they need. Even if the services exist and people have access to them, they might not use them. Universal health coverage cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable. In turn, universal access, although necessary, is not sufficient. Coverage builds on access by ensuring actual receipt of services. Thus, universal health coverage and universal access to health services are complementary ideas. Without universal access, universal health coverage becomes an unreachable goal.

Wedging Equity and Environmental Justice into the Discourse on Sustainability
Gandy OH: tripleC 11(1): 221-236, 2013

In this paper, the author examines the problems and prospects for including meaningful indicators of equity into the city based regional planning efforts unfolding around the globe. The central focus of the paper is on the challenges that environmental justice (EJ) activists face as they attempt to frame the problem of equity in ways that the general public would see as not only informative, but compelling. After reviewing examples of successful efforts to reframe debates about equity, the author concludes with a discussion of a set of EJ concerns and indicators that have the greatest potential for capturing public attention and commitment despite mounting resistance to the use of redistributive policies in support of sustainability goals.

4. Values, Policies and Rights

A transformative stand-alone goal on achieving gender equality, women’s rights and women’s empowerment: Imperatives and key components
UN Women: June 2013

In this report, UN Women calls for a specific commitment to achieving gender equality, women’s rights and women’s empowerment in the post-2015 development framework and Sustainable Development Goals (SDGs), as well as robust mainstreaming of gender considerations across all parts of the framework. To make a difference, the new framework must be transformative, by addressing the structural impediments to gender equality and the achievement of women’s rights. In order to address the structural causes of gender-based discrimination and to support true transformation in gender relations, the report proposes an integrated approach that addresses three critical target areas of gender equality, women’s rights and women’s empowerment. 1. Freedom from violence against women and girls, which includes concrete actions to eliminate the debilitating fear and/or experience of violence as the centre-piece of any future framework. 2. Gender equality in the distribution of capabilities – knowledge, good health, sexual and reproductive health and reproductive rights of women and adolescent girls; and access to resources and opportunities, including land, decent work and equal pay to build women’s economic and social security. 3. Gender equality in decision-making power in public and private institutions, in national parliaments and local councils, the media and civil society, in the management and governance of firms, and in families and communities.

Health in All Policies: Seizing opportunities, implementing policies
Leppo K, Ollila E, Peña S, Wismar M and Cook S: Ministry of Social Affairs and Health, Finland, 2013

Health in All Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies and avoids harmful health impacts, in order to improve population health and health equity. An HiAP approach is founded on health-related rights and obligations. It emphasises the consequences of public policies on health determinants, and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making. Core features of HiAP include a strong foundation on human rights and social justice, and a focus on policy-making. It is often necessary to prioritise efforts; seek synergies to enhance health and other important societal goals; and seek to avoid harmful impacts on health. Application of HiAP involves identifying policy developments across sectors with potential implications for health and health equity; assessing impacts; and advocating and negotiating for changes. Long term vision and sustained efforts are often needed. This book looks at examples of HiAP from countries across the world, and has specific chapters on low-income countries, including those from Africa.

Human rights abuses and collective resilience among sex workers in four African countries: a qualitative study
Scorgie F, Vasey K, Harper E, Richter M, Nare P, Maseko S AND Chersich MF: Globalization and Health 9(33), 26 July 2013

In this study, researchers explored the impact of violence and related human rights abuses on the lives of sex workers, and how they have responded to these conditions, as individuals and within small collectives. They conducted 55 in-depth interviews and 12 focus group discussions with female, male and transgender sex workers in Kenya, South Africa, Uganda and Zimbabwe. In describing their experiences of unlawful arrests and detention, violence, extortion, vilification and exclusions, participants present a picture of profound exploitation and repeated human rights violations. This situation has had an extreme impact on the physical, mental and social well-being of this population. Underlying their stories, however, are narratives of resilience and resistance. Sex workers in this study draw on their own individual survival strategies and informal forms of support and very occasionally opt to seek recourse through formal channels. While criminal laws urgently need reform, the authors argue that supporting sex work self-organisation and community-building are key interim strategies for safeguarding sex workers’ human rights and improving health outcomes in these communities. If developed at sufficient scale and intensity, sex work organisations could play a critical role in reducing the present harms caused by criminalisation and stigma.

Inclusion of vulnerable groups in health policies: Regional policies on health priorities in Africa
Schneider M, Eide AH, Amin M, MacLachlan M and Mannan H: African Journal of Disability 2(1), 22 January 2013

In this paper, the authors analysed 11 African Union (AU) policy documents to ascertain the frequency and the extent of mention of 13 core concepts in relation to 12 vulnerable groups, with a specific focus on people with disabilities. The analysis highlighted the broad nature of the reference made to vulnerable groups, with a lack of detailed specifications of different needs of different groups. This is confirmed in the highest vulnerable group mention being for ‘universal’. The reading of the documents suggests that vulnerable groups are homogeneous in their needs, which is not the case. There is a lack of recognition of different needs of different vulnerable groups in accessing health care. The authors conclude that the need for more information and knowledge on the needs of all vulnerable groups is evident. The current lack of mention and of any detail on how to address needs of vulnerable groups will significantly impair the access to equitable health care for all.

Kenya needs surrogacy policy and legislation
Jiwaji A: Pambazuka News 641, 1 August 2013

In the absence of clear regulation, the practice of surrogacy in Kenya grows as an unchecked and unsupervised industry with no policy or law to fall back on if anything goes wrong during the treatment, says the author of this article. South Africa is the only country on the African continent to have surrogacy laws and policies. The growing use of commercial surrogacy, where a woman is paid to carry a child for a couple wanting to adopt, points to an urgent need to develop appropriate legislation, the author argues. She refers to the practice in India, which disproportionately affects the poor girls and women, who use surrogacy as a means of income. But these women are not protected by the law. She makes a number of recommendations for proposed legislation, covering various areas such as the interests of the surrogate mother and commissioning parents, ethical and moral aspects, financial support, dispute mechanisms and regulatory bodies, termination of a surrogate pregnancy, more lenient adoption laws and rights of both parties.

