EQUINET NEWSLETTER 168 : 01 February 2015

1. Editorial

EQUINET newsletter invites submissions
EQUINET steering committee

New year greetings! The EQUINET newsletter is now in its 168th issue and has been disseminating information on health equity in east and southern Africa for seventeen years. Thanks to all who have contributed. We'd like to hear more from you! We invite readers to submit short think pieces, debate pieces and information for the newsletter relating to the diversity of health equity issues affecting east and southern Africa. Please submit oped pieces of 1000 words or less with author name and institution to admin@equinetafrica.org. We also welcome information on useful resources, published papers, conferences and research grants on health. The newsletter and EQUINET website have searchable databases of publications on health equity in east and southern Africa as a resource for those engaging in various areas of research, policy and activism in health.

UN Special Rapporteurs Open Letter to the World Bank on the issue of human rights
Alston P: UN Special Rapporteur on extreme poverty and human rights, with 26 other Special Rapporteurs, 12 December 2014

Dear Mr. Jim Yong Kim,
We have the honor to address you in our capacities as special procedures mandate-holders of the United Nations Human Rights Council. We are writing to you with regard to the World Bank’s draft Environmental and Social Framework (“ESF”), which was released for consultation on July 30, 2014. We would like to share with you a number of concerns relating to the approach to ‘Safeguards’ reflected in the current draft ESF.

At the outset, we wish to underscore the significance of the Bank’s first adoption of such standards some thirty years ago. And we commend the Bank for its continued recognition of the central importance of a carefully calibrated framework of standards to ensure that its programs to promote sustainable development, poverty elimination, environmental protection and social standards do not have a negative impact on a diverse range of important values. Most of those values represent important components of international human rights law, to which the Bank’s Member States have subscribed within the framework of the United Nations. It is because the Safeguards implicate human rights so directly that we have chosen to write to you as independent human rights experts appointed by United Nations Member States to provide our inputs to the Bank’s consultation process.

As the Bank seeks to revise and adapt its Safeguards approach to the challenges of the twenty-first century, we believe that it is imperative that the standards should be premised on a recognition of the central importance of respecting and promoting human rights. But there is no such provision in the current draft. Instead, by contemporary standards, the document seems to go out of its way to avoid any meaningful references to human rights and international human rights law, except for passing references in the Vision statement and Environmental and Social Standard (ESS). The Bank restricts itself to noting that its operations are, in ways that are not explained or elaborated, ‘supportive’ of human rights and that it will ‘encourage respect for them in a manner consistent with the Bank’s Articles of Agreement’. As noted below, however, the convoluted and anachronistic interpretation of the Articles that has so far prevailed ensures that this is a largely empty undertaking.

While the Bank is clearly committed to ending extreme poverty and improving the quality of life of people in developing countries, the pursuit of these worthy goals does not automatically ensure that the resulting programs and projects will promote and respect human rights. We acknowledge that it is not the Bank’s role to act as an enforcer of human rights, but there are a great many other ways in which it can assist governments in meeting their own international obligations, provide support and advice on how programs and projects might be made more human rights compliant, and build knowledge and understanding of human rights into its own work. By opting not to take these steps, the Bank is setting itself apart from other international organizations and agencies which have long since recognized the importance of human rights in the context of carrying out their specialized mandates, and have also rejected the notion that human rights are somehow problematically ‘political’ in ways that the many other accepted goals of development policy are not.

In many contexts, the international community has accepted that development and human rights are interdependent and mutually reinforcing. This has been recognized, for example, in the 1993 Vienna World Conference on Human Rights, the 2000 Millennium Summit and the 2005 and 2010 World Summits. Reference might also be made to a document that is cited on the Bank’s own website which is the 2003 UN Common Understanding adopted by the United Nations Development Group. The Common Understanding requires that human rights guide all development cooperation and that development cooperation “contributes to the development of the capacities of ‘duty-bearers’ to meet their obligations and/or of ‘rights-holders’ to claim their rights”. It is fair to say that the vast majority of development actors, from the European Investment Bank to the United Nations Development Programme, have expressed a clear commitment to human rights in their policies, thus making the Bank an increasingly isolated outlier in this regard.

The Bank’s official reluctance to engage operationally with human rights also stands in marked contrast to the lessons that its formal statements suggest it has drawn from its own experience, including through the work of the Nordic Trust Fund (“NTF”). The Bank acknowledges on its website and in many of its non-operational policy analyses that a focus on human rights can improve development outcomes. This is consistent with the seminal insight provided in the work of Amartya Sen, undertaken in his capacity as a Presidential Fellow at the Bank, who argued that freedoms are essential means for achieving development. There are many examples of analyses and reports by the Bank that highlight the potential or actual importance of human rights in promoting the achievement of the Bank’s proclaimed goals, such as those relating to gender equality and the role of women in society.

