EQUINET NEWSLETTER 154 : 01 December 2013

1. Editorial

No Progress towards Universal Health without Health Workers: A Civil Society Commitment
EQUINET, EPHA, HPA, Health Workers for All and All for Health Workers, ALAMES , MMI, PHM, PSI, CHESTRAD and WEMOS: 3rd Global Forum on Human Resources for Health, Recife, November 12 2013

At the 3rd Global Forum on Human Resources for Health, Recife, Brazil, November 2013 a group of civil society organisations and regional networks produced a statement of commitment on the key role of health workers in universal systems. The statement from EQUINET, European Public Health Alliance, Health Poverty Action, Health Workers for All and All for Health Workers, Latin-America Association of Social Medicine ALAMES , Medicus Mundi International Network MMI, People’s Health Movement PHM, Public Services International PSI, The Centre for Health Sciences Training, Research and Development CHESTRAD and WEMOS is shown below.

The health workforce crisis remains a core barrier to achieving the Millennium Development Goals (MDGs) for health with only 31% and 12% respectively of 75 Countdown countries likely to attain MDGs 4 and 5. Despite donor and country commitments at the 1st and 2nd Global Forums on Human Resources for Health, the global health workers’ shortage persists. Of the 57 countries identified as falling below the WHO target only 19 have seen an improvement in their aggregate health worker density. Earlier commitments to increase domestic resources or external aid, as well as implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, remain largely unfulfilled.

National and international funds have been channelled to strengthen health workforce programs, like task shifting and the scaling-up of community health worker’s programmes. However, too little investment has been targeted at the recurrent costs of health workforce development, for instance on salaries, education and social protection measures for health workers. The inequitable distribution of health workers through increased mobility and migration within and between countries adversely affects access to health.

Health workers and a robust health system are essential for universal health coverage (UHC), and realizing the right to health through universal health systems.

Therefore at the 3rd Global Forum on Human Resources for Health in Recife, Brazil, we, the undersigned representatives of civil society organizations hereby commit that we will:
• Help amplify the voices of health workers, especially those at the lower levels of care and support their work to influence national and global health policies and plans.
• Assist local civil society organizations to ensure their voices are heard in global and national health workforce policy discussions.
• Assist in strengthening the capacity of patient groups to advocate for equitable and quality services staffed by sufficient, competent and equipped health workers at all levels of care.
• Recognise the gender dimensions of the health workforce and champion the rights of women health workers, and

To catalyse a strong movement for health workers, we will:
• Advocate for governments at all levels to institute plans and allocate adequate resources for human resources for health (HRH) to ensure that every person has access to a trained, supported and equipped health worker.
• Press bilateral and multilateral organizations and civil society actors to increase health workforce development efforts and financing, including of national training institutions, in alignment with government plans.
• Work with training institutions, professional and regulatory bodies to achieve quality in health worker education, including on the social determinants, so that every health worker is competent to provide quality care and accountable to the populations they serve.
Strengthen the advocacy of health workers and civil society for improved infrastructure, support and working conditions
• Support the development of a strong, motivated, public workforce to counter some of the ill- effects of an increasingly globalised, inequitable and unstable economy and rapidly changing health and demographic patterns.
• Commit our own resources and expertise to assist in converting HRH policy and plans into action.

To ensure accountable HRH systems at national and global levels, we will:
• Work with governments, the Global Health Workforce Alliance, the World Health Organization, and other stakeholders to develop mechanisms to measure progress towards improved and equitable access to competent health workers
• Monitor and report on progress of public HRH commitments made by global actors and governments.
• Assist citizens and health workers in developing strategies to enhance accountability of national and global actors and challenge inequitable policies that impact on HRH development.
• Increase transparency of our programmatic and technical contributions to national HRH strategies and attempt to reduce onerous reporting requirements placed on countries. We will commit ourselves to supporting a strong public sector for health workforce development and be accountable in our own funding and technical programs to mitigate the ‘internal brain drain’ from the public to the private sector.

We will hold donors, government and multilateral actors accountable to:
• Ensure that economic governance arrangements and fiscal space enables the development of a strong national health workforce as a long-term investment in the wellbeing of the people and the economy of a country. The return on investment to employ a health worker is many times higher than to bail out a bank.
• Provide the leadership, resources and stewardship needed to fulfil commitments made to urgently and effectively address the health workforce crisis and ensure improved and equitable access for every person to competent health services.
• By 2015, develop, finance, and implement HRH action plans, including strengthening national training institutions, with concrete targets and integrate them into national health plans.
• Ensure that health workers and civil society organizations are active partners in the health workforce policies, planning and development.
• Promote equitable access to health care by investing especially in health workers at primary and community levels and in community structures to facilitate citizens’ voices.
• Improve investment in health workforce development, including salaries and social protection, and in national training institutions in order to rapidly increase numbers of HRH.
• Assist in development of robust HRH information systems to facilitate improved planning and management and
• Respect and implement the Global Code of Practice on the International Recruitment of Health Personnel including additional enforceable legislation and redistribution mechanisms to compensate for the international ‘brain drain’ that exacerbates global health inequalities.

