When the news came of Nelson Mandela’s death messages came spontaneously on our list from colleagues from across the 16 countries in EQUINET. We can’t include them all but some are below. They signal the pride that Mandela gave to all in being African, the many facets of justice and wisdom he symbolized for people in the continent, his respect for power being located within the people and the inspiration that people drew and will continue to draw from his life. Hamba Kahle Madiba.
From Amuda Baba in Democratic Republic of Congo: It is a big loss for Africa. We have lost a symbol of peace, unity and humility. May his soul rest in peace.
From Severina Lemachokoti in Kenya: His wisdom was unique and his wise words will forever remain to build people of all races in the years to come.
From Moses Lungu in Zambia: We will draw lessons from him on equity, equal and social justice for all. Bless his family and nation
From Sam Wamani in Uganda: Mandela was and will remain a true love for all people of all colours. Africa and the world will always remember Madiba.
From Isabella Matambanadzo in Zimbabwe: He gave us an unmatchable sense of the dignity in being black Africans and of our humanness. ..May we always carry the best of you with us.
From Elisha Sibale in Tanzania: His lifelong commitment to social justice for all was a beacon to the world.
From Dennis Chibuye in Zambia: The world has lost of a true patriot and visionary leader. …Long Live Mandela Spirit.
From: Kingsley Chikaphupha in Malawi: An icon, statesman and a true son of Africa!!
From Wilson Asibu in Malawi: May his life inspire us all, especially the youth who have a great opportunity to sculpture their lives into greatness.
From Jacob Ongala Owiti in Kenya: Mandela had the unique ability to take power to the people - So, who will take up the Mandela's spear and move it forward?
From Fortunate Machingura in Zimbabwe: He said: “To be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others” he said…enhancing the freedom of others implies our joint action as a collective.…it’s now up to us Comrades… the struggle continues!
We wish all a 2014 in which our struggles for health and justice flourish.
1. Editorial
If our health systems ‘listen’ better to people’s input, will this make them more responsive to people’s needs? Will strengthening people’s voice and role in decisions in health systems help overcome the significant inequalities that exist in east and southern Africa - and more widely - in access to and use of health services? What do we need to do to ensure that the substantial resources that flow to and in health systems reach the primary care and community level?
These were questions that we tackled at a recent regional joint workshop of the Community of Practitioners in Accountability and Social Action in Health (COPASAH) and the Regional Network for Equity in Health in East and Southern Africa (EQUINET) hosted by TARSC in Zimbabwe. Thirty people attended this workshop, including community health activists, civil society organisations, health workers, academics and researchers from Kenya, South Africa, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe. As a group, they came from a wide range of contexts and experiences, working with or representing people living with HIV and AIDS, elderly people, women and children, health workers and people whose health rights had been violated. Participants came from organisations whose goals included supporting and strengthening community roles in monitoring health service delivery, and advocating for equity and quality of health services and increased resources for health.
Given the wide social inequalities in our societies, all who attended the meeting are working in some way to invest in and support community capacities to articulate their needs, present their conditions, negotiate for resources that improve their lives, and monitor the delivery on state commitments towards improving health. We agreed that, in order for this to happen and for it to have an impact upstream, beyond the more common ways that people support health services - such as caring for people who are ill or contributing their own resources or time to improve services - people also need to have a greater role in the planning, delivery and monitoring of their health services.
We brought our own stories of how greater citizen engagement with service providers, especially around social action on health and social accountability in services, makes for more effective and acceptable health services. For example, participants from South Africa, Kenya and Zambia noted that setting up community-health worker committees had helped to improve dialogue and collective action. Uganda CSOs reported on a randomized field experiment of community-based monitoring of public primary health care providers in Uganda by Björkman and Svensson in 2007 that showed how social accountability mechanisms led to large increases in utilization of services and improved health outcomes.
For this to happen, however, we see that the health system needs to change. When the health system itself does not give any authority to frontline workers, it is difficult for the same workers to respond to communities. Decentralisation of power and resources within the system to local levels, together with the capacities for it, is thus necessary if people at community level are to be effective in providing input to the organisation of services. The health system needs to make clear what entitlements people have, and what obligations service providers have, and to communicate this widely to health workers and the public as a prerequisite for delivering health rights and building social accountability. If our health systems are to become more people-centred, they need to not only develop skills, knowledge and procedures around technical issues, but they also need the skills, knowledge and procedures for health workers and managers to facilitate meaningful community engagement and involvement, including in decision making. And these are most needed where the communities enter the system, that is, at the primary care level. To build ‘people centred’ health systems it is essential that resources, including medicines and skilled health workers, reach the primary care level.
This touches on the power dynamics within health systems. The inequalities in health systems are not just inequalities in relation to resources, or to access to services. There are also inequalities in power: between service providers and communities, between different kinds of health personnel and between different levels of the health system. This is an issue that is largely invisible but that has impact on the participation in and use of health systems by more marginalised groups. So a great part of our meeting tackled the sort of mechanisms and processes that can address this power imbalance. For example, mechanisms such as community prioritising of health needs, monitoring service delivery using community score cards, community- health centre meetings and community action planning, can help to make service providers more accountable to communities, and can potentially support and improve interactions between communities and frontline service providers. This strengthened interaction can then, if based on a mutual listening and understanding, lead to alliances between local health workers, managers and communities in negotiating with higher level authorities for improvements in services.
