EQUINET NEWSLETTER 166 : 01 December 2014

1. Editorial

Changing the talk and the walk: Challenges for a different practice in health systems research
Amit Sengupta, Associate Global Co-ordinator, Peoples Health Movement

The Health Systems Research Symposium in Cape Town was an experience to savour. It was particularly refreshing in shifting away from the rather restricted vision of the earlier symposia in Montreux and Beijing. Opening it to debates on ‘people centered health systems’ raised the opportunity to move from the confines of the restricting, dominant neoliberal concept of Universal Health Coverage (UHC) that has circumscribed the discourse in the earlier symposia, with its focus on a narrow and preconceived template of issues, largely informed by the language of health financing and insurance. In contrast, this year’s symposium promoted a public health language of care (not just coverage) and of solidarity, equity, gender justice and rights.

Several speakers, especially in the plenaries, articulated the profound impact different dimensions of power and power relations are having on health systems. In the Peoples Health Movement, we see this as an important and extremely positive sign of our collective intent to confront and challenge these power relations. Several presentations talked about the role of social movements in building, safeguarding, nurturing and expanding health systems that are truly people centered.

There is, however, a gap between our rhetoric and our praxis. We need to integrate concerns about power and an articulation of the role of popular mobilization and of social movements in challenging power relations that undermine health into the priorities and practice of the research community. Here we have a gap, with too little practical translation of these concerns into research priorities and practice. Existing power structures play a hegemonic role in influencing research –using their financial clout and exercising dominance in the domain of ideas. Unless we are able to change this, our work will continue to be informed by a hegemonic discourse that legitimates injustice and inequity. This is a challenge for young researchers, to be bold and innovative in questioning the dominant paradigm of the current research system.

We need to build on the deliberations of the symposium to change our current practice, in all stages of the research cycle. Health research should name and interrogate the practices of those who perpetuate inequity at a grand scale by their cynical use of power. There is robust evidence on this that is waiting to be mined. It was heartening to see evidence in the symposium that there is now a growing interest in participatory research that places people at the center of research systems and not just as passive ‘beneficiaries’ of the outcomes of research. A research community that views research as a tool for change must give attention to the role of civil society and of social movements in catalyzing and driving sustainable change. Civil society is often seen as an afterthought in the research cycle. It is brought in late to legitimize often deceptive or limited evidence that maintains the status quo. Civil society in general and social movements in particular should, in contrast, have a meaningful and decisive counter-hegemonic role to drive an alternative research practice that can propel change, including research that is conceived of and driven by civil society. We need, for example, to develop work that examines the role social movements play in shaping, nurturing and advancing health systems that are solidarity based and sustained by the public.

In the symposium, there was talk of bringing to the foreground the ‘shadow reports’ that are produced by civil society at key forums. Surely we should walk the extra mile and view such shadow reports as the real reports? They present the popular concerns and aspirations and mainstream the voices of the unheard majority. Civil society thus has a task to produce evidence in such reports that is people driven, robust and that challenges the conventional wisdom replicated in the often glossier versions produced by multilateral organisations and well-heeled private foundations. The Peoples Health Movements’ Global Health Watch is one effort at taking up this challenge.

The long shadow of the current Ebola epidemic reminded all of us at the symposium about all that we have failed to do. It has directed our attention to the collective failure of public health and health research to harness evidence and action to promote public services - publicly owned, nurtured and conceived by the people. Health systems that are in the public domain are failing in many regions of the world, in spite of evidence that they are the main life-line for poor, marginalized and voiceless people. They are failing because of deliberate acts of commission that are bringing down, brick by brick, the edifice of public systems. They are failing because evidence that favours nurturing solidarity based public systems has been disregarded. Instead evidence has been used in a selective fashion to promote the notion that market based systems in healthcare delivery are superior. The Ebola epidemic was preventable, in part if overwhelming evidence on building public health systems had not been brushed aside. As a health research community we need to accept part responsibility for the current failure, in our not being vocal enough in the pursuit and use of good evidence.

As we look towards the next symposium due to take place in 2016, can we at least make partial amends for what we have failed to do? Can we collectively raise our evidence and voice to call for public health systems, built around solidarity and justice, rather than the current dominant model of spliced and diced healthcare delivery, designed for trade in the market?

These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the issues raised see the PHM website at http://www.phmovement.org/

Reflections on the 3rd Global Symposium on Health Systems Research
Sharmila Mhatre, IDRC Canada

The final session of what was without a doubt one of the best symposiums in health lent itself to reflection on four days of sessions that sparked debate and hopefully action on people centred health systems. As a funder of health systems research in low and middle income countries for over a decade, International Development Research Centre has supported the Health Systems Research Symposium from its birth, with an aspiration that be one of the processes that contribute to access to health and health care for all.