Rather than seeing human rights as a means by which to facilitate the participation and empowerment of the beneficiaries of development, the Bank’s proposed new Safeguards seem to view human rights in largely negative terms, as considerations that, if taken seriously, will only drive up the cost of lending rather than contributing to ensuring a positive outcome. While a 2010 report by the Bank’s Independent Evaluation Group (“IEG”) concluded that the benefits of Safeguards outweigh their costs, the approach in the draft Safeguards seems to be driven by the desire to privilege rapid approval of loans over all else, an orientation which has long been identified as a problem for the Bank. A sense of being increasingly in competition with other lenders to secure the ‘business’ of developing country borrowers seems to be at the root of this approach. The Bank has defended its increased reluctance to engage with human rights on the basis that alternative sources of development financing are emerging, which do not require meaningful Safeguards, thus providing the latter with a significant advantage over the Bank. In our view, the failure of other lenders to require that projects they fund should respect human rights standards is not a valid reason for the World Bank to follow suit. We believe that the problems that will flow from such a race to the bottom are already becoming apparent, and it will be for us, in different contexts, to make this clear to the relevant lenders.

Human rights are not merely a matter of sound policy, but of legal obligation. As an international organization with international legal personality, and as a UN specialized agency, the Bank is bound by obligations stemming not only from its Articles of Agreement, but also from human rights obligations arising under ‘general rules of international law’ and the UN Charter. Moreover, each of the 188 Member States of the World Bank has ratified at least one (and, in almost all cases, several) of the core international human rights treaties.16 Those States are also bound by human rights obligations stemming from other sources of international law. It is widely recognized that Member States should take their international human rights obligations into account when acting through an international organization such as the World Bank. States that borrow from the Bank also continue to be bound by their own international human rights obligations in the context of Bank-financed development projects and the Bank has a due diligence responsibility not to facilitate the violations of their human rights obligations, or to otherwise become complicit in such violations.

In the past, the Bank has often pointed to its ‘non-political mandate’ to argue that it is prohibited from, or at least restricted in, its ability to deal with human rights more directly. But the Bank’s Articles of Agreement should be interpreted in the context of today’s international legal order, rather than that of the mid-1940s. The Bank and its Member States are bound by both the Articles of Agreement, and by international human rights law. The provisions of the Articles can clearly be interpreted in a way that underlines their consistency with international human rights law. Since all States have long ago accepted human rights as a “legitimate concern of the international community” the suggestion that these remain little more than political considerations is not sustainable.

Our call for the Bank to include HR within its overall program objectives does not amount to suggesting that the Bank should ‘sanction’ countries with a poor human rights record. Consistent with international law, with its own obligations and with those of its Member States, the Bank should acknowledge the relevance of human rights in its overall program objectives, as well as incorporate human rights due diligence into its risk management policies. The Bank should also avoid funding projects that would contravene the international human rights obligations of its borrowers.

In the annex, we have highlighted our particular concerns with elements of the proposed ESF. Our aim is to indicate specific means by which a human rights dimension would strengthen the Bank’s new Framework and ensure its compliance with international law. As Bank President, you have repeatedly undertaken that this revision process will not result in a dilution of the human rights components of the Safeguards. We believe that honoring this promise requires a significantly different approach from that which is now being pursued and there are strong legal, policy and instrumental reasons why human rights should be given a central role in the work of the Bank. The current Safeguard Review process provides a critical opportunity for the Bank to fully integrate human rights in its policies and standards. We will be submitting this letter together with its annex to the World Bank’s public consultation process and plan to issue a press release in due course. We stand available to engage further with the Bank in this process and can be reached for any comments and views on our letter. Your response will be made available in a report to be presented to the Human Rights Council for its consideration.

For further information on this open letter see www.ohchr.org/Documents/Issues/EPoverty/WorldBank.pdf

2. Latest Equinet Updates

Annotated bibliography of e- platforms used in participatory and peer to peer exchange and learning
Loewenson T: TARSC, EQUINET Harare, 2014

Visual and information technologies are now more diversified and widely accessible. Digital images and mapping enhance access and exchange on local realities; social media (blogs, tweets and others) provide new methods for communicating experience for collective analysis, mobile phones facilitate communication and pooling of evidence across wider social networks and mapping and crowd-sourcing technology provide systems for citizen reporting, including in poorest communities. internet based resources point to the possibilities for information technology to support peer to peer learning and participatory action research to overcome the ‘local’ nature of processes and link groups with shared interest. To support discussion on these areas this work aimed to provide an annotated description of existing internet resources that have features that may guide out thinking in developing an e platform for participatory reflection and action across similar groups in different areas.

3. Equity in Health

Leaving no one behind: an agenda for equity
Watkins K: Lancet, 384, 9961, 2248–2255, 2014

Shortly before his death, Mahatma Gandhi offered a useful reflection that helps to cut through some of the complexity surrounding debates about equity. “Recall the face of the poorest and the weakest person you may have seen and ask yourself if the step you contemplate is going to be any use to them.” It’s a simple but compelling guide for policy makers concerned with combating extreme inequality. Something of the same spirit underpins the report of the High Level Panel established by the UN Secretary General to make recommendations for the post-2015 development agenda. Going beyond the identification of universal goals, the report calls for “a focus on the poorest and most marginalised” and a commitment to “leave no one behind". This approach is argued to be in-keeping with other work on the post-2015 agenda, including the Global Sustainable Development Report. Far more than the Millennium Development Goals (MDGs)—which were largely neutral on the issue of inequality—the High Level Panel report includes a wide-ranging social justice agenda. If adopted by governments and backed by national policy commitments and a new global partnership, the Panel’s agenda could, the author argues, put exclusion, inequality, and marginalisation at the centre of the post-2015 development framework.

