EQUINET NEWSLETTER 172 : 01 June 2015

1. Editorial

Civil society defines the changes that must happen for delivery on UHC
Itai Rusike, Executive Director-Community Working Group on Health, Zimbabwe

The way a healthcare system is designed, financed and performs has consequences for inequality. User fees, for example, prevent people from accessing healthcare and push over 100 million people each year into poverty. The 2001 Abuja Declaration committing at least 15% of their budgets to health was signed by African governments with a goal that every member of society have access to healthcare when they need it, without risk of financial ruin. Thirteen years later, less than ten countries in the Africa region have increased their national or provincial budget to at least 15%, as stipulated in the declaration. Less than 10% of African people are reported to be protected from financial risks associated with using health care, even though health care plays an important role in the still unfinished business of achieving the Millennium Development Goals. Unless health budgets are adequate to meet priority health needs, inequalities in access to health services will remain high and these goals will not be achieved for all.

The concept of universal health coverage (UHC) offers an opportunity to address these challenges. UHC is seen as a means to deliver on the principle of Health for All that was set out more than 30 years ago in the Alma-Ata declaration. In 2005, there were calls to revitalize primary health care (PHC). The principle of universal coverage was reaffirmed in the 2008 world health report on PHC and various subsequent World Health Assembly resolutions. In May 2012 in the World Health Assembly, WHO Director General Margaret Chan’s asserted that UHC is “the single most powerful concept that public health has to offer” to reduce the financial impoverishment caused by people spending on health care and to increase access to key health services. In December of that year, the United Nations General Assembly adopted a resolution on UHC, urging governments to move towards providing all people with access to affordable, quality health-care services, given the important role that health care plays in achieving international development goals.

Achieving these goals is, however, first and foremost a political process. It involves a political negotiation between different interest groups in society over what services are provided, how services are allocated and who should fund them.

On this understanding civil society organisations have come together to form a network - the African Platform for Universal Health Coverage (AFP- UHC) - to remind African leaders of their duty to shape health policies so that everyone can enjoy their right to health. Civil society organisations have already contributed to increased community roles in decision-making in health; have acted as watchdogs of service delivery and demanded accountability on policy commitments. Civil society has represented and defended the rights of poor and vulnerable people. In doing so they are vital for building more equitable health systems. The organisations involved bring existing civil society organisations together in national coalitions, engaging the public and governments through a variety of tools, including stakeholder engagement, policy briefs, strategic meetings and press briefings. Member organisations have held radio talk shows in Ethiopia, workshops in Egypt, public marches in Ghana, meetings targeted at policy makers in Kenya, campaigns challenging inequalities and user fees in Malawi, television programmes and lobbying of the Prime Minister in Mali, a public march in Kampala and a UHC Day commemoration in Zimbabwe.

The AFP-UHC thus brings civil society organisations together to contribute to, support and implement policies promoting UHC, on the basis that health is a human right. The organisations seek to bring UHC to the political agenda of African countries. The network thus seeks to support national non state organisations to advocate that UHC be achieved through people-centered, right based approaches, in a manner that guarantees people’s right to health services. The network measures its value by the extent to which it is able advocate for and achieve an increase in public sector health budgets and in the political commitment towards health. These changes are seen as key to improving the lives and wellbeing of the most vulnerable people in the society, whose rights to health are usually infringed though their sustained neglect by governments.

The network expects to see governments abolish user fees, raise and spend budgets for health more equitably, increase public sector health financing, ensure that UHC is included in global and national goals post 2015 and that governments set targets and deliver on those goals.

The author is the Zimbabwe coordinator of the African Platform for Universal Health Coverage (AFP- UHC), a network of African non government organisations with a long experience working together to demand a set of measures from governments to move towards Universal Health Coverage. Further information on the network can be found at http://www.africaforuhc.org/. Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.

2. Latest Equinet Updates

Case Study Brief: Health centre committee involvement in local government planning for health in Zambia

Neighbourhood Health Committees (NHCs) have been set up in all ten provinces in Zambia and district community health offices. Their role is being strengthened across the country, and there are many examples of efforts that have been made to promote their participation in planning, budgeting and health actions. This brief outlines these initiatives and the lessons from the work.

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.

3. Equity in Health

It is time to focus on the real drivers of malaria
Tarlton D: UNDP Blog, April 2015

The author argues that eliminating malaria seems like a straightforward issue. Decades of malaria control efforts show there is more to the story. Much of the vulnerability to malaria, it turns out, is determined by human actions. The conditions in which people are born, grow, work, live, and age define to a great extent who is vulnerable to malaria and who is not. Malaria is both a result and a cause of a lack of development. The author asserts that we know that it is those countries with the lowest levels of human development that are most affected by malaria. And within populations, those living in the poorest circumstances also suffer disproportionately. This year 2015 is argued to mark a turning point in the world’s response to malaria with adoption of the new global framework Action and Investment to defeat Malaria (2016-2030) that places the management of the disease as a development issue. Under this plan, countries will for the first time report their progress on incorporating non-health sector interventions into their malaria control efforts.

