EQUINET NEWSLETTER 163 : 01 September 2014

1. Editorial

When it comes to transforming health systems, who counts?
Rene Loewenson, Training and Research Support Centre

Our health systems are sites of constant change and struggle. In east and southern Africa national health services centred on comprehensive primary health care (PHC) have been ‘reorganised’ through waves of liberalisation, privatisation, disease focused verticalisation, performance based financing and many other reforms. People have come to services to find new rules for what is free and what is charged, for what medicines and supplies are present and what is not, and community health activities and workers have appeared, disappeared and appeared again.

The drive for a universal national health service was embedded in national liberation struggles. The PHC approach was a global concept that resonated strongly with popular expectations of what post independent health systems should look like. Many of the subsequent changes have emerged as waves of international reform, increasingly influenced by global level actors. When we ask people in participatory sessions to form a human sculpture of how their health systems are organised around a patient visiting for care, the sculpture most commonly has health workers, managers and others looking upwards to the next level to get the resources and attention they need to solve problems, (most looking away from the patient), usually with the person representing a powerful but distant global funder elevated in both power and stature on a chair in a far corner of the room.

While these may be caricatures, they raise the question- when it comes to changes in health systems, who counts? Whose views, expectations, ideas, evidence, numbers, analysis and knowledge is used to generate change?

This matters because health is ‘a state of mental, physical and social wellbeing and not just the absence of disease’, because health outcomes reflect conditions that are socially created, and health systems are thus social institutions, built out of and influencing society. The explosion of knowledge on the biomedical basis of disease and on risk factors in public health has informed massive advances in survival. It has, however, weakly addressed and often ignored the social context and determinants of health and the social nature of health systems. As a consequence we face persistent and sometimes widening inequality in health and in access to services, rising levels of multiple morbidity and chronic conditions, epidemic resurgence and antibiotic resistance, amongst other challenges.

The problem does not lie in the extraordinary scientific innovation and creativity that lay behind these medical advances. The problem lies in one form of knowledge subjugating others, excluding and disempowering others from the creative processes that transform society, a mistake akin to suggesting that the trunk of the elephant is the whole elephant.

That knowledge as socially constructed is not a new concept. This understanding has been central to social sciences and to cultural, anticolonial, gender and indigenous struggles. With the failure to implement what is known, in health sciences it has led to increased attention to fields such as health systems and policy research, where rather than absolute prescriptions, there is a quest to better understand ‘what works where and for whom’.

This wider lens will generate a better understanding of context in health sciences. Will it also overcome a tendency for ordinary people to be the last to know the waves of reforms transforming their health systems? Freire argued decades ago that meaningful social transformation, including of health systems, can only occur with the deep involvement of the people affected. The incubation of the PHC approach, the efforts to build national health services across diverse countries, the refusal to allow health care to be commodified, the gains in access to improved living and working conditions have all been a product of social and political action.

This type of action does not grow out of knowledge and perspective built in distant corridors. In the last century activist scientists such as Orlando Fals Borda in Latin America pointed to a different understanding of science, one that seeks to not only understand the world but to transform it, and, as importantly, one in which knowledge is built from lived experience and from the learning and self-awareness that grows from action. Participatory action research (PAR) has developed in different forms as a method for such science. It overcomes the separation between subject and object. Those affected by the problem are the primary source of information and the primary actors in generating, validating and using the knowledge for action, and using action and change as a means to new knowledge. A new methods reader on ‘Participatory action research in health systems’ produced by EQUINET and TARSC with Alliance for Health Policy and Systems Research and IDRC Canada that can be obtained on the EQUINET website in end September details the principles and methods of PAR, its challenges and the many ways and levels at which it is being used.

In different parts of the world, PAR has built a more direct link between theory building and practice in health systems. Workers and unions have used PAR to expose and organise for change in working conditions that are harmful to their health. Young people in high and low income countries have used it to raise visibility of and engage with authorities on harmful community environments. Indigenous communities have used it to negotiate the organisation of their health care. It has been used in continuous processes in local authorities in shaping PHC, learning from cycles of transformation.

The practice of PAR flags that change is not itself a problem in health systems in east and southern Africa. It is rather a problem when the knowledge used to guide this change does not draw on the experience, knowledge and wisdom of those directly involved, through methods that build their power to inform, learn from and shape that change.

