EQUINET NEWSLETTER 171 : 01 May 2015

1. Editorial

Open Letter to his Excellency Jacob Zuma
Mia Couto, Chairperson, Fernando Leite Couto Foundation, Mozambique

We remember you in Maputo, in the 1980s, from that time you spent as a political refugee in Mozambique. Often our paths crossed on Julius Nyerere Avenue and we would greet each other with the casual friendliness of neighbours. Often I imagined the fears that you must have felt, as a person persecuted by the apartheid regime. I imagined the nightmares you must have experienced at night when you thought of the ambushes plotted against you and against your comrades in the struggle. But I don’t remember ever seeing you with a bodyguard. In fact it was we Mozambicans who acted as your bodyguards. For years we gave you more than a refuge. We offered you a house and we gave you security at the cost of our security. You cannot possibly have forgotten this generosity.

We haven’t forgotten it. Perhaps more than any other neighboring country, Mozambique paid a high price for the support we gave to the liberation of South Africa. The fragile Mozambican economy was wrecked. Our territory was invaded and bombed. Mozambicans died in defence of their brothers on the other side of the border. For us, Mr President, there was no border, there was no nationality. We were all brothers in the same cause, and when apartheid fell, our festivities were the same, on either side of the border.

For centuries Mozambican migrants, miners and peasants, worked in neighbouring South Africa under conditions that were not far short of slavery. These workers helped build the South African economy. There is no wealth in your country that does not carry the contribution of those who today are coming under attack.

For all these reasons, it is not possible to imagine what is going on in your country. It is not possible to imagine that these same South African brothers have chosen us as a target for hatred and persecution. It is not possible that Mozambicans are persecuted in the streets of South Africa with the same cruelty that the apartheid police persecuted freedom fighters, inside and outside the country. The nightmare we are living is more serious than that visited upon you when you were politically persecuted. For you were the victim of a choice, of an ideal that you had embraced. But those who are persecuted in your country today are guilty merely of having a different nationality. Their only crime is that they are Mozambicans. Their only offence is that they are not South Africans.

Mr President, the xenophobia expressed today in South Africa is not merely a barbaric and cowardly attack against “the others”. It is also aggression against South Africa itself. It is an attack against the “Rainbow Nation” which South Africans proudly proclaimed a decade or more ago. Some South Africans are staining the name of their motherland. They are attacking the feelings of gratitude and solidarity between nations and peoples. It is sad that your country today is in the news across the world for such inhuman reasons.

Certainly measures are being taken. But they are proving inadequate, and above all they have come late. The rulers of South Africa can argue everything except that they were taken by surprise. History was allowed to repeat itself. Voices were heard spreading hatred with impunity. That is why we are joining our indignation to that of our fellow Mozambicans and urging you: put an immediate end to this situation, which is a fire that can spread across the entire region, with feelings of revenge being created beyond South Africa’s borders. Tough, immediate and total measures are needed which may include the mobilization of the armed forces. For, at the end of the day, it is South Africa itself which is under attack.

Mr President, you know, better than we do, that police actions can contain this crime but, in the current context, other preventive measures must be taken. So that these criminal events are never again repeated.

For this, it is necessary to take measures on another scale, measures that work over the long term. Measures of civic education, and of exalting the recent past in which we were so close, are urgently needed. It is necessary to recreate the feelings of solidarity between our peoples and to rescue the memory of a time of shared struggles. As artists, as makers of culture and of social values, we are available so that, together with South African artists, we can face this new challenge, in unity with the countless expressions of revulsion born within South African society. We can still transform this pain and this shame into something which expresses the nobility and dignity of our peoples and our nations. As artists and writers, we want to declare our willingness to support a spirit of neighbourliness which is born, not from geography, but from a kinship of our common soul and shared history.

This editorial is reproduced from Brittle Paper and is an open letter addressed to President Zuma, written by award-winning Mozambican novelist Mia Couto.

People's March against Xenophobia: We are One
Coalition of trade unions, civil society and social movements in South Africa against Xenophobia

The attacks against foreigners in KwaZulu Natal, Johannesburg and other parts of our country are shameful. If we close our eyes, or turn away, we bring shame on ourselves. The attacks present South Africans to the world as a barbaric, violent and murderous nation. We are not. Our march will show another South Africa to ourselves and the world. We are the country of Nelson Mandela, Oliver Tambo and all people who gave their lives for freedom. In our freedom struggle we had vital help from our sisters, brothers and comrades throughout Africa and the World. In 1994 we voted for peace, not war. We have the fairest Constitution in the world - that protects ALL who live here.

We link arms with our sisters and brothers from other countries who live with us here in South Africa. We are proud our extended family transcends national borders, languages, cultures and religions - because we need each other, because we are one! We will march to celebrate our solidarity with everyone from other countries living amongst us - particularly the poor, people seeking refuge, and political and economic migrants who have come to our country to try and survive. We will march to show our deep concern and solidarity to all poor communities where chronic unemployment, inadequate housing, rising crime and bad schools have become the norm. We will march to appeal to people who live in poor communities not to resort to violence. Do not to be distracted by blaming people from other countries who are also poor. The poor of the world must unite!

We will march to expose employers who play one group of workers off against another in order to maximize their profit. They are part of the problem right across our Africa. Workers, do not to be fooled: recognize that it is only by uniting workers and communities within and across national borders that a real challenge to poverty, pay and conditions can be fought and won.

International solidarity helped end apartheid. Likewise, we must build unity within and across our national boundaries. Our struggle against all forms of oppression continues. Authorities must listen to our pleas, and improve and protect our communities and respond positively.
We are all human beings. We must be treat one another with respect, and live our lives in dignity. It is time for all good people to come together. We are the majority. We reject division, and it is time for real change! Don't turn away. Don't make excuses. Join us! Come from your school, workplace, union, your church, your university, your business, your community. Take three hours to march for life, dignity and equality. Together, let us show the world and our countrymen and women that another South Africa exists - where solidarity defeats xenophobia!

