EQUINET NEWSLETTER 175 : 01 September 2015

1. Editorial

Examining evidence on the private for-profit healthcare sector
Jessica Hamer, Health Policy Adviser, Oxfam GB

Challenges of high costs, out of pocket spending, regulation and quality affect the contribution the for-profit private sector makes in healthcare, according to presenters in a session on ‘Private sector and Universal Health Coverage: Examining evidence and deconstructing rhetoric’ hosted by Oxfam and Dr. Anuj Kapilashrami, of the Global Public Health Unit, University of Edinburgh, in the July 2015 International Conference on Public Policy.

The session aimed to look at new and existing evidence on the role of the private for-profit sector in health, and to critically evaluate this in the context of achieving UHC in low- and middle-income countries. The five papers on experiences in Asia and Africa presented at the session looked at a wide range of private sector actors in health care delivery but raised a number of common themes and challenges.

One common feature was high levels of out-of-pocket spending (OOPS), or cash payments by households for services, medicines and other charges. This was found for example where state insurers pay for services from private providers. Asha Kilaru presented study findings that people covered by state insurance schemes in Karnataka, India still had out of pocket spending for services, even for schemes where all costs should be covered. The study found that 93% of those insured by at least one government scheme sought care from a private hospital, and that only 8% reported receiving completely free care. Even where healthcare was provided for free, additional costs, such as multiple hospital referrals for different tests and treatment, meant OOPS still occurred. One of the respondents’ interviewed in the study stated:
‘Only the operation [C-section] was free. At the government hospital, a C-section would be only Rs3-4000, but we went to a private hospital since we had insurance and wound up spending so much. It seems like government are agents that send us to a private hospital. In this yojana [Yeshasvini insurance scheme] the government spends and we also spend’.

As the respondent indicated, high costs of care can be a burden to both households and the state. While this particular scheme (Yeshasvini) claimed to be self-funded, Kilaru found that it received Rs. 40 crore (equivalent to more than US$6 million) as a government grant in 2012-13 and Rs. 45 (or almost US$7 million) crore in the 2013-14 budget.

Jane Doherty, from University of the Witwatersrand, South Africa presented evidence in the session on the for-profit private healthcare sector in east and southern Africa. She noted that out of sixteen countries, ‘no country places a ceiling on the prices that its private hospitals may charge’ (although there may be some limitations to reimbursement payments made by insurers in two of the countries). Her study found ‘little control of the fees charged by health professionals or limits placed on their total incomes, except in Kenya’.

These challenges in controlling out of pocket spending and the overall costs of private healthcare present significant obstacles to achieving universal health coverage, and especially to ensuring access to healthcare for the poorest. Another recurring barrier to equitable access that was highlighted is the location of private services. Indranil Mukhopadhyay of the Public Health Foundation of India reported from a mapping of India’s private healthcare provision that urban, metropolitan areas have the majority of private hospitals. In rural areas, where more poor people live, the private sector is largely comprised of individual practitioners. Moreover, almost half of India’s private hospitals were located in cities with a population of more than 5 million. Mumbai alone has 16% of all India’s private hospitals. The same bias towards urban provision was reported by Jane Doherty in east and southern Africa.

Iornumbe Usar, of Queen Margeret University, Edinburgh, investigated perceptions of shops selling medicines in Nigeria. His paper for the session highlighted major concerns around ‘pervasive regulatory infringements’ by these shops, especially in selling medicines beyond the scope of their licenses, as well as the lack of training of their staff. The paper raised the challenges of regulating medicine vendors in Nigeria in order to improve their quality, highlighting how this has been constrained by inadequate funding, weak institutional capacity, the often-remote location of the shops, and conflicts between the different agencies responsible for regulation.

The same problem of poor regulation was reported by Jane Doherty in relation to for-profit private providers in east and southern Africa. Both an absence of regulation, and poor enforcement of regulation where it exists, were found to contribute to distortions in the wider health system, such as in treatment decisions or in the brain drain of health personnel from the public sector. She observed that ‘there is little monitoring by governments of quality and health outcomes, or attention to how the private health sector supports national health objectives’. She observed that there is also little regulation to guard against anti-competitive behaviour, such as when insurers, providers and pharmacies are all owned by the same company. She flagged in her presentation the challenges to regulation in the region, including patchy regulatory frameworks, the high cost of introducing new regulation, limited available information on the private sector, and the resistance of key stakeholders to regulation, or their “capture” of regulation to safeguard their own interests. In South Africa, for example, attempts to regulate dispensing fees for pharmacists have been resisted heavily.

As Doherty concluded, these ‘legislative gaps and enforcement problems, together with the fact that prices are not contained in any meaningful way, either through price controls or active reimbursement mechanisms, mean that for-profit private care in the region is likely to become increasingly unaffordable for any but the wealthiest’. Yet, Doherty also concluded that the for-profit private sector is growing, so that these impacts need to be addressed.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information see the full papers from the meeting at http://tinyurl.com/psma5ov; Oxfam’s 2009 paper “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” www.oxfam.org/en/research/blind-optimism and the EQUINET discussion papers 87 http://tinyurl.com/3gky5k2 and 99 http://tinyurl.com/ou2dh4n on the growth and legislation of the private health sector in east and southern Africa. Oxfam will be hosting additional discussion on its Global Health Check blog on the issues raised in the coming months.

