EQUINET NEWSLETTER 153 : 01 November 2013

1. Editorial

A step beyond the rhetoric: Key choices to be made on pathways to universal systems

Google the words “universal health” and in under 3 seconds you’ll get 165 million results. There is a crescendo of talk on universal health coverage. But has it been translated into terms that can engage social debate? The two editorials in this month’s newsletter and several of the papers suggest that such debate across all of society is critical, given how deep the consequences for society of the choices made. In the first editorial, Latin American social medicine and health scientists warn of the negative impacts of segmented insurance options. The second editorial, drawn more from African experience, argues a similar case. Both urge for exploration of tax funding, particularly given that universal systems are a right of all citizens not a benefit of particular employees or contributors. There are clearly debates and choices- are they reaching the people who will be most affected by them?

Build Universal public health systems as a path to the right to health
Latin American Social Medicine Association (ALAMES) and CEBES (Centro Brasileiro de Estudos de Saúde/Brasilian Centre for Health Studies/), Brazil

ALAMES and CEBES, in the framework of the Second Brazilian Congress of Policy , Planning and Management in Health of the Associacao Brasileira de Saúde Coletiva (ABRASCO) affirm that the path to full exercise of the right to health for the peoples of Latin America involves building, strengthening and developing universal public health systems (the ‘SUS’), as opposed to the campaign launched by international financial institutions and neoliberal governments around ‘universal health coverage’ based on the expansion of different forms of insurance, with a limited package of services for the poor and through promoting private investment in health.

This position is based on the following considerations:

• Universal health care systems are expressions of public and social commitment in each country to implement the principles of universality, equality, integrity and non-discrimination in relation to peoples’ health needs. They are part of state policies aimed at ensuring social rights.
• A single universal and public health system (a national health service) contributes to the implementation of universal policies, in the context of social and human development, that break with the social inequalities and inequities that are inherent in the logic of the market. Their management and financing can be sustained through fair tax policies that promote a fairer distribution of wealth.
• The neoliberal reforms in various countries in the region to date demonstrate that systems of health insurance based on targeting and limited service packages have deepened social differences in care by placing at the core of their design alleged financial constraints and greater private sector roles in health services.
• The momentum that agencies, foundations and corporations are giving to the debate and implementation of so-called ‘universal health coverage’ is an expression of an interest in locating health as a key field of capital accumulation. This can rob countries of resources that are vital for health and reproduces injustices and inequities in health care.

We should be alert to the efforts being made to deepen exclusionary insurance systems and loss of health rights in Peru, Colombia and Mexico.

We call on the Latin American and global movement for the right to health to express their rejection of deepening processes of market insurance and privatization that are advancing right now in Peru, Colombia and Mexico.

• In Peru, using a questionable granting of legislative powers to the Executive Branch to drive the process that bypasses the Congress, the Ministry of Health and Ministry of Finance intend to introduce new laws that seek to deepen market participation in the health sector through the promotion of public-private partnerships, contracting of services and deregulated insurance. This lowers the possibility of equalizing the access to comprehensive health care and social security that only a third of Peruvians currently enjoy. The first laws passed under these legislative powers have violated the labour rights of health workers, undermining their security of pay, with further uncertain implications. This is despite a constant demand from social movements and professional associations in health in most parts of the country to build a reform based on universal principles.

• In Colombia, universal coverage based on insurance has had disastrous consequences, with the collapse of national insurance funding declared by government itself to be a national health emergency. Despite this, the reform initiated today merely changes names on the same entities and processes that have for twenty years undermined access to health, blocked avenues for claiming the right to health and subordinated claims on the right to health to macro-economic considerations. The reforms do not address any of these underlying factors and despite the flow of funds, the health system is literally dismembered. The fact that health is only a business for insurance companies has been associated with a rise in corruption and paramilitarism in the sector.

• Mexico is currently presented as a promising example of neoliberal reform. However, claims in the reform of having achieved universal coverage hide the fact that a significant share of the insured population has no real access to care, that there has been a reduction in benefits covered by insurance, and that the introduction of private insurers seeking to make profits in the sector is raising the risk for millions of people of losses in social security health benefits.

All countries need universal health systems.

• Recognizing the complexities and particularities of each country, it is urgent that social movements drive and ensure the formation of Universal Health Systems, understood as an inalienable responsibility of the state and society, to build institutions that guarantee the right to health universally and equally outside the logic of the market and profit. This requires progressively overcoming the fragmentation of sub-systems through innovative management and through a commitment to sustainable financing.
• We recognize the national health system (the ‘SUS’) in Brazil as an example of social momentum based on universalist principles, and call for its defense and for deepening it in all necessary areas. We especially support popular demands to allocate 10% of the gross federal revenue to support the expansion of the SUS and to limit the growth of private services. We defend Brazil's SUS as a source of inspiration and an example of the real possibility of reversing the expansion of an individualist model of health insurance that breaks the concept of and responsibility for public health.
• In this regard we urge the Brazilian government to publicize and defend the SUS internationally, presenting it as an alternative to guarantee the right to health of the people.

For the right to health, universal public health systems for all countries of Latin America!

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For the original declaration in Spanish see http://www.alames.org , entry two for October.

Overcoming the blind spot: health insurance schemes are leaving the poor behind
Ceri Averill, Oxfam GB

Social health insurance schemes, introduced in the name of universal health coverage (UHC), are excluding the majority of people and leaving the poor behind. So argues a new report from Oxfam ‘Universal health coverage: why health insurance schemes are leaving the poor behind’.

