EQUINET NEWSLETTER 164 : 01 October 2014

1. Editorial

Last month we lost a champion for health justice: A luta continua Thomas Deve
EQUINET Steering Committee

Thomas Deve, a member of the EQUINET steering committee, passed away on Sunday 7th September. The diversity of people who have written tributes show how widely he connected from local to global level. He brought a personal connect to people and struggles across the continent and critical analysis and debate to our network. He was a researcher, a policy analyst, a band manager, a teacher, a thinker, an activist and much more. We bid him a reluctant farewell and Thomas, our struggle to reclaim the resources for health will continue.

When will we get better control over access to medicines?
Rangarirai Machemedze, SEATINI

At the recent 2014 International AIDS Conference we heard that 35 million people are living with HIV, but 55% haven’t been tested. Under the 2013 WHO guidelines, UNAIDS reported in 2013 that the HIV treatment coverage in low and middle-income countries represented only 34% of the 28.6 million people eligible in 2013. Medicines for malaria, pneumonia and other common conditions don’t reach many low income communities and there are new challenges in ensuring the long term treatment for chronic conditions.

Access to medicines continues to be a major preoccupation in African health systems. Beyond the unequal distribution of access to essential medicines globally and within countries, resistance to anti-malarials, antibiotics, and treatments for TB and other conditions can worsen the problem. The new medicines developed are frequently more expensive and may also require more stringent supervision to ensure they are properly used. For example in the 2014 AIDS Conference it was noted that there is a 10 fold price increase from first to second line treatment, and the World Health Organization (WHO) reported in 2012 that the 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB) longer and more expensive treatment. These medicines are often imported, at a cost that consume a large share of health budgets. Countries in east and southern Africa (ESA) often draw on support from external funders to meet these costs.

This rising challenge, coupled with high levels of dependency on external producers and funders makes ESA countries very externally dependent when it comes to medicines. This, and the potential contribution that pharmaceutical manufacture could make to economies and trade within the continent, especially given the rich natural resources for medicines, prompted the African Union and its sub regions in east and southern Africa to come up with plans to enhance local pharmaceutical production. African Ministers of Finance, Planning and Economic Development in Nigeria in March 2014 noted: “There is growing consensus that strengthening the local production of essential medicines is a priority, along with advancing industrial development and moving the continent towards sustainability of treatment programmes for HIV, tuberculosis and malaria, and improving access to safe and effective medicines to treat a broad range of communicable and non-communicable diseases.”

The Pharmaceutical Manufacturing Plan for Africa (PMPA), the Southern Africa Development Community (SADC) Pharmaceutical Business Plan 2007-2013 and the East African Community (EAC) Regional Pharmaceutical Manufacturing Plan of Action 2012-2016 all propose policy measures to create the conditions for and support local production, as one, albeit not the only way to strengthen access to medicines.

The same plans are also rather clear about the obstacles that have to be overcome to achieve this, including in terms of ensuring adequate legal provisions, improved and reliable energy, transport and other infrastructure, technology, skills and research and development capacities to enable and sustain production and finance capital. The same 2014 conference of African Ministers of Finance, Planning and Economic Development cited above noted in its statement: “The challenges the pharmaceutical industry faces in upgrading facilities and production practices in Africa include the requirement for large capital investments and the need for experts, specially trained workers, increased regulatory oversight and regulatory harmonisation at the regional and continental levels in order to create bigger markets.”

In research that we carried out in 2013 and 2014, we found signs of progress in overcoming these obstacles, but also many challenges. Kenya, Uganda and Zimbabwe, for example, produce medicines that are not only consumed in their own countries, but are exported to other countries in the region. Some of the factors that appear to support this include the presence of a sound regulatory framework for the pharmaceutical sector, partnerships with other countries bringing investments in manufacturing and in capacities for it (such as in Uganda), local skills and research and development institutions that can support the technology for local production. Further, existing practice points to the critical importance of regional trade as a way of ensuring adequately sized markets to provide a return on investments. These are examples in practice of measures that are articulated in the regional plans.

However, we also found that while many countries have national pharmaceutical policies that articulate such goals, they also depend on policy in other areas, such as energy and infrastructure, and that there is a gap between policies and their implementation.

