EQUINET NEWSLETTER 167 : 01 January 2015

1. Editorial

To a peaceful, just and healthy new year
EQUINET steering committee

The steering committee of the Regional Network for Equity in Health in East and Southern Africa wish all a healthy new year and renewed energy in our efforts to advance equity and social justice in health. The editorial this month shows how wide is the deficit, but also how vigorous the struggle!

We are not done yet. Lets close the gap!
Constance Georgina Khaendi Walyaro, Kenya

This year, as we look back upon 26 years of World Aids Days, we honour the millions of heroes and heroines who fought the good fight against AIDS but are no longer with us. We need to make sure that this day and the year that follows is about what we do to ensure that people continue living positive, productive lives, with great decency and dignity.

As a young person, I grew up hearing statistics like more than 4 young people are infected with HIV every minute and over 6 000 are newly infected every day. Over half of all new HIV infections were amongst young people in my age group. We had even been called the doomed generation, because many of us had never known a world without HIV and AIDS. AIDS had become our disease and it was feared that within a decade, we would be reduced to mere statistics.

Stigma and exclusion had hindered the efforts of many young people seeking the counselling, testing, treatment and support they required to ensure that those who were not infected remained uninfected, and the infected and affected were well cared for. Many carried the virus for years without knowing.

HIV changed our communities and civilizations, hacking away more than twenty years of hard gains in education, food security and socio- economic development; making our families poorer, and driving us into poverty.

While the scale of devastation caused by the epidemic was unmatched, we also knew that we could beat it - with quality treatment and effective prevention. So we began to fight back, to reclaim our spaces through advocacy, education and awareness. We changed and reclaimed our lives, forcing the epidemic into retreat in many places.

We were not always supported. To save lives we had to successfully confront the monopolies that endorsed skewed TRIPS+ trade agreements, greatly limiting the flexibilities that were won within TRIPs in the Doha Declaration to protect public health and increase access to essential medicines. We had to confront transnational corporations that had tried to challenge Indian law in an attempt to shut down 'the pharmacy of the developing world' - one of the largest producers of affordable generic medication. We had to claim our right to affordable and accessible quality medication.

But we are not done yet.

According to the UNAIDS GAP Report 2014, less than 50% of the 35 million people living with HIV globally know they are HIV positive. Adolescent girls and young women in Sub-Saharan Africa account for a quarter of the new infections. Gender based discrimination, poverty, and the denial of their economic, social and cultural rights continues to drive the epidemic. We are also facing high rates of antibiotic resistance and a reduction in the effectiveness of other medicines we have struggled to access. As a result people with drug resistant diseases like MDR TB need more expensive drugs. This has put a great burden on health services that are already underfunded.

World AIDS Day 2014 and every day after presents the opportunity for us to harness the power of social change to put people first and to close the gap. Ending the AIDS epidemic by 2030 is possible, but only if we leave no-one behind.

Closing the gap means enabling all people, everywhere, to access the services they need,
• By closing the HIV testing gap, so that the 19 million people who are unaware of their HIV-positive status can begin to get support.
• By closing the treatment gap, so that all 35 million people living with HIV have access to life-saving medicine.
• By closing the gap in access to medicines and care for all children living with HIV, and not just the 24% who have access today.
• By closing the gap in power so that young women, children, people of all ages, income and cultures can be included as part of the solution.

We are not done yet. Let’s close the Gap!

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.

2. Latest Equinet Updates

Meeting report: The Role of Health Committees in Equitable, People-centred Health Systems in the Southern and East African Region
Mdaka K, Haricharan H, London L: Learning Network for Health and Human Rights, CEHURD, UCT and EQUINET, November 2014

A two-day consultation on health committees as vehicles for community participation was held in Cape Town on September 27th and 28th 2014 prior to the 3rd Global Health Systems Research Conference. The meeting, funded by the International Development Research Council (IDRC Canada), had 38 participants from 12 countries of which nine were African countries. The meeting build on previous regional networking to share experiences of health committees as vehicles for community participation from countries across the globe. The discussion focused particularly on health committees in the African region, but benefited from considerations of experiences from other countries of the South (Guatemala and India). The discussions also reaffirmed the importance of health committees for Health System responsiveness and highlighted the importance of health committees as autonomous structures able to enhance democratic governance of health systems through monitoring and evaluation of health service performance and holding the state accountable. This applies irrespective of how services are delivered. To achieve this, it is critically important for health committees to be capacitated to fulfil this role through appropriate training, health systems design and sustainable support. Government should recognize the importance of health committees for their health systems, and invest appropriate human and financial resources to ensure functional health committees. Such investments are part of state obligations with respect to realising the Right to Health. Further, strategies must be developed to obtain buy-in of health workers, managers and policy-makers in supporting meaningful participation by health committees.