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 Participatory action research in health systems: a methods reader, available on the EQUINET website www.equinetafrica.org from end September 2014

2. Latest Equinet Updates

Policy brief 36: Increasing African agency in the design of Performance Based Financing
U Sheffield, et al: EQUINET, Harare, July 2014

Billions of dollars are channelled each year to African governments by external funders, from global institutions such as the World Bank and Global Fund to support health systems. Much of the money is provided in the form of “Performance Based financing” (PBF) schemes. In 2013/4 we reviewed the decision making on and design of these PBF schemes, including through interviews with officials in Africa and at Africa regional and global levels. This brief explains what PBF schemes are and the reasons for their popularity. It presents the positive and negative features of and views expressed on PBF. It presents a set of questions national authorities should take into account when negotiating any PBF type scheme within health systems and makes recommendations for African officials who wish to improve the design and implementation of PBF schemes to support national health system goals.

Policy Brief 37: Health Centre Committees as a vehicle for social participation in health systems in east and southern Africa
TARSC with CWGH, Medico: EQUINET Harare June 2014

The adoption of primary health care (PHC) in all east and Southern African(ESA) countries means that public participation is central to the design and implementation of health systems. One mechanism for this is through Health Centre Committees (HCCs) that involve representatives of communities and primary-care level health workers in planning, implementing and monitoring health services and activities. Known by different names in different countries, they are a common mechanism for communities to ensure that health systems access and use resources to address their needs and are responsive and accountable to them. They have been found to have a positive impact on health outcomes. This brief presents information and experiences from document review and from the exchanges of people working with HCCs in ESA countries at a 2014 EQUINET regional meeting on how HCCs are functioning in the region. It presents proposals for improving their functioning and impact.

Policy Brief 38: Taking the WHO Global code of Practice on the International Recruitment of health Personnel in Africa from bottom drawer to negotiating table
U Limpopo, ECSA, ACHEST, TARSC: EQUINET, Harare, July 2014

ESA countries face many challenges in the absolute shortages, maldistribution, low production and poor utilisation of their health workforces. The World Health Organisation (WHO) Global Code of Practice on the International Recruitment of Health Personnel (the “Code”) was unanimously adopted by the World Health Assembly in May 2010 to address recruitment and migration of health workers. However, its implementation has shown limited progress in east and southern Africa, according to a study in the EQUINET Research programme on global health diplomacy. Health worker migration is not seen to be the scale of problem it was a decade ago in the region. While concerns from the region were mostly included in the Code,the demand for “mutuality of benefit” and “compensation” were not. This was interpreted by some stakeholders to mean that the Code did not fully accommodate African interests. Implementation of the Code is reported to be impeded by lack of champions; of resources for implementation; by weak functional data (systems) on mobility of health personnel, and by limited domestication and dissemination of the Code in ESA countries. This brief presents opportunities to use the Code in negotiating bilateral agreements and suggests ways of strengthening its implementation.

3. Equity in Health

Social Determinants of Health Equity
Marmot M, Allen J: American Journal of Public Health: 104, S4, S517-S519, September 2014

This supplement explores social determinants of equity in health and highlights differences by socioeconomic status and geographic location, among others. The paper highlights that to reduce health inequalities requires action to reduce socioeconomic and other inequalities. There are other factors that influence health, but these are outweighed by the overwhelming impact of social and economic factors—the material, social, political, and cultural conditions that shape our lives and our behaviours.

Southern African states to collaborate on Ebola
Makholwa A: BusinessDay live, 7 August 2014

HEALTH ministers in the Southern African Development Community (SADC) have agreed to collaborate in the event of an outbreak of Ebola in the region. The ministers held an extra ordinary meeting in Johannesburg in August to plan a coherent response should the Ebola outbreak in West Africa spread to other regions of the continent as feared. There has not been a reported case of Ebola in the SADC region but there is a risk. People travel frequently between Southern and West African countries. Among other things, the SADC ministers agreed to organise cross-border consultations to facilitate the exchange of information, and to strengthen surveillance of the virus. They agreed to commit additional financial resources, but proposed a regional fund for emergency situations as a long-term solution. South Africa was chosen as the centre of excellence in Ebola laboratory diagnosis in the region. It is expected to help with the training of health professionals treating infected individuals.

The men’s health gap: men must be included in the global health equity agenda
Baker P, Dworkin S, Tong S, Banks I, Shand T, Yamey G: Bulletin of the World Health Organization 2014;92:618-620

In most parts of the world, health outcomes among boys and men continue to be substantially worse than among girls and women, yet this gender-based disparity in health has received little national, regional or global acknowledgement or attention from health policy-makers or health-care providers. Including both women and men in efforts to reduce gender inequalities in health as part of the post-2015 sustainable development agenda would improve everyone’s health and well-being. This paper notes that three types of intervention targeting men have emerged in recent years – outreach, partnership and gender transformation – and there is now evidence to support all three approaches. The authors argue that global, regional and national health and development agencies could certainly learn from the success of civil society groups in promoting policies that target men. For example, the South African non-profit organization Sonke Gender Justice successfully pushed the government to add interventions targeting men within South Africa’s national HIV strategic plan. Closing the men’s health gap, it is argued, can benefit men, women and their children.