Social Determinants of Migrant Health
Lefkowitz B; Cacari-Stone L: The Conference on Social Determinants of Migrant Health, October 2014

This conference reports on work on the integration of social determinants of health – socioeconomic and structural factors – into immigrant health research and policy. A cross-national framework was used to consider issues of place, migration and health. In addition to public health, it drew upon the fields of economics, sociology of immigration, and social epidemiology, and incorporated three theoretical frameworks: the life-course framework from social epidemiology, the ‘push-pull’ factor theories from geography and economics, and transnational theory from sociology. It built upon recent academic literature, including a Social Sciences and Medicine (SSM) supplement on immigration and health, to formulate areas where more research is needed and to recommend potentially fruitful program interventions and policy changes. It integrated work with North American Latino immigrants, Asian and South Asian immigrants, African and Afro-Caribbean immigrants, and Arab immigrants, and research linking the migration to Europe of Arab, Turks and other populations, and to the Middle East of immigrants from Africa.

Unexplained health inequality – is it unfair?
Asada Y, Hurley J, Norheim OF, Johri M: International Journal for Equity in Health 14(11), 2014

Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health – a difference in health – is inequitable. Empirically operationalising definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question – whether unexplained health inequality is unfair – determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity.

Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program
Spiegel JM; Breilh J; Yassi A: Globalization and Health 2015, 11(9), 2015

A focus on social determinants of health provides a welcome alternative to the bio-medical illness paradigm. However, the tendency to concentrate on the influence of risk factors related to living and working conditions of individuals, rather than to more broadly examine dynamics of the social processes that affect population health, has triggered critical reaction not only from the Global North but especially from voices the Global South where there is a long history of addressing questions of health equity. In this article, the authors elaborate on how focusing instead on the language of “social determination of health” has led to application of more equity-sensitive approaches to research and related policy and praxis. The authors briefly explore the epistemological and historical roots of epidemiological approaches to health and health equity that have emerged in Latin America to consider its relevance to global discourse. In this region marked by pronounced inequity, context-sensitive concepts such as “collective health” and “critical epidemiology” have been prominent, albeit with limited acknowledgement by the Global North. The authors illustrate attempts to apply a social determination approach (and the “4 S” elements of bio-Security, Sovereignty, Solidarity and Sustainability) in five projects within their research collaboration linking researchers and knowledge users in Ecuador and Canada, in diverse settings (health of healthcare workers; food systems; antibiotic resistance; vector borne disease [dengue]; and social circus with street youth). The authors argue that the language of social determinants lends itself to research that is more reductionist and beckons the development of different skills than would be applied when adopting the language of social determination. They conclude that this language leads to more direct analysis of the systemic factors that drive, promote and reinforce disparities, while at the same time directly considering the emancipatory forces capable of countering negative health impacts. It follows that “reverse innovation” must not only recognise practical solutions being developed in low and middle income countries, but must also build on the strengths of the theoretical-methodological reasoning that has emerged in the South.

4. Values, Policies and Rights

Assisted dying: Avron Moss – another casualty of legal uncertainty
Thamm M: Daily Maverick, 10 March 2015

In January 2015, a few days before he would feature as Applicant No 1 in a groundbreaking High Court application for the right to an assisted death, Avron Moss ended his life using medication he had smuggled into South Africa from Mexico. Diagnosed with melanoma, Moss knew when he offered to act as the applicant that it would be a race against time. This article discusses the history and legal and social implications of assisted dying for the terminally ill in South Africa.

Gender-responsive HIV programming for women and girls
UNAIDS: UNAIDS Geneva 2014

This document guides countries on how to include a gender perspective and promote equality and human rights for women and girls in their national HIV responses, drawing upon the latest technical developments, guidelines and investment approaches. This is relevant as women and girls continue to be profoundly affected by HIV. The brief seeks to support a gender-responsive HIV response, as a first step towards the application of key tools and resources that help integrate gender considerations into concept notes, proposals, and national strategic plans.

Multisectoral Action Framework for Malaria
Roll Back Malaria Partnership; UNDP: UNDP New York, 2015

This Multisectoral Action Framework for Malaria makes a clear case for re-structuring the way countries address malaria. It presents a menu of concrete, implementable processes and actions to transform malaria
responses—from being a concern of the health sector only, towards a coordinated multi-pronged effort that harnesses expertise across a range of sectors and institutions. The Framework calls for action at several levels and in multiple sectors, globally and across inter- and
intra-national boundaries, and by different organizations. It emphasizes complementarity, effectiveness and sustainability, and capitalizes on the potential synergies to accelerate both socio-economic development and malaria control. It involves new interventions as well as putting new life into those that already exist, and coordinates and manages these in new and innovative ways. It is a guide for policymakers and practitioners and a stimulus for innovation.

World Malaria Day 2015: Invest in the Future, Defeat Malaria
Mosca D; Motus N: International Labour Organisation for Migration, April 2015

In 2013, there were about 198 million malaria cases in the world and an estimated 584,000 deaths from the disease. The countries endemic for malaria are also some of the poorest countries in the world. The burden of malaria on the poor, including migrants and displaced populations in these countries further fuels the cycle of poverty. IOM works with governments and partners, mostly in Africa and Asia, to ensure universal access to health care, including malaria prevention, early diagnosis, and treatment services among migrants and hard-to-reach populations. This year’s theme for World Malaria Day on April 25th was 'Invest in the Future: Defeat Malaria'. It focused on reaching 2015 malaria targets in all malaria-endemic countries, as well as scaling up efforts in malaria elimination and control beyond 2015.

