EQUINET NEWSLETTER 158 : 01 April 2014

1. Editorial

Effective health centre committees can bring life into our health systems
Delegates to the EQUINET Regional Meeting on Health Centre Committees February 2014

Post-independent governments in east and Southern African (ESA) countries have all recognised that social participation is central to the success of primary health care (PHC) oriented health systems. There are, however, wide differences in how far they are implementing this policy view. The 2012 EQUINET Equity Watch report found many shortfalls in meaningful levels of social participation in health systems. Health Centre Committees (HCCs) are known by a range of names in different countries but are joint community- health worker structures at primary care level. They offer one way for systems to facilitate social participation and shared decision making between communities and health personnel. There is evidence that they can contribute to quality of and equity in access to health care and improved health outcomes. At a recent EQUINET regional meeting delegates identified ways to better tap into and support this valuable resource for health.

Building on prior work in EQUINET, twenty delegates from seven ESA countries and three international organisations, all working with HCCs, gathered at a regional meeting in February 2014 hosted by Training and Research Support Centre in association with Community Working Group on Health and Medico International in February 2014 to exchange experience on and learning from work to train and strengthen the role of HCCs (The report of the meeting and background paper are available at www.equinetafrica.org).

Dr Portia Manangazira from Zimbabwe’s Ministry of Health and Child Care opening the meeting concurred that HCCs provide a key mechanism for communities to participate in revitalising PHC and for strengthening and monitoring service delivery.

Despite this, while HCCs exist in some form in most countries, they often have no formal legal status or are not trained, resourced or active. In Zambia, the 1995 National Health Services Act provided in law for the District Health Boards and Neighbourhood Health Committees (NHCs). When this was repealed in 2006, it removed the legal mandate for HCCs. Yet in Zimbabwe it has been raised that expecting HCCs to manage public funds from government or external funders without a clear legal mandate is a problem. Even where government guidelines provide for HCCs, they vary in detail. For Zambia, an NHC working group has prepared explicit operational guidelines on establishment, composition, functions and monitoring mechanisms for NHCs. In South Africa, on the other hand, the provisions are more vague and left for the provincial authorities to decide. Generally while guidelines often set HCC composition and duties, they are less clear on how they are funded or on their role in towards social accountability. Despite their role in bringing community voice to service planning and the requirement that they represent communities, HCC members are not always elected by communities, have variable levels of community involvement and influence and may be liable to political control.

To some extent this reflects ambivalence towards whether HCCs are more a voice for the community to influence health services, or an outreach for services to reach and influence communities. Both roles are important, but where do HCCs focus their time and energies? In the Western Cape, South Africa for example, a baseline assessment in two districts found that HCC members spent limited time engaging the community and were spending more time as service volunteers - in security or as queue monitors for example. Similar concerns existed in Uganda. There was concern that in some countries HCC roles have become ‘commodified,’ with the resources available to them based less on community interests or needs than on what is paid for, often by international organisations.

Hence rather than the common practice of a long list of apparently delinked and equally weighted roles, the meeting identified roles of an HCC in a more systemic way, linking these to processes in health systems. The process starts with building an informed health literate community, obtaining community views and drawing on this to bring community voice and experience into the interaction with health service personnel, to jointly design and implement plans and budgets for the health system at primary care and community level. This joint role in governance gives the HCC the information, authority and motivation to go back to communities to facilitate dialogue and social action on health plans; to make sure that the agreed plans have been implemented, and that the duty bearers are capacitated, supported and resourced to deliver on plans and that they do so in a manner that is responsive to the community. HCC members should thus bring the direct experience and views of communities into the system, supporting understanding and reflection within communities on how to improve health, and advocating for improvements, with other sectors or at higher levels of the health system. This means that HCCs are more likely to thrive where health systems are themselves PHC oriented, facilitate action on the social determinants of health and support participatory planning and practice, than where they are organised largely around individual medical care with top down power.

HCC members need to have resources and skills across all these areas of functioning to complement their inherent social capacities and to enable them to overcome power imbalances in the relationships between themselves and health authorities. While there is a lot of training activity taking place, this may be limited to specific disease problems or interventions, may not address the general community health literacy or spectrum of HCC abilities needed and may lack follow up to evaluate its effectiveness or to sustain it. Training may not include some key areas such as budget tracking or assessment of community benefit. Further those providing training for HCCs may themselves lack competencies to build skills in areas such as budget planning or tracking.

Delegates also recognised that for HCCs to be effective in PHC oriented roles, communities themselves need to be health literate and empowered. Social rights to health care, to information and meaningful participation can provide a foundation for this and should be included in all constitutions of the region and in updated national or public health law. Regulations should more clearly define the duties, powers, roles and constitution of HCCs, and guidelines set these in a more systematic manner. However all this is likely to remain on paper unless it is accompanied by processes for capacitating systems and for supporting social activism and information.

The meeting thus proposed a number of areas for follow up attention and action by national authorities and organisations working in health, in relation to legal provisions, guidance, election, composition, functioning and capacity building of HCCs. While the specific cultural contexts differ, it was proposed that the ESA region set minimum guidance for these areas, such as on the core content of and processes for comprehensive HCC training, and that countries budget for the capacity building and functioning of HCCs. As for all other areas of health system performance, it was proposed that the health information system and communities monitor and collect information on the functioning, performance and impact of HCCs. Selected indicators were proposed for this, for further dialogue and development.