UN working group agrees to proposed sustainable development goals
Bridges Africa: 24 July 2014

The UN working group charged with outlining a proposed set of sustainable development goals (SDGs) adopted an outcome document on Saturday. The recommended goals will now be sent to the UN General Assembly for consideration as part of the discussions around the post-2015 development agenda. The final 23-page document maintains the 17 goals outlined in a revised “zero draft” – released by the working group’s co-chairs in early July to serve as a basis for this final meeting – with 169 targets. Sixty-two of these can be classed as “means of implementation,” (MoI) or the methods to achieve each goal. During the closing plenary on Saturday morning, the working group co-chairs said that while they were happy with their efforts in steering participants towards an outcome document, they recognised the final product was not flawless. Another year of discussion is likely as the UN General Assembly reflects upon the proposed goals. The document does not yet contain indicators for measuring progress towards each goal and target, which was part of the working group’s original mandate. The eventual addition of indicators at a later stage may prove a useful opportunity to clarify some of the proposed targets and further work will likely be undertaken in this area.

4. Values, Policies and Rights

Back to the future: what would the post-2015 global development goals look like if we replicated methods used to construct the Millennium Development Goals?
Brolan CE, Lee S, Kim D and Hill PS: Globalization and Health (10)19, 3 April 2014

The Millennium Development Goals (MDGs) were ‘top-down’ goals formulated by policy elites drawing from targets within United Nations (UN) summits and conferences in the 1990s. Contemporary processes shaping the new post-2015 development agenda are more collaborative and participatory, markedly different to the pre-MDG era. This study examines what would the outcome be if a methodology similar to that used for the MDGs were applied to the formulation of the post-2015 development goals (Post-2015DGs), identifying those targets arising from UN summits and conferences since the declaration of the MDGs, and aggregating them into goals. The UN Department of Economic and Social Affairs (DESA) list of major UN summits and conferences from 2001 to 2012 was utilised to examine targets. The DESA list was chosen due to the agency’s core mission to promote development for all. Targets meeting MDG criteria of clarity, conciseness and measurability were selected and clustered into broad goals based on processes outlined by Hulme and Vandemoortele. The Post-2015DGs that were identified were formatted into language congruent with the MDGs to assist in the comparative analysis, and then further compared to the 12 illustrative goals offered by the UN High-Level Panel of Eminent Persons on the Post-2015 Development (High-Level Panel) Agenda’s May 2013 report. Ten Post-2015DGs were identified. Six goals expressly overlapped with the current MDGs and four new goals were identified. Health featured prominently in the MDG agenda, and continues to feature strongly in four of the 10 Post-2015DGs. However the Post-2015DGs reposition health within umbrella agendas relating to women, children and the ageing. Six of the 10 Post-2015DGs incorporate the right to health agenda, emphasising both the standing and interconnection of the health agenda in DESA’s summits and conferences under review. Two Post-2015DGs have been extended into six separate goals by the High-Level Panel, and it is these goals that are clearly linked to sustainable development diaspora. This study exposes the evolving political agendas underplaying the current post-2015 process, as targets from DESA’s 22 major UN summits and conferences from 2001 to 2012 are not wholly mirrored in the HLP’s 12 goals.

Controversial policy to regulate doctors on hold
Gonzalez L: Health-e News, 31 July 2014.

In late May, President Jacob Zuma South Africa signed into law long-dormant sections of the National Health Act that would give the Director General of Health the power to deny doctors operating licenses depending on where in the country the medical professional wished to operate, or open or expand a practice. Following this, doctors would have had to apply to the Department of Health for a “certificate of need,” or permission to work in an area, by 1 April 2016. SAMA, the South African Dental Association, and the specialist body, the South African Private Practitioners Forum have all vocally opposed Certificates of Need and were considering Constitutional Court litigation against the department over the matter. The Department of Health has, however, decided to shelve plans to regulate where doctors could practice – at least temporarily. Department of Health spokesperson Joe Maila stated that the intention is not to redraft the Act but to allow parties sufficient time to draft and engage with regulations before the act takes effect.

Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa
Dhana A, Luchters S, Moore L, Lafort Y, Roy A, Scorgie F and Chersich M: Globalization and Health (10)46, 2014

Several biological, behavioural, and structural risk factors place female sex workers (FSWs) at heightened risk of HIV, sexually transmitted infections (STIs), and other adverse sexual and reproductive health (SRH) outcomes. FSW projects in many settings have demonstrated effective ways of altering this risk, improving the health and wellbeing of these women. Yet the optimum delivery model of FSW projects in Africa is unclear. This systematic review describes intervention packages, service-delivery models, and extent of government involvement in these services in Africa. The authors located 149 articles, which described 54 projects. Most were localised and small-scale; focused on research activities (rather than on large-scale service delivery); operated with little coordination, either nationally or regionally; and had scanty government support (instead a range of international donors generally funded services). Almost all sites only addressed HIV prevention and STIs. Most services distributed male condoms, but only 10% provided female condoms. HIV services mainly encompassed HIV counselling and testing; few offered HIV care and treatment such as CD4 testing or antiretroviral therapy (ART). While STI services were more comprehensive, periodic presumptive treatment was only provided in 11 instances. Services often ignored broader SRH needs such as family planning, cervical cancer screening, and gender-based violence services. Sex work programmes in Africa have limited coverage and a narrow scope of services and are poorly coordinated with broader HIV and SRH services. To improve FSWs’ health and reduce onward HIV transmission, access to ART needs to be addressed urgently. Nevertheless, HIV prevention should remain the mainstay of services. Service delivery models that integrate broader SRH services and address structural risk factors are much needed. Government-led FSW services of high quality and scale would markedly reduce SRH vulnerabilities of FSWs in Africa.

5. Health equity in economic and trade policies

Africa: Time to reclaim class opportunities
Nicolson G: Daily Maverick, 20 August 2014

Narratives of “the hopeless continent” and “Africa rising”, pumped by the West, woven into its knowledge with nostalgic pop culture, rubber-stamped by media and financial institutions, are observed by the author to be false propaganda. A study by Standard Bank titled “Understanding Africa’s Middle Class”, notes African Development Bank’s (AfDB) claims that by 2010, 350 million people or 34% were middle-class in Africa, up from 27% in 1990. Examining 11 countries, chosen for, among other things, scale of population, growth and economy- Angola, Ethiopia, Ghana, Kenya, Mozambique, Nigeria, South Sudan, Sudan, Tanzania, Uganda and Zambia- the Standard Bank report noted that since 2000 the collective GDP of the 11 measured economies has grown tenfold from US$120 billion to today’s level of over US$1 trillion, with a growth in the middle class of 230% in the period. While East Africa is lagging behind in pushing low-income earners to the middle, the region is argued to offer the most interesting findings in the report, with a broad upward shift within the low-income band as households shift from deeply marginalised into less poor categories. Africa’s growing middle class may be driving the rising narratives, but the upward movement of low-income groups is argued to be where the most economic potential will be realised. It’s also these groups that will have the largest impact on political and social development. They’re the groups in the majority, the ones with the largest votes and the largest claim to the need for improved living conditions.

Rape of bodies, rape of resources, rape of a nation
Mayanja N: Pambazuka News, 691; 14 August 2014

The author argues that the situation in DRC illustrates the deficiency of global ethics, selfishness and the longstanding failure to value the lives of the African people. Tackling the DRC’s impasse requires a comprehensive approach and involvement of national, regional, continental and international communities. The author argues that the DRC is embroiled in a geo-political and economic strategic battle in the search for scarce resources that are abundant in Congo. It is the paradox of the resource curse. It is hardly remembered that sustainable extraction of the minerals would benefit global interests longer and the rain forests in the DRC are vital to curbing climate change. Tackling the DRC’s impasse is argued to require a comprehensive approach and involvement of national, regional, continental and international actors, coupled with continued research to inform policies and praxis. Equally, varied strategies designed from local cultures, African philosophy and interdisciplinary academic views are vital.

SADC-EU EPA negotiations to be concluded
Bridges Africa: 22 July 2014

Chief negotiators of the Southern African Development Community (SADC) have "initialled" the Economic Partnership Agreement (EPA) with the European Union during a joint negotiation session in Pretoria, South Africa on 15 July.

The Social, Economic and Environmental Implications of Diamond Mining in Chiadzwa
Chimonyo G, Mungure S, Scott P: Centre for Research and Development, 2014

This report documents the progression of events in Chiadzwa Zimbabwe in terms of diamond mining and trading, the socio-economic and environmental impacts and the conflict between authorities, (government agencies) and the local communities. The project had as its objective to inform the degree of adherence to the doctrine of 'Permanent Sovereignty over Natural Resources'. The intrusion of mining in Chiadzwa is argued to have displaced the cultural and social mosaic while privatising the commons and subjecting the villagers to several risks and harms with minimal benefits. The existence of clandestine networks is reported to have made an underhand diamond economy
injurious to the prospective diamond-anchored economic resurgence, limiting the benefit sharing arrangements. The authors argue that the extractive nature of the diamond industry should be accompanied with appropriate observance of environmental laws, appropriate corporate social responsibility and transparent accountability by all stakeholders.