3. Equity in Health

Deaths Ascribed to Non-Communicable Diseases among Rural Kenyan Adults Are Proportionately Increasing: Evidence from a Health and Demographic Surveillance System, 2003–2010
Phillips-Howard PA, Laserson KF, Amek N, Beynon CM, Angell SY, Khagayi S, Byass P, Hamel MJ, van Eijk AM, Zielinski-Gutierrez E, Slutsker L, De Cock KM, Vulule J, Odhiambo FO: PLoS ONE 9(11), November 2014

Monitoring systems require strengthening to attribute the Non communicable disease (NCD) burden and deaths in low and middle-income countries (LMICs). Data from health and demographic surveillance systems (HDSS) can contribute towards this goal. Between 2003 and 2010, 15,228 deaths in adults aged 15 years (y) and older were identified retrospectively using the HDSS census and verbal autopsy in rural western Kenya. 37% were ascribed to NCDs, 60% to communicable diseases (CDs), 3% to injuries, and <1% maternal causes. Median age at death for NCDs was 66y and 71y for females and males, respectively, with 43% of NCD deaths occurring prematurely among adults aged below 65y. NCD deaths were mainly attributed to cancers (35%) and cardio-vascular diseases (CVDs; 29%). The proportionate mortality from NCDs rose from 35% in 2003 to 45% in 2010. While overall annual mortality rates (MRs) for NCDs fell, cancer-specific MRs rose from 200 to 262 per 100,000 population, mainly due to increasing deaths in adults aged 65y and older, and to respiratory neoplasms in all age groups. NCDs constitute a significant proportion of deaths in rural western Kenya. Evidence of the increasing contribution of NCDs to overall mortality supports international recommendations to introduce or enhance prevention, screening, diagnosis and treatment programmes in LMICs.

The Link between Inequality and Population Health in Low and Middle Income Countries: Policy Myth or Social Reality?
Van Deurzen I, van Oorschot W, van Ingen E: PLoS ONE 9(12), 11 December 2014

An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). The study provides an empirical test of this idea: the authors utilized data collected by the Demographic and Health Surveys between 2000 and 2011 52 LMICs, and examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women' experience of child mortality. Based on multi-level analyses, the authors found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when they took into account the level of individuals' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country's level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. The paper concludes that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.

The State of African Cities 2014
UN Habitat, 13 March 2014

The African continent is currently in the midst of simultaneously unfolding and highly significant demographic, economic, technological, environmental, urban and socio-political transitions. Africa’s economic performance is promising, with booming cities supporting growing middle classes and creating sizable consumer markets. But despite significant overall growth, not all of Africa performs well. The continent continues to suffer under very rapid urban growth accompanied by massive urban poverty and many other social problems. These seem to indicate that the development trajectories followed by African nations since post-independence may not be able to deliver on the aspirations of broad based human development and prosperity for all. This report, therefore, argues for a bold re-imagining of prevailing models in order to steer the ongoing transitions towards greater sustainability based on a thorough review of all available options. That is especially the case since the already daunting urban challenges in Africa are now being exacerbated by the new vulnerabilities and threats associated with climate and environmental change.

4. Values, Policies and Rights

Can frameworks inform knowledge about health policy processes? Reviewing health policy papers on agenda setting and testing them against a specific priority-setting framework
Walt G and Gilson L: Health Policy and Planning 29 (suppl 3), June 2014

This article systematically reviews a set of health policy papers on agenda setting and tests them against a specific priority-setting framework. The article applies the Shiffman and Smith framework in extracting and synthesizing data from an existing set of papers, purposively identified for their relevance and systematically reviewed. Its primary aim is to assess how far the component parts of the framework help to identify the factors that influence the agenda setting stage of the policy process at global and national levels. It seeks to advance the field and inform the development of theory in health policy by examining the extent to which the framework offers a useful approach for organizing and analysing data. Applying the framework retrospectively to the selected set of papers, it aims to explore influences on priority setting and to assess how far the framework might gain from further refinement or adaptation, if used prospectively. The article also demonstrates how framework synthesis can be used in health policy analysis research.

How to make planning law work for Africa
Berrisford S: Africa Research Institute Counterpoints Series, November 2013

As competition for land intensifies in Africa’s rapidly growing towns and cities, planning laws assume a fundamental importance. They determine how urban growth is managed and directed. In most countries outdated, inappropriate and unintegrated laws are exacerbating urban dysfunction. The reform of planning law is frequently advocated as a necessary step for better management of urbanisation in Africa. But reform initiatives consistently founder. This is inevitable, given the approaches adopted. The promotion of “one-size-fits-all” and “model” planning laws from outside the continent has not served Africa well. Invariably it has created further legal uncertainty and a series of unanticipated, often pernicious consequences. This paper argues that more progressive, realistic urban planning in Africa will require a radically different approach to planning law reform, essential for sustainable and equitable urban development in Africa.

