EQUINET NEWSLETTER 162 : 01 August 2014

1. Editorial

How far does performance based financing tick the box of national ownership?
Amy Barnes, Garrett Wallace Brown, University of Sheffield and Sophie Harman, Queen Mary University

The roll out of Performance-based financing (PBF) in east and southern Africa is now widespread. Yet a recent study found cause for concern with this often ‘taken-for granted’ financing mechanism. As a result, there is a need to better understand and debate how PBF reinforces or contradicts other measures being used to build and strengthen universal health systems.

Performance-based financing has become increasingly popular in global health financing. It involves the transfer of money or goods based on implementation of a measurable action or achievement of a predetermined performance target. It is seen to increase accountability to both external funders and national stakeholders, by tracking of how money is spent. Having clear targets is argued to strengthen health systems by providing a way of assessing what programs are efficiently delivering ‘value for money’ and by rewarding good practice. Its proponents argue that external funders, generally large contributors to African heath systems, should transfer funds based on performance to achieve these gains.

In the past year we carried out research examining PBF in South Africa, Tanzania and Zambia, and with regional and global institutions (more fully reported in EQUINET discussion paper 102 at http://tinyurl.com/nudgky3). This work raised questions about how PBF affects the strength and equity of health systems, and what latitude African actors have to ‘reframe’ PBF mechanisms to address their concerns.

Certainly a majority of the African actors had a positive perception of PBF and its ability to strengthen health systems, a perception also evident in the general literature pertaining to PBF. In particular, evidence suggests that Africa actors believe that PBF is useful in curbing corruption, in incentivizing targeted health outputs, and in increasing accountability mechanisms. These benefits, where they have occurred, have generated support for and ownership of the approach.

Nevertheless, at the same time there were many concerns regarding the practice of PBF. Questions were raised about how performance criteria are selected and how far national input was factored into the design of PBF, a key principle in the Paris Declaration. We found that the space for genuine participation in the design of PBF was narrow, usually limited to high level personnel in national systems, and that it was affected by factors such as how much of the public budget is externally funded. Lower dependency on external funding appeared to give countries greater possibilities of setting their own targets and resisting funding conditions that potentially conflict with national strategic plans. We found, for example, that South Africa, with less than 10% of its health budget externally funded, had greater latitude to negotiate and resist unfavourable conditions. We also found that this ability to ‘push-back’ was less available in Tanzania and Zambia, where external funding contributes up to half of the health budget. Some African actors in health ministries and in service provision expressed weariness about the external conditions demanded by funders, and called for a more decisive national voice. As one senior African health official suggested, ‘when PBF is the result of national ownership then it has excellent potential to be a mechanism for change… however, if it is not, then it will certainly be doomed to…not deliver on its promises.’

We found that while there is great enthusiasm for monitoring and rewarding outcomes, in practice this needs substantive investment in health information systems. We found, as others have, that information systems lack the reliability, capacities and support to analyse and use evidence to evaluate performance. Unless this is recognized and addressed, use of performance indicators can cause weaker services (with poorer capacities to manage information) to do worse, reducing their PBF ‘score’ rating and thus restricting their funding. This causes considerable concern, since these services are usually the ones that are in more marginalized areas of highest need. In addition, many of the African actors we interviewed complained that the reporting systems required by funders are cumbersome, time-consuming and add considerable overhead costs. External funders, particularly the Global Fund, were reported to change reporting requirements and ‘goal posts’ mid-stream, without sufficient notification or technical assistance, leading to confusion and delays in programme reporting and roll out.

Furthermore, external auditing mechanisms were often found to be ‘not fit-for-purpose’, implemented by auditors with little health knowledge or understanding of the recipient country, with inadequate communication between auditors and recipients.. Audit processes were found to be inflexible on target satisfaction. For example, Local Fund Agents (LFA) of the Global Fund were reported to often refuse to answer recipient’s questions during report writing, to refuse to discuss reporting problems during the audit, or to allow the final LFA evaluations to be seen by recipients. This was argued to damage partnership and national input to PBF conditionalities.

Moreover, many African actors that we interviewed assumed the merits of PBF, without being able to refer to strong evidence to support this view. There is also a growing weariness about PBFs ability to ‘be all things to all people’ and an urge to have a more realistic national assessment of PBF as being one of many financing measures available.