WTO’s least developed countries submit collective request on services waiver
Bridges Africa, 25 July 2014

In July the WTO’s poorest members, known as the Least Developed Country (LDC) Group, submitted a collective request regarding the preferential treatment they would like to see for their services and service suppliers. The move comes seven months after the global trade body’s ministerial conference in Bali, Indonesia, where members agreed to take steps for bringing this “services waiver” into operation. The LDC services waiver, as it is referred to in trade circles, was initially an outcome of the 2011 WTO Ministerial Conference, held in Geneva, Switzerland. However, in the two years that followed, no preferences had been requested by LDCs or granted to them, prompting WTO members to reconsider ways to use the services waiver. As a result, at the WTO’s subsequent ministerial conference in Bali, Indonesia last December, members agreed to initiate a process aimed at promoting the “expeditious and effective operationalisation” of the LDC services waiver. Over the next six months, WTO members will engage in consultations with the LDC Group in order to respond to the collective request at the high-level meeting. The LDCs have reserved the right to modify the request’s terms ahead of the event.

6. Poverty and health

Cultivating unemployment: Can agriculture create jobs in South Africa?
Neves D: Institute for Poverty, Land and Agrarian Studies: 20 March 2014

Cultivating Unemployment takes a hard look at the realities of rural economies in South Africa and begins to grapple with the policy implications of these realities. The video shows the challenges and difficulties involved in creating rural economies that can multiply benefits for rural dwellers.

Opportunities and Challenges in Tanzania’s Sugar Industry: Lessons for SAGCOT and the New Alliance
Sulle E, Smalley R and Malale L: Institute for Poverty, Land and Agrarian Studies, Future Agricultures, Policy Brief 76, 1 August 2014

Sugarcane outgrower schemes are central to several policy and donor strategies for driving agricultural growth and reducing poverty, including the Southern Agricultural Growth Corridor project in Tanzania (SAGCOT). But field research into the outgrower component of Kilombero Sugar Company, Tanzania’s largest and best regarded sugar producer, demonstrates a pressing need for change. Sugarcane production in Kilombero has had benefits for farming households as well as the local and national economy. However, unsustainable expansion and governance issues in the outgrower scheme have created new risks. There are pressures on food security as a result of a decline in land for food crops, and on incomes, particularly when outgrowers’ cane remains unharvested and farmers’ payments are delayed. These problems have been aggravated by the importation of foreign sugar into the country. For this industry to provide its maximum benefits to the economy and to the household, a policy, legal and institutional framework is needed that provides greater efficiency, accountability and transparency, as well as greater security for all participating stakeholders. There are lessons for the sugar industry, as well as donors and investors of ongoing and future agribusiness developments in Tanzania.

7. Equitable health services

Assessing equity in the geographical distribution of community pharmacies in South Africa in preparation for a national health insurance scheme
Ward K, Sanders D, Leng H, Pollock A: Bulletin of the World Health Organization 92:482-489; 2014

The green paper for the national health insurance scheme in South Africa has identified private community pharmacies as potential access points for medicines, in combination with public clinics. This study examined changes in the ownership and geographical distribution of community pharmacies between 1994 and 2012 using routine national data. The authors summed community pharmacies and public clinics to assess their combined provincial distribution patterns against a South African benchmark of one clinic per 10000 residents. The study shows that monitoring trends in the distribution of community pharmacies is feasible. It shows that the increase in the number of community pharmacies has not kept pace with population growth and there are differences between urban and rural provinces and between the most and least deprived districts. Although corporations have seen substantial growth, this has not resulted in improved density ratios or equity in distribution.

Community-Based Interventions for the Prevention and Control of Infectious Diseases of Poverty
Sommerfeld J, Zhou X (eds): Infectious diseases of Poverty, 31 July 2014

Effective and simple interventions and tools exist that can be used to either prevent, treat or rehabilitate patients suffering from infectious diseases of poverty (IDoP). The delivery of these interventions and tools to the affected populations, however, has proven difficult due to weak public health systems in many disease-endemic countries. Disease control and public health programmes are increasingly advocating community-based delivery strategies and interventions. These depend, to a large degree, on trained community health workers whose performance in various areas of health care such as maternal and child health has been the subject of rigorous recent systematic reviews. Community-based delivery platforms are increasingly being proposed not only to ensure sustainability and combat co-infections, but also to build capacity for integration of NTDs with existing malaria, tuberculosis, and HIV/AIDS programs for which more sophisticated healthcare delivery systems already exist. This thematic series of eight papers provides an overview on infectious diseases of poverty and integrated community-based interventions, describes the analytical framework and the methodology used to guide the systematic reviews, reports findings for the effectiveness of community-based interventions for the prevention and control of helminthic NTDs, non-helminthic NTDs, malaria, HIV/AIDS and tuberculosis and proposes a way forward. While previous reviews focus on process and effectiveness of integrated community-based interventions under real life field conditions, this series of papers evaluates the efficacy of such interventions with respect to disease or prevention outcomes.

