EQUINET NEWSLETTER 165 : 01 November 2014

1. Editorial

Citizens making things happen
Risha Chande, Twaweza, Tanzania

Seven out of ten Tanzanians think that have no say in what Government does. Yet seven out of ten Tanzanians also think that voting is their only means of influence over Government. This may sound contradictory, but at core, they both reflect the same sentiment. Aside from the choices they make during elections, citizens do not feel that they influence government decision-making or activity. They appear to have little trust that formal institutions or local government officials will address their issues, and formal political institutions seem to play minimal roles in people’s lives. Nine out of ten people report that they have not interacted with their member of parliament in the last year, half have not interacted with their street or village chairman to raise issues and only one in seven citizens are members of any political party.

These findings were released by Twaweza in a research brief titled Citizens making things happen: are citizens active and can they hold government to account? The brief is based on data from Twaweza’s Sauti za Wananchi, Africa’s first nationally representative mobile phone survey that interviews households across Mainland Tanzania.

Sauti za Wananchi, (http://www.twaweza.org/uploads/files/Sauti-za-Wananchi-English.pdf) was initiated by Twaweza as a response to the concern that policy makers make decisions for the whole country, but with poor information on the experiences and realities of a large majority of citizens and on whether their policies are working on the ground across different places. It provides timely, low cost and reliable data and is a nationally representative barometer of the reality reported by Tanzanians. In 2014, together with our partners, we expect to conduct 20 survey rounds, and use widespread dissemination and intensive media outreach to share the findings, especially with policy actors, to shine a light on citizens’ experiences and views.

So how are people taking up their concerns? Despite the apparently low levels of interaction with formal channels uncovered by Sauti za Wananchi, 6 out of 10 citizens report that they made joint or collective complaints to officials in their community in the last 12 months, sometimes repeating the same complaint. Common complaints ranged from seeking improvements in local public services, to teacher absenteeism and access to clean and safe water. Just over a quarter of people reported raising complaints about the absence of drugs at local facilities, generally complaining several times in the past year.

When it comes to raising issues within the community, Sauti za Wananchi found that people are fairly vocal about problems they face. Eight out of ten citizens raise their issues in the groups they belong to, and three out of ten have called in to a radio station or complained to a friend. In contrast, people are much less likely to walk out of a discussion, attend a demonstration or protest or to refuse to pay tax, and far less report that they would or use force to achieve a political cause.

Community groups thus play a more significant role in people’s lives. Seven out of ten Tanzanians belong to one, often religious groups, but also savings and loans groups. Community solidarity appears to be high: almost all citizens believe that if an unforeseen incident, such as house fire, occurred, their community would get together to help. The same confidence doesn’t extend beyond immediate communities, and when asked whether they trust people generally, nine out of ten people felt that you had to be very careful with others. Citizens also strongly feel that they can rely on themselves to get things done. Seven out of ten citizens respond positively to statements about their own ability to overcome challenges, find solutions to their problems and accomplish their own goals.

People also contribute collectively to their services: Seven out of ten citizens directly contribute to constructing or maintaining public facilities, most giving money and the rest contributing time. While the level of tax collection is low, people are in one way or another contributing to the running of government. However these collections are not well regulated. The lack of transparency and checks and balances mean that contributions may not be collected fairly or used productively. In fact, four out of ten of those who contributed to local facilities say they were forced to do so, eroding public trust.

Sauti za Wananchi paints an interesting picture of the experience of Tanzanians. Rakesh Rajani, Head of Twaweza at the time, summed it up: “Tanzanians are active members of community groups and undertake collective action to complain to officials in their community. They also feel that they are able to tackle obstacles and make things happen in their own lives but express feelings of powerlessness when it comes to their influence over government. Thus far citizens have shied away from the more emphatic and vocal forms of citizen agency such as tax refusal, protests or walk outs. However significant service delivery challenges remain in all major sectors. If the Government does not become more responsive to this softer engagement, we may see citizens become more aggressive in the future.”

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the evidence, issues and processes raised in this op-ed please visit Twaweza at www.twaweza.org and read the full report at http://www.twaweza.org/uploads/files/CitizenAgency-EN-FINAL.pdf

2. Latest Equinet Updates

EQUINET Policy Brief 39: Enhancing local medicine production in east and Southern Africa

This brief outlines the factors that affect medicines production in East and Southern Africa, drawing on the African Union, Southern Africa Development Community (SADC) and East African Community (EAC) pharmaceutical plans. It identifies the barriers to local production as: lack of supportive policies, capital and skills constraints, gaps in regulatory framework, small market size and weak research and development capacities. It highlights, from case study work in selected countries in East and Southern Africa the potential opportunities for strengthening local medicine production. In the brief we propose that African countries strengthen domestic capacities, co-operation between domestic private and public sectors within ESA countries, and regional co-operation across ESA countries to address bottlenecks. Some areas such as infrastructure development and training may be important groundwork for others, such as technology transfer and research and development. South-south cooperation in medicines production can play a role in this but it cannot be assumed. Negotiations on south-south arrangements should look not only at the immediate production investment, but at strengthening capacities for research and development, for regulation, medicines price and quality monitoring, prequalification, infrastructure and human resource development.