The growing momentum for universal health coverage (UHC) is certainly cause for celebration. But in some cases health financing reforms are widening inequality by prioritising already advantaged groups in the formal sector and leaving the most poor and marginalised people – especially women – as last in line to benefit.

This raises the question of why there is an almost exclusive focus on contributory-based health insurance schemes as the way to achieve UHC. Although no country in the world has achieved anything close to UHC using voluntary insurance, private and community-based voluntary schemes are still being promoted by governments and external funders. India’s voluntary India’s voluntary Rashtriya Swasthya Bima Yojana insurance scheme for people below the poverty line is widely praised as a success. However evidence cited in the Oxfam report indicates that the scheme offers limited financial protection against impoverishing out of pocket spending on health and has skewed public resources to curative rather than preventative care.

For those who recognise the pitfalls of voluntary schemes, social health insurance (SHI) has emerged as the model of choice. SHI has worked to achieve UHC in a number of high-income countries. However attempts to replicate the same kind of employment-based models in low- and middle-income countries have proved unsuccessful. Even high-income countries struggled to achieve rapid scale up via SHI. In Germany UHC took 127 years to achieve using a SHI model. Surely people in low and middle income countries (LMICs) should not have to wait that long!

In low and middle income countries SHI schemes are typically characterised by large-scale exclusion. Ten years after the introduction of SHI schemes in Tanzania, according to a National Health Insurance Fund 2011 report, coverage had reached only 17 per cent. Kenya’s National Hospital Insurance Fund – established nearly 50 years ago – today insures just 18 per cent of Kenyans. Ghana’s National Health Insurance Scheme (NHIS), widely promoted as an SHI success story, covers only 36 per cent of the population.

Hopes that insurance contributions from those outside of formal employment would raise significant revenue have not been realised. In Ghana, cash premiums paid directly by those in the informal sector contribute just five per cent towards the cost of the NHIS, that also draws funds from earmarked tax and other sources. Governments also face huge bills to cover the SHI contributions of their workers. According to 2010 National Health Insurance Fund Tanzania and WHO evidence cited in the report, the Government of Tanzania spent $33m on employer contributions in 2009/10; this equated to $83 per employee – six times more than it spent per person, per year on health for the general population.

Instead of importing inappropriate health financing models from high-income countries, governments in LMICs should surely learn from the increasing number of home-grown UHC success stories in other, more comparable countries.

The countries making most progress towards UHC agree that entitlement to health care should be based on citizenship and/or residency and not on employment status or financial contributions. While their specific journeys differ, these countries fall into two broad camps. First there are examples of countries at all income levels, including Sri Lanka, Malaysia, and Brazil, which use tax revenues to fund UHC. Crucially, the 2009 report of a Task Force on Global Action for Health System Strengthening found that the only low-income countries to achieve universal and equitable health coverage did so by relying mainly on tax financing. A second option increasingly being adopted by another set of successful UHC countries, including Thailand, Mexico, and Kyrgyzstan, is to collect insurance premiums only from those in formal salaried employment, and to pool these where possible with tax revenues to finance health coverage for the entire population.

The growing momentum for UHC is welcome, exciting, and challenging. UHC has the potential to transform the lives of millions of people by bringing life-saving health care to those who need it most. But rather than focus efforts on collecting contributions from people who are too poor to pay, governments and external funders should focus on financing options that will work to deliver universal and equitable health care for all. The preoccupation with health insurance as the ‘default’ UHC model has left the crucial question of how to generate more tax revenues for health largely unexplored. This blind spot should be urgently addressed.

At its core, UHC is about the right to health. This means moving away from the idea of an employment or contributory basis for entitlement. People must be entitled to receive benefits by virtue of their citizenship and/or residency and not because they are formally employed or have paid to join a scheme. Women and men living in poverty must benefit at least as much as the better off every step of the way.

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 see the Oxfam report ‘Universal health coverage: why health insurance schemes are leaving the poor behind’ at www.oxfam.org/uhc

2. Latest Equinet Updates

Building empowered communities for health_A film on health literacy and participatory approaches to health in Zambia
EQUINET Video: TARSC, Lusaka District Health Management team, Ministry of Health Zambia September 2013

Health literacy is one process that empowers people to understand and act on health information to advance their health and improve their health systems. Based on participatory reflection and action approaches, it goes beyond just knowing about health and health care, to acting individually and collectively to advance health. It includes processes that support people driven action and engagement in health systems. Lusaka District Health Team in Zambia has implemented participatory reflection and action work since 2005 to strengthen detection of and action on health problems and their causes, and improve communication between health services and communities, working with TARSC in the pra4equity network in EQUINET. In 2012 the Ministry of Health adopted a proposal to scale up the work in Lusaka to national level. This video describes the origins and development of the work from the lens of the many different actors from communities, health workers and policy level that played a role in it.

EQUINET Regional Workshop on Health Centre Committees
Harare, January 30-Feb 1 2014

Health Centre committees (HCCs) (known by a range of names) are mechanisms that exist at community and primary care level for co-determination by communities and health workers on their health systems and on PHC. In January 2014 EQUINET through TARSC and with CWGH is holding a regional meeting on the role of health centre committees in primary health care. The regional workshop includes organisations doing work on training and strengthening HCCs in east and southern African countries. It aims to exchange and document information on the laws, capacities, training materials used, and monitoring systems used in HCCs, and to develop a shared monitoring framework for assessing how HCCs are functioning. Sponsorship for the workshop is now closed but EQUINET invites self funded delegates who may wish to attend to contact admin@equinetafrica.org for further information.