Surviving scarcities in Bulengo
Boneza RN: Pambazuka News 11 December 2014

In 2006, statistics showed that there were about three million internally displaced persons (IDPs) in the five Eastern provinces of Democratic Republic of Congo (DRC): The oriental Province, North Kivu, South Kivu, Maniema and Katanga. Lately, due to relative peace in the region, the number of IDPs dropped to around two million by 2013. While the number has decreased, however, this article highlights how the people still need assistance for their precarious vulnerability. The majority are elderly, children, women who were victims of sexual violence and teenage mothers affected with all sort of predicaments such famine, AIDS and other disabilities. MSF built a clinic in Bulengo to provide free health care to more than 40,000 people. MSF has conducted more than 25,000 consultations in this camp, mainly for diarrhea and respiratory infections. People are mainly sick due to poor living conditions accentuated by poor nourishment. The author argues that the UN and aid agencies should start planning longer-term assistance, and other governments should respond with the necessary funding. They should join their effort to support Doctors without Borders in providing the necessary services attached to their mandate such food, water supply, shelter distribution and hygienic installations.

Universal Health Coverage: Because nobody should have to choose between health, food and education
Hannah Yous, Health Advocacy Officer, Oxfam France 2014

Getting sick represents a risk of falling into poverty for millions of people around the world. The cost of health care put millions of people in the position to choose between buying food, sending children to school or paying to get healthcare. Yet the author argues that this is not inevitable because solutions exist: Universal Health Coverage (UHC) makes it possible for people to access health care without sacrificing other basic needs.

5. Health equity in economic and trade policies

A Primer to the Emerging Extractive Sector in Kenya: Resource Bliss, Dilemma or Curse
Oiro Omolo MW, Mwabu G: Institute of Economic Affairs, November 2014

In any economy, the extractive sector consists mainly of oil, gas and mining activities. Experience in countries such as Norway, Canada, Botswana and Ghana suggests that extractives can be effectively managed to contribute to sustainable economic growth. Experience, however, in other parts of the world including Nigeria, the Democratic Republic of Congo, South Sudan, and the Central African Republic suggest that extractives if not well managed can lead to conflict. Extractives in Kenya contribute approximately one per cent to gross domestic product. The sector is however emerging. In the recent past, there have been oil and more mining discoveries in Kenya. For instance, oil has been discovered in Turkana County, and there are new discoveries in the mining sectors for minerals such as titanium in Kilifi County and coal in Kitui County. In addition, Kenya is actively undertaking off shore explorations with the aim of making gas discoveries. The growing extractive sector in Kenya means that there is need to give more attention to the social and economic dynamics of the sector. For instance, when Kenya discovered oil in Turkana County in March 2012, the Government was faced with emergent issues such as environmental implications, community obligations and rights, a suitable governance framework, and effective utilisation of resources generated from the sector.

AFSA open letter opposing human feeding trials involving GM banana
Alliance for Food Sovereignty in Africa: Pambazuka News issue 706 December 9 2014

The Alliance for Food Sovereignty in Africa (AFSA), a Pan African platform comprising civil society networks and farmer organisations working towards food sovereignty, has submitted this Open Letter to the Bill and Melinda Gates Foundation, Dr. Wendy White from Iowa State University and the Human Institutional Review Board of Iowa State University expressing fierce opposition to the human feeding trials taking place at Iowa State University involving genetically modified (GM) bananas. The Letter is supported by more than 120 organizations from around the world. The letter states:"This so-called ‘Super-banana’, has been genetically modified to contain extra beta-carotene, a nutrient the human body uses to produce vitamin A. Unlike current GM crops in commercial production where agronomic traits have been altered, scientists have spliced genes into the GM banana to produce substances for humans to digest (extra beta carotene). The GM banana is a whole different ballgame, raising serious concerns about the risks to African communities who would be expected to consume it. Production of vitamin A in the body is complex and not fully understood. This raises important questions including inter alia, whether high levels of beta- carotene or vitamin A may carry risks and what the nature of those risks might be. While a risk assessment is a pre-requisite for GM foods under many national jurisdictions, the need for specific and additional food safety assessment for nutritionally enhanced GM crops such as the GM banana is acknowledged by the Codex Alimentarius Commission, as genetic modifications result in a composition that may be significantly different from their conventional counterparts".

Science and technology for development in Sub-Saharan Africa: Key topics, challenges and opportunities
Romo Ramos YJ: SciDev.Net 2014

SciDev.Net’s focus groups in Sub-Saharan Africa (SSA) are part of a global programme that aims to understand regional needs and contexts for science and technology in development. The programme started in 2012 in South East Asia and the Pacific, and reports are available online at www.scidev.net/global/content/learning-series.html This report highlights the key areas of interest in for development, and barriers and gaps in the use of science and technology evidence. It also provides suggestions for how communications about science and technology can be improved.