Health Committees as vehicles for community participation
Statement from the Regional Consultation 27 & 28 September 2014

Participants at the Regional Meeting on Health Committees co-hosted by the Learning Network for Health and Human Rights, the Centre for Health, Human Right and Development (CEHURD) and the Network on Equity in Health in East and Southern Africa (EQUINET), 27-28 September 2014, Cape Town developed the statement from the meeting committing themselves to strengthen regional learning networks between countries of the south for advancing health committees as vehicles for community participation and calling on governments to recognise and incorporate health committees into their health systems in ways that maintain their roles as autonomous agents for democratic governance; WHO to provide guidance on inclusion of Health Committees in Health Systems Governance; and for discussions on updating the WHO Building Blocks approach to recognise the role of collective community action through Health Committees when inserting notions of public and patient engagement.

Further details: /newsletter/id/39173

3. Equity in Health

Did Ebola emerge in West Africa by a policy-driven phase change in agroecology? Ebola’s social context
Wallace R G, Gilbert M, Wallace R, Pittiglio C, Mattioli R, Kock R: Environment and Planning A:46, 2014

The ongoing outbreak of human Ebola virus in West Africa, the largest and most extensive recorded, began in forest villages across four districts in southeastern Guinea as early as December 2013. The authors argue that the shifts in land use in Guinée forestière where the virus originated are also connected to government policies promoting neoliberal structural adjustment that, alongside divesting public health infrastructure, opened domestic food production to global capital with Ebola’s latest spillover arising due to massive expansion in the land allocated to corporate production of oil palm, taking over farmland, and bringing a a variety of disturbance-associated fruit bats attracted to oil palm plantations into more direct contact with informal pickers and contract farmers. Deforestation, including from oil palm planting, changes foraging behavior of the bat and expands interfaces among bats, humans and livestock. The authors suggest that deforestation, de-development, population mobility, peri-urbanization, cycle migration, and an inadequate health system that failed to recognize and isolate cases may have contributed, and that the the present outbreak signals the need to characterise the ecosystems on which humanity must routinely be reminded it depends.

Does the distribution of healthcare utilization match needs in Africa?
Bonfrer I, van de Poel E, Grimm M, Van Doorslaer E: Health Policy and Planning 29(7): 921-937, 10 October 2013

An equitable distribution of healthcare use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). The authors ex-amine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries. For almost all countries studied, healthcare utilization is considerably higher among the rich. When decomposing these inequalities wealth is found to be the single most important driver. In 12 of the 18 countries wealth is responsible for more than half of total inequality in the use of care, and in 8 countries wealth even explains more of the inequality than need, education, employment, marital status and urbanicity together. For the richer countries, notably Mauritius, Namibia, South Africa and Swaziland, the contribution of wealth is typical-ly less important. As the bulk of inequality is not related to need for care and poor people use less care because they do not have the ability to pay, healthcare utilization in these countries is to a large extent unfairly distributed. The weak average relationship between need for and use of health care and the potential reporting heterogeneity in self-reported health across socio-economic groups imply that the findings are likely to even underestimate actual inequities in health care.

Glimmers of hope on the Ebola front
Fleck F: Bull World Health Organ;92:704–705, 2014

Daniel Bausch - interviewed in this paper- has been assisting with patient care during the current Ebola virus disease outbreak in western Africa and – as part of a WHO-led international collaboration – is exploring the possible use of experimental therapies and vaccines. He explains in this paper why this outbreak is different. He notes that the outbreak response had outstripped the available resources. Although personnel were deployed he says "we are all late and it has gotten out of control. It’s too simplistic to lay the blame on one group. There has been a lot of finger pointing at WHO, no one is immune to criticism, but WHO has suffered a loss of personnel and resources. So it’s not only about what we should have done at any particular time, but the whole foundation for an international public health response that has been eroded by the global economic downturn". He further observes that the scale and public profile of this outbreak means that potential vaccines and therapies that were stalled are now being pushed through clinical trials. He argues that if vaccines and drugs are provided in the not too distant future, the problem will change and people will start knocking on the door demanding prevention and treatment, so this is a public health strategy as well, but stemming the outbreak will still depend primarily on the classic strategy of case identification, with isolation and treatment, and contact tracing.

The naked class politics of Ebola
Robb J: Pambazuka, Issue 699, September 2014

Ebola is also an epidemic, and the causes and conditions of the epidemic are social, economic, and political rather than natural. Outside of these social and economic conditions, the disease would have been contained or even eliminated long before now. The three countries at the centre of the Ebola epidemic are among the most impoverished in the world. The author argues that the permanent legacy of centuries of uninterrupted plunder is chronic and widespread malnutrition, dirt roads, poor or non-existent sanitation, unreliable or non-existent electric power, and one doctor per 100,000 inhabitants. These are the conditions in which an Ebola outbreak becomes an epidemic. For several months after the existence of Ebola was confirmed in the three countries of West Africa, it did not, the author argues, threaten the extraction of wealth from the region, and the first actions were to withdraw many volunteers including those working in health and to suspend flights. As cases were diagnosed in the USA and Europe, the response is reported to have been isolationist, with media spreading fear and speculation. Aid increased, but with limited personnel, except from Cuba. The author argues that West African health workers and volunteers are the ones who have carried out the socially necessary tasks of caring for patients, collecting and burying bodies, and educating the population in prevention and containment measures, despite inadequate safety equipment, serious threats to their own health, inadequate pay, and despite sometimes being ostracised in their own communities.

4. Values, Policies and Rights

Poverty Reduction and Regional Integration: A comparative analysis of SADC and UNASUR health policies (PRARI)
Open University, FLASCO, SAIIA, UNU-CRIS:

The Open University and Southampton University, South African SAIIA FLACSO-Argentina and UNU-CRIS are currently involved in the Poverty Reduction and Regional Integration (PRARI) project, a two year project studying what regional institutional practices and methods of regional policy formation are conducive to the emergence of embedded pro-poor health strategies, and what can national, regional and international actors do to promote these, particularly in South America and Southern Africa.