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

2. Latest Equinet Updates

Discussion paper 100: Laws on management of public and private funds for health in Zimbabwe
Bhala B: EQUINET, Harare, November 2013

This report provides a legal analysis of the provisions for institutional management of earmarked funds in health, drawing on the laws in Zimbabwe in terms of: 1. The legal definition and current law covering public funds; 2. Obligations in relation to the establishment of funds; 3. The oversight and governance of funds, including the powers, duties and responsibilities of the different parties involved in the control, management, protection and recovery of public funds, in relation to governance of funds and the measures and sanctions related to financial misconduct; 4. The collection, pooling, allocation and expenditure of funds, including duties and responsibilities in relation to collection, receipt, custody, control, issue or expenditure of public money, and in relation to management, audit and obligations of officers managing public funds; and 5. The reporting on funds and measures for transparency and accountability

Regional Meeting On Health Centre Committees, 30 January - 1 February 2014, Harare, Zimbabwe
Training and Research Support Centre, with Community Working Group on Heath and Medico Germany

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.

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 and Dwane N: PLoS One 8(9), 6 September 2013

South Africa is increasingly focused on reducing maternal mortality and documenting variation in access to maternal health services across one of is argued to assist in re-direction of resources. Analysis draws 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. Poorest women had near universal antenatal care coverage (ANC), but only 40% attended before 20 weeks gestation; higher in the wealthiest quartile. Women in rural-formal areas had lowest ANC coverage, completion of four ANC visits and share offered HIV testing. Testing levels were highest among the poorest quartile, but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage was lowest in the poorest quartile and rural formal areas. 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. Self-reported health status declined considerably with each drop in quartile, education level or age group.

Intersectoral action for health equity: a rapid systematic review
Ndumbe-Eyoh S and Moffatt H: BMC Public Health 13:1056. November 2013.

Action on the social determinants of health is considered a necessary approach to improving health equity. Case studies of intersectoral action are available, however there is limited information about the impact of intersectoral action on the social determinants of health and health equity. Search and retrieval of literature published between 2001 and 2011 was conducted in 6 databases. 17 articles of varied methodological quality met the inclusion criteria. One systematic review investigating partnership interventions found mixed and limited impacts on health outcomes. Primary studies evaluating the impact of upstream and midstream interventions showed mixed effects. Downstream interventions were generally moderately effective in increasing the availability and use of services by marginalized communities. The literature evaluating the impact of intersectoral action on health equity is limited. The included studies identified reveal a moderate to no effect on the social determinants of health. The evidence on the impact of intersectoral action on health equity is even more limited. The lack of evidence should not be interpreted as a lack of effect. Rigorous evaluations of intersectoral action are needed to strengthen the evidence base of this public health practice.

4. Values, Policies and Rights

Decisions and Declarations of Extraordinary Session of the Assembly of the African Union
African Union: Addis Ababa, Ethiopia, 12 October 2013

This document presents the decisions and declarations of Extraordinary Session of the Assembly of the African Union 12 October 2013 Addis Ababa, Ethiopia.

ICPD Beyond 2014 Declaration Affirms Africa’s Commitments to Sexual and Reproductive Health and Rights
High Level Task Force for ICPD, Addis Ababa, October 10, 2013

Following a week of intense negotiations, the Addis Ababa Declaration on Population and Development in Africa beyond 2014 was adopted on Friday, October 4, at the conclusion of the Ministerial Segment of the African Regional Conference on Population and Development. The declaration contains strong commitments by African States on sexual and reproductive health and rights. It calls for universal access to sexual and reproductive health information and services, with particular attention to the needs of adolescents, as well as emergency contraception, comprehensive sexuality education and critical services for survivors of violence against women and girls. It does not, however, call explicitly for the elimination of discrimination and violence in Africa based on sexual orientation and gender identity. At the press conference, the Task Force condemned the violence and discrimination endured by women and men in Africa based on their sexual orientation and gender identity.

Miracles Do Happen in Zambia
Lee R: Open Society Initiative for Southern Africa: 6 November 2013

This article reports Zambia's First Lady, Dr Christine Kaseba-Sata, calling for an end to discrimination against sexual minorities. Speaking at a UNAIDS hosted reception, she said that the "silence around issues of Men who have Sex with Men should be stopped and no one should be discriminated against on the basis of their sexual orientation. Rather, we should address reproductive health issues around this issue." She went further to assure people working in the sexual and reproductive health sector of her and the president's support.

Right to Food seminar presentations
Section 27: November 2013

SECTION27 hosted a Right to Food seminar on the 4th of November. This afforded the organisation and other stakeholders the opportunity to form a strategy to ensure the realisation of this critical but legislatively and judicially undefined right. The presentations given during the seminar can be accessed on the site. Attendees came from numerous organisations such as Action Aid, New Women’s Movement, COPAC, the Treatment Action Campaign, Foundation for Human Rights, Lawyers for Human Rights and Wits university.