6. Poverty and health

A cross-sectional ecological study of spatial scale and geographic inequality in access to drinking-water and sanitation
Yu W, Bain RES, Mansour S and Wright JA: International Journal for Equity in Health13(113): November 2014

Measuring inequality in access to safe drinking-water and sanitation is proposed as a component of international monitoring following the expiry of the Millennium Development Goals. This study aims to evaluate the utility of census data in measuring geographic inequality in access to drinking-water and sanitation. Spatially referenced census data were acquired for Colombia, South Africa, Egypt, and Uganda, whilst non-spatially referenced census data were acquired for Kenya. Four variants of the dissimilarity index were used to estimate geographic inequality in access to both services using large and small area units in each country through a cross-sectional, ecological study. Inequality was greatest for piped water in South Africa in 2001 and lowest for access to an improved water source in Uganda in 2008. For sanitation, inequality was greatest for those lacking any facility in Kenya in 2009 and lowest for access to an improved facility in Uganda in 2002. Although dissimilarity index values were greater for smaller area units, when study countries were ranked in terms of inequality, these ranks remained unaffected by the choice of large or small area units. International comparability was limited due to definitional and temporal differences between censuses. This five-country study suggests that patterns of inequality for broad regional units do often reflect inequality in service access at a more local scale. This implies household surveys designed to estimate province-level service coverage can provide valuable insights into geographic inequality at lower levels.

Grain Revolution: Finger Millet and Livelihood Transformation in Rural Zimbabwe
Muchineripi C: Africa Research Institute Policy Voice Series, October 2013

Food shortages are the root cause of poverty in Zimbabwe’s Gutu district. Rainfall is generally low and erratic. In most places the soil is sandy and over-cultivated. High population density means that the vast majority of the district’s 40,000 households are restricted to farming on small plots. By the mid-2000s the effect of an economic crisis on the government’s agricultural budget and an over-reliance on growing maize, a crop that requires high rainfall, had drastically undermined food security in Gutu. Following a severe drought in 2005, the Chinyika Communities Development Project was conceived to overcome the persistent threat of food shortages – and even famine – in Gutu. The objective was to persuade farmers dependent on maize production to plant finger millet, a neglected crop that is indigenous to Zimbabwe. Finger millet is drought-resistant and better suited to semi-arid and arid areas than maize. Although its cultivation is more labour-intensive, it requires fewer expensive inputs than maize. It is also highly nutritious and can be stored for up to 25 years. By 2014 almost every household in Gutu had participated in the project. Farmers with a nucleus of finger millet production each have 3-5 years of strategic food reserves and the collective capacity to produce a surplus of up to 2,000 tons a year. Accumulated reserves of finger millet exceed 20,000 tons. Families in Gutu now have a stable, dependable supply of food. This has been achieved without any external intervention or funding. The success of the Chinyika Communities Development Project was grounded in participatory research, community engagement and local ownership. The narrative is about much more than switching from one crop to another. A stable supply of food – and behavioural change – has imbued farmers with the confidence to pursue various income-generating activities. In Gutu, finger millet has been the key to the emergence of a diversified and innovative family farming system.

7. Equitable health services

Non-Communicable Disease on the rise in Uganda; Who is to blame?
Nsereko I: CEHURD newsletter December 2014

A recent survey carried out by the Center for Health, Human Rights and Development (CEHURD) with support from United Nations Development Program (UNDP) Uganda country office on the prevalence of risk factors for non communicable diseases among university students in and around Kampala found that up to 67% of the respondents did not know what NCDs were, 12% of students have used drugs, particularly Marijuana, 15% were current tobacco smokers, 9% smoked Shisha. More than 40% of the respondents were staying with parents who smoke, 10% have friends who smoke, 60% have smoked for less and 57% exposed to pro-cigarette advertisements. In areas where NCD services are available, these are often hampered by access to essential medicines.
A recent visit by the author to communities of Nyenga and Najja sub-counties of Buikwe district revealed that a huge percentage of the community members find no point in visiting health facilities for early screening for NCDs. The author suggests that government strengthen existing health facilities by providing essential NCD medicines and NCD screening services for at least all health center IVs.

Defining Motivational Intensity of Need for Family Planning in Africa
Kuang B, Ross J, Madsen EL: African Journal of Reproductive Health 18(3), September 2014

This study presents a new approach to defining high and low motivation groups of contraceptive users by stated intention to use, past use, and unmet need, to determine how these groups differ in characteristics and in region of residence. Data came from 23 DHS surveys in sub-Saharan countries. The low motivation non-users, with less past use and less intention to use in the future, are more rural, less educated, and closer to poverty. When used to guide planning, unmet need should be augmented with motivation, since the two classifications do not entirely overlap. Between 10 and 17 percent of current non-users of family planning are likely highly motivated to use, but are not captured in the unmet need classification. Programme implications for these non-using groups are discussed.