The organisations attending the meeting made a commitment as a network of practitioners working with HCCs to continue to link regionally, including to document, to share and make their work more visible. At a time of increasing attention to domestic resources for health, delegates drew attention to the most critical resources in the region- the people. The challenge was raised for policy actors in the region to turn commitments into action and to give systematic attention to the effective functioning of HCCs, as key social assets for health.

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 please visit www.equinetafrica.org. The report of the Regional meeting referred to can be found at

2. Latest Equinet Updates

Strengthening health centre committees as a vehicle for social participation in health in east and southern Africa: Regional Meeting Report, Harare, Zimbabwe 30 January - 1 February 2014
EQUINET: TARSC, CWGH, Medico Int: March 2014

EQUINET convened this Regional meeting on Health Centre Committees in East and Southern Africa to: i. Provide a forum for exchange of experience and learning between partners doing work on training and strengthening HCCs in countries in the ESA region; ii. Exchange and review information on the legal frameworks, capacities, training materials, and monitoring systems used in capacity building of HCCs, identify and discuss ways of advancing and documenting good practice in these aspects of HCCs; and iii. Develop a shared monitoring framework for assessment of the capacity, functioning and impact of HCCs, to apply to settings where HCCs are operating, and to discuss options for on-going exchange and documentation on the learning across settings. The meeting gathered 20 delegates representing seven countries from east and southern Africa, all of whom are involved in training and strengthening HCCs. The report provides the proceedings of the workshop.

3. Equity in Health

Mainstreaming Health Equity in the Development Agenda of African Countries
Economic Commission for Africa, Addis Ababa, Ethiopia 2008

Equity is emerging as an urgent policy priority in health sector reforms in many African countries. This report presents the findings of a study on “Mainstreaming health equity into the development agenda in Africa”. The widely reported fact that health outcomes in Africa are generally poor obscures the existence of a steep gradient in health outcomes between rural and urban areas, between better-off households and the less better-off. These differences in outcome are due in part to inequities in health. There is strong evidence that the poor health outcomes reported for most African countries are attributable to inequities in health. Reducing inequities in health is therefore argued to be integral to success in reaching the targets of the three health-related MDGs and the other MDGs where health is an important component.

Socioeconomic inequalities in smoking in low and mid income countries: positive gradients among women?
Bosdriesz JR, Mehmedovic S, Witvliet MI, Kunst AE: Int J Equity Health. 6;13(1):14, February 2014

The aim of this study was to assess if a positive gradient in smoking can also be observed in low and middle income countries in other regions of the world. The authors used data of the World Health Survey from 49 countries and a total of 233,917 respondents. Multilevel logistic regression was used to model associations between individual level smoking and both individual level and country level determinants. the results were stratified by education, occupation, sex and generation (younger vs. older than 45). Countries were grouped based on GDP and region. In Sub-Saharan Africa and Latin America no clear gradient was observed: inequalities were relatively small. Among men, no positive gradients were observed, and the strongest negative gradients were seen in South-East Asia and East Asia.

4. Values, Policies and Rights

Legality of Anti Homosexuality Act challenged in Constitutional Court by an unprecedented coalition of petitioners; Injunction against enforcement sought
Civil Society Coalition on Human Rights and Constitutional Law: Uganda, 11 March 2014

On 11th March 2014, the legality of the Anti Homosexuality Act was challenged in Constitutional Court by an unprecedented coalition of petitioners and an Injunction against enforcement sought. The petition was filed under the auspices of the Civil Society Coalition on Human Rights and Constitutional Law, a coalition of 50 indigenous civil society organisations that advocates for non-discrimination in Uganda. The petition argues that the Anti Homosexuality Act violates Ugandans’ Constitutionally guaranteed right to: privacy, to be free from discrimination, dignity, to be free from cruel, inhuman and degrading treatment, to the freedoms of expression, thought, assembly and association; to the presumption of innocence, and to the right to civic participation.

Reproductive Health and the Question of Abortion in Botswana: A Review
Smith S: Afr J Reprod Health 17[4]: 26-34, 2013

The complications of unsafe, illegal abortions are a significant cause of maternal mortality in Botswana. The stigma attached to abortion leads some women to seek clandestine procedures, or alternatively, to carry the fetus to term and abandon the infant at birth. The author conducted research into perceptions of abortion in urban Botswana in order to understand the social and cultural obstacles to women’s reproductive autonomy, focusing particularly on attitudes to terminating a pregnancy. She carried out 21 interviews with female and male urban adult Batswana. The findings however, suggest that socio-cultural factors, not punitive laws, present the greatest barriers to women seeking to terminate an unwanted pregnancy. It is argued that these factors must be addressed so that effective local solutions to unsafe abortion can be generated.

The social and gender context of HIV disclosure in sub-Saharan Africa: A review of policies and practices
Bott S, Obermeyer CM: Journal of Social Aspects of HIV/AIDS 10 (S1): S5-16, July 2013

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or – in some cases – mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.