This call was made by South Africans for a march on 23 April that involved about 30,000 people through Johannesburg, to demand an end to a recent wave of xenophobic attacks.

2. Latest Equinet Updates

Contributions of global health diplomacy to equitable health systems in east and southern Africa, Report of a Regional Research Workshop, 13-14 March 2015, Johannesburg South Africa

This report presents the proceedings of a meeting held on March 13 and 14 a regional meeting was convened with objectives to
i. Present and discuss the findings from the EQUINET research programme and from related research in Africa, and the implications for policy, negotiations and programmes in east and southern Africa;
ii. Review methods and challenges for implementing research and analysis on global health diplomacy for policy relevance, from review of research and experience of the work;
iii. Discuss and propose areas for follow up policy, action and research, within ESA and through south-south collaboration. It included senior officials involved in health from national and regional organisations, health diplomats, researchers from the EQUINET work and others working on health diplomacy and on south-south co-operation in the region and internationally.

Strengthening the capacities health centre committees as health advocates in Zimbabwe
CWGH; TARSC; EQUINET Case study Brief, Harare 2015

Health Centre Committees (HCCs) in Zimbabwe have made a vital contribution to health services and community health. HCCs have supported health activities and played a role in discussing how funds including those from fee collections are used in the clinics. In 2011 training materials were developed jointly by TARSC, CWGH and MoHCC for an approximately three to four day training for HCCs on these roles using participatory tools. This case study brief outlines the training of HCC members and of community members in health literacy.

3. Equity in Health

Determinants of immunization inequality among urban poor children: evidence from Nairobi’s informal settlements
Egondi T; Oyolola M; Mutua MK; Elung’ata P: International Journal for Equity in Health, 14(24), February 2015

Despite the relentless efforts to reduce infant and child mortality with the introduction of the National Expanded Programmes on Immunization in 1974, major disparities still exist in immunization coverage across different population sub-groups. In Kenya, while the proportion of fully immunized children increased from 57% in 2003 to 77% in 2008–9 at national level and 73% in Nairobi, only 58% of children living in informal settlement areas are fully immunized. This study aimed to determine the degree and determinants of immunization inequality among the urban poor of Nairobi, using data from the Nairobi Cross-Sectional Slum Survey of 2012 on full immunization status among children aged 12–23 months. The wealth index was used as a measure of social economic position for inequality analysis. Immunization inequality was found to be mainly concentrated among children from poor families. Decomposition of the results suggests that 78% of this inequality is largely explained by the mother’s level of education. The author suggests that efforts to reduce this inequality should aim at targeting mothers with low levels of education during immunization campaigns.

Distance decay and persistent health care disparities in South Africa
McLaren ZM; Ardington C; Leibbrandt M: BMC Health Services Research, 14(54), 2014

Access to health care is a particular concern given the important role of poor access in perpetuating poverty and inequality. South Africa has large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, even in remote rural areas. However, even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Using newly available health care utilization data from the first nationally representative panel survey in South Africa, together with administrative geographic data from the Department of Health, the authors use graphical and multivariate regression analysis to investigate the role of distance to the nearest facility on the likelihood of having a health consultation or an attended birth. Ninety percent of South Africans live within 7 km of the nearest public clinic, and two-thirds live less than 2 km away. However, 14% of Black African adults live more than 5 km from the nearest facility, compared to only 4% of Whites, and they are 16 percentage points less likely to report a recent health consultation and 47 percentage points less likely to use private facilities. Racial differentials in the likelihood of having a health consultation or an attended birth persist even after controlling for confounders. The results have two policy implications: minimizing the distance that poor South Africans must travel to obtain health care and improving the quality of care provided in poorer areas will reduce inequality.

4. Values, Policies and Rights

Breaking the Rules 2014: Evidence of Violations of the International Code of Marketing of Breastmilk Substitutes and subsequent resolutions compiled from January 2011 to December 2013
International Baby Food Action Network: May 2014

Breaking the Rules 2014 (BTR) is a 237-page monitoring report which describes evidence of 813 Code violations, from 81 countries, collected between Jan 2011 and Dec 2013. The Rules are the International Code of Marketing of Breastmilk Substitutes and subsequent World Health Assembly resolutions (the Code), which are the yardstick to measure compliance by all companies in all countries. Following the request for clarification of ‘inappropriate promotion’ of foods for infants and young children, BTR: in Brief provides examples of marketing tactics that should not be allowed. The emphasis is on toddler milks or growing up milks (GUMs), a product which has been generating huge profits for the baby food industry over the past decade or more. The inappropriate promotions reported are Code violations. This abridged report is meant to show how the 16 largest baby food companies continue to ignore international recommendations adopted to protect infants and young children the world over so the public and investors can hold them to account.

Global malaria eradication and the importance of Plasmodium falciparum epidemiology in Africa
Snow RW: BMC Medicine 13(23), February 2015 doi:10.1186/s12916-014-0254-7

The global agenda for malaria has, once again, embraced the possibility of eradication. The author argues that as history has shown, there will be no single magic bullet that can be applied to every epidemiological setting. Africa has a diverse malaria ecology, lending itself to some of the highest disease burden areas of the world and a wide range of clinical epidemiological patterns making control with our current tools challenging. This commentary highlights why the epidemiology of Plasmodium falciparum malaria in Africa should not be forgotten when planning an eradication strategy, and why forgetting Africa will, according to the author, once again, be the single largest threat to any hope for global eradication.