Universal health coverage: Beyond rhetoric
Sengupta A: Municipal Services Project Occasional Paper, November 2013

This paper raises critical questions around the wide and growing enthusiasm for Universal Health Coverage (UHC). Typically defined as a health financing system based on pooling of funds to provide health coverage for a country’s entire population, it often takes the form of a ‘basic package’ of services made available through health insurance and provided by a growing private sector. Such programs are now zealously promoted by global health agencies, yet the evidence to support their implementation remains extremely thin. The paper argues that re-imagining public health care – rather than the private sellout of health systems via UHC – is the only way forward in building truly universal health outcomes.

5. Health equity in economic and trade policies

Localization of health systems in low- and middle-income countries in response to long-term increases in energy prices
Dalglish SL, Poulsen MN and Winch PJ: Globalization and Health 9:56. November 2013.

External challenges to health systems, such as those caused by global economic, social and environmental changes, have received little attention in recent debates on health systems’ performance in low-and middle-income countries (LMICs). One such challenge in coming years will be increasing prices for petroleum-based products as production from conventional petroleum reserves peaks and demand steadily increases in rapidly-growing LMICs. Health systems are significant consumers of fossil fuels in the form of petroleum-based medical supplies; transportation of goods, personnel and patients; and fuel for lighting, heating, cooling and medical equipment. Long-term increases in petroleum prices in the global market will have potentially devastating effects on health sectors in LMICs who already struggle to deliver services to remote parts of their catchment areas. The authors propose the concept of “localization,” originating in the environmental sustainability literature, as one element of response to these challenges. Localization assigns people at the local level a greater role in the production of goods and services, thereby decreasing reliance on fossil fuels and other external inputs. Effective localization will require changes to governance structures within the health sector in LMICs, empowering local communities to participate in their own health in ways that have remained elusive since this goal was first put forth in the Alma-Ata Declaration on Primary Health Care in 1978. Experiences with decentralization policies in the decades following Alma-Ata offer lessons on defining roles and responsibilities, building capacity at the local level, and designing appropriate policies to target inequities, all of which can guide health systems to adapt to a changing environmental and energy landscape.

WIPO: US seeks to limit work on patent flexibilities
Bhattacharya A: Third World Network October 2013; 1

This report from the consultations at the World Intellectual Property Organisation (WIPO)suggests that the United States does not support a focus by the WIPO on patent flexibilities, an issue that developing countries consider to be central to their development concerns. WIPO’s work on patent flexibilities, including on exceptions and limitations to patent rights, has long been encouraged by developing countries participating in WIPO’s Standing Committee on the Law of Patents (SCP). In recent years proposals have been submitted by the Development Agenda Group of several developing countries, the Africa Group and Brazil to deepen analysis on patent flexibilities, which they consider to be central to development concerns. A work program had been agreed on at the last session of the SCP in February 2013 after intense consultations on the following topics: (i) Exceptions and Limitations to Patent Rights; (ii) Quality of Patents, including Opposition Systems; (iii) Patents and Health; (iv) Confidentiality of Communications between Clients and their Patent Advisors; and (v) Transfer of Technology. However, not all WIPO delegations were agreeable to enhancing of WIPO’s work on patent flexibilities. In a lengthy intervention at the Assemblies on 26 September on the agenda item on the SCP, the US expressed its intention to limit WIPO’s work on patent flexibilities. Its sentiment was not shared by developing countries that intervened on the agenda item. Instead they called for more work to be undertaken on the topics of exceptions and limitations to patent rights, the relationship between patents and health, and the improvement of patent quality.

6. Poverty and health

Costs of providing food assistance to HIV/AIDS patients in Sofala province, Mozambique: a retrospective analysis
Posse M and Baltussen R: Cost Effectiveness and Resource Allocation 11(20): 28 August 2013

As care and antiretroviral treatment (ART) for people living with HIV become widely available, the number of people accessing these resources also increases. Despite this exceptional progress, the estimated coverage in low- and middle-income countries is still less than half of all people who need treatment. In addition, treatment discontinuation and non-adherence are still concerns for ART programs. This study assessed the costs of a program providing food assistance to patients with HIV in Sofala province, Mozambique, in 2009. The authors performed a retrospective analysis of the costs of providing food assistance, based on financial and economic costs. The food distribution program was found to carry significant costs at $288 per patient over 3 months. To assess whether it provides value for money, the study results should be interpreted in conjunction with the program’s impact, and in comparison with other programs that aim to improve adherence to ART. The authors' costing analysis also revealed important management information, indicating that the program incurred relatively large overhead costs.