5. Health equity in economic and trade policies

Between the Rack and a Hot Place: Can we Reconcile Poverty Eradication and Tackling Climate Change?
Woodward D: Sussex Development Lecture, IDS, Sussex University, 20 February 2012

By any reasonable definition, the majority of humanity is on the rack of poverty; and a major obstacle to its eradication is the growing threat of extreme and irreversible climate change. The coexistence of a chronic crisis of serious under-consumption for most with an increasingly critical environmental crisis resulting from over-consumption in aggregate can only be explained by extreme inequality in the global distribution of income. Resolving both simultaneously, as envisaged in the Post-2015 Agenda, requires a fundamental reconsideration of the nature and objectives of economic policy, and of the global economic system. The lecture discusses the extent and implications of global inequality, before building on a number of working hypotheses to outline an alternative model of economic development more conducive to the achievement of these two most fundamental global goals.

Improving Access to Innovative Medicines in Emerging Markets: Evidence and Diplomacy as Alternatives to the Unsustainable Status Quo
Gorokhovich LE; Chalkidou K; Shankar R: Journal of Health Diplomacy 1(1)1-19, 2013

This work is a review of public sources including white papers, news and peer-reviewed literature with a focus on mainstream approaches used by the pharmaceutical industry (such as unaffordable price premiums for innovative medicines) and governments (such as denial of intellectual property rights) to support their interests. The authors also explore the implications of possible approaches on pharmaceutical policy in the context of global health diplomacy. The latter is a requirement for universal health coverage given the increasing power of state and non-state actors in emerging markets. The authors conclude that evidence and due processes, through inclusive and transparent priority-setting mechanisms, offer a reconciliatory way forward for both parties. Value-based pricing, underpinned by Health Technology Assessment (HTA), could leverage global health diplomacy to set priorities and resolve the perhaps unsustainable status quo. HTA is itself a diplomatic, consensus building and evidence-based approach that can help diffuse the current tension, enhance mutual understanding and perhaps help strengthen (or even mend) the current model of product development. Value-based pricing and HTA offer a potential priority setting mechanism that can serve as a transparent, non-adversarial platform for governments and the pharmaceutical industry to engage with each other and work towards enhancing access to medicines. Further quantitative research, exploring the impact of different policy-setting approaches by governments on medicine access using HTA, would strengthen this discourse.

Possible Health Hazards from Genetically Engineered Crops
Onwubiko HA: Bio-Research, 9(2), 2012

Genetic Engineering of crops means that recombination DNA technology is used to insert, delete, transpose and substitute new genes in plants. The author notes that new gene products may serve as allergens capable of inducing illness in consumers. Antibiotic resistance genes are reported to be used to enable the selection of bacteria harbouring the desired gene, a technique which is thought to contribute to increasing resistance of bacteria to well established antibiotics such as penicillin, ampicillin, tetracycline and numerous others. The effect of the viral vector used in gene transfers on the environment, crops and individual consumers is not known. The author calls for an active regulatory guide by the United Nation Organization to safeguard the human population, the environment and life in general.

South encouraged to use TRIPS flexibilities for public health
Third World Network SUNS #7758 7 March 2014

The Geneva-based South Centre has encouraged India and other developing countries "to continue to make full use of the TRIPS flexibilities for public health and other public policy objectives," consistent with their rights and obligations under the World Trade Organisation (WTO) rules.
In a statement released here, the intergovernmental organisation of developing countries called on WTO Members to respect the legitimacy of the use of TRIPS flexibilities for public health in light of new threats of unilateral trade measures by the United States against India over its intellectual property (IP) laws and regulations. The South Centre statement cautioned that continued pressures by the United States on India and other developing countries "to adopt an IPRs [Intellectual Property Rights] regime that would go beyond the minimum standards in the TRIPS [Trade-Related Aspects of Intellectual Property Rights] Agreement and that does not make use of the flexibilities that are part of TRIPS would have adverse social and developmental effects, including on the public's access to medicines."

6. Poverty and health

Enablers and barriers to large-scale uptake of improved solid fuel stoves: a systematic review
Rehfuess EA, Puzzolo E, Stanistreet D, Pope D, Bruce NG: Environ Health Perspect. 122(2):120-30, February 2014

Globally, 2.8 billion people rely on household solid fuels. Reducing the resulting adverse health, environmental, and development consequences will involve transitioning through a mix of clean fuels and improved solid fuel stoves (IS) of demonstrable effectiveness. To date, achieving uptake of IS has presented significant challenges. the authors performed a systematic review of factors that enable or limit large-scale uptake of IS in low- and middle-income countries. The authors conducted systematic searches through multidisciplinary databases, specialist websites, and consulting experts. The review drew on qualitative, quantitative, and case studies and used standardized methods for screening, data extraction, critical appraisal, and synthesis. They identified 31 factors influencing uptake from 57 studies conducted in Asia, Africa, and Latin America. All domains matter. Although factors such as offering technologies that meet household needs and save fuel, user training and support, effective financing, and facilitative government action appear to be critical, none guarantee success: All factors can be influential, depending on context. The nature of available evidence did not permit further prioritization. Achieving adoption and sustained use of IS at a large scale requires that all factors, spanning household/community and program/societal levels, be assessed and supported by policy.