Neglected tropical disease and emerging infectious disease: An analysis of the history, promise and constraints of two worldviews
Jackson Y, Stephenson N: Global Public Health 9(9), 2014

Emerging infectious diseases (EIDs) and neglected tropical diseases (NTDs) are medical terms referring to a group of diseases, yet they are simultaneously socio-political constructs (EID and NTD). When viewed as such, public health interest in EID has been criticised as prioritising free market, Global North interests. This paper asks if the recent turn to NTD, which directs attention and resources to ‘the bottom billion’ of the world's population, addresses the limitations of focusing on EID. Our approach involves comparing the specific socio-political framing, or ‘worldview’ of NTD, with that of EID. We examine the distinct history, rationales, morals, political and economic tensions and loci of power entailed in each worldview. This analysis suggests that efforts to foreground NTD constitute a site where humanitarian and biomedical industry actors and actions are increasingly blurred. We examine whether the NTD worldview constitutes a break with or a new version of a free market approach to global health, and whether it reworks or solidifies paternalistic Global North–South relations. We consider some of the limits of work on NTD to date, suggesting that although the NTD worldview does not escape the neo-colonial history of global health, it can actualise it under a different form.

The Ebola epidemic: a transformative moment for global health
Hill SR, Bero L, McColl G, Roughead E: Bulletin of the World Health Organization 93 (1), January 2014

The devastating effects of the current epidemic of Ebola virus disease in western Africa have put the global health response in acute focus. The index case is believed to have been a 2-year-old child in Guéckédou, Guinea, who died in December 2013. By late February 2014, Guinea, Liberia and Sierra Leone were in the midst of a full-blown and complex global health emergency. The response by multilateral and humanitarian organizations has been laudable and – at times – heroic. Much of the worst affected region is recovering from civil conflicts. This region is characterized by weak systems of government and health-care delivery, high rates of illiteracy, poverty and distrust of the government and extreme population mobility across porous, artificial boundaries. A more coordinated, strategic and proactive response is urgently needed.

4. Values, Policies and Rights

Spectre of Ebola Protectionism
Bangura Y: CODESRIA Newsletter, November 2014

A new kind of protectionism is argued by the author to be haunting the world: the spectre of ebola protectionism. As ebola ravages the societies of the Mano River Union (MRU) states of Guinea, Liberia and Sierra Leone, the author notes that there are increasing calls from conservative politicians, right-wing groups, and sections of the media to prevent people from these states from interacting with the rest of the world. The protectionist measures range from exit and entry controls, such as temperature checks and mandatory monitoring and quarantining of travellers from MRU states, to flight bans and denial of visas to holders of MRU passports. The virus poses less of a threat to rich countries with sound public health systems than poor West African countries that have extensive links with the MRU states. The author argues that exit and non-intrusive entry controls, not flight bans and visa restrictions that Australia and Canada have imposed, may be enough to manage the few cases that are likely to pop up in rich countries.

Towards an integrative post-2015 sustainable development goal framework: Focusing on global justice – peace, security and basic human rights
Lueddeke GR: South Eastern European Journal of Public Health, DOI 10.12908/SEEJPH-2014-26, 2014

The United Nations (UN) Millennium Declaration and eight Millennium Development Goals (MDGs) have been hailed as a unique achievement in international development. Although the MDGs have raised the profile of global health, particularly in low- and middle-income countries, progress has been uneven both between and within countries. A key reason suggested for this lack of progress is that the MDGs fall far short in terms of addressing the broader concept of development encapsulated in the Millennium Declaration, which includes human rights, equity, democracy, and governance. To strengthen the likelihood of realizing the post-2015 Sustainable Development Goals (SDGs), particularly with regard to “planet and population” health and well-being , UN and other decision-makers are urged to consider the adoption of an integrated SDG framework that is based on (i) a vision of global justice – underpinned by peace, security and basic human rights; (ii) the development of interdependent and interconnected strategies for each of the eleven thematic indicators identified in the UN document The World We Want; and (iii) the application of guiding principles to measure the impact of SDG strategies in terms of holism, equity, sustainability, ownership, and global obligation. While current discussions on the SDGs are making progress in a number of areas, the need for integration of these around a common global vision and purpose seems especially crucial to avoid MDG shortcomings.

5. Health equity in economic and trade policies

The International Monetary Fund and the Ebola outbreak
Kentikelenis A, King L, McKee M, Stuckler D: The Lancet, 21 December 2014

In recent months, the International Monetary Fund (IMF) has announced US$430 million of funding to fight Ebola in Sierra Leone, Guinea, and Liberia. By making these funds available, the IMF aims to become part of the solution to the crisis, even if this involves a departure from its usual approach. As IMF Director Christine Lagarde said at a meeting on the outbreak, “It is good to increase the fiscal deficit when it's a matter of curing the people, of taking the precautions to actually try to contain the disease. The IMF doesn't say that very often.” Yet, could it be that the IMF had contributed to the circumstances that enabled the crisis to arise in the first place? A major reason why the outbreak spread so rapidly was the weakness of health systems in the region. There were many reasons for this, including the legacy of conflict and state failure. Since 1990, the IMF has provided support to Guinea, Liberia, and Sierra Leone, for 21, 7, and 19 years, respectively, and at the time that Ebola emerged, all three countries were under IMF programmes. However, IMF lending comes with strings attached—so-called “conditionalities”—that require recipient governments to adopt policies that have been criticised for prioritising short-term economic objectives over investment in health and education. Indeed, it is not even clear that they have strengthened economic performance. Here the authors review the policies advocated by the IMF before the outbreak, and examine their effect on the three health systems.