So what were the key messages that I heard and have taken home.
Professor Thandika Mkandawire began by articulating that we need health systems to be democratic, social, inclusive and to contribute to development. At the same time Prof Irene Agyepong reminded us of a Nigerian proverb that a “goat that belongs to the whole village belongs to nobody - this is how health systems can be described, but we must not let it go that way.”
So as a funder I ask myself whether I will stick to, as one panelist said “the politics of the achievable”? My answer is no, as it would not do justice to the energy, excellence and commitment that I witnessed from participants over the course of the last three days and more importantly it would not do justice to the people who have no access to health or do not have a voice.

I’ve organised what I have heard into: the “not to dos”, the “must dos”, and the “how to do”.

As a ‘not to do’ Rene Loewenson reminded us that by simply putting people in the middle does not make it a people centred health system.

So what must we do? In terms of how we do people centred health system research, the knowledge that matters is the knowledge that facilitates change, as we were reminded by Kumanan Rasanathan. As Nancy Edwards suggested we must move from gold standards to platinum standards of methods. In practice this means, quoting several people from the conference:
• Firstly, that people’s knowledge and role in the production, analysis and interpretation is a critical driver of people centred health systems. It means that people are in control and researchers are the facilitators of the process.
• Secondly, making data work for people rather than have people work for data. In one session someone spoke about “chasing data to fit with multiple donors’ agendas”. We need to incorporate multiple types of evidence and to bring in other practices and methods.
• Thirdly, while strengthening capacities are key, we cannot assume that none exist. We should recognise that capacity strengthening goes beyond training to actually shifting power, as noted by Aku Kwamie.

As a further ‘not to do’ Gita Sen reminded us that we cannot confuse the PC of People Centred with the PC of Political Correctness. We must break divides of race, gender, class, caste, culture or language and come together. This was illustrated eloquently despite the English language barrier by Lina Roso Polomo, a researcher from Mexico, as she explained how international guidelines do not always recognise the cultural diversity of our countries.

So if accountability is brought in by people, then as Kausar Khan eloquently relayed, the ‘must do’s’ include duties for us to reduce ethnic and racial divides as we facilitate, mobilise, fund, engage and catalyse people-centred health systems. It cannot be ‘us’ and ‘them’ as Martin McKee reminded us. At the conference I saw reflected in the program the silos being reduced as ‘systems’ sessions starting to integrate with ‘disease’ sessions, and discussions moved to bridge social movements with think tanks. Inclusion and integration are key. After all, as Lucy Gilson said on the first day of the symposium, the challenge that we must squarely address is governance.

Throughout the conference there was concern about the double-edged sword of Ebola, that has served this community with deep and significant challenges. The West African Health Organisation is demonstrating commitment to work with all of us to address Ebola and the system failures that it has starkly uncovered. WHO, UNICEF and European funders are advancing initiatives that address both basic science and health systems but as a global community we must do more and USAID and the World Bank called a number of meetings throughout the symposium to discuss this.

Moving from the ‘not to dos’ and the ‘must dos’ to the ‘how to do’, the wisdom of the Emerging Leaders (young researchers) is the take home lesson for all of us here. They said that to change mindsets we need to see, talk about and deal with the gorilla in the room. To make an impact we need to take the time to stop and reflect, with others that are like minded and also with those who are not. Lastly they told us that in each of us we have the capacity to lead as we bridge divides to build collective ownership of health systems that - quoting Sheik, Ranson and Gilson from the Health Policy and Planning Supplement on the Science and Practice of People-Centred Health Systems - truly “serve people and society”.

These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the global symposium visit http://hsr2014.healthsystemsresearch.org/

2. Latest Equinet Updates

Participatory action research in people centred health systems International Workshop Report
EQUINET, TARSC, ALAMES: Cape Town, South Africa, 4 October 2014

Immediately following the 2014 Global Symposium on Health Systems Research, a one day workshop was held, convened by Training and Research Support Centre (TARSC) (www.tarsc.org) and the pra4equity network in the Regional Network for Equity in Health in east and southern Africa (EQUINET) with Asociación Latinoamericana de Medicina Social (ALAMES). The workshop was held to deepen the discussion on the use of participatory action research (PAR) in health policy and people centred health systems, including in acting on the social determinants of health. While there are many forms of participatory research, the workshop specifically focused on PAR, that is on research that transforms the role of those usually participating as the subjects of research, to involve them instead as active researchers and agents of change, where those affected by the problem are the primary source of information and the primary actors in generating, validating and using the knowledge for action, and that involves the development, implementation of, and reflection on actions as part of the research and knowledge generation process. PAR seeks to understand and improve the world by changing it, but does so in a manner that those affected by problems collectively act and produce change as a means to new knowledge. The one day workshop was open to delegates from all regions globally to foster cross regional exchange and to include people from the pra4equity network in east and southern Africa. This report presents the proceedings of the workshop.