Health in the sustainable development goals: ready for a paradigm shift?
Buse K; Hawkes S: Globalization and Health 2015, 11(13), 2015 doi:10.1186/s12992-015-0098-8

The Millennium Development Goals (MDGs) galvanised attention, resources and accountability on a small number of health concerns of low- and middle-income countries with unprecedented results. The international community is presently developing a set of Sustainable Development Goals as the successor framework to the MDGs. This review examines the evidence base for the current health-related proposals in relation to disease burden and the technical and political feasibility of interventions to achieve the targets. In contrast to the MDGs, the proposed health agenda aspires to be universally applicable to all countries and is broad in encompassing both communicable and non-communicable diseases as well as emerging burdens from, among other things, road traffic accidents and pollution. The authors argue that success in realising the agenda requires a paradigm shift in: 1) ensuring leadership for intersectoral coherence and coordination on the structural drivers of health; 2) shifting the focus from treatment to prevention through locally-led, politically-smart approaches to a far broader agenda; 3) identifying effective means to tackle the commercial determinants of ill-health; 4) further integrating rights-based approaches; and 5) enhancing civic engagement and ensuring accountability. The authors are concerned that neither the international nor the global health community truly appreciates the extent of the shift required to implement this health agenda which is a critical determinant of sustainable development.

South Africa's new food and nutrition policy fails to address constitutional right to food
Moyo B: Pambuzuka News 716, 4 March 2015

The author argues that the proposed food policy in South Africa shies away from confronting capital interests within the food value-chain. Apart from acknowledging that the emerging agricultural sector is in need of assistance, the policy is reported to be silent on the influence of big-business in the food system.

Strengthening the protection of sexual and reproductive health and rights in the African Region through human rights
Ngwena C; Durojaye E: Pretoria University Law Press, 2014

Strengthening the protection of sexual and reproductive health and rights in the African region through human rights uses rights-based frameworks seeks to address some of the serious sexual and reproductive health challenges that the African region is currently facing. The authors provide human rights approaches on how these challenges can be overcome. Human rights issues addressed by the book include: emergency obstetric care; HIV/AIDS; adolescent sexual health and rights; early marriage; and gender-based sexual violence.

5. Health equity in economic and trade policies

Corporate social responsibility in global health: an exploratory study of multinational pharmaceutical firms
Droppert H; Bennett S: Globalization and Health 2015, 11(15), April 2015

As pharmaceutical firms experience increasing civil society pressure to act responsibly, many are expanding and/or reforming their corporate social responsibility (CSR) strategies. The author’s sought to understand how multinational pharmaceutical companies currently engage in CSR activities in developing countries and their motivations for doing so. They conducted a small-scale, exploratory study combining (i) in-depth review of publicly available data on pharmaceutical firms’ CSR with (ii) interviews of representatives from 6 firms, purposively selected, from the highest earning pharmaceutical firms worldwide. Corporate social responsibility differed for each firm. Across the firms studied, the common CSR activities were: differential pharmaceutical pricing, strengthening developing country drug distribution infrastructure, mHealth initiatives, and targeted research and development. Primary factors that motivated CSR engagement were: reputational benefits, recruitment and employee satisfaction, better rankings in sustainability indices, entrance into new markets, long-term economic returns and improved population health. CSR strategies ranged from philanthropic donations to integrated business models. The authors indicate that the study points to the need to (i) develop clearer definitions of CSR in global health (2) strengthen indices to track CSR strategies and their public health effects in developing countries and (iii) undertake more country level studies that investigate how CSR engages with national health systems.

Improving regulatory capacity to manage risks associated with trade agreements
Walls HL; Smith RD; Drahos P: Globalization and Health 2015, 11(14), 2015 doi:10.1186/s12992-015-0099-7

Modern trade negotiations have delivered a plethora of bilateral and regional preferential trade agreements (PTAs), which involve considerable risk to public health, thus placing demands on governments to strengthen administrative regulatory capacities in regard to the negotiation, implementation and on-going management of PTAs. In terms of risk management, the administrative regulatory capacity requisite for appropriate negotiation of PTAs is different to that for the implementation or on-going management of PTAs, but at all stages the capacity needed is expensive, skill-intensive and requires considerable infrastructure, which smaller and poorer states especially struggle to find. It is also a task generally underestimated. If states do not find ways to increase their capacities then PTAs are likely to become much greater drivers of health inequities. Developing countries especially struggle to find this capacity. In this article the authors set out the importance of administrative regulatory capacity and coordination to manage the risks to public health associated with PTAs, and suggest ways countries can improve their capacity.

6. Poverty and health

Our Toilets Are Dirty: Report of the Social Audit into the Janitorial Service for Communal Flush Toilets in Khayelitsha, Cape Town
Social Justice Coalition; Ndifuna Ukwazi (Dare to Know): October 2014

Millions of South Africans still lack access to basic sanitation, including at least 500 000 in Cape Town. The report found that 26 percent of the toilets in Khayelitsha’s informal settlements do not work, with 15 percent of them blocked, 12 percent without water, and 6 percent without a sewage pipe. The report’s key findings also showed a lack of proper worker safeguards: janitors do not have proper training, protective gear, or the required cleaning equipment, and only one in eight cleaners is inoculated against disease. By attempting to verify public service delivery and facilitating transparency and accountability, the community-led social audit approach has been successful in exposing—and, over time, reducing—corruption and enhancing basic services in India and Ghana, and elsewhere in the global South. In South Africa, the community used a social audit to investigate how ZAR 60 million (about US$5 million) of public resources was utilized. The audit included the residents of Khayelitsha and various partners in inspecting 528 toilets and interviewing 193 Khayelitsha residents and 31 janitors. The report calls for specific and workable government actions to rectify gaps in services that are provided by the private sector via the local municipality.

The Prospects and Politics of Social Protection Reform in Zambia
Kuss MK: Institute of Development Studies Working Paper 453, April 2015

This paper analyses the prospects for social protection reform in Zambia under the ‘pro-poor’ government of the Patriotic Front (PF). The paper argues that the PF has been changing the development policy arena in ways that may modify domestic political structures providing more rights-based benefits especially for the extreme poor and vulnerable. It further argues that the persistence of the clientelistic dynamics of state-society relations and weak civil society organisations inhibit the expression of demands for formal social protection by poor people. It concludes that because the social protection reform is supply -, rather than demand-driven, its progress depends on the extent to which the government is motivated to sustain the provision of social protection in the long-run.