The implementation gap is evident in a number of areas. One is in the extent to which governments are supporting local production with tax and other incentives to create a conducive investment, business and trade environment. For example there could be stronger measures to exempt duty and value added tax (VAT) on imported pharmaceutical raw materials and packaging materials to stimulate local production and reduced corporate tax rates, investment tax credits and other incentives for companies to set up production. Yet sometimes we find that the opposite is in place. For example in Zimbabwe imported drugs were in 2000 exempted from duty and VAT, while the raw materials and packaging needed for local manufacturing attracted duties of up to 40% and VAT of 15%. This increases the cost of locally produced drugs, especially when other countries are not placing these high charges on their producers, making imports cheaper than locally produced medicines. This doesn’t make sense given the policy intentions and we should at least level the playing field and avoid tariff structures that promote de-industrialisation!

There is also a gap in the dialogue that should be going on between governments, pharmaceutical companies and training institutions on what capacities, skills and personnel are needed for the pharmaceutical industry and how these can be attracted and developed, including through schemes to attract and retain appropriate personnel in the public service and in countries.

While there is an emerging interest in south-south partnership agreements on some of these areas, it is equally important that attention be given to implementing the regional plans, to use memberships of Common Market for Eastern and Southern Africa, the Southern African Development and the East African Community to negotiate for a tripartite Free Trade Area between the three blocs to widen markets for medicines and to strengthen regional interactions on the technology, infrastructure, capacities, research and development and capital needed for pharmaceutical production.

In a continent with such high health need and demand for treatment, surely we need to not only be asking when we will get better access to medicines, but when we will get better control over access to medicines?

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

2. Latest Equinet Updates

EQUINET Satellite Session: New resources and opportunities for participatory research in health systems: areas of focus for Health systems Global
GSHSR Cape Town 30 September 1200-1400

EQUINET, COPASAH and Rotterdam Global Health Initiative Erasmus University, for the participatory cluster in the SHaPeS TWG for Health Systems Global is hosting a satellite workshop at the GSHSR on ”New resources and opportunities for participatory research in health systems: areas of focus for Health systems Global” on Tuesday, 30 September from 12.00 – 14.00. We welcome all interested in this work! The satellite session will be convened by the three organisations in the participatory cluster of the SHaPeS Technical working Group in HSR global. It will present and discuss with delegates interested in the cluster the issues, resources and capacities for the field and how these could be developed through the TWG, and will make available work we have done to date, particularly through EQUINET and COPASAH. It will review the experience of using participatory action research, (PAR), community monitoring and innovations in social media in transforming local health systems, the challenges faced and the areas for future participatory work in HSR. It will launch the EQUINET, AHPSR and IDRC methods reader on participatory action research and web tools from COPASAH. The session will identify field building inputs in terms of the resources, capacity building, methods and opportunities that need to be taken forward by the participatory cluster of the SHaPeS Technical Working Group and the people who are interested in playing a role in the different areas of work. Contact admin@equinetafrica.org with GSHSR SATELLITE in the subject line for further detail or to let us know of your participation.

EQUINET Three day skills workshop on participatory action research
4-6 October 2014, Cape Town

A three day skills workshop on PARTICIPATORY ACTION RESEARCH IN PEOPLE CENTRED HEALTH SYSTEMS is being hosted by EQUINET. It will include a one day workshop on 4 October hosted hosted by TARSC and the Regional Network for Equity in Health in east and southern Africa (EQUINET) and Asociación Latinoamericana de Medicina Social (ALAMES), following the Global Symposium on Health Systems Research (30th Sept–3rd October). The workshop will be held to deepen the discussion on the use of participatory action research in health policy and people centred health systems, including in acting on the social determinants of health. The workshops aim to deepen capacities in the use of participatory action research (PAR) particularly on
• Experiences and learning of the pra4equity network in using PAR and future work of the pra4equity network
• Knowledge and research paradigms and how they are reflected in the features and process of PAR
• Applying the theory and process of PAR in practice: Methods and tools for PAR; issues in and experiences of implementation
• Meta-analysis across sites and use of new technologies in PAR
• Ethical issues in PAR, and
• Documenting and reporting PAR
It will draw on and distribute the Reader on Participatory Action Research in Health system developed by EQUINET with the Alliance for Health Policy and Systems Research and IDRC Canada.