3. Equity in Health

Inequality in South Africa
Keeton G: Sangnet Pulse, 3 November 2014

South Africa remains one of the most unequal societies in the world. In its third South Africa Economic Update in 2012, the World Bank pointed out that the potential for economic growth has been held back by industrial concentration, skills shortages, labour market rigidities and chronically low savings and investment rates. The bank further stated that the economic growth has also been highly uneven in distribution and this continues to perpetuate inequality and economic exclusion. Despite this, the country is making some strides in tackling the socioeconomic ills faced by its poor majority. In this paper the author week’s writes that economic growth usually leads to increasing levels of inequality in developing countries. He notes, however, that as economies develop, larger portions of their populations move from agriculture into other sectors of the economy and their skills base expand to a point where inequality falls. He warns that there are no quick and easy solutions to South Africa’s inequality problem, adding that without substantive improvements in the human capital of the poor, income inequality will remain unacceptably wide.

4. Values, Policies and Rights

Challenging the negative discourse on human rights in Africa
Kasambala T: SAIIA Policy Briefing No 104, September 2014

The recent proliferation of non-governmental organisations (NGOs) and independent media across Africa is argued by the author to be an important positive development. They are said to play an essential role by investigating government policy, exposing corruption and human rights violations, advocating for the rights of minorities and vulner-able communities, and providing social services. However the continent’s leaders reject what they see as an imposition of ‘Western’ ideas of human rights. This policy briefing highlights the shift in human rights discourse among African leaders towards more anti-imperialist rhetoric and the placing of African traditions above human rights. It provides examples of how local civil society organisations (CSOs) are challenging this view in the face of increasing government attacks. CSOs are argued to be crucial to positive transformation and the universal protection and promotion of human rights, and the author proposes that more needs to be done to protect human rights and create an enabling environment for CSOs.

Gendering peasant movements, gendering food sovereignty
Bell B: Pambazuka News, 207, 12 November 2014

A problem peasant women face is invisibility in the feminist and women’s movements. A second problem is the weakness with which the food sovereignty concept has dealt with the challenges of feminism. Latin America has assumed the struggle for food sovereignty as an alternative to the neoliberal economic model. Food sovereignty is based on the conviction that each people has the right to make decisions about its own food systems: about its own eating habits; about its production, marketing, distribution, exchange, and sharing; and about keeping food and seeds in the public sphere. This interview report presents the views from a feminist point of view on how people make decisions, who decides how power is organised and how to turn food sovereignty into a tool to strengthen and empower peasant women.

5. Health equity in economic and trade policies

Agricultural Export Restrictions and the WTO: What Options do Policy-Makers Have for Promoting Food Security?
Anania G: Bridges news, November 2014

Agricultural export restrictions have been seen by many as worsening food price volatility, and pushing up world prices, to the detriment of poor consumers in developing countries. At the same time, others have argued that these measures can help safeguard domestic food security, support government revenues and help countries add value to farm exports. This paper examines the likely trade, food security and development implications of various options for disciplining agricultural export restrictions. The paper seeks to provide policy-makers, negotiators and other policy actors with an impartial, evidence-based analysis of the likely trade, food security and development implications of various options for disciplining agricultural export restrictions.

Transitioning from the Informal to the Formal Economy - In the Interests of Workers in the Informal Economy
WIEGO Network Platform: November 2014

This report was developed from a platform was developed in a series of regional workshops held in Argentina, Peru, South Africa, and Thailand. Hosted by WIEGO and local partners, the workshops used a participatory approach to gather feedback and insight from representatives of domestic workers, home-based workers, street vendors, waste pickers, and others.
The platform sets out common core needs and demands for informal workers around economic, social and labour rights, voice and bargaining power, legal identity and standing, and social protection. For all informal workers, it is argued that formalization must offer benefits and protections – not simply impose the costs of becoming formal. It must restore the universal rights from which workers in the informal economy have been marginalized by the neo-liberal model of governance over the past 40 years.

6. Poverty and health

Acceptability of conditions in a community-led cash transfer programme for orphaned and vulnerable children in Zimbabwe
Skovdal M, Robertson L, Mushati P, Dumba L, Sherr L, Nyamukapa C, Gregson S: Health Policy and Planning 29(7): 809-817, September 2013

Evidence suggests that a regular and reliable transfer of cash to households with orphaned and vulnerable children has a strong and positive effect on child outcomes. However, conditional cash transfers are considered by some as particularly intrusive and the question on whether or not to apply conditions to cash transfers is an issue of controversy. This article sets out to investigate the overall buy-in of conditions by different stakeholders and to identify pathways that contribute to an acceptability of conditions. The article draws on data from a cluster-randomized trial of a community-led cash transfer programme in Manicaland, eastern Zimbabwe. The study found a significant and widespread acceptance of conditions primarily because they were seen as fair and a proxy for good parenting or guardianship. In a socio-economic context where child grants are not considered a citizen entitlement, community members and cash transfer recipients valued the conditions associated with these grants. The community members interpreted the fulfilment of the conditions as a proxy for achievement and merit, enabling them to participate rather than sit back as passive recipients of aid.