2. Equity in Health

Tanzania's Countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015
Afnan-Holmes H; Magoma M; John T; Levira F; Msemo G; Armstrong C; Martínez-Álvarez M; Kerber K; Kihinga C; Makuwani A; Rusibamayila N; Hussein A; Lawn J; Tanzanian Countdown Country Case Study Group: The Lancet Global Health 3(7) e396–e409, 2015

Tanzania is on track to meet Millennium Development Goal (MDG) 4 for child survival, but is making insufficient progress for newborn survival and maternal health (MDG 5) and family planning. To understand this mixed progress and to identify priorities for the post-2015 era, Tanzania was selected as a Countdown to 2015 case study. The authors analysed progress made in Tanzania between 1990 and 2014 in maternal, newborn, and child mortality, and unmet need for family planning, in which they used a health systems evaluation framework to assess coverage and equity of interventions along the continuum of care, health systems, policies and investments, while also considering contextual change (eg, economic and educational). In the past two decades, Tanzania's population has doubled in size, necessitating a doubling of health and social services to maintain coverage. Trends along the continuum of care varied, with preventive child health services reaching high coverage (≥85%) and equity (socioeconomic status difference 13–14%), but lower coverage and wider inequities for child curative services (71% coverage, socioeconomic status difference 36%), facility delivery (52% coverage, socioeconomic status difference 56%), and family planning (46% coverage, socioeconomic status difference 22%). Mixed progress in reproductive, maternal, newborn, and child health in Tanzania were found to indicate a complex interplay of political prioritisation, health financing, and consistent implementation.

3. Values, Policies and Rights

Reclaim our future. Oppose the Corporate Development Agenda
People’s Health Movement, 27 July 2015

In September 2015 Heads of States and Governments will gather at the United Nations (UN) headquarters in New York City to agree on a new set Sustainable Development Goals (SDGs) and a 'global plan of action for people, planet and prosperity'. The latest draft of this declaration which promises to 'transform our world' by 2030 and ensure that no one will be left behind in the process has just recently been released. However, the PHM notes that many of these same governments, particularly the more powerful ones among them, are also currently negotiating new 'free trade' deals that will have far-reaching implications for peoples in both the global North and South and for the future of the world economy and the planet. These agreements as they are currently framed and when adopted side-by-side, will not usher a new dawn for humanity. Instead they are likely to further concentrate power and wealth in the hands of the 1% on the one hand, and deepen the dispossession, exploitation and oppression of peoples and environmental plunder on the other. A call, initiated by the Campaign for People's Goals for Sustainable Development, notes that people will not accept a development agenda that will serve as a vehicle for strengthening corporate power, re-legitimise the global capitalist growth model and perpetuate neoliberal globalisation.

Sexual health, human rights and the law
WHO: WHO, Geneva, 2015

This report demonstrates the relationship between sexual health, human rights and the law. Drawing from a review of public health evidence and extensive research into human rights law at international, regional and national levels, the report shows how states in different parts of the world can and do support sexual health through legal and other mechanisms that are consistent with human rights standards and their own human rights obligations.

The invisibility of men in South African violence prevention policy: national prioritisation, male vulnerability, and framing prevention
van Niekerk A; Tonsing S; Seedat M; Jacobs R; Ratele K; McClure R: Glob Health Action 8( 27649), 2015

In the last two decades, there have been a plethora of South African policies to promote safety. However, indications suggest that the policy response to violence is not coherently formulated, comprehensive, or evenly implemented. This study examines selected South African national legislative instruments in terms of their framing and definition of violence and its typology, vulnerable populations, and prevention. This study comprises a directed content analysis of selected legislative documents from South African ministries mandated to prevent violence and its consequences or tasked with the prevention of key contributors to violence. The legislative documents recognised the high levels of violence, confirmed the prioritisation of selected vulnerable groups, especially women, children, disabled persons, and rural populations, and above all drew on criminological perspectives to emphasise tertiary prevention interventions. There is a policy focus on the protection and support of victims and the prosecution of perpetrators, but near absent recognition of men as victims. The authors argue for the policy framework to be broadened from primarily criminological and prosecutorial perspectives to include public health contributions, and to enlarge the conceptions of vulnerability to include men alongside other vulnerable groups.