Policy Brief 35: Legislation on the for-profit private health sector in East and Southern Africa
Doherty J (2013) with UCT HEU, TARSC. Wemos Foundation, EQUINET, Harare

While the private sector contributes new resources to the health system, international evidence shows that if left unregulated it may distort the quantity, distribution and quality of health services, and lead to anti-competitive behaviour. As the for-profit private sector is expanding in east and southern African (ESA) countries, governments need to strengthen their regulation of the sector to align it to national health system objectives. This policy brief examines how existing laws in the region address the quantity, quality, distribution and price of private health care services, based on evidence made available from desk review and in-country experts. It proposes areas for strengthening the regulation of individual health care practitioners, private facilities and health insurers. A more detailed discussion paper (#87) on the laws and information covered in the brief including country specific information is available at www.equinetafrica.org/bibl/docs/EQ%20Diss%2087%20Private%20HS.pdf.

3. Equity in Health

Addressing the Social Determinants of Noncommunicable Diseases
United Nations Development Programme, New York, October 2013

This paper offers two unique contributions to existing global and regional frameworks on multisectoral action on NCDs and their social determinants. The first is a typology of multisectoral action that highlights three general categories of possible action outside the health sector: expanding delivery platforms; NCD-specific actions on social determinants; and NCD-sensitive actions on social determinants. This paper’s second contribution is a framework that outlines more specific areas and opportunities for actors outside the health sector to take action on the social determinants of NCDs. The framework has two parts. The first describes opportunities for NCD-specific and NCD-sensitive actions across the policy and programme lifecycle. The second part describes opportunities to create an enabling environment that promotes multisectoral action. Actors outside the health sector are uniquely positioned to help build political will, enabling legal frameworks, enforcement mechanisms and effective governance structures that are multisectoral and participatory – all anchored in a human rights-based approach.

Tanzania urges EAC countries to re-focus on MDGs
Sekanjako H: New Vision, 20 August 2013

The East African community (EAC) partner states have been urged to re-focus monitoring and achieving of the Millennium Development Goals (MDGS) as the set deadline 2015 draws near. According to Tanzanian vice-president Dr. Mohammed Gharib Bilal, there is need for constant monitoring of MDGs by EAC partner states especially THE ‘shelter for all’ goal as an important agenda in social - economic development. Gharib addressed a two-day East African Legislative Assembly (EALA) conference on MDGs in Arusha Tanzania. He told the conference that Tanzania had taken measures aimed at addressing the challenges of unplanned settlement and slums in the urban population and was undertaking a study with the United Nations-Habitat. Legislators must re-focus their oversight activities in the development agenda, he argued: they should not only be critical of their governments but must stress what has been achieved, where the failures are and the reasons whether they resulted from inadequate resources or misplaced priorities.

4. Values, Policies and Rights

Draft Framework Convention on Global Health
The Joint Action and Learning Initiative on National and Global Responsibilities for Health, October 2013

Following consultation by the Joint Action and Learning Initiative on National and Global Responsibilities for Health on the FCGH in Geneva in May 2013, JALI and several partners who participated in the consultation developed a draft Framework for an FCGH. This is aimed at providing greater clarity on the principles and core content of the FCGH, building on the FCGH Manifesto. In the hopes of forging a broad consensus around this document, JALI is circulating the draft and calling for feedback on the Framework to improve it and ensure that it represents a shared vision. The Framework will then serve as a platform for a Campaign for an FCGH.

Health rights in the post-2015 development agenda: Including non-nationals
Brolan CE, Dagron S, Forman L, Hammonds R, Latife LA and Waris A: Bulletin of the World Health Organisation 91(10): 719-719A, October 2013

Much debate around the September 2013 meeting of the United Nations General Assembly on the post-2015 Development Agenda, has focused on the health and intersectoral development goals. Little of this debate has to do, however with how the “right to the highest attainable level of health” applies to non-nationals, who normally have no access to health care services, according to this editorial. The right to health obligates governments to facilitate access to health care to nationals and non-nationals alike, the authors argue. Ensuring that governments apply new development goals that include non-nationals is an issue of pressing concern in the post-2015 agenda. The denial of preventive and curative care to non-nationals is often linked to policies regulating cross-border movement. The global health community cannot afford to ignore the in-country inequalities that exist within the public health care systems.

UN Special Event 25 September: Outcome Document
UN General Assembly, September 2013

Governments meeting at the UN General Assembly (GA) in September have heeded civil society demands for human rights to be at the core of the global commitments succeeding the Millennium Development Goals (MDGs) in 2015. The outcome document of the GA Special Event on the MDGs, held on 25 September, calls for a universal framework of goals applicable to all countries which promotes “human rights for all”. Once a lightning rod at UN development forums, human rights appear to have garnered consensus as a central foundation of development - at least on paper.

Universal health coverage, real or selective? Time for global health advocates to unite
Gorik Ooms

Universal health coverage “developed within the particular epidemiological, economic, socio-cultural, political and structural context of each country in accordance with the principle of national ownership”, as it is formulated in the 2012 UN General Assembly resolution, can, it is argued by the author, to possibly mean anything and everything. In low-income countries, it could mean something that looks a lot like selective primary health care, excluding antiretroviral treatment. For AIDS activists, universal health coverage could mean a giant step backwards. However the International HIV/AIDS Alliance came out with a statement in support of “universal health coverage. The words that matter are “rights-based approach”, as the author proposes that universal health coverage anchored in the right to health requires at least comprehensive primary health care, with duty-based international assistance to countries that are unable to provide comprehensive primary health care without assistance.