The right to health: what model for Latin America?
Heredia N, Laurell AC, Feo O, Noronha J, González-Guzmán R, Torres-Tovar M: The Lancet, Early Online Publication, 16 October 2014

The drive for Universal Health Coverage is currently very intense. Everybody seems to agree on this objective. However, the term is argued to be ambiguous term and in Latin America two different notions
are used. One refers to forms of health insurance, be they voluntary or compulsory and public or private, and in variable combinations. The other refers to a single public health system—ie, a unified tax-funded health system as an obligation of the state. The authors argue that it is critical to distinguish between these two notions and to set uniform criteria of analysis to compare their achievements. In this context, these are: population and medical coverage in their categories of universal or segmented access and use of service and possible barriers; origin and management of health funds; type of providers; health expenditure, public and private; distribution of costs and amount of out-of-pocket expenditure; impact on public health actions and health conditions; and equity, popular participation, and transparency. Taken together, these reveal the extent to which the right to health, a widely held social value, is attained. The authors analyse the largely pluralist health insurance in Latin America and argue that it does not grant the right to health, understood as equal access to the necessary services for equal need. By contrast with the intrinsic restrictions of universal health insurance, the problems of the single public health system are identified as operational. Where implemented in Latin America, while they have problems to resolve, these unified publicly funded systems are argued to be 'on their way to grant the right to health'.

UN Rapporteur on right to health calls for review of investment treaties
Gopakumar K: TWN Info Service on Health Issues, October 2014

Investment treaties should be reviewed to ensure that States have the right to make changes in their laws and policies to further human rights regardless of the impact of such changes on investors’ rights. This recommendation came from the Special Rapporteur on Right to Health, Mr. Anand Grover in his last report to the UN General Assembly (UNGA). The report notes that nearly 40 countries have already began renegotiation of international investment treaties. The Grover report calls for an international treaty to hold transnational corporations (TNCs) accountable for their violations on human rights. The report presents the current state of play with regard to the accountability of TNCs with regard to human rights violations. Two other sub-sections discuss the shortcomings of international investment treaties and the investor -state dispute settlement mechanism.

5. Health equity in economic and trade policies

#WorldvsBank protests the World Bank Doing Business Rankings
Our land, our business; October 2014

On October 10, the World Bank met for its Annual General Meeting in Washington DC. Around the world, in 12 cities, people came out to protest against the Bank’s Doing Business rankings. 'WorldvsBank', a global campaign asked the Bank to dump the Doing Business Rankings that only serve big business. The World Bank’s Doing Business ranking gives points to countries when they act in favor of the “ease of doing business.” This is argued by the campaign to smooth the way for corporations’ activity by, for instance, cutting administrative procedures, lowering corporate taxes, removing environmental and social regulations, or lowering trade barriers. The ranking system is also argued to encourage land reforms that tend to make land just a marketable commodity, easily accessible to wealthy corporations, in process neglecting human rights, the protection of workers, and the sustainable use of natural resources.

Deadly economic violence of the big banks
Burger V: Pambazuka News, Issue 699, October 2014

The author highlights through a case study the pattern of reckless lending, high interest rates that, over time, significantly inflate the sum of the original loan, strong-arm debt recovery tactics such as threats of legal action and telephone harassment, that is argued in this article to be cases of 'economic violence'. She describes how the extreme distress induced by these practices was manifested in 2012, when thousands of desperate, poorly paid, over-indebted Marikana mineworkers, while striking for a R12 500 per month living wage, refused to back down and chose to face bullets to escape the suffocating squeeze of the omashonisa (money lenders). The article proposes that debt for an increasing number of South Africans has literally become life threatening, and that there is as yet no meaningful challenge to it.

LDCs and TRIPS: Overcoming challenges, seeking solutions
Bridges Africa editorial team: Bridges, 3; 8 October 2014

The Bridges Africa editorial team features various analyses that take a closer and fresh look at the unique challenges facing least developed countries in the context of the trade-innovation nexus. The dynamics underpinning the IPR and public policy debate are often epitomised by the topic of the protection of patented drugs by LDCs. In 2001, the latter obtained a separate waiver to implement TRIPS provisions on pharmaceutical products until January 2016. Should LDCs seek the renewal of this waiver before it expires, or does the general extension for the TRIPS Agreement until July 2021 already allow for exemptions from patent protection motivated by public health concerns? These and related questions are addressed in this edition.

6. Poverty and health

Perceptions and experiences of access to public healthcare by people with disabilities and older people in Uganda
Mulumba M, Nantaba J, Brolan CE, Ruano AL, Brooker K, Hammonds R: International Journal for Equity in Health, 13:76, 2014

A global discussion regarding how to renew the Millennium Development Goals (MDGs) is underway and it is in this context that the Goals and Governance for Global Health (Go4Health) research consortium conducted consultations with marginalized communities in Asia, Latin America, the Pacific and Africa as a way to include their voices in world’s new development agenda. The goal of this paper is to present the findings of the consultations carried out in Uganda with two groups within low-resource settings: older people and people living with disabilities. This qualitative study used focus group discussions and key informant interviews with older people in Uganda’s Kamwenge district, and with persons with disabilities from the Gulu region. Thematic analysis was performed and emerging categories and themes identified and presented in the findings. Our findings show that a sense of community marginalization is present within both older persons and persons living with disabilities. These groups report experiencing political sidelining, discrimination and inequitable access to health services. This is seen as the key reason for their poor health. Clinical services were found to be of low quality with little or no access to facilities, trained personnel, and drugs and there are no rehabilitative or mental health services available.