Participatory action research in health systems: a methods reader
Loewenson R, Laurell AC, Hogstedt C, D’Ambruoso L, Shroff Z: TARSC, AHPSR, WHO, IDRC Canada, EQUINET, Harare, 2014

In the 21st century there is a growing demand to channel collective energy towards justice and equity in health, and to better understand the social processes that influence health and health systems. Communities,frontline health workers and other grass-roots actors play a key role in responding to this demand, in raising critical questions, building new knowledge and provoking and carrying out action to transform health systems and improve health. There is a widening array of methods, tools and capacities – old and new – to increase social participation and power in generating new knowledge through participatory research. At the same time, we need to be clear about exactly what participatory research is and what it can offer. This reader promotes understanding of the term ‘participatory action research’ (PAR) and provides information on its paradigms, methods, application and use, particularly in health policy and systems. This reader was produced through the Regional Network for Equity in Health in East and Southern Africa (EQUINET), with Alliance for Health Policy and Systems Research (AHPSR) and International Development Research Centre (IDRC) Canada and is being launched at the Third Global Symposium on Health Systems Research in South Africa September 30 2014 after which the full reader will replace this leaflet. The result of team work, the reader draws on experience and published work from all regions globally and explains:
• key features of participatory action research and the history and knowledge paradigms that inform it;
• processes and methods used in participatory action research, including innovations and developments in the field and the ethical and methods issues in implementing it; and
• communication, reporting, institutionalization and use of participatory action research in health systems.

Regional Consultation on Health Committees – Vehicles for realising the right to health and strengthening health systems
Cape Town 27-28 September 2014

The Learning Network for Health and Human Rights, in conjunction with the Network on Equity in Health in East and Southern Africa (EQUINET) will be holding a 2-day regional consultation on the role of Health Committees in Equitable, People-centred Health Systems in the Southern and East African region as a satellite meeting linked to the 3rd Global Symposium on Health Systems Research. The regional consultation will take place in Cape Town on Sat 27th and Sun 28th of September 2014 at the University of Cape Town and is funded by a grant from the International Development Research Council. The meeting has been called to share experiences from the southern and east Africa region of community participation in health systems governance through health committees. The focus of the consultation is on health committees as a strategy for realising the right to health and strengthening health systems. The consultation will build on previous meetings by the different partners in Kampala, Kiboga and Harare over the past 4 years. The target participants are those who have experience of working with health committees and community participation structures.

3. Equity in Health

Ebola: Recovery of Americans sharpens divisions in global health
Ndika AC: Pambazuka News, Issue 693, 11 September 2014

In August ZMAPP, an untested serum-based therapy in humans, was successfully administered to two American health workers infected with the Ebola virus, who were later declared free from the virus. The public announcement raised hopes for a new front in the fight against the ravaging epidemic. Besides the ethical and equity challenges present in distributing the limited quantity of the experimental therapies, the remarkable survival and first-rate quality of treatments provided to the American patients, as well as the water-tight public health containment measures employed, paint in a very stark manner the contours of divisions in global health, which were already widening before Ebola and have been worsen by the outbreak. The authors argue that an emergency-only response by African countries and the international community would fail to bridge those divisions that will continue in future to manufacture new and remerging epidemics like Ebola at an alarming rate as well as with frightening impact on a global scale. Africa’s endemic diseases like Ebola affect mostly its bottom millions. As such, the patients do not form a viable consumer base enough to motivate pharmaceutical industry to invest in innovative drugs and treatments for them. The WHO has put together a list of 17 neglected poverty-related diseases (NTDs). According to one study, of the about 1,393 new chemical entities introduced between 1975 and 1999, only 16 targeted NTDs.

4. Values, Policies and Rights

Transforming the development agenda requires more, not less, attention to human rights
Saiz I, Balakrishnan R: Center for Economic and Social Rights, Open Global Rights 15 September 2014

The UN General Assembly later this month will begin negotiations over the content of the Sustainable Development Goals (SDGs), to succeed the Millennium Development Goals (MDGs) in 2015. The draft SDGs contain very few explicit references to human rights, and are conspicuously silent on their role as a universal normative framework for sustainable development. This article explores how human rights advocates should navigate these contentious issues over the coming year. Three key shifts in strategy are presented as necessary to turn the tables on the stale geo-political dynamics that threaten to undermine the SDGs as an endeavour that is truly transformative and human rights-centred. Firstly, human rights advocates need to underscore the extraterritorial obligations of wealthier states to respect and protect human rights beyond their borders, and to cooperate internationally in their fulfilment. Secondly, advocates must counter the corporate influence on the post-2015 process with a much stronger push for corporate accountability. Thirdly, the human rights community must build more effective platforms and alliances with development, social justice and environmental movements to amplify the human rights voice in these debates, avoiding the fragmentation and issue-specific silos that have characterized advocacy to date.