Questions and answers on Universal Health Coverage …and some more comments and open questions
Medicus Mundi International Network: Discussion paper, August 2013

This discussion paper presents key elements of the concept of UHC as promoted by the World Health Organisation and reflects them based on Medicu Mundi International’s (MMI) own ambition of Health for All such as stated in the MMI Network Policy. The paper consists of three sections (1) “What is in Universal Health Coverage?” (2) “Financing UHC”, and (3) “UHC and health equity”. MMI argues that if its Network is to promote Universal Health Coverage in view of improving health equity, then it should be willing to be truly involved in the political and ideological battle that will enfold over the coming period. Unless the international community pushes the right to health up in its scale of values and stops considering health as a dependent variable of the global economy, and unless it makes the respect of human rights mandatory and those who violate them legally accountable, UHC is unlikely to yield the expected results. Issues needing further investigation include: Universal Health Coverage and gender equity (almost entirely missing in the current debate); Universal Health Coverage and sustainability; the political economy of Universal Health Coverage; and the transformative power of the UHC concept for social mobilisation and political change towards Health for All.

5. Health equity in economic and trade policies

Debating the scope of a health research and development convention
Moran M: Bulletin of the World Health Organisation 91(8): 618-620, August 2013

In 2012, the World Health Organisation’s Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG) proposed a binding convention that would mandate every signatory country to invest a minimum of 0.01% of its gross domestic product (GDP) in research and development (R&D) falling within the established scope. In this article, the author explores the proposed convention’s possible ramifications. In its narrowest interpretation, the convention would only address R&D gaps in areas where no suitable products exist. This would involve funding a publicly-driven pharmaceutical effort since, by definition, no commercial incentive exists in these areas. But even this approach leaves room for interpretation, the author argues. If narrowly interpreted, coverage would be limited to R&D gaps for Type II and III diseases; if more broadly interpreted, coverage would also extend to R&D gaps in Type I products suitable for developing countries. The author argues that, despite advances in global health, developing countries continue to have a shortage of appropriate tools to prevent, diagnose and treat many diseases. The proposed convention is intended to address this problem, but lack of clarity in the convention’s remit has left its scope open to interpretation. He calls for this uncertainty to be resolved in order for discussions to move forward.

Medicines Patent Pool and Roche Sign HIV Medicines Agreement: Focus on Preventing Blindness in People Living with HIV
Medicines Patent Pool: 5 August 2013

The Medicines Patent Pool and Roche have announced an agreement to increase access in developing countries to valganciclovir, a key easy-to-take oral medicine to treat cytomegalovirus (CMV), a viral infection that can cause blindness in people living with HIV. The agreement will significantly improve access to Roche's valganciclovir for people living with HIV in 138 developing countries by making it up to 90% cheaper than current prices. As a second step, the Medicines Patent Pool and Roche will also enter into licensing and technology transfer negotiations to encourage the development of internationally approved quality generic versions of valganciclovir. The most widely used treatment for CMV in developing countries requires injections directly to the eye, which can be painful and also difficult to administer on a large scale. The Medicines Patent Pool will also work with other key stakeholders to develop long-term treatment strategies for scaling up the use of valganciclovir for treatment of HIV-related CMV in developing countries.

The Economic Benefits of Investing in Reproductive, Maternal, Newborn and Child Health: A Systematic Literature Review
Saha S and Gerdtham U: Partnership for Maternal, Newborn & Child Health, November 2012

This study reviewed evidence on the impact of reproductive, maternal, newborn, and child health (RMNCH) on economic growth and development. The authors performed a systematic search of the published literature in electronic databases and consulted grey literature such as working papers and reference lists of selected articles. They found that GDP loss attributable to maternal mortality varies from US$0 per year in Botswana to US$504 per year in Ethiopia. If maternal mortality increases by one death, GDP per capita decreases by US$0.36 per year on average in 45 sub-Saharan countries. AIDS was found to have a negative effect on economic growth, especially in sub-Saharan Africa, although the magnitude varies among studies from 0.05% to 1% decline in GDP per capita. The intergenerational effect of HIV and AIDS is much higher, at 30-50% reduction of GDP per capita over four generations at a 15-20% HIV prevalence rate. The review revealed inadequate evidence on the impact of RMNCH on economic growth and development, which may, in part, be due to difficulties in measuring economic impact over extended time periods, and may also be due to the breadth of health states that fall within the RMNCH continuum. The authors argue that future research should focus on identifying the most cost-effective policy, programmes and interventions to prevent, reduce, delay or eliminate the complications of RMNCH.

The equity implications of fiscal consolidation
Rawdanowicz L, Wurzel E and Christensen AK: Organisation for Economic Co-operation and Development, January 2013

The authors of this paper argue that there is scope to balance current fiscal consolidation efforts in favour of more equity with only limited adverse impact on potential growth. In particular, relatively little weight has been given to reducing tax expenditures and raising taxes on immovable property. A number of consolidation instruments are consistent with equity goals while doing little or no harm to potential growth: increases in the effective retirement age, raising efficiency in the education and health care systems, cutting certain tax expenditures, hiking taxes on immovable property and broadly-based consumption taxes. Increases in capital income taxes would also be equitable but need to be well designed to avoid being distortive. Calculations based on simplifying assumptions indicate that increasing household direct taxes would reduce income inequality, while cutting transfers by the same amount would have a larger and opposite effect on inequality. However, raising progressive labour income taxes could have adverse effects on long-run growth. Cuts in government wages and employment can yield fast consolidation gains but the authors warn that this needs to be accompanied by increases in efficiency of service delivery to avoid that reductions in public services mainly hit poor people.

The Question of Patent Eligible Subject Matter and Evergreening Practices
Kilic B and Palombi L: Infojustice.org, 27 July 2013

In this article, the authors discuss the issue of how medicines may be eligible for patents and how this affects evergreening practices, whereby pharmaceutical companies extend the patent on their medicines by making slight modifications. However, evergreening of pharmaceutical patent protection, also includes patent monopolies over manufacturing processes, formulations, dosages, uses and methods of treatment. The authors present data that shows that evergreening patents have extended patent protection to nearly 50 years in some cases, well beyond the 20 year period provided in TRIPS. They argue that the net cost for society of evergreening patents is substantial and they have been proven to interfere and hinder fair competition in the pharmaceutical market, with the result that pharmaceutical companies can charge high monopoly prices for far longer than is justified. Because of its critical implications for competition and public health, India’s s.3(d) is becoming a model criteria for patent eligible subject matter in other countries. For instance, Brazil’s patent reform proposes to adopt such a provision. The invention threshold plays a critical role in the patent system. Setting the bar too low makes it easier for the patent system to be improperly exploited by those that use extended patent monopolies to extract economic rents. This behaviour should not be facilitated, the authors argue, as it unreasonably restricts society’s ability to benefit from the technology transfer trade-off.