Dietary diversity of formal and informal residents in Johannesburg, South Africa
Drimie S, Faber M, Vearey J and Nunez L: BMC Public Health 13(911): 2 October 2013

This paper considers the question of dietary diversity as a proxy for nutrition insecurity in communities living in the inner city and the urban informal periphery in Johannesburg. It argues that the issue of nutrition insecurity demands urgent and immediate attention by policy makers. A cross-sectional survey was undertaken for households from urban informal and urban formal areas in Johannesburg, South Africa. Foods consumed by the respondents the previous day were used to calculate a Dietary Diversity Score. Respondents from informal settlements consumed mostly cereals and meat/poultry/fish, while respondents in formal settlements consumed a more varied diet. Significantly more respondents living in informal settlements consumed a diet of low diversity versus those in formal settlements. When grouped in quintiles, two-thirds of respondents from informal settlements fell in the lowest two, versus 15% living in formal settlements. Respondents in the informal settlements were more nutritionally vulnerable.

Re-examining ‘Zero Tolerance’ Child Labour Policies in Africa
Lisa Nho: Africa Portal, July 17, 2013

Globally, many human rights NGOs seek to expose the dire situations where children work at a young age, often under exploitative conditions and without adequate compensation. According to the International Labour Organization, child labour occurs most frequently in Sub-Saharan Africa — 28 percent of all 5-14 year-olds are engaged in paid and unpaid work across the continent, compared to 14 percent in Asia and 9 percent for Latin America. The author argues that what’s often missing from these official statistics, however, are routine household work activities that are less visible than those in the industrial sector. These less conspicuous types of labour are varied and, despite the potential for violations to go unseen, can sometimes be part of a healthy childhood. The distinction between ‘child work’ (less harmful work that may have beneficial impacts on a child’s development) and ‘child labour’ (blatantly hazardous forms of work that disrupt the healthy development of a child), can therefore be a helpful one to make.

‘No access to sanitation’ – the big euphemism
de Albuquerque C: United Nations Special Rapporteur on the human right to safe drinking water and sanitation, 15 November 2013

The United Nations Special Rapporteur on the human right to safe drinking water and sanitation, Catarina de Albuquerque, has warned that the sanitation target set by the UN Millennium Development Goals (MDG) is today the most off-track of all, leaving around one billion people still practicing open defecation on a daily basis, and one-third of the world’s population ‘without access to improved sanitation.’ The human rights expert hailed the UN General Assembly’s decision declaring 19th of November as UN World Toilet Day. “I hope this declaration galvanises national and international action to reach the billions of people who still do not benefit from this basic human right,” the Special Rapporteur said.

7. Equitable health services

Chronic non-communicable disease and healthcare access in middle-aged and older women living in Soweto, South Africa
Lopes Ibanez-Gonzalez D and Norris SA: PLoS One 8(10), 29 October 2013

This study described the healthcare access, beliefs, and practices of middle-aged and older women residing in Soweto, South Africa. The study instrument was administered to 1102 caregivers. Over half the respondents reported having at least one chronic non-communicable disease (NCD), only a third of whom reported accessing a healthcare service in the last six months. Reported availability of private medical practice and government clinics was high (75% and 62% respectively). The low utilisation of healthcare services by women with NCDs is a concern for health care management.

Contribution of community-based newborn health promotion to reducing inequities in healthy newborn care practices and knowledge: evidence of improvement from a three-district pilot program in Malawi
Callaghan-Koru JA, Nonyane BAS, Guenther T, Sitrin D, Ligowe R, Chimbalanga E, Zimba E, Kachale F, Shah R and Baqui AH: BMC Public Health 13:1052. November 2013.

Inequities in both health status and coverage of health services are considered important barriers to achieving Millennium Development Goal 4. Community-based health promotion is a strategy that is believed to reduce inequities in rural low-income settings. This paper examines the contributions of community-based programming to improving the equity of newborn health in three districts in Malawi. This study is a before-and-after evaluation of Malawi's Community-Based Maternal and Newborn Care (CBMNC) program, a package of facility and community-based interventions to improve newborn health. Health Surveillance Assistants (HSAs) within the catchment area of 14 health facilities were trained to make pregnancy and postnatal home visits to promote healthy behaviours and assess women and newborns for danger signs requiring referral to a facility. Core groups of community volunteers were also trained to raise awareness about recommended newborn care practices. Baseline and endline household surveys measured the coverage of the intervention and targeted health behaviours for this before-and-after evaluation. Wealth indices were constructed using household asset data and concentration indices were compared between baseline and endline for each indicator. Despite modest coverage levels for the intervention, health equity improved significantly over the study period for several indicators. Greater improvements in inequities were observed for knowledge indicators than for coverage of routine health services. Although these results indicate promising improvements for newborn health in Malawi, the extent to which the programme contributed to these improvements in coverage and equity are not known. The strategies through which community-based programs are implemented likely play an important role in their ability to improve equity, and further research and monitoring are needed to ensure that the poorest households are reached by community-based health programs.

8. Human Resources

A Universal Truth: No Health Without a Workforce - Third Global Forum on Human Resources for Health Report
World Health Organisation, Geneva, 2013.

