EQUINET NEWSLETTER 152 : 01 October 2013

1. Editorial

Addressing health inequities through Universal Health Coverage
Lara Brearley, Save the Children

Addressing inequities in access to quality needed care and financial risk protection must be a first priority in efforts to achieve Universal Health Coverage (UHC). We have the opportunity to implement equitable pathways towards UHC by including appropriate targets and measures in the post-2015 development framework. These are the main messages of a joint report titled ‘Universal Health Coverage: A commitment to close the gap’ launched this month by Save the Children, the Rockefeller Foundation, UNICEF and WHO and available at http://www.savethechildren.org.uk/resources/online-library/universal-health-coverage.

Prioritising equity in pathways towards UHC is not just the right thing to do from a moral perspective, but it also brings value for money. Research implemented for the report reveals that the deaths of 1,8 million children under-five and 100 000 mothers could be averted each year by eliminating wealth related inequities that occur within countries in the coverage of essential maternal and child health interventions in 47 of the 75 countries where more than 95% of all maternal and child deaths occur (http://www.countdown2015mnch.org/). If in 2013 to 2015 all groups were able to reach the coverage levels of the highest fifth of people by wealth, this would reduce maternal and child mortality by almost one-third and one-fifth respectively.

We present evidence in the report that more equitable health financing saves lives. Pooled funding comes from prepayments and pooling makes it available to distribute to those with higher need. If the share of health financing that is pooled were to increase by ten percentage points, while keeping total health expenditure constant, we estimate in the report that there would be fifteen fewer deaths in children under five years of age for every 1000 live births in the same 75 countries on average. This could enable thirteen countries that are currently off-track to achieve their Millennium Development Goal (MDG) 4 target of a two-thirds reduction in the rate of child mortality. In countries where health services are more equitably distributed, the reduction in child deaths may be even greater.

It is thus possible to make huge improvements in health outcomes and access to health care. It is possible, for instance, to reduce by almost half the number of children who die each year when compared to the rates in 1990. Despite this, too many people are denied their right to health. In 2012 for instance, 6,6 million children died before the age of five and most of these deaths could have been prevented. High levels of out-of-pocket payments (cash at point of care) for health care act as a barrier for poor people to access the care they need or can lead to an increase in poverty due to health spending. About 150 million people are estimated to incur catastrophic (impoverishing) expenditures for health care each year. This is a scandal that must be addressed.

The health system’s response to this challenge must be Universal Health Coverage – which we define as ensuring “that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them”. Momentum for UHC is soaring at country and global levels, and this must be seized to ensure the needs of the poor and vulnerable are prioritised as countries design and implement the policy reforms for UHC.

In the report we identify a number of policy lessons for equitable pathways towards UHC in low- and middle-income countries, particularly in relation to health financing. One policy lesson is that countries increase equitable funding for health through mandatory, progressive prepayment mechanisms, including revenues from taxation, and eliminate out-of-pocket spending. Risk and resource pools must be consolidated to facilitate effective redistribution. A universal benefit package should be designed for all, and delivered in a manner that meets the needs of the poorest and most vulnerable in society, through strategic purchasing of services and through providing incentives that ensure health providers promote quality of care. The policy lessons point to the importance of taking a ‘whole-system’ approach to UHC, and for coordinating reforms across health system building blocks such as financing, health workers, commodities, social participation and others. To overcome pervasive inequities in the coverage of quality health services and to ensure that people are not impoverished from health spending we need to also act on the wider social determinants of health. Political will and strong mechanisms for effective accountability are critical for implementing the measures needed for equitable pathways towards UHC.

As the MDGs have shown, what gets measured is more likely to get done. Negotiations on the sustainable development agenda must guide equitable progress towards UHC, with clear indicators of and targets for such measures that strengthen health systems and close the equity gap.