6. Poverty and health

Exploring the paradox: double burden of malnutrition in rural South Africa
Kimani-Murage EW: Global Health Action 6(100), 24 January 2013

This paper explores the double burden of malnutrition in rural South Africa, to understand the profiles of malnutrition among children and adolescents in a poor, high HIV prevalent context. A cross-sectional survey was conducted in 2007 of 4,000 children and adolescents aged 1–20 years. The study found stunting at an early age and adolescent obesity, particularly among girls, co-existing in the same socio-geographic population. HIV is a risk factor for poor nutritional outcomes. Significant predictors of undernutrition at an early age include child's HIV status, age and birth weight, maternal age, age of household head, and area of residence. Significant predictors of overweight/obesity and risk for metabolic disease during adolescence include child's age, sex, and pubertal development, household-level food security, socio-economic status, and household head's highest education level. The combination of early stunting and adolescent obesity raises concerns as paediatric obesity and adult short stature are risk factors for metabolic syndrome and metabolic diseases in adulthood.

The Cost of Hunger in Africa: The Social and Economic Impact of Child Undernutrition in Ethiopia
World Food Programme: 2012

The Cost of Hunger in Africa (COHA) study links the role of child nutrition and human development to Ethiopia’s Growth and Transformation Plan (GTP). This plan, that projects a sustained GDP growth of 11% to 15% from 2010 to 2015, represents the national strategy of Ethiopia towards poverty eradication. The results of the study strongly suggest that in order for the country to achieve sustainable human and economic growth, special attention must be given to the early stages of life as the foundation of human capital. The results of the study are supported by a strong evidenced base, and a model of analysis specially adapted for Africa, which demonstrates the depth of the consequences of child undernutrition in health education and labour productivity. This paper further quantifies the potential gains of addressing child undernutrition as a priority. Now, stakeholders have not only the ethical imperative to address child nutrition as a main concern, but a strong economic rationale to position stunting in the centre of the development agenda, the paper concludes.

The hunger grains: Biofuels and malnutrition
Oxfam: September 2013

In 2009, European Union (EU) governments committed to sourcing 10% of transport energy from renewable sources by 2020: they are set to meet this target almost exclusively using biofuels made from food crops. This decision has several important implications for developing countries, according to this report. Land grabs are occurring in developing countries with poor protection of land rights – most of which are to grow crops that can be used for biofuels – which means that many land deals for biofuel production are concluded without the consent of affected communities. Affected countries in Africa include Mozambique, Kenya and Ethiopia. In terms of production, if the land used to produce biofuels for the EU in 2008 had been used to produce wheat and maize instead, it could have fed 127 million people for the entire year. On top of this, biofuel mandates are an incredible inelastic source of demand for food crops; by 2020, EU biofuel mandates alone could push up the price of some foods by as much as 36%. Biofuel mandates are not even a solution to climate change; modeling shows that plowing up carbon sinks to meet EU biofuel mandates could be as bad for the environment as putting an extra 26 million cars on Europe’s roads. Oxfam concludes by calling on EU governments to scrap EU biofuel mandates.

The science of agribusiness profits, versus science for healthy, chemical-free, patent-free food
Jehu-Appiah A: Pambazuka News 641, 31 July 2013

The Sixth Africa Agriculture Science Week was held in Accra from 15-20 July 2013. However, the authors of this article express their concern that the current scientific approach to improve agricultural productivity, and food nutrition of small-scale farmers in particular, is being heavily distorted and influenced by well-funded information campaigns of the big agro-chemical companies. These agribusinesses, and their allies aim to increase their profits by selling chemicals and inputs and one of their key objectives is to introduce patented genetically engineered seed into Ghana and other African countries. The authors argue that genetic engineering (GE) is not about science, it is about money. They point out there is very little record of success in developing countries in helping small scale farmers to improve productivity and adapt to climate change. GE seed is also more expensive for farmers than saving seed for the next planting. The authors argue that small scale Ghanaian farmers need research and extension in support of agro-ecological farming, and this includes access to markets, infrastructure, good roads and transportation, and protection from landgrabs.

Understanding the Biofuel Trade-offs between indirect land use change, hunger and poverty
Searchinger T: Friends of the Earth Europe, 2013

The author of this paper identifies two main concerns with regard to biofuel policies: one involves the likely consequences of biofuels for greenhouse gas emissions because of the ploughing up of forests and grasslands and their release of carbon, while the other involves the consequences for hunger and poverty. What is not broadly understood is that the two consequences closely and inversely relate: the less farmers plough up forest and grassland, the greater the impacts on hunger; but the lower the impacts on hunger, the more farmers emit greenhouse gases from land use change. Much of the uncertainty about the consequences of biofuels relate to how much of which undesirable response the world will get. When biofuels divert crops from food there are three basic alternative responses: (1) the crops are not replaced; (2) crops are replaced by land use change; and (3) crops are replaced by boosting production on existing agricultural land. The author argues that the evidence indicates that biofuels are fuelling hunger, land grabs and climate change.

7. Equitable health services

Impact of inter-facility transport on maternal mortality in the Free State Province
Schoon MG: South African Medical Journal 103(8): 534-537, August 2013

In December 2011, having identified inter-facility transport as a problem in the maternity service, the Free State Department of Health procured and issued 48 vehicles including 18 dedicated to maternity care. Subsequently, a sustained reduction in mortality was observed. The author of this paper probed the role of inter-facility transport in effecting this reduction in mortality. The author conducted a before-after analysis of data from two separate databases, including the district health information system and the emergency medical and rescue services call-centre database. Results showed that the maternal mortality decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The mean dispatch interval decreased from 32.01 to 22.47 minutes. The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7%. Monthly mean dispatch interval curves closely mirrored the maternal mortality curve. The author concludes that effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality. Health authorities should prioritise funding for inter-facility vehicles for maternity services to ensure prompt access of pregnant women to centres with skills available to manage obstetric emergencies.