5. Health equity in economic and trade policies

Brazil’s patent reform innovation towards national competitiveness
Chamber of Deputies, Centre for Strategic Studies and Debates: 2013

In this paper the author argues that Brazil follow the same route as India and continue to adopt and apply the regime of absolute novelty to prevent non-innovative patents from being unduly granted. They argue that the patent system should respect Constitutional duties to promote technological, economic and social development, especially as Brazil’s path has implications for other developing countries that are affected by intellectual property rights related to medicines and other pharmaceutical products.

Developing global health technology standards: what can other industries teach us?
Masum H, Lackman R, Bartleson K: Globalization and Health 9(49), 17 October 2013

There is a lack of effective and affordable technologies to address health needs in the developing world. In this paper, the authors argue that we can better develop standards for global health technologies if we learn lessons from other industries, such as by speeding the pace of innovation, unlocking health systems from single providers and approaches, and lowering barriers to entry. The authors consider relevant cases of standards development from other industries and propose that standardised platforms can lower barriers to entry, improve affordability, and create a vibrant ecosystem of innovative new global health technologies.

New EU Custom Regulation Might Allow Wrongful Seizures Of Generic Drugs In Transit, NGOs Say
Saez C: Intellectual Property Watch, 17 October 2013

A recent European Union (EU) regulation on customs enforcement of intellectual property rights (N° 608/2013) has raised concerns among civil society actors who find that the regulation might not be an improvement over its previous version under which seizure of legal generic medicines in transit occurred a few years ago, leading to a World Trade Organisation dispute. Civil society organisation, Act-Up Paris has said the new regulation does not solve the problem as it continues to allow the seizing of goods over a simple suspicion of ‘intellectual property’ infringement without checking beforehand whether these goods are headed to the European territory or just in transit. The group argue that the EU did not take into account the December 2011 Court of Justice of the European Communities’ decision which stated that goods coming from a third-party State could not be described as ‘counterfeit goods’ or ‘pirated goods’ just by entering the customs territory of the EU. The in-transit medicines are not intended for commercialisation in EU territory and thus intellectual property status according to the national law of EU countries should be irrelevant. The EU is standing by its new regulation.

Using law to accelerate treatment access in South Africa: An analysis of patent, competition and medicines law
Park C, Prabhala A and Berger J: United Nations Development Programme, October 2013

This study aims to contribute to the implementation of South Africa’s National Strategic Plan (NSP) on HIV, STIs and TB 2012–2016 by making specific recommendations on law and policy reforms to achieve an enabling and accessible legal framework in three key areas: patent, competition, and medicines law. The South African Patents Act, as it currently stands, does not take full advantage of the flexibilities available in respect of limitations to patent rights. The study recommends that the Patents Act make use of the full range of express exclusions from patentability available under TRIPS, and proposes that the process for issuing compulsory licenses be significantly streamlined, with clear legislative guidelines for determining the grounds upon which compulsory licenses can be granted, as well as their terms and conditions to prevent unnecessary delays. The study concludes by emphasising that its recommendations are aimed at achieving mutually reinforcing goals: promoting access to essential medicines and developing and supporting policies conducive to the growth and development of the domestic generic pharmaceutical industry. The process of reforming South Africa’s laws could benefit from a policymaking approach that is consultative, coherent and developed with the input of all relevant actors, governmental and non-governmental alike.

6. Poverty and health

Analysis: The future of food aid
IRIN, Johannesburg, 26 July 2013

By 2023 the number of food-insecure people is likely to increase by nearly 23 percent to 868 million (at a slightly faster rate than projected population growth of 16 percent). Despite improvements over the years, sub-Saharan Africa is projected to remain the most food-insecure region in the world. In the past decade global food aid, including the amount making its way to sub-Saharan Africa, has been on a downward trend. Only 2.5 million tons reached sub-Saharan Africa in 2011, whereas during the decade as a whole it ranged from just under three million tons to just over 5 million tons, according to World Food Programme (WFP) data. In this article IRIN presents views of some of the world’s leading experts on the future of food aid.

7. Equitable health services

Drivers and deterrents of facility delivery in sub-Saharan Africa: A systematic review
Moyer CA and Mustafa A: Reproductive Health 10(40), 20 August 2013

The authors conducted this review to identify articles published in English from 1995-2011 that reported on original research into facility-based delivery (FBD) conducted entirely or in part in sub-Saharan Africa. Sixty-five studies met inclusion criteria, 62 of which were cross-sectional, and 58 of 65 relied upon household survey data. Fewer than two-thirds (43) included multivariate analyses. The factors associated with facility delivery were categorised as maternal, social, antenatal-related, facility-related, and macro-level factors. Maternal factors were the most commonly studied, probably due to overwhelming reliance on household survey data. Multivariate analysis suggests that maternal education, parity / birth order, rural / urban residence, household wealth / socioeconomic status, distance to the nearest facility, and number of antenatal care visits were the factors most consistently associated with FBD. In conclusion, FBD is a complex issue that is influenced by characteristics of the pregnant woman herself, her immediate social circle, the community in which she lives, the facility that is closest to her, and context of the country in which she lives. More research is needed that explores regional variability, examines longitudinal trends, and studies the impact of interventions to boost rates of facility delivery in sub-Saharan Africa.