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 visit www.savethechildren.org.uk/resources/online-library/universal-health-coverage and www.equinetafrica.org

2. Latest Equinet Updates

Bringing African Perspectives to Global Health Diplomacy discourse
Dept of Health South Africa, University of Pretoria, EQUINET: Public Health Association of South Africa Conference workshop, Cape Town, 25 September 2013

EQUINET co-operated with Department of Health South Africa and University of Pretoria to co-host a workshop at the September 2013 PHASA conference on African Perspectives in Global Health diplomacy. The workshop explored, through an interactive panel discussion, how African countries could and are positioning themselves to advance African health interests in global health discourse. It involved speakers from Ministry of Health, Kenya, from EQUINET, from Department of International Relations and Cooperation, South Africa and ambassadors and programmes from countries that have health co-operation with Africa. The panellists and delegates explored African experiences of foreign policy and global diplomacy for health and the opportunities, risks, key issues and lessons for African countries in raising health as a foreign policy issue.

3. Equity in Health

Equity in Maternal Health in South Africa: Analysis of Health Service Access and Health Status in a National Household Survey
Wabiri N, Chersich M, Zuma K, Blaauw D, Goudge J, Dwane N: PLoS ONE 8(9): e73864. doi:10.1371/journal.pone.0073864 September 2013

South Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources.
This analysis drew on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data. The survey found that the poorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile (95%CI adjusted odds ratio = 1.2–6.1). Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group. Aside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health.

Inequalities in multimorbidity in South Africa
Ataguba J: International Journal for Equity in Health, 12:64, 2013

Very little is known about socioeconomic related inequalities in multi-morbidity, especially in developing countries. Traditionally, studies on health inequalities have mainly focused on a single disease condition or different conditions in isolation. This paper examines socioeconomic inequality in multi-morbidity in illness and disability in South
Africa between 2005 and 2008. Data were drawn from the 2005, 2006, 2007, and 2008 rounds of the nationally representative annual South African General Household Surveys. Indirectly standardised concentration indices were used to assess socioeconomic inequality. A proxy index of socioeconomic status was constructed, for each year, using a selected set
of variables that are available in all the GHS rounds. Multi-morbidity in illness and disability were constructed using data on nine illnesses and six disabilities contained in the GHS. Multi-morbidity was found to affect a substantial number of South Africans. Most often, based on the nine illness conditions and six disability conditions considered, multi-morbidity in illness and multi-morbidity in disability were each found to
involve only two conditions. In 2008 in South Africa, the multi-morbidity that affected the greatest number of individuals combined high blood pressure with at least one other illness. Between 2005 and 2008, multi-morbidity in illness and disability was more prevalent among poor people; in disabilities this is yet more consistent. While there is a dearth of information on the socioeconomic distribution of multi-morbidity in many
developing countries, the paper shows that its distribution in South Africa indicates that the poor bear a greater burden of multi-morbidity. The author argues that, given the high burden and skewed socioeconomic distribution of multi-morbidity, there is a need to design policies to address this situation, and surveys that specifically assess multi-morbidity.

4. Values, Policies and Rights

Litigating health rights: Can courts bring more justice to health?
Alicia Ely Yamin: Center for Health and Human Rights, Harvard University, Boston, MA, for the 141st APHA Annual Meeting, November 2013

Beginning with HIV and AIDS cases, the last fifteen years have seen a tremendous growth in the number of health rights cases. Yet questions still persist as to when and how litigation can lead to greater social justice in health and enhance the functioning of health systems, rather than distorting practices. In a number of countries, courts are in effect setting health policy and shaping funding priorities. Yet, little systematic attention has been paid to the equity implications of this litigation. Based on a comprehensive study of litigation in Argentina, Brazil, Costa Rica, Colombia, India and South Africa, this presentation traces the beginnings of health rights litigation; reviews factors leading to judicial activism in health around the world; stresses the importance of differentiating contexts and kinds of interventions; and will discuss different methodologies for measuring impacts of litigation. Health rights litigation is extremely varied around the world. Factors that must be considered in assessing equity implications relate to the legal opportunity structure as well as other dimensions of the legal system, the organization of the health system, and the way in which the executive branch responds to judicial decisions.