4. Health equity in economic and trade policies

Debt is back!
Jubilee Debt Campaign: Third World Resurgence 298/299, 5-7, 2015

Rising inequality, along with financial deregulation, has spurred the significant increase in global debt levels. Although much of the media spotlight has focused on Greece recently, the fact is that more than 90 countries are either in or at risk of a new debt crisis. This articles presents the executive summary of a new report by the Jubilee Debt Campaign which highlights this phenomenon. Debt crises have become dramatically more frequent across the world since the deregulation of lending and global financial flows in the 1970s. An underlying cause of the most recent global financial crisis, which began in 2008, was the rise in inequality and the concentration of wealth. This made more people and countries more dependent on debt, and increased the amount of money going into speculation on risky financial assets. International debt has been increasing since 2011, after falling from 2008-11. The total net debts owed by debtor countries, by both their public and private sectors, which are not covered by corresponding assets owned by those countries, have risen from $11.3 trillion in 2011 to $13.8 trillion in 2014. We at the Jubilee Debt Campaign predict that in 2015 they will increase further to $14.7 trillion. Overall, net debts owed by debtor countries will therefore have increased by 30% - $3.4 trillion - in four years. Alongside this increase in global debt levels, there is also a boom in lending to impoverished countries, particularly the most impoverished - those called 'low-income' by the World Bank. Foreign loans to low-income-country governments trebled between 2008 and 2013, driven by more 'aid' being provided as loans - including through international financial institutions, new lenders such as China, and private speculators searching overseas for higher returns because of low interest rates in Western countries.

New International Study Reveals South Africa has Saltiest Kiddies Chicken Burger Globally
Heart and Stroke Foundation South Africa, World Action on Salt and Health: Sangonet Pulse, August 2015

World Action on Salt and Health (WASH), with the support of the Heart and Stroke Foundation South Africa, has conducted a survey which investigated the salt content of 387 popular kid’s meal combinations. The study found that of all countries surveyed, South Africa’s brand chicken burger and chips aimed at children, have the highest salt content of all kiddies chicken burgers globally (more than ½ a teaspoon) per meal. The study also warns that too much salt in childhood, habituates children to the taste of salt, which could increase their blood pressure, and lead to strokes and heart failure later in life. “With South Africa having one of the highest rates of high blood pressure worldwide and 1 in 10 children already suffering from high blood pressure, we simply cannot afford to allow such high levels of salt in popular children’s meals,” argues Christelle Crickmore, science and programme development manager at WASH.

Public-private partnerships in Uganda cost the country dearly
Harper P: Jubilee Debt Campaign, August 2015

Privatisation of the Ugandan electricity sector, initiated in 1999 as a condition of the debt relief programme, was supposed to mean the end of state support. Yet, by 2013 a special committee of the Ugandan Parliament reported that subsidies were higher than ever before, preventing the government supporting critical development programmes. Between 2005 and 2012 the government had paid out subsidies totalling $600m to the privatised companies, alongside nearly $300m in rebates for ‘losses’ under their deal with the new electricity distribution company. An independent report is calling for the plant to be brought into public ownership because
“The high cost of electricity in Uganda has reached unsustainable levels that are severely eroding local industries’ competitiveness and domestic consumers’ disposable income”. The head of the government-owned Uganda Electricity Generation Company, has confirmed that discussions are ongoing to explore the viability of this proposal, which is designed to rein in costs and re-establish a degree of sovereign control over Uganda’s national energy sector.

South stress balanced approach to patents for public health and development
TWN Info Service on Intellectual Property Issues, Aug15/01, August 2014

Developing countries stressed the need for a balanced approach to patents to ensure public health and development interests at the 22nd session of the Standing Committee on the Law of Patents (SCP) of the World Intellectual Property Organisation (WIPO). Nigeria on behalf of the African Group stated that it recognises the instrumental role of the SCP in building knowledge, understanding the application of various patent related norms and effective use of the international patent system. However, Nigeria pointed out that SCP’s activities “include enabling factors encapsulated in the Development Agenda Recommendations, with the objective of enhancing patent related uses for social, technological and economic development and noted their disposition to actively engage within the SCP, on identified issues that support the objectives of the region, giving due regard to the different levels of development of WIPO Member States”. It stressed that the “policy space for Member States will therefore be of utmost relevance in SCP discussions and their outcomes”. Pakistan on behalf of the Asia Pacific Group (Japan is not part of the Group) stressed the need for balanced discussions on all topics on the agenda. It stated that, “ The work of this committee is critical in balancing the rights of patent owners and public interest particularly in the area of public health, technology transfer and patent flexibilities. It is essential to find the right balance between patent rights and the right to health in light of the differences in the levels of social, economic and technological development among members, TRIPS flexibilities and respect for intellectual property law and the needs of all Member States”. It further stated that the balanced approach to patents “not only allow governments, especially in resource-constrained countries, with the necessary policy space to meet health needs but also promote further innovation”. Brazil on behalf of GRULAC stated that it was “important for Member States to learn from each other’s experiences and practices under these two topics. While acknowledging similar practices in some countries, it is important to recognise that IP policies and legislation should address national economic and scientific issues as well as development concerns”. Third World Network remarked that 22nd Session of the Standing Committee on the Law of Patents is taking place exactly after the 20th year of the TRIPS Agreement. During the last twenty years there is plenty of evidence to show that the TRIPS Agreement has failed to fulfil its promises especially in the context of addressing developmental challenges of developing countries.