Geographical variation and factors influencing modern contraceptive use among married women in Ethiopia: Evidence from a national population based survey
Lakew Y, Reda AA, Tamene H, Benedict S and Deribe K: Reproductive Health 10(520, 26 September 2013

Though there is an evidence of increased overall contraceptive prevalence, a substantial effort remains behind in Ethiopia. This study aimed to identify factors associated with modern contraceptive use and to examine its geographical variations among 15–49 married women in Ethiopia. Researchers conducted secondary analysis of 10,204 reproductive age women included in the 2011 Ethiopia Demographic and Health Survey (DHS). Results indicated that being wealthy, more educated, being employed, higher number of living children, being in a monogamous relationship, attending community conversation, being visited by health worker at home strongly predicted use of modern contraception. While living in rural areas, older age, being in polygamous relationship, and witnessing one’s own child’s death were found negatively influence modern contraceptive use. The central and south-western parts of the country had higher prevalence of modern contraceptive use than that of the eastern and western parts. The findings indicate significant socio-economic, urban–rural and regional variation in modern contraceptive use among reproductive age women in Ethiopia. Strengthening community conversation programmes and female education should be given top priority.

Strengthening the evidence-policy interface for patient safety: enhancing global health through hospital partnerships
Syed SB, Dadwal V, Storr J, Riley P, Paul R et al: Globalization and Health 9(47), 16 October 2013

Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. According to this paper, brokerage inherent in hospital-to-hospital partnerships can boost relationships between ‘evidence’ and ‘policy’ communities and move developing countries towards evidence-based patient safety policy. In particular, the authors use the experience of a global hospital partnership programme focused on patient safety in the African Region to explore how hospital partnerships can be instrumental in advancing responsive decision-making, and the translation of patient safety evidence into health policy and planning. A co-developed approach to evidence-policy strengthening with seven components is described, with reflections from early implementation. The rapidly expanding field of towards evidence-based patient safety policy calls shared learning across continents, the authors conclude, in keeping with the principles and spirit of health systems development in a globalised world.

Tackling Antibiotic Resistance for Greater Global Health Security
Gemma L. Buckland Merrett, Centre on Global Health Security

In this paper the author argues that antibiotic resistance is now recognized as a major global health security issue that threatens a return to the pre-antibiotic era, with potentially catastrophic economic, social and political ramifications. An extra burden is likely to hit resource-poor countries. Although bacteria naturally adapt to outsmart antibiotics, human actions accelerate the development and spread of resistance. Antibiotics need to be used judiciously, with effective stewardship and infection prevention and control, and a harmonized approach to their use in animal and human health should be fostered. There is also a need for practical economic models to develop new products that avoid rewarding researchers for what they do already. Choosing the right paradigms for sustainably stimulating R&D requires new measures to align the financial incentives for drug and diagnostic test development with public health needs. Incentives for infection control and appropriate stewardship are equally important. Integrated efforts involving academia, policy-makers, industry and interest groups will be required to produce a global political response with strong leadership, based on a coherent set of priorities and actions.

8. Human Resources

Health system challenges to integration of mental health delivery in primary care in Kenya- perspectives of primary care health workers
Jenkins R, Othieno C, Okeyo S, Aruwa J, Kingora J, Jenkins B: BMC Health Services Research 2013, 13:368

This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness. Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training). These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues.

Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review
Mwai G, Mburu G, Torpey K, Frost P, Ford N, Seeley J: Journal of the International AIDS Society 2013, 16:18586

The provision of HIV treatment and care in sub-Saharan Africa faces multiple challenges, including weak health systems and attrition of trained health workers. One potential response to overcome these challenges has been to engage community health workers (CHWs). A systematic literature search for quantitative and qualitative studies describing the role and outcomes of CHWs in HIV care between inception and December 2012 in sub-Saharan Africa was performed. A narrative synthesis approach was used to analyze common emerging themes on the role and outcomes of CHWs in HIV care in sub-Saharan Africa. In total, 21 studies met the inclusion criteria, documenting a range of tasks performed by CHWs. These included patient support (counselling, home-based care, education, adherence support and livelihood support) and health service support (screening, referral and health service organization and surveillance). CHWs were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised, with no differences in virologic failure and mortality comparing patients under community-based and those under facility-based care. Despite these benefits, CHWs faced challenges related to lack of recognition, remuneration and involvement in decision making. CHWs can clearly contribute to HIV services delivery and strengthen human resource capacity in sub-Saharan Africa. For their contribution to be sustained, CHWs need to be recognized, remunerated and integrated in wider health systems. Further research focusing on comparative costs of CHW interventions and successful models for mainstreaming CHWs into wider health systems is needed.

9. Public-Private Mix

An assessment of opportunities and challenges for public sector involvement in the maternal health voucher programme in Uganda
Okal J, Kanya L, Obare F, Njuki R, Abuya T et al: Health Research Policy and Systems 11(38), 18 October 2013

This paper describes a reproductive health voucher programme that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the programme to include public sector facilities. Researchers conducted interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher programme in south-western Uganda. Barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the programme by involving public sector facilities were investigated. The findings show that access to sexual and reproductive health services in south-western Uganda is constrained by both facility and individual level factors that can be addressed by inclusion of the public facilities in the programme. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher programme with other services is likely to address some of the barriers. Accrediting public facilities has the potential to increase voucher programme coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening links between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilisation of resources to support the sustainability of the programmes. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher programme.

10. Resource allocation and health financing

Does investment in the health sector promote or inhibit economic growth?
Reeves A, Basu S, McKee M, Meissner C, Stuckler D: Globalization and Health 2013, 9:43

In this study, the authors evaluate the economic effects of alternative types of government spending by estimating “fiscal multipliers” (the return on investment for each $1 dollar of government spending). While the study is implemented using data from Europe the findings may have wider relevance: they indicate that government spending on health may have short-term effects that make recovery more likely.