7. Equitable health services

A Wake-up Call - Lessons from Ebola for the world's health systems
Wright S; Hanna L; Mailfert M; Gushulvili D; Kite G: Save the Children 2015

Ebola has taken a dreadful toll in the three West African countries hit by the current outbreak – Guinea, Sierra Leone and Liberia. In this report, Save the Children documents the existing weaknesses of the health services in the three main countries affected by Ebola. There is broad agreement that the Ebola crisis was not quickly contained, reversed or mitigated because national health systems in these countries were dangerously under-resourced, under-staffed and poorly equipped. The virus was able to spread, in part, due to the poor state of these health services, which were quickly overwhelmed and lacked the ability to cope with a major disease outbreak. This inability to cope with a major health emergency reflects a similar inability to cope with the daily health needs of their populations over the longer term. The authors argue that one of the most important lessons from the Ebola crisis is the need to build comprehensive health services with sufficient funding, staff and equipment, to deal with everyday problems as well as infectious
disease outbreaks.

Drivers of routine immunisation coverage improvement in Africa: findings from district-level case studies
LaFond A; Kanagat N; Steinglass R; Fields R; Sequeira J; Mookherji S: Health Policy and Planning 30(3) 298-308, 2014

There is limited understanding of why routine immunisation (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, the authors conducted in-depth case studies to understand pathways to coverage improvement by comparing immunisation programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques the authors compared the experience of districts where diphtheria–tetanus–pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunisation services and drivers of coverage improvement. The results informed a model for immunisation coverage improvement that emphasises the dynamics of immunisation systems at district level. In all districts, whether improving or steady, the authors found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. They found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness and identified six common drivers of RI coverage performance improvement—four direct drivers and two enabling drivers—that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasise the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunisation system performance.

E-procurement in support of universal health coverage
Humphreys G: Bulletin of the World Health Organization, 93(3) 138-139, 2015

Kenya is gearing up for digital bidding on essential medicines’ contracts, part of a wave of African countries looking at procurement to improve transparency, bring down costs and support universal health coverage. John Kabuchi, procurement manager for the Kenya Medical Supplies Authority, notes: “We are currently gearing up for full e-procurement functionality, including electronic bidding, and I am hopeful that supporting legislation will be passed before next June.” Kenya hopes to make the most of new technologies and approaches, such as e-procurement, to support efforts to make essential health care more widely available.

Factors influencing the use of maternal healthcare services and childhood immunization in Swaziland
Tsawe M; Moto A; Netshivhera T; Ralesego L; Nyathi C; Susuman AS: International Journal for Equity in Health, 14(32), 2015 doi:10.1186/s12939-015-0162-2

This study examined the factors that influence the use of maternal healthcare services and childhood immunization in Swaziland. The study used secondary data from the Swaziland Demographic and Health Survey 2006–07 using univariate, bivariate and multivariate analysis. The study findings showed a high use rate of antenatal care and delivery care and a low rate of postnatal care use. The uptake of childhood immunization is high, averaging more than 80%. Factors found to be influencing the use of maternal healthcare and childhood immunization included: woman’s age, parity, media exposure, maternal education, wealth quintile, and residence. Programs to educate families about the importance of maternal and child healthcare services should be implemented and should focus on: (a) age differentials in use of maternal and child health services, (b) women with higher parities, (c) women in rural areas, and (d) women from the poor quintiles.

Feasibility of establishing a biosafety level 3 tuberculosis culture laboratory of acceptable quality standards in a resource-limited setting: an experience from Uganda
Ssengooba W; Gelderbloem SJ; Mboowa G; Wajja A; Namaganda C; Musoke P; Mayanja-Kizza H; Joloba ML: Health Research Policy and Systems 13(4), 2015

Despite the recent innovations in tuberculosis (TB) and multi-drug resistant TB (MDR-TB) diagnosis, culture remains vital for difficult-to-diagnose patients, baseline and end-point determination for novel vaccines and drug trials. The authors share their experience of establishing a BSL-3 culture facility in Uganda as well as 3-years performance indicators and post-TB vaccine trials (pioneer) and funding experience of sustaining such a facility. Between September 2008 and April 2009, the laboratory was set-up with financial support from external partners. After an initial procedure validation phase in parallel with the National TB Reference Laboratory and legal approvals, the laboratory registered for external quality assessment and instituted a functional quality management system. Pioneer funding ended in 2012 and the laboratory remained self-sustainable with internationally acceptable standards in both structural and biosafety requirements. With the demonstrated quality of work, the laboratory attracted more research groups and post-pioneer funding, which helped to ensure sustainability. The high skilled experts in this research laboratory provide an excellent resource for national discussion of laboratory and quality management systems.

The “child size medicines” concept: policy provisions in Uganda
Nsabagasani X; Ogwal-Okeng; Mbonye A; Ssengooba F; Nantanda R; Muyinda H; Holme Hansen E: Journal of Pharmaceutical Policy and Practice 8(2), 2015 doi:10.1186/s40545-015-0025-7

In 2007, the World Health Organization (WHO) launched the ‘make medicines child size’ (MMCS) campaign by urging countries to prioritize procurement of medicines with appropriate strengths for children’s age and weight and, in child-friendly formulations of rectal and flexible oral solid formulations. This study examined policy provisions for MMCS recommendations in Uganda. This was an in-depth case study of the Ugandan health policy documents to assess provisions for MMCS recommendations in respect to oral and rectal medicine formulations for malaria, pneumonia and diarrhea, the major causes of morbidity and mortality among children in Uganda- diseases that were also emphasized in the MMCS campaign. Asthma and epilepsy were included as conditions that require long term care. Schistomiasis was included as a neglected tropical disease. Content analysis was used to assess evidence of policy provisions for the MMCS recommendations. For most medicines for the selected diseases, appropriate strength for children’s age and weight was addressed. However, policy documents neither referred to ‘child size medicines’ concept nor provided for flexible oral solid dosage formulations like dispersible tablets, pellets and granules- indicating limited adherence to MMCS recommendations. Some of the medicines recommended in the clinical guidelines as first line treatment for malaria and pneumonia among children were not evidence-based. The Ugandan health policy documents reflected limited adherence to the MMCS recommendations. This and failure to use evidence based medicines may result into treatment failure and or death. A revision of the current policies and guidelines to better reflect ‘child size’, child appropriate and evidence based medicines for children is recommended.