5. Health equity in economic and trade policies

Global health security: the wider lessons from the west African Ebola virus disease epidemic
Heymann D et al: The Lancet 385 (9980),1884–1901, 2015

The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. Out of this human calamity has come renewed attention to global health security—its definition, meaning, and the practical implications for programmes and policy. For example, how does a government begin to strengthen its core public health capacities, as demanded by the International Health Regulations? What counts as a global health security concern? In the context of the governance of global health, including World Health Organization reform, it will be important to distil lessons learned from the Ebola outbreak. Prof. Heymann led a group of respected global health practitioners to reflect on these lessons, to explore the idea of global health security, and to offer suggestions for the next steps. The paper describes some of the major threats to individual and collective human health, as well as the values and recommendations that should be considered to counteract such threats in the future. Many different perspectives are proposed but their common goal is a more sustainable and resilient society for human health and wellbeing.

Social determinants of malaria and health care seeking patterns among rice farming and pastoral communities in Kilosa District in central Tanzania
Shayoa EH: Rumishaa SF; Mlozib M; Bwanac VM; Mayalaa BK; Malimac RC; Mlachaa T; Mboera L: Acta Tropica 144: 41-9, 2015

This study was carried out to understand the role social determinants and health seeking behavior among rice farming and pastoral communities in Kilosa District in central Tanzania. The study involved four villages; two with rice farming communities while the other two with pastoral communities. In each village, heads of households or their spouses were interviewed to seek information on livelihoods activities, knowledge and practices on malaria and its preventions. A total of 471 individuals were interviewed. Only 23.5% of the respondents had adequate knowledge on malaria. Fifty-six percent of the respondents could not associate any livelihood activity with malaria transmission. Majority (79%) of the respondents believed that most of fevers were due to malaria; this was higher among the pastoral (81.7%) than rice farming communities (76.1%). Cases of fever were significantly higher in households with non-educated than educated respondents. Women experienced significantly more episodes of fever than men. Fever was reported more frequently among pastoral than rice farming communities. Treatment seeking frequency differed by the size of the household and between rice farming and pastoral communities. In conclusion, education, sex, availability of health care facility and livelihood practices were the major social determinants that influence malaria acquisition and care seeking pattern in central Tanzania. The authors argue for an ecohealth approach to address the links of livelihoods and malaria transmission among rural farming communities.

6. Poverty and health

Innovations for health: Use of appropriate technologies in Primary Health Care in Zimbabwe - Report of an assessment
Training and Research Support Centre (TARSC); CBRT: TARSC, Harare, 2015

Zimbabwe has had a notable record of innovation and use of appropriate technologies in primary health care (PHC), particularly in environmental health. These technologies are generally defined as small-scale, decentralized, people centred, labour-intensive, energy-efficient, environmentally sound, and locally controlled. This pilot assessment aimed to explore and map specific appropriate technology innovations being developed and used at community level for health in rural and urban districts of Zimbabwe. The assessment looked at the technologies, their materials, purpose and use and related issues around their development and use, with the evidence gathered by community based researchers within three main themes (i) food safety and nutrition, (ii) water, sanitation, waste management and housing and (iii) prevention and control of diseases. The results are presented in tables, with pictures of the technologies. While noting the limited size of the sample, the results suggest the wealth of innovations and appropriate technologies that exist, and the possibilities that may be found from a more systematic and wider assessment.

7. Equitable health services

Determinants of access to healthcare by older persons in Uganda: a cross-sectional study
Wandera SO; Kwagala B; Ntozi J: International Journal for Equity in Health, 14(26), 2015

Older persons report poor health status and greater need for healthcare. However, there is limited research on older persons’ healthcare disparities in Uganda. This paper reports on factors associated with older persons’ healthcare access in Uganda, using a nationally representative sample. The authors conducted secondary analysis of data from a sample of 1602 older persons who reported being sick in the last 30 days preceding the Uganda National Household Survey. They used frequency distributions for descriptive data analysis and chi-square tests to identify initial associations and fit generalised linear models (GLM) with the poisson family and the log link function, to obtain incidence risk ratios (RR) of accessing healthcare in the last 30 days, by older persons in Uganda. More than three quarters (76%) of the older persons accessed healthcare in the last 30 days. Access to healthcare in the last 30 days was reduced for older persons from poor households; and with some or with a lot of walking difficulty. Conversely, accessing healthcare in the last 30 days for older persons increased for those who earned wages and missed work due to illness for 1–7 and 8–14 days. In addition, those who reported non-communicable diseases (NCDs) such as heart disease, hypertension or diabetes were more likely to access healthcare during the last 30 days. In the Ugandan context, health need factors (self-reported NCDs, severity of illness and mobility limitations) and enabling factors (household wealth status and earning wages in particular) were the most important determinants of accessing healthcare in the last 30 days among older persons.