6. Poverty and health

For Town and Country: A New Approach to Urban Planning in Kenya
Ngau P: Africa Research Institute Policy Voice Series, 5 December 2014

Urban and regional planning is under the spotlight in Kenya. The 2009 National Housing and Population Census forecast that the percentage of Kenyans living in urban settlements will increase from 32 percent to 54 percent by 2030. Residents of Nairobi await the details of a new city master plan. The devolution of power and allocation of central resources to the 47 county governments created by the 2010 constitution is under way – a process that requires integrated development plans to be in place. In the post-independence era, urban planning was deployed as a tool for “modernisation” in Kenya. But in the 1980s and 1990s modernisation was supplanted by autocracy and straitened economic circumstances. In turn, planning became a means for securing control, exclusion and further enrichment of political and economic elites redolent of the colonial era. Legislation based on outdated and inappropriate models such as the UK’s 1947 Town and Country Planning Act was routinely used to carry out mass evictions and demolitions in informal settlements in Kenya. By the end of the 20th century, the planning profession had become irrelevant or discredited to all but its few beneficiaries. In this paper the author describes in detail how the Department of Urban and Regional Planning (DURP) at the University of Nairobi – and other institutions – have sought to revitalise and encourage the adoption of more progressive approaches among planning professionals. Curricula reform, research and innovation, close links with other planning schools in Africa, and working partnerships with civil society organisations in informal settlements are the bedrock of the effort to ensure that Kenya’s future urban planners are equipped to manage rapid urban transformation.

7. Equitable health services

Expensive medicines: ensuring objective appraisal and equitable access
Kennedy SB, Nisbett RA: Bulletin of the World Health Organization 93 (1), January 2014

In response to requests for the funding of new drugs, reimbursement agencies are re-evaluating some of the methods used in assessing these products. Many trials submitted for the regulatory review of new drugs do not provide adequate data for subsidy decisions. The authors argue that all involved in bringing medicines to market need to be explicit about the additional information required, decide how these data should be collected and assessed and the methods that should be used to set a fair price for a new drug.

Pharmaceutical Availability across Levels of Care: Evidence from Facility Surveys in Ghana, Kenya, and Uganda
Masters SH, Burstein R, DeCenso B, Moore K, Haakenstad A, et al: PLoS ONE 9(12), 31 December 2014

In this study the authors use facility-level data from nationally representative surveys conducted in Ghana, Kenya, and Uganda in 2012 to understand pharmaceutical availability within the three countries. The authors both availability of essential medicines, as defined by the various essential medicine lists (EMLs) of each respective country, and availability of all surveyed pharmaceuticals deemed important for treatment of various high-burden diseases, including those on the EMLs. The authors find that there is heterogeneity with respect to availability across the three countries with Ghana generally having better availability than Uganda and Kenya. They found that the factors associated with stock-out vary by country, but across all countries both presence of a laboratory at the facility and of a vehicle at the facility are significantly associated with reduced stock-out. The study highlights poor availability of essential medicines across these three countries and suggest more needs to be done to strengthen the supply system so that stock remains uninterrupted.

The Vaccine and Cervical Cancer Screen (VACCS) project: Acceptance of human papillomavirus vaccination in a school-based programme in two provinces of South Africa
Botha MH, Haynes van der Merwe F, Snyman LC, Dreyer G: South African Medical Journal 105(1), 28 November 2014

The incidence of cervical cancer in South Africa remains high, and the current screening programme has had limited success. New approaches to prevention and screening tactics are needed to investigate acceptance of school-based human papillomavirus (HPV) vaccination, as well as the information provided, methods of obtaining consent and assent, and completion rates achieved. Information on cervical cancer and HPV vaccination was provided to 19 primary schools in Western Cape and Gauteng provinces participating in the study. Girls with parental consent and child assent were vaccinated during school hours at their schools. A total of 3 465 girls were invited to receive HPV vaccine, of whom 2 046 provided written parental consent as well as child assent. Sufficient vaccination was achieved in 92% of the vaccinated cohort. The implementation project demonstrated that HPV vaccination is practical and safe in SA schools. Political and community acceptance was good, and positive attitudes towards vaccination were encountered. During the study, which mimicked a governmental vaccine roll-out programme, high completion rates were achieved in spite of several challenges encountered.