Universal Health Protection: Progress to date and the way forward
Social protection Department, International Labour Office: ILO Geneva September 2014

This paper proposes policy options based on ILO research and experiences that aim at universal coverage and equitable access to health care. The policy options discussed focus on ensuring the human rights to social security and health and on the rights-based approaches underpinning the need for equity and poverty alleviation. This paper also provides insights into aspects of implementation and related challenges. It includes an overview of ILO concepts, definitions and strategic approaches to achieving socially inclusive and sustainable progress and highlights recent global trends.

5. Health equity in economic and trade policies

The BRICS: Yash Tandon asks tough questions – which we all need to ponder
Bond P: Pambuzuka News 682, 11 June 2014

Patrick Bond addresses questions raised by Yash Tandon in regards to the role of the BRICS in Africa and in the current configuration of the neoliberal international capitalist order. The challenge is for critics of BRICS to strategise with the world’s progressive forces to build a genuine anti-imperialist movement.

6. Poverty and health

Colloquium on lone mothers, social security and dignity in South Africa
Neves D, Noble M, Ntshongwana P and Wright G: Conference and seminar papers, June 2014

In South Africa lone mothers of working age are only entitled to social assistance for themselves if they are disabled. A means-tested Child Support Grant is payable on behalf of their children but, though important, it is small in amount and is not intended to contribute to the caregiver's living expenses. In the context of South Africa’s Constitution which declares that ‘everyone has the right to have their dignity respected and protected’ and that access to social security is to be progressively realised, this project explored the meaning of dignity in lone mothers' lives and the extent to which social security protects or erodes their dignity. The themed reports of the project cover the definition of lone motherhood in South Africa, the impact of poverty and inequality on lone mothers in South Africa and social security and the dignity of lone mothers in South Africa.

The IPCC's Fifth Assessment Report What's in it for Africa?
Inter-governmental Panel on Climate Change, Climate and Development Knowledge Network, 2014

The Fifth Assessment Report of the Inter-governmental Panel on Climate Change (IPCC) finds, beyond reasonable doubt, that the Earth’s climate is warming. Climate change will have widespread impacts on African society and Africans’ interaction with the natural environment. Since the 1950s, the rate of global warming has been unprecedented compared to previous decades and millennia. The Fifth Assessment Report presents a long list of changes that scientists have observed around the world. Since the mid-19th century, the average increase in the temperature of the Earth’s surface has been 0.85 degrees Centigrade(°C). Sea levels have risen faster than at any time during the previous two millennia. In many regions, including Africa, changing rainfall or melting snow and ice are altering freshwater systems, affecting the quantity and quality of water available. The IPCC finds that there is 95% scientific certainty that human activity, by increasing concentrations of greenhouse gases in the atmosphere, has been the dominant cause of the observed warming since the mid-20th century. The impacts of climate change will affect food security, water availability and human health in Africa significantly. Given the interdependence between countries in today’s world, the impacts of climate change on resources or commodities in one place will have far-reaching effects on prices, supply chains, trade, investment and political relations in other places. Thus, climate change will progressively threaten economic growth and human security.

The State of Food Insecurity in the World 2014
Food and Agriculture Organisation: New York, September 2014

The 2014 edition of The State of Food Insecurity in the World was released this month. SOFI 2014 presents updated estimates of undernourishment and progress towards the Millennium Development Goal (MDG) and World Food Summit (WFS) hunger targets. The 2014 report also presents further insights into the suite of food security indicators introduced in 2013 and analyses in greater depth the dimensions of food security – availability, access, stability and utilization. In addition, the 2014 report examines the diverse experiences of seven countries, with a specific focus on the enabling environment for food security and nutrition that reflects commitment and capacities across four dimensions: policies, programmes and legal frameworks; mobilization of human and financial resources; coordination mechanisms and partnerships; and evidence-based decision-making.