Where PBF is seemingly most successful is in cases where there is a strong sense of national ownership and multi-sectoral partnership. PBF has had positive impacts where robust information systems exist, so that future targets can be based on valid data, where performance monitoring is possible, and where evaluations can be made reliably. It is seemingly most successful when targeted on tightly focused health interventions, like payment per patient seen, and not on broad whole-of-system targets, where it is difficult to isolate and track individual variables. A better understanding of the positive features can contribute to health system strengthening.

However our study also found evidence of negative consequences that can weaken national health systems. Reaching PBF targets can sometimes compromise quality of care, vertical PBF schemes can create ‘health silos’ that are not always fully integrated into comprehensive primary health care, and PBF schemes are often not well embedded into a sustainable long-term health strategy.

These are issues that partners can identify, negotiate on and attempt to resolve. So our findings on the weaknesses of partnerships and genuine national leadership of the PBF agenda – as raised in this editorial and detailed in the full report- are crucial issues to be discussed and debated; to build better partnerships between global and African institutions and to design better systems for strengthening African health systems. As one senior health official commented, ‘we should be accountable for the money we receive and we should try to get as much value for money as possible... this is the non-debated part of PBF and a reason why it is so popular… but exactly how to best generate value for money is still open for discussion and for PBF to work effectively it will be important to get its processes right and to then generate agreement by all those who have to deliver these processes.’

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

2. Latest Equinet Updates

EQUINET Discussion paper 102: African participation and partnership in performance-based financing: A case study in global health policy
Barnes A; Brown G; Harman S; Papamichail A; Banda P; Hayes R; Muliamba C : EQUINET, Harare, June 2014

Participation is a key policy concept in global health, and relates to the ability of stakeholders to engage with and shape health policy at four intersecting levels: local, national, regional and global. Such engagement remains the key normative aim behind debates about furthering more equitable health diplomacy and has, as a result, been increasingly integrated into the agenda of global agencies, including the Global Fund to Fight AIDS, TB and Malaria and the World Bank. This report forms part of a research programme led by EQUINET focusing on the participation of African actors in global health diplomacy. The report focuses on the participation of African actors in global health governance. In an attempt to better understand the spaces and places within which participation can occur, and particularly the ways in which global actors such as the Global Fund and the World Bank provide such opportunities, the research explored the following questions: • How do the Global Fund and World Bank provide spaces for participation in global health governance processes? • To what extent can African actors nationally and regionally extend their agency within these participatory spaces? • What role does the World Health Organisation (WHO) and its own governance play in the interface between African actors and the Global Fund and World Bank?

3. Equity in Health

Human Development Report 2014: Sustaining Human Progress: Reducing Vulnerabilities and Building Resilience
United Nations Development Programme: New York, July 2014

The 2014 Human Development Report— Sustaining Progress: Reducing Vulnerabilities and Building Resilience—looks at two concepts which are both interconnected and immensely important to securing human development progress. As successive Human Development Reports (HDRs) have shown, most people in most countries have been doing steadily better in human development. Advances in technology, education and incomes hold ever-greater promise for longer, healthier, more secure lives. But there is also a widespread sense of precariousness in the world today—in livelihoods, in personal security, in the environment and in global politics. High achievements on critical aspects of human development, such as health and nutrition, can quickly be undermined by a natural disaster or economic slump. Theft and assault can leave people physically and psychologically impoverished. Corruption and unresponsive state institutions can leave those in need of assistance without recourse. Based on analysis of the available evidence, the Report makes a number of important recommendations for achieving a world which addresses vulnerabilities and builds resilience to future shocks. It calls for universal access to basic social services, especially health and education; stronger social protection, including unemployment insurance and pensions; and a commitment to full employment, recognizing that the value of employment extends far beyond the income it generates. It examines the importance of responsive and fair institutions and increased social cohesion for building community-level resilience and for reducing the potential for conflict to break out.

