EQUINET NEWSLETTER 173 : 01 July 2015

1. Editorial

More than a voice: invest in community representatives capacities for them to be heard
Hélène Rossert, USA, Robert Bourgoing, France

In a 2015 report on the Representation and Participation of Key Populations on Country Coordinating Mechanisms (CCMs) in Swaziland, Lesotho, South Africa, Botswana, Zimbabwe and Zambia, (http://tinyurl.com/obuudjv) Aidspan noted that key population representatives (KPRs) “have often in the past been seen as somewhat token CCM members” and that “their ability to contribute, and the quality of their participation in the processes of these bodies [is] unclear”.

We believe indeed that building the capacity of KPRs to contribute their indispensable share to the governance of Global Fund-supported programs is a central condition for achieving the vision of ending HIV, tuberculosis and malaria as public health threats by 2030.
Women and girls, men who have sex with men, people who inject drugs, transgender people, sex workers, prisoners, refugees and migrants, people living with HIV, adolescents and young people, orphans and vulnerable children… Giving those groups a voice by opening the doors of CCMs to their representatives is a major step in the right direction. But to unleash their potential to be heard and become a trusted force for change, they need support to build essential skills and competencies.

The Global Fund and its success against AIDS, TB and malaria owe a lot to the extraordinary contributions of civil society representatives worldwide. With the new rules of engagement in the Global Fund governance systems, activists with high levels of formal education are now making room for a new generation of civil society representatives, whose level of preparedness varies considerably, as highlighted in the Aidspan report. These new arrivals must absorb a tremendous volume of information and data that is made available, at an increasing speed, about the Fund, its partners and health-related issues.

A variety of toolkits, manuals, guidelines, tutorials and training workshops has already been produced around Global Fund policies and processes. But these good initiatives are scattered, developed separately, written primarily in English, sometimes in French and Spanish, and generally not designed with a focus on the specific needs of less-educated or extremely marginalized groups. Let’s face it: how many KPRs have been efficiently trained through sporadic two or three-day workshops? How many have excelled basing their knowledge and understanding of program implementation through Global Fund orientation sessions? Self-education and workshops cannot by themselves be substitutes for a better structured and adapted training curriculum for KPRs.

In a 2014 study on the engagement in the funding model of key populations from 11 countries (at http://tinyurl.com/qxwuzd7), the Global Fund Board’s communities delegation observed: “In cases where community representatives had received capacity building over the longer term, KPs were empowered to engage, raise concerns, challenge existing power structures and decision making processes and influence final outcomes. In cases where capacity building was lacking, KP representatives were engaged only in a tokenistic way and faced stigma during the process, labelled as incompetent and seemingly reinforcing negative preconceptions about key affected communities”.

KPRs have access to extended networks and an intimate knowledge of the needs and priorities of some of the most hard-to-reach communities. They bring a unique expertise that other CCM members, be they doctors, academics, government representatives or other high-level officials don’t have. But to make the most of it, to enter CCM discussions confidently and influence public health decision-making in a credible way, they must learn to speak the language spoken at CCM meetings and in public health circles. They need to master the technical complexities of Global Fund procedures and be fully at ease with using the language of decision makers to represent the interests of their groups. This needs long-term capacity building.

We see four main components for such a curriculum, which could be conceived as a training-of-trainers program to reach out to members of marginalized communities in their own languages. Program management, from design to evaluation, is an area where KPRs and communities can bring true innovation, especially in monitoring and qualitative program evaluation. Good governance of their own community organizations is another essential component of their credibility. Advocacy is a third area that requires special skills, especially in the context of a complex international multistakeholder partnership. To develop and implement effective strategies that attract attention to their cause or to play constructive watchdog functions, KPRs must be able to conduct needs assessments and evaluations of service delivery systems, notably public ones.

Underlying those three areas, the importance of information literacy cannot be overstated. To keep learning, KPRs must develop essential skills to navigate their way through a vast and expanding array of information resources (websites, social media channels, mailing lists, databases, etc.). This is critical to building their networks, understanding where their priorities fit in the bigger picture, and keeping a strategic watch over the most relevant developments in their field of interest while avoiding information overload.

This may seem like a formidable challenge. The good news is that today’s internet offers cheap and reliable channels to deliver certified courses in multiple languages at no cost to participants, to connect to a global and diverse audience, reaching out to distant individuals at their own pace and offering a space for networking with their peers around the world. Although face to face training will remain indispensable to provide more targeted support, open online courses can offer an extraordinary channel to deliver training to very large groups, to monitor its results and to address concerns over fake, ineffective and costly training. The KPRs’ skills and knowledge gaps, as well as the technology to deliver a program that addresses them, can quite easily be figured out. For the Global Fund and its partners, it is mostly a matter of making this a priority and investing in the design and development of a curriculum for maximum impact, in a coordinated way.