Implementation of a breast cancer genetic service in South Africa – lessons learned
Schoeman M, Apffelstaedt JP, Baatjes K and Urban M: South African Medical Journal 103(8): 529-553, August 2013

Genetic testing for BRCA mutations has been available in the Western Cape of South Africa since 2005, but practical implementation of genetic counselling and testing has been challenging. The authors of this paper describe an approach to breast cancer genetic counselling and testing developed in a resource-constrained environment at Tygerberg Hospital in Cape Town, Western Cape. Genetic counselling was offered in a stepwise manner to our diverse patient population, with a focus on affected probands, and subsequent cascade testing. A record review of BRCA testing between 2005 and 2011 was performed. During this period 302 probands received genetic testing, with increasing numbers tested over time. Of 1,520 women treated for breast cancer since 2008, 226 (14.9%) accepted BRCA testing, and 39 tested positive (17.3% of those tested, and 2.6% of all women). Common founder mutations were detected in 11.9% of women, and comprised 73% of mutations detected. Cascade testing increased after 2010: 16 female and 4 male family members of 19 probands accepted testing, with 6 positives being detected. In conclusion, this protocol-driven approach focusing on probands, with initial pre-test counselling by primary care staff was proven effective in establishing the service.

Post-abortion care quality status in health facilities of Guraghe zone, Ethiopia
Tesfaye G and Oljira L: Reproductive Health 10(35), 23 July 2013

Ethiopia has one of the highest maternal mortality ratios (673 per 100,000 live births) in the world, and unsafe abortion was estimated to account for 32% of all maternal deaths in Ethiopia. The objective of this study was to assess post-abortion care quality status in health facilities of Guraghe zone, in Ethiopia. A facility based cross-sectional study design with both quantitative and qualitative methods was conducted, which included six health centres, two hospitals and 422 post-abortion patients. Patient-provider interaction was generally satisfactory from the patient’s perspective as, overall, 83.5% of the patients were satisfied with the services. Those who said waiting time was long were less satisfied and unemployed women were more satisfied than others. However, from a clinical service delivery stand point, important medical information on danger signs, follow-up needs of post abortion clients and care associated pain management were neglected by most of the health professionals. Almost all of the health facilities had basic and appropriate medical equipment and supplies required for providing post-abortion services. This study has also shown that significant proportions of providers were trained on important aspects of pregnancy and ante-natal care.

8. Human Resources

Association between health worker motivation and healthcare quality efforts in Ghana
Alhassan RK, Spieker N, van Ostenberg P, Ogink A, Nketiah-Amponsah E and de Wit TF: Human Resources for Health 11(37), 14 August 2013

A baseline survey of 324 health workers in 64 primary healthcare facilities in two regions in Ghana found that the quality of care in health facilities was generally low. Most facilities did not have processes for continuous quality improvement and patient safety. Staff motivation appeared low, particularly in public facilities. Significant positive associations were found between staff satisfaction levels and working conditions and the clinic’s effort towards quality improvement and patient safety. The authors called for more comprehensive staff motivation interventions to be integrated into quality improvement strategies, especially in public health services where working conditions are perceived to be poor.

Effectiveness of African regional professional associations
Browne E: GSDRC, 8 August 2013

This report provides examples of professional and academic associations which work across three or more African countries, and which have some evidence of success. The author aims to identify the characteristics of these organisations which enable their success. Types of impact are varied, but are usually identified as strong membership, attendance at national or international meetings, awareness of the organisation in the wider sphere, dissemination and uptake of publications, and connection or influence on policy and policy-makers. The report particularly tries to draw out any impacts on governance in the wider public sphere, however, most of the indicators of success are input or output rather than outcome-focused, and do not identify broader social or policy change. The author emphasises the need for strongly committed individuals at the centre of the organisation, personal leadership, involvement of policy-makers and the quality of outputs. Independence and neutrality are seen as important values, allowing professional development free from politics.

Factors affecting job satisfaction and retention of medical laboratory professionals in seven countries of sub-Saharan Africa
Marinucci F, Majigo M, Wattleworth M, Paterniti AD, Hossain MB and Redfield R: Human Resources for Health 11(38), 17 August 2013

Effective implementation and sustainability of quality laboratory programmes in Sub-Saharan Africa relies on the development of appropriate staff retention strategies, argue the authors of this paper. Assessing the factors responsible for job satisfaction and retention is key for tailoring specific interventions aiming at improving the overall impact of health programmes. They developed a survey to assess these factors among 224 laboratorians working in the laboratory programme the University of Maryland implemented in seven Sub-Saharan African countries. Lack of professional development was the major reason for leaving the previous job for 28% of interviewees who changed jobs in the past five years. Professional development/training opportunities was indicated by almost 90% of total interviewees as the most important or a very important factor for satisfaction at their current job. Similarly, regular professional development/opportunities for training was the highest rated incentive to remain at their current job by 80%. Laboratory professionals employed in the private sector were more likely to change jobs than those working in the public sector. The findings were used for developing specific strategies for human resources management, in particular targeting professional development, aiming at improving laboratory professionals within the University of Maryland laboratory programme and hence its long-term sustainability.

The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe
Chirwa Y, Witter S, Munjoma M, Mashange W, Ensor T et al: BMC Health Services Research 13(197), 28 May 2013

This study aimed to examine the links between human resources for health (HRH) and changes in health policy on user fees in Zimbabwe, with particular respect to reproductive, maternal and newborn health (RMNH). The authors used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011. They found that past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Health workers face challenges in managing demand, including from migration, and low pay. In four provinces they found that there are not enough doctors to provide more complex care, and only three provinces could provide skilled personnel for deliveries taking place in facilities. The authors argue that that there is a need to jointly address user fees that place financial burden on clients of RMNH services and to improve the terms and conditions of health staff.

Toward Interventions in Human Resources for Health in Ghana
Appiah-Denkyira E, Herbst CH, Soucat A, Lemiere C and Saleh K (Eds): World Bank, 2013

This book was produced to support the policy dialogue on Human Resources for Health (HRH) in Ghana. Despite some recent successes, further improvements in health outcomes are in part hampered by the lack of skilled service providers, or human resources for health (HRH), particularly in rural areas, that prevent critical health services from being accessed and adequately delivered to those that need them most. To address the lack of information to guide the development of policies and programmes on HRH, the book aims to paint a comprehensive picture on HRH, consolidating new and existing evidence on some of the underlying determinants impacting stock, distribution and performance of health workers in Ghana, including health worker production and attrition, management and accountability structures, the capacity of health training institutions, and health worker compensation. As is made clear, any potential policies to improve the situation on HRH need to be well targeted, and take into account some of the fiscal and political challenges that are specific to the health labour market in Ghana. The book is intended to provide a basis for Ghanaian decision makers and external partners to dialogue on HRH and related policies, resulting in concrete HRH actions. More broadly, it will be of interest to all those working to improve HRH in Africa and beyond.