Momentum builds to achieve more Millennium Development Goals by end of 2015: UN report
United Nations: New York, 7 July 2014

With many MDG targets already met on reducing poverty, increasing access to improved drinking water sources, improving the lives of slum dwellers and achieving gender parity in primary school, The Millennium Development Goals Report 2014, says many more targets are within reach by their 2015 target date. If trends continue, the world will surpass MDG targets on malaria, tuberculosis and access to HIV treatment, and the hunger target looks within reach. Other targets, such as access to technologies, reduction of average tariffs, debt relief, and growing political participation by women, show great progress. The MDG report is based on comprehensive official statistics and provides the most up-to-date summary of all Goals and their targets at global and regional levels, with additional national statistics available online. Results show that concentrated efforts to achieve MDG targets by national governments, the international community, civil society and the private sector are working to lift people out of extreme poverty and improve their futures. It notes that much greater effort and investment will be needed to alter inadequate sanitation facilities. High dropout rates remain a barrier to universal primary education. Despite considerable advancements in recent years, the report says reliable statistics for monitoring development remain inadequate in many countries, but better statistical reporting on the MDGs has led to real results.

4. Values, Policies and Rights

Nurses association creates ethics commission
ANGOP, Lubango, Angola 13 May 2014

The Angola National Nurses Association in Lubango, southern Huila Province, created an Ethics Commission with a view to making the services rendered in this sector more humanised. The spokesman of ANEA, Rufino Kulamba, who was speaking at the International Nurses Day commemorations, said that the commission will be tasked with supervising the nursing activity. He stressed that the idea is to make professionals in this area have a better and better relationship with patients, as well as bring about professional improvements in this sector. He also explained that the commission will facilitate the filing of complaints against nurses who violate the principles of professional ethics.

5. Health equity in economic and trade policies

Fine print of the food wars
Shiva V: Pambazuka News, 688, 24 July 2014

Creating “ownership” of seed through patents and intellectual property rights and imposing it globally through the World Trade Organisation, the author argues that the biotech industry has established a monopoly empire over seed and food. The author argues that the biotech industry is denying citizens the right to safe food and attempting to dismantle national laws on biosafety across Africa. The author argues that the public relations machinery of the biotech industry undermines counterarguments to GMOs by unfounded attacks on scientists. However she also points to growing citizens’ outrage, and to sovereign countries rejecting the industrial monopoly over food systems.

GMOs and food sovereignty: Which way Africa?
Makori H: Pambazuka news, 688, 24 July 2014

African governments are under intense pressure from within but also from big agribusiness and Western governments to embrace genetically modified organisms (GMOs). Throughout Africa, GMOs - organisms that have been biologically modified to incorporate genes with desired traits - are now being touted as a major solution to hunger and mass poverty. Supporters of biotechnology, like Kenyan-born Harvard scholar Prof Calestous Juma, believe that with GMOs Africa, which has 60 per cent of all the arable land, will be able to feed not just its people but the world. The author argues that governments must resist all forms of arm-twisting and food colonialism and make their biotechnology choices based on the facts. There are three basic concerns about GMOs. First, the science is at best inconclusive regarding the safety of genetically engineered organisms on human health and the environment. The second concern is about food sovereignty. Opponents are convinced that the campaign for GMOs is part of the neoliberal agenda to place agricultural production in the hands of a few corporate giants through seed patents and deny small farmers control of production. Finally, the author argues that the GMOs crusade distorts the debate about food security and poverty alleviation. The problems afflicting small farmers are argued to have very little to do with technology, and almost everything to do with unequal access to land, water, affordable inputs, markets and other resources.

Honest Accounts? The true story of Africa’s billion dollar losses
Health Poverty Action et al: July 2014

The rest of the world takes from Africa much more than the continent receives. Almost $60 billion more. $192 billion flows out of Africa each year. This report outlines the range of different flows draining out of Africa, as well as the costs imposed on the continent as a result of climate change and explores the reasons for this. Curbing illicit financial flows is argued to demand greater transparency and accountability in the global financial system. This would involve clamping down on shell corporations; improved disclosure of beneficial owners of companies; stricter company
reporting regulations on sales, profits and taxes; and exchanging tax information across borders. Instead of talking about ‘good governance in Africa’ the authors argue that Northern countries must take the lead to reduce the mass extraction of African capital that embeds poverty and inequality, including revenue leakages from extractive industries and fairer trade practices between African countries and MNCs.