5. Poverty and health

Facilitators and Obstacles in Youth Saving: Perspectives from Ghana and Kenya
Zou L; Tlapek S; Njenga G; Appiah E; Opai-Tetteh D; Sherraden M: Global Social Welfare 2(2) 65-74, 2015

Youth are a rapidly growing percentage of the Sub-Saharan African population, and many are economically vulnerable. Financial inclusion for youth, particularly the promotion of savings behaviour, is associated with a number of positive social and economic outcomes and is an international priority. However, the majority of youth in Sub-Saharan Africa are not saving, and limited qualitative research exists to aid understanding of the possible explanations. This paper aims to increase the understanding of factors that facilitate and obstruct youth saving by exploring the savings behaviour of youth participating in the YouthSave Project in Ghana and Kenya. The authors conducted in-depth interviews with four triads comprised of youth, a parent or caregiver, and a school stakeholder in each country to develop case studies for the YouthSave Project. Findings indicate that support from parents, school staff, and financial institutions is conducive to youth participation in saving, even though youth participants struggle with limited financial resources and conflicting demands for money.

Profile of people with hypertension in Nairobi’s slums: a descriptive study
Hulzebosch A; van de Vijver S; Oti S;, Egondi T; Kyobutungi C: Globalization and Health 11(26), 27 June 2015

Cardiovascular disease is a rising health burden among the world’s poor with hypertension as the main risk factor. In sub-Saharan Africa, hypertension is increasingly affecting the urban population of which a substantial part lives in slums. This study aims to give insight into the profile of patients with hypertension living in slums of Nairobi, Kenya. Socio-demographic and anthropometric data as well as clinical measurements including BP from 440 adults with hypertension aged 35 years and above living in Korogocho, a slum on the eastern side of Nairobi, Kenya, was be collected at baseline and at the first clinic visit. The study population showed high prevalence of overweight and abdominal obesity as well as behavioural risk factors such as smoking, alcohol and a low vegetable and fruit intake. Furthermore, the majority of hypertensive patients do not take anti-hypertensive medication and the ones who do show little adherence.

Redefining shared sanitation
Rheinländer T; Konradsen F; Keraita B; Apoya P; Gyapong M: Bulletin of the World Health Organization 93 (7) 509-510, July 2015

According to the latest estimates from the World Health Organization/United Nations Children’s Fund Joint Monitoring Programme for water and sanitation (JMP), 2.5 billion people worldwide do not have access to any type of improved sanitation. Current definitions do not account for the diversity of shared sanitation: all shared toilet facilities are by default classified as unimproved by JMP because of the tendency for shared toilets to be poorly managed and unhygienic. However, the authors argue that shared sanitation should not be automatically assumed to be unimproved. They also argue that it is necessary to have a new look at how we define shared sanitation and to use specific subcategories including household shared (sharing between a limited number of households who know each other), public toilets (intended for a transient population, but most often the main sanitation facility for poor neighbourhoods) and institutional toilets (workplaces, markets etc.). This sub-classification will, it is argued, identify those depending on household shared sanitation, which the authors consider to be only a small step away from achieving access to private and improved sanitation. This subcategory of shared sanitation is, therefore, worth discussing in greater detail. The authors argue that the focus for future sanitation programmes should be on improving the hygienic standards of shared facilities to a level that satisfies and protects sanitation users.

6. Equitable health services

Emergency care in 59 low- and middle-income countries: a systematic review
Obermeyer Z; Abujaber S; Makar M; Stoll S; Kayden SR; Wallis LA; Reynolds TA; the Acute Care Development Consortium: Bulletin of the World Health Organization 93 (8), August 2015

This systematic review of emergency care in low- and middle-income countries (LMICs) analysed reports published from 1990 onwards. The authors identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care. Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.

A qualitative study of the experiences of care and motivation for effective self-management among diabetic and hypertensive patients attending public sector primary health care services in South Africa
Murphy K; Chuma T; Mathews C; Steyn K; Levitt N: BioMed Central 15(303), 1 August 2015

Diabetes and hypertension constitute a significant and growing burden of disease in South Africa. Presently, few patients are achieving adequate levels of control. In an effort to improve outcomes, the Department of Health is proposing a shift to a patient-centred model of chronic care, which empowers patients to play an active role in self-management by enhancing their knowledge, motivation and skills. This study explored patients’ current experiences of chronic care, as well as their motivation and capacity for self-management and lifestyle change. The study involved 22 individual, qualitative interviews with a purposive sample of hypertensive and diabetic patients attending three public sector community health centres in Cape Town. Participants were a mix of Xhosa and Afrikaans speaking patients and were of low socio-economic status. The concepts of relatedness, competency and autonomy from Self Determination Theory proved valuable in exploring patients’ perspectives on what a patient-centred model of care may mean and what they needed from their healthcare providers. Overall, the findings indicate that patients experience multiple impediments to effective self-management and behaviour change, including poor health literacy, a lack of self-efficacy and perceived social support. With some exceptions, the majority of patients reported not having received adequate information; counselling or autonomy support from their healthcare providers. Their experiences suggests that the current approach to chronic care largely fails to meet patients’ motivation needs, leaving many of them feeling anxious about their state of health and frustrated with the quality of their care. In accordance with other similar studies, most of the hypertensive and diabetic patients interviewed were found to be ill equipped to play an active and empowered role in self-care. It was clear that patients desire greater assistance and support from their healthcare providers.