7. Equitable health services

Access to institutional delivery care and reasons for home delivery in three districts of Tanzania
Exavery A, Kanté AM, Njozi M, Tani K, Doctor HV, Hingora A and Phillips JF: International Journal for Equity in Health (13) 48, 2014

This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania. Data was drawn from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery. Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area.

Mobile health for non-communicable diseases in Sub-Saharan Africa: a systematic review of the literature and strategic framework for research
Bloomfield GS, Vedanthan R, Vasudevan L, Kithei A, Were M and Velazquez EJ: Globalization and Health (10)49, 2014

Mobile health (mHealth) approaches for non-communicable disease (NCD) care seem particularly applicable to sub-Saharan Africa given the penetration of mobile phones in the region. The evidence to support its implementation has not been critically reviewed. The authors systematically searched databases and grey literature for studies reported between 1992 and 2012 published in English or with an English abstract available. mHealth for NCDs in sub-Saharan Africa appears feasible for follow-up and retention of patients, can support peer support networks, and uses a variety of mHealth modalities. Whether mHealth is associated with any adverse effect has not been systematically studied. Only a small number of mHealth strategies for NCDs have been studied in sub-Saharan Africa. There is insufficient evidence to support the effectiveness of mHealth for NCD care in sub-Saharan Africa. The authors present a framework for cataloging evidence on mHealth strategies that incorporates health system challenges and stages of NCD care. This framework can guide approaches to fill evidence gaps in this area.

8. Human Resources

The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross-sectional study

Motivation and job satisfaction have been identified as key factors for health worker retention and turnover in low- and middle-income countries. District health managers in decentralised health systems usually have a broadened 'decision space' that enables them to positively influence health worker motivation and job satisfaction, which in turn impacts on retention and performance at district-level. The study explored the effects of motivation and job satisfaction on turnover intention and how motivation and satisfaction can be improved by district health managers in order to increase retention of health workers. The authors conducted a cross-sectional survey in three districts of the Eastern Region in Ghana and interviewed 256 health workers from several staff categories (doctors, nursing professionals, allied health workers and pharmacists) on their intentions to leave their current health facilities as well as their perceptions on various aspects of motivation and job satisfaction. The effects of motivation and job satisfaction on turnover intention were explored through logistic regression analysis. Overall, 69% of the respondents reported to have turnover intentions. Motivation and job satisfaction were significantly associated with turnover intention and higher levels of both reduced the risk of health workers having this intention. The dimensions of motivation and job satisfaction significantly associated with turnover intention included career development, workload, management, organisational commitment and burnout. The authors’ findings indicate that effective human resource management practices at district level influence health worker motivation and job satisfaction, thereby reducing the likelihood for turnover. Therefore, they argue that it is worth strengthening human resource management skills at district level and supporting district health managers to implement retention strategies.

What elements of the work environment are most responsible for health worker dissatisfaction in rural primary care clinics in Tanzania?
Mbaruku GM, Larson E, Kimweri A and Kruk ME: Human Resources for Health (12)38: August 2014

In countries with high maternal and newborn morbidity and mortality, reliable access to quality healthcare in rural areas is essential to save lives. Health workers who are satisfied with their jobs are more likely to remain in rural posts. Understanding what factors influence health workers' satisfaction can help determine where resources should be focused. Although there is a growing body of research assessing health worker satisfaction in hospitals, less is known about health worker satisfaction in rural, primary health clinics. This study explores the workplace satisfaction of health workers in primary health clinics in rural Tanzania. Overall, 70 health workers in rural Tanzania participated in a self-administered job satisfaction survey. Results showed that 73.9% of health workers strongly agreed that they were satisfied with their job; however, only 11.6% strongly agreed that they were satisfied with their level of pay and 2.9% with the availability of equipment and supplies. Two categories of factors emerged from the PCA: the tools and infrastructure to provide care, and supportive interpersonal environment. Nurses and medical attendants (compared to clinical officers) and older health workers had higher satisfaction scale ratings. Two dimensions of health workers' work environment, namely infrastructure and supportive interpersonal work environment, explained much of the variation in satisfaction among rural Tanzanian health workers in primary health clinics. Health workers were generally more satisfied with supportive interpersonal relationships than with the infrastructure. Human resource policies should, it is argued, consider how to improve these two aspects of work as a means for improving health worker morale and potentially rural attrition

9. Public-Private Mix

The IFC’s Health in Africa initiative is failing to reach the poor
Mohga Kamal-Yanni: Global Health Check, Sep 10th, 2014