To legislate or not to legislate? A comparison of the UK and South African approaches to the development and implementation of salt reduction programs
Charlton K, Webster J, Kowal P: Nutrients 6(9), 3672-3695, 2014

The World Health Organization promotes salt reduction as a best-buy strategy to reduce chronic diseases, and Member States have agreed to a 30% reduction target in mean population salt intake by 2025. Whilst the UK has made the most progress on salt reduction, South Africa was the first country to pass legislation for salt levels in a range of processed foods. This paper compares the process of developing salt reduction strategies in both countries and highlights lessons for other countries. Like the UK, the benefits of salt reduction were being debated in South Africa long before it became a policy priority. Whilst salt reduction was gaining a higher profile internationally, undoubtedly, local research to produce context-specific, domestic costs and outcome indicators for South Africa was crucial in influencing the decision to legislate. In the UK, strong government leadership and extensive advocacy activities initiated in the early 2000s have helped drive the voluntary uptake of salt targets by the food industry. It is too early to say which strategy will be most effective regarding reductions in population-level blood pressure. Robust monitoring and transparent mechanisms for holding the industry accountable will be key to continued progress in each of the countries.

7. Equitable health services

Treatment of Infections in Young Infants in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis of Frontline Health Worker Diagnosis and Antibiotic Access
Lee AC, Chandran A, Herbert HK, Kozuki N, Markell P, et al.: PLoS Med 11(10), 14 October 2014

Inadequate illness recognition and access to antibiotics contribute to high case fatality from infections in young infants (<2 months) in low- and middle-income countries (LMICs). The authors aimed to address three questions regarding access to treatment for young infant infections in LMICs: (1) Can frontline health workers accurately diagnose possible bacterial infection (pBI)?; (2) How available and affordable are antibiotics?; (3) How often are antibiotics procured without a prescription? Data were identified from 37 published studies, 46 WHO/Health Action International national surveys, and eight service provision assessments. Availability of first-line injectable antibiotics appears low in many health facilities in Africa and Asia. Improved data and advocacy are needed to increase the availability and appropriate utilization of antibiotics for young infant infections in LMICs.

WHO’s antibiotic resistance draft action plan soft on critical issues
Gopakumar KM: TWN Info Service on Intellectual Property Issues 16 October 2014

The 67th World Health Assembly (WHA) in May 2014 mandated the WHO Secretariat “to develop a draft global action plan to combat antimicrobial resistance, including antibiotic resistance, which addresses the need to ensure that all countries, especially low and middle income countries. The Global Action Plan (GAP) is to be submitted to the 68th WHA through the 136th Session of the Executive Board meeting which will take place on 26 January to 3 February 2015 in Geneva. The author argues that the draft GAP fails to provide bold solutions especially where the pharmaceutical transnational corporations (TNCs) and their home countries have vested interests. The areas where the plan is argued to raise concern are: on the mechanism to ensure access to antimicrobial medicines at affordable prices, including local production capabilities of antimicrobial medicines and diagnostics, technology transfer and public procurement. Another major area of strategic silence is the research and development (R&D) of new AMR medicines including antibiotics and diagnostics. Other important omissions are the explicit mention of promotion of rational use of antimicrobial medicines and the management of conflict of interests.

8. Human Resources

Free State’s Community Health Workers’ Case Postponed to 29 January 2015
Sangonet pulse: October 14 2014

Over a hundred community health workers (CHW)’s and the members of the Treatment Action Campaign appeared at the Bloemfontein Magistrate’s Court today, regarding their criminal charges following their arrest at a peaceful vigil on 10 July 2014. The 129 community health care worker’s case was postponed to the 29th of January 2015. The South African Police Services (SAPS) arrested the CHW’s in the early hours of the 10th of July, during a peaceful vigil through which they were protesting the crumbling state of the public health system in Free State, their poor conditions of employment, and the 15 June’s autocratic decision of the MEC for Health in the Free State department of Health, Benny Malakoane to effectively terminate their employment without warning. The postponement is meant for the prosecution to provide the CHW’s the evidence against them and for the CHW’s to make representations to the National Director of Public Prosecutions, Mxolisi Nxasana, that the charges should be unconditionally withdrawn.

Heroes dressed in white
Hernández LM: Pambazuka October 2914

Cuba recently sent a medical team of 165 internationalist collaborators, consisting of 63 doctors and 102 nurses from across the country, with more than 15 years practical experience and of which 81 % had served on previous international missions. They went to Sierra Leone to support efforts to contain the Ebola outbreak. It is a mission they made clear were happy to undertake that goes to the heart of Cuba’s people-to-people solidarity. The author argues that is affirms that Cuba doesn’t give what it has left over, but its most precious commodity: its sons, its heroes in white coats.