Are We Prepared for the Next Global Epidemic? The Public Doesn't Think So
Kim JY: World Post, 5 August 2015

This article incudes evidence from a public opinion poll on pandemic preparedness.
It highlights three concrete actions on how we can be better prepared for the next global epidemic. The author states "First, let's ensure that all countries invest in better preparedness. This starts with a strong health system that can deliver essential, quality care; disease surveillance; and diagnostic capabilities. We should expand successful efforts such as those by Ethiopia and Rwanda to train cadres of community health workers, who can expand access to care and serve as the frontline response to future disease outbreaks. The goal must be universal health coverage - both to ensure everyone can get the care they need, and also because those areas without adequate coverage put everyone at risk." He also calls for a smarter, better coordinated global epidemic preparedness and response system that draws upon the expertise of many more players - including a better-resourced WHO; and a pandemic emergency financing facility that can respond more quickly to epidemics.

First malaria vaccine given green light by European regulators
Kollewe J: The Guardian, July 2015

The world’s first malaria vaccine has been given the green light by European regulators and could protect millions of children in sub-Saharan Africa from the life-threatening disease. The European Medicines Agency (EMA) recommended that RTS,S, or Mosquirix, should be licensed for use in young children in Africa who are at risk of the mosquito-borne disease. The shot has been developed by GlaxoSmithKline (GSK) and part-funded by the Bill and Melinda Gates Foundation. It has taken 30 years to develop vaccine, at a cost of more than $565m (£364m) to date. It will now be assessed by the World Health Organisation, which has promised to give its guidance on how and where it should be used before the end of the year. GSK will then apply to the WHO for a scientific review of the vaccine, which will be used by the UN and other agencies to help make purchasing decisions. The roll-out of the vaccine, which also has to be approved by national health authorities in sub-Saharan Africa, is likely to be funded by GAVI.

7. Human Resources

An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study
Gaziano T; Abrahams-Gessel S; Denman C; Montano C; Khanam M; Puoane T; Levitt N: The Lancet Global Health 3 (9), e556–e563, 2015,

Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study the authors investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community's predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35–74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The study found that community health workers can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease.

Long-term outcomes of a pediatric HIV treatment program in Maputo, Mozambique: a cohort study
Walter J; Molfino L; Moreno V; Edwards CG; Chissano M; Prieto A; Bocharnikova T; Antierens A; Lujan J: Glob Health Action 8 (26652), 2015

This paper describes long-term treatment outcomes of a paediatric HIV cohort in Mozambique, in the Chamanculo Health District of Maputo. The subjects involved a total of 1,335 antiretroviral treatment (ART) naïve children <15 years of age enrolled in HIV care between 2002 and 2010. The interventions included HIV care, ART (since 2003), task shifting to lower cadre nurses, counseling by lay counselors, active patient tracing, nutritional support, support by a psychologist, targeted viral load testing, and switch to second-line treatment. The main outcome measures included Kaplan–Meier estimates for retention in care (RIC), CD4 cell percentage, body mass index for age z-score, and adjusted incidence rate ratios for attrition (death or loss to follow-up) as calculated by Poisson regression. The RIC at 6 years in the pre-ART cohort was 44% and the one at 8 years in the ART cohort was 70%. Risk factors for attrition included young age, low CD4 percentage, underweight, active tuberculosis, and enrollment/treatment initiation after 2006. The mean CD4 percentage increased strongly at 1 year on treatment and remained high thereafter. The body mass index for age sharply increased at 1 year after treatment initiation before stabilizing at pre-ART levels thereafter. The study concludes that good clinical and immunological treatment outcomes up to 8 years of follow-up on ART can be achieved in a context of shortage of health workers and a high level of task-shifting approach.

8. Public-Private Mix

CSOs voice concerns over corporate takeover of WHO
Raja K: Third World Resurgence, 298/299, 35-37, 2015

At the World Health Assembly in May, civil society organisations criticised the rich countries for refusing an increase in their assessed contributions to WHO and opposing actions by the agency which would be contrary to the interests of their corporations. THE Framework for Engagement with Non-State Actors (FENSA), initiated to safeguard the independence, integrity and credibility of the World Health Organisation (WHO), now seems to bear the threat of facilitating and legitimising corporate capture of the organisation, civil society groups have charged. 'Many proposals by rich countries in draft FENSA text [are] promoting corporate capture of WHO in the name of promotion of engagements without discussion on any comprehensive mechanism to avoid conflict of interest. These proposals, if accepted, would institutionalise the undue corporate influence on WHO,' said Lida Lhotska of the International Baby Food Action Network (IBFAN) in a press release. Over the last 20 years, the proportion of WHO's budget which is met through mandatory assessed contributions has fallen from 75% to 20%. This is a consequence of continuing new functions being added to the organisation and a continuing freeze on assessed contributions. The remaining 80% is met by voluntary donations, including from the rich countries, the World Bank and the Bill & Melinda Gates Foundation.