Health In Africa is a $1 billion investment project launched by the IFC in 2008, which aimed to ‘catalyze sustained improvements in access to quality health-related goods and services in Africa [and] financial protection against the impoverishing effects of illness’, through harnessing the potential of the private health sector. Specifically, it sought to improve access to capital for private health companies, and to help governments incorporate the private sector into their overall health care system. Health In Africa would do this through three mechanisms: an equity vehicle, a debt facility, and technical assistance. Perhaps of most importance, the initiative would make extra efforts to ‘improve the availability of health care to Africa’s poor and rural population’. The author reports that Oxfam’s assessment of the sporadic investment information available finds that far from delivering health care for the poorest, Health In Africa has favoured high-end urban hospitals, many of which explicitly target a country’s wealthy and expatriate populations. The initiative’s biggest investment to date has been in South Africa’s second largest private hospital group Life Healthcare. This $93 million endowment no doubt supported the company in its subsequent expansion, but there is no evidence it has used this investment to expand access to health care for the 85% of South Africans without health insurance. Oxfam has called on the IFC to cease all Health In Africa investments until a robust, transparent and accountable framework is put in place to ensure that the initiative is pro-poor, and geared towards meeting unmet need. In addition, it calls on the World Bank Group to conduct a full review of the IFC’s operations and impact to date in the health sector in low- and middle-income countries, to investigate how they are aligned with, and are accountable to, the overarching goals of the World Bank Group: to end extreme poverty and promote shared prosperity.

10. Resource allocation and health financing

African activists meet in Johannesburg to demand more transparent health budgets
Africa Health Budget Network: Johannesburg, South Africa, July 2014

African civil society organizations have called for greater accountability and transparency from African leaders regarding the use of public funds for the survival of mothers and babies. This call to action marks the launch of an African-led network demanding better use of existing funds for African women and children’s health as well as a greater share of African national budgets allocated to mothers and babies’ survival. While most African government have already made commitments about improving the health of their population, including through greater spending, it is difficult to check whether they are keeping their promises if the budget is not publicly available or if the information in the budget is not clearly presented. The members of the Africa Health Budget Network have compiled a scorecard[1] showing how open African Governments are about their health spending. Out of the 26 African countries profiled, only one, South Africa, is reported to be sufficiently transparent.

11. Equity and HIV/AIDS

Equity in utilisation of antiretroviral therapy for HIV-infected people in South Africa: a systematic review
Tromp N, Michels C, Mikkelsen E, Hontelez J, Baltussen R: International Journal for Equity in Health (13) 60, August 2014

About half a million people in South Africa are deprived of antiretroviral therapy (ART), and there is little systematic knowledge on who they are ? e.g. by severity of disease, sex, or socio-economic status (SES). The authors performed a systematic review to determine the current quantitative evidence on equity in utilisation of ART among HIV-infected people in South Africa. The authors conducted a literature search based on the Cochrane guidelines. The authors considered ART utilisation inequitable for a certain criterion (e.g. sex) if between groups (e.g. men versus women) significant differences were reported in ART initiation/adherence on that criterion. Twelve studies met the inclusion criteria. For sex, 2 out of 10 studies that investigated this criterion found that men are less likely than women to utilise ART, while the other 8 found no differences. For age, 4 out of 8 studies found inequities and reported less utilisation for younger people. For area of living, 3 out of 4 studies showed that those living in rural areas or certain provinces have less access and 2 out of 6 studies looking at SES found that people with lower SES have less access. One study which looked at the marital status found that those who are married are less likely to utilise ART. For severity of disease, 5 out of 6 studies used more than one outcome measure for disease stage and reported within their study contradicting results. One of the studies reported inconclusive findings for ethnicity and no study had looked at religion and sexual orientation. The authors suggest that men, young people, those living in certain provinces or rural areas, people who are unemployed or with a low educational level, and those being unmarried have less access to ART. As studies stem from different contexts and use different methods conclusions should be taken with caution.