9. Public-Private Mix

Advertisement and knowledge of tobacco products among Ellisras rural children aged 11 to 18 years: Ellisras Longitudinal study
Monyeki KD, Kemper HCG, Amusa LO and Motshwane M: BMC Pediatrics 13(111), May 2013

Tobacco products use is the leading cause of chronic diseases morbidity and mortality. This study explores an exposure to tobacco advertisements factors and knowledge, an association with snuff/pipe usage and cigarette smoking among rural children aged between 11 to 18 years in Ellisras, South Africa. A total of 1,654 subjects (854 boys and 800 girls) completed the questionnaire. Results showed that a significant number of boys (11.7%) compared to girls (8.8%) received free cigarettes from the members of the community. Bill boards were successful in advertising tobacco products among the Ellisras rural boys (17% boys and 12.8% for girls). The authors found significant association between cigarette smoking and advertisements of tobacco products on the TV screens, videos or movies. Though tobacco products legislation exists in South Africa, the authors argue that efforts should be taken by the health professionals to emphasise the danger of using tobacco products even among the illiterate. Teachers and parents should refrain from advertising tobacco products at schools and at homes.

Irreconcilable Conflict: The Tobacco Industry and the Public Health Challenge of Tobacco Use
Novotny TE: PLoS Medicine 10(5), 28 May 2013

The public health approach to regulatory intervention is normally very inclusive, bringing all stakeholders to the table to present their perspectives, to argue about the impacts of the interventions on their organisations, and to find compromises that work for the greater good of all those involved. However, the author of this paper argues against including the tobacco industry as a stakeholder in public health decisions, based on the reputation of the industry in obfuscating the truth about the harm of tobacco use, dividing the public health community over harm reduction approaches, and befuddling critically important regulatory processes. The profits from selling cigarettes and alternative tobacco products are simply too great for the tobacco industry to be a genuine stakeholder in public health, the author notes. Thus, the public health community needs to do what it does best: to rally popular support for strong, science-based approaches to prevention of tobacco use, to expose the truths about the harms of tobacco use to current users, and to support government agencies in carrying out their legislatively mandated duties to protect public health. The author highlights the irreconcilable conflict between the public health community and the global tobacco industry.

10. Resource allocation and health financing

Does Abolishing User Fees Lead to Improved Health Status? Evidence from Post-Apartheid South Africa
Tanaka S: Social Science and Research Network, July 2013

In this paper, the author examines the impact of removing user fees from healthcare on the health status of poor children in South Africa. By comparing health development across similar children, the author found that free healthcare improved the health status of all children, but to a greater extent for boys than for girls. These results present several important policy implications for other developing countries contemplating the abolition of user fees. First, removing user fees is effective in improving child health status through increased access to and utilisation of health services in an environment where poor households face significant budget constraints. Second, increased access to health services is an important determinant of better health outcomes. Third, free health services are often challenged by a potential trade off between quantity and quality of services. The study supports the assertion that the quality of health services appears to have deteriorated, due to poor financial management, leading to lower health status among older children in the high treatment region. However, the net benefits were still positive and significant for children who received free healthcare.

Global health actors no longer in favour of user fees: a documentary study
Robert E and Ridde V: Globalization and Health 9(29), 26 July 2013

This study identified and analysed the stance of global health actors (GHAs) in the debate on user fees. The authors reviewed public documents published by and officially attributed to GHAs from 2005 to 2011. They identified 56 GHAs, and analysed 140 documents. Among them, 55% were in favour of the abolition of user fees or in favour of free care at the point of delivery. None of the GHAs stated that they were in favour of user fees, although 30% did not take a stand. The World Bank declared support for both user fees and free care at point of service. GHAs generally circumscribe their stance to specific populations (pregnant women, children under 5 years, etc.) or to specific health services (primary, basic, essential). Three types of arguments are used by GHAs to justify their stance: economic, ethical and pragmatic. While the principle of “user pays” certainly seems to have fallen out of favour, the authors suggest that the next step is yet to be taken, ie for GHAs to provide technical and financial support to those countries that have chosen to implement user fee exemption policies.

Health financing for universal coverage and health system performance: concepts and implications for policy
Kutzin J: Bulletin of the World Health Organisation 91(8): 602-611, August 2013

All countries that are seeking to improve equity in the use of health services, service quality and financial protection for their populations must pursue universal health care (UHC), according to the author of this paper. He argues that health financing policy is an integral part of efforts to move towards UHC. To be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Adding schemes for specific social groups is incompatible with a universal coverage approach and may even undermine UHC, as scheme members protect their own benefits to the cost of wider equity.

Promoting universal financial protection: contracting faith-based health facilities to expand access – lessons learned from Malawi
Chirwa ML, Kazanga I, Faedo G and Thomas S: Health Research Policy and Systems 11(27), 16 August 2013

This study examined the features of Service Level Agreements (SLAs) and their effectiveness in expanding universal coverage in Malawi. Research was conducted in five Christian Health Association of Malawi (CHAM) health facilities: Mulanje Mission, Holy Family, and Mtengowanthenga Hospitals, and Mabiri and Nkope Health Centres. A total of 155 clients from an expected 175 were recruited in the study. The study findings revealed key aspects of how SLAs were operating, the extent to which their objectives were being attained and why. In general, the findings demonstrated that SLAs had the potential to improve health and universal health care coverage, particularly for the vulnerable and underserved populations. However, the findings show that the performance of SLAs in Malawi were affected by various factors including lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate human and material resources, and lack of systems to monitor performance of SLAs, amongst others. The authors provide recommendations to policy makers for the replication and strengthening of SLA implementation in the roll-out of universalisation policy.