Hunger Map 2014
World Food Programme: November 2014

From Africa and Asia to Latin America and the Near East, there are 805 million people in the world who do not get enough food to lead a normal, active life. The World Food Programmae downloadable Hunger Map provides information that maps the distribution of food insecurity globally.

NGOs Call for Ban of Liquor Sachets in Malawi
Sangonet Pulse, 4 November 2014

Several non-governmental organisations (NGOs) in Malawi and consumer watchdogs have demanded a total ban on the sale of liquor spirit sachets, which they blame for fueling alcohol abuse among the youth. Consumers Association of Malawi executive director, John Kapito, states that, “Malawians are poor, so the most attractive recreational drug they can afford is liquor in sachets. Sadly, these sell at less the cost of a lottery ticket.” Liquor sold in small sachets was first outlawed in the Southern African country in May of 2013, but the move was appealed by manufacturers and since then, liquor sachet sales have risen, resulting in more youth becoming dependent on alcohol – and some dying after taking too many on an empty stomach

The Global One Health Paradigm: Challenges and Opportunities for Tackling Infectious Diseases at the Human, Animal, and Environment Interface in Low-Resource Settings
Gebreyes WA, Dupouy-Camet J, Newport MJ, Oliveira CJB, Schlesinger LS, et al: PLoS Negl Trop Dis 8(11), 13 November 2014

Zoonotic infectious diseases have been an important concern to humankind for more than 10,000 years. Today, approximately 75% of newly emerging infectious diseases (EIDs) are zoonoses that result from various anthropogenic, genetic, ecologic, socioeconomic, and climatic factors. These interrelated driving forces make it difficult to predict and to prevent zoonotic EIDs. Although significant improvements in environmental and medical surveillance, clinical diagnostic methods, and medical practices have been achieved in the recent years, zoonotic EIDs remain a major global concern, and such threats are expanding, especially in less developed regions. The current Ebola epidemic in West Africa is an extreme stark reminder of the role animal reservoirs play in public health and reinforces the urgent need for globally operationalizing a One Health approach. The complex nature of zoonotic diseases and the limited resources in developing countries areargued by the authors to be a reminder of the need for implementation of Global One Health in low- resource settings is crucial. This review highlights advances in key zoonotic disease areas and the One Health capacity needs.

7. Equitable health services

Cervical Cancer Screening among University Students in South Africa: A Theory Based Study
Hoque ME, Ghuman S, Coopoosmay R, Van Hal G: PLoS ONE 9(11), 11 November 2014

Cervical cancer is a serious public health problem in South Africa. Even though the screening is free in health facilities in South Africa, the Pap smear uptake is very low. The objective of the study is to investigate the knowledge and beliefs of female university students in South Africa. A cross sectional study was conducted among university women in South Africa to elicit information about knowledge and beliefs, and screening history. A total of 440 students completed the questionnaire. Regarding cervical cancer, 55.2% had ever heard about it. Results indicated that only 15% of the students who had ever had sex and had heard about cervical cancer had taken a Pap test. Pearson correlation analysis showed that cervical cancer knowledge had a significantly negative relationship with barriers to cervical cancer screening. Susceptibility and seriousness score were significantly moderately correlated with benefit and motivation score as well as barrier score. Self-efficacy score also had a moderate correlation with benefit and motivation score. Students who had had a Pap test showed a significantly lower score in barriers to being screened compared to students who had not had a Pap test. This study showed that educated women in South Africa lack complete information on cervical cancer. Students who had had a Pap test had significantly lower barriers to cervical cancer screening than those students who had not had a Pap test.

Disrespectful and abusive treatment during facility delivery in Tanzania: a facility and community survey
Kruk M, Kujawski S, Mbaruku G, Ramsey K, Moyo W, Freedman L: Health Policy and Planning, 1 October 2014

Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. The authors measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania, using a structured questionnaire. A total of 1779 women participated in the exit survey and 593 were re-interviewed at home. Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is argued by the author to be a health system crisis that requires urgent solutions both to ensure women’s right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.

How people-centred health systems can reach the grassroots: experiences implementing community-level quality improvement in rural Tanzania and Uganda
Tancred T, Mandu R, Hanson C, Okuga M, Manzi F, Peterson S, Schellenberg J, Waiswa P, Marchant T, The EQUIP Study Team: Health Policy and Planning, 1 October 2014

Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here the authors share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff. The study aims to describe experiences implementing EQUIP’s QI approach at the community level. A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. The authors outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce. Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.