This report is intended to inform proceedings at the Third Global Forum on Human Resources for Health and to inform a global audience and trigger momentum for action. It aims to consolidate what is known on human resources for health and how to attain, sustain and accelerate progress on universal health coverage. The report uses mixed methods in selecting, collating and analysing country data. This includes analysing the workforce data in the WHO Global Health Observatory, searches of human resources for health progress in 36 countries and horizon-scanning of “big picture” challenges in the immediate future. The report presents a case that the health workforce is central to attaining, sustaining and accelerating progress on universal health coverage and suggests three guiding questions for decision-makers. What health workforce is required to ensure effective coverage of an agreed package of health care benefits? What health workforce is required to progressively expand coverage over time? How does a country produce, deploy and sustain a health workforce that is both fit for purpose and fit to practice in support of universal health coverage?

Migration of South African health workers: the extent to which financial considerations influence internal flows and external movements
George G, Atujuna M, Gow J: BMC Health Services Research 2013, 13:297

The loss of human resource capacity has had a severe impact on the health system in South Africa. This study investigates the causes of migration focussing on the role of salaries and benefits. Health professionals from public, private and non-governmental (NGO) health facilities located in selected peri–urban and urban areas in KwaZulu-Natal, South Africa were surveyed about their current positions and attitudes toward migration. The study uses cross-sectional data collected in 2009. A total of 694 health professionals (430 in the public sector, 133 in the NGO sector and 131 in the private sector) were surveyed. An additional 11 health professionals were purposively selected for in-depth interviews. Odds ratios with 95% confidence intervals were calculated to determine whether salaries influenced HWs decisions to migrate. HWs decision to move was not positively associated with lower salaries. It was found, instead, that the consideration to move was determined by other factors including age, levels of stress experienced and the extent to which they were satisfied at their current place of work. The OSD appears to have lowered the risk of HWs migrating due to low salaries. However, the results also indicate that the South African Department of Health needs to improve working conditions for HWs within the public health sector to assist in retention.

9. Public-Private Mix

Health in Africa over the next 50 Years
Ncube M, Abou-Sabaa A, Lufumpa CL and Soucat A: African Development Bank, March 2013

This report reviews the progress made in the health sector in Africa over the last 50 years, in terms of health outcomes, and particularly in the
utilization of, and access to, healthcare services. The current challenges faced by the health sector are assessed, and the discussion lays the groundwork for projections regarding the future of healthcare in Africa over the next 50 years. The authors outline that the private sector has been playing an increasingly important role in health financing in Africa, and that in some countries, such as Angola and Mali, all private expenditure is direct payments from households. Lack of continuity in policy, lack of resources, poor management of available resources, and poor policy implementation are identified as major impediments to improving the health systems. The private sector is playing a major role in the delivery of health services to citizens, yet dialogue and the sharing of information between the private and public sector is rare. They indicate that in addition to scaling up public spending, there needs to be a drive to ensure better value for money throughout the health system. They also suggest that The health sector will become a labor-intensive industry that can provide an estimated 2–3 million skilled jobs for young Africans and contribute to economic growth on the continent. As the pharmaceutical, medical technologies, and ICT segments develop, there will be more opportunities in research and development, manufacturing, sales and distribution. Within this industry, other opportunities will be driven by the hospital, health insurance, and medical education segments.

Promoting social security and prevention of occupational diseases in Africa
Konkolewsky HH: African Newsletter on Occupational Health and Safety 23 (2):28-30, August 2013

Occupational diseases are posing an ever increasing challenge to workers’ compensation systems. Out of the 2.34 million annual work-related deaths reported by the International Labour Organization (ILO) , the vast majority – approximately 2.02 million – are due to work-related diseases. As a consequence, occupational safety and health policy is shifting from an injury and accident centered approach to one that increasingly is occupational disease focused. To effectively address occupational diseases (ODs), many social security organizations responsible for insuring and compensating these risks are adopting a more proactive and preventive approach. Their leitmotif can best be described as ‘prevention is better than compensation’. Adopting such an approach also forms part of a broader understanding of the role that social security can play in promoting and shaping a national prevention culture.

10. Resource allocation and health financing

Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya
Mulupi S, Kirigia D and Chuma J: BMC Health Services Research 13: 474, 12 November 2013

Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. This study contributes to this process by exploring communities' understanding and perceptions of health insurance and their preferred designs features. Data collection methods included a cross-sectional household survey and focus group discussions. About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance but limited knowledge of how it functions or of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority.

11. Equity and HIV/AIDS

Balancing efficiency, equity and feasibility of HIV treatment in South Africa - development of programmatic guidance
Baltussen R, Mikkelsen E, Tromp N, Hurtig A, Byskov J, Olsen O, Bærøe K, Hontelez JA, Singh J and Norheim OF: Cost Effective Resource Allocation 11 (1): 26, 9 October 2013

South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment. the authors argue there are two reasons for this. First, priority setting decisions on HIV treatment are argued to fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process without adequate participatory processes in place to incorporate stakeholders' views and evidence. They propose an alternative approach that integrates procedural fairness and a multi-criteria decision analysis that assesses feasibility, efficiency, and equity of programme options, including trade-offs.