Making Health a Right for all: Universal health coverage and Nutrition
ACF Int, Global Health Advocates, Terre des Hommes: France, 2013

This briefing paper explores how UHC can deliver on nutrition, and addresses in particular maternal and child undernutrition. The authors point to the need to ensure that Universal Health Coverage (UHC) can deliver on the fight against undernutrition. They recommend that national, European and global development policies consider a shift from emergency-focused interventions to ones that prevent and treat undernutrition. Budgetary and extra-budgetary resources need to be mobilised within health programs to reach UHC for scaling up the implementation of nutrition interventions. They present evidence that the implementation of community approaches will be mostly effective if designed in an integrated manner combining the most effective child and maternal interventions. Governments, through pooled risk funding,should ensure access for the most vulnerable and marginalised groups as defined by the specific country context and scale up the implementation of effective nutrition specific interventions within the health policies to reach UHC, such as by integrating the prevention and treatment against chronic and sever acute malnutrition into the management of childhood illnesses of WHO guidelines; and integrating at the national level the prevention and treatment of chronic acute malnutrition or severe acute malnutrition into primary health
care packages.

5. Health equity in economic and trade policies

Beijing Declaration of the Ministerial Forum of China-Africa Health Development
Ministers of health of the People’s Republic of China and African countries, August 2013

The ministers of health of the People’s Republic of China and African countries as well as representatives of the African Union, the World Health Organization, UNAIDS, UNFPA, UNICEF, the World Bank, the Global Fund to fight against HIV / AIDS Fund, Tuberculosis and Malaria and GAVI, met in Beijing in August 2013 to implement the Beijing Action Plan 2013-2015, adopted by the 5th China-Africa Cooperation Forum Ministerial in 2012. Under the theme of “Priorities of China-Africa Cooperation Health in the New Era”, the meeting reviewed previous health cooperation between China and Africa and reached consensus on the priorities for and ways of health cooperation. The meeting agreed on various areas of future links including on health worker training; cooperation between research institutions in China and Africa, strengthening of health information systems; prevention and control of communicable and non-communicable diseases; support for health infrastructure development donating modulated clinics to Africa, adapted to local conditions; cooperation in standard setting and inspection of medical products through capacity building and use of appropriate technology and promotion of health technology transfer to reduce the price of health commodities including pharmaceuticals, diagnostics, vaccines and equipment, and to increase their affordability.

China-Africa Health Cooperation: A New Era?
Victoria Fan, Center for Global Development

Since 2000, China has hosted six ministerial Fora on China-Africa Cooperation (FOCAC), held every three years, in which health is but one of many areas of attention. In the last FOCAC, the accompanying Beijing Action Plan for 2013-15 listed cooperation in many areas – 6 in political, 9 in economic, 6 in cultural, and 6 in development – of which ‘medical aid and public health’ is one. This opinion piece discusses the strengths and challenges of the inaugural forum on health held in August 2013 and the Beijing declaration after the Forum, seen by the author to mark a turning point in the history of Chinese development and health cooperation to Africa. The author notes that China’s top-level leadership clearly sees the political, economic, and perhaps health importance of global engagement especially in Africa.

Further details: /newsletter/id/38657
East African Agriculture and Climate Change: A Comprehensive Analysis
Waithaka M, Nelson G, Thomas T, Kyotalimye M: IFPRI issue brief 76 August 2013

How to foster agricultural development and food security in East Africa as the effects of climate change become more serious is the subject of the study East African Agriculture and Climate Change: A Comprehensive Analysis. The authors develop several weather-based scenarios for how climate change might affect countries in the region between now and 2050. National contributors from Burundi, the Democratic Republic of Congo (DRC), Eritrea, Ethiopia, Kenya, Madagascar, Rwanda, Sudan, Tanzania, and Uganda review the scenario results for their countries and propose a variety of policies to counter the effects of climate change on agriculture and food security. These policies include greater investment in agricultural research and extension, equitable access to land and inputs such as seeds and fertilizer, expanded irrigation, and improved infrastructure.

6. Poverty and health

GMOs - who will feed us and what will they feed us?
Amamu NA: Pambazuka news 647 September 2013

The International Convention for the Protection of New Varieties of Plants, known as UPOV 91 is argued by the author to be dangerous to African farmers. It will force farmers to buy patented corporate seeds and agrochemicals from the same corporations. The ETC Group, the Action Group on Erosion, Technology, and Concentration has released the report: ‘Putting the Cartel Before the Horse …and Farm, Seeds, Soil, Peasants, etc. Who Will Control Agricultural Inputs, 2013?’ The report details how the agribusiness giants have gobbled up most of the seed and agrochemical companies and control most of the agriculture in the US and Europe and are now aiming to take over the agriculture of the global south, particularly Africa. Peasant farmers, who feed at least 70 percent of the world’s population – are not tied to the corporate seed chain. The agribusiness giants want to tie them in. They are focusing on ‘education’ which seeks primarily to stop farmers from saving seeds.