Community leaders and KPRs represent the untapped ‘human resources’ of current and future public health efforts. By pooling together different capacity building initiatives and internet possibilities, public health training for KPRs is at our grasp. Let’s support their capacity to be heard, if we really hope to win the fight against disease.

A longer version of this post was published in Aidspan’s Global Fund Observer newsletter Issue 266 28 May 2015 http://tinyurl.com/pd7bhz3 and in R. Bourgoing’s Aid Transparency blog at http://tinyurl.com/owr4qb2 and it has been used with the authors permission. Hélène Rossert is a US-based Global Fund advocate and former Vice Chair of the Global Fund Board. Robert Bourgoing is an aid transparency advocate and trainer, and former Manager of Global Fund Online Communications.

2. Latest Equinet Updates

Case Study Brief: Health centre committees ensuring services respond to the needs of people living with HIV in Malawi

Malawi's 1994 Constitution obliges the state to provide adequate health care within the resources available, and guarantees equality in access to these health services. Community participation is a central pillar for implementing PHC in Malawi’s 2011-2016 Health Sector Strategic Plan, which commits to ensuring that local communities have a voice and an opportunity to participate in issues that affect their health. This brief describes the role ad functioning of health centre advisory committees in supporting services to be responsive to the needs of people living with HIV. The committee members worked with volunteers, visiting villages with messages about prevention of vertical transmission and the services available for it.

3. Equity in Health

Global evidence on inequities in rural health protection: New data on rural deficits in health coverage for 174 countries
Scheil-Adlung X: International Labour Office, ESS Document No. 47, Geneva, 2015

While inequities in health protection are increasingly recognized as an important issue in current policy debates on universal health coverage (UHC) and in the post-2015 agenda, the rural/urban divide is largely ignored. 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.

Global vaccination targets ‘off-track’ warns WHO
WHO: Geneva, April 2015

Progress towards global vaccination targets for 2015 is far off-track with 1 in 5 children still missing out on routine life-saving immunizations that could avert 1.5 million deaths each year from preventable diseases. WHO issued this statement calling for renewed efforts to get progress back on course in the lead-up to World Immunization Week in April 2015.

State of inequality: Reproductive, maternal, newborn and child health
World Health Organisation: Global Health Observatory Data, WHO Geneva, 2015

The report delivers both promising and disappointing messages about the situation in low- and middle-income countries with respect to reproductive, maternal, newborn and child health indicators. Within-country inequalities have narrowed, with a tendency for national improvements driven by faster improvements in disadvantaged subgroups. 

However, inequalities still persist in most reproductive, maternal, newborn and child health indicators. The extent of within-country inequality differed by dimension of inequality and by country, country income group and geographical region. The patterns of change in inequality over time varied by health indicator, and according to country and dimension of inequality. The report observes that while national averages and improvements over time are important indications of progress on a global level, reporting inequalities within countries shows how any progress in national averages is realized by population subgroups. Establishing goals and targets that specify a reduction in inequality encourages the orientation of policies, programmes and practices to promote health in disadvantaged subgroups. Without a dedicated focus on equity, efforts to improve health can risk perpetuating or intensifying within-country inequality, even as increases in national coverage are achieved.

4. Values, Policies and Rights

African performance on human rights
Anambo Ongoche E: Pambuzuka News 730, 10 June 2015

Almost two decades after adoption of the African Charter on Human and Peoples' Rights, the record of adherence to its provisions across the continent is mixed. Some countries have made notable progress, but others show persistent serious violations of human rights. African performance on human rights as spelled out in the Charter varies from one country to another. The author elaborates the situation in different countries on the continent against the rights set out in the Charter. The author concludes that Africa has a long way to go in the practice and upholding of human rights at out in the Charter. He urges that governments be made accountable to ensure that human rights are upheld.

The health-systems response to violence against women
García-Moreno C; Hegarty K; d’Oliveira A; Koziol-McLain J; Colombini M; Feder G: The Lancet 385(9977), 1567-1579, 2015

Health systems have a crucial role in a multisector response to violence against women. Some countries have guidelines or protocols articulating this role and health-care workers are trained in some settings, but generally system development and implementation have been slow to progress. Substantial system and behavioural barriers exist, especially in low-income and middle-income countries. Violence against women was identified as a health priority in 2013 guidelines published by WHO and the 67th World Health Assembly resolution on strengthening the role of the health system in addressing violence, particularly against women and girls. In this Series paper, we review the evidence for clinical interventions and discuss components of a comprehensive health-system approach that helps health-care providers to identify and support women subjected to intimate partner or sexual violence. Five country case studies show the diversity of contexts and pathways for development of a health system response to violence against women. Although additional research is needed, strengthening of health systems can enable providers to address violence against women, including protocols, capacity building, effective coordination between agencies, and referral networks.