Universal health coverage and non-communicable diseases: a mutually reinforcing agenda
The NCD Alliance, October 2014

This policy brief analyses the relationships between Universal Health Coverage (UHC) and Non-Communicable Diseases (NCDs). It covers the unique challenges the NCD epidemic poses to achieving UHC, and the role of UHC in strengthening the NCD response. It also explores the implications and possible position of health, NCDs and UHC in the post-2015 development agenda. The key messages from the report include: UHC is a goal that all governments should commit to. It can help focus greater attention on coverage of quality services, health equity, and guar-anteeing financial-risk protection. The NCD epidemic poses unique challenges to the three dimensions of UHC. Access and availability to essential NCD services remains unacceptably low in many LMICs; major inequalities exist in terms of NCD risk, access to services, and health outcomes; and the epidemic imposes a huge economic burden on national budgets and can push households into poverty. Attainment of UHC will be dependent on prioritising NCD prevention and control in UHC design and implementation. When achieved, UHC can provide a powerful vehicle to accelerate progress on NCD outcomes, inequalities, and socio-economic impact. Lessons learnt from the NCD response can help support pathways to UHC. These include a focus on health promotion and prevention, multi-sectoral approach-es, addressing the social determinants of health, and domestic innovative financing mechanisms (including taxation on unhealthy products). For the post-2015 development agenda to be truly transformative for health, NCDs must be recognised as a priority and UHC must be articulated as a means to achieve improved health outcomes.

Using the unmet obstetric needs indicator to map inequities in life-saving obstetric interventions at the local health care system in Kenya
Echoka E, Dubourg D, Makokha A, Kombe Y, Olsen ØE, Mwangi M, Evjen-Olsen B and Byskov J: International Journal for Equity in Health 13(112), December 2014

Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located. A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The most common MOI was caesarean section, commonly indicated by Cephalopelvic Disproportion (CPD)–narrow pelvis. In absolute terms, 22 (11%) women in 2008 and 12 (6%) in 2009, who required a life saving intervention failed to get it. Deficits in terms of unmet needs were identified in rural areas.

8. Human Resources

A scoping review of training and deployment policies for human resources for health for maternal, newborn, and child health in rural Africa
Tomblin Murphy G, Goma F, MacKenzie A, Bradish S, Price S, Nzala S, Elliott Rose A, Rigby J, Muzongwe C, Chizuni N, Carey A and Hamavhwa D: Human Resources for Health 12(72), December 2014

Most African countries lack the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. A scoping review was conducted to identify the type, extent, and quality of evidence that exists on workforce policies for rural MNCH in Africa. Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. There was an overall paucity of information on workforce training and deployment policies for MNCH in rural Africa. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for workforce management or MNCH. Relevant government websites varied in functionality and in the availability of policy documents.

Overcoming the Health Workforce Gap
Peoples Health Movement: Global Health Watch, November 2014

In this new piece, Remco van de Pas and Linda Mans, researchers in public health, draw attention to a key chapter, titled ‘The Global Health Workforce Crisis’, of the latest edition of the Alternative World Health Report, Global Health Watch 4. They argue that overcoming the health work force gap is one of the key lessons we should learn from the current Ebola outbreak.
The chapter of GHW4 discusses how 'ceilings’ in the public wage bill imposed by the International Monetary Fund in Africa have contributed to migration of health workforce from the continent towards northern countries. It provides shocking numbers on the cost of health workforce training to governments in the south, and corresponding subsidy to governments in the north. The chapter also highlights that concerns of ‘economic efficiency’ threaten reducing health workers' role to undertaking selective diagnosis and treatment. It concludes that a strong health workforce, supported by public funds, is a requirement for strong, universal health systems.

Rwanda's evolving community health worker system: a qualitative assessment of client and provider perspectives
Condo J, Mugeni C, Naughton B, Hall K, Antonia Tuazon M, Omwega A, Nwaigwe F, Drobac P, Hyder Z, Ngabo F and Binagwaho A: Human Resources for Health 12(72), December 2014

In Rwanda, which faces a significant gap in health workers, the Ministry of Health expanded its community health programme in 2007, eventually placing 4 trained CHWs in every village in the country by 2009. The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme, as perceived by the CHWs and their beneficiaries. A cross-sectional descriptive study was conducted using focus group discussions to collect qualitative information regarding educational background, knowledge and practices of CHWs, and the benefits of community-based care as perceived by CHWs and household beneficiaries. A random sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level (low, middle and high). CHWs were found to be closely involved in the community, and widely respected by the beneficiaries. Rwanda's community performance-based financing was an incentive, but CHWs were also strongly motivated by community respect. The key challenges identified were an overwhelming workload, irregular trainings, and lack of sufficient supervision.