Population Trends and Policy Options in Selected Developing Countries
Thomas J: Partners in Population and Development, Bangladesh, 2012

This compendium of Population Stabilisation Reports was an outcome of the research work done by different authors from the nine countries namely Bangladesh, India (Bihar), Ghana, Kenya, Mali, Nigeria, Senegal, Uganda and Zimbabwe. The reports focus on the demographic realities that take into consideration the age structure, sex ratios, migrations, population projections as well as adolescent pregnancy, fertility and mortality. The historical, religious, cultural, political, resource and environmental considerations are reviewed in the reports. The underlying principals of poverty eradication, sustainable growth, universal education, with a focus on girls, gender equality and empowerment, food security, access to primary health services and a rights-based approach to sexual and reproductive health, are fundamental to the principals and practices that are prescribed within the framework of the reports. The edited book provides an integrated approach to changing
population stabilisation strategies, including attention to sustainable development and gender equity, with case studies from African countries.

7. Equitable health services

Accounting for geographical inequalities in the assessment of equity in health care: a benefit incidence analysis
Anselmi L, Fernandes Q, Hanson K, Lagarde M: The Lancet, 381, S9, 17 June 2013

Equity in health expenditure in low-income and middle-income countries is commonly analysed using benefit incidence analysis (BIA). In BIA, the monetary value of the subsidy associated with public sector health-care utilisation (approximated by the cost of the service) is attributed to each individual according to their frequency and type of health-care utilisation. The benefit distribution is measured according to socioeconomic status. Despite widespread within-country geographical inequalities in health status and public expenditure, BIA has rarely accounted for such differences. The authors investigate how results would differ if geographical inequalities were taken into account for outpatient public health-care expenditure in Manica Province, Mozambique using data from the Household Budget Survey 2008/09, Census 2007, Ministry of Health, and Ministry of Finance records. The analysis showed that the gap in benefit from public expenditure between highest and lowest quintiles widened substantially if differences in health status and expenditure across districts are taken into account, increasing from a ratio of 1.2 to 2.0. Results suggest that the methods currently used may underestimate inequities in public health expenditure in contexts where geographical inequalities exist. Refinement of BIA using disaggregated data available from local institutions may improve estimates, stimulate local information systems' strengthening, and ultimately provide insights for a more equitable and efficient allocation of resources.

Closing the poor-rich gap in contraceptive use in urban Kenya: are family planning programs
Fotso JC, Speizer IS, Mukiira C, Kizito P, LumumbaV: International Journal for Equity in Health 12:71, 2013

Kenya is characterized by high unmet need for family planning (FP) and high unplanned pregnancy, in a context of urban population explosion and increased urban poverty. It witnessed an improvement of its FP and reproductive health (RH) indicators in the recent past, after a period of stalled progress. The paper describes inequities in modern contraceptive use, types of methods used, and the main sources of contraceptives in urban Kenya; examines the extent to which differences in contraceptive use between the poor and the rich widened or shrank over time; and attempts to relate these findings to the FP programming context, with a focus on whether the services are increasingly reaching the urban poor. It uses data from the 1993, 1998, 2003 and 2008/09 Kenya demographic and health survey. The authors found a dramatic change in contraceptive use between 2003 and 2008/09 that resulted in virtually no gap between the poor and the rich in 2008/09, by contrast to the period 1993–1998 during which the improvement in contraceptive use did not significantly benefit the urban poor.

Distance as a barrier to health care access in South Africa
aren Z, Ardington C, Leibbrandt M: SALDRU Working paper 97, June 2013

Access to health care is a particular concern given the centrality of poor access in perpetuating poverty and inequality. Even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Using new data from the first nationally representative panel survey in South Africa together with administrative geographic data from the Department of Health, the authors investigate the role of distance to the nearest facility on patterns of health care utilization. Ninety percent of South Africans live within 7km of the nearest public clinic, and two-thirds live less than 2km away. However, 15% of Black African adults live more than 5km from the nearest facility, in contrast to only 7% of coloureds and 4% of whites. There is a clear income gradient in proximity to public clinics. The poorest people tend to reside furthest from the nearest clinic and an inability to bear travel costs constrains them to lower quality health care facilities. Within this general picture, men and women have different patterns of health care utilization, with the reduction in utilization of health care associated with distance being larger for men than it is for women.