The end of AIDS: Possibility or pipe dream? A tale of transitions
Whiteside A and Strauss M: African Journal of AIDS Research (2) 13, 101–108, 2014

Globally, in the last 20 years health has improved. In this generally optimistic setting HIV and AIDS accounts for the fastest growing burden of disease. The data show the bulk of this is experienced in Southern Africa. In this region, HIV and AIDS (and tuberculosis [TB]) peaks among young adults. Women carry the greater proportion of infections and provided most of the care. South Africa has the dubious distinction of having the largest number of people living with HIV in the world, 6.4 million. HIV began spreading from about 1990 and today the prevalence among antenatal clinic attendees is 29.5%. A similar situation exists in other nations of the region. It is an expensive disease, requiring more resources than are available, and it is slipping off the global agenda, both in terms of attention and international funding. Those halcyon days of the decade from 2000 to 2010 are over. This paper explores the concept of three transition points: economic, epidemiological and programmatic. The first two have been developed and written about by others. The authors add a third transition point, namely programmatic, argue this is an important concept, and show how it can become a powerful tool in the response to the epidemic. The economic transition point assesses HIV incidence and mortality of people infected with HIV. Until the number of newly infected people falls below the number of deaths of people living with HIV, the demand for treatment and costs will increase. This is a concern for the health sector, finance ministry and all working in the field of HIV. Once an economic transition occurs the treatment future is predictable and the number of people living with HIV and AIDS decreases. This paper plots two more lines. These are the number of new people from the HIV infected pool initiated on treatment and the number of people from the HIV infected pool requiring treatment. This introduces new transition points on the graph. The first when the number of people initiated on treatment exceeds the number of people needing treatment. The second when the number initiated on treatment exceeds the new infections. That is the theory. When applying South African data from the ASSA2008 model, the authors were able to plot transition points marking progress in the national response. They argue these concepts can and should be applied to any country or HIV epidemic.

12. Governance and participation in health

A local vision of climate adaptation: Participatory urban planning in Mozambique
Castán Broto V, Boyd E and Ensor J: Climate and Development Knowledge Network, May 2014

With an estimated population of 1.1 million, Maputo is the most densely populated city in Mozambique. The city is sharply divided into two areas: ’the cement city’, or the old colonial centre with paved roads and high-rise buildings, and the bairros – largely underserved, congested areas that house the majority of the city’s population. Situated on the Indian Ocean, the city is highly vulnerable to climate change impacts such as cyclones, flooding and sea level rise. Poverty and inequality, which are concentrated in the bairros, further exacerbate climate change vulnerabilities in the city. Chamanculo C is one such bairro where vulnerabilities have become evident during recent flood events. Responding to the urgent need to address urban deprivation, the municipality is currently implementing a neighbourhood upgrading programme in a participatory manner in Chamanculo C.

Ebola and Global Health Governance: Time for the Reckoning
Fidler D: Chatham House Expert briefing, 22 September 2014

The author writes that the suffering inflicted by the Ebola outbreak - and the ineffective reactions to it - reveals a massive failure of global health governance. States and international organizations are scrambling, from the Security Council to the streets of Monrovia, to triage the damage to social order and human dignity from the outbreak of Ebola in West Africa. It remains to be seen whether scaled-up responses can control the epidemic. But, he argues, there awaits another reckoning—the challenge of identifying what went wrong, where mistakes were made, why we ended up in crisis and how to ensure a similar failure does not happen again. He proposes that the UN Security Council should establish an independent investigation into the outbreak and the international community’s responses. The investigation should probe what happened from the local level to the office of the director-general of the World Health Organization. It should gather information on when and how other actors in global health—countries, regional organizations, NGOs and airlines and other corporations—responded.

13. Monitoring equity and research policy

Open access: academic publishing and its implications for knowledge equity in Kenya
Matheka D, Nderitu J, Mutonga D, Otiti M, Siegel K and Demaio A: Globalization and Health (10)26, 2014

Traditional, subscription-based scientific publishing has its limitations: often, articles are inaccessible to the majority of researchers in low- and middle-income countries (LMICs), where journal subscriptions or one-time access fees are cost-prohibitive. Open access (OA) publishing, in which journals provide online access to articles free of charge, breaks this barrier and allows unrestricted access to scientific and scholarly information to researchers all over the globe. At the same time, one major limitation to OA is a high publishing cost that is placed on authors. Following recent developments to OA publishing policies in the UK and even LMICs, this article highlights the current status and future challenges of OA in Africa. The authors place particular emphasis on Kenya, where multidisciplinary efforts to improve access have been established. They note that these efforts in Kenya can be further strengthened and potentially replicated in other African countries, with the goal of elevating the visibility of African research and improving access for African researchers to global research, and, ultimately, bring social and economic benefits to the region. The authors (1) offer recommendations for overcoming the challenges of implementing OA in Africa and (2) call for urgent action by African governments to follow the suit of high-income countries like the UK and Australia, mandating OA for publicly-funded research in their region and supporting future research into how OA might bring social and economic benefits to Africa