Tracing shadows: How gendered power relations shape the impacts of maternal death on living children in sub Saharan Africa
Yamin A; Bazile J; Knight L; Molla M; Maistrellis E; Leaning J: Social Science and Medicine 135, 143-150, 2015

A mixed-methods study was conducted in four countries in sub-Saharan Africa to investigate the impacts of maternal death on families and children. The analysis identified gender as a fundamental driver not only of maternal, but also child health, through manifestations of gender inequity in household decision making, labour and caregiving, and social norms dictating the status of women. Focus group discussions were conducted with community members, and in depth qualitative interviews with key-informants and stakeholders, in Tanzania, Ethiopia, Malawi, and South Africa between April 2012 and October 2013. Findings highlighted that socially constructed gender roles, which define mothers as caregivers and fathers as wage earners, and which limit women's agency regarding childcare decisions, among other things, create considerable gaps when it comes to meeting child nutrition, education, and health care needs following a maternal death. Additionally, the findings show that maternal deaths have differential effects on boy and girl children, and exacerbate specific risks for girl children, including early marriage, early pregnancy, and school drop-out. The authors conclude that investment in health services interventions should be complemented by broader interventions regarding social protection, with a shifting of social norms and opportunity structures regarding gendered divisions of labour and power at household, community, and society levels.

Tracking universal health coverage: First global monitoring report
WHO; World Bank: Joint WHO/World Bank Group report, June 2015

Universal health coverage (UHC) means that all people receive the quality, essential health services they need, without being exposed to financial hardship. Moving towards UHC is a dynamic, continuous process that requires changes in response to shifting demographic, epidemiological and technological trends, as well as people’s expectations. But in all cases, countries need to integrate regular monitoring of progress towards targets into their plans. In May 2014, the World Health Organization and the World Bank jointly launched a monitoring framework for UHC, based on broad consultation of experts from around the world. The framework focuses on indicators and targets for service coverage – including promotion, prevention, treatment, rehabilitation and palliation – and financial protection for all. This report is the first of its kind to measure health service coverage and financial protection to assess countries’ progress towards universal health coverage. It shows that at least 400 million people do not have access to one or more essential health services and 6% of people in low- and middle-income countries are tipped into or pushed further into extreme poverty because of health spending.

5. Health equity in economic and trade policies

Agenda 2063 Vision and Priorities
African Union, Addis Ababa, May 2015

The African Union set out its vision of An Integrated, prosperous and peaceful Africa, driven by its own citizens and representing a dynamic force in the global arena. Aiming to encourage discussion among all stakeholders, Agenda 2063 is an approach to how the continent should effectively learn from the lessons of the past, build on the progress now underway and strategically exploit all possible opportunities available in the immediate and medium term, so as to ensure positive socioeconomic transformation within the next 50 years. Agenda 2063 emphasizes the importance of Pan-Africanism, unity, self-reliance, integration and solidarity that was a highlight of the triumphs of the 20th century. It highlights the need to more effectively use African resources for the benefit of people in the continent. It raises regional political, institutional renewal and financing/resource mobilization issues, as well as the changing nature of Africa’s relationships with the rest of the world. The AU is calling for input to the agenda.

BRICS Bank could be game-changer
Klomegah K: Pambuzuka News 731, 19 June 2015

The July BRICS Summit ratified an agreement on the establishment of a $100 billion BRICS pool of currency reserves, according to a document published early May 2015. It is reported that the bank will invest primarily in infrastructure projects in both BRICS and non-BRICS countries. The establishment of its first regional office in Johannesburg will give access to the Africa, where infrastructure development needs are highest. The idea to set up BRICS bank was first proposed by India and that topped the agenda at the summit of the group in New Delhi in March 2012. India believes a joint bank would be in line with the growing economic power of the five-nation group. The bank could firm up the position of BRICS as a powerful player in global decision-making. India believes that a BRICS bank could, among others, issue convertible debt, which would arguably be top-rated and can be bought by central banks of all BRICS countries. BRICS countries would thus have a vessel for investment risk-sharing.

Running ahead: Food security and agricultural development
Kamau MN: Pambuzuka News 730, 10 June 2015

Agriculture has the potential not only to feed all of Africa’s people but also to earn the continent revenues for development. There are numerous practical ways in which this can be achieved. the Comprehensive Africa Agriculture Development Programme (CAADP) is a programme of African Union, which was endorsed in Maputo in 2003 with the aim of improving and promoting agriculture across Africa calls for countries to allocate 10% of their national income to agricultural development. Most countries have poor storage facilities and transportation systems which have led to post-harvest losses in both grains and vegetables. Maize has been affected by aflatoxin. There has been persistent price fluctuation of agricultural products which makes it almost impossible to plan for the earnings. The foreign income is minimal since most countries engage in primary exports, where the market is saturated. The author indicates that it is time Africa embraced the concept of value addition, exporting finished products will give an upper hand in the global market. Enhancing tariff barriers will make imports expensive boosting the demand for local products.