8. Human Resources

Understanding the factors influencing health-worker employment decisions in South Africa
George G, Gow J and Bachoo S: Human Resources for Health 11(15), 23 April 2013

Little is known about the nonfinancial factors that influence South African health workers’ (HWs) choice of employer (public, private or nongovernmental organisation) or their choice of work location (urban, rural or overseas). To fill these gaps in the literature, researchers used a cross-sectional survey to gather data in 2009 in the province of KwaZulu-Natal. HWs in the public sector reported the poorest working conditions, as indicated by participants’ self-reports on stress, workloads, levels of remuneration, standard of work premises, level of human resources and frequency of in-service training. However, HWs in the NGO sector expressed a greater desire than those in the public and private sectors to leave their current employer. The authors call for innovative efforts to address the causes of HWs dissatisfaction and to further identify the nonfinancial factors that influence work choices of HWs. Policymakers must consider a broad range of nonfinancial incentives that encourage HWs to remain in the already overburdened public sector.

9. Public-Private Mix

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

Public-private collaborations are increasingly being utilized to universalize health care. In Malawi, the Ministry of Health contracts selected health facilities owned by the main faith-based provider, the Christian Health Association of Malawi (CHAM), to deliver care at no fee to the most vulnerable and underserved populations in the country through Service Level Agreements (SLAs). This study examined the features of SLAs and their effectiveness in expanding universal coverage. The study involved a policy analysis focusing on key stakeholders around SLAs as well as a case study approach to analyse how design and implementation of SLAs affect efficiency, equity and sustainability of services delivered by SLAs. It used qualitative and quantitative research methods in five CHAM health facilities, with national and district level decision makers and providers and clients associated with the health facilities. 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 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. There was strong consensus and shared interest between the government and CHAM regarding SLAs. The free services provided by SLAs had an impact on the impoverished locals that used the facilities. However, lack of supporting systems, inadequate infrastructure and shortage of health care providers affected SLA performance.

10. Resource allocation and health financing

Efficiency and effectiveness of strategies for promoting access for the poor and vulnerable groups within user fee system: Mwanza and Misungwi districts, Tanzania
Kumallja GJ: MPH Thesis University of Dar es Salaam, September 2013

The implementation of user fees while fostering equity in access of quality health services for the poor is still a problem in health facilities in Tanzania. A cross sectional exploratory descriptive study was conducted in Mwanza at Sekou- Toure (public) and Bukumbi (Voluntary) hospitals in June 2002 to investigate the strategies for promoting access for the poor and vulnerable groups within their user fee systems, through exit interviews, documentary reviews and observations. Of 150 respondents from each hospital, only 36% of the public and 26% of the voluntary hospitals respondents were aware of the existence of the exemption mechanism in those hospitals. The findings from the study showed that the strategies implemented by the public and voluntary hospitals are not enough to effectively and efficiently identify the poor in their user fee system. The implementation of user fees while fostering equity in access of quality health services for the poor is still a problem in health facilities in Tanzania.

Human Rights, Social Inclusion and Health Equity in International Donors' Policies
Eide AH, Amin M, MacLachlan M, Mannan H, Schneider M: Disability, CBR and Inclusive Development Journal, 23, 4, 144, 2012

Health policies have the potential to be important instruments in achieving equity in health. A framework – EquiFrame - for assessing the extent to which health policies promote equity was used to perform an equity audit of the health policies of three international aid organizations, to assess the extent to which social inclusion and human rights feature in the health policies of DFID (UK), Irish Aid, and NORAD (Norway). EquiFrame was used as a tool for analysing equity and quality of health policies with regards to social inclusion and human rights. Each health policy was analyzed with regards to the frequency and content of a predefined set of Vulnerable Groups and Core Concepts. The three policies varied but were all relatively weak with regards to social inclusion and human rights issues as defined in EquiFrame. The needs and rights of vulnerable groups for adequate health services were largely not addressed. In order to enhance a social inclusion and human rights perspective that will promote equity in health through more equitable health policies, it is suggested that EquiFrame can be used to guide the revision and development of the health policies of international organizations, aid agencies and bilateral donors in the future.