Global evidence on inequities in rural health protection
Scheil-Adlung X; ILO: ILO ESS Paper Series, 2015

This paper presents global estimates on rural/urban disparities in access to health-care services. The report uses proxy indicators to assess key dimensions of coverage and access involving the core principles of universality and equity. Based on the results of the estimates, policy options are discussed to close the gaps in a multi-sectoral approach addressing issues and their root causes both within and beyond the health sector. The paper presents global evidence that suggests significant differences between rural and urban populations in health coverage
and access at global, regional and national levels. Based on the evidence provided, place of residence largely determines coverage and access to health care in all regions and within all countries. . Efficient and effective multisectoral policies to address the root causes of rural inequities should consider the specific living and working characteristics of rural populations. The authors argue that if not addressed, the rural/urban disparities identified in access to health care carry the potential to considerably hamper overall socio-economic development in many developing countries.

Innocent lives lost and saved: the importance of blood transfusion for children in sub-Saharan Africa
Dzik WH: BMC Medicine 13(22), 2015

Severe anemia in children is a leading indication for blood transfusion worldwide. Severe anemia, defined by the World Health Organization as a hemoglobin level&#8201;<5 g/dL, is particularly common throughout sub-Saharan Africa. Analysis of data from the Fluid Expansion as Supportive Therapy trial offers new insights into the importance of blood transfusion for children with severe anemia. This analysis found that life-threatening anemia in children is a frequent presenting condition in East Africa; that delays in transfusion therapy are lethal; and that inadequate transfusion is probably more common than currently recognized. The findings of this study highlight the need for changes in blood inventory management in sub-Saharan hospitals and the need for more research on transfusion therapy for children in peril.

Management of severe paediatric malaria in resource-limited settings
Maitland K: BMC Medicine 13(42), 2015

Over 90% of the world’s severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the AQUAMAT trial in 2010 showing that in artesunate-treated children, the relative risk of death was 22.5% lower than in those receiving quinine. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.

8. Human Resources

Health workers’ experiences, barriers, preferences and motivating factors in using mHealth forms in Ethiopia
Medhanyie AA, Little Am Yebyo H, Spigt M, Tadesse K, Blanco R, Dinant GJ: Human Resources for Health 13(2), 2015

Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. A pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. Identified barriers for not using electronic forms consistently included challenges related to electronic forms and smartphones and health system issues such as frequent movement of health workers. Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, tyhe authors found that sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.

Radical changes in medical education needed globally
Ebrahim S, Squires N, di Fabio J, Reed G, Bourne P, Keck W, Neusy AJ, Chalkidou K: The Lancet 3(3), 2015

New medical schools in Africa have developed curricula that include community and rural health components, long-term family attachments, and admission processes that are more equitable for disadvantaged students. These worthwhile innovations have been incorporated in previous reforms of medical education, but the authors ask in this paper if they are sufficient to meet the challenges of achieving universal health care.

The reality of task shifting in medicines management- a case study from Tanzania
Wiedenmayer K; Kapologwe N; Charles J; Chilunda F; Mapunjo S: Journal of Pharmaceutical Policy and Practice 8(13), 2015

Tanzania suffers a severe shortage of pharmaceutical staff negatively affecting the provision of pharmaceutical services and access to medicines, particularly in rural areas. Task shifting has been proposed as a way to mitigate this. This study aimed to understand the context and extent of task shifting in pharmaceutical management in Dodoma Region, Tanzania. The authors explored 1) the number of trained pharmaceutical staff as compared to clinical cadres managing medicines, 2) the national establishment for staffing levels, 3) job descriptions, 4) supply management training conducted and 5) availability of medicines and adherence to Good Storage Practice in 270 public health facilities in 2011. In 95.5% of studied health facilities medicines management was done by non-pharmaceutically trained cadres, predominantly medical attendants. Task shifting was found to be a reality in the pharmaceutical sector in Tanzania occurring mainly as a coping mechanism rather than a formal response to the workforce crisis. Pharmacy-related tasks and supply management were informally shifted to clinical staff without policy guidance, explicit job descriptions, and without the necessary support through training. It was argued that implicit task shifting be recognised and formalised and job orientation, training and operational procedures be used to support non-pharmaceutical health workers to effectively manage medicine supply.

9. Public-Private Mix

Conflicts of interest and global health and nutrition governance - The illusion of robust principles
Richter J: BMJ, doi: http://dx.doi.org/10.1136/bmj.g5457, 2015

This is a response to a BMJ paper 'Do the solutions for global health lie in healthcare?' where in the run-up to the Second International Conference on Nutrition (ICN2), the author warned against downplaying the fundamental differences between the commercial interests of multinational food companies and those of public sector agencies. If public health officials do not acknowledge the divergent interests, he suggested, they risk harming their public health mission, institutional integrity and ultimately public trust. In the response, the author suggests that the current discourse ignores the problem of involving food transnational corporations in public decision-making processes, acceptance of funds and resources in the name of partnership or stakeholder engagement. The trend to increase such engagement reduces and almost eliminates public policy spaces without corporations. The author argues that that robust, comprehensive conflict of interest safeguards do not exist with respect to global food and nutrition governance. This obscures the fact that conflicts of interest are an important legal concept and that establishing conflict of interest policies are an integral part of UN agencies’ duty to establish the Rule of Law.