Utilization of health care services in rural and urban areas: A determinant factor in planning and managing health care delivery systems
Oladipo JA: African Health Sciences (2)14: 322-333

Disparities in use of healthcare services between rural and urban areas have been empirically attributed to several factors. This study explores the existence of this disparity and its implication for planning and managing healthcare delivery systems. The objectives determine the relative importance of the various predisposing, enabling, need and health services factors on utilisation of health services; similarity between rural and urban areas; and major explanatory variables for utilisation. A four-stage model of service utilisation was constructed with 31 variables under appropriate model components. Data is collected using cross-sectional sample survey of 1086 potential health services consumers in selected health facilities and resident milieu via questionnaire. Data is analysed using factor analysis and cross tabulation. The 4-stage model is validated for the aggregate data and data for the rural areas with 3-stage model for urban areas. The order of importance of the factors is need, enabling, predisposing and health services. 11 variables are found to be powerful predictors of utilisation. Planning of different categories of health care facilities in different locations should be based on utilisation rates while proper management of established facilities should aim to improve health seeking behaviour of people.

8. Human Resources

Getting Treatment and Care to the Last Mile: Analyzing the Health Surveillance Assistant Cadre in Malawi
Martiniuk A, Smith S, Deveridge A, Berman J, Negin J, Mwambene N, Chingaipe E: Africa Initiative Discussion Paper 10, 23 2014

As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to take on a growing role in strengthening health systems. Health surveillance assistants (HSAs) — as the community health cadre in Zomba District, Malawi is known — play a vital role by connecting the community with the formal health care sector. The latest research from the Africa Initiative provides a situational analysis of the HSA cadre and its contribution to the delivery of health services in Malawi. The authors’ findings show that HSAs face numerous challenges related to training, as well as challenges in defining their roles and those of their supervisors. They conclude with recommendations to improve HSA training and policy, with the ultimate goal of improving the effectiveness of this cadre of worker, and improving the health of the population.

Pilot-testing service-based planning for health care in rural Zambia
Goma F, Murphy G, Libetwa M et al: BMC Health Services Research 14(Suppl 1):S7, 2014

The objective of the study was to demonstrate the effectiveness of service-based human resources for health (HRH) planning through its adaptation in two rural Zambian districts, Gwembe and Chibombo. The health conditions causing the greatest mortality and morbidity in each district were identified using administrative data and consultations with community health committees and health workers. The number and type of health care services required to address these conditions were estimated based on their population sizes, incidence and prevalence of each condition, and desired levels of service. The capacity of each district’s health workers to provide these services was estimated using a survey of health workers (n=44) that assessed the availability of their specific competencies. The primary health conditions identified in the two districts were HIV/AIDS in Gwembe and malaria in Chibombo. Although the competencies of the existing health workforces in these two mostly aligned with these conditions, some substantial gaps were found between the services the workforce can provide and the services their populations need. The largest gaps identified in both districts were: performing laboratory testing and interpreting results, performing diagnostic imaging and interpreting results, taking and interpreting a patient’s medical history, performing a physical examination, identifying and diagnosing the illness in question, and assessing eligibility for antiretroviral treatment.

Supporting middle-cadre health care workers in Malawi: Lessons learned during implementation of the PALM PLUS package
Sodhi S, Banda H, Kathyola D, et al: BMC Health Services Research 14(Suppl 1):S8, 2014

The government of Malawi is committed to the rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package. A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings. Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances.

9. Public-Private Mix

Roundtable discussion: what is the future role of the private sector in health?
Stallworthy G, Boahene K, Ohiri K, Pamba A and Knezovich J: Globalization and Health (10) 55, 2014

The role for the private sector in health remains subject to much debate, especially within the context of achieving universal health coverage. This roundtable discussion offered perspectives from a range of stakeholders – a health funder, a representative from an implementing organisation, a national-level policy-maker, and an expert working in a large multi-national company – on what the future may hold for the private sector in health. The health funder argued that the discussion about the future role of the private sector has been bogged down in language. He argued for a ‘both/and’ approach rather than an ‘either/or’ when it comes to talking about health service provision in low- and middle-income countries. An implementer of health insurance in sub-Saharan Africa examined the comparative roles of public sector actors, private sector actors and funding agencies, suggesting that they must work together to mobilize domestic resources to fund and deliver health services in the longer term. Thirdly, a special advisor working in the federal government of Nigeria noted that the private sector plays a significant role in funding and delivering health services there, and that the government must engage the private sector or be left behind. Finally, a representative from a multi-national pharmaceutical corporation gave an overview of global shifts that are creating opportunities for the private sector in health markets. No community member views were provided.