11. Equity and HIV/AIDS

Does the ‘inverse equity hypothesis’ explain how both poverty and wealth can be associated
Hargreaves JR, Davey C, White RG: J Epidemiol Community Health 67: 526–529, 2013

Whether it is relative wealth or relative poverty that drives the HIV epidemic in sub-Saharan Africa, is a controversial aspect of HIV/AIDS epidemiology. The authors suggest that the social epidemiology of HIV in Africa is changing. Previously, new infections were more rapidly acquired by those of relatively higher socioeconomic position (SEP). More recently, those of relatively low SEP are at greater risk. The authors explored in this paper whether the pattern would be compatible with the ‘inverse equity hypothesis’, that suggests that those of higher SEP benefit first from new health interventions. Using available evidence from the region, the authors suggest that in the early phase of the epidemic, HIV infections were concentrated among those of higher SEP in many countries. The inverse equity hypothesis suggests that new infections will increasingly concentrate among those of lower SEP. If further analysis confirms this hypothesis, the authors suggest that policy responses must be considered to ensure that interventions reach poorer groups and that structural approaches tackle the social determinants of HIV infection.

12. Governance and participation in health

A review of the role of civil society in advocacy and lobbying for enforcement of health policy in Kenya
Omungu PA: African Population Studies, 25, s1, 78-91, 2011

Advocacy and lobbying are more taking an ever more central place in health agendas of African countries. It is impossible to have a conversation about public policy these days without someone mentioning 'civil society'. The author argues that clarity and rigor are conspicuously absent within civil society. A States' first duty towards citizens is to respect the right to health by refraining from adopting laws or measures that directly impinge on people's health. The paper presents evidence from the literature of civil society organization (CSO) intervention in support of primary health care, equity in health and state health services covering 38 online documents and from interviews with key informants from government and civil society. They suggest from the findings that countries ensure that public health principles and priorities are clear and legally binding; that countries have a clear coordinating mechanism on issues of trade and health that involve government, particularly health ministries and civil society and that civil society disseminate health and trade information in accessible ways.

Frustrated Freedom: The Effects of Agency and Wealth on Wellbeing in Rural Mozambique
Victor B, Fischer E, Cooil B, Vergara A, Mukolo A, Blevins M: World Development, 47, 30-41, July 2013

In the capability approach to poverty, wellbeing is threatened by both deficits of wealth and deficits of agency. Sen describes that “unfreedom,” or low levels of agency, will suppress the wellbeing effects of higher levels of wealth. In this paper the authors introduce another condition, “frustrated freedom,” in which higher levels of agency belief can heighten the poverty effects of low levels of wealth. Presenting data from a study of female heads of household in rural Mozambique, they find that agency belief moderates the relationship between wealth and wellbeing, uncovering evidence of frustrated freedom.

“by seeing with our own eyes, it can remain in our mind.”: Evidence of participatory video's ability to reduce gender-based violence in conflict-affected settings
Gurman T, Trappler R, Acosta A, Cooper C, Goodsmith L: 141st APHA Annual Meeting, November 2013

Although gender-based violence (GBV) exists worldwide, it is especially pervasive and challenging in conflict-affected settings. The breakdown of the family unit, high population density, and lack of community safeguards pose obstacles to implementation of GBV prevention programs. Unfortunately, little evidence exists regarding effective GBV prevention interventions in these settings. Through Our Eyes (TOE), a multi-year participatory video project, addressed GBV by stimulating community dialogue and action in humanitarian settings in South Sudan, Uganda, Thailand, Liberia and Rwanda. The authors used evidence from transcripts from focus group discussions and key informant interviews with individuals who created the videos to those who attended video screenings. Data was analysed using a Grounded Theory approach. The assessment found that TOE contributed to a growing awareness of women's rights and gender equity. Furthermore, both men and women reported attitudinal and behavioural changes related to topics such as intimate partner violence. The fostered community dialogue helped de-stigmatize GBV and encourage survivors to access services. Participatory video is argued to have the ability to tailor messages to specific community needs, engage men as key players, foster community dialogue, and initiate social change related to GBV in a variety of conflict-affected settings. The authors argue that public health professionals should employ participatory video as an innovative technique to address GBV and promote positive gender norms within conflict-affected and other humanitarian settings.