Where Do the Rural Poor Deliver When High Coverage of Health Facility Delivery Is Achieved? Findings from a Community and Hospital Survey in Tanzania
Straneo M, Fogliati P, Azzimonti G, Mangi S, Kisika F: PLoS ONE 9(12), December 2014

As part of maternal mortality reducing strategies, coverage of delivery care among sub-Saharan African rural poor will improve, with a range of facilities providing services. Whether high coverage will benefit all socio-economic groups is unknown. Iringa rural District, Southern Tanzania, with high facility delivery coverage, offers a place to address this question. Delivery services are available in first-line facilities (dispensaries, health centres) and one hospital. The authors assessed whether all socio-economic groups access the only comprehensive emergency obstetric care facility equally, and surveyed existing delivery services. Hospital population socio-demographic characteristics were compared to District population using multivariable logistic regression. Women from the hospital compared to the district population were more likely to be wealthier. Poorer women remain disadvantaged even where coverage is high, as they access lower level facilities and are under-represented where life-saving transfusions and caesarean sections are available.

8. Human Resources

A Community Health Worker “logic model”: towards a theory of enhanced performance in low- and middle-income countries
Naimoli JF, Frymus DE, Wuliji T, Franco LM and Newsome MH: Human Resources for Health12(56), 2014

There has been a resurgence of interest in national Community Health Worker (CHW) programs in low- and middle-income countries (LMICs). A lack of strong research evidence persists, however, about the most efficient and effective strategies to ensure optimal, sustained performance of CHWs at scale. To facilitate learning and research to address this knowledge gap, the authors developed from document review and consultations a generic CHW logic model that proposes a theoretical causal pathway to improved performance. The logic model draws upon available research and expert knowledge on CHWs in LMICs. The generic CHW logic model posits that optimal CHW performance is a function of high quality CHW programming, which is reinforced, sustained, and brought to scale by robust, high-performing health and community systems, both of which mobilize inputs and put in place processes needed to fully achieve performance objectives. Multiple contextual factors can influence CHW programming, system functioning, and CHW performance.The model is argued to offer new thinking about CHWs. It places CHW performance at the center of the discussion about CHW programming, recognizes the strengths and limitations of discrete, targeted programs, and is comprehensive, reflecting the current state of both scientific and tacit knowledge about support for improving CHW performance. It offers guidance for continuous learning about what works.

Community health workers programme in Luanda, Angola: an evaluation of the implementation process
Giugliani C, Duncan BB, Harzheim E, Lavor AC, Lavor MC, Machado MM, Barbosa MI, Bornstein VJ, Pontes AL and Knauth DR: Human Resources for Health 12(68), 9 December 2014

The Community Health Workers (CHWs) Programme was launched in Luanda, Angola, in 2007 as an initiative of the provincial government. The aim of this study was to assess its implementation process. This is a case study using document analysis, CHWs reports, individual interviews and focal groups. Until June 2009, the programme had placed in the community 2548 trained CHWs, providing potential coverage for 261 357 families. Analysis of qualitative data suggested an association of CHWs with improvements in maternal and child access to health care, as well as an increase in the demand for health services, generating further need to improve service capacity. Nevertheless, critical points for programme sustainability were identified. For continuity and scaling up, the programme needs medium- and long-term technical, political and financial support.

Effects of a performance and quality improvement intervention on the work environment in HIV-related care: a quasi-experimental evaluation in Zambia
Bazant E, Sarkar S, Banda J, Kanjipite W, Reinhardt S, Shasulwe H, Mulilo JMC, Kim YM: Human Resources for Health, 13 (1), 14 January 2015

At health facilities of the Zambian Defence Forces, a performance and quality improvement approach was implemented to improve HIV-related care and was evaluated in 2010/2011. Changes in providers’ work environment and perceived quality of HIV-related care were assessed to complement data on provider performance. The intervention involved on-site training, supportive supervision, and action planning focusing on detailed service delivery standards. The quasi-experimental evaluation collected pre- and post-intervention data from eight intervention and comparison facilities matched on defence force branch and baseline client volume. The intervention group providers reported improvements in the work environment on adequacy of equipment, feeling safe from harm, confidence in clinical skills, and reduced isolation, while the comparison group reported worsening of the work environment on supplies, training, safety, and departmental morale. The performance and quality improvement intervention implemented at Zambian Defence Forces’ health facilities was associated with improvements in providers’ perceptions of work environments consistent with the intervention’s focus on commodities, skills acquisition, and receipt of constructive feedback.

9. Public-Private Mix

Does Ownership Matter? An Overview of Systematic Reviews of the Performance of Private For-Profit, Private Not-For-Profit and Public Healthcare Providers
Herrera CA, Rada G, Kuhn-Barrientos L, Barrios X: PLoS ONE 9(12), 1 December 2014

Ownership of healthcare providers has been considered as one factor that might influence their health and healthcare related performance. The authors provide an overview of what is known about the effects on economic, administrative and health related outcomes of different types of ownership of healthcare providers -namely public, private non-for-profit (PNFP) and private for-profit (PFP)- based on the findings of systematic reviews (SR). Of the 5918 references reviewed, fifteen SR were included, but six of them were rated as having major limitations, so they weren't incorporated in the analyses. According to the nine analysed SR, ownership does seem to have an effect on health and healthcare related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of mortality of patients and payments to facilities have been found, both being higher in PFP facilities. In terms of quality and economic indicators such as efficiency, there are no conclusive results. When comparing PNFP and public providers, as well as for PFP and public providers, no clear differences were found. PFP providers seem to have worst results than their PNFP counterparts, but there are still important evidence gaps in the literature that needs to be covered, including the comparison between public and both PFP and PNFP providers. More research is needed in low and middle income countries to understand the impact on and development of healthcare delivery systems.