6. Poverty and health

International parental migration and the psychological well-being of children in Ghana, Nigeria, and Angola
Mazzucato V; Cebotari V; Veale A; White A; Grassi M; Vivet J: Social Science and Medicine 135, 215-224, 2015

When parents migrate, leaving their children in the origin country, transnational families are formed. Transnational family studies on children who are “left behind” indicate that children suffer psychologically from parental migration. Many of the factors identified as affecting children's responses to parental migration however are not considered in child psychology and family sociology studies. This study aimed to bridge these areas of knowledge by quantitatively investigating the association between transnational families and children's psychological well-being. It analyzed a survey conducted in three African countries in 2010–11 (Ghana N = 2760; Angola N = 2243; Nigeria N = 2168) amongst pupils of secondary schools. The study compared children in transnational families to those living with their parents in their country of origin. Children's psychological well-being was measured through the Strengths and Difficulties Questionnaire. Multiple regression analyses reveal that children in transnational families fare worse than their counterparts living with both parents but not in Ghana where living conditions mediate this relationship. Specific characteristics of transnational families and country contexts mattered: (1) changing caregivers is associated with poorer well-being in all countries; (2) which parent migrates does not make a difference in Ghana, when mothers migrate and fathers are caregivers results in poorer well-being in Nigeria, and both mother's and father's migration result in worse outcomes in Angola; (3) the kin relationship of the caregiver is not associated with poorer well-being in Ghana and Nigeria but is in Angola; (4) children with parents who migrate internationally do not show different results than children whose parents migrate nationally in Ghana and Nigeria but in Angola international parental migration is associated with poorer psychological well-being. The study showed that broader characteristics in the population rather than parental migration per se are associated with decreased levels of well-being.

Knowledge, perception and practices about malaria, climate change, livelihoods and food security among rural communities of central Tanzania
Mayala BK; Fahey CA; Wei D; Zinga MM; Bwana VM; Mlacha T; Rumisha SF; Stanley G; Shayo EH; Mboera L: Infectious Diseases of Poverty 4(21), April 2015, doi: 10.1186/s40249-015-0052-2

This study determined knowledge, perceptions and practices as regards to malaria, climate change, livelihoods and food insecurity in a rural farming community in central Tanzania. Using a cross-sectional design, heads of households were interviewed on their knowledge and perceptions on malaria transmission, symptoms and prevention and knowledge and practices as regards to climate change and food security. A total of 399 individuals (mean age = 39.8 ± 15.5 years) were interviewed. Nearly all (94.7%) knew that malaria is acquired through a mosquito bite. Three quarters (73%) reported that most people get sick from malaria during the rainy season. About 50% of the respondents felt that malaria had decreased during the last 10 years. The household coverage of insecticide treated mosquito nets was high (95.5%). Ninety-six percent reported to have slept under a mosquito net the previous night. Only one in four understood the official Kiswahili term (Mabadiliko ya Tabia Nchi) for climate change. However, there was a general understanding that the rain patterns have changed in the past 10 years. Sixty-two percent believed that the temperature has increased during the same period. Three quarters of the respondents reported that they had no sufficient production from their own farms to guarantee food security in their household for the year. Three quarters (73.0%) reported to having food shortages in the past five years. About half said they most often experienced severe food shortage during the rainy season. The authors concluded that farming communities in Kilosa District have little knowledge on climate change and its impact on malaria burden, but that food insecurity. They recommend integrating control of malaria and food insecurity interventions.

Mind the Gap: House Structure and the Risk of Malaria in Uganda
Wanzirah H; Tusting LS; Arinaitwe E; Katureebe A; Maxwell K; Rek J; Bottomley C; Staedke SG; Kamya M; Dorsey G; Lindsay SW: PLOS One, January 2015, doi: 10.1371/journal.pone.0117396

Good house construction may reduce the risk of malaria by limiting the entry of mosquito vectors. The authors assessed how house design may affect mosquito house entry and malaria risk in Uganda. 100 households were enrolled in each of three sub-counties: Walukuba, Jinja district; Kihihi, Kanungu district; and Nagongera, Tororo district. CDC light trap collections of mosquitoes were done monthly in all homes. All children aged six months to ten years (n = 878) were followed prospectively for a total of 24 months to measure parasite prevalence every three months and malaria incidence. Homes were classified as modern (cement, wood or metal walls; and tiled or metal roof; and closed eaves) or traditional (all other homes). The human biting rate was lower in modern homes than in traditional homes. The odds of malaria infection were lower in modern homes across all the sub-counties, while malaria incidence was lower in modern homes in Kihihi but not in Walukuba or Nagongera. The authors concluded that house design is likely to explain some of the heterogeneity of malaria transmission in Uganda and represents a promising target for future interventions, even in highly endemic areas.