13. Monitoring equity and research policy

Strengthening local-level cause of death surveillance: a case study of Western Cape Province, South Africa
Groenewald P, Naledi T, Daniels J, Shand L, Neethling I, Berteler M, Misra M, Jacobs C, Thompson V, Msemburi W, Matzopoulos R, Bradshaw R: The Lancet, 381, S54, 17 June 2013

The Western Cape Province has a local-level mortality surveillance system that has been upgraded to do automated cause of death coding using IRIS software, in concordance with the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes. This paper reviews the achievements in providing district-level and subdistrict-level mortality data, and describes the lessons learnt and the challenges for sustaining such a system. Cause of death coding was upgraded from a shortlist to full ICD-10 coding for natural causes of death in a customised data capture system. A total of 33 564 deaths from natural causes were coded for 2009, with 9.4% due to ill-defined causes. Completeness was estimated at 83.7% and mortality profiles were provided for all health districts for the first time, highlighting district variations in age-standardised mortality rates, although HIV and tuberculosis were the leading causes of premature mortality across all districts. It is necessary to train data capturers in medical terminology and doctors in death certification, as well as building quality assurance measures into the system. Local cause of death coding enables quality issues to be identified and addressed directly at source. IRIS makes it possible to standardise coding across districts for routine cases. Dissemination of local mortality information creates a demand for updated results, which are sometimes difficult to meet. Challenges include securing the appropriate resource allocation, integrating into a fragmented health system, and ensuring co-operation between government departments. Utilisation of information technology opportunities (eg, electronic registration of death) remains a challenge.

14. Useful Resources

Conference in Global Health Diplomacy: The new realm in international relations- event video
ECSA Health Community, Arusha, August 2013

This video covers the one day meeting held by the ECSA Health Community on global health diplomacy prior to the ECSA HC best practices forum.

The women sing at both sides of the Zambezi
Audio-library established by African women

This is an audio-library established by African women to share their stories and knowledge with their sisters across the continent, and with all listeners wherever they are. The collection celebrates the art and power of storytelling, and the creativity of African women, their achievements in arts, culture and media. The current weekly on-line release of new interviews forms a foundation for audio-visual training and creative media projects with women in the Zambezi region in 2014. The doors of this internet-archive are always open for listeners and for storytellers, who wish to contribute their stories and responses to the collection. In October, “Ibhayisikopo Film Project” and “radio continental drift” will join forces for a women-driven film- and media project. We want to train young women in Bulawayo as trainers in film-production and creative media. The facilitators are inviting listeners, artists and storytellers to build the sound-library of storytelling by contribute local recordings to the All Africa Sound Map and place African arts and culture on the global map.

15. Jobs and Announcements

Call for applicants: Consultancy for e-mHealth Strategy Development for ECSA HC
Call closes 27 October 2013

This call is for a consultant to design an E/M health strategy and its implementation plan for the ECSA Health Community region in consultation with relevant stakeholders and regional players, ie to undertake an in-depth assessment of the status of implementation of e/mhealth in the ECSA region; present the findings of the assessment to ECSA secretariat; develop the draft regional e/mhealth strategy based on the findings of the situational assessment and an implementation plan for the strategy and present it at a draft regional validation workshop and submit the final regional e/mhealth strategy to ECSA secretariat. Further details at the ECSA HC website.

Call for applicants: Consultant Documentation and Sharing of Best Practice in Retention of Health Workers: Assessment of Kenya and Malawi Retention Packages
Call closes 30 November 2013

The main purpose of the assignment is to document and share best practices on retention of HRH as a strategy for motivation and improved productivity with specific objectives of: determining the various retention strategies in Kenya and Malawi; identifying best practices in retention of health workers, including those for reproductive health and family planning; and
benchmarking with best practices regionally and internationally with a view to create a conducive environment for public health workers. Further information can be found on the ECSA HC website.