Primary care priorities in addressing health equity: summary of the WONCA 2013 health equity workshop
Shadmi E, Wong W, Kinder K, Heath I, Kidd M: Int Jo for Equity in Health 13;104, November 2014

Research consistently shows that gaps in health and health care persist, and are even widening. While the strength of a country’s primary health care system and its primary care attributes significantly improves populations’ health and reduces inequity (differences in health and health care that are unfair and unjust), many areas, such as inequity reduction through the provision of health promotion and preventive services, are not explicitly addressed by general practice. Substantiating the role of primary care in reducing inequity as well as establishing educational training pro-grams geared towards health inequity reduction and improvement of the health and health care of underserved populations are needed. This paper summarizes the work performed at the World World Organization of National Colleges and Academies of Family Medicine 2013 Meetings’ Health Equity Workshop which aimed to explore how a better understanding of health inequities could enable primary care providers /general practitioners (GPs) to adopt strategies that could improve health outcomes through the delivery of primary health care. It explored the development of a health equity curriculum and opened a discussion on the future and potential impact of health equity training among GPs.

The Impact of Text Message Reminders on Adherence to Antimalarial Treatment in Northern Ghana: A Randomized Trial
Raifman JRG, Lanthorn HE, Rokicki S, Fink G: PLoS ONE 9;10, October 2014

Low rates of adherence to artemisinin-based combination therapy (ACT) regimens increase the risk of treatment failure and may lead to drug resistance, threatening the sustainability of current anti-malarial efforts. The authors assessed the impact of text message reminders on adherence to ACT regimens. Health workers at hospitals, clinics, pharmacies, and other stationary ACT distributors in Tamale, Ghana provided flyers advertising free mobile health information to individuals receiving malaria treatment. The messaging system automatically randomized self-enrolled individuals to the control group or the treatment group with equal probability; those in the treatment group were further randomly assigned to receive a simple text message reminder or the simple reminder plus an additional statement about adherence in 12-hour intervals. The main outcome was self-reported adherence based on follow-up interviews occurring three days after treatment initiation. The authors estimated the impact of the messages on treatment completion using logistic regression. The results of this study suggest that a simple text message reminder can increase adherence to antimalarial treatment and that additional information included in messages does not have a significant impact on completion of ACT treatment. Further research is needed to develop the most effective text message content and frequency.

8. Human Resources

Health labour market policies in support of universal health coverage: a comprehensive analysis in four African countries
Sousa A, Scheffler R, Koyi G, Ngah Ngah S, Abu-Agla A, M’kiambati H, Nyoni J: Human Resources for Health 12(55), 26 September 2014

Progress toward universal health coverage in many low- and middle-income countries is hindered by the lack of an adequate health workforce that can deliver quality services accessible to the entire population. The authors used a health labour market framework to investigate the key indicators of the dynamics of the health labour market in Cameroon, Kenya, Sudan, and Zambia, and identified the main policies implemented in these countries in the past ten years to address shortages and maldistribution of health workers. Despite increased availability of health workers in the four countries, major shortages and maldistribution persist. Several factors aggravate these problems, including migration, an aging workforce, and imbalances in skill mix composition. In this paper, the authors provide new evidence to inform decision-making for health workforce planning and analysis in low- and middle-income countries. Partial health workforce policies are not sufficient to address these issues. It is argued top be crucial to perform a comprehensive analysis in order to understand the dynamics of the health labour market and develop effective polices to address health workforce shortages and maldistribution as part of efforts to attain universal health coverage.

9. Public-Private Mix

A comparative study of an NGO-sponsored CHW programme versus a ministry of health sponsored CHW programme in rural Kenya: a process evaluation
Aridi J, Chapman S, Wagah M, Negin J: Human Resources for Health 12:64, November 2014

This paper presents the results of process evaluations conducted on two different models of Community Health Worker (CHW) programme delivery in adjacent rural communities in in Gem District of Western Kenya. One model was implemented by the Millennium Villages Project (MVP), and the other model was implemented in partnership with the Ministry of Health (MoH) as part of Kenya’s National CHW programme. Both the MVP and national CHW programmes faced challenges in implementation. Due to better flexibility, resources and scope for rapid innovation on the ground, the MVP model was able to introduce a number of innovations that aimed to strengthen CHW management, supervision and improve CHW responsiveness. Many of these innovations proved very effective in smoothing programme operations, but programme adherence still faced a number of challenges with respects to ensuring that CHW coverage was adequate, visitation frequency was sufficient and services were delivered with the same consistency over time by all CHWs.

Investing for the Few: The IFC’s Health in Africa initiative
Marriott A, Hamer J, Oxfam International, September 2014

The authors argue that the World Bank Group should focus on supporting African governments to expand publicly provided healthcare – a proven way to save millions of lives worldwide and to drive down inequality. The International Finance Corporation (IFC)’s Health in Africa initiative is argued to be at odds with the World Bank Group’s welcome commitment to universal and equitable health coverage and to shared prosperity. The $1bn initiative, which promotes private sector healthcare delivery, is reported to be extremely unlikely to deliver better health outcomes for poor people, and the IFC is noted to fail to measure the extent to which Health in Africa impacts on people living in poverty.