10. Resource allocation and health financing

The promise and limitations of cash transfer programs for HIV prevention
Fieno J and Leclerc-Madlala S: African Journal of AIDS Research (2) 13, 153–160, 2014

This article examines elements of a successful cash transfer program from Latin America and discusses challenges inherent in scaling-up such programs. The authors attempt a cost simulation of a cash transfer program for HIV prevention in South Africa comparing its cost and relative effectiveness – in number of HIV infections averted – against other prevention interventions. If a cash transfer program were to be taken to scale, the intervention would not have a substantial effect on decreasing the force of the epidemic in middle- and low-income countries. The integration of cash transfer programs into other sectors and linking them to a broader objective such as girls’ educational attainment is argued by the authors as one way of addressing doubts raised by the authors regarding their value for HIV prevention.

11. Equity and HIV/AIDS

Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind
Burford G: CAFOD August 2014

This commentary was written on the International AIDS Conference in Melbourne 20-25 July 2012, the 20th gathering of the largest regular conference of any health or development issue, bringing together politicians, scientists, epidemiologists, practitioners, policy makers, the private sector and communities of people living with and affected by HIV. There is uniqueness in this fight against HIV in that it is a social movement, pulling people together and putting people at the forefront of the response to sustain efforts on addressing HIV. The theme of the 2014 conference was ‘Stepping up the Pace,’ and the author comments that we must redouble our efforts on areas like stigma and discrimination, which after 30 years is still increasing in some regions. 'We have the tools; we need to step up the pace.’ Today, there are 15 million people on treatment, yet there are still alarming challenges that must be tackled in order to even contemplate an AIDS free generation. Statistics from 2013 show there were 1.5 million HIV deaths, 2.1 million new infections and 35 million people living with HIV. Of the 35 million people living with HIV, 55% (19 million) don’t know they have the virus. They haven’t been tested and if they don’t find this out, they will die. The conference highlighted many reasons as to why people do not access or drop out of treatment. The author argues that people must not become those tired advocates beating the same drum, but come back from the conference championing the successes of work over the last 30 years and enter a phase of renewed energy to step up the pace and most importantly leave no one behind.

12. Governance and participation in health

New and old global health actors: effectiveness vs. legitimacy?
van Shaik L, van de Pas R: Clingendael, 1-66, July 2014

The democratic legitimacy of transnational arrangements for global health is contested. The traditional United Nations’ body for health, the World Health Organization (WHO), is subject to severe criticism regarding its focus, effectiveness, and independence from country specific, and private sector interests. It is confronted by budget cuts and a fundamental reorganization. Other major actors, such as the Global Alliance for Vaccines and Immunization (GAVI), Global Fund and the Bill and Melinda Gates Foundation (hereafter The Gates), make significant contributions to international health projects, but they can be criticized for not being representative and accountable. The global health landscape in general has become an intransparent patchwork of organizations and interests, where objectives of public health, development, economy, security, and foreign policy dominate to various degrees, and sometimes clash. This paper discusses the principal arrangements for transnational governance in the area of global health, and analyses their democratic legitimacy using five different prisms: (1) representation; (2)accountability; (3) transparency; (4) effectiveness; and (5) deliberation.

The accountability for reasonableness approach to guide priority setting in health systems within limited resources - findings from action research at district level in Kenya, Tanzania, and Zambia
Byskov J, Marchal B, Maluka S, Zulu J, Bukachi S, Hurtig A, Blystad A, Kamuzora P, Michelo C, Nyandieka L, Ndawi B, Bloch P, Olsen Ø: Health Research Policy and Systems 12:49, 2014

Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. District stakeholders were able to take greater charge of closing the gap between nationally set planning on one hand and the local realities and demands of the served communities on the other within the limited resources at hand. This study provided arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.

13. Monitoring equity and research policy

Assessing the ability of health information systems in hospitals to support evidence-informed decisions in Kenya
Kihuba E, Gathara D, Mwinga S, Mulaku M, Kosgei R, Mogoa W, Nyamai R, English M: Global Health Action, 7, July 2014.

Hospital management information systems (HMIS) is a key component of national health information systems (HIS), and actions required of hospital management to support information generation in Kenya are articulated in specific policy documents. The authors evaluated core functions of data generation and reporting within hospitals in Kenya to facilitate interpretation of national reports and to provide guidance on key areas requiring improvement to support data use in decision making. Study findings indicated that the HMIS does not deliver quality data. Significant constraints exist in data quality assurance, supervisory support, data infrastructure in respect to information and communications technology application, human resources, financial resources, and integration.