One of the ways of embedding a shift in power relations and to strengthen that alliance and interaction between communities and primary health care actors, is through using participatory reflection and action (PRA) approaches. PRA uses a variety of visual and verbal methods to provoke discussion, analysis and planning for action in such a way that it can strengthen the power that people have to change their own lives, their communities and the institutions that affect them. For the last 10 years, the pra4equity network in EQUINET has been exploring how this approach can support the strengthening of a people-centred health system. At our meeting we built on this to examine how PRA can be used to shift attention and resources towards the primary care level of the health system, to make those at higher level more accountable to the needs of communities, and to ensure the capacities of frontline services to deliver on those needs. In reviewing some of the blocks and deficits raised in our current health systems, we concluded that PRA does have a role to play in improving transparency, improving dialogue between rights holders and duty bearers, and establishing platforms for feedback and consultation.
This was a unique opportunity to bring together and build synergies between two bodies of work, on PRA approaches and on social accountability. It also raised the potential for PRA approaches to position our engagement on accountability within a dialogue between communities and their frontline health workers, for both to listen to and engage with the realities and experience of the other. We already have evidence, in the work of the pra4equity network published on the EQUINET site, that this improves local service quality for both health workers and communities. The question we are yet to test, and will be exploring in our follow up work, is whether this shared power is able to address imbalances in institutional resources and power within the health system, so that the resources, skills, commodities and authorities reach the primary and community level services, where they are most needed.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Further information on the issues raised in the oped can be found in the report of the meeting and other publications on the EQUINET website at www.equinetafrica.org and in the COPASAH website at www.copasah.net
2. Latest Equinet Updates
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.
In 2013 TARSC through COPASAH and EQUINET held a regional workshop on Participatory Approaches to Strengthening People-Centred Health Systems in the east and southern Africa (ESA) region. The training brought together 28 delegates from 7 countries in east and southern Africa to discuss and deepen understanding on ways to strengthen primary health care through improved public involvement and health service accountability. The training came about because of a joint interest within all three lead organisations to explore how Participatory Reflection and Action (PRA) approaches could be used to raise community voice in strengthening the functioning and resourcing of primary health care (PHC) systems in the region
3. Equity in Health
The Millennium Development Goals have centred on social outcomes, primarily in the fields of poverty, health and education. The goal of halving extreme poverty globally has already been met, albeit in large part thanks to the remarkable performance over three decades of the Chinese economy. Greater ambition is expected for a post-2015 agenda, with the eradication of extreme poverty a possible new goal. However, this goal is very unlikely to be reached by 2030 if business as usual is the order of the day. Paradoxically, this partly reflects the lack of ambition in the conventional poverty line of $1.25 per day, which is by any standard extremely low. However UNCTAD also argue that it is also because poverty eradication, even at this level of ambition, will not happen without addressing the more challenging issue of global inequality.UNCTAD argue that there is an emerging consensus that existing levels of inequality are not only morally unacceptable, but also economically and politically damaging. Moving beyond the Millennium Development Goals, inequality should therefore become a prominent part of the post-2015 development narrative.
The linkage between the socio-economic inequality and HIV outcomes was analysed using data from a population-based household survey that employed multistage-stratified sampling, to help refocus attention on how HIV is linked to inequalities. A socio-economic index (SEI) score, derived using multiple correspondence analysis of measures of ownership of durable assets, was used to generate three SEI groups: Low (poorest), Middle, and Upper (no so poor). Distribution of HIV outcomes (i.e. HIV prevalence, access to HIV/AIDS information, level of stigma towards HIV/AIDS, perceived HIV risk and sexual behaviour) across the SEI groups, and other background characteristics was assessed using weighted data. Univariate and multivariate logistic regression was used to assess the covariates of the HIV outcomes across the socio-economic groups. More women than men were found in the poor SEI. HIV prevalence was highest among the poor and declined as SEI increased. Individuals in the upper SEI reported higher frequency of HIV testing compared to the low SEI. Only 21% of those in poor SEI had good access to HIV/AIDS information compared to 80% in the upper SEI. A higher percentage of the poor had a stigmatizing attitude towards HIV/AIDS and personal HIV risk perception compared to those in the upper SEI. Our findings underline the disproportionate burden of HIV disease and HIV fear among the poor and vulnerable in South Africa, who are further disadvantaged by lack of access to HIV information and HIV and AIDS services.
4. Values, Policies and Rights
The WHO Executive Board meeting in Geneva in Jan 2014 will consider a proposal from Finland (see EB134/1 Add.1) entitled: “Contributing to social and economic development: sustainable action across sectors to improve health and health equity” which is a follow up from the 8th Global Health Promotion Conference in Helsinki in June 2013. Finland has requested the inclusion of a new agenda item for the 134th session
of the Executive Board. It will provide an opportunity for the Board to have a debate, adopt a recommendation for an Assembly resolution calling for concrete steps forward, carried out within existing resources, and expressing the importance of actions across sectors for health and health equity in the final efforts to achieve the MDGs and in the debate on the post-2015 development agenda.
In this blog Thandika Mkandawire writes about the role Nelson Mandela played in inspiring his generation of political activists.He writes that if the life imprisonment of Mandela seemed like a major reversal for African nationalism and a victory for the remaining racist and fascist regimes, Mandela's statement at the dock of the court on 20 April 1964 was one the most inspiring statements for his generation: “This is the struggle of the African people, inspired by their own suffering and experience. It is a struggle for the right to live. I have cherished the ideal of a democratic and free society, in which all persons live together in harmony and with equal opportunity. It is an ideal which I hope to live for and achieve. But, if needs be, my Lord, it is an ideal for which I am prepared to die.” Mkandawire writes that four things strike him as to why the man is the most admired among Africans. One was Mandela's deep commitment to the liberation of the African people. A second was Mandela’s deep sense of duty and a warm sense of respect for the people he led and the movement to which he had been of selfless service. The third feature was Mandela’s eminently sane relationship to power and his contribution by example in his own exercise of power. The fourth was his commitment to democracy and rule of law.