Understanding the dynamic interactions driving Zambian health centre performance: a case-based health systems analysis
Topp S; Chipukuma J; Hanefeld J: Health Policy and Planning, 30(4), 2014, doi: 10.1093/heapol/czu029

Despite being central to achieving improved population health outcomes, primary health centres in low- and middle-income settings continue to underperform. Little research exists to adequately explain how and why this is the case. This study aimed to test the relevance and usefulness of an adapted conceptual framework for improving understanding of the mechanisms and causal pathways influencing primary health centre performance. A theory-driven, case-study approach was adopted. Four Zambian health centres were purposefully selected with case data including health-care worker, patient and key informant interviews; direct observation of facility operations. Structural constraints included limited resources creating challenging service environments in which work overload and stockouts were common. Health workers’ frustration with such conditions interacted with dissatisfaction with salary levels eroding service values and acting as a catalyst for different forms of absenteeism. Such behaviours exacerbated patient–provider ratios and increased the frequency of clinical and administrative shortcuts. Weak health information systems and lack of performance data undermined providers’ answerability to their employer and clients, and a lack of effective sanctions undermined supervisors’ ability to hold providers accountable for these transgressions. Weak answerability and enforceability contributed to a culture of impunity that masked and condoned weak service performance in all four sites.

8. Human Resources

Public health nurse educators’ conceptualisation of public health as a strategy to reduce health inequalities: a qualitative study
Mabhala MA: International Journal for Equity in Health14(14), 2015 doi:10.1186/s12939-015-0146-2

Nurses have long been identified as key contributors to strategies to reduce health inequalities. This qualitative research project explored public health nurse educators’ understanding of public health as a strategy to reduce health inequalities. 26 semi-structured interviews were conducted with higher education institution-based public health nurse educators. Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health. Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than population approaches.

9. Public-Private Mix

Safe male circumcision in Botswana: Tension between traditional practices and biomedical marketing
KKatisia M; Daniela M: Global Public Health, DOI: 10.1080/17441692.2015.1028424 April 2015

Botswana has been running Safe Male Circumcision (SMC) since 2009 and has not yet met its target. The objective of this paper is to explore responses to SMC in relation to circumcision as part of traditional initiation practices. More specifically, the authors present the views of two communities in Botswana on SMC consultation processes, implementation procedures and campaign strategies. The methods used include participant observation, in-depth interviews with key stakeholders, community leaders and men in the community. The authors observe that consultation with traditional leaders was done in a seemingly superficial, non-participatory manner. While SMC implementers reported pressure to deliver numbers to the World Health Organisation, traditional leaders promoted circumcision through their routine traditional initiation ceremonies at breaks of two-year intervals. There were conflicting views on public SMC demand creation campaigns in relation to the traditional secrecy of circumcision. In conclusion, initial cooperation of local chiefs and elders was reported to have turned into resistance.

10. Resource allocation and health financing

Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue
Opwora A; Waweru E; Toda M; Noor A; Edwards T; Fegan G; Molyneux S; Goodman C: Health Policy and Planning, 30(4), 2014 doi: 10.1093/heapol/czu026

With user fees now seen as a major hindrance to universal health coverage, many countries have introduced fee reduction or elimination policies, but there is growing evidence that adherence to reduced fees is often highly imperfect. In 2004, Kenya adopted a reduced and uniform user fee policy providing fee exemptions to many groups. The authors present data on user fee implementation, revenue and expenditure from a nationally representative survey of 248 Kenyan public health centres and dispensaries in 2010. No facilities adhered fully to the user fee policy across eight tracer conditions, with adherence ranging from 62.2% for an adult with tuberculosis to 4.2% for an adult with malaria. Three quarters of exit interviewees had paid some fees and a quarter of interviewees were required to purchase additional medical supplies at a later stage from a private drug retailer. No consistent pattern of association was identified between facility characteristics and policy adherence. User fee revenues accounted for almost all facility cash income, with average revenue of USD 683 per facility per year. Fee revenue was mainly used to cover support staff, non-drug supplies and travel allowances. Adherence to user fee policy was very low, leading to concerns about the impact on access and the financial burden on households. However, the potential to ensure adherence was constrained by the facilities’ need for revenue to cover basic operating costs, highlighting the need for alternative funding strategies for peripheral health facilities.

Tax Experiments in Developing Countries: A Critical Review and Reflections on Feasibility
Mascagni G: CDI Practice Paper 11, March 2015

This CDI Practice Paper provides a critical assessment of the literature on tax experiments to date. It examines the main conceptual, methodological and data-related challenges, and provides practical reflections on how to move forward in low- and middle-income countries where this type of research is still underdeveloped. It offers a guide for practitioners on the main challenges in quantitative research on tax compliance and on the methods used tackle them, which may be of interest for evaluation research more generally.

11. Equity and HIV/AIDS

African ministers of finance call for increased investment to end the AIDS epidemic by 2030
UNAIDS, 1 April 2015

African ministers of finance and key partners in the AIDS response meeting in Addis Ababa, Ethiopia, have called for increased national investment to end the AIDS epidemic as a public health threat by 2030. The international community has committed to meeting the 90–90–90 treatment targets, under which 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression. If the 90–90–90 targets are met by 2020, ending the AIDS epidemic a decade later is achievable.