14. Useful Resources

2014 Durban International Film Festival Winners

The 35th Edition of the Durban International Film Festival came to a close last week with an awards ceremony that saw the unveiling of the fest’s new statuette, the Golden Giraffe. Of particular note, Rehad Desai‘s Marikana documentary Miners Shot Down was awarded “South Africa’s Best Documentary Film.” The film uses the point of view of the Marikana miners as it follows the strike from day one.

International Drug Price Indicator Guide
Management Sciences for Health: Boston, 2014

The International Drug Price Indicator Guide contains a spectrum of prices from pharmaceutical suppliers, international development organizations, and government agencies. The Guide aims to make price information more widely available in order to improve procurement of medicines of assured quality for the lowest possible price. Comparative price information is important for getting the best price, and this is an essential reference for anyone involved in the procurement of pharmaceuticals. Management Sciences for Health (MSH) has published the International Drug Price Indicator Guide since 1986 and updates it annually.

Introducing the Open and Collaborative Science in Development Network
Open and Collaborative Science in Development Network, July 2014

The Open and Collaborative Science in Development Network (OCSDNet) announces the launch of the network and a public Call for Concept Notes on case studies that explore the linkages between Open Science and development initiatives. Open and Collaborative Science (OCS) is a set of ideas and practices that aims to change the traditional culture of research by making the production and dissemination of scientific knowledge inclusive and publicly accessible. Open approaches to science include increased sharing of research plans and data, participatory citizen science, distributed “crowdsourced” forms of data collection, and innovative models of large or small scale scientific collaborations, enabled by networked technologies. While principles of openness and collaboration are recognized as critical for development, they remain to be realized. Moreover, there is limited awareness about the benefits and practices of OCS in the Global South. If the global scientific community understands how scientific knowledge can be effectively made more open and inclusive, then researchers and research-users in the Global South and North can work to ensure that scientific knowledge informs development efforts.

15. Jobs and Announcements

10th Public Health Association of South Africa
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 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.

14th Association for Health Information and Libraries in Africa Congress
Dar es Salaam, Tanzania, 20-24 October 2014

The Association for Health Information and Libraries in Africa (AHILA) will hold its 14th Biennial Congress in Dar es Salaam, Tanzania. AHILA was founded in 1984 with the aim of improving provision of up-to-date and relevant health information; encourage professional development of health librarians; promote information resource sharing in Africa and exchange of experiences as well as promoting the development and standardization and exchange of health databases in Africa. The main theme of the 14th AHILA Congress is: ICTs, access to health information and knowledge: building strong knowledge societies for sustainable development in Africa.

British Chevening Scholarships for International Students
Applications close 15 November 2014, 23:59 GMT.

Chevening Scholarships are the UK government’s global scholarship programme, funded by the Foreign and Commonwealth Office (FCO) and partner organisations. The programme makes awards to outstanding scholars with leadership potential from around the world to study postgraduate courses at universities in the UK. The programme provides full or part funding for full-time courses at postgraduate level, normally a one-year Master’s degree, in any subject and at any UK university.

Journal of Health Diplomacy (call for papers on Africa, health and diplomacy
Call closes: 3 November 2014

The Journal of Health Diplomacy (JHD) is now receiving manuscripts for its third issue, titled: Africa, health and diplomacy. This issue is broadly concerned with the theory and practice of health diplomacy of African states, as a co-operation with the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The issue will include invited and submitted manuscripts. To be considered for the latter, please submit your proposed manuscript to mark.pearcey@carleton.ca by 3 November 2014. Manuscripts submitted to JHD will undergo a peer-review process, with referees selected for their particular knowledge/experience on the topic of the manuscript. In light of this, we ask authors to ensure that their identity is not revealed directly or indirectly on any page. Manuscripts that are being considered for publication elsewhere, or that have been previously published must not be submitted to the journal. A complete set of author guidelines is available on the journal website. JHD welcomes contributions from all academic disciplines, including international relations, political science, anthropology, sociology, history and geography. We are also interested in interdisciplinary perspectives that cross the boundaries between different theoretical fields and represent novel understandings of health diplomacy.

Third Global Symposium on Health Systems Research
Cape Town International Convention Centre, South Africa, 30 September to 3 October 2014

The Third Global Symposium on Health Systems Research which will be held in Cape Town, South Africa, from 30 September to 3 October 2014 with pre-Symposium satellite sessions on 29 and 30 September. The theme of the symposium is the science and practice of people-centred health systems, chosen to enable participants to address current and critical concerns of relevance across countries in all parts of the world. Researchers, policy-makers, funders, implementers and other stakeholders, from all regions and all socio-economic levels, will work together on the challenge of how to make health systems more responsive to the needs of individuals, families and communities. Participation is encouraged from experts and newcomers to the broad field of health systems research.


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