The financial burden from non-communicable diseases in low- and middle-income countries: a literature review
Kankeu HT, Saksena P, Xu K, Evans DB: Health Research Policy and Systems 2013, 11:31, 16 August 2013

In this paper, the authors present a literature review on the costs imposed by non-communicable diseases (NCDs) on households in low- and middle-income countries (LMICs). They examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. These financial costs deter many people suffering from NCDs from seeking the care they need. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. The authors identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

11. Equity and HIV/AIDS

Intervening Upstream: A Good Investment for HIV Prevention
Heise L and Watts C: AIDStarone, 2013

This paper examines some of the evidence linking structural factors to HIV risk; research gaps, including the pathways through which factors affect HIV vulnerability and interaction among factors; and explores the advantages of taking a “structurally informed” approach to HIV planning and implementation, namely the value of influencing clustered risk factors, the potential to influence multiple outcomes, and opportunities for co-financing. The authors argue that attention to structural forces that either heighten HIV vulnerability or create AIDS resiliency is an important but under-researched and under-programmed area of HIV prevention. There is long-standing evidence that demonstrates that a variety of social forces have both direct and indirect effects on HIV transmission, and undermine the effectiveness of proven biomedical prevention programmes. Intervening “upstream” yields multiple benefits: it allows programmes to potentially affect multiple risk factors at once (especially when they cluster), and it offers promise to influence a range of health and development outcomes through a single intervention. The authors argue that structural approaches to HIV prevention are an efficient and effective strategy in our current era of global fiscal austerity.

Operationalising Structural Interventions for HIV Prevention: Lessons from Zambia
Bowa C and Mah TL: AIDStarone, 2013

While global guidance for HIV prevention recognises the importance of structural HIV prevention, evidence for the effectiveness of these interventions, and their implementation, are lagging behind other areas of prevention. The challenges to implementation at the community and national levels are less well understood. This paper examines the United States (US) President’s Emergency Plan for AIDS Relief (PEPFAR)/US Agency for International Development (USAID) experience with implementing structural interventions in Zambia. Despite challenges to implementing, monitoring, and evaluating structural interventions, they can and have been implemented successfully and are necessary for a long-term and sustained response to both HIV and social and economic development needs, the authors argue. Better identification of causal pathways, involvement of key stakeholders and collaborators, and enhanced monitoring will strengthen implementation of structural interventions and provide the necessary data to understand their outcomes and impacts. Such efforts and stronger links between structural interventions and other biomedical and behavioural interventions will result in a true combination approach to HIV prevention, yielding better results.

Policy and programme responses for addressing the structural determinants of HIV
Pronyk Paul and Lutz Brian: Aidstarone, June 2013

According to this report, one reason that HIV prevention efforts have not kept pace has been insufficient attention to HIV’s “structural factors”, namely those areas beyond individual knowledge or awareness that shape risk and vulnerability to infection. Examples are often context-specific but can include economic inequality and livelihood insecurity, as well as hunger, gender inequality, and lack of education. These factors, many of which are rooted in various formal and informal types of marginalisation, underpin the diversity of HIV epidemics, helping to explain why some countries have a higher HIV burden than others. Structural factors have been demonstrated to influence treatment access and retention. The authors argue that action on structural factors can have multiple beneficial impacts not only on HIV-related goals but also on other health, development and human rights objectives. Implementing structural approaches requires a range of disciplinary perspectives that extend beyond the health sector, as well as cross-sector governance and financing.

12. Governance and participation in health

Barriers to the participation of people with psychosocial disability in mental health policy development in South Africa: a qualitative study of perspectives of policy makers, professionals, religious leaders and academics
Kleintjes S, Lund C and Swartz L: BMC International Health and Human Rights 13(17), 2013

This paper outlines stakeholder views on environmental barriers that prevent people who live with psychosocial disability from participating in mental health policy development in South Africa. The authors conducted 56 semi-structured interviews with national, provincial and local South African mental health stakeholders between August 2006 and August 2009. Respondents included public sector policy makers, professional regulatory council representatives, and representatives from non-profit organisations (NPOs), disabled people’s organisations (DPOs), mental health interest groups, religious organisations, professional associations, universities and research institutions. Respondents identified three main environmental barriers to participation in policy development: stigmatisation and low priority of mental health, poverty, and ineffective recovery and community supports. The authors conclude that a number of attitudes, practices and structures undermine the equal participation of South Africans with psychosocial disability in society. They call for a human rights paradigm and multi-system approach to enable full social engagement by people with psychosocial disability, including their involvement in policy development.

Leveraging HIV-related human rights achievements through a Framework Convention on Global Health
Buse K, Eba P, Sigurdson J, Thomson K and Timberlake S: Health and Human Rights 15(1), June 2013

The global AIDS response has shown that at the core of health lie considerations of social justice, human rights, and accountability. As momentum builds for a Framework Convention on Global Health (FCGH), the authors of this paper argue that there is an opportunity to take stock of lessons learned from the response to HIV and AIDS and ensure that they are replicated and institutionalised in an eventual Convention. They further argue that the most critical aspect to the success of the HIV response has been the leadership and activism of civil society. Success requires active monitoring of progress and shortcomings, combined with political and social mobilisation to expand investment and access to the services and underlying conditions that protect and advance health. While the FCGH must make civil society support and engagement an indispensable principle, the AIDS movement can contribute substantive content and mobilisation for its adoption. A broad international legal framework for health can help address some of the key legal, policy, regulatory, and programmatic challenges that continue to hinder effective responses to HIV.

New Law Undermines Rights of Ugandans
Burnett M: Human Rights Watch, August 6, 2013

Uganda’s parliament passed the Public Order Management bill, which gives Ugandan police broad powers to permit or disallow any “public meeting”. The law defines a public meeting as any gathering of more than three people in any public place where the “failure of any government, political party, or political organisation” is discussed. This definition includes peaceful demonstrations of more than three people, and organisers would be required to inform police in advance or face criminal sanction. The law allows police to use force – including, in several instances, firearms – no matter what the alleged offense. The Bill has been passed to the President to gazette into law.

The role of community-based health planning and services strategy in involving males in the provision of family planning services: a qualitative study in Southern Ghana
Adongo P, Tapsoba P, Phillips JF, Tabong P, Stone A, Kuffour E, Esantsi SF and Akweongo P: Reproductive Health 10(36), 26 July 2013

This study took place in Northern Ghana to assess the impact of male involvement in reproductive health and Family Planning (FP) services. Twelve focus group discussions were held with both male and female community members, six in communities with functional community health-based planning and services strategy (CHPS) and six for communities with less/no-functional CHPS. Fifty-nine in-depth interviews were held with other stakeholders at both district and regional levels. The results revealed a general high perception of an improved health status of children in the last ten years in the communities; however, participants reported that malnutrition was still rife in the community. The results also revealed that women still needed to get spousal approval to use contraceptives; however, the matrilineal system appears to give more autonomy to women in decision-making. The CHPS strategy was perceived as very helpful with full community participation at all levels of the implementation process. Males were more involved in FP services in communities with functioning CHPS than those without functioning CHPS. The authors argue that involving males in reproductive health issues including FP is important to attain reproductive health targets.