Hopes dashed as HIV measure found to be useless
Kahn T: BDLive, 25 February 2015

Hopes that a South African-developed vaginal gel containing tenofovir would protect women against HIV were dashed after a major new study found that it did not work. Scientists had been optimistic that the microbicide would protect millions of women from HIV, after a phase 2 study of 900 women in KwaZulu-Natal found it reduced the risk of getting the virus by 39%. The development was hailed as a breakthrough, though the scientists who led the work were careful to emphasise that further research was needed to replicate the findings. At that stage, 11 other trials testing six other products had failed. The findings had a wide margin of error, with the efficacy of HIV protection estimated to lie between 6% and 60%. A much larger Follow-on African Consortium for Tenofovir Studies (FACTS) 001 trial was launched in 2011 to confirm its findings. The consortium scientists announced at the annual Conference on Retroviruses and Opportunistic Infections in Seattle, however, that the tenofovir-containing microbicide provided to 2,059 women aged between 18 years and 30 years did not protect them from HIV.

US PEPFAR abstinence and faithfulness funding had no impact on sexual behaviour in Africa
Alcorn K: aidsmap, 25 February 2015

Nearly US$1.3 billion spent on US-funded programmes to promote abstinence and faithfulness in sub-Saharan Africa is argued by the author of this paper to have had no significant impact on sexual behaviour in 14 countries in sub-Saharan Africa, as shown from an analysis of sexual behaviour data. The preliminary findings were presented by Nathan Lo of Stanford University School of Medicine at the Conference on Retroviruses and Opportunistic Infections (CROI 2015) in Seattle, USA. The Pepfar programmes aimed to delay sexual debut in order to reduce the period of high risk during adolescence, especially for girls, and to reduce partner numbers. The study investigated trends in sexual behaviour derived from national Demographic and Health Surveys in 14 PEPFAR focus countries before and after the beginning of PEPFAR funding in 2004, and compared these to a counterfactual: trends in eight other African countries – largely in West Africa – where PEPFAR funding was not determining the content of prevention campaigns. They found no significant change in PEPFAR countries relative to non-PEPFAR countries over time for any of the measures assessed, for men or women, although there was a trend towards a lower number of reported sexual partners for men in both PEPFAR and non-PEPFAR countries.

12. Governance and participation in health

Community case management of malaria: exploring support, capacity and motivation of community medicine distributors in Uganda
Banek K; Nankabirwa J; Maiteki-Sebuguzi C; DiLiberto D; Taaka L; Chandler C; Staedke S: Health Policy and Planning, 30(4), 2014, doi: 10.1093/heapol/czu033

In Uganda, community services for febrile children are expanding from presumptive treatment of fever with anti-malarials through the home-based management of fever (HBMF) programme, to include treatment for malaria, diarrhoea and pneumonia through Integrated Community Case Management (ICCM). To understand the level of support available, and the capacity and motivation of community health workers to deliver these expanded services, the authors interviewed community medicine distributors (CMDs), who had been involved in the HBMF programme in Tororo district, shortly before ICCM was adopted. Between October 2009 and April 2010, 100 CMDs were recruited to participate by convenience sampling. The survey included questionnaires to gather information about the CMDs’ work experience and to assess knowledge of fever case management, and in-depth interviews to discuss experiences as CMDs including motivation, supervision and relationships with the community. CMDs faced multiple challenges including high patient load, limited knowledge and supervision, lack of compensation, limited drugs and supplies, and unrealistic expectations of community members. CMDs described being motivated to volunteer for altruistic reasons; however, the main benefits of their work appeared related to ‘becoming someone important’, with the potential for social mobility for self and family, including building relationships with health workers. At the time of the survey, over half of CMDs felt demotivated due to limited support from communities and the health system. Community health worker programmes rely on the support of communities and health systems to operate sustainably. When this support falls short, motivation of volunteers can wane. If community interventions, in increasingly complex forms, are to become the solution to improving access to primary health care, greater attention to what motivates individuals, and ways to strengthen health system support are required.

Our public water future: The global experience with remunicipalisation
Kishimoto S; Lobina E; Petitjean O: TNI, PSIRU, Multinationals Observatory, MSP and EPSU, 2015

After three decades of often catastrophic results, many cities, regions and countries are closing the book on water privatisation. A quiet citizen revolution is reported to be unfolding as communities across the world reclaim control of their water services to manage this crucial resource in a democratic, equitable and ecological way. Over the last 15 years, 235 cases of water remunicipalisation have been recorded in 37 countries. More than 100 million people have been affected by this global trend, whose pace is accelerating dramatically. From Jakarta to Paris, from Germany to the United States, this book draws lessons from this vibrant movement to reclaim water services. The authors show how remunicipalisation offers opportunities for developing socially desirable, environmentally sustainable and quality water services benefiting present and future generations. The book aims to engage citizens, workers and policy-makers in the experiences, lessons and good practices for returning water to the public sector.

Understanding The Rising Powers' Contribution to the Sustainable Development Goals
Constantine J; Pontual M: Institute of Development Studies Rapid Response Briefing 9, March 2015

Rising powers such as Brazil, India and China have been criticised for their inputs in the negotiations on the post-2015 development agenda. The start of the United Nations (UN) negotiations saw high expectations for the role of these countries in shaping the Sustainable Development Goals (SDGs) that have not materialised. However, what appears to be a confrontational style of diplomacy is in fact an assertive affirmation of long-standing principles. The G77 and China have consistently
called for the reform of the UN Security Council, and of the Bretton Woods institutions, which resulted in International Monetary Fund reform being nominally approved in 2010 before being blocked by the United States (US) Congress. The issues defended by the Brazilian negotiators centred on poverty eradication, its relationship with inequality; sustainable production and consumption; financing and keeping climate change strictly within the UNFCCC process. Brazil is keen to avoid what it sees as the securitisation of development through the SDGs. It supports governance as a general principle guiding the SDGs, but is adamant in its refusal to consider security as a stand-alone goal. The Brazilians are prioritising the ‘how’ of the SDGs, concentrating on the means of implementation for sustainable development through data disaggregation and exploring how to reutilise the structure of the MDGs as well as Brazil’s experience of participatory development in implementation. The authors argue that a more nuanced understanding of these countries’ positions in the post-2015 process is required.

