The EQUINET steering committee wishes you a healthy new year, and one that brings greater justice in our communities, countries and globally.
This is a short newsletter, given the time of year. However, the EQUINET newsletter is now 15 years old, and the monthly issues share a growing number of stories of both the challenges to health equity, and the many examples of innovative practice within the region. At a recent regional conference in 2015, delegates raised that in our east and southern African region, we still do not adequately document or publish what we are doing, so that our story is often told by others, or not at all. Until the lions write their story, tales of the hunt will always glorify the hunter. We have used the EQUINET newsletter to give more profile to publication from and on our region, and have included journal papers and reports, but also new media such as videos, online interviews, maps, tools, graphics and exhibits. We will be listening even more for this in 2016.
So we are asking you to please speak out and share your ideas, work and stories on health! Please send us your reports, papers, news, conference announcements or other forms of information [to admin@equinetafrica.org], or write a short piece that we can use as an editorial.
We also invite you to be involved in the work that EQUINET will be carrying out in 2016 to inform and strengthen learning and action on health equity. Our website (www.equinetafrica.org) provides more information on these activities.
We look forward to working with you in the coming year!
1. Editorial
2. Equity in Health
Following the recommendations of the Commission on Social Determinants of Health (2008), the World Health Organisation (WHO) developed the Urban Health Equity Assessment and Response Tool (HEART) to support local stakeholders in identifying and planning action on health inequities. This report analysed the experiences of cities in implementing Urban HEART to inform how the tool could support local stakeholders better in addressing health inequities. Independent evaluations were conducted in 2011–12 on Urban HEART piloting in 15 cities from seven countries in Asia and Africa: Indonesia, Iran, Kenya, Mongolia, Philippines, Sri Lanka, and Vietnam. Local or national health departments led Urban HEART piloting in 12 of the 15 cities. Improving access to safe water and sanitation was a priority equity-oriented intervention in 12 of the 15 cities, while unemployment was addressed in seven cities. Cities who piloted Urban HEART displayed confidence in its potential by sustaining or scaling up its use within their countries. Engagement of a wider group of stakeholders was more likely to lead to actions for improving health equity. Indicators that were collected were more likely to be acted upon. Quality of data for neighbourhoods within cities was one of the major issues.
3. Values, Policies and Rights
In 2007, Malawi became an early adopter of integrated community case management for childhood illnesses (iCCM), a policy aimed at community-level treatment for malaria, diarrhoea and pneumonia for children below 5 years. Through a retrospective case study, this article explores critical issues in implementation that arose during policy formulation through the lens of the innovation and of the institutions involved in the policy process. iCCM was compatible with the Malawian health system due to the ability to build on an existing community health worker cadre of health surveillance assistants (HSAs) and previous experiences with treatment provision at the community level. In terms of institutions, the Ministry of Health (MoH) demonstrated leadership in the overall policy process despite early challenges of co-ordination within the MoH. WHO, United Nations Children’s Fund (UNICEF) and implementing organisations played a supportive role in their position as knowledge brokers. Greater challenges were faced in the organisational capacity of the MoH. Regulatory issues around HSA training as well as concerns around supervision and overburdening of HSAs were discussed, though not fully addressed during policy development. Similarly, the financial sustainability of iCCM, including the mechanisms for channeling funding flows, also remains an unresolved issue. This analysis highlights the role of implementation questions during policy development.
The 62nd ECSA Health Ministers’ Conference (HMC) was held at InterContinental Resort Balaclava Fort, Republic of Mauritius under the theme: Transitioning from Millennium Development Goals to Sustainable Development Goals with the following sub-themes; Enhancing Universal Health Coverage Through Innovations in Health Financing for Risk Protection; Surveillance and Control of Emerging Conditions: (NCDs and Trauma); Regional Collaboration in the Surveillance and Control of Communicable Diseases; Innovations in Health Professional Training Using the ECSA College of Health Sciences Model. The Conference passed Resolutions on: Transitioning From MDGs to SDGs in the ECSA Region; Enhancing UHC through innovation in Health Financing for Risk Protection; Surveillance and Control of Non- Communicable Diseases and Trauma; Regional Collaboration in the Surveillance and Control of Communicable Diseases; Innovations in Health Professional Training using the ECSA College of Health Sciences Model; Global Health Diplomacy and Strengthening Ministries of Health Leadership and Governance Capacity for Health in the ECSA-HC Region; and Strengthening the Use of Evidence in Health Policy.