9. Public-Private Mix

Board of Healthcare Funders and Government: ‘I’ll change if you’ll change’
Bateman C: South African Medical Journal104(10), October 2014

While the South African government and private healthcare funders urged one another to make internal changes to enable faster progress towards a more equitable healthcare system, some concrete evidence of vitally needed partnership did emerge from the Board of Healthcare funders' conference held in August 2014. Government’s new Essential Drugs Committee will include representatives of the private healthcare funding industry to obtain consensus on just which essential medicines should be available to patients.
A blueprint on how the National Department of Health (NDoH) can partner
with the private healthcare funding sector in conducting economic evaluations of products to save both sectors time and money (and avoid
longstanding unnecessary duplication) has been drawn by NDoH. National Health Minister Dr Aaron Motsoaledi also pleaded with delegates to ‘embrace change’, warning that they would be hardest hit by the‘exploding’ epidemic of non-communicable diseases if they failed to introduce health promotion and disease prevention measures.

Can the private sector help overcome nursing shortages?
Resyst project: LSHTM, 2013

The demand for nurses is growing and has not yet been met in most low and middle-income countries. In India, Kenya, South Africa and Thailand, there has been a rapid proliferation of private training institutions to increase the supply of nurses. This infogram summarises evidence from RESYST research examining the role of these private institutions, their contribution to the wider health systems, and how governments in these countries have managed the opening of markets to the private sector. Private nurse training institutions are reported to be playing an increasingly important role in producing nurses in many low and middle income countries. Governments need to ensure that graduates from both private and public institutions are of sufficient quality to meet the health needs of their populations, and that training institutions have the capacity to train more nurses. In some countries including India and Kenya, the benefits of expanding nurse production through the private sector have been hindered by high levels of international migration. A balance needs to be struck between producing nurses for export, and ensuring sufficient supply and skill-mix for domestic markets.

10. Resource allocation and health financing

Strategic Purchasing Factsheet
Asia Pacific Observatory on health policy and systems: October 2014

A core function of health care financing is purchasing – the process by which funds are allocated to providers to obtain health services on behalf of the population. If designed and undertaken strategically, purchasing can improve health systems performance by promoting quality, efficiency, equity and responsiveness in health service provision. This brief discusses dimensions of purchasing in ten countries.

11. Equity and HIV/AIDS

Fertility Desires and Intentions among HIV-Positive Women during the Post-natal period in Uganda
Gutin SA, Namusoke F, Shade SB, Mirembe F: African Journal of Reproductive Health 18(3), September 2014

This study describes the fertility intentions and discusses the potential reproductive health needs of post-natal HIV-infected Ugandan women. HIV-infected mothers attending post-natal services in Kampala, Uganda participated in this cross-sectional study using structured interviewer administered questionnaires. Among 403 participants, 35% desired more children. Of these, 25% wanted another child within 2 years and 75% within 3 years or more. In multivariable analyses, believing that one’s partners wanted more children was associated with the desire for future children while having more living children was negatively associated with the desire for future children. A minority of women desired future pregnancies, and most wanted to delay pregnancy for 3 years. These women are in need of family planning methods to meet stated desires to delay or end future pregnancies. Perceived partner desire for children also impacts on women’s fertility intentions, highlighting the importance of engaging men during the post-natal period.

HIV in (and out of) the clinic: Biomedicine, traditional medicine and spiritual healing in Harare
O’Brien S, Broom A: SAHARA J (Journal of Social Aspects of HIV/AIDS Research Alliance) 11(1), 14 July 2014

Contemporary lived experiences of the human immunodeficiency virus (HIV) are shaped by clinical and cultural encounters with illness. In sub-Saharan countries such as Zimbabwe, HIV is treated in very different ways in various therapeutic contexts including by biomedical experts, traditional medicine and faith healers. The co-existence of such expertise raises important questions around the potencies and limits of medicalisation and alternative healing practices in promoting HIV recovery. First, in this study, drawing on in-depth qualitative interviews with 60 people from poor urban areas in Harare, the authors explore the experiences of people living with and affected by HIV. They sought to document, interrogate and reflect on their perceptions and experiences of biomedicine in relation to traditional medicine and spiritual healing. Their accounts indicate that traditional medicine and spiritual beliefs continue to significantly influence the way in which HIV is understood, and the forms of help and care people seek. The authors observe the dramatic and overwhelmingly beneficial impact of Antiretroviral Therapy and conclude through Zimbabwean’s own stories that limitations around delivery and wider structural inequalities impede its potential. The authors explore some practical implications of the biomedical clinic (and alternative healing practices) being understood as sites of ideological and expert contestation.