10. Resource allocation and health financing

Costs of Eliminating Malaria and the Impact of the Global Fund in 34 Countries
Zelman B, Kiszewski A, Cotter C, Liu J: PLoS ONE 9(12), December 2014

This study aims to 1) assess past total and Global Fund funding to the 34 current malaria-eliminating countries, and 2) estimate their future funding needs to achieve malaria elimination and prevent reintroduction through 2030. Historical funding is assessed against trends in country-level malaria annual parasite incidences (APIs) and income per capita. Following Kizewski et al. (2007), program costs to eliminate malaria and prevent reintroduction through 2030 are estimated using a deterministic model. The cost parameters are tailored to a package of interventions aimed at malaria elimination and prevention of reintroduction.The majority of Global Fund-supported countries experiencing increases in total funding from 2005 to 2010 coincided with reductions in malaria APIs and also overall GNI per capita average annual growth. The total amount of projected funding needed for the current malaria-eliminating countries to achieve elimination and prevent reintroduction through 2030 is approximately US$8.5 billion, or about $1.84 per person at risk per year (PPY). Although external funding, particularly from the Global Fund, has been key for many malaria-eliminating countries, sustained and sufficient financing is argued to be critical for furthering global malaria elimination.

The administrative costs of community-based health insurance: a case study of the community health fund in Tanzania
Borghi J, Makawia S, Kuwawenaruwa A: Health Policy and Planning 30 (1)19-27, December 2014

Community-based health insurance expansion has been proposed as a financing solution for the sizable informal sector in low-income settings. However, there is limited evidence of the administrative costs of such schemes. We assessed annual facility and district-level costs of running the Community Health Fund (CHF), a voluntary health insurance scheme for the informal sector in a rural and an urban district from the same region in Tanzania. Information on resource use, CHF membership and revenue was obtained from district managers and health workers from two facilities in each district. The administrative cost per CHF member household and the cost to revenue ratio were estimated. Revenue collection was the most costly activity at facility level (78% of total costs), followed by stewardship and management (13%) and pooling of funds (10%). Stewardship and management was the main activity at district level. The administration cost per CHF member household ranged from USD 3.33 to USD 12.12 per year. The cost to revenue ratio ranged from 50% to 364%. The cost of administering the CHF was high relative to revenue generated. Similar studies from other settings should be encouraged.

11. Equity and HIV/AIDS

Feasibility and acceptability of a bar-based sexual risk reduction intervention for bar patrons in Tshwane, South Africa
Morojele NK, Kitleli N, Ngako K, Kekwaletswe CT, Nkosi S, Fritz K, Parry CDH: SAHARA J (Journal of Social Aspects of HIV/AIDS Research Alliance) 11(1), 2014

Alcohol consumption is a recognised risk factor for HIV infection. Alcohol serving establishments have been identified as appropriate venues in which to deliver HIV prevention interventions. This paper describes experiences and lessons learnt from implementing a combined HIV prevention intervention in bar settings in one city- and one township-based bar in Tshwane, South Africa. The intervention consisted of peer-led and brief intervention counselling sub-components. Thirty-nine bar patrons were recruited and trained, and delivered HIV and alcohol risk reduction activities to their peers as peer interventionists. At the same time, nine counselors received training and visited the bars weekly to provide brief motivational interviewing counselling, advice, and referrals to the patrons of the bars. The intervention was overall well received and suggests that bar patrons and servers can accept a myriad of intervention activities to reduce sexual risk behaviour within their drinking settings. However, HIV- and AIDS-related stigma hindered participation in certain intervention activities. The buy-in received from the relevant stakeholders (i.e. bar owners/managers and patrons, and the community at large) was an important contributor to the feasibility and acceptability of the intervention.

12. Governance and participation in health

Annotated bibliography on participatory consultations to help aid the inclusion of marginalized perspectives in setting policy agendas
Siddiqui FR: International Journal for Equity in Health 13(124), December 2014

This bibliography presents studies from peer-reviewed and grey literature that used consultations and other participatory strategies to capture a community’s perspective of their health priorities, and of techniques used to elevate participation from the implementation phase to a more upstream phase of prioritisation, policymaking and agenda setting. It covers studies that worked with marginalised populations or sub-populations. It begins by first offering some philosophical and conceptual frameworks that link participatory interventions with inclusive policy making or agenda setting, and a rationale for prioritising marginalised populations in such an undertaking. It further looks at various participatory instruments for consultations, for reaching out to marginalised populations, and for communicating the results to policymakers. A final section presents a reflective and evaluative look at the recruitment, instruments and examples.