7. Equitable health services

Do antenatal care visits always contribute to facility-based delivery in Tanzania? A study of repeated cross-sectional data
Choe SA; Kim J; Kim S; Park Y; Kullaya SM; Kim CY: Health Policy and Planning, June 2015, doi: 10.1093/heapol/czv054

There is a high disparity in access to perinatal care services between urban and rural areas in Tanzania. This study analysed repeated cross-sectional data from Tanzania to explore the relationship between antenatal care (ANC) visits, facility-based delivery and the reasons for home births in women who had made ANC visits. The relationship between the number of ANC visits (up to four) and facility delivery in the latest pregnancy was explored. For rural women, there was no significant relationship between the number of ANC visits and facility delivery rate. The most frequent reason for home delivery was ‘physical distance to facility’, and a significant proportion of rural women reported that they were ‘not allowed to deliver in facility’. The disconnect between ANC visits and facility delivery in rural areas may be attributable to physical, cultural or familial barriers, and quality of care in health facilities. This suggests that improving access to ANC may not be enough to motivate facility-based delivery, especially in rural areas.

Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania
Baker U; Peterson S; Marchant T; Mbaruku G; Temu S; Manzi F; Hanson C: Bulletin of World Health Organization 93, 22 April 2015, http://dx.doi.org/10.2471/BLT.14.141879

The authors aimed to estimate the effective coverage of key maternal and newborn health interventions in rural parts of the United Republic of Tanzania and to identify bottlenecks in implementation. They used data from an observational, cross-sectional study that was performed in Tandahimba and Newala districts in south-eastern United Republic of Tanzania. They investigated five key maternal and newborn health interventions: (i) syphilis screening; (ii) pre-eclampsia screening; (iii) use of a partograph to monitor labour; (iv) active management of the third stage of labour; and (v) postpartum care in a health facility. The largest bottleneck in Tandahimba was health facility readiness, which was associated with a 52% reduction in coverage. Clinical practice was another large bottleneck, with an attrition of 35%. In Newala, clinical practice was the largest bottleneck, causing an attrition of 57%. The authors provide a framework that could help operationalize measurements and track progress towards universal health coverage in all areas of health care.

8. Human Resources

Unpaid Care Work Programme: Uganda Country Progress Report (2012–2014)
Nesbitt-Ahmed Z; Malinga Apila H: Institute of Development Studies Evidence Report 126, IDS Sussex, 2015

The Institute of Development Studies (IDS) partnered with ActionAid International (AAI) in Uganda to develop and implement an advocacy strategy to make unpaid care work more visible in public policy, as well as to integrate unpaid care issues into each country’s programming. It used an action learning methodology to look at what works and does not work in making the care economy more visible. It aimed to track and capture changes in policy and practice in order to improve understanding around the uptake of evidence. This report covers the progress of the programme in Uganda over the first two and a half years of the four-year programme. The work identified that making unpaid care work more visible calls for a collective voice amongst those involved and engaging and working effectively with the media with clear messaging.

What do community health workers have to say about their work, and how can this inform improved programme design? A case study with CHWs within Kenya
Oliver M; Geniets A; Winters N; Rega I; Mbae S: Global Health Action 8, May 2015, doi: http://dx.doi.org/10.3402/gha.v8.27168

Community health workers (CHWs) are often spoken about or for, but there is little evidence of CHWs’ own characterisation of their practice. This paper addresses this issue. A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. CHWs’ accounts of both successes and challenges involved material elements: leaky tins and dishracks evidenced successful health interventions, whilst bicycles, empty first aid kits and recruiting stretcher bearers evidenced the difficulties of resourcing and geography they are required to overcome. CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a ‘deficit’ position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The authors suggest that programmes co-designed with CHWs will be easier to implement because of their relevance to their practices and experiences, whereas those that seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work.

9. Public-Private Mix

Malawi govt backtracks on hospital user fees
Chauwa A: Nyasa Times April 5 2015

The Malawi government has said that medical services in all public health facilities will remain free. Minister of Health spokesperson Henry Chimbali told Nyasa Times that government has introduced by-pass fees [and not user fees] in referral hospitals in order to decongest the facilities. He also noted that the ministry will review the current arrangement between the Ministry and Christian Health Association of Malawi (CHAM) saying the current Memorandum of Understanding (MoU) dates back to 2002, is well overdue for review and needs to take into account some of the emerging issues that have taken place such as the passing into law of the new Act on Public Private Partnership Agreements (PPPs) which is the basis of the arrangement between the Ministry of Health and CHAM. The proposal is to work out a mechanism that will see greater access to quality health services by all Malawians especially those in rural and hard to reach areas. He also noted that the Ministry of Health seeks to establish a Health Fund to support health service delivery and widen coverage of medical insurance for those who can afford it.