4. Health equity in economic and trade policies
The Forum on China-Africa Cooperation (FOCAC) under the theme: "China-Africa Progressing Together: Win-Win Cooperation for Common Development" was held on 4-5 December in Johannesburg, South Africa. This was the first time that a leaders’ summit level of FOCAC is held in Africa. The Summit which also celebrated the 15th anniversary of the partnership was co-chaired by Chinese President Xi Jinping and South African President Jacob Zuma. The FOCAC was established fifteen years ago with its first Ministerial Forum held in Beijing in 2000. With six Ministerial Meetings and two at Summit level already organised, FOCAC has evolved over the years to become a prominent example of South-South cooperation. In the two-day event, Chinese President Xi Jinping and over 50 African leaders gathered in South Africa to discuss together the blueprints of cooperation and show to the world the power of solidarity among developing countries. To build China-Africa comprehensive strategic and cooperative partnership, the conference was informed that China will implement ten cooperation plans with Africa in the next three years. Guided by the principle of government guidance, businesses being the major actors, market operation and win-win cooperation, these plans aim at addressing three bottleneck issues holding back Africa’s development, namely, inadequate infrastructure, lack of professional and skilled personnel, and funding shortage, accelerating Africa’s industrialization and agricultural modernization, and achieving sustainable self-development.
The health consequences of tobacco use are well known, but less recognised are the significant environmental impacts of tobacco production and use. The environmental impacts of tobacco include tobacco growing and curing; product manufacturing and distribution; product consumption; and post-consumption waste. The World Health Organisation’s Framework Convention on Tobacco Control addresses environmental concerns in Articles 17 and 18, which primarily apply to tobacco agriculture. Article 5.3 calls for protection from policy interference by the tobacco industry regarding the environmental harms of tobacco production and use. The authors detail the environmental impacts of the tobacco life-cycle and suggest policy responses.
5. Poverty and health
Agenda 2063 - The Africa We Want is a flagship campaign of the African Union. This policy argues for using the opportunity offered by urbanisation and the demographic shift to fulfil the vision of an African renaissance. With urbanisation firmly on the agenda across Africa there is a need for a constructive policy dialogue on what exactly urbanisation in Africa might mean. To support such a process the Cities Alliance secretariat has awarded a grant to the African Centre for Cities (ACC) at the University of Cape Town to establish an independent think tank dedicated to this issue. In this video Gustave Massiah, an Urban Specialist with the United Cities and Local Governments of Africa, discusses the key challenges facing African urbanisation in a post-industrial period. Gustave sees the main challenges of African urbanisation to be those faced by the continent as a whole: inequality, unemployment and the resistance of external exploitation. He proposes a new conception of informality based on the dynamism and power of the individual. With no obvious answer to informality, society then has to review its definition of informal and to better understand people's own experience of their conditions.
6. Equitable health services
The 2015 UHC day comes after a year of the international community being busy in producing numerous reports on learning from the Ebola crisis. Most of the learning from these documents has focused on mechanisms for effective global response to outbreaks. However, the author argues that more attention should be directed to learning from the role of local institutions in tackling the Ebola outbreak including how critically needed advances towards UHC can be achieved. Two key ingredients for effective epidemic prevention and response require particular focus: community engagement and health systems strengthening. The WHO interim panel’s report on Ebola recognised that “Risk assessment was complicated by factors such as weak health systems, poor surveillance, little early awareness of population mobility, spread of the virus in urban areas, poor public messaging, lack of community engagement, hiding of cases, and continuing unsafe (e.g. burial) practices”.