In the shadowlands of global health: Observations from health workers in Kenya
Prince RL, Otieno P: Global Public Health, 9(8):927-945, September 2014

This paper draws on ethnographic research conducted in HIV clinics and in a public hospital to examine how health workers experience and reflect upon the juxtaposition of 'global' medicine with 'local' medicine. We show that health workers face an uneven playing field. High-prestige jobs are available in HIV research and treatment, funded by donors, while other diseases and health issues receive less attention. Outside HIV clinics, patient's access to medicines and laboratory tests is expensive, and diagnostic equipment is unreliable. Clinicians must tailor their decisions about treatment to the available medical technologies, medicines and resources. How do health workers reflect on working in these environments and how do their experiences influence professional ambitions and commitments? The need to improvise in the face of inadequate diagnostic tools and unreliable facilities was stressful for all health workers. Added to this stress was the degree to which health workers had to attend to patient poverty. While staff within HIV/AIDS clinics also faced these issues, hospital staff often found them overwhelming as they were confronted daily and relentlessly with the moral dilemma of how to deal with patients who could not afford treatment. In this situation, the strain of being forced to practice medicine that was only ‘good enough’ was a source of stress and frustration. Among interns, the moral complexity of their situation added to their uneasy positioning as young professionals struggling to gain a sense of professional identity and competence.

9. Public-Private Mix

Negotiating markets for health: an exploration of physicians’ engagement in dual practice in three African capital cities
Russo G, McPake B, Fronteira I, Ferrinho P: Health Policy and Planning 29 (6): 774 - 783, 26 September 2013

Scarce evidence exists on the features, determinants and implications of physicians’ dual practice, especially in resource-poor settings. This study considered dual practice patterns in three African cities, Cape Verde, Maputo and Guinea Bissau, and the respective markets for physician services, with the objective of understanding the influence of local determinants on the practice. Forty-eight semi-structured qualitative interviews were conducted in the three cities to understand features of the practice and the respective markets. A survey was carried out in a sample of 331 physi-cians to explore their characteristics and decisions to work in public and private sectors. Descriptive analysis and infer-ential statistics were employed to explore differences in physicians’ engagement in dual practice across the three loca-tions. Different forms of dual practice were found to exist in the three cities, with public physicians engaging in private practice outside but also inside public facilities, in regulated as well as unregulated ways. Thirty-four per cent of the respondents indicated that they worked in public practice only, and 11% that they engaged exclusively in private prac-tice. The remaining 55% indicated that they engaged in some form of dual practice, 31% ‘outside’ public facilities, 8% ‘inside’ and 16% both ‘outside’ and ‘inside’. Local health system governance and the structure of the markets for phy-sician services were linked to the forms of dual practice found in each location, and to their prevalence. The authors analysis suggests that physicians’ decisions to engage in dual practice are influenced by supply and demand factors, but also by how clearly separated public and private markets are. Where it is possible to provide little-regulated services within public infrastructure, less incentive seems to exist to engage in the formal private sector, with equity and effi-ciency implications for service provision. The study shows the value of analysing health markets to understand physi-cians’ engagement in professional activities, and contributes to an evidence base for its regulation.

Public-Private Partnerships, Financial Extraction and the Growing Wealth Gap
Hildyard N: Manchester Business School, Centre for Research on Socio-Cultural Change (CRESC), July 2014

This presentation looks at Public-Private Partnerships (PPPs) in infrastructure through the lens of inequality, as wealth becomes concentrated in fewer and fewer hands and as the gap between rich and poor widens globally, regionally and within countries. PPPs are now used in more than 134 developing countries, are on the rise in the aftermath of the 2008 global financial crisis, and have moved from physical infrastructure into the provision of “social infrastructure,” such as schools, hospitals and health services. For the private sector, a PPP project needs to provide a stable, guaranteed income stream. Projects are devised to create multiple avenues for a flow of money that is transformed into private profit through loans, derivatives, shares, securitised income streams, and contract sales that anyone can buy and sell. The author argues that a PPP project enables millions of dollars worth of ancillary trading, mainly for the purpose of hedging risks. The choice of what infrastructure to build is thus argued to be heavily influenced by what serves the long-term profit-making interests of the private sector – and the state or public sector becomes more and more aligned with the interests of infrastructure investors and private companies. PPPs are thus reported to be not about building and providing public services but about constructing the subsidies, fiscal incentives, capital markets, regulatory regimes and other support systems necessary to transform “infrastructure” into an asset class that yields above average returns of 13-25%.

10. Resource allocation and health financing

Innovative Financing Mechanisms: Potential Sources of Financing the WHO Tobacco Convention
Ko Sy D, Syam N, Velásquez G: South Centre Research Paper No. 54, September 2014

This research paper is produced as part of the South Centre’s research on expanding fiscal policies for global and national tobacco control. The objective of this research is to identify innovative solutions to fill the funding gaps in the implementation of the WHO Framework Convention on Tobacco Control (FCTC). Ideas and mechanisms for generating additional funding may be spawned from a review of the popular forms of non-traditional financing mechanisms that have been aimed at mobilizing resources for developmental programmes. The General Assessment section for each innovative financing idea in the paper reflects lessons learned and best practices that provide the reader with some framework when evaluating an innovative financing mechanism. Some are more administratively feasible than others but in all cases, political feasibility is a critical element. A deeper understanding of the political concerns would surface and can possibly be addressed only if the ideas are allowed to be debated on, and sufficient space to explore is provided in the appropriate forum.