The process of mythologizing represents a contestation between symbolism and mythology, writes Firoze Manji. The greatest disservice that we could pay to Mandela is to allow the complexity, courage and humanity of his long life to be reduced to a fairy tale. Mandela represents for so many the finest values of courage, liberation and freedom.
Kofi Annan speaks with the unhurried, temperate tone of someone confident of being listened to. Last week the former UN secretary-general met his match, however, in the form of hundreds of Sowetan schoolchildren blowing vuvuzelas in a football stadium. "Silence please," Annan was forced to plea as his speech was interrupted, something that can rarely have happened to him at the UN general assembly or even mediating in Syria.
Annan warned the audience drawn from 190 countries that the benefits of globalisation have not been shared fairly and the gap between rich and poor is unsustainable. It is a theme that he shares further on in this interview with the Guardian. There must be greater accountability and transparency, he says, to ensure Africa's vast natural resources benefit all its people.
As a means of enforcing the justiciability of the right to health, on 3 March 2011, Petition Number 16 of 2011 on cases of maternal mortality was filed in Uganda’s Constitutional Court by the Centre for Health, Human Rights and Development (CEHURD) and others. This case argued, among others, that by not providing essential health services and commodities for pregnant women and their new-borns, Government was violating fundamental human rights guaranteed in the Constitution, including the right to health, the right to life, and the rights of women. However, court dismissed the case on grounds that the the constitutional court had no power to determine the matter. CEHURD appealed to the Supreme Court asserting that the petition was fully with in the mandate of the constitutional court. The hearing could not however be started because the government was not represented in court at the first hearing of the Appeal leading to its postponement.
5. Health equity in economic and trade policies
The idea that Africans have never had it so good is rapidly becoming economic orthodoxy. This article comments that foreign investors, media and politicians from William Hague to Jacob Zuma have championed a narrative usually summed up in two words: "Africa rising". However the author asserts that the majority of Africans themselves feel that the picture is far less rosy, complaining that the continent's much vaunted economic growth is failing to trickle down to their daily lives, according to the biggest survey of its kind. "After a decade of growth in Africa, little change in poverty at the grassroots," is the title of a report by the Afrobarometer research project, covered in the article which questioned 51,605 respondents in 34 countries from October 2011 to June this year. He reports critics who have warned that the boom is benefiting only a narrow elite while leaving the poor and jobless behind, exacerbating inequality and potentially sowing seeds of unrest. The wave of "Afro-optimism" should be qualified, they argue.
The East African Community (EAC) modeled on the EU has enormous potential and resources. Resolving political differences and harmonizing with other regional blocks remains the foremost challenges. The East African Community (EAC) heads of state are due to sign a monetary union paving a way for a single currency for Uganda, Kenya, Tanzania, Rwanda, Burundi and those other countries that will join the community later on. The benefits of monetary union include a single currency; low transaction costs for business people; tuition and visa fees of the same value in all the countries; amongst others. The author explores the geopolitical, demographic and resource potentials for the east African community. The paper also argues that there is no single formula for regional integration. Rather than being competitors, the various regional blocks provide avenues for more complex and beneficial collaboration in the continent.
According to 2012 estimates, internet penetration in Africa has reached 15.6%. Though the actual number of people on whom the internet has an impact is undoubtedly much higher, this statistic does demonstrate a significant infrastructural disparity between Africa and other continents. Currently, this connectivity gap is being filled by other media, such as in the astonishing growth rate in the African mobile market. Radio remains one of the cheapest, most versatile and most widespread forms of mass communication there is and a powerful tool for African educators, despite its lack of interactivity. In this paper the author explores the opportunities of combining the pervasiveness of radio with the enhanced connective power of the internet. The paper describes trials to test the viability of white space broadband technologies to extend information access in several African countries in schools, healthcare centres and libraries.
Global spending on prescription medicines will accelerate next year to exceed $1tn for the first time, fuelled by the launch of more innovative drugs and rising health expenditure in emerging markets led by China. The rise was projected by the IMS Institute for Healthcare Informatics. The rise is attributed in part to emerging markets, where rising demand for healthcare paid out of pocket by the growing middle class is being matched by an expansion in universal health coverage programmes to extend provision, with targeted public health policies such as rising vaccination rates. The jump comes at a time of growing use of cheaper off-patent generic medicines, predicted to grow from 27 per cent to 36 per cent of the global market by 2017 and as high as 63 per cent in the fast-growing emerging economies. The report projects that two-thirds of the total medicines market in 2017 will be accounted for by the eight markets of the US, France, Germany, the UK, Italy and Spain, as well as China and Japan, which will also be responsible for nearly 60 per cent of the total growth in spending.
Emerging regional powers in the South have produced powerful finance capitalists. In this paper an example is given of an Egyptian firm buying land, rights to water and precious metals in other African countries. Consolidation of the formal economies of Southern countries has meant not only expansion into existing markets but ‘diversification’ into new markets, domestically and regionally. Allied with global governance institutions, the author argues that such finance capitalists represent greater control over vital resources and distribution routes for private wealth accumulation.