World AIDS Day: What does HIV teach us about access to medicines for Ebola?
Kamal-Yanni M: Oxfam UK, November 2014

In 2001, the new antiretroviral medicines had started to work miracles, bringing people from their deathbeds back to life. Yet as a Ugandan doctor truly said: ‘the medicine is in the North but the disease is in the South’. The author argues that the pharmaceutical industry was happy to sell the medicines at very high prices in rich countries while turning a blind eye to the rest of the world. It was largely thanks to a huge global mobilisation of civil society led by people living with HIV that leaders and pharmaceutical companies started to feel embarrassed about denying access to life-saving medicines to millions of people. But it was only after generic competition kicked in that access to medicines became something policymakers talked about. An offer by an Indian company to sell a cocktail of the three basic medicines for one dollar a day slashed the prices of antiretrovirals, meaning that today over 9 million people are on treatment,, including over 7 million in Africa. The profit from treatment of HIV infected people in rich country provided the necessary market that has stimulated R&D for antiretroviral medicines. This is not the case for the Ebola market, which consists of small numbers of people in poor countries. Pharmaceutical companies had no commercial incentive to enter into R&D for vaccines or medicines for Ebola – or any other haemorrhagic fever. For this reason Ebola is the other side of the coin to HIV as the intellectual property rights system allows the market to shape R&D priorities, rather than public health needs. The author argues that it is not ethical, sustainable nor safe to leave commercial interests decisions and financing for R&D for products, capable of modifying global health threats, to be dictated by the commercial interests of pharmaceutical companies.

12. Governance and participation in health

A concept in flux: questioning accountability in the context of global health cooperation
Bruen C, Brigha R, Kageni A and Wafula F: Globalization and Health 10:73, 2014

Accountability in global health is a commonly invoked though less commonly questioned concept. Critically reflecting on the concept and how it is put into practice, this paper focuses on the who, what, how, and where of accountability, mapping its defining features and considering them with respect to real-world circumstances. Changing dynamics in global health cooperation - such as the emergence of new health public-private partnerships and the formal inclusion of non-state actors in policy making processes - provides the backdrop to this discussion. In mapping some defining features, accountability in global health cooperation is shown to be a complex problem not necessarily reducible to one set of actors holding another to account. Clear tensions are observed between multi-stakeholder participatory models and more traditional vertical models that prioritise accountability upwards to donors, both of which are embodied in initiatives like the Global Fund. For multi-constituency organisations, this poses challenges not only for future financing but also for future legitimacy.

Food label reading and understanding in parts of rural and urban Zimbabwe
Chopera P, Chagwena DT, Mushonga NGT: African Health Sciences 14(3), September 2014

Overweight and obesity prevalence is rapidly rising in developing countries. The reading and understanding of nutrition information on food packages has been shown to improve food choices and instill healthy eating habits in individuals. The aim of this study was to describe the prevalence of food label usage and understanding among urban and rural adults in Zimbabwe and its association with demographic and socio economic factors. A cross sectional study was conducted on 320 adults (147 urban and 173 rural) using a validated questionnaire. A high proportion (77%) of the respondents read food labels. Food label reading differed significantly by educational, employment status and locality. Only 41% of food label readers mostly understood the information on the food labels. More urban shoppers (86%) read food labels than their rural counterparts (67%). A significant number of participants (81%) indicated they would like to be educated on the meaning of food labels and 80% preferred the nutrition information on food labels to be simplified. The study found above average reported reading of nutrition information on food labels with partial understanding. The authors recommend that efforts be made to determine how all consumers could be made to understand the nutrition information on food labels and use it effectively in decision making.

13. Monitoring equity and research policy

Monitoring of non-communicable diseases such as hypertension in South Africa: Challenges for the post-2015 global development agenda
Day C, Groenewald P, Laubscher R, van Schaik N, Bradshaw D: South African Medical Journal 10(104), October 2014

Examining the non-communicable disease (NCD) profile for South Africa (SA) is crucial when developing health interventions that aim to reduce the burden of NCDs. The objective was to review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example. Age, gender, district of death and underlying cause of death data were obtained for 2008 and 2009 mortality unit records from Statistics SA and adjusted using STATA 11. Data for raised blood pressure were obtained from four national household surveys: the South African Demographic and Health Survey 1998, the Study on Global Ageing and Adult Health 2007, and the National Income Dynamics Study 2008 and 2010. The proportion of years of life lost due to NCDs was highest in the metros and least-deprived districts, with all metros (especially Mangaung) showing high age-standardised mortality rates for ischaemic heart disease, cerebrovascular disease and hypertensive disease. The prevalence of hypertension has increased since 1998. National household surveys showed a measured hypertension prevalence of over 40% in adults aged ¬25 years in 2010. Treatment coverage was 35.7%. Only 36.4% of hypertensive cases (on treatment) were controlled. Further work is needed if NCD monitoring is to be enhanced. Priority targets for NCDs must be integrated into national health planning processes. Surveillance requires integration into national health information systems. Within primary healthcare, a larger focus on integrated chronic care is essential.