Health technology assessments as a mechanism for increased value for money: Recommendations to the Global Fund
Teerawattananon Y, McQueston K, Glassman A, Yothasamut J and Myint CY: Globalization and Health 9(35), 21 August 2013

The Global Fund is experiencing increased pressure to optimise results and improve its impact per dollar spent, according to this study. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. The authors assess the efficacy of current Global Fund investment and examine how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidised by the Global Fund. In addition, they identify areas where the application of HTAs can exert the greatest impact and propose ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, they address the challenges facing the Global Fund in realising the full potential of HTAs.

The 2013 DATA Report: Financing the Fight for Africa’s Transformation
One.org: Berlin, 2013

The world has officially entered the final leg of its 15-year journey to halve extreme poverty and reduce child mortality by two-thirds, reverse the tide against HIV/AIDS and malaria, and ensure that more people have access to basic services, such as primary education and safe drinking water. Despite a challenging global economic environment, many low and middle-income countries are making dramatic progress towards the highly ambitious MDG targets. ONE’s 2013 DATA Report examines the recent progress of individual countries against eight MDG targets, focusing particular attention on sub-Saharan Africa, and compares that progress against African government and donor spending in three key poverty-reducing sectors: health, education, and agriculture.

11. Equity and HIV/AIDS

UNAIDS Special report: How Africa turned AIDS around
Michel Sidibe: African Union Summit | May 2013, UNAIDS Geneva

An African proverb teaches us that “if you want to go fast, go alone—but
if you want to go far, go together”. The AIDS epidemic threatened to overcome Africa—but instead, Africa and the world have united to overcome AIDS, going farther than most ever thought possible. This special report presents in a graphical, compelling and accessible manner the many dimensions of progress on AIDS in Africa.

12. Governance and participation in health

Influence of mhealth interventions on gender relations in developing countries: a systematic literature review
Jennings L, Gagliardi L: International Journal for Equity in Health 2013, 12:85

Research has shown that mHealth initiatives, or health programs enhanced by mobile phone technologies, can foster womens empowerment. Yet, there is growing concern that mobile-based programs geared towards women may exacerbate gender inequalities. A systematic literature review was conducted to examine the empirical evidence of changes in men and women?s interactions as a result of mHealth interventions. Out of the 173 articles retrieved for review, seven articles met the inclusion criteria and were retained in the final analysis. Most mHealth interventions were SMS-based and conducted in sub-Saharan Africa on topics relating to HIV/AIDS, sexual and reproductive health, health-based microenterprise, and non-communicable diseases. Several methodological limitations were identified among eligible quantitative and qualitative studies. The current literature suggests that mobile phone programs can influence gender relations in meaningfully positive ways by providing new modes for couples health communication and cooperation and by enabling greater male participation in health areas typically targeted towards women. MHealth initiatives also increased womens decision-making, social status, and access to health resources. However, programmatic experiences by design may inadvertently reinforce the digital divide, and perpetuate existing gender-based power imbalances. Domestic disputes and lack of spousal approval additionally hampered women?s participation. Efforts to scale-up health interventions enhanced by mobile technologies should consider the implementation and evaluation imperative of ensuring that mHealth programs transform rather than reinforce gender inequalities. The evidence base on the effect of mHealth interventions on gender relations is weak, and rigorous research is urgently needed.

Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings
BMC Health Services Research 2013, 13:320

Using a descriptive literature review, this paper examines the factors that influence the functioning of accountability mechanisms and relationships within the district health system, and draws out the implications for responsiveness to patients and communities. We also seek to understand the practices that might strengthen accountability in ways that improve responsiveness – of the health system to citizens’ needs and rights, and of providers to patients. The review highlights the ways in which bureaucratic accountability mechanisms often constrain the functioning of external accountability mechanisms. For example, meeting the expectations of relatively powerful managers further up the system may crowd out efforts to respond to citizens and patients. Organisational cultures characterized by supervision and management systems focused on compliance to centrally defined outputs and targets can constrain front line managers and providers from responding to patient and population priorities.

The Impact of Transparency and Accountability Initiatives
Gaventa J and McGee R: Development Policy Review 31(S1): s3-s28

In this review, the authors highlight the silos that currently characterise transparency and accountability initiatives (TAIs). The authors argue that a decade on from their inception, and notwithstanding a growth in litigation-based social accountability that invokes popular mobilisation and democratic rights, there is much to suggest that TAIs in aid and development are increasingly being used within an efficiency paradigm, with scant attention to underlying issues of power and politics. Many TAIs focus on the delivery of development outcomes, neglecting or articulating only superficially the potential for deepening democracy or empowering citizens, overemphasising tools to the detriment of analysis of context, of forms of mobilisation and action, and of the dynamics behind potential impact. Many TAIs focus on achieving‘downstream’ accountability –the efficient delivery of policies and priorities – bypassing the question of how incorporating citizen voice and participation at earlier stages of these processes could have shaped the policies, priorities and budgets ‘upstream’. The authors contrast new public management approaches with rights based approaches. The paper examines ways of assessing effectiveness of TAIs.

13. Monitoring equity and research policy

Health policy and system research in access to medicines: A prioritised agenda for low- and middle-income countries
Bigdeli M, Javadi D, Hoebert J, Laing R and Ranson K: Health Research Policy and Systems 11(37), 14 October 2013

In this study researchers aimed to identify priority policy issues in access to medicines (ATM) relevant for low- and middle-income countries, to identify research questions that would help address these policy issues, and to prioritise these research questions in a health policy and systems research (HPSR) agenda. The study involved i) country- and regional-level priority-setting exercises performed in 17 countries across five regions, with a desk review of relevant grey and published literature combined with mapping and interviews of stakeholders. A list of 18 research questions was formulated according to four ranking criteria (innovation, impact on health and health systems, equity, and lack of research). The top three research questions were: i) In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of medicines, sustainability of the insurance system, and financial impact on the insured? ii) How can stakeholders use the information available in the system, e.g., price, availability, quality, utilisation, registration, procurement, in a transparent way towards improving access and use of medicines? and iii) How do policies and other interventions into private markets, such as information, subsidies, price controls, donation, regulatory mechanisms, promotion practices, etc., impact on access to and appropriate use of medicines? The HPSR agenda discussed here adopts a health systems perspective and will guide relevant, innovative research, likely to bear an impact on health, health systems and equity.