Linking poverty and violence: The South African scenario
Muller A: AJOL March 2014

In present-day South Africa people are daily confronted with individual or group scenes of violence in places people live in poverty. Despite political promises, the common experience is of a housing shortage, poor education, few jobs and very little prospect of alleviating profound poverty. This article explores the possible and potential links between poverty and violence, in order to gain deeper insight into their intrinsic meaning and the circularity of linkage between the two. In order to do so, it revisits the definitions of poverty and violence, emphasises the extremely important role ‘human needs’ play in both poverty and violence,
examines the phenomenon of the ‘behavioural sink’ which refers to the
negative effect of overcrowding on humans as biological beings and establishes whether theories on male violence offer insight into the problem.

The Environment in Social Science and Humanities in Africa
Murombedzi J: Codesria Newsletter March 2014

The environment is taking center stage in local, national and global discourse and policies. This increasing focus is occurring in a neo-liberal context defined by unprecedented land grabs, increasing militarization of natural resource use and governance, and privatization/commercialization of the environment facilitated by the neo-liberal market hegemony. Climate change has come to dominate contemporary environmental debates and to shape development policy. African Social Scientists in, usually in collaboration with scholars from other continents, have begun to respond to the climate crisis, focusing particularly on its implications on various facets of development and livelihoods. Given the urgency of environmental challenges facing the continent, the author argues that an African social science perspective to inform appropriate policy responses is urgent. What is needed is an approach that gives new impetus to environmental research in the social sciences and humanities, ensuring better integration into all the disciplines and recognition of the extreme urgency of the need to develop appropriate paradigms on the environment-development linkages.

7. Equitable health services

Assessment of psychological barriers to cervical cancer screening among women in Kumasi, Ghana using a mixed methods approach
Williams M, Kuffour G, Ekuadzi E, Yeboah M, ElDuah M, Tuffour P: African Health Sciences 13; 4; 1054-1061, December 2013

Cervical cancer is the leading cause of cancer death among women in Ghana, West Africa. The cervical cancer mortality rate in Ghana is more than three times the global cervical cancer mortality rate. Pap tests and visual inspection with acetic acid wash are widely available throughout Ghana, yet less that 3% of Ghanaian women get a cervical cancer screening at regular intervals. This exploratory study identified psychological barriers to cervical cancer screening among Ghanaian women with and without cancer using a mixed methods approach.Semi-structured interviews were conducted with 49 Ghanaian women with cancer and 171 Ghanaian women who did not have cancer. The results of the quantitative analysis indicated that cancer patients were not more likely to have greater knowledge of cancer signs and symptoms than women without cancer. Analysis of the qualitative data revealed several psychological barriers to cervical cancer screening including, common myths about cervical cancer, misconceptions about cervical cancer screening, the lack of spousal support for screening, cultural taboos regarding the gender of healthcare providers, and the stigmatization of women with cervical cancer.

Impact of Training traditional birth attendants on maternal mortality and morbidity in Sub-Saharan African countries
Kayombo EJ: Tanzanian Journal of Health Research,15:2:2013

This paper presents discussion on impact of training traditional birth attendants (TBAs) on overall improvement of reproductive health care with focus on reducing the high rate of maternal and new-born mortality in rural settings in sub-Saharan Africa. The author argues that trained TBAs in sub-Sahara Africa can have positive impact on reducing maternal and new-born mortality if the programme is well implemented with systematic follow-up after training. This could be done through joint meeting between health workers and TBAs as feed and learning experience from problem encountered in process of providing child delivery services. TBAs can help to break socio-cultural barriers on intervention on reproductive health programmes. However projects targeting TBAs should not be of hit and run; but gradually familiarize with the target group, build trust, transparency, and tolerance, willing to learn and creating a better relationship with them. In this paper, some case studies are described on how trained TBAs can be fully utilized in reducing maternal and new-born mortality rate in rural areas. The author suggests that what is needed is to identify TBAs, map their distribution and train them on basic primary healthcare related to child deliveries and complications which need to be referred to conventional health facilities immediately.

Strengthening health systems by health sector reforms
Senkubuge F, Modisenyane M, Bishaw T: Glob Health Action. 137:23568 February 2014

here is a growing recognition that the global health agenda needs to shift from an emphasis on disease-specific approaches to strengthening of health systems, including dealing with social, environmental, and economic determinants through multisectoral responses. A review and analysis of data on strengthening health sector reform and health systems was conducted. Attention was paid to the goal of health and interactions between health sector reforms and the functions of health systems. The authors explored how these interactions contribute toward delivery of health services, equity, financial protection, and improved health. they found that health sector reforms cannot be developed from a single global or regional policy formula. Any reform will depend on the country's history, values and culture, and the population's expectations. Some of the emerging ingredients that need to be explored are infusion of a health systems agenda; development of a comprehensive policy package for health sector reforms; improving alignment of planning and coordination; use of reliable data; engaging 'street level' policy implementers; strengthening governance and leadership; and allowing a holistic and developmental approach to reforms.