How AIDS Invented Global Health
Brandt AM: The New England Journal of Medicine 368(23): 2149-2152, 6 June 2013

This paper presents how the changes wrought by HIV have affected research, clinical practice, and policy. The AIDS epidemic provided the foundation for a revolution that upended traditional approaches to international health, replacing them with innovative global approaches to disease. Over the past half-century, historians have used episodes of epidemic disease to investigate scientific, social, and cultural change. Underlying this approach is the recognition that disease, and especially responses to epidemics, offers fundamental insights into scientific and medical practices, as well as social and cultural values.

Masculine attitudes of superiority deter men from accessing antiretroviral therapy in Dar es Salaam, Tanzania
Nyamhanga TM, Muhondwa EP and Shayo R: Global Health Action (6), 22 October 2013

This article presents part of the findings from a larger study that sought to assess the role that gender relations play in influencing equity regarding access and adherence to antiretroviral therapy (ART). Review of the literature has indicated that, in Southern and Eastern Africa, fewer men than women have been accessing ART, and the former start using ART late, after HIV has already been allowed to advance. The main causes for this gender gap have not yet been fully explained. To explore how masculinity norms limit men's access to ART in Dar es Salaam, the authors implemented a qualitative study, with a stratified purposive sampling and a thematic analysis. The findings revealed that men's hesitation to visit the care and treatment clinics can be related to norms of masculinity that require men to avoid displaying weakness. Since men are the heads of families and have higher social status, they reported feeling embarrassed at having to visit the care and treatment clinics. Specifically, male respondents indicated that going to a care and treatment clinic may raise suspicion about their status of living with HIV, which in turn may compromise their leadership position and cause family instability. Because of this tendency towards 'hiding', the few men who register at the public care and treatment clinics do so late, when HIV-related signs and symptoms are already far advanced. They argue that HIV control programmes need to factor in the deconstruction of such norms of masculinity.

12. Governance and participation in health

Despite the state's violence, our fight to escape the mud and fire of South Africa's slums will continue
S'bu Zikode, Abahlali baseMjondolo, The Guardian, 11 November 2013

Abahlali baseMjondolo formed in 2005 has more than 12,000 members in more than 60 shack settlements. The organisation campaigns against evictions, and for public housing: struggling for a world in which human dignity comes before private profit, and land, cities, wealth and power are shared fairly. The article by the founder of Abahlali baseMjondolo expresses people's frustration with lack of delivery on rights to free housing, free education and free healthcare in urban South Africa, and the consequent resolve to take direct action to move rights from paper to reality, from abstract to concrete. While they acknowledge that this brings risk to their members, the author raises frustration with political and civil society processes, they also argue that they no choice but to take their own place in the cities and in the political life of the country.

How to Keep the Ambition and Complexity, Be Less Fuzzy and Get More Traction
Lipovsek V, Rajani R: Oxfam Blog October 11 2013

This article poses reflections from two leads of Twaweza, an east African non government organisation, on their approaches and work, particularly in response to a series of blogs on this by D Green (Oxfam GB advisor. They reflect on learning on citizen action; and on the need to better articulate what is meant by citizen action, including private v public and individual v collective. "In essence, this is a move away from an unexplained “magic sauce” model where we feed some inputs (i.e. information) into a complex system, hope twaweza-logothat the (self-selecting, undifferentiated) citizens will stir it themselves, and voila – a big outcome (such as increased citizen monitoring of services, and improved service delivery) will somehow pop out on the other end".

So what should Twaweza do differently? How accountability work is evolving
Green D: Oxfam GB, Blog post October 31 2013

This blog discusses issues and seven lessions raised by evaluations of the theory of change and first four years of work by an East African NGO, Twaweza. The author comments that research by groups like the Africa Power and Politics Programme and Matt Andrews argues that both demand side (build the citizens) and supply side (build the state) have failed in generating change. What works, they think, is collective problem solving, bringing together citizens, states and anyone else with skin in the game, to build trust and find solutions. People on the ground, like Goreti Nakabugo, Twaweza’s Uganda coordinator, get this: ‘we know we need buy-in from the government, officials, local politicians. We are brokering relationships with them on a daily basis’. Not only that, but in practice, even differentiating between citizen and state can be problematic – neither category is a monolith, and in some cases, the most active citizens are themselves state employees, members of public trade unions etc.