Shooting our hard drive into space and other ways to practise responsible development data
Antin K, Byrne R, Geber T, van Geffen S, Hoffmann J, Jayaram M, Khan M, Lee T, Weinberg F, Wilson C, Rühling B, Rahman Z, Simeoni C: 9 October 2014

This book is offered as a first attempt to understand what responsible data means in the context of international development programming. It takes a broad view of development and also anticipates that some of the methods and lessons may have resonance for related fields and practitioners. It is intended to support thoughtful and responsible thinking as the development community grapples with relatively new social and ethical challenges stemming from data use. This book builds on a number of resources and strategies developed in academia, human rights and advocacy, but aims to focus on international development practitioners so touches primarily upon issues specifically relevant to development practitioners and intermediaries working to improve the lives and livelihoods of people.

14. Useful Resources

Data Visualisation: Africa’s Hydropower Future
SciDevNet, 2014

From Cote d’Ivoire in the west to Ethiopia in the east, Africa is home to some of the world’s fastest growing economies. Debates often proclaim a new era of economic boom, innovation and social opportunity for the continent. But beyond the hype, millions of people remain affected by severe poverty, and at the root of this lies a perennial problem: energy poverty. This data visualisation explores a creative way of interrogating the notion of whether hydropower could hold the key to energy access in Africa.

How to use Instagram for research communication
Patton B: Research to Action: 22 October 2014

Instagram, the social networking service that enables its users to take pictures and videos, apply digital filters to them, and share them across Facebook, Twitter, Tumblr and Flickr, is becoming increasingly popular. A free application that can be downloaded onto mobile phones and tablets. Instagram currently has a predominantly young adult audience and is used as a tool to generate interest in campaigns.

15. Jobs and Announcements

Call for papers European Conference on African Studies (ECAS) 2015: Living in State Housing: Expectations, contradictions and consequences – call for panel papers
Closing Date: 9 January 2015

State-supported low-cost housing is a significant tool and electoral strategy across African cities, which often draws on notions of urban formality, social decency, rights, material integrity, welfare, and citizenship to underpin its aims. This session examines he contradictions of
housing urban poor people in cities where affordable and well-located
space is highly restricted, where social inequalities and tensions are
rife, and where unemployment persists in shaping residents daily
lives. The panel hopes to attract papers from across the continent to
build understanding of the lived experiences of state-housing in an
effort to contribute to further scholarship in this relatively
neglected area. Delegates can submit paper titles and abstracts via the link on the website and will be notified by email of the acceptance or rejection of their proposal.

Emerging Powers in Africa Project call for grant proposals
Call closing December 2014 (negotiable)

Fahamu’s Emerging Powers Project is issuing a call for grant proposals to examine the political, economic, social and cultural impact of the emerging powers footprint in Africa. The grant is specifically related to empowering civil society actors in gaining the appropriate knowledge and developing the necessary tools to articulate an informed perspective on the emerging powers in Africa and the corresponding impact. In particular, attention should be given to the forthcoming China-Africa Forum (FOCAC), the India-Africa Forum Summit, and the South Korea-Africa development cooperation meeting that is going to take place in 2015, as well as the recent Africa-Turkey Summit that took place in November 2014. Applicants are encouraged to explore how these platforms inform Africa’s relationship with emerging actors; what impact have these engagements had on Africa’s relationship with these and other actors; and how African civil society actors should advance African voice. The grants are for 5000 Euro, with further details on the application procedure on the website.

Save the Children South Africa: Action/2015 Campaign Coalition Coordinator
Call for applicants closes January 10 2015

The action/2015 Campaign Coalition Coordinator will help drive the strategic direction and delivery of the South African action/2015 coalition. This is a high-level position which will play a key role in building a broad based national action/2015 coalition and in supporting the design and delivery of the coalition’s action/2015 campaign. This is a 3 month consultancy opportunity. Further information on the website.

Universal Health Coverage network to be launched in Africa on UHC Day
Africa Civil Society Network for Universal Health Coverage, Accra, December 2014

The African Platform for Universal Health Coverage (AP-UHC) will be launched with events in 9 African countries and online during the first Global Day for Universal Health Coverage (12th December 2014). The same date, two years ago, all countries unanimously supported a resolution at the United Nations General Assembly which encouraged member states to “plan or pursue the transition of their health systems towards Universal Health Coverage”. AP-UHC will contribute to civil society efforts for the implementation of Universal Health Coverage policies at national, and Africa level as the practical expression of the Right to Health in Africa. The network is a result of the global effort to improve and expand healthcare delivery to every locality where everybody receives the health services they need. The network will provide adequate support to national NGOs in their advocacy, using people-centred, right-based approach, to influence governments and policy makers at regional, national and community levels to implement Universal Health Coverage policies.


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