6. Poverty and health
The author examines associations between ambient air pollutants and respiratory outcomes among schoolchildren in Durban, South Africa, in a cross sectional survey of primary schools from within each of seven communities in two regions of Durban (the highly industrialised south compared with the non-industrial north) and measurement of particulate matter (PM), sulphur dioxide (SO2) and carbon monoxide at each school, and nitrogen oxides (NOx) at other sites. Children had a prevalence of asthma symptoms of any severity of 32%, higher in schools with higher SO2 levels. Schoolchildren from industrially exposed communities experienced higher covariate-adjusted prevalences of persistent asthma than children from communities distant from industrial sources. The authors indicate that the findings are strongly suggestive of industrial pollution-related adverse respiratory health effects among these children.
Lack of access to health care is a persistent condition for most African indigents, to which the common technical approach of targeting initiatives is an insufficient antidote. To overcome the standstill, an integrated technical and political approach is needed. Such policy shift is dependent on political support, and on alignment of international and national actors. The authors explore if the analytical framework of social exclusion can contribute to the latter. The authors produce a critical and evaluative account of the literature on three themes: social exclusion, development policy, and indigence in Africa–and their interface. First, the authors trace the concept of social exclusion as it evolved over time and space in policy circles. They then discuss the relevance of a social exclusion perspective in developing countries. Finally, this perspective is applied to Africa, its indigents, and their lack of access to health care. The concept of social exclusion as an underlying process of structural inequalities has needed two decades to find acceptance in international policy circles. Initial scepticism about the relevance of the concept in developing countries is now giving way to recognition of its universality. For a variety of reasons however, the uptake of a social exclusion perspective in Africa has been limited. Nevertheless, social exclusion as a driver of poverty and inequity in Africa is evident, and manifestly so in the case of the African indigents. The concept of social exclusion provides a useful framework for improved understanding of origins and persistence of the access problem that African indigents face, and for generating political space for an integrated approach.
In October, the Global AgeWatch Index issued a report on the quality of life of older people in 91 nations. The report included several factors such as income security, health and well-being, employment and education. African nations did not fare well. South Africa was the highest ranked African nation at number 65 while Ghana, Morocco, Nigeria, Malawi, Rwanda and Tanzania came in at numbers 69, 81, 85, 86, 87 and 90 respectively. Other African nations were not included in the report because there was not sufficient data. With South Africa leading the pack in elderly well-being, it helps to decipher the various ways it deals with its senior citizens.
The intake of added sugar appears to be increasing steadily across the South African population. Children typically consume approximately 40-60 g/day, possibly rising to as much as 100 g/day in adolescents. This represents roughly 5-10% of dietary energy, but could be as much as 20% in many individuals. This paper briefly reviews current knowledge on the relationship between sugar intake and health. There is strong evidence that sugar makes a major contribution to the development of dental caries. The intake of sugar displaces foods that are rich in micronutrients. Therefore, diets that are rich in sugar may be poorer in micronutrients. Over the past decade, a considerable body of solid evidence has appeared, particularly from large prospective studies, that strongly indicates that dietary sugar increases the risk of the development of obesity and type 2 diabetes, and probably cardiovascular disease too. These findings point to an especially strong causal relationship for the consumption of sugar-sweetened beverages (SSBs). The authors propose that an intake of added sugar of 10% of dietary energy is an acceptable upper limit. However, an intake of < 6% energy is preferable, especially in those at risk of the harmful effects of sugar, e.g. people who are overweight, have prediabetes, or who do not habitually consume fluoride (from drinking fluoridated water or using fluoridated toothpaste). This translates to a maximum intake of one serving (approximately 355 ml) of SSBs per day, if no other foods with added sugar are eaten. Beverages with added sugar should not be given to infants or to young children, especially in a feeding bottle. The current food-based dietary guideline is: “Use foods and drinks containing sugar sparingly, and not between meals”. This should remain unchanged. An excessive intake of sugar should be seen as a public health challenge that requires many approaches to be managed, including new policies and appropriate dietary advice.
7. Equitable health services
Health system weaknesses in Africa are well known, constraining progress in reducing the burden of both communicable and non-communicable disease. This paper used a focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care in Kenya. The discussions found weaknesses in 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, especially in district level targets, resulting in the exclusion of mental health from such district level supervision and a lack of awareness in the district management team about mental health. Generic health system weaknesses in Kenya are reported to impact on efforts for horizontal integration of mental health into routine primary care practice, and to frustrate health worker efforts. The authors report that a major lever for horizontal integration of mental health into the health system would be the inclusion of mental health in the national health sector reform strategy at community, primary care and district levels rather than just at the higher provincial and national levels.
Lesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres HCs) to scale up the provision of antiretroviral therapy (ART). This paper compares outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho. In rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.
The importance of poor-quality anti-tuberculosis drugs cannot be underestimated, as they may disrupt all major complex interventions to ensure treatment efficacy. Not only treatment failure may ensue, but, more importantly, rapid emergence of acquired drug resistances can also be favoured. The authors raise that a relevant proportion of underqualified medicines could be detected through relatively inexpensive and simple assays at destination countries, based on chromatographic techniques. Such tests are able to identify the type and concentrations of the various components. They note that their execution is not compulsory and only rarely pursued. They describe a vicious cycle where local regulatory authorities fail to implement controls of fraudulent manufacturers being encouraged to enter the market.
8. Human Resources
Migration of health workers from low- and middle-income countries (LMICs) to high-income countries is one of the most controversial aspects of globalization, having attracted considerable attention in the health policy discourse at both the technical and political level. Some countries train health workers to export them overseas and reap the financial benefits of remittances; such investments should therefore be considered as driven primarily by economic—rather than population health—motives. In most cases, however, migration of health professionals is unplanned for and represents a “brain drain” for source countries, a result of enormous wage differences and poor working conditions, including lack of support, adequate infrastructure, and career development opportunities, in LMICs. The paper presents the policy options for both low income and OECD countries for addressing health worker migration.