8. Human Resources

Comprehensive health workforce planning: re-consideration of the primary health care approach as a tool for addressing the human resource for health crisis in low and middle income countries
Munga MA, Mughwira A. Mwangu: Tanzania Journal of Health Research, 15:2 2013

Although the Human Resources for Health (HRH) crisis is apparently not new in the public health agenda of many countries, not many low and middle income countries are using Primary Health Care (PHC) as a tool for planning and addressing the crisis in a comprehensive manner. The aim of this paper is to appraise the inadequacies of the existing planning approaches in addressing the growing HRH crisis in resource limited settings. A descriptive literature review of selected case studies in middle and low income countries reinforced with the evidence from Tanzania was used. Consultations with experts in the field were also made. In this review, we propose a conceptual framework that describes planning may only be effective if it is structured to embrace the fundamental principles of PHC. We place the core principles of PHC at the centre of HRH planning as we acknowledge its major perspective that the effectiveness of any public health policy depends on the degree to which it envisages to address public health problems multi-dimensionally and comprehensively. The proponents of PHC approach in planning have identified inter-sectoral action and collaboration and comprehensive approach as the two basic principles that policies and plans should accentuate in order to make them effective in realizing their pre-determined goals. Two conclusions are made: Firstly, comprehensive health workforce planning is not widely known and thus not frequently used in HRH planning or analysis of health workforce issues; Secondly, comprehensiveness in HRH planning is important but not sufficient in ensuring that all the ingredients of HRH crisis are eliminated. In order to be effective and sustainable, the approach need to evoke three basic values namely effectiveness, efficiency and equity.

Perceived Impact of Health Sector Reform on Motivation of Health Workers and Quality of Health Care in Tanzania: the Perspectives of Healthcare Workers and District Council Health Managers in Four Districts
Mubyazi GM, Njunwa KJ: Rwanda Journal of Health Sciences, 2:1: 2013

Literature on the impact of health sector reform (HSR) on motivation of healthcare workers (HWs) and performance in health service provision in developing countries is still limited. This paper describes the impact of HSR on HW motivation and performance in providing quality health care in Tanzania. Methods: Four districts selected from three regions were covered, involving in-depth interviews with HWs in public health facilities (HFs), focus group discussions with district managers and researchers’ observations. The cost-sharing system in public HFs and national health ‘basket’ funding system introduced in 1990s were the key HSR elements identified by the study participants as impacting on HWs motivation and performance. User-fees for public healthcare services was acknowledged as having supplemented government funds allocated to public HFs, although such facilities still experienced ‘stock-outs’ of essential medicines and other supplies, HF understaffing, low/lack of essential remuneration, shortage of and unrepaired staff houses, meagre office space, lack of transport facilities for emergency cases, minimal recognition of HWs at local primary healthcare committees and the district health service budgeting system being controlled by district and central level authorities, leaving little room for lower level stakeholders to participate. For the national healthcare system to succeed, the authors argue that HSRs will need to involve and motivate HWs who are frontline implementers of the reform strategies.

Recruitment and Retention of Mental Health Workers in Ghana
Jack H; Canavan M; Ofori-Atta A; Taylor L; Bradley E: PLOS One; 8, 2, February 2013

Despite the great need to recruit and retain mental health workers in low-income countries, little is known about how these workers perceive their jobs and what drives them to work in mental health care. Using qualitative interviews, the authors aimed to explore factors motivating mental health workers in order to inform interventions to increase recruitment and retention. The authors conducted 28 in-depth, open-ended interviews with staff in Ghana’s three public psychiatric hospitals and used the snowballing method to recruit participants and the constant comparative method for qualitative data analysis, with multiple members of the research team participating in data coding to enhance the validity and reliability of the analysis. The use of qualitative methods allowed the authors to understand the range and depth of motivating and demotivating factors. Respondents described many factors that influenced their choice to enter and remain in mental health care. Motivating factors included 1) desire to help patients who are vulnerable and in need, 2) positive day-to-day interactions with patients, 3) intellectual or academic interest in psychiatry or behavior, and 4) good relationships with colleagues. Demotivating factors included 1) lack of resources at the hospital, 2) a rigid supervisory hierarchy, 3) lack of positive or negative feedback on work performance, and 4) few opportunities for career advancement within mental health. Because many of the factors are related to relationships, these findings suggest that strengthening the interpersonal and team dynamics may be a critical and relatively low cost way to increase worker motivation. The data also allowed the authors to highlight key areas for resource allocation to improve both recruitment and retention, including risk pay, adequate tools for patient care, improved hospital work environment, and stigma reduction efforts.

The Labour Market for Health Workers in Africa : New Look at the Crisis
Soucat A, Scheffler R: Journal of the World Bank, April 2013

Health systems in Sub-Saharan Africa have changed profoundly over the last 20 years. The economic crisis of the 1980s and 1990s rattled public health care systems, which were largely holdovers from the colonial and postcolonial eras. The later wave of structural adjustments and public sector reforms wrought further change. As African economies opened to market based approaches, the private sector became a sizable source of health care service. This paper presents data from the World Bank's Africa Region Human Resources for Health Program.