Reclaiming public health through community-based monitoring: The case of Maharashtra, India
Shukla A, Saha Sinha S and SATHI: Municipal Services Project, September 2014

Community-based monitoring and planning (CBMP) of health services in Maharashtra state, India represents an innovative participatory approach to improving accountability and healthcare delivery. Supported by diverse stories of change, the paper shows how this process created various forums and spaces for dialogue and led to systematic data collection on health indicators that point to greater accessibility and quality of services at village as well as primary health centre levels. The authors ask whether this experience could inform ‘communitization’ of health services in diverse contexts, as an alternative to privatization and as a means to enhancing the ‘publicness’ of health services.

14. Useful Resources

Raising her Voice
Oxfam: September 2014

All around the world women's voices are absent from the many places and spaces in which the decisions that affect their everyday lives are made. Oxfam aims to change this by strengthening the way in which women's individual and collective voices influence decisions about services, investments, policies and legal frameworks so that worldwide, those in power, from village leaders to politicians and law-makers, become more accountable to them.From 2008-2013, the global Raising Her Voice programme, supported projects in 17 countries to enable over 1 million women to take part in, shape and monitor the decisions that most affect their lives. Although formal funding for RHV ended in March 2013, Oxfam is continuing to work on women's political rights and empowerment worldwide. This website provides case studies and videos on the work from African countries.

The Open Budget Survey
International Budget Partnership: September 2014

The Open Budget Survey is a comprehensive analysis and survey that evaluates whether governments give the public access to budget information and opportunities to participate in the budget process at the national level. The Survey also assesses the capacity and independence of formal oversight institutions. The IBP works with civil society partners in 100 countries to collect evidence. To easily measure the commitment to transparency, IBP created the Open Budget Index from the Survey. The Open Budget Index allows for comparisons among countries and across years. the website provides a 2014 calculator to predict the outcome of the next survey and see where transparency can improve.

15. Jobs and Announcements

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

Global Health Watch 4
Peoples Health Movement, Publishing on 13 November 2014

The Global Health Watch integrates rigorous analysis, alternative proposals and stories of struggles and change to present a compelling case for the imperative to work for a radical transformation of the way we approach actions and policies on health. It is designed to question present policies on health and to propose alternatives. Find out more by visiting: www.ghwatch.org. GHW4 is a collaborative effort by activists and academics from across the world, and has been coordinated the People’s Health Movement, Asociación Latinoamericana de Medicina Social, Health Action International, Third World Network and Medact. This edition of the GHW, published by ZED Books, will be available from 13 November 2014. PHM request you to disseminate the evidence and analysis in GHW4 and invite you to consider launching the GHW4 in your region, starting from December 2014. For this purpose ‘launch kits’ will be available by early November 2014 and PHM will send 10 to 20 books for each event. For more information contact asengupta@phmovement.org.

Joint Global Research Programme: Women’s and children's health
Closing date: 21 October 2014 16:00pm

The Medical Research Council (MRC) in the UK and the Department of Biotechnology (DBT)opens in new window in India in collaboration with Department of International Development (DFID)opens in new window are pleased to announce a joint call to fund Global Health Research which will bring together researchers from the UK, India and Low Income Countries. This call for collaborative proposals will require applicants based in India, Low Income Countries and the UK to work together in partnership within cross national teams on research projects. Bids must include at least one institution from each of India, UK and a LIC. For more information please visit the website.

Secure Grants from the Elizabeth Taylor AIDS Foundation
Deadline: 31 December 2014

The Elizabeth Taylor AIDS Foundation accepts grant applications from all the HIV/AIDS communities worldwide. Organizations working in the sector of HIV/AIDS are required to send a statement of need along with the proposed program description and the organizations’ capacity to implement the proposed program.The Elizabeth Taylor AIDS Foundation supports two kinds of organizations, Those: 1.Delivering direct care and services to people living with HIV/AIDS and 2.Providing education to the public regarding the AIDS virus and the prevention of AIDS. For further information visit the website.


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