Defend the World Health Organization from corporate takeover
People’s Health Movement, 18 May 2015

Ahead of the first meeting of the drafting group on Framework for Engagement with Non – State Actors (FENSA), Civil Society Organisations and Social Movements expressed their deep concern on perceived attempts to facilitate a corporate takeover of WHO. The joint statement signed by over 40 organisations called on WHO member states to take such time as is necessary to achieve a robust framework for engagement with non-state actors, to protect the WHO from undue influence. Further, the statement also called on member states to support the director general's proposals to increase the assessed contributions. The framework was initiated to safeguard the independence, integrity and credibility of WHO, but the organisations have a strong apprehension that the negotiations on FENSA may fundamentally alter the influence of the private sector and philanthropic foundations and NGOS sponsored by the private sector in a manner that compromises the credibility of WHO.

Keep a Strong FENSA: Safeguard WHO's Independence From Private Interests
Gopa Kumar KM; Kishore S; Reed T; Kiddell-Monroe R: Huffington Post Blog, 21 May 2015

The authors write from the 68th World Health Assembly, where a drafting group of Member States are discussing the Framework of Engagement With Non-State Actors (FENSA). This process aims to determine the rules of engagement between WHO and non-State actors (NSAs), a moniker encompassing academia, nongovernmental organizations, philanthropic foundations, and the private sector. Many from civil society view this process as a way of safeguarding WHO's independence from private interests. The authors outline the fault lines in the proposals of contentious issues. During the open-ended process, India supported including language in paragraph 44 that named specific industries WHO should exercise caution in engaging with, such as the food, beverage, alcohol, and infant formula industries. India further proposed, "WHO's engagement will be strictly limited to assisting such industries to comply with WHO's norms and standards or guideline or policy." On behalf of the African group, Zimbabwe asserted that the "framework should explicitly list the types of industries that WHO will deal cautiously with and the reasons for the cautious engagement," also naming alcohol, food, and beverage. Greece argued, "strict rules should govern its [WHO] engagement with the pharmaceutical industries." Finland recommended a "high level of restriction" for engagement with industries that have "clear interests in health policies," referencing non-communicable disease control. Yet these calls were rejected by Canada, Denmark, Norway, and the United States. U.S. sought to eliminate the line concerning "other industries affecting human health" altogether. Other issues up for debate have been secondments from the private sector, as well as restrictions and/or ceilings on financial contributions from non state actors. The authors urged member states to ensure that FENSA creates a strong enough "fence" to safeguard public health.

10. Resource allocation and health financing

New evidence: tax financing for UHC
Mohga Kamal-Yanni: Oxfam Global Health Check, May 2015

The Ebola crisis exposed the weaknesses of healthcare systems in low- and middle-income countries created mainly by insufficient funding. Given the global community’s commitment to universal health coverage (UHC), the Ebola outbreak has prompted serious reflection among health policy decision-makers. One of the central features of this debate is financing: how can relatively poor countries find the money to pay for universal health coverage? To date, low- and middle-income countries have been growing toward UHC through social health insurance systems funded through employment. Yet, progress has been slow and uneven leaving people in the informal sector, who are the majority of the population, out was insurance schemes. Rather than seeking innovative solutions to this old problem, this blog outlines how Aaron Reeves argues that what is needed is a renewed commitment to an old solution: tax-based financing. Using data from low- and middle-income countries my colleagues and I examined the association between tax revenues and health spending. We found that tax revenue was a major statistical determinant of progress towards UHC. Each $10 per-capita increase in tax revenue was associated with an additional $1 of public health spending per capita. Whereas each $10 increase in GDP per capita was associated with an increase of $0.10. Crucially, tax revenues sit on the pathway between economic growth and health spending. In short, tax financing is an efficient way of translating economic growth into health spending. Countries with more tax revenues have also made more progress on other indicators of UHC, even after adjusting for economic activity in the country. Among tax poor countries, greater tax revenues are associated with more women being attended by a skilled healthcare worker during pregnancy and greater access to healthcare for all people.

Tracking development assistance for health to fragile states, 2005–2011
Graves CM; Haakenstad A; Dieleman JL : Globalization and Health 2015, 11(12), 2015

Development assistance for health (DAH) has grown to more than $31.3 billion in 2013. This paper presents evidence on the degree to which countries with high concentrations of conflict, violence, inequality, debt and corruption have received health aid compared to other countries. The authors combined DAH estimates and a multidimensional fragile states index for 2005 to 2011 comparing 'fragile' versus 'stable' states. Comparing low-income countries, fragile countries received $7.22 per person while stable countries received $11.15 per person. Funders preferred funding to low-income fragile countries that have refugees or ongoing external intervention but tended to avoid funding countries perceived to have political gridlock, flawed elections, or economic decline. While external health funding to 'fragile' countries has increased since 2005, it is per person almost half as much as the DAH provided to more stable countries of comparable income levels.