To present the findings of the first round of monitoring of the global implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel (“the Code”), WHO requested that its Member States designate a national authority for facilitating information exchange on health personnel migration and the implementation of the Code. Each designated authority was then sent a cross-sectional survey with 15 questions on a range of topics pertaining to the 10 articles included in the Code. A national authority was designated by 85 countries. Only 56 countries reported on the status of Code implementation. Of these, 37 had taken steps towards implementing the Code, primarily by engaging relevant stakeholders. In 90% of countries, migrant health professionals reportedly enjoy the same legal rights and responsibilities as domestically trained health personnel. In the context of the Code, cooperation in the area of health workforce development goes beyond migration-related issues. An international comparative information base on health workforce mobility is needed but can only be developed through a collaborative, multi-partnered approach. Reporting on the implementation of the Code has been suboptimal in all but one WHO region. Greater collaboration among state and non-state actors is needed to raise awareness of the Code and reinforce its relevance as a potent framework for policy dialogue on ways to address the health workforce crisis.
The provision of health care in South Africa has been compromised by the loss of trained health workers (HWs) over the past 20 years. The public-sector workforce is overburdened. There is a large disparity in service levels and workloads between the private and public sectors. There is little knowledge about the nonfinancial factors that influence HWs choice of employer (public, private or nongovernmental organization) or their choice of work location (urban, rural or overseas). This paper aims to fill these gaps in the literature. The study utilized cross-sectional survey data gathered in 2009 in the province of KwaZulu-Natal from three public hospitals, two private hospitals and one nongovernmental organization hospital in urban areas, from professional nurses, staff nurses and nursing assistants. HWs in the public sector reported the poorest working conditions, as indicated by participants’ self-reports on stress, workloads, levels of remuneration, standard of work premises, level of human resources and frequency of in-service training. Health workers in the non state sector expressed a greater desire than those in the public and private sectors to leave their current employer. Innovative efforts are required to address the causes of HWs dissatisfaction and to further identify the nonfinancial factors that influence work choices of HWs. The results highlight the importance of considering a broad range of nonfinancial incentives that encourage HWs to remain in the already overburdened public sector.
9. Public-Private Mix
The focus in Tanzania has mainly been on communicable diseases, in particular HIV/AIDS, TB and Malaria. Childhood illnesses, including diarrhoea and upper respiratory tract infections, have also received a great deal of attention. More recently, efforts have been directed towards neglected tropical diseases. However, the burden of communicable diseases is still high, so the increase in non-communicable diseases (NCD) creates a double burden to both individuals and the health system in general.The prevention of NCDs at the workplace is argued by the authors to require a multisectoral approach. The occupational health law (Occupational Health and Safety Act of 2003) in Tanzania stipulates that each employee undergo
a medical examination at enrolment. This could be expanded to include periodic examinations. Employers should push insurance companies to cover such examinations. Other options that could be useful are noted as the HIV committees already in place at workplaces. These structures could be used to also co-ordinate NCD prevention activities at workplaces.Another option could be to promote physical activity at the workplace through sports competitions, designated sports days or sports bonanzas. More advocacy is needed to raise the profile of the burden of NCDs and to bring them to the attention of policy-makers.
The United States Agency for International Development (USAID)/Tanzania
commissioned the SHOPS project and the IFC-World Bank Health in Africa
Initiative to conduct a private sector assessment of mainland Tanzania,
in response to a request from the Public-Private Partnership Technical
Working Group (PPP-TWG) in Tanzania. The assessment is intended
to assist the Ministry of Health and Social Welfare to develop a
prioritized agenda for more effectively engaging the private health sector
and building public-private partnerships focused on the country’s
key health challenges: HIV/AIDS, reproductive and child health, malaria,
and tuberculosis. It notes that although the private health sector in Tanzania is smaller than in some east African countries, it is sizable, diverse, and actively engaged throughout the health system
10. Resource allocation and health financing
The Budget and Expenditure Monitoring Forum (BEMF) in South Africa hosted a two-day workshop before the Minister of Finance Pravin Gordhan tabled the 2013 Medium Term Budget Policy Statement in Parliament. Under the theme “Reflections on the Medium Term Budget Policy Statement : How Do We Know If There is Enough Money to Provide For Delivery of Services?” numerous civil society organisations and representatives from organised labour, Parliament, the Auditor General’s office and academia came together to develop a deeper understanding of Government’s future medium term spending plans for 2014 – 2016. The workshop was opened by a presentation on what the National Development Plan (NDP) envisions for public service delivery and the implications of the NDP goals for the allocation of resources. An overview of South Africa’s macro-economic policy was provided illustrating the political choices made by Government to raise money for the delivery of services while promoting economic growth and curbing public debt. The workshop then turned to an assessment of the adequacy of the Education and Health budgets and analysis of the Social Development budgets for funding of Children’s Act services. The workshop also provided participants with an opportunity to be updated on the role of the Parliamentary Budget Office and the critical role that Parliament can and should be playing in exercising oversight of the Executive’s budget policy proposals. On the last day of the workshop participants were given an opportunity to hear about various budget and expenditure monitoring methodologies ranging from social audits to citizen journalism. A 2014 steering committee was established to guide the activities of the forum into 2014.The presentations given at the meeting are provided in the website.