13. Monitoring equity and research policy

A narrative review of research impact assessment models and methods
Milat AJ; Bauman AE; Redman S: Health Research Policy and Systems 13(18), 18 March 2015

Research funding agencies continue to grapple with assessing research impact. This narrative literature review synthesized evidence on processes and conceptual models used for assessing policy and practice impacts of public health research. The review involved keyword searches of electronic databases, including MEDLINE, CINAHL, PsycINFO, EBM Reviews, and Google Scholar in July/August 2013. The review included theoretical and opinion pieces, case studies, descriptive studies, frameworks and systematic reviews describing processes, and conceptual models for assessing research impact. A total of 16 different impact assessment models were identified, with the ‘payback model’ the most frequently used conceptual framework. Typically, impacts were assessed across multiple dimensions using mixed methodologies, including publication and citation analysis, interviews with principal investigators, peer assessment, case studies, and document analysis. The vast majority of studies relied on principal investigator interviews and/or peer review to assess impacts, instead of interviewing policymakers and end-users of research.

Climate for evidence informed health system policymaking in Cameroon and Uganda before and after the introduction of knowledge translation platforms: a structured review of governmental policy documents
Ongolo-Zogo P; Lavis JN; Tomson G; Sewankambo NK: Health Research Policy and Systems 13(2), 1 January 2015

There is a scarcity of empirical data on African country climates for evidence-informed health system policymaking (EIHSP) to backup the longstanding reputation that research evidence is not valued enough by health policymakers as an information input. In this paper, the authors assess whether and how changes have occurred in the climate for EIHSP before and after the establishment of two Knowledge Translation Platforms housed in government institutions in Cameroon and Uganda since 2006. The authors merged content analysis techniques and policy sciences analytical frameworks to guide this structured review of governmental policy documents geared at achieving health Millennium Development Goals. They combined i) a quantitative exploration of the usage statistics of research-related words and constructs, citations of types of evidence, and budgets allocated to research-related activities; and (ii) an interpretive exploration using a deductive thematic analysis approach to uncover changes in the institutions, interests, ideas, and external factors displaying the country climate for EIHSP. Descriptive statistics compared quantitative data across countries during the periods 2001–2006 and 2007–2012. The use of evidence syntheses to frame poverty and health problems, select strategies, or forecast the expected outcomes has remained sparse over time and across countries. The budgets for research increased over time from 28.496 to 95.467 million Euros (335%) in Cameroon and 38.064 to 58.884 million US dollars (155%) in Uganda, with most resources allocated to health sector performance monitoring and evaluation. The consistent naming of elements pertaining to the climate for EIHSP features the greater influence of external donors through policy transfer. The authors indicate that the review illustrated a conducive climate for EIHSP in Cameroon and Uganda but a persistent undervalue of evidence syntheses and recommend that global and national health stakeholders raise the profile of evidence syntheses (e.g., systematic reviews) as an information input when shaping policies and programmes.

Setting research priorities across science, technology, and health sectors: the Tanzania experience
de Haan S, Kingamkono R, Tindamanyire N, Mshinda H, Makandi H; Tibazarwa F; Kubata B; Montorzi G: Health Research Policy and Systems 13(14), 12 March 2015

Identifying research priorities is key to innovation and economic growth, since it informs decision makers on effectively targeting issues that have the greatest potential public benefit. The authors report here on a major cross-sectoral nationwide research priority setting effort recently carried out in Tanzania by the Tanzania Commission for Science and Technology (COSTECH) in partnership with the Council on Health Research for Development (COHRED) and the NEPAD Agency. The first of its type in the country, the process brought together stakeholders from 42 sub-sectors in science, technology, and health. The cross-sectoral research priority setting process consisted of a ‘training-of-trainers’ workshop, a demonstration workshop, and seven priority setting workshops with representatives from public and private research and development institutions, universities, non-governmental organisations, and other agencies affiliated to COSTECH. The workshops resulted in ranked listings of research priorities for each sub-sector, totalling approximately 800 priorities. This large number was significantly reduced by an expert panel in order to build a manageable instrument aligned to national development plans that could be used to guide research investments. The Tanzania experience is an instructive example of the challenges and issues to be faced in when attempting to identify research priority areas and setting a science, technology, and health research agenda in low- and middle-income countries. As countries increase their investment in research, it is essential to increase investment in research management and governance as well, to make proper use of research investments.

14. Useful Resources

Health literacy toolkit for low- and middle-income countries
Dodson S; Good S; Osborne R: WHO Regional Office for South-East Asia, 10 February 2015

This series of information sheets introduces health literacy, its relevance to public policy, and the ways it can be used to inform the promotion of good health, the prevention and management of communicable and noncommunicable diseases, and the reduction of health inequities. It provides information and links to further resources to assist organisations and governments to incorporate health literacy responses into practice, service delivery systems, and policy. It seeks to governments, politicians and policy makers; academic institutions; public, civil society, and non-governmental organisations; and practitioners; relevant private sectors promoting health and well-being; communities, community-based organisations and social networks; WHO and other UN partners and development organisations.

The SA SURE Project Stories of Change
Health Systems Trust: : SA SURE Stories of Change 1(1): January 2015

Health System Trust announces the first edition of the SA SURE Project’s Stories of Change – a quarterly publication presenting case stories that describe how SA SURE Project teams partner with Health Department personnel to apply policy in contextual practice in facilities across the country, and thus achieve sustainable responses to HIV, AIDS and TB. They share these stories to convey the beginnings of good practice: interesting experiences of how key challenges are being addressed using various tools, enterprise and connection to support service quality improvement at clinic level.