11. Equity and HIV/AIDS

Prevention of mother-to-child transmission of HIV in rural Uganda: Modelling effectiveness and impact of scaling-up PMTCT services
Woodward D: Glob Health Action 2015, 8 (26308), 2015

The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010, and this may be an overestimation as it does not measure completion. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care, HIV testing, and ARVs for the woman and the baby. This study was based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008–2010. Using modelling, it was estimated that HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction. The results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT.

Screening for tuberculosis and testing for human immunodeficiency virus in Zambian prisons
Maggard KR, Hatwiinda S, Harris JB, Phiri W, Krüüner A, Kaunda K, Topp SM, Kapata N, Ayles H, Chileshe C, Henostroza G, Reid SE: Bulletin of the World Health Organisation 93(2) 65-132, 2015

This study aimed to improve the Zambia Prisons Service’s implementation of tuberculosis screening and human immunodeficiency virus (HIV) testing. For both tuberculosis and HIV, the authors implemented mass screening of inmates and community-based screening of those residing in encampments adjacent to prisons. They also established routine systems – with inmates as peer educators – for the screening of newly entered or symptomatic inmates. We improved infection control measures, increased diagnostic capacity and promoted awareness of tuberculosis in Zambia’s prisons. In a period of 9 months, the authors screened 7638 individuals and diagnosed 409 new patients with tuberculosis. They tested 4879 individuals for HIV and diagnosed 564 cases of infection. An additional 625 individuals had previously been found to be HIV-positive. Including those already on tuberculosis treatment at the time of screening, the prevalence of tuberculosis recorded in the prisons and adjacent encampments was 18 times the national prevalence estimate of 0.35%. Overall, 22.9% of the inmates and 13.8% of the encampment residents were HIV-positive. Both tuberculosis and HIV infection are common within Zambian prisons. The authors enhanced tuberculosis screening and improved the detection of tuberculosis and HIV in this setting. These observations should be useful in the development of prison-based programmes for tuberculosis and HIV elsewhere.

Tenofovir substitution in Namibia based on an analysis of the antiretroviral dispensing database
Kalemeera F; Mengistu A; Gaeseb J: Journal of Pharmaceutical Policy and Practice 8(14), 2015

In the management of HIV infection, tenofovir (TDF) is preferred to its predecessors based on its safety profile, despite some adverse reactions which warrant its substitution for some patients. This review measured the rate of TDF’s substitution from January 1 2008 to November 30 2011, and compared the gender difference in these rates of substitution using dispensing records from the national antiretroviral dispensing database. No gender difference was observed and the authors indicate that further investigation is required to determine the clinical reasons for TDF’s withdrawal.

12. Governance and participation in health

Citizen Participation and Accountability for Sustainable Development
Shahrokh T; Franco LE; Burns D: Institute of Development Studies Rapid Response Briefing 10, 2015

Meaningful accountability can shift power imbalances that prevent sustainable development for people living in poverty and marginalisation. Accountability consists of both the rights of citizens to make claims and demand a response, and the involvement of citizens in ensuring that related action is taken. However, for the poorest and most marginalised people accountability is often unattainable. They face multiple barriers in influencing social, political and economic decision-making processes and accessing the services they are entitled to. This briefing draws on research by the Participate initiative to highlight the key components necessary for processes of accountability to be meaningful for all.

Evidence for Informing Health Policy Development in Low- Income Countries (LICS): Perspectives of Policy Actors in Uganda
Nabyonga-Orem J; Mijumbi R: International Journal of Health Policy and Management 4(5), 285-293, 2015

Although there is a general agreement on the benefits of evidence informed health policy development given resource constraints especially in Low-Income Countries (LICs), the definition of what evidence is, and what evidence is suitable to guide decision-making is still unclear. The authors’ explored health policy actors’ views regarding what evidence they deemed appropriate to guide health policy development, with 51 key informants interviewed. Different stakeholders lay emphasis on different kinds of evidence. While external funders preferred international evidence and Ministry of Health officials looked to local evidence, district health managers preferred local evidence, evidence from routine monitoring and evaluation and reports from service providers. Service providers on the other hand preferred local evidence and routine monitoring and evaluation reports whilst researchers preferred systematic reviews and clinical trials. Although policy actors look for factual information, they also require evidence on context and implementation feasibility of a policy decision.

Framework of engagement with non-State actors
World Health Organisation: Draft Resolution Sixty-eighth World Health Assembly A68/A/CONF./X Agenda item 11.2, May 2015

This resolution presents a Framework of Engagement with non-State actors to replace the Principles governing relations between the World Health Organization and nongovernmental organizations and Guidelines on interaction with commercial enterprises to achieve health outcomes;(1) to implement the Framework of Engagement with non-State actors; (2) to establish the register of non-State actors in time for the Sixty-ninth World Health Assembly; (3) to report on the implementation of the Framework of Engagement with non-State actors to the Executive Board at each of its January sessions under a standing agenda item, through the
Programme Budget and Administration Committee; (4) to conduct in 2018 an evaluation of the implementation of the Framework of Engagement
with non-State actors and its impact on the work of WHO with a view to submitting the results, together with any proposals for revisions of the Framework, to the Executive Board in January 2019,through the Programme Budget and Administration Committee.