Ten best resources for conducting financing and benefit incidence analysis in resource-poor settings
Wiseman V, Asante A, Price J, Hayen A, Irava W, Martins J, Guinness L, Jan S: Health Policy and Planning: 24 September 2014

Many low- and middle-income countries are seeking to reform their health financing systems to move towards universal coverage. This typically means that financing is based on people’s ability to pay while, for service use, bene-fits are based on the need for health care. Financing incidence analysis (FIA) and benefit incidence analysis (BIA) are two popular tools used to assess equity in health systems financing and service use. FIA studies examine who pays for the health sector and how these contributions are distributed according to socioeconomic status (SES). BIA determines who benefits from health care spending, with recipients ranked by their relative SES. In this article, the authors identify 10 resources to assist researchers and policy makers seeking to undertake or interpret findings from financing and benefit incidence analyses in the health sector. The article pays particular attention to the data requirements, computations, methodological challenges and country level experiences with these types of analyses.

11. Equity and HIV/AIDS

Antiretroviral Therapy for Refugees and Internally Displaced Persons: A Call for Equity
Mendelsohn JB, Spiegel P, Schilperoord M, Cornier N, Ross DA: PLoS Med 11(6), 10 June 2014

Available evidence suggests that refugees and internally displaced persons (IDPs) in stable settings can sustain high levels of adherence and viral suppression. Moral, legal, and public health principles and recent evidence strongly suggest that refugees and IDPs should have equitable access to HIV treatment and support. Exclusion of refugees and IDPs from HIV National Strategic Plans suggests that they may not be included in future national funding proposals to major funders. Levels of viral suppression among refugees and nationals documented in a stable refugee camp suggest that some settings require more intensive support for all population groups. Detailed recommendations are provided for refugees and IDPs accessing antiretroviral therapy in stable settings.

The HIV/AIDS epidemic in South Africa: Convergence with tuberculosis, socioecological vulnerability, and climate change patterns
Abayomi A, Cowan MN: South African Medical Journal104(8):583, 9 July 2014

Recent assessment reports suggest that climate change patterns are threatening social and ecological vulnerability and resilience, with the strong potential of negatively affecting human health. Persons living with HIV/AIDS (PLWHA) have weakened physiological responses and are immunologically vulnerable to pathogens and stressors in their environment, putting them at a health disadvantage in climate-based rising temperatures, water scarcity, air pollution, potential water- and vector-borne disease outbreaks, and habitat redistributions. These climatic aberrations may lead to increased surface drying and decreased availability of arable land, threatening food/nutrition security and sanitary water practices. Coupled with HIV/AIDS, climate change threatens ecological biodiversity via a larger-scale socio-economic recourse to natural resources. Corresponding human and environmental activity shape conditions conducive to exacerbating high rates of HIV/AIDS. In South Africa, this epidemic is forming a ‘syndemic’ with tuberculosis (TB), which has come to include multidrug-resistant TB (MDR-TB) and extremely drug-resistant TB (XDR-TB) strains. Be-cause of high convergence rates, one epidemic cannot be addressed without understanding the other. Concurrent climate change mitigation and adaptation strategies are becoming increasingly important to curb changes that negatively affect the biospheres on which civilisation is ultimately dependent – from an agricultural, a developmental, and especially a health standpoint. Mitigation strategies such as reducing carbon emissions are essential, but may be only partially effective in slowing the rate of surface warming. However, global climate assessments assert that these are not sufficient to halt climate change patterns. Regionally specific climate research, socioecologically sustainable industrialisation paths for developing countries, and adoption of health system strengthening strategies are therefore vital.

12. Governance and participation in health

Community participation in formulating the post-2015 health and development goal agenda: reflections of a multi-country research collaboration
Brolan CE, Hussain S, Friedman E, Ruano AL, Mulumba M, Rusike I, Beiersmann C, Hill PS: International Journal for Equity in Health, 13:66, 2014

Global discussion on the post-2015 development goals, to replace the Millennium Development Goals when they expire on 31 December 2015, is well underway. While the Millennium Development Goals focused on redressing extreme poverty and its antecedents for people living in developing countries, the post-2015 agenda seeks to redress inequity worldwide, regardless of a country’s development status. Furthermore, to rectify the UN’s top-down approach toward the Millennium Development Goals’ formulation, widespread negotiations are underway that seek to include the voices of people and communities from around the globe to ground each post-2015 development goal. This reflexive commentary, therefore, reports on the early methodological challenges the Go4Health research project experienced in its engagement with communities in nine countries in 2013. Led by four research hubs in Uganda, Bangladesh, Australia and Guatemala, the purpose of this engagement has been to ascertain a ‘snapshot’ of the health needs and priorities of socially excluded populations particularly from the Global South. This is to inform Go4Health’s advice to the European Commission on the post-2015 global goals for health and new governance frameworks. Five methodological challenges were subsequently identified from reflecting on the multidisciplinary, multiregional team’s research practices so far: meanings and parameters around qualitative participatory research; representation of marginalization; generalizability of research findings; ethical research in project time frames; and issues related to informed consent. Strategies to overcome these methodological hurdles are also examined. The findings from the consultations represent the extraordinary diversity of marginal human experience requiring contextual analysis for universal framing of the post-2015 agenda. Unsurprisingly, methodological challenges will, and did, arise. We conclude by advocating for a discourse to emerge not only critically examining how and whose voices are being obtained at the community-level to inform the post-2015 health and development goal agenda, but also how these voices are being translated and integrated into post-2015 decision-making at national and global levels.