6. Poverty and health

Somalia Briefing: Threats to food security & remittances
Africa Research Institute: Sound cloud July 2014

This is a recording of ARI's 'Somalia Briefing' panel discussion, which took place on July 14 2014. The event focused on food security, remittances and the links between the two. Speakers were: Degan Ali, Executive Director of Adeso; Abdirashid Duale, CEO of Dahabshiil and Sara Pantuliano, Director, Humanitarian Policy Group, ODI. The event was organised by Africa Research Institute in partnership with ODI and Adeso.

Successful sodium regulation in South Africa
Hofman K: WHO Afro, 2013

Hypertension is neither unique nor novel to South Africa (SA), but the legislative actions undertaken by the South African government reflect a new approach to addressing this growing burden. Research has shown that a significant portion of hypertension is linked to sodium consumption, and a major proportion of sodium consumption in SA comes from bread--part of the staple diet. Aware of the burden of hypertension and the high levels of sodium in processed foods, Minister of Health Aaron Motsoaledi and the National Department of Health (NDOH) spearheaded legislative action to regulate sodium in food products at the manufacturing level. Based on the mixed results of voluntary regulation in other countries, the NDOH decided to initiate mandatory regulation to effectively curb sodium consumption. Answers to a questionnaire distributed to food industry members showed that about half of the groups who answered preferred to have regulated rather than voluntary sodium, because they believed this could even the playing field. The government devoted a significant amount of time and effort to understanding the industry's concerns, many of which were considered in negotiations. Years of South African research and inter-sectoral interactions between government, academia, and industry culminated in successfully signed regulations. Even with this first successful step, the hypertension problem is far from solved. This report concludes with a discussion on plausible recommendations that calls for international collaboration across the African continent, in order to further address the growing prevalence of hypertension.

7. Equitable health services

Contribution of Noncommunicable Diseases to Medical Admissions of Elderly Adults in Africa: A Prospective, Cross-Sectional Study in Nigeria, Sudan, and Tanzania.
Akinyemi RO1, Izzeldin IM, Dotchin C, Gray WK, Adeniji O, Seidi OA, Mwakisambwe JJ, Mhina CJ, Mutesi F, Msechu HZ, Mteta KA, Ahmed MA, Hamid SH, Abuelgasim NA, Mohamed SA, Mohamed AY, et al: J Am Geriatr Soc. July 2014

The authors describe the nature of geriatric medical admissions to teaching hospitals in three countries in Africa (Nigeria, Sudan, Tanzania) and compare them with data from the United Kingdom. They included all people aged 60 and older urgently medically admitted from March 1 to August 31, 2012. Data were collected regarding age, sex, date of admission, length of stay, diagnoses, medication, date of discharge or death, and discharge. In Africa, noncommunicable diseases (NCDs) accounted for 81.0% (n = 708) of admissions (n = 874), and tuberculosis, malaria, and the human immunodeficiency virus and acquired immunodeficiency syndrome accounted for 4.6% (n = 40). Cerebrovascular accident (n = 224, 25.6%) was the most common reason for admission, followed by cardiac or circulatory dysfunction (n = 150, 17.2%). Rates of hypertension were remarkably similar in the United Kingdom (45.8%) and Africa (40.2%).In the elderly population, the predicted increased burden of NCDs on health services in Africa appears to have occurred. Greater awareness and some reallocation of resources toward NCDs may be required if the burden of such diseases is to be reduced.

8. Human Resources

Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya
Ojakaa D, Olango S, Jarvis J: Human Resources for Health, 12:33, 6 June 2014.