The role of civil society organisations in promoting community participation
Serunjogi F: CEHURD Newsletter, May 2015

In an initiative to promote the decentralizing of the health system, the government of Uganda through Ministry of Health called for an establishment of Health Unit Management Committees (HUMCs) at each government health facility as a way of empowering community members to participate in influencing health system for better service delivery. As part of an action research process, the Center for Health Human Rights and Development (CEHURD) carried out a case study on two HUMCs in Kikoolimbo health center III in Kyankwanzi district and Nyamiringa health center II Kiboga district. The purpose of this case study was to provide an understanding of the experiences of HUMCs in performing their roles and what role Civil Society can play to support them perform their roles and responsibilities as well as advancing health rights and addressing health inequities using the human rights based approach. The findings revealed that these two health unit management committees had limited knowledge of the HUMCs guidelines. The committee members were trained by CEHURD and community dialogues held to inform community members about the existence of these committees as well as their roles and responsibilities. The author noted that when communities are empowered, they can differentiate between performing and non-performing committees.

Working with marginalised communities on using data and technology in advocacy
Ganesh M; Slater D; Martini B: Beatrice Martini Blog on Tech and Tools for Justice and Rights, May 2015

Mutual trust and respect, real commitment to collaboration and flexibility are all essential elements to be responsibly equipped to work with a marginalised community. And they are not even enough. The authors write in this paper about the experience of working with marginalised communities on using data and technology in advocacy as they think it could greatly help other practitioners planning to collaborate with groups struggling to get their rights honoured and their voices heard. The authors summarise advice emerging from the case study as to: listen to and learn from the community, keeping assumptions at bay; give ownership of the work to the community itself; build capacity tailored to its needs and abilities, accessibly and sustainably; provide people with the tools and methodologies that equip them to work independently on more successful initiatives in the future.

13. Monitoring equity and research policy

Balancing the personal, local, institutional, and global: multiple case study and multidimensional scaling analysis of African experiences in addressing complexity and political economy in health research capacity strengthening
Ager A; Zarowsky C: Health Research Policy and Systems 13(5), 2015

Strengthening health research capacity in low- and middle-income countries remains a major policy goal. The Health Research Capacity Strengthening (HRCS) Global Learning (HGL) program of work documented experiences of HRCS across sub-Saharan Africa. The authors reviewed findings from HGL case studies and reflective papers regarding the dynamics of HRCS. Analysis was structured with respect to common challenges in such work, identified through a multi-dimensional scaling analysis of responses from 37 participants at the concluding symposium of the program of work. Symposium participants identified 10 distinct clusters of challenges: engaging researchers, policymakers, and donors; securing trust and cooperation; finding common interest; securing long-term funding; establishing sustainable models of capacity strengthening; ensuring Southern ownership; accommodating local health system priorities and constraints; addressing disincentives for academic engagement; establishing and retaining research teams; and sustaining mentorship and institutional support. Analysis links these challenges to three key and potentially competing drivers of the political economy of health research: an enduring model of independent researchers and research leaders, the globalisation of knowledge and the linked mobility of (elite) individuals, and institutionalisation of research within universities and research centres and, increasingly, national research and development agendas. The authors identify tensions between efforts to embrace the global ‘Community of Science’ and the promotion and protection of national and institutional agendas in an unequal global health research environment. A nuanced understanding of the dynamics and implications of the uneven global health research landscape is required, along with a willingness to explore pragmatic models that seek to balance these competing drivers.

Validating estimates of prevalence of non-communicable diseases based on household surveys: the symptomatic diagnosis study
James SL; Romero M; Ramírez-Villalobos D; Gómez S; Pierce K; Flaxman A; Serina P; Stewart A; Murray CJL; Gakidou E; Lozano R; Hernandez B: BMC Medicine 13(15), 2015

Easy-to-collect epidemiological information is critical for the more accurate estimation of the prevalence and burden of different non-communicable diseases around the world. Current measurement is restricted by limitations in existing measurement systems in the developing world and the lack of biometry tests for non-communicable diseases. Diagnosis based on self-reported signs and symptoms (“Symptomatic Diagnosis,” or SD) analysed with computer-based algorithms may be a promising method for collecting timely and reliable information on non-communicable disease prevalence. This study developed and assessed the performance of a symptom-based questionnaire to estimate prevalence of non-communicable diseases in low-resource areas. The authors collected 1,379 questionnaires in Mexico from individuals who suffered from a non-communicable disease that had been diagnosed with gold standard diagnostic criteria or individuals who did not suffer from any of the 10 target conditions. To make the diagnosis of non-communicable diseases, the authors selected the Tariff method, a technique developed for verbal autopsy cause of death calculation. They assessed the performance of this instrument and analytical techniques at the individual and population levels. The questionnaire revealed that SD is a viable method for producing estimates of the prevalence of non-communicable diseases in areas with low health information infrastructure. This technology can provide higher-resolution prevalence data, more flexible data collection, and potentially individual diagnoses for certain conditions.