Examining the links between community participation and health outcomes: a review of the literature
Rifkin S: Health Policy and Planning 29, suppl 2 ii98-ii106, 2014

As a key principle of Primary Health Care (PHC) and Health Systems Reform, community participation has a prominent place in the current global dialogue. Participation is not only promoted in the context of provision and utilization of health services. Advocates also highlight participation as a key factor in the wider context of the importance of social determinants of health and health as a human right. However, the evidence that directly links community participation to improved health status is not strong. Its absence continues to be a barrier for governments, funding agencies and health professionals to promote community participation. The purpose of this article is to review research seeking to link community participation with improved health status outcomes programmes. It updates a review undertaken by the author in 2009. The search includes published articles in the English language and examines the evidence of in the context of health care delivery including services and promotion where health professionals have defined the community’s role. The results show that in most studies community participation is defined as the intervention seeking to identify a direct causal link between participation and improved health status modeled on Randomized Control studies (RCT). The majority of studies show it is not possible to examine the link because there is no standard definition of ‘community’ and ‘participation’. Where links are found, they are situation-specific and are unpredictable and not generalizable. In the discussion, an alternative research framework is proposed arguing that community participation is better understood as a process. Once concrete interventions are identified (i.e. improved birth outcomes) then the processes producing improved health status outcomes can be examined. These processes may include and can lead to community uptake, ownership and sustainability for health improvements. However, more research is needed to ensure their validity.

The Sub-Saharan Media Landscape - Then, Now and in the Future
Balancing Act: August 2014

Focus groups, one-to-one interviewees and surveys in Ghana, Senegal and
Tanzania, Nigeria. Ethiopia and South Africa provided the evidence cited in this research report. They were asked what had changed most about media and communications in the last five years. Two responses were common to all those who took part: the greater amount of media available and the presence of the Internet. These key changes have created haves and the have-nots. On almost every media measure, those living in rural Africa are at a disadvantage to their urban counterparts. The research found that over five years Facebook has grown from practically no users in Sub-Saharan Africa to become the most widely used social media platform, and the number of Africans who own or have access to mobile phones, computers, laptops, smartphones and tablets has grown considerably. Based on trends the authors predict that smartphone use will grow to between 10-20% of the population depending on the country, as will phones with internet access. While the current pattern of mobile phone use in the countries in focus has largely been voice and SMS, the numbers accessing the internet and social media is projected to grow over the next five years to between 10-25% of the population depending on the country.

13. Monitoring equity and research policy

A World That Counts
UN Data Revolution Group, 24 October 2014

This is the draft report of the UN Secretary General’s Expert Advisory group on the data revolution for sustainable development. This report is not about how to create a data revolution – it is argued to be already happening – but how to mobilise it for sustainable development. In the first section the authors describe what the data revolution is, and the opportunities and pitfalls it presents. The second section highlights the current state of data, and the kind of world the authors foresee if the promise of the revolution is realised. Finally, the third section provides a “vision” of a possible world of data in 2030, and some recommendations for how to achieve it. The authors believe that governments, and governments acting together through the UN, have a crucial role to play. This report offers options for using the data revolution not only to monitor progress towards sustainable development goals, but also to accelerate their achievement.

Equity-Oriented Monitoring in the Context of Universal Health Coverage
Hosseinpoor AR, Bergen N, Koller T, Prasad A, Schlotheuber A, et al.: PLoS Med 11(9), 22 September 2014

Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, the authors recommend forming subgroups as quintiles, and for urban/rural inequality the authors recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. The authors recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC.

Monitoring and Evaluating Progress towards Universal Health Coverage in South Africa
Ataguba JE, Day C, McIntyre D: PLoS Med 11(9), 22 September 2014

The South African health system is tiered with the minority of the population using private health services and the majority relying mainly on tax-funded health services. South Africa (SA) bears a quadruple burden of disease com-prising tuberculosis, HIV and AIDS, high levels of maternal and child mortality, injuries, and non-communicable dis-eases. The burden of these diseases falls most heavily on the poor. In 2007 the SA government committed itself to implementing National Health Insurance (NHI) in order to move the country toward universal health coverage (UHC). This paper, as part of a series of case studies commissioned by the World Health Organization (WHO) to develop ap-propriate measures of UHC, provides a case study of SA’s current situation in relation to UHC using the WHO-proposed indicator framework. Drawing on different national data sources, the paper shows that disparities exist in the proposed indicators in the SA context. The paper notes that the framework may be more appropriate for monitoring progress towards UHC over time, rather than as a tool for evaluating a country’s status relative to UHC goals at a single point in time. This paper also points to the need to have UHC-related ‘benchmarks’ against which to compare country data. Further, the proposed indicators by themselves do not provide clear insights into health system reforms required to promote UHC; there is need for a more detailed system-level analysis.

Monitoring Progress towards Universal Health Coverage at Country and Global Levels
Boerma T, Eozenou P, Evans D, Evans T, Kieny MP, Wagstaff A: PLoS Med 11(9), 22 September 2014

This paper summarizes the findings from 13 country case studies and five technical reviews, which were conducted as part of the development of a global framework for monitoring progress towards Universal health coverage (UHC). The case studies show the relevance and feasibility of focusing UHC monitoring on two discrete components of health system performance: levels of coverage with health services and financial protection, with a focus on equity. These components link directly to the definition of UHC and measure the direct results of strategies and policies for UHC. The studies also show how UHC monitoring can be fully embedded in often existing, regular overall monitoring of health sector progress and performance. Several methodological and practical issues related to the monitoring of coverage of essential health services, financial protection, and equity, are highlighted. Addressing the gaps in the availability and quality of data required for monitoring progress towards UHC is critical in most countries.