Attitudes of Gatekeepers Towards Adolescent Sexual and Reproductive Health in Ghana
Kumi-Kyereme A, Awusabo-Asare K, Darteh EKM: African Journal of Reproductive Health 18(3), September 2014

Adults constitute gatekeepers on adolescent sexual and reproductive health (ASRH). This qualitative paper discusses the views of adults on ASRH problems and challenges based on 60 in-depth interviews conducted among adults in Ghana in 2005. Adults were purposively selected based on their roles as parents, teachers, health care providers and community leaders. The major ASRH problems mentioned were teenage pregnancy and HIV/AIDS. The results indicated a number of challenges confronting ASRH promotion including resistance from parents, attitudes of adolescents, communication gap between adults and adolescents and attitudes of health care providers. Among health workers three broad categories were identified: those who were helpful, judgmental and dictators. Some adults supported services for young people while others did not. Some served as mediators and assisted to ‘solve’ ASRH problems, which occurred in their communities. It is argued that exploring the views of adults about their fears and concerns will contribute to the development of strategies and programmes which will help to improve ASRH,

The state of HIV sector local governance in Malawi and Zambia: Evidence from five districts
Steyn J: Commonwealth Journal of Local Governance 15, 128-140, 2014

This paper reports on a project that aimed to improve the levels of HIV governance at the district level in Malawi and Zambia by encouraging public participation in an effort to more effective use of local resources. The methodology for this project included a barometer which assessed perceptions among key stakeholders on effectiveness, efficiency, rule of law, accountability, participation and equity at district level. The stakeholders ranged from administrators, political representatives, community-based organisations and the private sector on the supply side and citizens on the demand or beneficiary side. Communication and transparency appear to be major issues underpinning the bottlenecks and shortcomings in the HIV sector governance at the district level. Information gaps have given rise to accountability deficits and coordination deficiencies. Addressing these matters would make more effective use of resources and lessen dependence on external funding sources.

13. Monitoring equity and research policy

Development of Health Equity Indicators in Primary Health Care Organizations Using a Modified Delphi
Wong ST, Browne AJ, Varcoe C, Lavoie J, Fridkin A, Smye V, Godwin O, Tu D: PLoS ONE 9(12): e114563. doi:10.1371/journal.pone.0114563

The purpose of this study was to develop a core set of indicators that could be used for measuring and monitoring the performance of primary health care organizations' capacity and strategies for enhancing equity-oriented care. Indicators were constructed based on a review of the literature and a thematic analysis of interview data with patients and staff using procedures for qualitatively derived data. Indicators were considered part of a priority set of health equity indicators if they received an overall importance rating of>8.0, on a scale of 1–9, where a higher score meant more importance. Seventeen indicators make up the priority set. Items were eliminated because they were rated as low importance (<8.0) in both rounds and were either redundant or more than one participant commented that taking action on the indicator was highly unlikely. The indicators assess performance of staff and outcomes which can be directly attributable to equity responsive primary health care.

Indicators for Universal Health Coverage: can Kenya comply with the proposed post-2015 monitoring recommendations?
Obare V, Brolan CE, Hill PS: International Journal for Equity in Health 13(123), 20 December 2014

Monitoring progress towards achieving Universal Health Coverage (UHC) is seen to be critical at both country and global level, and a monitoring framework for UHC was proposed by a joint WHO/World Bank discussion paper in December 2013. This study determined the feasibility of the proposed framework in Kenya. The study used the WHO/World Bank UHC monitoring framework and the Bellagio meeting report sponsored by WHO and the Rockefeller Foundation to informed the list of indicators used to determine the feasibility of the framework using published literature. Kenya has yet to establish an official policy on UHC that provides a clear mandate on the goals, targets and monitoring and evaluation of performance. The country has the capacity to reasonably report on five out of the seven proposed UHC indicators, but very limited capacity to report on the two service coverage indicators for the chronic condition and injury interventions and wider systemic challenges to meet the data requirements of the proposed UHC monitoring framework.

Qualitative research synthesis for health policy analysis: what does it entail and what does it offer?
Gilson L: Health Policy Plan. 29 (Suppl 3), 11 November 2014

This edition presents a set of five articles that, through synthesis of available research, seek to consolidate and develop the body of health policy analysis work in low- and middle-income countries. This work is found to be currently fragmented across geographic settings and policy issues, is more descriptive than analytic and is weakly theorized.

14. Useful Resources

2015 Elections in Africa: Africa Research Institute interactive resource page
Africa Research Institute, 15 January 2015

This page provides an election map where users can click on highlighted countries on the map for pop-up fact boxes and links to recommended reading, a timeline where users can scroll through for a chronological view of the year’s elections. There is also an area for further reading providing space to browse a variety of articles, from survey reports to ambassadorial blog posts on electoral systems and performance, by country.

Budget Bites
Africa Health Budget Network, January 2015

The Africa Health Budget Network is a group of African and global organizations and individuals already using or wishing to use budget advocacy as a tool to improve health service delivery in Africa. The network has three strands of work and provides formal training opportunities, events and tools. The network promotes learning and sharing within the network and coordinated and focused pressure on African leaders with respect to their health financing commitments.

Okayafrica’s Top Films of 2014
Sefaboyake J: December 2014

On this website Okayafrica have picked some of the finest cinema originating from the continent from 2014. Some have courted controversy for their subject matter while others have been heralded as highly imaginative celebrations of Afrofuturist landscapes from the past to the present. The projects, from rising stars and celebrated auteurs alike, come from Mauritania, Ghana, South Africa, Nigeria and Kenya include documentaries, anthology films, full-length features and shorts. They address topics as varied as excessive use of police force in a South African mining community to vignettes delving into the lives of Kenya’s LGBTQI community. Each of these films (and filmmakers) are reported to push cinema boundaries in the stories they tell.