14. Useful Resources

A luta continua
Film by Medicusmundi and Kanaki Films on Mozambiques efforts to build its public health system

Since achieving independence in 1975, Mozambique is a country in constant change. In this context, governments, foundations, NGOs and companies declare noble intentions in order to improve the precarious health situation of the population. "A Luta Continua" ("The Struggle Continues") is a film that reviews the achievements, challenges and difficulties in order to build a health system for all in an increasingly unequal country where, sometimes, aid strategies do not always walk in the same direction.

Materials for Facilitators Series on Health Budgets and Monitoring Budget Implementation
International Budget Partnership, USA

These materials are aimed at trainers and facilitators conducting workshops for people interested in using budgets as a tool to enhance advocacy and research. The series’ provide guidance on how to run workshops on budget-related topics as well as relevant materials and tasks for the workshop. IBP uses an adult education approach in participatory workshops and rely on good preparation by the facilitator and strong interaction and reflection by participants.

Online directory about NGOs and other development organisations in South Africa
Prodder: SANGONeT NGO Pulse Portal

Information and knowledge have become critical determinants of development and the driving forces behind economic progress in today's competitive world. Access to credible information is a strategic prerequisite for the success of development projects and processes. It empowers decision-making and enables action across a wide range of development issues. This directory highlights the activities of organisations involved in development work in South Africa.

Perinatal deaths in South Africa, 2011-2013
Statistics South Africa, April 2015

Statistics South Africa (Stats SA) has published statistics on perinatal deaths based on administrative records captured on death notification forms collected from the South African civil registration system maintained by the Department of Home Affairs.

15. Jobs and Announcements

2015 Drivers of Change Awards Nominations Now Open
Closing date for nominations: 31 July 2015

The 24th African Union Summit declared 2015 as “The Year of Women's Empowerment and Development towards Africa’s Agenda 2063.” To embrace this, the 2015 Drivers of Change Awards will recognise people driving change in women empowerment and development, gender equity, the promotion of equality and rights for women and girls. Nominations for the 2015 Drivers of Change Awards are now open!&#8232;&#8232; The website allows people to nominate individuals, businesses, civil society organisations and governments that are making a real impact in changing the lives of women and girls in southern Africa.

3rd International Association of Social Sciences and Humanities in HIV (ASSHH) Conference, Stellenbosch, South Africa
Closing date for pre-conference registration: 19 June 2015

The 3rd Conference of the Association for the Social Sciences and Humanities in HIV (ASSHH) will be held in South Africa. The goal is to ask the kinds of critical questions it is sometimes difficult to pose in other settings, and to contribute to new and creative ways of thinking about the HIV epidemic. The conference will critically examine the growing gap between rhetoric and reality in the national and international HIV response and will provide opportunities for wide-ranging discussion and debate on the following themes: (Re)-writing the history of AIDS: whose facts, whose visions, whose stories?, An ‘epidemic of signification - cultural and media representations 30 years on, in the era of PrEP and ‘universal’ access, Sexual orientation and gender identity - a new or enduring battleground?, The politics of 'practice': research and practitioner perspectives on intervention and programme development, Power, politics and resistance: the demise of agency in the face of constraint, Positive nostalgia(s) and the international HIV response and Renewing social sciences and humanities research.

9th Action Learning, Action Research (ALARA) and 13th Participatory Action Research World Congress
4-7 November 2015, Pretoria, South Africa

This World Congress is a challenge to Action Learning / Action Research practitioners to explain how they are contributing to the creation of a fairer world. The ALARA World Congress 2015 will create a space for dialogue over questions such as: How do we know we are asking the right questions to promote sustainable learning? How do we capacitate people to address the intricate interplay of social, economic, political and cultural factors that combine to preserve injustice? How do we ensure authentic collaboration between stakeholders across all levels? How do we use AL/AR to forge innovative, sustainable responses to contemporary complex challenges? How do we know we are successful in mediating sustainable change? Delegates from developing countries should register before 28 July 2015.

Call for submissions – Emerging Public Health Practitioner Award
Closing date: 26 June 2015

The South African Health Review Emerging Public Health Practitioner Award is offered to South African candidates under the age of 35 to submit a chapter dealing with public health or policy in South Africa for publication in the South African Health Review. Click on link for further details.

Medicines Utilisation Research in Africa: Botswana Workshop and Symposium
27 - 29 July 2015, University of Botswana

The workshop and symposium are intended to develop and progress medicines utilization research in Africa. The workshop will cater for all personnel including those just starting research in this area and those already undertaking medicine utilization research. This will be achieved through two workshop streams (parallel sessions) and a one day symposium for researchers to present their projects and findings. Topics will depend on the content of the submitted abstracts. There will be both oral and poster presentations. Particular consideration will be given to abstracts describing current drug utilisation research and activities with ARVs.

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

The 11th Annual Conference of the Public Health Association of South Africa takes place between 7-9 October 2015 in Durban, KwaZulu-Natal. 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.

Rural Doctors Association of South Africa (RuDASA)
23-26 September 2015, Mpumalanga, South Africa

An annual RuDASA conference has been organised almost every year since 1996, and attracts a range of rural health professionals from all over the country. The conference is a much-anticipated, vibrant forum which combines a mixture of sessions ranging from clinical skills updates for and by a wide range of health professionals to emotive discussions and workshops on issues such as justice and equity.


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