Brazil is becoming an influential player in development cooperation, also thanks to its high-visibility health projects in Africa and Latin America. The 4th High-level Forum on Aid Effectiveness held in Busan in late 2011 marked a change in the way development cooperation is conceptualised. The present paper explores the issue of emerging donors’ contribution to the post-Busan debate on aid effectiveness by looking at Brazil’s health cooperation projects in Portuguese-speaking Africa. The authors first consider Brazil’s health technical cooperation within the country’s wider cooperation programme, aiming to identify its key characteristics, claimed principles and values, and analysing how these translate into concrete projects in Portuguese-speaking African countries. Then study discuss the extent to which the Busan conference has changed the way development cooperation is conceptualised, and how Brazil’s technical cooperation health projects fit within the new framework. The authors conclude that, by adopting new concepts on health cooperation and challenging established paradigms - in particular on health systems and HIV/AIDS fight - the Brazilian health experience has already contributed to shape the emerging consensus on development effectiveness. However, its impact on the field is still largely unscrutinised, and its projects seem to only selectively comply with some of the shared principles agreed upon in Busan. Although Brazilian cooperation is still a model in the making, not immune from contradictions and shortcomings, it should be seen as enriching the debate on development principles, thus offering alternative solutions to advance the discourse on cooperation effectiveness in health.
Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. This study contributes to this process by exploring through a cross sectional survey communities’ understanding and perceptions of health insurance and their preferred designs features. Kenyans should understand the implications of health financing reforms and their preferred design features considered to ensure acceptability and sustainability. About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance schemes but limited knowledge of how health insurance functions as well as understanding 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.
Ghana’s National Health Insurance Scheme (NHIS) was established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing. This study analyses NHIS members’ perceptions of service provision at the national level using data from the 2008 Ghana Demographic Health Survey. Results demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, the study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. The authors conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate.
This paper is focused on the question: why do the governments of low income countries not raise more tax revenues? Two different but complementary approaches are used to answer it. The first approach is comparisons: among countries today, and within countries over time. This approach tends to generate relatively conservative answers to the central question. It leads to an emphasis on the ‘sticky’ nature of the taxation. For any individual country in ‘normal times’ – i.e. excluding situations of war, major internal conflict, the collapse or rapid reconstruction of state power - revenue collections, measured as a proportion of GDP, do not change much from year to year. This is partly because effective taxation systems require a great deal of coordination and cooperation between revenue agencies and other organisations, both inside and outside the public sector. It is hard quickly to improve the effectiveness of a complex organisational network. The ‘stickiness’ of tax collections also reflects the fact that the overall tax take – i.e. the proportion of GDP raised as public revenue – is to a significant degree determined by the structure of national economies. For logistical reasons, it is much easier to raise revenue from economies (a) that are high income, urban and non-agricultural and (b) where the ratio of international trade to GDP is high. The government of the average low income country raises less than 20 per cent of GDP in revenue. The author argues that this weakens the ability of such governments to aim to match OECD tax takes of 30-45 per cent of GDP.
11. Equity and HIV/AIDS
Africa is leading the world in expanding access to antiretroviral therapy, with 7.6 million people across the continent receiving antiretroviral therapy as of December 2012, including 7.5 million people in sub-Saharan Africa. Eastern and Southern Africa is scaling up faster, by more than doubling the number of people on treatment between 2006 and 2012. At least 10 countries (Botswana, Cape Verde, Eritrea, Kenya, Namibia, Rwanda,
South Africa, Swaziland, Zambia and Zimbabwe) reported reaching 80% or more
of adults eligible for antiretroviral therapy, under the 2010 WHO guidelines. However, new WHO guidelines on HIV treatment in 2013 have since made many more people eligible for treatment.
WHO and many other organisations are very interested in implementing treatment-as-prevention as a global policy to control the HIV pandemic.1 Widespread treatment of HIV-infected individuals with antiretroviral therapy will reduce HIV transmission, because it decreases viral load and hence infectiousness. To implement the rollout of treatment-as-prevention in an efficient manner, estimation of the number of HIV-infected individuals and where they live is needed. This assessment will be difficult to accomplish, particularly in areas of sub-Saharan Africa with severe HIV epidemics. The authors propose a solution to this problem by using geospatial statistical techniques and global positioning system (GPS) data.
The rapid scale-up of free antiretroviral therapy has lead to a decline in adult mortality at the population level and reduction of vertical transmission. Consequently, some couples living with HIV are maintaining their reproductive decisions; marrying and having children. This paper analyses policies and guidelines on HIV, AIDS and sexual and reproductive health in Malawi for content on marriage and childbearing for couples living with HIV. The authors report that analysis of guidelines and policies showed nonprescriptiveness on issues of HIV, AIDS and reproduction: they do not reflect the social cultural experiences of couples living with HIV. In addition, they found; lack of clinical guidelines, external influence on adoption of the policies and guidelines and weak linkages between HIV and AIDS and sexual and reproductive health services. The findings are argued to provide a strong basis for updating the policies and development of easy-to-follow guidelines in order to effectively provide services to couples living with HIV in Malawi.
12. Governance and participation in health
A group of United Nations Special Rapporteurs today urged the Government of Kenya to reject legislation that would impose severe restrictions on civil society. “The Bill is an evidence of a growing trend in Africa and elsewhere, whereby governments are trying to exert more control over independent groups using so-called ‘NGO laws,’” the human rights experts warned. The Bill, which was presented to Parliament on 30 October, would amend Kenya’s Public Benefit Organization Act of 2012 and grant the Government sweeping powers to deny registration for such organizations, including non government organisations. It would also cap foreign funding at 15% of their total budgets and channel all their funding through a government body, rather than going directly to beneficiary organizations.