For almost 70 years, the World Health Organisation (WHO) has coordinated the norms and technical standards required to improve global health. This is the role people most often associate with WHO. However, the organisation’s constitution also calls on it to “furnish technical assistance and, in emergencies, necessary aid” to governments, a role WHO has played on countless occasions. Despite initial delays in the western Africa Ebola outbreak response, the tide of this unprecedented health crisis has now been turned. While still requiring intense and focused action to bring new cases to zero, the outbreak is now limited to only a few cases per week. Deficiencies in capacity, expertise and approach revealed by WHO’s response to Ebola suggest that organisation-wide change is needed:WHO must ensure it can prepare for and respond to outbreaks and emergencies in a way that genuinely supports national efforts and fully integrates with international partners. WHO has begun reviewing systems and capacities throughout the organisation to streamline the way it works in outbreaks and emergencies.These changes focus on six key areas: (i) a unified WHO platform for outbreaks and emergencies with health and humanitarian consequences; (ii) a global health emergency workforce, to be effectively deployed in support of countries; (iii) core capacities at country-level under the International Health Regulations; (iv) functioning, transparency, effectiveness and efficiency of the International Health Regulations; (v) a framework for research and development preparedness and capacity during outbreaks or emergencies; and (vi) adequate international financing for pandemics and other health emergencies, including a 100 million United States dollars contingency fund and a pandemic emergency financing facility. No single organisation can deliver the wide range of services and systems needed for a truly global mechanism that prepares for and responds to outbreaks and emergencies. This is why WHO will continue seeking advice from our partners inside and outside the UN system to make needed change. With their collaboration and support, WHO will be well positioned to deliver what the world needs when outbreaks and emergencies occur: a timely response that rapidly contains the consequences – for economies and societies as well as for human health.
The Ideal Clinic programme was initiated by the South African National Department of Health (NDoH) in July 2013 in order to systematically improve Primary Health Care (PHC) facilities and the quality of care they provide. Provinces have submitted their three-year scale-up plans that indicate in which year each facility will reach Ideal Clinic status. Typically, the purpose of a health facility is to promote health and prevent illness and further complications through early detection, treatment and appropriate referral. An Ideal Clinic is defined as a clinic with good infrastructure, adequate staff, adequate medicine and supplies, good administrative processes, and sufficient adequate bulk supplies. It uses applicable clinical policies, protocols and guidelines, and it harnesses partner and stakeholder support. It also collaborates with other government departments, the private sector and non-governmental organisations to address the social determinants of health.
7. Human Resources
This paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. This paper presents the findings from South Africa. The study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. The study found that there has been a decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to skilled health worker migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself. In the near past, South Africa’s health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease shortages to some extent.
8. Public-Private Mix
‘Dual practice’, or multiple job holding, generally involves public sector-based health workers taking additional work in the private sector. This form of the practice is purported to help retain public health care workers in low and middle-income countries’ public sectors through additional wage incentives. There has been little conceptual or empirical development of the relationship between dual practice and retention. This article helps begin to fill this gap, drawing on empirical evidence from a qualitative study focusing on South African specialists. Fifty-one repeat, in-depth interviews were carried out with 28 doctors (predominantly specialists) with more than one job, in one public and one private urban hospital. Findings suggest dual practice can impact both positively and negatively on specialists’ intention to stay in the public sector. This is through multiple conceptual channels including those previously identified in the literature such as dual practice acting as a ‘stepping stone’ to private practice by reducing migration costs. Dual practice can also lead specialists to re-evaluate how they compare public and private jobs, and to overworking which can expedite decisions on whether to stay in the public sector or leave. Numerous respondents undertook dual practice without official permission. The idea that dual practice helps retain public specialists in South Africa may be overstated. Yet banning the practice may be ineffective, given many undertake it without permission in any case. Regulation should be better enforced to ensure dual practice is not abused. The conceptual framework developed in this article could form a basis for further qualitative and quantitative inquiry.
9. Resource allocation and health financing
This white paper outlines South Africa’s path to universal health coverage over 14 years and proposes dramatic changes in the role of private medical aid among others. Released on the 10th of December 2015, the long awaited white paper begins by providing the background and justification of the country’s moves to join other countries like the Brazil, the United Kingdom and Thailand in introducing universal healthcare coverage. The document notes that healthcare in South Africa is comprised of a two-tiered system divided along socio-economic lines. The private medical aid sector is comprised of 83 medical aid schemes that fund healthcare services for about 16 percent of the population. The paper noted that spending through medical schemes in South Africa is the highest in the world and is six times higher than in Organisation for Economic Co-operation and Development (OECD) countries. The paper argues that this two-tiered system has led to fragmented funding and risk pools in healthcare and posits that the creation of a National Health Insurance (NHI) will improve healthcare equity by combining fragmented private and public health funding pools and eliminating out-of-pocket payments.The paper notes that the NHI will ultimately deliver a comprehensive package of health services that include services such as rehabilitation and palliative care, mental health care including that related to substance abuse and maternal and child health care. The paper is made available to call for stakeholder feedback.