UN must prioritise equality, urge world's developing countries
Tran M: The Guardian, 6 August 2013

Equality before the law, corruption-free government, inclusiveness, gender equality, and respect for the environment are among the priorities for any future set of development goals, as identified during four civil society and government meetings on the Millennium Development Goals (MDGs) and the targets that should replace them when they expire in 2015. Four "ground-level panels" were held in four developing countries, including Uganda. Respondents on the panel in Uganda agreed that no one should be left behind, urging a grassroots approach to policy. They proposed that bottom-up processes, where the people decide what is to be done by their government, must be a priority. The panel also felt foreign investment should create opportunities for Ugandans, and external investors should respect local customs and culture.

What Matters Most? Evidence from 84 Participatory Studies with Those Living with Extreme Poverty and Marginalisation
Leavy J and Howard J: Institute for Development Studies, July 2013

This report draws on the experiences and views of people living in extreme poverty and marginalisation in 107 countries. The authors distil messages from 84 participatory research studies published in the last seven years. Forty-seven of these studies are based on creative material coming from visual participatory methods. Their findings show that a development framework post-2015 will have legitimacy if it responds to the needs of all citizens, in particular those who are most marginalised and face ongoing exclusion from development processes. The framework has to incorporate shared global challenges and have national level ownership if it is to support meaningful change in the lives of people living in poverty. The authors first focus on understanding the lessons learnt from people's experiences of predominantly international development assistance, before they merge these findings with learning from the second phase of the synthesis, adding a substantive focus on national and local level policy and development planning and how relationships, and accountability between citizens and governance institutions at these levels can be strengthened through the active engagement of those most marginalised in decision-making.

13. Monitoring equity and research policy

Addressing research capacity for health equity and the social determinants of health in three African countries: the INTREC programme
Hofman K, Blomstedt Y, Addei S, Kalage R, Maredza M et al: Global Health Action 2013(6), April 2013

INTREC (INDEPTH Training and Research Centres of Excellence) was established to provide training for researchers from the INDEPTH network on associations between health inequities, the social determinants of health (SDH), and health outcomes, and on presenting their findings in a usable form to policy makers. The authors of this paper assessed the current status of SDH training in three of the African INTREC countries – Ghana, Tanzania, and South Africa – as well as the gaps, barriers, and opportunities for training. Results indicated that SDH-relevant training is available, but the number of places available for students is limited, the training tends to be public-health-oriented rather than inclusive of the broader, multi-sectoral issues associated with SDH, and insufficient funding places limitations on both students and on the training institutions themselves, thereby affecting participation and quality. The authors argue that there is a clear role for INTREC to contribute to the training of a critical mass of African researchers on the topic. This work will be accomplished most effectively by building on pre-existing networks, institutions, and methods.

An Open Letter to the Executive Director of The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Wilkerson M: AIDS-Free World, July 2013

According to this letter, the Global Fund indicators that have been used in the past do not reflect a commitment to strengthening the response for women and girls. Many key indicators of progress do not address the differing realities for women and girls versus men and boys. For example, the indicator for new HIV infections is not disaggregated by sex. Similarly, the Global Fund has administered many grants with a focus on orphans and vulnerable children (OVC), but few of the programmes use indicators that reflect that the experiences of orphans and vulnerable children who are girls will differ from those of boys, both in the opportunities and obstacles they will encounter. The author argues that failure to measure progress in preventing new infections among women, or to measure the effects of OVC programmes on girls, means there is no incentive for countries that receive Global Fund grants to ensure that their efforts are addressing the specific challenges faced by women and girls. Other necessary indicators must be developed about the specific effects of HIV and AIDS on women, such as access to testing, counseling, and treatment among women who are not pregnant. Integration of HIV services and contraception provision, as well as violence experienced by all women - not just those who are married or cohabiting – need to be addressed, especially as research has repeatedly shown that sexual violence puts women and girls at elevated risk of contracting HIV.

Further details: /newsletter/id/38577
Efficiency of Health System Units in Africa: A Data Envelopment Analysis
Kirigia JM: University of Nairobi Press, 2013

Despite spending huge sums of money on health every year the African regions burden of disease is persistently high. Weaknesses are identified in factors as health leadership and governance, service delivery, health workforce, medicines, vaccines, and health technologies; health information; and health system financing that have undermined the capacity of health systems of countries in the region to improve population health without wastage of resources. In this book, the author applies a data envelopment analysis technique, interlacing lecture notes with research articles and case studies to equip students and practitioners of economics, operations research, management science, and public health with knowledge and skills for undertaking technical efficiency, allocative efficiency, cost efficiency, and total factor productivity analyses.

Embedding health policy and systems research into decision-making processes in low- and middle-income countries
Koon AD, Rao KD, Tran NT and Ghaffar A: Health Research Policy and Systems 11(30), 8 August 2013

This literature review was conducted to identify examples of embedded health policy and systems research (HPSR) used to inform decision-making in low- and middle-income countries (LMICs). The authors found that multiple forces converge to create context-specific pathways through which evidence enters into decision-making. Depending on the decision under consideration, the literature indicates that decision-makers may call upon an intricate combination of actors for sourcing HPSR. While proximity to decision-making does have advantages, it is not the position of the organisation within the network, but rather the qualities the organisation possesses, that enable it to be embedded. These findings suggest that four qualities influence embeddedness: reputation, capacity, quality of connections to decision-makers, and quantity of connections to decision-makers and others. In addition to this, the policy environment (e.g. the presence of legislation governing the use of HPSR, presence of strong civil society, etc.) strongly influences uptake. The authors’ conceptual model highlights several important considerations for decision-makers and researchers about the arrangement and interaction of evidence-generating organisations in health systems.