This study investigated factors influencing motivation and retention of HCWs at primary health care facilities in three different settings in Kenya - the remote area of Turkana, the relatively accessible region of Machakos, and the disadvantaged informal urban settlement of Kibera in Nairobi. A cross-sectional cluster sample design was used to select 59 health facilities that yielded interviews with 404 health care workers, grouped into 10 different types of service providers. Data were collected in November 2011 using structured questionnaires and a Focus Group Discussion guide. Findings were analyzed using bivariate and multivariate methods of the associations and determinants of health worker motivation and retention. The levels of education and gender factors were lowest in Turkana with female HCWs representing only 30% of the workers against a national average of 53%. A smaller proportion of HCWs in Turkana feel that they have adequate training for their jobs. Overall, 13% of the HCWs indicated that they had changed their job in the last 12 months and 20% indicated that they could leave their current job within the next two years. In terms of work environment, inadequate access to electricity, equipment, transport, housing, and the physical state of the health facility were cited as most critical, particularly in Turkana. The working environment is rated as better in private facilities. Adequate training, job security, salary, supervisor support, and manageable workload were identified as critical satisfaction factors. Family health care, salary, and terminal benefits were rated as important There are distinct motivational and retention factors that affect HCWs in the three regions. Findings and policy implications from this study point to a set of recommendations to be implemented at national and county levels. These include gender mainstreaming, development of appropriate retention schemes, competitive compensation packages, strategies for career growth, establishment of a model HRH community, and the conduct of a discrete choice experiment.

Task-shifting and prioritization: A situational analysis examining the role and experiences of community health workers in Malawi
Smith S, Deveridge A, Berman J, Negin J, Mwambene N, Chingaipe E, Puchalski-Ritchie L, Martiniuk A: Human Resources for Health 12:24, 2014

The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs’ perspectives on their roles and responsibilities. A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre’s role and to triangulate collected data. HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs. This study provides insights into HSAs’ perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre’s effectiveness in addressing the country’s health priorities.

9. Public-Private Mix

Faith-based health services as an alternative to privatization? A Ugandan case study
Dambisya YM, Manenzhe M, Kibwika-Muyinda A: Municipal Services Project Occasional Paper July 2014

This study examines the delivery of health services by faith-based organizations (FBOs) as a possible alternative to privatization in Uganda, where they have been servicing communities since the mid-19th century. Their facilities focus on primary care and operate in rural, under-serviced areas where they provide access to care without discrimination on the basis of religion or ethnic group, charging affordable user fees while also treating those who cannot pay. The sector presently contributes to more than a quarter of all health services in the country, including the training of health professionals. Based on literature reviews and more than 30 key informant interviews, this research finds that FBOs promote solidarity through multi-stakeholder engagement and through cross-subsidization using mechanisms such as community health financing schemes that protect patients from catastrophic health expenditure. It analyzes how this ‘private not-for-profit’ sector fosters the development of a strong quasi-public ethos in service delivery, especially at the primary level of the Ugandan health system, posing a challenge to western liberal ideas about how the state and religion interface.

10. Resource allocation and health financing

Aid and its implications for governance
Soko KB: Pambazuka News, 3 July 2014

Malawi is one of the most aid dependent countries in the world. When one considers the work that is done by international NGOs, however, or by them through local surrogates, it is argued that there is no aspect of life in Malawi that has escaped external funding. With July 6, 2014 a day 50 years to the day when Malawi became an independent state the author argues that it’s important to accentuate the discussion on aid in Malawi and its implications for Malawi. the author argues that a heavy reliance on external funding means that foreigners, not the citizens, are in charge of the country’s governance.

Implementing Global Fund programs: a survey of opinions and experiences of the Principal Recipients across 69 countries
Wafula F, Marwa C, McCoy D: Globalization and Health 10(15): 24 March 2014

Principal Recipients (PRs) receive money from the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) to manage and implement programs. However, little research has gone into understanding their opinions and experiences. This survey set out to describe these, thereby providing a baseline against which changes in PR opinions and experiences can be assessed as the recently introduced new funding model is rolled out. An internet based questionnaire was administered to 315 PRs. A total of 115 responded from 69 countries in Africa, Asia, Eastern Europe and Latin America. The study was conducted between September and December 2012. Three quarters of PRs thought the progress update and disbursement request (PU/DR) system was a useful method of reporting grant progress. However, most felt that the grant negotiation processes were complicated, and that the grant rating system did not reflect performance. While nearly all PRs were happy with the work being done by sub-Recipients (92%) and Fund Portfolio Managers (86%), fewer were happy with the Office of the Inspector General (OIG). Non-government PRs were generally less happy with the OIG’s work compared to government PRs. Most PRs thought the Global Fund’s Voluntary Pooled Procurement system made procurement easier. However, only 29% said the system should be made compulsory. When asked which aspects of the Global Fund’s operations needed improvement, most PRs said that the Fund should re-define and clarify the roles of different actors, minimize staff turnover at its Secretariat, and shorten the grant application and approval processes. All these are currently being addressed, either directly or indirectly, under a new funding model. Vigorous assessments should nonetheless follow the roll-out of the new model to ensure the areas that are most likely to affect PR performance realize sustained improvement. Opinions and experiences with the Global Fund were varied, with PRs having good communication with Fund Portfolio Managers and sub-Recipients, but being unhappy with the grant negotiation and grant rating systems. Recommendations included simplifying grant processes, finding performance assessment methods that look beyond numbers, and employing Local Fund Agents who understand public health aspects of programs.