10. Resource allocation and health financing

Inequities in accessibility to and utilisation of maternal health services in Ghana after user-fee exemption: a descriptive study
Ganle JK, Parker M, Fitzpatrick R, Otupiri E: International Journal for Equity in Health13(89), 1 November 2014

Inequities in accessibility to, and utilisation of maternal healthcare services impede progress towards attainment of the maternal health-related Millennium Development Goals. This study examined the extent to which maternal health services are used in Ghana, and whether inequities in accessibility to and utilization of services have been eliminated following the implementation of a user-fee exemption policy, that aims to reduce financial barriers to access, reduce inequities in access, and improve access to and use of birthing services.. The authors analyzed data from the 2007 Ghana Maternal Health Survey for inequities in access to and utilization of maternal health services. In measuring the inequities, frequency tables and cross-tabulations were used to compare rates of service utilization by region, residence and selected socio-demographic variables. Findings show marginal increases in accessibility to and utilisation of skilled antenatal, delivery and postnatal care services following the policy implementation (2003-2007). However, large gradients of inequities exist between geographic regions, urban and rural areas, and different socio-demographic, religious and ethnic groupings. The findings raise questions about the potential equity and distributional benefits of Ghana’s user-fee exemption policy, and the role of non-financial barriers or considerations. Exempting user-fees for maternal health services is a promising policy option for improving access to maternal health care, but might be insufficient on its own to secure equitable access to maternal health services in Ghana. Ensuring equity in access will require moving beyond user-fee exemption to addressing wider issues of supply and demand factors and the social determinants of health, including redistributing healthcare resources and services, and redressing the positional vulnerability of women in their communities.

The prevalence and determinants of catastrophic health expenditures attributable to non-communicable diseases in low- and middle-income countries: a methodological commentary
Goryakin Y, Suhrcke M: International Journal for Equity in Health 13(107), November 2014

Non-communicable diseases (NCDs) have been spreading fast in low and middle income countries and may also impose a substantial economic cost. One way in which NCDs might impact people’s economic well-being may be via the out-of-pocket expenditures required to cover treatment and other costs associated with suffering from an NCD. In this commentary, the authors identify and discuss the methodological challenges related to cross-country comparison of-out-of-pocket and catastrophic out-of-pocket health care expenditures, attributable to NCDs, focussing on low and middle income countries. There is evidence of substantial cost burden placed by NCDs on patients living in low and middle income countries, with most of it being heavily concentrated among low socioeconomic status groups. However, a large variation in definition of COOPE between studies prevents cross-country comparison. In addition, as most studies tend to be observational, causal inferences are often not possible. This is further complicated by the cross-sectional nature of studies, small sample sizes, and/or limited duration of follow-up of patients.

11. Equity and HIV/AIDS

Intimate Partner Violence after Disclosure of HIV Test Results among Pregnant Women in Harare, Zimbabwe
Shamu S, Zarowsky C, Shefer T, Temmerman M, Abrahams N: PLoS ONE 9(10), October 2014

HIV status disclosure is a central strategy in HIV prevention and treatment but in high prevalence settings women test disproportionately and most often during pregnancy. This study reports intimate partner violence (IPV) following disclosure of HIV test results by pregnant women. The study demonstrated the interconnectedness of IPV, HIV status and its disclosure with IPV which was a common experience post disclosure of both an HIV positive and HIV negative result. The authors argue that health services must give attention to the gendered nature and consequences of HIV disclosure such as enskilling women on how to determine and respond to the risks associated with disclosure. Efforts to involve men in antenatal care must also be strengthened.

12. Governance and participation in health

Workshop report: Politicizing African urban ecologies: Enabling radical geographical research practices for African scholars
Duminy J: University of Pretoria, South Africa, November 2014

The term “urban political describes a critical approach to studying cities across a number of areas, from environmental issues (such as climate change, air pollution, and nature conservation) to urban flows (such as sanitation and electricity provision). Many scholars believe that there is a need for a more explicitly political approach to these topics that draws attention to who wins and who loses as cities change, as well as to how urbanization as a process is shaped by power relations. These ideas informed the Urban Political Ecology in African Cities Workshop, Pretoria South Africa held in September 2014, organized by the Situated Ecologies collective (SUPE). The report presents discussions on options for scholars and residents in cities of Africa and the global South to integrate power relations in their work on urban change.