10. Resource allocation and health financing

Disability Grant: a precarious lifeline for HIV/AIDS patients in South Africa
Govender V; Fried J; Birch S; Chimbindi N; Cleary S: BMC Health Services Research 15(227), June 2015, doi:10.1186/s12913-015-0870-8

In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, the authors consider inequalities in access to the DG for patients on ART and implications of DG access for on-going access to healthcare. Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. Grant recipients were comparatively worse off than non-recipients in terms of employment and wealth. The regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed. Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG. The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.

NHI far from reality but progress made in improving public health
Health E-News, 1 June 2015

South Africa's proposed National Health Insurance (NHI) scheme, is many years away, but many of the country’s 10 pilot sites are reported to be making progress. Of the 10 NHI pilot districts Health e-news investigated all – with the exception of OR Tambo in the Eastern Cape – are making reasonable progress in improving public health. The pilot districts, covering 20 percent of the population, were set up almost five years previously after Health Minister Aaron Motsoaledi announced the NHI as government policy. Negative patient experiences in public health facilities led government to concentrate on cleaning its own house before attempting any engagement of the NHI with the private sector.

11. Equity and HIV/AIDS

Doubt, defiance, and identity: Understanding resistance to male circumcision for HIV prevention in Malawi
Parkhurst J; Chilongozi D; Hutchinson E: Social Science and Medicine 135, 15-22, 2015

Global policy recommendations to scale up of male circumcision (MC) for HIV prevention tend to frame the procedure as a simple and efficacious public health intervention. However, there has been variable uptake of MC in countries with significant HIV epidemics. In this paper the authors present an in-depth analysis of Malawi's political resistance to MC, finding that ethnic and religious divisions dominating recent political movements aligned well with differing circumcision practices. Political resistance was further found to manifest through two key narratives: a ‘narrative of defiance’ around the need to resist 'donor manipulation', and a ‘narrative of doubt’ which seized on a piece of epidemiological evidence to refute global claims of efficacy. Further, the authors found that discussions over MC served as an additional arena through which ethnic identities and claims to power could themselves be negotiated, and therefore used to support claims of political legitimacy.

Students want HIV testing in schools: a formative evaluation of the acceptability of HIV testing and counselling at schools in Gauteng and North West provinces in South Africa
Madiba S; Mokgatle M: BMC Public Health 15(388), April 2015, doi:10.1186/s12889-015-1746-x

The proposal by the South African Health Ministry to implement HIV testing and counselling (HTC) at schools in 2011 generated debates about the appropriateness of such testing. However, the debate has been between the Ministries of Education and Health, with little considerations of the students. This study assessed the students’ opinions and uptake of HIV testing and counselling in general, and the acceptability of the provision of HIV testing and counselling in schools. A survey was conducted among grade 10–12 high school students in North West and Gauteng provinces, South Africa. Seventeen high schools (nine rural and eight urban) were randomly selected for the administration of a researcher-assisted, self-administered, semi-structured questionnaire. A total of 2970 students aged 14–27 years participated in the study. Having multiple sexual partners, age, and gender were significantly associated with increased odds of having had a HIV test. Fear, being un-informed about HTC, and low HIV risk perceptions were the reasons for not getting tested. The acceptability of HTC at school was high (n = 2282, 76.9%) and 2129 (71.8%) were willing to be tested at school. Appropriateness, privacy, and secrecy were the main arguments for and against HTC at school. One-third had intentions to disclose their HIV status to students versus 42.5% for teachers. Stigma, discrimination and secrecy were the primary reasons students did not intend to disclose. A high acceptability of HTC and willingness to be tested at school suggest that HIV prevention programs tailored to youth have a high potential of success given the readiness of students to uptake HTC. The authors conclude that bringing HIV testing to the school setting will increase the uptake of HTC among youth and contribute towards efforts to scale up HTC in South Africa.

12. Governance and participation in health

Global health security: the wider lessons from the west African Ebola virus disease epidemic
Heymann D et al (23 co-authors): The Lancet 385 (9980),1884–1901, 2015

The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. It drew 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? This 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.

Monitoring Pro-Poor Health-Policy Success in the SADC Region
Amaya A;, Bagapi K; Choge I; De Lombaerde P: Kingah S: Kwape I; Luwabelwa M; Mathala O: Mhehe E: Moeti T: Mookodi L; Ngware Z; Phirinyane P: PRARI Policy brief April 2015

In the area of health, the Southern African Development Community (SADC) has conducted important work in understanding how poor health and poverty coincide, are mutually reinforcing, and socially-structured by gender, age, class, ethnicity and location, demonstrated by the key health policy documents that have been facilitated by the secretariat. Yet the time lapse between the formulation of guidelines and policies and their implementation has at times been uneven. This brief describes the Poverty Reduction and Regional Integration indicator-based monitoring system addressing health priorities for the region, under the institutional leadership of the SADC secretariat and with the support from its Member States that are the main beneficiaries of the process.