15. Jobs and Announcements

Call for Applications: 2015 Small Grants Programme for Thesis Writing
deadline for the receipt of applications: Wednesday 15th April, 2015.

The Council for the Development of Social Science Research in Africa (CODESRIA) announces the twenty-sixth session of its Small Grants Programme for Thesis Writing. The grants serve as part of the Council’s contribution to the development of the social sciences in Africa, and the continuous renewal and strengthening of research capacities in African universities, through the funding of primary research conducted by graduate and postgraduate students. Candidates whose applications are successful are encouraged to use the resources provided under the grants to cover the cost of their fieldwork, the acquisition of books and documents, the processing of data which they have collected and the printing of their theses/dissertations. As the Council is strongly committed to encouraging African researchers to engage one another on a sustained basis, recipients of the small grants will also be supported to order books and journals produced by African scholarly publishers, including CODESRIA itself. They will also be encouraged to apply for participation in CODESRIA research methodology workshops.

Call for Grant Applications or/and letters of interest: Selection of universities to manage TDR International Post Graduate Training Scheme (2015 to 2019)
Deadline 28 February 2015

This call is for applications from universities in low- and middle-income countries (LMICs) to host and manage the TDR international post graduate training scheme on implementation research (IR). The long term goal is to strengthen capacity of disease endemic countries for identifying public health needs, develop appropriate solutions and translate them into policy and practice for improved health and wellbeing of their populations.

Call for papers: Towards the 8th Pan African Congress
Congress date: March 2015

Veteran and young Pan Africanist leaders will meet to discuss Pan Africanism and a vision for Africa’s future in March 2015 in Accra. Towards the 8th Congress in 2015, the Local Organising Committee is inviting papers from all Africans on the continent and the Diaspora. Some of the papers will be presented at the plenaries and working groups during the 8th Congress and the will be published as part of post Congress for knowledge building. Authors can choose to write one or two papers from a list provided or propose a topic of interests within the wider Pan African discourse. Papers can either be in French or English and will be subject to peer review. Submissions should be presented in soft copy, double spaced and not more than 3,000 words. For information on the themes please visit the link and email papers to zyeebo@gmail.com.

Call of Expressions of Interest: Politics of Domestic Resource Mobilization for Social Development: Zimbabwe Case Study
Project from: 2011 to 2015

UNRISD invites expressions of interest from researchers for two further research papers for its ongoing project case study on Zimbabwe from researchers with extensive expertise on Zimbabwe, either on taxation or social policy. Two papers will be commissioned as a result of this call: The Political Economy of Taxation and Fiscal Governance in Zimbabwe and Social Policy and Social Spending in Zimbabwe.

Multinational Working Groups 2015 Competition
Deadline: February 28, 2015

The Council for the Development of Social Science Research in Africa (CODESRIA) invites proposals from African and Diaspora researchers for its 2015 Multinational Working Groups Competition. The Council’s Multinational Working Groups Competition is for researchers to explore themes covering multiple countries. Researchers should apply as individuals with clearly-thought out projects. CODESRIA’s evaluators will identify the best applications and the Council will constitute groups of 12 to 15 researchers around dominant themes. Each group constituted will be led by a CODESRIA-appointed coordinator who will oversee group activities, follow up on progress by members, facilitate the exchange of ideas among group members and help ensure quality. The Multinational Working Groups Competition provides grants of USD 5000 to each researcher over a 15-month period to facilitate the completion of already-started work. Researchers are supposed to produce an article or book chapter at the end of the grant period.

National Research Forum: Evidence for advancing Universal Health Coverage in Zimbabwe
19th and 20th March 2015; MoHCC, NIHR, TARSC, Harare, Zimbabwe

The Ministry of Health and Child Care, the National Institute of Health Research and the Training and Research Support Centre in collaboration with the Technical Working Group on Universal Health Coverage and the ‘Rebuild programme’ is holding a one and a half day National Research Forum with the THEME “Evidence for advancing Universal Health Coverage (UHC) in Zimbabwe” on 19th and 20th March 2015 in Harare. The forum aims to gather people from all constituencies and sectors doing research on any aspect of UHC in Zimbabwe, to present and share their research findings, discuss the policy implications and identify priorities for future work. Registration for the conference will open on 5th January 2015, and interested delegates are asked to email to their name, institution, address and whether they can meet the registration fee or whether they need sponsorship for it.

PhD position at the Centre for Development and Environment / University of Bern in the R4D project "Towards food sustainability: Reshaping the coexistence of different food systems in South America and Africa
Deadline 20 February 2015

This PhD is part of a project that addresses the sustainability of food systems in Kenya and Bolivia. It is focusing on the five basic aspects of food sustainability: Food security, the right to food, poverty and inequality, environmental integrity, and social-ecological resilience. The aim of the project is to analyse different food systems according to these aspects, develop an framework for assessing ‘food sustainability’ in concrete contexts, formulate policies and discuss them in local to global policy dialogues and workshops to communicate the results.


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