Performance-based Incentives in Mozambique: A Situational Analysis
Connor, C, Cumbi A, Borem P, Beith A, Eichler R, Charles J: Abt Associates Bethesda, MD: Health, 2011

This report presents the findings of USAID’s Health Systems 20/20 Project assessment of local interest in and capacity to implement PBIs. PBIs are reported to be legally and culturally feasible. Given the low level of health spending, limited population coverage, and estimates of unmet need in
Mozambique, the authors argue that PBIs should be designed to improve system efficiency but not be expected to reduce spending in absolute terms. Local stakeholders are repirted to be open to the PBI concept, citing CDC, USAID, and World Bank being ready to support introducing PBIs in Mozambique; however, some authorities and health worker staff express concerns about sustainability and equity of paying for performance.

Performance-based Incentives to Improve Health Status of Mothers and Newborns: What Does the Evidence Show?
Rena Eichler, Koki Agarwal, Askew I, Iriarte E, Morgan L, Watson J: Journal of Health, Population and Nutrition; 31:4: December 2013

Performance-based incentives (PBIs) aim to counteract weak providers’ performance in health systems of many developing countries by providing rewards that are directly linked to better health outcomes for mothers and their newborns. Translating funding into better health requires many actions by a large number of people. The actions span from community to the national level. While different forms of PBIs are being implemented in a number of countries to improve health outcomes, there has not been a systematic review of the evidence of their impact on the health of mothers and newborns. This paper analyzes and synthesizes the available evidence from published studies on the impact of supply-side PBIs on the quantity and quality of health services for mothers and newborns. This paper reviews evidence from published and grey literature that spans PBI for public-sector facilities, PBI in social insurance reforms, and PBI in NGO contracting. Some initiatives focus on safe deliveries, and others reward a broader package of results that include deliveries. The Evidence Review Team that focused on supply-side incentives for the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives, reviewed published research reports and papers and added studies from additional grey literature that were deemed relevant. After collecting and reviewing 17 documents, nine studies were included in this review, three of which used before-after designs; four included comparison or control groups; one applied econometric methods to a five-year time series; and one reported results from a large-scale impact evaluation with randomly-assigned intervention and control facilities. The available evidence suggests that incentives that reward providers for institutional deliveries result in an increase in the number of institutional deliveries. There is some evidence that the content of antenatal care can improve with PBI. We found no direct evidence on the impact of PBI on neonatal health services or on mortality of mothers and newborns, although intention of the study was not to document impact on mortality. A number of studies describe approaches to rewarding quality as well as increases in the quantities of services provided, although how quality is defined and monitored is not always clear. Because incentives exist in all health systems, considering how to align the incentives of the many health workers and their supervisors so that they focus efforts on achieving health goals for mothers and newborns is critical if the health system is to perform more effectively and efficiently. A wide range of PBI models is being developed and tested, and there is still much to learn about what works best. Future studies should include a larger focus on rewarding quality and measuring its impact. Finally, more qualitative research to better understand PBI implementation and how various incentive models function in different settings is needed to help practitioners refine and improve their programmes.