Nurses who moonlight strain the health system
Rispel L: Business Day Live (BDLive), July 2015

Between 2009 and 2010, the author reports that the South African government spent about R1.49bn hiring nurses for the public health sector from nursing agencies. In that period, the provincial spending on agency nurses ranged from a low of just under R36.4m in Mpumalanga to a high of R356.4m in the Eastern Cape. In that financial year, this article reports that more than 5,300 registered nurses could have been employed by provincial governments instead of agency nurses, according to the published research. The government’s spending on agency nursing is argued to be a result of nursing vacancies, poorly managed staff absenteeism, sub-optimal planning for patient loads and not involving nurses in decisions on their shifts or how best to cover hospital wards. Nursing agencies provide a vehicle for nurses to moonlight, as they could be employed concurrently in a public or private sector hospital as well as the agency. These agencies are not obliged to ask nurses whether they have concurrent employment. The author argues that the nursing agency spending is, however, an indication of the bigger crisis in South African nursing.

Private healthcare is ‘wasteful’
Culling K: Health-e News, 28 July 2014

Private healthcare is wasteful and over-dependent on hospitals, which makes it too expensive for a large group of working people to join medical schemes, Health-e news reports. As a result, scheme membership has stagnated at around 8,5 million people and is skewed towards older, sicker members. This was the assessment of healthcare consultant Dr Brian Ruff, speaking at the opening day of the Board of Healthcare Funders (BHF), the group that represents medical schemes and administrators in South Africa. Ruff said that families with an income of R7000 to R12000 a month may be able to afford membership of around R300 a month, yet no medical scheme could provide such a cheap service.

WHO reform: opening the floodgates to the private sector?
Richter J: Third World Resurgence 298/299, 20-23, 2015

The author presents in this paper how in the name of 'reform', against a backdrop of a funding crisis, a greater collaboration between WHO and big business is being justified. She provides a historical overview of the process which began in 1992 with the drive for UN 'reforms', naming it as a euphemism for the neoliberal restructuring of the world body. Both the idea of attracting more funding from private foundations and the commercial sector and the notion of dealing with global health and nutrition matters through multi-stakeholder approaches are argued to carry major risks to WHO's role as the highest authority in international public health. Even though the regular World Health Forum is abandoned at the moment, the notion of greater involvement of the private sector as legitimate 'stakeholders' in public health affairs is not. She calls for an urgent reflection on whether this path should be pursued, noting that the 'privatisation' of public agencies and spaces increases the reliance on private sector funding, as well as inviting profit-motivated actors into public decision-making forums, and sometimes removing specific public issues from the public sphere altogether. This is seen to be the opposite of ensuring financial independence of public institutions and safeguarding and enlarging of spaces for public debate.

9. Resource allocation and health financing

National health accounts data from 1996 to 2010: a systematic review
Bui AL; Lavado R; Johnson EK; Brooks B; Freeman MK; Graves, CM; Haakenstad A; Shoemaker B; Hanlon M; Dieleman JL: Bulletin of the WHO 93 (8), August 2015

The paper reports on work to collect, compile and evaluate publicly available national health accounts (NHA) reports produced worldwide between 1996 and 2010. The authors compiled data in the four main types used in these reports: (i) financing source; (ii) financing agent; (iii) health function; and (iv) health provider. The authors identified 872 NHA reports from 117 countries containing a total of 2936 matrices for the four data types. Most countries did not provide complete health expenditure data: only 252 of the 872 reports contained data in all four types. Some countries reported substantial year-on-year changes in both the level and composition of health expenditure that were probably produced by data-generation processes. All study data are publicly available at http://vizhub.healthdata.org/nha/. Data from NHA reports on health expenditure are often incomplete and, in some cases, of questionable quality. Better data would help finance ministries allocate resources to health systems, assist health ministries in allocating capital within the health sector and enable researchers to make accurate comparisons between health systems.

10. Equity and HIV/AIDS

Influence of parental factors on adolescents’ transition to first sexual intercourse in Nairobi, Kenya: a longitudinal study
Okigbo C; Kabiru C; Mumah J; Mojola S; Beguy D: Reproductive Health 12(73), 2015

The objective of the study was to assess the influence of parental factors (monitoring, communication, and discipline) on the transition to first sexual intercourse among unmarried adolescents living in urban slums in Kenya. Longitudinal data collected from young people living in two slums in Nairobi, Kenya were used. The sample was restricted to unmarried adolescents aged 12–19 years. Parental factors were used to predict adolescents’ transition to first sexual intercourse. Relevant covariates including the adolescents’ age, sex, residence, school enrollment, religiosity, delinquency, and peer models for risk behaviour were controlled for. Approximately 6 % of the sample transitioned to first sexual intercourse within the one-year study period; there was no sex difference in the transition rate. In the multivariate analyses, male adolescents who reported communication with their mothers were less likely to transition to first sexual intercourse compared to those who did not. This association persisted even after controlling for relevant covariates. However, parental monitoring, discipline, and communication with their fathers did not predict transition to first sexual intercourse for male adolescents. For female adolescents, parental monitoring, discipline, and communication with fathers predicted transition to first sexual intercourse; however, only communication with fathers remained statistically significant after controlling for relevant covariates. This study provides evidence that cross-gender communication with parents is associated with a delay in the onset of sexual intercourse among slum-dwelling adolescents. Targeted adolescent sexual and reproductive health programmatic interventions that include parents may have significant impacts on delaying sexual debut, and possibly reducing sexual risk behaviours, among young people in high-risk settings such as slums.