Zero Stigma, Zero Discrimination toolkit
South African National AIDS Council

World AIDS Day is commemorated each year on the 1st of December and is an opportunity for every community to unite in the fight against HIV, show support for people living with HIV and remember those who have died. The UNAIDS World AIDS Day theme for 2011 to 2015 is: “Getting to Zero”. This year, South Africa will focus on ZERO DISCRIMINATION, without losing sight of the other ‘zeroes’, Zero new HIV infections; and Zero AIDS related deaths. A group of HIV-positive people have told their stories and experiences of stigma and discrimination. These are not stories of despair and hopelessness, but stories of courage and hope, and tell of how key people in their lives helped them to overcome challenges. These stories have been captured on video, in photographs and in text. They are available free of charge on the SANAC website for civil society, the private sector, media and others to use in their World AIDS Day campaigns.

15. Jobs and Announcements

9th Action Learning, Action Research (ALARA) and 13th Participatory Action Research World Congress, Pretoria, South Africa, 4-7 November
Final date for submission of abstracts: 12 May 2015

The theme of this World Congress is a challenge to Action Learning / Action Research practitioners the world over, whether working in resource rich or more socio-economically challenged contexts, to explain how they are contributing to the creation of a fairer world. Abstracts should be emailed to conferencepl@gmail.com. Abstracts should be 250 words max, typed in single space Arial 12 using the following headings as a guide:
Background: an overview of the issue under discussion, the problem the research addresses and the purpose and objective of the research
Methods: the study period / setting / location, study design, study population, data collection and methods of analysis used. Results: the findings / outcome of the study. Please summarize any specific results.
Conclusions: the significance of findings / outcomes of the study and future implications of the results.

Call for applications for CODESRIA Textbook Programme
Deadline for submission of applications: 26 August 2015

The Council for the Development of Social Science Research in Africa (CODESRIA) is pleased to announce its programme for the publication of textbooks for use in African universities. The programme is aimed at making available to teachers and students textbooks that are adapted to the African context and the research and learning environment on the continent. African researchers are invited to submit their textbook manuscripts to the Council. This programme is for senior scholars with a proven track record of academic achievement and a demonstrable knowledge of the domain in which they wish to produce a textbook. In selecting proposals, the Council will lay emphasis on the value which is likely to be added by the manuscript. Proposals can be submitted by single authors or by a team of contributors. Each textbook can be organised around a discipline, a body of disciplines, or a specific theme. The textbooks will cover the African continent, a sub-region or a specific country.

Public Health Association of South Africa (PHASA) Conference
7-9 October, 2015, Durban, South Africa

With 2015 being the target date for the achievement of the Millennium Development Goals, the conference will provide an opportunity to reflect on the challenges faced by South Africa and Africa in trying to achieve the MDGs. The focus of the conference though will be on moving forward and identifying potential solutions both within and outside the health system in order to improve the health status of our population. This is reflected in the theme of conference “Health and Sustainable Development: The Future”. The 2015 PHASA Conference will be more interactive than previous PHASA conferences. A panel debate involving politicians, civil society and academics is set to be one of the highlights of the 2015 PHASA Conference. There will be a greater media and social media presence at the 2015 PHASA Conference ensuring that research findings and key issues reach a broader audience.

Public health governance in Africa, November 12-13, 2015, Windhoek, Namibia
Application deadline: May 31, 2015

The ongoing Ebola Virus Disease (EVD) outbreak has brought to the fore many themes that often rise to the surface in debates on public health in Africa. Many of these issues, which had come up at the height of the HIV/AIDS pandemic are being reharshed with new undertones and inflections. They include questions of global inequalities and their impact on public health in developing countries, the challenges of public healthcare provision and problems of social welfare and social security systems in developing countries and the intricacies of intra and inter-state relations in the face of healthcare challenges. Through its conference on the theme ‘Public health governance in Africa’ CODESRIA wishes to seize on opportunities for debate presented by the ongoing EVD epidemic to rekindle wider conversations about public health governance in Africa. While acknowledging the biological dimension of diseases and the systems that are (supposed to be) put in place to deal with them at a societal level, this conference will deliberately seek to insert conversations about these in broader discussions concerning economics, politics, culture and spirituality. CODESRIA invites abstracts from scholars and practitioners that are interested in participating in this conference. Authors of abstracts selected should be ready to submit full papers by 31st August 2015.
All documents should be sent by email to grp@codesria.sn. Please use the subject line ‘Governance Research Program’ when sending your email.

Sexual violence research initiative 4th international conference 2015
Stellenbosch, South Africa, 14-17 September 2015

The forum brings together researchers, gender activists, funders, policy makers, service providers, practitioners and survivors from around the world and will showcase innovation to end sexual violence, intimate partner violence and child abuse, and strengthen responses to survivors in low and middle income countries. The SVRI Forum is a key platform for sharing research, innovation and networking. SVRI Forum 2015 will focus debate on the following key questions: What are the intersections of different forms of gender-based and other forms of violence across the lifespan and why do they matter? What social norms are related to sexual violence and intimate partner violence, child abuse and neglect and how do we change them? How should we evaluate social norm change interventions and other forms of prevention? How can we integrate prevention and responses to violence into other sectors including health, education, social development, sports and justice sectors? If we know it works, what does it cost and how do we scale up effective programs? What works to prevent or respond to sexual violence in conflict, post conflict and humanitarian settings?

UNESCO-Equatorial Guinea International Prize for Research in the Life Sciences
Closing date: 30 June 2015

The United Nations Educational, Scientific and Cultural Organisation (UNESCO) – Equatorial Guinea International Prize for Research in the Life Sciences rewards the projects and activities of an individual, individuals, institutions, other entities or non-governmental organisations for scientific research in the life sciences, which have led to improving the quality of human life. The Prize encourages research as well as the establishment and development of networks of centres of excellence in the life sciences. Candidates shall have made significant research contribution to the life sciences to enhance the quality of human life. The prize winners, maximum three, shall be selected by the Director-General of UNESCO on the basis of the assessments and recommendations made to her by an international jury. The nomination form should be completed in English or French only, and should reach UNESCO no later than 30 June 2015.


Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter

SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to admin@equinetafrica.org Please forward this to others.

SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to admin@equinetafrica.org

This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact admin@equinetafrica.org immediately regarding any issues arising.