9. Resource allocation and health financing

Fiscal Space for Domestic Funding of Health and Other Social Services
McIntyre D and Meheus F: Chatham House working paper 5, March 2014

There is a need to increase government expenditure on health and other social services in many countries in order to achieve universal health coverage (UHC) and promote inclusive social and economic development. Individual governments have an obligation to allocate the maximum available resources from domestic sources, and not simply rely on international assistance, in order to achieve the progressive realization of fundamental human rights. Ultimately, this requires adequate levels of government expenditure on a range of social services. While government expenditure as a percentage of GDP is on average higher in ‘advanced economies’ than in other countries, there is no strong correlation between levels of government spending and economic development across individual countries (i.e., the size of a country’s GDP does not ‘predetermine’ or dictate government spending levels).Government revenue generation is the strongest determinant of government expenditure levels within individual countries; hence, emphasis should be on increasing government revenue. The report outlines progressive options for achieving this.

Investing in health
Yates R, Dhillon R: The Lancet, Volume 383, Issue 9921, 949 - 950, 15 March 2014

Public financing is the path to universal health coverage (UHC). UHC is rapidly becoming the overarching goal for national health systems and two recent events mark a new consensus that public financing is the way to get there. The Lancet Commission on Investing in Health2 focused on public financing mechanisms (including aid) in reaching UHC and explicitly rejected the 1993 World Development Report's emphasis on private health financing, including user fees. Similarly all 11 countries that presented at the Global Conference on UHC (Dec 6, 2013, Tokyo, Japan) hosted by the World Bank and Government of Japan, highlighted their use of public financing to increase service coverage and improve financial protection. None had used private voluntary financing to any significant extent. What is the basis for this consensus? UHC is fundamentally about rights and equity. It requires that the healthy and wealthy subsidise health services for the sick and poor. This cannot happen through private market-based systems of user fees and private insurance, including voluntary community-based schemes.Across the world, countries are instead realising that the only way to secure the cross-subsidies needed for UHC is through compulsory contributions into redistributive risk pools. In particular, tax financing is proving essential to close coverage gaps for households in the informal sector. Since only the state can mandate progressive payments and ensure that benefits are allocated according to need, only public financing systems can achieve the combination of universality, equity, and financial protection needed for UHC. Many of the governments that have learnt these lessons are now the ones leading the charge for UHC to be included in the post-2015 agenda. As noted by the World Bank President, one of these countries, Thailand, achieved UHC by rejecting the advice of the World Bank in the 1993 World Development Report to not rely on public financing. These countries represent the new consensus on health financing: universal coverage can only be accomplished through public financing systems in which the state plays a leading part in raising revenues, pooling funds, and purchasing services.

10. Equity and HIV/AIDS

Demographic and health surveys indicate limited impact of condoms and HIV testing in four African countries
Hearst N, Ruark A, Hudes ES, Goldsmith J, Green EC: African Journal of AIDS Research 12(1): 9–15, 2013

Condom promotion and HIV testing for the general population have been major components of HIV prevention efforts in sub-Saharan Africa’s high prevalence HIV epidemics, although little evidence documents their public health impact. The authors analysed the latest demographic and health surveys (DHS) and AIDS information surveys (AIS) from four sub-Saharan African countries with high prevalence, heterosexually transmitted HIV epidemics (Côte d’Ivoire, Swaziland, Tanzania and Zambia; N = 48 298) to answer two questions: 1) Are men and women who use condoms less likely to be HIV-infected than those who do not?; and 2) Are men and women who report knowing their HIV status more likely to use condoms than those who do not? Consistent condom use was associated with lower HIV infection rates for Swazi men but with higher HIV infection rates for women in Tanzania and Zambia; it made no significant difference in the other five sex/country subgroups analysed. Inconsistent condom use was not significantly associated with HIV status in any subgroup. Knowing one’s HIV status was consistently associated with higher rates of condom use only among married people who were HIV-positive, even though condom use in this group remained relatively low. Effects of knowing one’s HIV status among other subgroups varied. These results suggest that condoms have had little population-wide impact for HIV/AIDS prevention in these four countries. HIV testing appears to be associated with increased condom use mainly among people in stable partnerships who test positive. HIV testing and condom promotion may be more effective when targeted to specific groups where there is evidence of benefit rather than to general populations.

Governing AIDS through aid to civil society: Global solutions meet local problems in Mozambique
Foller M: African Journal of AIDS Research 12(1): 51–61, 2013

This article explores how international funders influence civil society organisations (CSOs) in Mozambique through funding mechanisms, the creation of partnerships, or inclusion in targeted programmes. The main focus is the relationship between external funders and AIDS non-governmental organisations (NGOs). The main questions the paper aims to answer are: Who is setting the agenda? What power mechanisms are in place to fulfil planned projects and programmes? Are there any forms of resistance from civil society AIDS-organisations in the face of the donor interventions? The actions are analysed through the lens of governmentality theory. The study concluded that external funders have the power to set the agenda through predetermined programmes and using various technologies. Their strongest weapons are audit mechanisms such as the result based management model used as a control mechanism, and there is still a long way to go to achieve a situation with multiple forms of local resistance to the conditions set by economically powerful funders. The standardisation imposed through clustering external funders into like-minded groups and other constellations gives them power to govern the politics of AIDS.