Implementation Research in Health: A Practical Guide
Alliance for Health Policy and Systems Research

Billions are spent on health innovations, but very little on how best to apply them in real-world settings. Despite the importance of implementation research, it continues to be a neglected field of study, partly because of a lack of understanding regarding what it is and what it offers. Intended for newcomers to the field, those already conducting implementation research, and those with responsibility for implementing programmes, this guide provides an introduction to basic implementation research concepts and briefly outlines what it involves, and describes the many exciting opportunities that it presents.

14. Useful Resources

CIVICUS Enabling Environment Index, 2013

The CIVICUS `Enabling Environment Index’ (EEI) is the first rigorous attempt to measure and compare the conditions that affect the potential of citizens to participate in civil society and ranks the governance, socio-cultural and socio-economic environments for civil society in 109 countries. While recent years have seen popular uprisings from the Arab Spring to the Occupy Wall Street movement, there have also been many crackdowns on the ability of citizens to mobilise. This tool is intended to help understand the conditions facing civil society in different parts of the world. It also helps identify countries where special attention needs to be paid to strengthening civil society by the international community. Angola, Ethiopia, Zimbabwe and the Democratic Republic of Congo rank among the 10 lowest countries on the Index.

Crowd-Sourced Film on Samsung Debuts
The Wall Street Journal-Asia, October 9, 2013

When South Korean director Kim Tae-yun said he wanted to make a film about workers who came down with leukemia and other rare diseases during the time they worked at Samsung Electronics Co. factories, just about everyone told him he would struggle to secure financial backing. Two years later, the film has premiered at the ongoing Busan International Film Festival‒in part thanks to crowd-sourced funds from nearly 7,000 individuals who paid for more than a quarter of the billion-won ($932,700) budget. Close to half was self-funded and the rest has been made as IOUs. It marks a rare coup for Korean cinema, where independent producers struggle to secure funding without support from major film studios. Critics say close family and business ties between major movie companies and the nation’s biggest corporations prevent films with negative portrayals of those conglomerates from being made.

Global Health Versus Private Profit
John Lister

The book Global Health Versus Private Profit focuses on the changes taking place in global health care systems. It presents evidence on how market-style reforms result in health care systems that are more unequal, more costly, more fragmented and less accountable – but which offer more profits to the private sector. The book offers an analysis of the “menu” of market-style reforms to health care systems that have been rolled out in country after country, despite the absence of evidence for their effectiveness, and ignoring the evidence of harm that is being done. These include the emphasis on competition rather than planning and cooperation, the splitting of health care systems into purchasers and providers, privatisation in various guises – including buying in services from the private sector that were previously delivered by public sector providers – the imposition of user fees, and the focus on health insurance and managed care in place of social provision and universal coverage. Many of these policies are being implemented in rich countries and poor alike, but they are having the most devastating impact on the poorest. They are argued to sap vital resources, dislocate and fragment systems, prevent them from responding to health needs, and obstruct the development of planning. My book argues that these so called “reforms” are driven not by evidence, but by ideology – but that behind the ideology is a massive material factor: the insatiable pressure from the private sector which is desperate to recapture a much larger share of the massive $5 trillion-plus global health care industry, much of which only exists because of public funding. The concluding chapter argues “It doesn’t have to be this way” and brings together a lot of different ideas, emphasising that the policies we are opposing are not inevitable products or even a rational response to the current situation, but choices that have been deliberately made by politicians working to a neoliberal agenda. They can be rejected and defeated by mass political action.

The truth about extreme global inequality
Jason Hickel, Aljazeera, 14 Apr 2013

The crisis of capital, the rise of the Occupy movement and the crash of Southern Europe have brought the problem of income inequality into mainstream consciousness in the West for the first time in many decades. The video featured in this article points out that the richest 300 people on earth have more wealth than the poorest 3bn - almost half the world's population. In truth the situation is even worse: the richest 200 people have about $2.7 trillion, which is more than the poorest 3.5bn people, who have only $2.2 trillion combined. The video shows how this widening disparity operates between countries. It argues that the gap is growing in part because of neoliberal economic policies that liberalise markets, opening them to multinational corporations with a serious cost to poor countries of around $500bn per year in GDP. The video aims to help people to visualise this flow, and to show how it pumps up the Global North at devastating expense to the Global South.

15. Jobs and Announcements

Call for participation: PHM Health for All Campaign
Global Secretariat, People's Health Movement

The PHM Health for All (HFA) campaign is a platform for expressing solidarity, mutual learning and sharing experiences with struggles across the world. We are bringing together existing campaigns and new campaigns under the umbrella of Health for All. The PHM call for individuals and organisations to share what they are already engaged with and what local initiatives already exist that fit the Health for All Campaign and offer showcase your actions on the PHM website. Send your ideas, action, struggles, interests to globalsecretariat@phmovement.org.