Multi-level Pro-Poor Health Governance, Statistical Information Flows, and the Role of Regional Organisations in South America and Southern Africa
Amaya A; Kingah S: De Lombaerde, P: PRARI Working Paper 15/1, The Open University-United Nations University Institute on Comparative Regional Integration Studies, Milton Keynes, UK 2015

In this paper, the authors analyse regional to national-level data flows with the use of two case studies focusing on UNASUR (Bolivia and Paraguay) and SADC (Swaziland and Zambia). Special attention is given to pro-poor health policies, those health policies that contribute to the reduction of poverty and inequities. The results demonstrate that health data is shared at various levels. This takes place to a greater extent at the global-country and regional-country levels, and to a lesser extent at the regional-global levels. There is potential for greater interaction between the global and regional levels, considering the expertise and involvement of UNASUR and SADC in health. Information flows between regional and national bodies are limited and the quality and reliability of this data is constrained by individual Member States’ information systems. Having greater access to better data would greatly support Member States’ focus on addressing the social determinants of health and reducing poverty in their countries. This has important implications not only for countries but to inform regional policy development in other areas. By serving as a foundation for building indicator-based monitoring tools, improving health information systems at both regional and national levels can generate better informed policies that address poverty and access to health.

PHM WHO Watch notes of World Health Assembly May 2015
Peoples Health Movement: Global Health Watch, June 2015

WHO Watch is an intervention in global health governance. It provides a current account of global policy dynamics in relation to a wide and growing range of health issues. The links enable local activists to keep in touch with the global policy movements which shape the context for such local struggles. They also help to ensure that policy analysis and policy advocacy at the regional and global levels is informed by the reality of grass roots activism, both in health systems and around the conditions which shape health. This link provides the WHO Watch notes from the World Health Assembly May 19-26 2015. It covers the discussions on 23 major items at the Assembly.

13. Monitoring equity and research policy

Sex and gender matter in health research: addressing health inequities in health research reporting
Gahagan J; Gray K; Whynacht A: International Journal for Equity in Health 2015, 14(12), 2015

Attention to the concepts of ‘sex’ and ‘gender’ is increasingly being recognised as contributing to better science through an augmented understanding of how these factors impact on health inequities and related health outcomes. However, the ongoing lack of conceptual clarity in how sex and gender constructs are used in both the design and reporting of health research studies remains problematic. Conceptual clarity among members of the health research community is central to ensuring the appropriate use of these concepts in a manner that can advance understanding of the sex- and gender-based health implications of the research findings. During the past twenty-five years much progress has been made in reducing both sex and gender disparities in clinical research and, to a significant albeit lesser extent, in basic science research. Why, then, does there remain a lack of uptake of sex- and gender-specific reporting of health research findings in many health research journals? This question, the authors argue, has significant health equity implications across all pillars of health research, from biomedical and clinical research, through to health systems and population health.

Surveys of measles vaccination coverage in eastern and southern Africa: a review of quality and methods used
Kaiser R; Shibeshi M; Chakauya J; Dzeka E; Masresha B; Daniel F; Shivute N: Bulletin of the World Health Organization 93(5), 285-360, 2015

This study assessed the methods used in the evaluation of measles vaccination coverage in 2012/3 in eastern and southern Africa, identified quality concerns and made recommendations for improvement. Of the 13 reports the authors reviewed, there were weaknesses in 10 of them for ethical clearance, 9 for sample size calculation, 6 for sampling methods, 12 for training structures, 13 for supervision structures and 11 for data analysis. The authors recommend improvements in the documentation of routine and supplementary immunisation, via home-based vaccination cards or other records. They recommend that standards be developed for report templates and for the technical review of protocols and reports. This would ensure that the results of vaccination coverage surveys are accurate, comparable, reliable and valuable for programme improvement.

The ethics of health systems research: Selected guidelines and studies
Molyneux S; Pratt B; Wassenaar D; Rogers W: Research in Gender and Ethics (RinGs) Building stronger health systems,2015

There is a growing interest in the ethics of health systems research, and some debate about whether a specific ethical framework or set of guidance is needed. The authors provide a framework to begin to think about this, organised around eight considerations: (1) the nature of intervention; (2) types of research subjects; (3) units of intervention and observation; (4) informed consent; (5) controls and comparisons; (6) risk assessment; (7) inclusion of vulnerable groups within different contexts, and; (8) benefits of research. This is a starting place for researchers interested in health systems research ethics. The authors note several challenges to thinking about the ethics of health systems research, including the diverse range of studies and disciplines involved, the grey zone between research and non-research, and the many overlaps of issues with other types of health research. They call for more conceptual work and empirical research aimed at better understanding this topic.