11. Governance and participation in health

Investing in health
Chiriboga D et al on behalf of 42 signatories: The Lancet, Volume 383, Issue 9921, Page 949, 15 March 2014

As public health professionals devoted to global health equity, the authors express our deep concern with the The Lancet Commission Global health 2035: a world converging within a generation (Dec 7, p 1898),1 a re-run of the 1993 World Development Report, whose policies contributed to the shrinkage of government institutions and massive privatisation and fragmentation of health-care systems, effectively decreasing coverage and accessibility. The authors observe that its recommendations are based on the principle of return on investment, not on health equity, while creating a double standard: one for the rich and another for the rest of us. Any policy for the poor is by definition a poor policy. The Lancet Commission's recommendations are argued to not represent the global health community and are fundamentally flawed by neglecting the principle of the right to health. The report analyses Millennium Development Goals progress without reference to stagnant levels of health inequity: 20 million deaths each year, more than a third of all deaths, are avoidable and caused by socio-economic injustice—a number and a proportion that have not changed for the past 40 years. Every individual, organisation, or government working to promote heath equity and WHO's objective of enjoyment by all peoples of the best attainable level of health should be on their guard.

Patient Satisfaction and Factor of Importance in Primary Health Care Services in Botswana
Bamidele AR, Hoque ME, and van der Heever H: Afr. J. Biomed. Res. 14;1 -7

This study aims to assess patient satisfaction and factor of importance on the service they receive at the primary health care facility in Botswana. The study was a cross sectional study in which 360 systematically selected participants completed 5 point likert scale self-administered questionnaire to rate their satisfaction level as well as factors of importance where best service was provided. Results showed that pharmacy received the highest satisfaction level while the nurse got the least level of satisfaction in terms of services rendered. 14.4% of participants still think time is not important to them as factor as long as they got what they wanted. Participants mentioned that an increase in personnel and staff training stood out as areas that need to be significantly considered
for improvement.

What can a teacher do with a cellphone? Using participatory visual research to speak back in addressing HIV&AIDS
Mitchell C, de Lange N: South African Journal of Education; 33,4: 1-13, 2013

Their ubiquity in South Africa makes cellphones an easily accessible tool to use in participatory approaches to addressing HIV and AIDS issues, particularly in school contexts. In this article the authors explore a participatory visual approach undertaken with a group of rural teachers, using cellphones to produce 'cellphilms' about youth and risk in the context of HIV and AIDS. Noting that the teachers brought highly didactic and moralistic tones into the cellphilms, the authors devised a “speaking back” approach to encourage reflection and an adjustment to their approaches when addressing HIV and AIDS issues with learners. They draw on the example of condom use in one cellphilm to demonstrate how a “speaking back” pedagogy can encourage reflection and participatory analysis, and contribute to deepening an understanding of how teachers might work with youth and risk in the context of HIV and AIDS.

12. Monitoring equity and research policy

Biomedical research, a tool to address the health issues that affect African populations
Peprah E and Wonkam A: Globalization and Health 9(50): 21 October 2013

In this paper, the authors discuss how research using biomedical technology, especially genomics, has produced data that enhances the understanding and treatment of both communicable and non-communicable diseases in sub-Saharan Africa. The authors further discuss how scientific development can provide opportunities to pursue research areas responsive to the African populations. The authors limit our discussion to biomedical research in the areas of genomics due to its substantial impact on the scientific community in recent years but they also recognize that targeted investments in other scientific disciplines could also foster further development in African countries.

Building research capacity in Africa: equity and global health collaborations
Chu KM, Jayaraman S, Kyamanywa P, Ntakiyiruta G: PLoS Med. 11;11(3)March 2014

The authors discuss the impact of high-income country investigators conducting research in low- and middle-income countries and explore lessons from the effective and equitable relationships that exist. Global health has increased the number of high-income country (HIC) investigators conducting research in low- and middle-income countries (LMICs). They note that partnerships with local collaborators rather than extractive research are needed. They conclude that LMICs have to take an active role in leading or directing these research collaborations in order to maximize the benefits and minimize the harm of inherently inequitable relationships.

13. Useful Resources

"If you could do one thing..." Nine local actions to reduce health inequalities
British Academy of Science, UK January 2014

The report seeks to help local policymakers improve the health of their communities by presenting evidence from the social sciences that can help reduce inequalities in health. Each of the authors has written an article, drawing on the evidence base for their particular area of expertise, identifying one policy intervention that they think local authorities could introduce to improve the health of the local population and reduce health inequalities.

Still Standing and War on Women
IRIN: March 2014

IRIN, the UN's service for humanitarian news and analysis, has produced two powerful new films dealing with sexual violence. "Still Standing" is the story of a young rape survivor in Kenya, Ziborah Iala, and her seemingly endless quest for justice and healing. "War on Women" addresses "sexual violence in the Democratic Republic of Congo (DRC), with gripping testimonies from both survivors and perpetrators and insight from analysts and civil society activists. Impunity helps drive the horrific levels of sexual violence in DRC: it is more than a "weapon of war", and is not confined to the battlefield."