11. Equity and HIV/AIDS

ICYMI: Ten Things You Should Know From AIDS 2014
Lewis S: AIDS Free World 25 July 2014

The author lists ten things raised at the 2014 Global AIDS conference in Melbourne Australia, listing backwards from 10 to 1: 10. There may be fewer people living with HIV than we thought. 9. Decriminalizing commercial sex work could significantly decrease new HIV infections among sex workers. 8. Ninety is the new zero. For years now, we’ve been hearing a chorus of ‘zero new HIV infections, zero HIV-related discrimination, and zero AIDS-related deaths.’ But this week, UNAIDS changed course, promising to have 90% of all people with HIV aware of their status, 90% of people on treatment, and 90% of those on treatment with lasting viral suppression by the year 2020. 7. Women using injectable hormonal contraceptives are at greater risk of contracting HIV, but WHO isn’t planning to inform women before they choose birth control methods. 6. UNAIDS is still leaving out one of the most at-risk groups of all: women. 5. Children and adolescents are dying at an alarming rate. 4. There is a huge shortfall in funding for harm reduction. 3. HIV-positive women are being pressured to undergo sterilization by health workers. 2. Undetectable viral loads.Calling it “the closest thing we have to a cure for HIV,” activists issued a challenge this week to bring viral loads to undetectable levels by 2020. and 1. Funding for activists is drying up, and with it, the voices to spur governments and agencies to action. Section27's Mark Heywood issued a cri de coeur to delegates of AIDS 2014, lamenting that "AIDS is fast becoming just another disease of the poor, criminalised and marginalised...just another manifestation of global complacency about poverty and inequality."

12. Governance and participation in health

Nonprofit Sustainability is the Responsibility of Leadership
Brown A: Sangonet pulse July 14 2014

In this article, the author shares few tips on sustainability, leadership and everything that could help NPOs to sustain their development interventions Money in the bank does not necessarily mean that an organisation will be sustainable. The author argues that a strong sense of being mission-driven, measuring impact and sharing results is what leaders of charities and nonprofit organisations (NPOs) should strive to embed into the consciousness of everyone involved in the organisation, this is how an organisation can shift the status quo from fretting over money to creating future plans. Using the seven dimensions for nonprofit sustainability as a guideline, leaders can embrace these characteristics for determining board competencies and delegation of duties for oversight, good governance and quality performance that will ensure continuity. The seven dimensions encompass the following; legal good standing and compliance; organisational capacity and expertise to do the work; financial viability of the organisation; advocacy for the work undertaken that will make a difference; quality and professionalism of service provision; stable infrastructure and building of a brand that portrays a positive public image.

Statelessness = invisibility in West Africa
IRIN: 15 July 2014

At least 750,000 people are stateless in West Africa, according to the UN Refugee Agency (UNHCR), which is calling for governments to do more to give or restore the nationality of stateless individuals, and improve national laws to prevent statelessness. Many in the region are both stateless and refugees, said Emmanuelle Mitte, senior protection officer on statelessness with UNHCR in Dakar, but the overwhelming majority of stateless persons in West Africa are stateless within their own country, lacking proof of the criteria required to guarantee their nationality. Statelessness can block people’s ability to access health care, education or any form of social security. In the case of children who are separated from their families during emergencies, the lack of official documentation makes it much harder to reunite them, says the UN Children’s Fund (UNICEF). Lack of official identification documents can mean a child enters into marriage, the labour market, or is conscripted into the armed forces, before the legal age. Statelessness can also render people void of protection from abuse. Denied the right to work or move, they risk moving into the invisible underclass, said UNHCR’s West Africa protection officer, Kavita Brahmbhatt, who gave the example of a group of stranded non-documented Sierra Leonean migrants living in the slums of Liberia’s capital, Monrovia, selling charcoal as they were too poor to do anything else, and too scared to return home for fear of being punished. “They became a member of Monrovia’s underclass,” she said. “Birth registration is more than just a right. It’s how societies first recognize and acknowledge a child’s identity and existence,” said Geeta Rao Gupta, UNICEF deputy executive director in a late 2013 communique launching the report Every Child’s Birth Right: Inequities and trends in birth registration.

13. Monitoring equity and research policy

Fulfilling the Health Agenda for Women and Children: The 2014 Report
Countdown to 2015: Geneva June 2014

The 2014 Report, Fulfilling the Health Agenda for Women and Children, was released exactly 18 months to the day from the deadline for the Millennium Development Goals at the end of 2015. Like previous Countdown reports, it includes an updated, detailed profile for each of the 75 Countdown countries, which together account for more than 95% of the global burden of maternal, newborn and child death. The report shows that progress has been impressive in some areas, but it also highlights the vast areas of unfinished business that must be prioritized in the post-2015 framework. The 2014 Report also provides an assessment of the state of the data to support evidence-based decisions in women's and children's health, and describes elements of the Countdown process that might inform ongoing efforts to hold the world to account for progress. It concludes by laying out concrete action steps that can be taken now to ensure continued progress for women and children in the years ahead.