Translating health research evidence into policy and practice in Uganda
Mbonye AK and Magnussen P: Malaria Journal 12(274), 5 August 2013

In Uganda, a team of researchers, policy makers, civil society and the media has been formed to build a collaboration that would help in discussing appropriate strategies to mitigate the high disease burden in Uganda. A preparatory secretariat identified researchers and key resource persons to guide four workshops, which were held between 2006 and 2009. A total of 322 participants attended of whom mid-level policy makers, researchers and the media were consistently high. The workshops generated a lot of interest that lead to presentation and discussion of nationally relevant health research results. The workshops had an impact on the participants’ skills in writing policy briefs, participating in the policy review process and entering into dialogue with policy makers. A number of lessons were learned: getting health research into policy is feasible but requires few self-motivated individuals to act as catalysts; and adequate funding and a stable internet are necessary to support the process. Mid-level policy makers and programme managers had interest in this initiative and are likely sustain it as they move to senior positions in policy making, the authors report.

14. Useful Resources

Getting Started: A Medical Research and Development Primer
FasterCures: 2012

This Primer contains tools and resources to help navigate the medical research and development (R&D) paradigm. The Primer provides information on discovery research; translational research; clinical research; regulatory application and approval; and non-profit actors and their roles in the R&D process.

Global Health Primer
Bio Ventures For Global Health (BVGH): 2013

The Global Health Primer connects the innovators that drive research and development for new drugs, vaccines and diagnostics to the neglected diseases where innovation is desperately needed. It provides a source of compiled and synthesised information for 25 neglected diseases of the developing world and the drugs, vaccines, and diagnostics in use or in development for the management of these diseases. The Primer tracks and analyses progress in global health research and development, provides an evidence base to support decision making, policy change and action, and brings new innovators to the table to address the main medical needs of poor people.

Rapid Retention Survey Toolkit: Designing Evidence-Based Incentives for Health Workers
CapacityPlus: 2012

In the context of severe health worker shortages in rural areas, this toolkit is intended to help health leaders find out what motivates health workers to accept posts in rural areas and to stay there. The toolkit builds on the World Health Organisation’s global policy recommendations for rural retention and is based on the discrete choice experiment, a powerful research method that identifies the trade-offs health professionals are willing to make between specific job characteristics and determines their preferences for various incentive packages, including the probability of accepting a post in a rural health facility. The toolkit guides human resources managers through a survey process to rapidly assess health professional students’ and health workers’ motivational preferences to accept a position and continue working in underserved facilities. It allows for rapid data-gathering and analysis, and the results can be used to create evidence-based incentive packages. It includes step-by-step instructions, sample formats, and examples that can easily be adapted to a specific country context, including survey planning, survey design, survey instrument development using a specialised software programme, survey administration, data analysis and interpretation, and how to present results to stakeholders.

Where there is no lawyer: Guidance for fairer contract negotiation in collaborative research partnerships
Marais D, Toohey J, Edwards D and Jsselmuiden CI: COHRED, 2013

Recent snapshot surveys of research institutions in the African and Asian regions have revealed some significant gaps in the contracting and contract management capacity of low- and middle-income country (LMIC) institutions in these regions. Many institutions had not previously considered research contracting to be a legal issue and reported having no specialist legal expertise, with the result that contractual terms and conditions were often poorly understood. Without adequate legal capacity, contract negotiations can lead to agreements which disadvantage the LMIC partner. This guidance booklet is aimed at optimising research institution building through better contracts and contracting in research partnerships. It highlights the key issues for consideration when entering into formalised research partnerships, and provides tools and resources for negotiating fairer research contracts. Better contract negotiation expertise in LMIC institutions will help improve the distribution of benefits of collaborative research, such as overhead costs, data ownership, institutional capacity in research management, technology transfer, and intellectual property rights.

15. Jobs and Announcements

Call for participants: East and Southern Africa regional training workshop on participatory methods for a people-centred health system: Strengthening community focused, primary health care oriented approaches to social accountability and action: 7–11 Octo
Deadline: 3 September 2013

TARSC, through COPASAH, a network for accountability in health, and EQUINET, are planning to hold a regional workshop on Participatory Approaches to Strengthening People Centred Health Systems in the east and southern African region, focusing on ways of improving public involvement, social action and accountability in health for local action and advocacy. The workshop will explore how to raise community voice in strengthening the resourcing and functioning of primary health care (PHC) systems through the use of participatory approaches to build community roles in accountability and action. It seeks to support work at national, district and local level with health systems and communities in health, with a major focus on the interactions at primary health care level. Interested applicants should submit a one or two page ‘expression of interest’, a personal CV including community based research and training and any prior experience of, training in or use of PRA or social accountability methods, and some brief information on the institution that they work in. Note that applicants who are not already members of COPASAH are requested to complete their membership form on line as part of the application process. See http://www.copasah.net/copasah-membership.html

Further details: /newsletter/id/38580
IDRC Doctoral Research Awards
Deadline: 2 October 2013

IDRC offers these awards twice a year in April and October to Canadians, permanent residents of Canada, and citizens of developing countries pursuing doctoral studies at a Canadian university. They are intended for field research in one or more developing countries, and are aimed at promoting the growth of Canadian and developing-country capacity in research on sustainable and equitable development from an international perspective. Candidates must conduct their research in areas corresponding to IDRC programme priorities and must ensure that their research project aligns with these priorities. IDRC is looking for field research proposed in specific developing countries, including only two countries in east, central and southern Africa: Democratic Republic of Congo and Zimbabwe. These awards support field research of three to 12 months and cover justifiable field research expenses up to US$19,000 a year.

Study While You Work: Applications For 2014 Master in Public Health (MPH)
Applications Close: 3 September 2013

The MPH at the University of the Western Cape aims to equip health professionals to: quantify and prioritise health needs; design, implement and evaluate Comprehensive Primary Health Care Programmes; and manage District Health Systems. The Programme is designed for a range of health and welfare professionals and managers from middle to senior level, at district, provincial or national levels, staff of NGO’s and academic research contexts. The Programme may be taken over two to three years. Admission requirements: A four year degree (Honours Degree) or its equivalent in any discipline, or in exceptional cases, five years of relevant experience assessed by the university through a Recognition of Prior Learning (RPL) process. Contact Mrs Janine Kader at the email address given.

UCT Rehabilitation Conference 2013
2-4 September 2013: Cape Town

The Department of Health and Rehabilitation Sciences at the University of Cape Town, South Africa, is holding its first Rehabilitation Conference in September 2013. The conference will host speakers from diverse disciplinary fields on a range of themes such as: policy: influencing development and implementation; evidence for action: a research agenda; responsive rehabilitation service delivery; and optimising human resourcing for rehabilitation.

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