Georgetown University Law Center Global Health Law Scholars
O'Neill Institute Global Health Law, USA,

The Global Health Law Program offers up to five prestigious Global Health Law scholarships per academic year. Global Health Law Scholars, in addition to the title, will receive full or partial tuition awards. These awards may be sponsored by Georgetown Law and/or major outside organizations in law and health, and may be coupled with internship opportunities. Applicants will be selected by a committee on the basis of their (1) academic qualifications in the fields of law/ethics and public health, health policy, health economics, bioethics, or other relevant disciplines; (2) public or private sector work experience on global or domestic health law issues; and (3) demonstrated potential for excellence within the field of global health law. Students' financial needs may also be considered. For more information visit the website.

High level Symposium on Global Health diplomacy
12 November 2013 : Geneva

The 6th Annual High-level Symposium on Health Diplomacy, jointly organised by the Global Health Programme and the Swiss Academy of Medical Sciences, will convene experts on the subject of "Health Diplomacy Meets Science Diplomacy" in order to discuss the dimensions of diplomacy for science, science in diplomacy, and science for diplomacy. The all-day event will be moderated by Professor Michel Kazatchkine, Senior Fellow at the GHP and UN Secretary-General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia and will feature keynote presentations from Dr. Vaughan C. Turekian, Editor-in-Chief of Science & Diplomacy and Sir George Alleyne, Director Emeritus, Pan American Health Organization. The event will also include panel discussions and presentations from high-level professionals, ambassadors, ministers, esteemed academics and representatives of international organisations. Registration (free) on the website.

International Conference on AIDS and STIs in Africa (ICASA), Cape Town South Africa
Durban, South Africa, 7-11 December 2013

ICASA 2013 - 17th International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA 2013) will take place in South Africa on 7-11 December 2013. The 17th ICASA is an opportunity to renew this global commitment by drawing the world’s attention to the fact that the legacy is now under threat as a result of the global economic downturn. This year’s ICASA is an opportunity for the international community, and all Africans, to join efforts in committing to achieving an AIDS-free Africa. Given the urgency of the issue we are anticipating 7 000 -10 000 of the world’s leading scientists, policy makers, activists, PLHIV, government leaders – as well as a number of heads of state and civil society representatives – will be joining the debate on how to achieve this vision.

MAHSC Global Health update: new funding call for health systems research
Deadline for application: 14th January 2014

This call for proposals is the first of three annual Health Systems Research Initiative calls, jointly supported by DFID, ESRC, MRC and the Wellcome Trust targeting research in Low and Middle-Income Countries. The aim is to fund rigorous, high quality research that will:
1. Generate evidence on how to strengthen health systems and improve health outcomes in low- and middle-income countries.
2. Inform the delivery of evidence-based interventions or structural changes.
3. Provide evidence that is of direct relevance to decision makers and users in the field.
Research should generate practical solutions to implementing health system improvements, including technical, economic, and cultural or governance/managerial components of implementation and sustainability. No particular diseases or health-related problems are prioritised for this call. All projects should focus on impacts on the most vulnerable populations and/or those in poorly resourced settings. A total of up to £15 million is available over a three year period to support several awards. There will be one call each year with a budget of £5million ’per call’ to cover a number of awards. Applications may be for:
* Development grants with a duration of 1-2 years and a total budget of around £100k each. These grants are tailored to assist interdisciplinary teams to develop robust and competitive proposals.
* Full-scale research projects of up to 5 years duration. Typically the funders would expect a project of 3-4 years with costs of £100-£200k per annum.
For more information see the website.

Making All Voices Count: Grand Challenge
First Call for Proposals open NOW. Applications close November 8, 2013

Making All Voices Count is a global initiative that supports innovation, scaling-up, and research to deepen existing innovations and help harness new technologies to enable citizen engagement and government responsiveness. This Grand Challenge focuses global attention on creative and cutting-edge solutions, including those that use mobile and web technology, to ensure the voices of all citizens are heard and that governments have the capacity, as well as the incentive, to listen and respond. Invited to apply are: individuals ( Innovation grants only) universities, academic institutions, research institutes, organisations ( all registered non-government associations; charities or societies; faith-based organisations; community-based organisations; not-for-profit and for-profit companies and corporations; social enterprises; and government), as well as private sector companies.

Third Global Symposium on Health Systems Research, Cape Town, South Africa, 30 September -3 October 2014
Call for Abstracts: Call closes 15 January 2014

The Third Global Symposium on Health Systems Research will be held in Cape Town, South Africa, from 30 September to 3 October 2014.The theme of the symposium is the science and practice of people-centred health systems. Researchers, policy-makers, funders, implementers and other stakeholders, from all regions and all socio-economic levels, will work together on the challenge of how to make health systems more responsive to the needs of individuals, families and communities. The symposium invites abstract submissions. The Organized session abstract submission closes 15 January 2014 and the Individual abstract submission closes 3 March 2014. More information is available on the symposium website.

World AIDS Day, 1 December 2013
World Health Organisation Geneva

World AIDS Day on 1 December brings together people from around the world to raise awareness about HIV/AIDS and demonstrate international solidarity in the face of the pandemic. The day is an opportunity for public and private partners to spread awareness about the status of the pandemic and encourage progress in HIV/AIDS prevention, treatment and care in high prevalence countries and around the world. Between 2011-2015, World AIDS Days will have the theme of "Getting to zero: zero new HIV infections. Zero discrimination. Zero AIDS related deaths". The World AIDS Campaign focus on "Zero AIDS related deaths" signifies a push towards greater access to treatment for all; a call for governments to act now. It is a call to honour promises like the Abuja declaration and for African governments to at least hit targets for domestic spending on health and HIV.

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