13. Monitoring equity and research policy

Assessing communities of practice in health policy: a conceptual framework as a first step towards empirical research
Bertone MP, Meessen B, Clarysse G, Hercot D, Kelley A, Kafando Y, Lange I, Pfaffmann J, Ridde V, Sieleunou I and Witter S: Health Research Policy and Systems 11(39): 20 October 2013

Communities of Practice (CoPs) are groups of people that interact regularly to deepen their knowledge on a specific topic. Thanks to information and communication technologies, CoPs can involve experts distributed across countries and adopt a ‘transnational’ membership. This has allowed the strategy to be applied to domains of knowledge such as health policy with a global perspective. CoPs represent a potentially valuable tool for producing and sharing explicit knowledge, as well as tacit knowledge and implementation practices. They may also be effective in creating links among the different ‘knowledge holders’ contributing to health policy (e.g., researchers, policymakers, technical assistants, practitioners, etc.). CoPs in global health are growing in number and activities. As a result, there is an increasing need to document their progress and evaluate their effectiveness. This paper represents a first step towards such empirical research as it aims to provide a conceptual framework for the analysis and assessment of transnational CoPs in health policy. The framework is developed based on the findings of a literature review as well as on the authors' experience, and reflects the specific features and challenges of transnational CoPs in health policy. It organizes the key elements of CoPs into a logical flow that links available resources and the capacity to mobilize them, with knowledge management activities and the expansion of knowledge, with changes in policy and practice and, ultimately, with an improvement in health outcomes. Additionally, the paper addresses the challenges in the operationalization and empirical application of the framework

14. Useful Resources

A complete set of online resources for information activism and investigative journalism
Exposing the Invisible, November 2013

This website should come under a section called many useful resources! It provides resources for people to use for research work. It provides links to various databases and tools, links to tools available to keep data safe; and an array of tools to learn how to efficiently communicate the conclusions of investigations, from data visualisation to animations, showing what others have done and how to find the most appropriate medium to display evidence. It provides resources for keeping the internet and communications tools secure. The site also provides links to sites that they hope will inspire.

Fuelling Poverty
Buni TV, November 2013

This short documentary by Ishaya Bako and Oliver Aleogena, and featuring Nobel Prize laureate Wole Soyinka, provides an insight into the Nigerian fuel subsidy. The film presents the social government spending from the subsidy and presents the reasons for its removal and how this has plunged many Nigerians into poverty.

Global Health and Human Rights Database
Lawyers Collective and the O'Neill Institute

The Global Health and Human Rights Database is a free and fully searchable online database of more than 1000 judgments, constitutions and international instruments on the intersection between health and human rights.

HRH Global Resource Center eLearning Platform

Capacity plus provides free online courses to build the capacity of country-based users in critical skills. The courses include
• Designing Evidence-Based Incentives to Attract and Retain Health Workers
• An Introduction to Monitoring and Evaluation of HRH
• Foundations of Gender Equality in the Health Workforce, and
• iHRIS Administrator: Level 1

Universal health: From private coverage to public care
Municipal Services Project video, November 2013

The universal health coverage agenda is opening the door for privatization of public health systems in the global South. In India, insurance-based coverage has skewed public health priorities and starved primary care. This animation video calls on people everywhere to mobilize around public alternatives to achieve health for all. Spanish subtitles are available.

15. Jobs and Announcements

2013 Edition of the Zimbabwe Social Forum
Raylton Sports Club, Harare, 12-13th December 2013

The Zimbabwe Social Forum is a space dedicated to those struggling against, and directly challenging corporate fascism, neo-liberalism and market-led globalization. The Event will be held at the Raylton Sports Club in Harare under the theme “Our Resources, our Future!!!” Reclaiming the Social Movements Agenda for Social and Economic Justice. Participating Thematic Clusters are as follows: Gender and Women’s Rights; Debt and Trade; Students and Youths; Social Service Delivery; Labour; Media; Democracy and Rights; Natural Resources Governance; Health; Disability; Land, Environment and Climate Justice; Art s and Culture. Send enquiries to the email below.

Annual Helen Kanzira Lecture: The Power of Advocacy
Mr Stephen Lewis: Hatfield Campus, University of Pretoria, 9 December 2013

This public lecture on ‘The Power of Advocacy’ will be presented by Mr Stephen Lewis, who will draw on his extensive international experience to illustrate the power of advocacy in the fight for social justice, reproductive rights, global health and gender equality. He is the co-founder and co-director of AIDS-Free World (www.aidsfreeworld.org), which is an international advocacy organisation that works to promote more urgent and more effective global responses to HIV/AIDS.

Conference on Rights of Women in Africa
Pretoria, South Africa, 9 - 10 December 2013

The Centre for Human Rights at the Faculty of Law, University of Pretoria, is hosting an international conference to commemorate the tenth anniversary of the adoption of the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa on 8 - 9 December 2013. Commemorating the tenth anniversary of the adoption of the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa: Exploring possibilities for promoting women’s sexual and reproductive rights. The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (also called the ‘Maputo Protocol’) was adopted in 2003 and entered into force in 2005. It has now been ratified by two-thirds of AU member states. One of the most important provisions of the Protocol is article 14, dealing with the health and reproductive rights of women. The conference will reflect on these and other innovative aspects of the Protocol.