14. Useful Resources

Ebola Fund Watch: Tracking For Ebola Crisis in West Africa
BudgIT; Open Society Initiative for West Africa: June 2015

This resource gathers evidence on the use of funds for the containment of the Ebola outbreak as provided by external funders. It also plans to create a narrative of cumulative experiences of how emergency funds were applied to survivors, victims, healthcare workers, institutions and other beneficiaries. It focuses on curating, tracking and demanding accountability for funds meant for Ebola virus treatment and containment across the sub region.

Evidence for policy and practice
Murphy L: Eldis 2015

Quality assured research synthesis documents from a selected set of publishers who focus is on supporting evidence-informed decision-making on issues relevant to international development. This Guide provides access to a set of quality assured research synthesis documents specifically intended to assist evidence-informed decision-making in development policy and practice. They are selected by the Eldis team from a limited set of "approved" publishers who have been assessed to ensure a robust methodological approach to quality assurance. The Guide also provides a space for discussion on some of the debates on what constitutes "evidence", the use of different methods for quality assessment and the various approaches to impact evaluation

Online Rational Medicines Use Course Module
Bradley H: Schools of Public Health & Pharmacy, 2015

This module is specifically developed to equip healthcare professionals such as pharmacists, doctors and nurses with the necessary skills to improve rational medicines use. It will be of value to members of Pharmacy and Therapeutics Committees, Masters of Public Health students and staff working in pharmacy and health departments in South Africa and other African countries. Additional online modules focusing on Pharmaceutical Public Health will be available in 2016. The module covers rational medicines use and problems associated with irrational medicine use; medicines use problems using several quantitative methods; qualitative methods to investigate prescribing behaviour and medicine use; promotion of rational medicine use including educational, managerial, economic and regulatory interventions; medicines Use evaluation and its application to programmes; essential medicines concept and the development of Standard Treatment Guidelines and Essential Medicines Lists using evidence-based decision making principles; infection control and antimicrobial resistance and pharmacy and therapeutics committees.

15. Jobs and Announcements

Call for applicants: Strengthening PhD programmes in African Universities
Application deadline: 21 August 2015

The Council for the Development of Social Science Research in Africa (CODESRIA) calls for applications from research laboratories and doctoral schools in African universities for the first phase of its initiative to support research in the social sciences and humanities. The objective of this initiative is to restore and/or enhance the seminar culture within research laboratories, doctoral schools in African universities, while encouraging the use of multi and interdisciplinary approaches. After a rigorous selection exercise by an international independent selection committee, selected research laboratories and doctoral schools will receive a grant of 10,000 dollars from CODESRIA, which is expected to be used for: the purchase of books and journals for the benefit of the entire academic community; a scientific seminar exposing PhD students to relevant literature, current debates, and theoretical approaches in relation to a given topic; a methodology seminar, and a scientific writing workshop. Further information can be found at the website.

Call for Applications: PhD Applications at HEARD/UKZN, South Africa
Closing date for applications: 1 August 2015

HEARD is calling for applications for up to four full-time PhD Research Scholarships in any of the following key areas of strategic focus Sexual and Reproductive Health; Health Systems Strengthening and Economics of Critical Enablers in HIV Programming. Award of the HEARD PhD Research Scholarship is conditional on candidates meeting the requirements for PhD registration at the University of KwaZulu-Natal, and on participating in a compulsory training component during the first year of study. The training component will be conducted over four two-week blocks during the first year of study. Candidates will produce a thesis related to one of HEARDs priority research nodes, as detailed above. The Scholarship programme emphasises the mastery of quantitative and qualitative methods for understanding policy problems and for devising, evaluating and/or implementing policy solutions. The intention of providing PhD scholarships is to produce expertly qualified graduates to advise or to be part of influential policy making organisations in Africa. During their PhD, students will be strongly encouraged to present their work at international meetings. Successful candidates will be based in Durban, South Africa, for the duration of the scholarship, with the exception of the time during which they may undertake field research elsewhere. Applications are invited from citizens of all African countries. Female candidates and, in the case of South Africa, those from previously disadvantaged backgrounds, are especially encouraged to apply.

The Public Health Association of South Africa (PHASA) Conference
7 – 9 October 2015, 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. The conference theme is Health and Sustainable Development: The Future. The 2015 PHASA Conference will be more interactive than previous PHASA conferences. 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. The target audience is policy makers, public health academics and students, health professionals, health service managers and individuals from non-governmental and community-based health organisations.

Travel Scholarships for Scientific Conferences
Canon Foundation

The Canon Foundation for Scientific Research is seeking applications to provide support for scientists and academics from developing countries in the scientific and engineering fields who would like to attend local or international conferences, symposia and workshops or undertake other postgraduate study. The Foundation welcomes applications from researchers who would like to attend local or international conferences, symposia and workshops or undertake other postgraduate study. In most cases, they will meet all or part of travel, accommodation and registration costs. They also consider offering financial assistance to qualified researchers wishing to further their expertise at an internationally recognised overseas institution.


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