Why passion has a place at a health systems symposium: reflections on Cape Town 2014
Balabanova D, Lazarus J: Health System Global, October 2014

Passion. It is not a word that is used often in the health systems discourse, and it may be the last word that people outside of health systems circles would associate with our work. But, the authors argue in this blog, passion is what emerged throughout the recent Third Global Symposium on Health Systems Research in Cape Town, South Africa. Across two jam-packed days of satellite events and another three days of conference sessions, the 1,700 participants from 92 countries collectively made the symposium into a unique teaching, learning and networking opportunity. Whether people approach health systems from the realms of academia, policy-making, civil society or elsewhere, they are excited about the potential for the levers of various forms of health systems to be triggered in ways that will make the world a healthier and more equitable place. Being able to share that excitement with other people is an invaluable and invigorating experience. In early 2015, the leadership of Health Systems Global is likely to develop concrete strategies and initiatives to foster a more diverse membership base and encourage representation of more regions and countries in the global health systems discourse.

14. Useful Resources

Global Health Watch 4: An Alternative World Health Report
Coming November 13 2014

The Global Health Watch is widely perceived as the definitive voice for an alternative discourse on health. It 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. GHW4 is a collaborative effort by activists and academics from across the world, and has been coordinated the People’s Health Movement, Asociacion Latinoamericana de Medicina Social, Health Action International, Third World Network and Medact. This edition of the GHW will be available in November 2014 and PHM invite people to consider launching the GHW4 from December 2014. For this purpose ‘launch kits’ will be available by early November 2014.

The Right to Dream
Eduardo Galeano: March 2011

In 1948 and again in 1976, the United Nations proclaimed long lists of human rights, but the immense majority of humanity enjoys only the rights to see, hear and remain silent. Eduardo Galeano in this poem posits that suppose we start by exercising the never-proclaimed right to dream? Suppose we rave a bit? He asks us to set our sights beyond the abominations of today to divine another possible world.

15. Jobs and Announcements

2015 African Doctoral Dissertation Research Fellowships

The African Population and Health Research Center (APHRC), in partnership with the International development Research Centre (IDRC), is pleased to announce the eighth call for applications for the African Doctoral Dissertation Research Fellowships (ADDRF). The ADDRF Fellowship Program seeks to facilitate more rigorous engagement of doctoral students in research, strengthen their research skills, and provide them an opportunity for timely completion of their doctoral training. The Program targets doctoral students with strong commitment to a career in training and/or research. The overall goal of the ADDRF Program is to support the training and retention of highly-skilled, locally-trained scholars in research and academic positions across the region. The ADDRF will award about 20 fellowships in 2015. These fellowships will be awarded to doctoral students who are within two years of completing their thesis at an African university and whose dissertation topics focus on health systems. The fellowship will primarily support research (including data collection and/or analysis). Funds will not be used to support coursework. Applicants must be citizens or permanent residents of a sub-Saharan African country. For further details and application procedures see the website.

Amref Health Africa International Conference
November 24th - 26th 2014, Nairobi, Kenya

From November 24th - 26th 2014, Amref Health Africa in partnership with the World Health Organization will be holding its first international conference themed ‘From Evidence to Action: Lasting Health Change for Africa’ in Nairobi, Kenya . The three day conference will focus on exchange of scientific results and debates on strategic ideas and application of knowledge to inform health care financing, human resources for health, community systems strengthening and the post 2015 health agenda. It brings together leaders, players and partners in African health development and advocacy. It provides a forum for discussions on how Africa can influence the global health agenda to improve health and health rights on the continent.

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.

Forum 2015: People at the center of research and innovation for health
25-27 August 2015, Manila, Philippines

The Global Forum for Research and Innovation for Health is the successor of the Global Forum for Health Research that merged with the Council on Health Research for Development (COHRED) in 2011. Forum 2015, as it will be abbreviated, will provide an opportunity for everyone interested in pursuing global health, equity and development to meet, exchange information, find partners, design solutions and set research and innovation agendas - nationally, regionally and globally.

IDRC Fellowship at the Center for Global Development
Application deadline: 30 November 2014

The Center for Global Development (CGD), an independent Washington-based think tank, invites applications from scholars from developing countries for a one-year visiting fellows program sponsored by Canada’s International Development Research Centre (IDRC).

International Civil society Week: Citizen action, People power
Civicus: 19-25 November, Johannesburg, South Africa

To celebrate South Africa's 20th anniversary of freedom and democracy, CIVICUS and its partners will gather change makers from around the world at the University of Witwatersrand in Johannesburg for International Civil Society Week from 19-25 November 2014. International Civil Society Week 2014 will involve a diverse, multi-stakeholder partnership that seeks to tackle the world’s most pressing challenges. Under the banner of Citizen Action, People Power, the week long series of events will gather global thinkers, innovation leaders and influential organisations.

Journal Of Health Diplomacy: Call For Papers on Africa, Health And Diplomacy
Call Closes: 30 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 irwin@sipri.org by 30 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.

Medical Humanities: Call for applications for 3 year doctoral fellowships
Closing date for applications: 15 December 2014

Further details: /newsletter/id/39143
One week course on Tax Justice
MS Training Centre for Development Cooperation: 24-28 November 2014, Arusha, Tanzania

MS-TCDC is conducting a one-week course on Tax Justice Campaign from 24-28 November 2014 in Arusha, Tanzania. The overall objective of the course is to enable participants to appreciate the importance of taxation and revenue collection in relation to social change. They will also understand taxation form a development view point, and acquire skill to mobilise and support efforts to demand utilisation of funds from tax for poverty elimination. The course is aimed at practitioners working in CSOs, government and other development agencies engaged in governance and accountability work.


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