The spread and perpetuation of the HIV/AIDS epidemic in South Africa has hindered the country’s social and economic growth after apartheid. This paper documents experiences of interactions with the Treatment Action Campaign (TAC), an organization which has taken a multidimensional approach in order to educate people about HIV/AIDS and to provide access to medicines. It reports how TAC has used both traditional and non-traditional methods of advocacy to combat the epidemic and equate access to health care to a social justice issue by empowering marginalized communities. The author uses three dimensions of lawyering and equates TAC to a single cause lawyer, signifying that multi-dimensional activism is not limited to individuals, but can also be applied at the firm level. The three dimensions include: (a) advocacy through litigation, (b) advocacy in stimulating progressive change, and (c) advocacy as a pedagogic process. He suggests that TAC’s multi-dimensional approach and its inherent practice of the three dimensions has contributed to its success and may be useful for other processes.
The field of transparency is packed with vocabulary that suggests opposition or conflict, with labels that imply, somehow, that the watchers are above the watched, like white knights fighting the dark forces of development aid, the corrupt and incompetent. However collaboration between watched and watchers may also offers a better chance of generating positive change, by understanding the political context of the activities being monitored, targeting the right people, in a non-threatening way, offering solutions as much as identifying problems. In other words, being a successful ‘watchdog’ is argued to be all about knowing how to approach different people in different circumstances to achieve mutually beneficial goals. This article explores how to build the demand side of aid transparency. It raises that beyond accessing relevant, timely and accurate data, is to learn to make use of it in a strategic way, with a constructive mind, taking into consideration local political dynamics, and the reality and psychology of the people whose performance one aims to monitor and improve.
Talking to French magazine Esprit, theorist Achille Mbembe discusses a postcolonial thinking that has developed in a transnational, eclectic vein, enabling a specific take on globalization. He outlines three cardinal moments in the development of postcolonial thought. The first, of anti-colonial struggles, included the self-reflection by people of their colonization and debates on the relationship between class and race as factors. The discourse centred on the politics of autonomy, to acquire citizen status and, thereby, to participate in the universal. The second moment, around the 1980s, he outlines as the moment of "high theory", with new thinking on knowledge about modernity. This understood the colonial project beyond its military-economic system, to one that was underpinned by a discursive infrastructure and a whole apparatus of knowledge the violence of which was as much epistemic as it was physical. The second post colopnial discourse sought to recover the voices and capabilities of decolonization's rejects (peasants, women, underprivileged people) and to better understand why the anti-colonial struggle led not to a radical transformation of society. Mbembe argues also argues that it sought to expose the procedures by which individuals are subjugated to categories of race and class that block access to the status of subject in history. In the third moment, Mbembe argues that globalisation has, as for colonial capitalism, subjugated living spheres to economic appropriation, and that the "colony" was in fact a laboratory for the wider authoritarian destiny of today’s globalisation. He proposes that in this context the reinvention of politics in postcolonial conditions first requires people to reinvent their place in history, not in a logic of repeating the same violence as vengeance, but in a demand for a justice that supports an "ascent in humanity“.
13. Monitoring equity and research policy
The Global AgeWatch Index is the first-ever overview of the wellbeing of older people around the world.As the number and proportion of older people increases at an unprecedented rate, this ground-breaking report illustrates how the world is adapting to this new reality by ranking more than 90 countries in terms of how their older populations are faring.
The World Health Organization developed the Handbook on health inequality monitoring: with a special focus on low- and middle-income countries to provide an overview for health inequality monitoring within low- and middle-income countries, and act as a resource for those involved in spearheading, improving or sustaining monitoring systems. The aim of this handbook is to serve as a comprehensive resource to clarify the concepts associated with health inequality monitoring, illustrate the process
through examples and promote the integration of health inequality monitoring within health information systems of low- and middle-income countries.
This paper explores parasite movements as a source of valuable information for planning control strategies for malaria. Mobile parasite carrying individuals can instigate transmission in receptive areas, spread drug resistant strains and reduce the effectiveness of control strategies. The identification of mobile groups, their routes of travel and how these movements connect differing transmission zones, potentially enables limited resources for interventions to be efficiently targeted over space, time and populations. National data on population and migration were linked to migration, travel, and other data to understand malaria movement patterns. Together with existing spatially referenced malaria data and mathematical models, network analysis techniques were used to quantify the demographics of human and malaria movement patterns in Kenya, Uganda and Tanzania. Patterns of human and malaria movements varied between demographic groups, within country regions and between countries. Migration rates were highest in 20–30 year olds in all three countries, but when accounting for malaria prevalence, movements in the 10–20 year age group became more important.
14. Useful Resources
In a book 'The Hungry Season: Feeding Southern Africa’s Cities' Leonie Joubert. tells the story of food security, or its lack, through the voices of people. Through the lives of eight people in eight southern African places she looks at the complexity of food security in urban areas. Joubert shows that food has been a major driver of our technological development over the past 12 000 years. Food availability has allowed our cities to grow big, and ironically, has produced a lack of food security for many living in those cities. This is an animation of The Hungry Season, and tackles the question – why, when southern Africa produces enough calories and nutrients to feed the region, are so many people living with hunger or the fear of hunger? It is a journey through eight people’s lives in eight different regions.