Rising School Enrollment and Declining HIV and Pregnancy Risk Among Adolescents in Rakai District, Uganda, 1994–2013
Santelli J; Mathur S; Song X; Huang T; Wei Y; Lutalo T; Nalugoda F; Gray R; Serwadda D: Global Social Welfare 2(2), 87-103, 2015

Poverty, family stability, and social policies influence the ability of adolescents to attend school. Likewise, being enrolled in school may shape an adolescent’s risk for HIV and pregnancy. The authors identified trends in school enrollment, factors predicting school enrollment (antecedents), and health risks associated with staying in or leaving school (consequences). Data from the Rakai Community Cohort Study (RCCS) were examined for adolescents 15–19 years (n&#8201;=&#8201;21,735 person-rounds) from 1994 to 2013. Trends, antecedents, and consequences were assessed. Qualitative data were used to explore school leaving among HIV+ and HIV&#8722; youths (15–24 years). School enrollment and socioeconomic status (SES) rose steadily from 1994 to 2013 among adolescents and orphanhood declined after availability of antiretroviral therapy. Antecedent factors associated with school enrollment included age, SES, orphanhood, marriage, family size, and the percent of family members <20 years. In qualitative interviews, youths reported lack of money, death of parents, and pregnancy as primary reasons for school dropout. Among adolescents, consequences associated with school enrollment included lower HIV prevalence, prevalence of sexual experience, and rates of alcohol use and increases in consistent condom use. Young women in school were more likely to report use of modern contraception and never being pregnant. Young men in school reported fewer recent sexual partners and lower rates of sexual concurrency.

11. Governance and participation in health

Xenophobia under spotlight during SADC Parliamentary Forum
Buthelezi Z: SABC News, 7 July 2015

South Africa has continued to face questions about the recent xenophobic violence directed at African immigrants. The issue was raised during a discussion on migration on the side-lines of the 37th Session of the South African Development Community (SADC) Parliamentary Forum meeting at Zimbali north of Durban. Lawmakers, experts and government officials were among those who participated in the discussion on migration. At least seven people were killed and thousands others displaced from their homes during attacks on foreign nationals that started in KwaZulu-Natal in April. Speakers called for the movement of people around the continent - including of South Africans - to be encouraged. The Director of the United Nations African Institute for Economic Development and Planning, Professor Adebayo Olukoshi, argued that African countries need to take a developmental approach to migration policies - in the same way that countries like the US have done. A South African provincial special reference group led by former UN Human Rights Chief Navi Pillay is looking into the causes of xenophobic violence and what should be done to prevent it from re-emerging. The group is expected to conclude its work in October.

12. Monitoring equity and research policy

How many people lack access to health care? (Hint: More than WHO and the World Bank report)
Freidman E: O Neil Institute, August 2015

A recent World Bank press release on a World Bank and WHO report announced that "400 million people do not have access to essential health services.” The author argues in this article that this would be a highly over-optimistic misread of what WHO and the World Bank found. By more reasonable understandings of how many people lack access to essential health services, untold hundreds of millions more than 400 million people lack access to essential health services. He notes that the road ahead to universal health coverage is considerably longer than the headline figure implies. The report itself – beneath the headlines – covers many concerns and raises issues of quality and other concerns in a more complex reality. The author of this article notes that official monitoring should capture this complexity as what is monitored may well affect what governments prioritize, and the health services people actually receive, and so that a singular focus on access does not hide other aspects of people’s right to health – including the quality of health services and their acceptability.

Research on health inequalities: A bibliometric analysis (1966–2014)
Bouchard L, Albertini M, Batista R, de Montigny J: Social Science & Medicine, 141, 100-108, 2015

This study reported on research production and publications on health inequalities through a bibliometric analysis covering publications from 1966 to 2014 and a content analysis of the 25 most-cited papers. A database of 49,294 references was compiled from the search engine Web of Science. The first article appears in 1966 and deals with equality and civil rights in the United States and the elimination of racial discrimination in access to medical care. By 2003, the term disparity has gained in prominence relative to the term inequality which was initially elected by the researchers. The paper shows that research on health inequalities grown exponentially in the last 30 years; the terms inequity, inequality and disparity have been inconsistently used over time; the most-cited papers studied socioeconomic factors and impacts on health inequities with first reports studying relations of socioeconomic conditions and health outcomes and research growing toward theoretical models and proposals on methodological approaches.

13. Useful Resources

"How AIDS changed everything” Fact Sheet
UNAIDS: August 2015

The UNAIDS 2014 Global HIV/AIDS Statistics contains key data from the recent publication "How AIDS changed everything”. Global statistics include: 15 million people accessing antiretroviral therapy as of March 2015. 36.9 million [34.3 million– 41.4 million] people globally were living with HIV and 2 million [1.9 million – 2.2 million] people became newly infected with HIV. In 2014, 1.2million [980 000 – 1.6 million] people died from AIDS-related illnesses.