Zinduka is a call to East Africans to wake up
Odhiambo T: Pambazuka News, 702, 11 November 2014

The word ‘Zinduka’ means re-awaken or stir up in Kiswahili – more or less like ‘pambazuka’. In Kirundi it simply means wake up. It is a call to prepare to work; to do something for the day. The Zinduka Festival that was held in Arusha, Tanzania, between 6 and 8 November was a call on ordinary East Africans to wake up, to be alert about the slow pace by politicians in integrating the region. Zinduka – sponsored by the akibaUhaki and other regional partners and hosted at the Sheikh Amri Abeid Stadium – was meant to celebrate the common people’s efforts and intensify those efforts to bring the different communities together. The theme was: People’s Voices, Sustainable Development, through Arts, Culture and Conversations. The author argues that Kiswahili can be a key driver of regional integration but that it will need massive efforts to systemize or standardize this lingua franca; integrate it in businesses, schools, offices and in their spiritual and personal life.

13. Monitoring equity and research policy

Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success
Rodney AM, Hill PS: International Journal for Equity in Health (13) 72, 10 October 2014

Equity should be implicit within universal health coverage (UHC) however, emerging evidence is showing that without adequate focus on measurement of equity, vulnerable populations may continue to receive inadequate or inferior health care. This narrative review aims to: (i) elucidate how equity is contextualised and measured within UHC, and (ii) describe tools, resources and lessons which will assist decision makers to plan and implement UHC programmes which ensure equity for all. Eighteen journal articles consisting mostly of secondary analysis of country data and qualitative case studies in the form of commentaries/reviews, and 13 items of grey literature, consisting largely of reports from working groups and expert meetings focusing on defining, understanding and measuring inequity in UHC (including recent drafts of global/country monitoring frameworks) were included. The literature advocates for progressive universalism addressing monetary and non-monetary barriers to access and strengthening existing health systems. This however relies on countries being effectively able to identify and reach disadvantaged populations and estimate unmet need. Recently published resources contextualise equity as a measurable component of UHC and propose several useful indicators and frameworks. Country case-studies also provide useful lessons and recommendations for planning and implementing equitable UHC which will assist other countries to consider their own requirements for UHC monitoring and evaluation.

Exploring the Ethics of Health Systems Research
Health Systems Global Thematic Working Group on Health Systems Research Ethics, November 2014

Health systems research is increasingly being funded by international donors and conducted in low and middle-income countries but little conceptual work has been done to clarify the field’s ethical dimensions. This is problematic because health systems research has distinctive features relative to clinical research that may restrict the applicability of existing ethical guidance. This webinar asks: What makes health systems research different from clinical research? What are the key ethical issues in externally-funded health systems research in low and middle-income countries? And do they deserve special consideration in, for example, project design and ethics review? The moderated discussion covers the features of health systems research and examples of what it entails in practice, distinctive ethical issues that arise during the conduct of such research and challenges faced by ethics review committees when considering health systems research projects.

Health Inequalities and Social Determinants of Aboriginal Peoples’ Health
Reading CL, Wien F: National Collaborating Centre for Aboriginal Health, 2009

This paper uses available data to describe health inequalities experienced by diverse Aboriginal peoples in Canada. Its method is useful for those working on indigenous people's health in other regions. The data are organized around social determinants of health across the life course and provide evidence that not only demonstrates important health disparities within Aboriginal groups and compared to non-Aboriginal people, but also links social determinants, at proximal, intermediate and distal levels, to health inequalities. The Integrated Life Course and Social Determinants Model of Aboriginal Health is introduced as a promising conceptual framework for understanding the relationships between social determinants and various health dimensions, as well as examining potential trajectories of health across the life course. Data from diverse and often limited literature is provided to support claims made by the authors of this paper and others about health disparities among Aboriginal peoples and the degree to which inequalities in the social determinants of health act as barriers to addressing health disparities.

Video: Learning more about ethics in health systems research, Kenya
Kemri Wellcome Trust, Kenya, November 2014

In this video researchers from Kemri Wellcome Trust in Kenya outline some of the ethical dilemmas that they encounter in their day to day lives. RinGs is a project and learning platform that aims to support researchers on understanding and integrating gender and ethics into their work.

14. Useful Resources

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, benefits 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.

Think Tank Initiative’s Policy Engagement and Communications Program — Anglophone Africa: A toolkit for researchers and communications officers
Results for Development Institute, CommsConsult, Anglophone Africa PEC program team: September 2014

In July 2013, 13 think tanks in Ethiopia, Ghana, Kenya, Nigeria, Tanzania, and Uganda embarked on a mission to strengthen their Policy Engagement and Communications (PEC) capacity. Over the course of 15 months, the think tanks worked with a mentor to diagnose their capacity needs and develop a PEC workplan to strengthen their knowledge and capacity. Work included designing and refining communciation strategies, engaging peers and external stakeholders, and leveraging tools to sharpen their strategic messaging and outreach. The work resulted in the creation of new tools, skillsets, and shared lessons and strategies. This toolkit is a collection of the knowledge generated over the course of the work. It is intended to help the 13 think tanks - and many others - continue excelling and improving in their PEC abilities. It contains guiding principles, tips and suggested approaches to help better plan, package, disseminate and evaluate PEC strategies.