14. Jobs and Announcements

Africa in 50 years time – inventing a new Africa
Call for submission of papers: Deadline Friday 16th May 2014

On 25 May 2014 the African Union (AU) will be 12 years old, having been set up in Addis Ababa on 9 July 2002. In May 2014 Pambazuka News seeks to have a special issue on projecting into the future what Africa will look like in 50 years time. What kind of Africa do women, youth, trade union activists, environmentalists, human rights, LBGTI and sex worker activists envision? What are the dreams of African writers, poets, scientists, engineers, agronomists, musicians for the continent in 50 years time? The revolutionary Thomas Sankara heeded that: “we must dare to invent the future.” What future will Africans create in 50 years time? Will we continue to ape the intellectual paradigms of the West, in terms of economic models, fashion and style? Is this imitation an inevitable aspect of “globalisation”? What institutional challenges face the AU in the next 50 years? These are the issues and questions they hope the special issue will grapple with and address in articles. Poems, short stories and personal opinion pieces are welcome.

Call for Letters of Intent: Implementation Research Teams
Deadline: 20 May 2014

The Innovating for Maternal and Child Health in Africa program is launching a call for letters of intent for the selection of Implementation Research Teams. This program is funded by Canada’s Global Health Research Initiative, a collaboration of Foreign Affairs, Trade and Development Canada, the Canadian Institutes of Health Research, and IDRC.Sub-Saharan Africa is the program’s region of focus. The proposed research project must take place in at least one of the targeted countries: Ethiopia, Ghana, Malawi, Mali, Mozambique, Nigeria, Senegal, South Sudan, and Tanzania. (Research can also take place concurrently in other countries.

Call for Proposals: Health Policy and Research Organizations
Deadline: 11 June 2014

The Innovating for Maternal and Child Health in Africa program is launching a call for proposals for the selection of Health Policy and Research Organizations. This program is funded by Canada’s Global Health Research Initiative, a collaboration of Foreign Affairs, Trade and Development Canada, the Canadian Institutes of Health Research, and IDRC. Sub-Saharan Africa is the program’s region of focus, targeting these nine countries: Ethiopia, Ghana, Malawi, Mali, Mozambique, Nigeria, Senegal, South Sudan, and Tanzania.

CODESRIA National Working Groups: Call for 2014 Proposals
Deadline: 31 May, 2014

One of the most important vehicles that CODESRIA uses to mobilise national-level research capacities and channel them into organised reflections has been the National Working Groups (NWGs). Through this mechanism, it encourages African researchers to autonomously organise and pursue research on priority themes of their choice. In line with the retention of NWGs as important instruments for promoting research, publication and the exchange of knowledge on important national issues in Africa by CODESRIA’s 2012-2016 strategic plan, the Council invites proposals for the constitution of NWGs under its 2014 grants competition. The Council particularly desires proposals that seek to weld structured empirical research into innovative theoretical reflections on important national issues.

Elearning Africa "Through Your Lens" Photo Competition 2014
Closing Date: Monday, April 14th 2014

The eLearning Africa “Through your Lens” Photo Competition is back this year in its fifth edition. Under the theme of “Social Africa: building bridges through ICT”, budding photographers are invited to submit snapshots depicting how ICT is enhancing the way individuals and communities in Africa live, learn, cooperate and connect. Contributions from all sectors and walks of life are welcome. The photo should show how communication tools and information technologies can build bridges and foster relationships between people and be accompanied by a brief description outlining the inspiration behind their idea.

Fourth Ethics, Human Rights And Medical Law Conference
Gallagher Convention Centre, Midrand, Johannesburg, South Africa, 6-8 May 2014

The 4th Ethics, Human Rights and Medical Law Conference is a must attend event for healthcare professionals in South Africa and the surrounding region. A one-day conference that is fully dedicated to the above topics, it was created to demonstrate how important all three subjects are, as well as how they connect to one another.

Pambazuka News: Call for volunteer translators
No closing date

Pambazuka News needs volunteers to translate articles. Published weekly in English and French, and every 15 days in Portuguese, our electronic newsletter sometimes translates articles from one language to another. Through this, they aim to break down language barriers, give more audience to relevant analysis for our contributors and encourage exchanges between linguistic communities in Africa and around the world. In this Pambazuka is unique.To deal with increasing translation needs, they are looking for volunteers to strengthen our team of volunteer translators who assist us in this task and contribute to what Pambazuka is.They engage to sign all translated articles with the name of their authors.

Practicum On Monitoring And Evaluation Of Health Communication Programs, June 2-4, 2014, Accra, Ghana
Deadline For Registration April 30, 2014.

The African Network for Strategic Communication in Health and Development (AfriComNet), a network of health communication practitioners across 50 countries, proposes an interactive three-day practicum focused on health communication monitoring and evaluation. The practicum will address topics such as how health communication strategy design influences monitoring and evaluation plans; the use of behaviour change theories/models to guide evaluation planning; using evaluation and monitoring data to inform program strategies; using health communication research to test theories; and effectively disseminating and using evidence and findings to improve the science of health communication. Early registration is encouraged as the practicum is limited to a maximum of 150 participants. To register, please complete the registration form on the website.


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