Dakar Financing Summit for Africa’s Infrastructure Development
NEPAD Agency and African Union Commission: 13-14 December 2013, Dakar Senegal

On 13 and 14 December 2013, the Government of Senegal will host the “Dakar Financing Summit” on Africa’s infrastructure. African Heads of State and Government, influential business leaders and financiers will meet to provide concrete outcomes to accelerate financial investments for priority regional infrastructure projects on the continent. The Summit is a rallying call for the public and private sectors to partner towards infrastructure development in Africa. The Dakar Financing Summit is organized by the NEPAD Agency and African Union Commission, in collaboration with the African Development Bank (ADB) and UNECA. To register go to the website given.

Delivering UHC: what role for the for-profit private sector? LSHTM, Oxfam, London, 4 April 2014
Call for papers: Call closes 13 December 2013

LSHTM and Oxfam are inviting proposals for conference papers on the role of the for-profit private sector in delivering Universal Health Coverage (UHC) in low and middle income countries. The conference will take place at the LSHTM in London, UK on 4 April 2014. The conference will bring together academics, policy makers and civil society to explore evidence on the role and contribution of the for-profit private sector in scaling up access to achieve UHC. The organisers are seeking papers that demonstrate promising and innovative examples of for-profit private sector health care delivery in low- and middle-income countries that have made a significant and positive contribution to closing the health care gap and advancing UHC. Papers exploring examples from high-income countries will also be considered. Papers can have a country or regional (e.g. Africa/ Asia/ Europe/ Caucasus/ Latin America) focus and should pay particular attention to how for-profit providers expand access to quality and effective services for under-served populations as well as the challenges they face in doing so. Papers will also be considered that explore the specific role of for-profit providers within country wide successful advances towards UHC. Abstracts should be submitted as email attachments to deliveringuhc@oxfam.org.uk in English. All conference proceedings will be conducted in English.

Distance learning course on occupational safety and health, 9 February 2014 – 31 July 2014
Applications close: 20 January 2014

The International Training Centre of the International Labour
Organization (ILO) is offering a distance learning course on OSH delivered through an internet based platform. The proposed programme will incorporate the international ILO experience on OSH and the ITC-ILO’s international training experience applied to the methodology. This programme is addressed to participants of both developing and developed countries, who will thus have an opportunity to share their different experiences. People interested in participating should complete and submit the application form available on the website http://socialprotection.itcilo.org/forms/A977128/ not later than 20 January 2014. Applications should be accompanied by a nomination letter from the sponsoring institution indicating how the participant will be financed.

Eliminating Women and Girls Sexual and Reproductive Health Vulnerabilities in Africa
February 3 – 7, 2014 | Yaoundé, Cameroon

The Sixth Africa Conference on Sexual Health and Rights will be held in Yaoundé, Cameroon from February 3 – 7, 2014, and hosted by the Women in Alternative Action (WAA), Cameroon. The theme of the conference is “Eliminating Women and Girls Sexual and Reproductive Health Vulnerabilities in Africa”. The conference is part of a long-term process of building and fostering regional dialogue on sexual health and rights that leads to concrete action that will enhance stakeholders’ ability to influence policy and programming in favour of a sexuality healthy continent including that of the African Union and its bodies.

ICASA Conference 2013
CTICC, Cape Town, South Africa 7-11 December 2013

The conference theme “Now More Than Ever: Targeting Zero” is derived from the UNAIDS’ vision of striving for “Zero new HIV infections. Zero discrimination. Zero AIDS-related deaths”, but it also highlights the need to “now more than ever” maintain the commitment to ensure access to treatment for everyone in Africa irrespective of their ability to pay for such treatment. The hosting of this Conference in South Africa is highly symbolic as it was in South Africa during the XIIIth International AIDS in 2000 that a turning point was reached in breaking the silence around AIDS in Africa, which resulted in an unprecedented commitment by donors, government and civil society to increase access to treatment in an attempt to turn the tide of this epidemic. 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.

Linkages across the continuum of HIV services for key populations affected by HIV
Call for applicants: Call closes 16 December 2013

USAID invites applications to carry out a five year, $72 million, global program to strengthen the capacity of governments and civil society in partner countries to implement high quality, sustainable, evidence-based and comprehensive HIV and AIDS prevention, care and treatment services with key populations at scale. Grant number SOL-OAA-14-000013

Masters in occupational safety and health (3rd edition), English; Distance + Turin, 8 September 2014 – 30 September 2015
Call for applicants: Closing date 31 May 2014

The University of Turin, Italy, in partnership with the International Training Centre (ITC) of the International Labour Organization (ILO), is offering a Master course in Occupational Safety and Health. This one-year programme, to be held in English, includes an Internet-based distance learning phase, a face-to-face residential period on the ITC/ILO's campus in Turin followed by another distance phase for the preparation of the dissertation. The proposed programme combines the advantages of the academic experience in OSH of Turin University with the ITC/ILO's international training experience. An international approach has been applied to the contents, the methodology development as well as to the composition of the training team. This programme involves participants from both developing and developed countries, who will thus have an opportunity to share their different experiences. Applicants to visit the website for information on applications. A number of partial fellowships are available only for participants from developing countries on a competitive basis.


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