Training resources on sexual and reproductive health
Rights-Oriented Research & Education Network in and Reproductive Health, November 2014

The Rights-Oriented Research & Education Network in Sexual & Reproductive Health (SRH) aims to generate transformative and robust evidence for policies and programmes on SRH. RORE is involved in determining new indicators and domains of data to identify rights-realization/gender equality related influences on SRH issues (e.g. on reasons for not using services) and exploratory cross-regional research to evolve concepts from the perspective of those affected. Education and training activities of the Network aim to build capacity in research from a gender and human rights perspective on sexual and reproductive health. RORE provides educational materials, training and mentoring focused on gender and human rights based SRH research and online courses with lectures focused on promoting research with a gender and rights perspective for SRH.

15. Jobs and Announcements

Call for Applications: Teen and Young Adult Reading Groups
Closing date: 12 December 2014

FunDza aims to get youth reading and writing for pleasure. The organisation creates, collects and shares stories that ignite the imagination of youth from under-resourced communities. FunDza is calling for applications from reading groups to apply to join its 'Popularising reading' programme. The programme is designed to support reading groups for teens and young adults, especially in South Africa. Small organisations and reading groups are also welcome to apply.

Call for conference session papers: Private sector and Universal Health Coverage: Examining evidence and de-constructing rhetoric
Closing date: 15th January 2015

The international Conference on Public Policy is being held 1st to 4th July 2015 in Milan Italy and will include a session on "Private sector and Universal Health Coverage: Examining evidence and de-constructing rhetoric". The conference aims to support exchanges between researchers on public policy from all over the world and registration opens 1st January 2015. The specific session aim seeks to discuss evidence on the scope and effectiveness of the commercial sector (and the paradigm of public private partnerships) in achieving Universal Health Coverage in low and middle income countries. The organisers invite abstracts for papers reporting findings of empirical research to critically examine role of private sector, scope of public-private interactions, and their implications for the UHC agenda. Abstracts should outline original research/ reviews and methodologies suitable for examining private sector engagement in health care systems. Commentaries/ Opinion pieces will NOT be accepted. Abstracts should include title, authors and affiliations (please * presenting author), abstract text (500 words); keywords (up to 5); a statement listing any research funders or other sources of financial support which have contributed to the work presented and declaration of potential conflict of interest. For further details please contact Oxfam UK.

Citizens call to action on a petition on Ebola
Mahta Ba A: August 2014

A petition has been launched by Africans calling for concerted in the struggle to contain the Ebola epidemic in West Africa. It suggests three affirmative actions and rejects isolationist measures. Sign on to the petition is invited.

Even It Up Campaign
Oxfam International

Oxfam has launched a global campaign to end extreme inequality, with campaigns in 37 countries uniting behind the call for a more equal world. Extreme inequality is argued to be threatening to undo much of the progress made over the past 20 years in tackling poverty. It is not inevitable. It is the consequence of economic and political choices. The campaign invites people to play a critical role and provides a pack of content, including ‘sharegraphics’ to share on social media platforms. From targeting big corporations whose tax dodging activities help deny developing countries billions in revenue, to demanding policies that can close the gender gap, the campaign invites people to play a key role in amplifying the call to even it up and raise extreme inequality to the top of government’s agendas.

Global Health Watch 4
Peoples Health Movement: Zed books, November 2014

With the world still battling the Ebola outbreak, the evidence of a clear link between the inability of affected countries to deal with the crisis and the collapse of public health systems is becoming stronger. Extreme poverty in the affected region, engendered by neo-liberal policies, further created the conditions for the rapid spread of the epidemic. This is the context that informs the contents of the 2014 Global Health Watch (GHW) report that was released in November. With contributions from more than 80 experts from across the globe, GHW4 addresses key issues in the health sector. Through its five sections, it covers diverse issues related to health systems and the range of social, economic, political and environmental determinants of health. GHW4 locates decisions and choices that impact on health in the structure of global power relations and economic governance and is complemented by the ' Watching' section that scrutinises global processes and institutions. The final section on 'Alternatives, Action and Change', documents inspiring stories of struggles and actions for change.

MRC/DFID African Research Leader scheme
Applications Close 27 November 2014, 16:00 GMT

The UK Medical Research Council and the UK Department for International Development announce a further call for proposals for the prestigious African Research Leader awards. The MRC/ DFID jointly funded scheme aims to strengthen research leadership across sub-Saharan Africa (SSA) by attracting and retaining exceptionally talented individuals who will lead high quality programmes of research on key global health issues pertinent to SSA. The African Research Leader (ARL) should be supported by an enthusiastic local research environment and by a strong linkage with a UK partner.


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