How to build a theory of change for an impact evaluation
3ie International Initiative for Impact Evaluation

3ie’s How-To videos use a simple step-by-step approach for explaining theoretical concepts. The How-To videos on impact evaluation draw from examples of impact evaluations to show viewers how to apply technical concepts. The videos in this series explore various topics related to designing, implementing and using impact evaluations. A short quiz at the end of each lecture will help assess your understanding of the subject covered in the video.

Lesser Known International Funders
fundsforNGOs: 6 August 2015

fundsforNGOs are offering a free download to their resource on ‘Lesser Known International Donors You should look for Funding in 2015’. It contains a list of profiles of those funding agencies that are not very well known but do offer active grants to NGOs around the world. Their application process is not as complex as that of traditional donors and there is less competition for seeking grants from them. These agencies also fund ideas for social change.

14. Jobs and Announcements

18th International Conference on AIDS and STIs in Africa
29 November to 4 December 2015, Harare, Zimbabwe

As ICASA Zimbabwe coincides with the MDG target year, the International Conference on AIDS and STIs in Africa is offering the strategic first forum for post-MGD to leaders, activists, scientists and community to take stock of the outcomes of the MDG high level meeting challenges and to pave the way for a new, innovative and efficient approach towards an Africa AIDS free generation.

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

The theme of this World Congress is a challenge to Action Learning / Action Research practitioners the world over, whether working in resource rich or more socio-economically challenged contexts, to explain how they are contributing to the creation of a fairer world. The ALARA World Congress 2015 will create a space for dialogue as we ponder 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?

Call for ideas: A picture is worth a thousand words : what if we sketched Universal Health Coverage together ?
Submission deadline: 30th of September 2015, midnight GMT

What are the challenges the UHC system is facing in your country? Is it a learning system? Do the government actors who are leading the charge know how to dialogue with and involve other stakeholders (civil society, NGOs, the media…)? In your own organisation, do experts on UHC share their knowledge and experience with other team members? What analytical capacity is in place? Are there mechanisms for identifying good practices and promoting and verifying they are being applied well? These are some of the questions asked in this competition. To enter put the idea on paper - describe the situation you want to share. To make a good cartoon, your idea must be clear and precise. This contest is NOT limited to Africa. You can submit as many ideas as you have. A jury made up of experts familiar with UHC challenges and learning organisations will then select the best ideas to submit to the cartoonist. All those participants selected in this first round will get a prize. And it is from this pool that the cartoonist will choose what to draw. To participate in this competition, please send your ideas in English or in French, in a Word document (one scenario per file please) to Yamba Kafando, FAHS CoP facilitator (cdpafss@gmail.com). You will get a confirmation you’re your scenario has been received, as well as a number for that scenario. Include your name and surname, the country in which you work, and your job title or role.

Call for Papers: Fourth CODESRIA Conference on Electronic Publishing on The Open Access Movement and the Future of Africa’s Knowledge Economy
Submission deadline: December 30, 2015

The Council for the Development of Social Science Research in Africa (CODESRIA) announced the fourth in its electronic publishing conference series. This year’s theme focuses on the open access publishing model with particular attention to its possible impact on the future knowledge economy in Africa. This conference will explore core concepts and ideas, and help identify new technological and conceptual configurations. It will provide a rare opportunity for academics, librarians, publishers and policy-makers to come together for dialogues, discuss new research directions, methods and theories, and reflect upon the evolutionary issues about open access and their implications on research dissemination in Africa. With this scope in mind, the major topics of interest include, but are not limited to: Open access in the context of Africa; Value-added and marketing of African scientific information in the open access era; Africa in the emerging global politics of open access; Opening indigenous knowledges; Open access and Africa’s knowledge economy; The politics of open access. CODESRIA will provide funding support to paper presenters who show evidence that they are unable to cater for their participation.

Call for Proposals: 2015 Postdoctoral Fellowship Competition African Diaspora Support to African Universities Program
CODESRIA: Application Deadline:15th September 2015

The Council for the Development of Social Science Research in Africa (CODESRIA) has launched an African Diaspora support to African Universities program. This call for proposals targets academics based in African universities, and those in the Diaspora within Africa and outside Africa (Europe, North America, Canada, Australia), in the SSH, both of whom have attained their PhDs in the last five years, or are at the advanced stage of their PhDs, to submit proposals for post-doctoral research, preferably, but not exclusively on issues related to one of the following themes: The African academic Diaspora and the revitalisation of Higher education in Africa; Current trends in economic theorisation on African social and economic development; The Social Sciences and the Place of African Higher Education in the World; African Citizenship, migration and economic mobility within and outside Africa. Individual applicants selected under this call will be invited to attend a methodological workshop in the early stages of implementation of their research projects.

Researcher - Southern Africa (Lusaphone) for Amnesty International
Closing Date: 13 September 2015, Location: Johannesburg

The mobile revolution, geopolitical power shifts and a radically altered global economy constitute some of the evidence to demonstrate that the world is changing, and so is the way that people fight for their rights. In order to be effective, Amnesty International’s (AI) International Secretariat needs to change how it works. That’s why the Southern Africa Regional Office needs research expertise on the ground and is advertising for this position. This is a permanent position.


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