Call for Applicants: Human Rights Scholarship
Deadline: 31 October 2013

The Human Rights Scholarship (HRS) is awarded to local or international applicants wishing to undertake graduate research studies at the University of Melbourne in the human rights field and who are able to demonstrate their commitment to the peaceful advancement of respect for human rights. Each year the University offers two HRSs. Applicants must be able to demonstrate that their commitment to the peaceful advancement of respect for human rights extends beyond their academic studies (such as voluntary work and/or work experience). Applicants must have applied for, or be currently enrolled in a graduate research degree in the human rights field at the University of Melbourne. Applicants who have commenced their graduate research degree must have at least 12 months full-time or equivalent candidature remaining. International students must have an unconditional course offer at the University of Melbourne for the course for which they seek the support of a HRS.

Call for papers: Science & practice of people-centred health systems
Deadline: 13 November 2013

The journal Health Policy and Planning and the organisers of the Third Global Symposium on Health Systems Research are pleased to issue a call for papers for a special supplement on the theme of "The science and practice of people-centred health systems". People-centred health systems are founded on pro-people philosophies of social justice and equity, recognise the role of social exclusion and inequities as determinants of poor health, and can also actively work to address them. They consider the health needs and preferences of individuals, families and communities, and create the channels through which these can be articulated and realised. They also recognise and actively progress people’s rights to participate in and determine how health systems are organised, resources are allocated, and services are delivered. Original research articles as well as review papers are invited. The theme may reflect either in the topic or focus of the paper (e.g. research on people-led governance, health worker rights or patient-led health care), in the analytical approach adopted (e.g. ethical analysis, approaches that help understand people’s behaviour and motivation), or in the manner of conduct of research (e.g. participatory approaches, focus on researcher reflexivity).

Call for Papers: Science & Practice of People-Centred Health Systems
Deadline: 13 November 2013

The journal Health Policy and Planning and the organisers of the Third Global Symposium on Health Systems Research are pleased to issue a call for papers for a special supplement on the theme of "The science and practice of people-centred health systems". People-centred health systems are founded on pro-people philosophies of social justice and equity, recognise the role of social exclusion and inequities as determinants of poor health, and can also actively work to address them. They consider the health needs and preferences of individuals, families and communities, and create the channels through which these can be articulated and realised. They also recognise and actively progress people’s rights to participate in and determine how health systems are organised, resources are allocated, and services are delivered. Original research articles as well as review papers are invited. The theme may reflect either in the topic or focus of the paper (e.g. research on people-led governance, health worker rights or patient-led health care), in the analytical approach adopted (e.g. ethical analysis, approaches that help understand people’s behaviour and motivation), or in the manner of conduct of research (e.g. participatory approaches, focus on researcher reflexivity).

Civil Society Week: Bringing Citizen Voice into the Post-2015 Development Vision
Johannesburg, South Africa: 10-15 November 2013

CIVICUS is calling for participants to a series of civil society events taking place between 10 and 15 November 2013 in Johannesburg, South Africa. Coming just two months after the UN General Assembly meetings in New York in September 2013, the week of strategising, dialogue and mobilisation will provide a space for global civil society to chart a route forwards on how to bring real citizen voice, accountability and mobilisation into the newly emerging development vision. Two major global civil society conferences, at the heart of the week, are being hosted for the first time outside of Europe. 1. The conference on Building a Global Citizens Movement, convened by CONCORD/DEEEP, will take place on 11-12 November, and bring grassroots activists and social movements together with organised civil society. A session hosted by CIVICUS and partners, with a special South African focus, will connect the experiences of yesterday’s struggle activists with more recent social justice movements. 2. The International Civil Society Centre's Global Perspectives 2013 conference engages global and national CEOs of leading international civil society organisations in a dialogue around navigating disruptive change. The conference is co-hosted by ActionAid International and CIVICUS and will take place on 13-15 November.

Seventh SAHARA Conference 2013
7-10 October 2013: Dakar, Senegal

The Social Aspects of HIV and AIDS Research Alliance (SAHARA), established in 2001 by the Human Sciences Research Council (HSRC), is an alliance of partners established to conduct, support and use social sciences research to prevent the further spread of HIV and mitigate the impact of its devastation in sub-Saharan Africa. The SAHARA 7 conference theme is "Translating evidence into action: Engaging with communities, policies, human rights, gender, service delivery".


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