The Promise of Community-Based Participatory Research for Health Equity: A Conceptual Model for Bridging Evidence With Policy
Cacari-Stone L, Wallerstein N, Garcia AP, and Minkler M: Am J Public Health. Published online ahead of print e1–e9, July 17 2014

Insufficient attention has been paid to how research can be leveraged to promote health policy or how locality-based research strategies, in particular community-based participatory research (CBPR), influences health policy to eliminate racial and ethnic health inequities. To address this gap, the authors highlighted the efforts of two CBPR partnerships to explore how these initiatives made substantial contributions to policymaking for health equity. They present a new conceptual model and two case studies to illustrate the connections among CBPR contexts and processes, policymaking processes and strategies, and outcomes. They extended the critical role of civic engagement by those communities that were most burdened by health inequities by focusing on their political participation as research brokers in bridging evidence and policymaking.

14. Useful Resources

Cape Town Conference 2014: Putting Public in Public Services.
Municipal Services Project, July 2014

Presenters' insights and experiences with progressive public services inspired and energized the 150+ people who came from across South Africa and around the world for this three-day event last April. All panel presentations and plenary talks recorded by students from the University of the Western Cape are available online.

Online course: Gender and Health Systems Strengthening
Constance Newman: CapacityPlus, IntraHealth International, July 2014

The Global Health Learning Centre offers an online course By the end of the course, the learner will understand how health systems components interact with each other, how gender plays a role in each health systems component, and how to address these gender issues in health systems strengthening activities in order to improve health and social outcomes. This course examines gender considerations for each of six health systems components described in the World Health Organization's health systems components and ways to promote gender equality and women’s empowerment in health systems strengthening interventions so that health systems better meet the health needs of women, men, girls, and boys. Each section of the course first discusses and illustrates gender issues that affect a particular health system component and then proposes solutions to address these issues and strengthen health systems. The course considers some of the gender norms that drive health behavior, health decision making, and the provision and utilization of health care. It highlights programmatic examples that illustrate aspects of gender equality and women's empowerment in health systems strengthening.

15. Jobs and Announcements

10th Public Health Association of South Africa,
Protea Ranch Resort, Polokwane, South Africa, 3-6 September 2014

The 10th anniversary of the Public Health Association of South Africa (PHASA) conference will be celebrated with the hosting of the conference in Polokwane (Limpopo) from 3 to 6 September 2014. The workshops will take place on the 3rd, the actual conference on the 4th and 5th, and the student symposium on the 6th of September. The theme for the 2014 conference is ‘Dignity, rights and quality: towards a health care revolution’. An invitation is extended to all our members, stake holders, policy makers, public health academics and students, health professionals, health service managers and individuals from non-governmental and community-based health organisations.

Call for proposals: The role of non-state providers in strengthening health systems towards Universal Health Coverage
Call Closes August 5 2014

The Alliance for Health Policy and Systems Research in collaboration with the WHO Department of Service Delivery and Safety, Canada’s International Development Research Centre and the Rockefeller Foundation, is launching a new research program focused on the role of non-state providers in strengthening health systems towards the achievement of Universal Health Coverage. Research funded under this call must contribute to answering the research question: What are the factors that have enabled or hindered interventions by governments to engage non-state providers in strengthening health systems towards the achievement of Universal Health Coverage and what are the reasons for it? Between 8-12 proposals will be awarded amounts of up to US$ 120,000 depending on the context in which the study is taking place. The Principal Investigator must be a researcher in an institution based in a low or middle income country. further detail and application procedures can be found on the website for the call.

Pre-GSHSR meeting organised by the Emerging Voices for Global Health 2014: Cape Town, September 29, 2014
University of the Western Cape , Call closes 15 September 2014

This Pre-conference is organised by the Emerging Voices for Global Health 2014. The programme showcases oral and poster presentations from 'Emerging Voices' (EV) who are young promising researchers from across the globe.
The EV's aim to bring a fresh perspective on People-Centred Health Systems and other Health Systems Research themes at the Pre-conference.


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