CODESRIA, the Council for the Development of Social Science Research in Africa, launched the first issue of its Newsletter in December 2013. CODESRIA, headquartered in Dakar, Senegal, was established in 1973 as an independent pan-African research organisation primarily focusing on social sciences research in Africathat aims to be a source of regular information about the work of CODESRIA and its partners. The newsletter aims to stimulate discussion around the most important issues facing Africa.
Albie Sachs talks in this video about the design of the Constitutional Court of South Africa, a building that is “a place for everybody”. He spoke about how dreams, methods and madness formed a relationship that led to a building that came to symbolise the new constitutional democracy in South Africa. Situated where an old fort prison once stood, the Constitutional Court removes the negativity of the area and replaces it with a positive symbol of South Africa’s future. Sachs also spoke about the design of the Constitutional Court logo, which expresses, captures, projects and adds to what South African’s democracy stands for.
The KidsRights Index is an initiative by the KidsRights Foundation and the Erasmus University Rotterdam to monitor the status of children’s rights across the world in order to promote and foster the realisation of these rights. The KidsRights Index is the first global ranking on how countries are adhering to children’s rights. The country-ranking will be published yearly and will be made available to the public through a comprehensive website. New dimensions may be added over time to enrich the index. The Index draws on two key available sources of information: The Concluding Observations adopted by the United Nations Committee on the Rights of the Child and UNICEF’s annual State of the World’s Children reports.
Architecture plays a role in our culture, health and wellbeing. The 21st century has brought social and economic transformation to Africa, and has been coined as the century of the cities, with high levels of urbanisation in Africa. This magazine, edited in Dar es Salaam and produced by architects, writers and students from several countries in Africa provides a vibrant resource for discussion of urban architectural and social issues connected with growing cities, as a vehicle for open criticism and a constructive exchange of opinions; a platform to launch innovation solutions; a place for the discussion of typical local phenomena, and as a source of information for decision makers.
This documentary captures such an effort done in 12 villages of Bolangir district, Orissa State, India where the community is taught as to the money that is allocated to various schemes at the community level to deliver health entitlements. Such demand for accountability is done while the community is actively engaging with the public health system within the larger processes of community mobilisation and monitoring to demand accountability from the health system. Our Health Our Money, a film produced by CHSJ showcases the work done in Odisha around decentralised monitoring of health expenditure. The film is 25 minutes, with English subtitles.
15. Jobs and Announcements
COncern is seeking applicants to manage the implementation of Concern Kenya's programme in line with its Country Strategic Plan (2012-1016) and its programme strategies maintaining and strengthening focus on community empowerment, system strengthening and emergency preparedness.
This call is fo articles about BRICS from a critical perspective. There are many avenues for publishing about the BRICS from an optimistic, uncritical standpoint, not least the BRICS governments’ own academic ‘think tank’ network and the mainstream media. But the authors of this call argue that social movements, labour organizations and other active citizens need analyses that advance the cause of justice, that do not suffer a failure of investigative nerve, and that fearlessly pose problems and alternatives. They seek contributions from all five countries as well as those that are in the immediate hinterland of BRICS. The articles will be published in mid-March 2014, in time for the Fortaleza BRICS Summit.
An upcoming Special Issue on "How Public Health Can Meet the Challenges of the Twenty-First Century," will be published in the Public Health subject area of BioMed Research International in July 2014. A call for papers has been made for the Special Issue, which is open to both original research articles as well as review articles. BioMed Research International is an open access journal, which means that all published articles are made freely available online without a subscription, and authors retain the copyright of their work.
Lend your voice to a continuing discussion that is helping to shape Africa's future. The inspiring contributions of our speakers are the key component behind eLearning Africa’s position as the most relevant networking event for practitioners and professionals working in ICT, education and training on the Continent. Whether you’re using a mobile app to engage young people with citizenship programmes, implementing state of the art technology to bring rural communities onto the grid and online, researching the impact of tablets in vocational learning, coordinating a local iHub to encourage home-grown innovation or lobbying government to prioritise ICT in national education policy, the eLearning Africa Conference audience wants to hear about it. they are are looking for the stories, experiences, research, thinking and expertise that make up the picture of ICT for development, education and training in Africa today, under the overall theme of Opening Frontiers to the Future.
What does post-westernness look like? What does it mean to be a cultural practitioner working outside the current imperial centres? What happens when water becomes more expensive than oil? How will south-south co-operation change things? What colour is the future? This call is for written submissions to “The State”, a media space for written and audiovisual communications, critical texts, interrogative narratives, images, manifestos and conversations. Send pitches or submissions of new work or pieces in English that have not yet been published in English, along with a brief bio, to submit@thestate.ae, by January 15th, 2014. Commissioned pieces will receive an honorarium.
Partners In Health is seeking an Executive Director. They are looking for a strong leader who can develop the PIH platform of care in the district where we provide direct service, create innovative approaches that address burdens of disease and gaps in service delivery, partner with national and local Ministry officials, and build the programs into models of system-level global health delivery. For more information, please contact Jennifer Fitzpatrick.
Royal Tropical Institute (KIT) Masters program inform that for a number of KIT courses there are scholarships available from the Netherlands Fellowship Programme (NFP). The courses are: Master in Public Health, Master in Public Health, track in Sexual and Reproductive Health; Master in Public Health, track in HIV and AIDS and E-learning short course: Health Systems Strengthening and HIV. Applicants must apply at KIT for admission to the course. Apply for the NFP Scholarship separately at Nuffic: Go for details on the scholarship and list of NFP countries to: www.nuffic.nl/nfp Application deadline: 4th of February 2014.
Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to editor@equinetafrica.org Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to info@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact editor@equinetafrica.org immediately regarding any issues arising.