10. Equity and HIV/AIDS
About half a million people in South Africa are deprived of antiretroviral therapy (ART), and there is little systematic knowledge on who they are – e.g. by severity of disease, sex, or socio-economic status (SES). The authors performed a systematic review to determine the current quantitative evidence-base on equity in utilisation of ART among HIV-infected people in South Africa. The authors conducted a literature search based on the Cochrane guidelines. A study was included if it compared for different groups of HIV infected people (by sex, age, severity of disease, area of living, SES, marital status, ethnicity, religion and/or sexual orientation (i.e. equity criteria)) the number initiating/adhering to ART with the number who did not. The authors considered ART utilisation inequitable for a certain criterion (e.g. sex) if between groups (e.g. men versus women) significant differences were reported in ART initiation/adherence. Twelve studies met the inclusion criteria. For sex, 2 out of 10 studies that investigated this criterion found that men are less likely than women to utilise ART, while the other 8 found no differences. For age, 4 out of 8 studies found inequities and reported less utilisation for younger people. For area of living, 3 out of 4 studies showed that those living in rural areas or certain provinces have less access and 2 out of 6 studies looking at SES found that people with lower SES have less access. One study which looked at the marital status found that those who are married are less likely to utilise ART. For severity of disease, 5 out of 6 studies used more than one outcome measure for disease stage and reported within their study contradicting results. One of the studies reported inconclusive findings for ethnicity and no study had looked at religion and sexual orientation. It seems that men, young people, those living in certain provinces or rural areas, people who are unemployed or with a low educational level, and those being unmarried have less access to ART. As studies stem from different contexts and use different methods conclusions should be taken with caution.
11. Governance and participation in health
There is a global trend towards the use of ad hoc participation processes that seek to engage grassroots stakeholders in decisions related to municipal infrastructure, land use and services. The authors present the results of a scholarly literature review examining 14 articles detailing specific cases of these processes to contribute to the discussion regarding their utility in advancing health equity. They explore hallmarks of compromised processes, potential harms to grassroots stakeholders, and potential mitigating factors. The authors conclude that participation processes in urban areas often cut off participation following the planning phase at the point of implementation, limiting convener accountability to grassroots stakeholders, and, further, that where participation processes yield gains, these are often due to independent grassroots action. Given the emphasis on participation in health equity discourse, this study seeks to provide a real world exploration of the pitfalls and potential harms of participation processes that is relevant to health equity theory and practice.
Action for Global Health (AfGH) in partnership with the Network of West African NGO Platforms, (REPAOC) convened a conference in Dakar, Senegal, 17-19th February 2014, which brought together civil society actors from 23 countries and five continents. The main purpose of the workshop was to gain clarity and consensus on what Universal Health Coverage (UHC) incorporates, building upon Civil Society Organisation’s (CSO) country experiences from a grassroots level; develop a common understanding of the strengths of the UHC concept and the pitfalls of its implementation; define a clear position on how UHC should be framed to achieve the highest attainable standard of health for all; and outline a course of action for CSO advocacy on the right to health. The meeting concluded with a declaration – Ensuring UHC is fit for contributing to the right to health – which captured the main discussion points and reflections of the CSOs present.
Regional organisations can effectively promote regional health diplomacy and governance through engagement with regional social policy. Regional bodies make decisions about health challenges in the region, for example, the Union of South American Nations (UNASUR) and the World Health Organisation South East Asia Regional Office (WHO-SEARO). The Southern African Development Community (SADC) has a limited health presence as a regional organisation and diplomatic partner in health governance. This article identifies how SADC facilitates and coordinates health policy, arguing that SADC has the potential to promote regional health diplomacy and governance through engagement with regional social policy. The article identifies the role of global health diplomacy and niche diplomacy in health governance. The role of SADC as a regional organisation and the way it functions is then explained, focusing on how SADC engages with health issues in the region. Recommendations are made as to how SADC can play a more decisive role as a regional organisation to implement South–South management of the regional social policy, health governance and health diplomacy agenda.
12. Monitoring equity and research policy
Integrated Community Case Management of Childhood Illness (iCCM) is a policy for providing treatment for malaria, diarrhoea and pneumonia for children below 5 years at the community level, which is generating increasing evidence and support at the global level. This article explores whether, how and why evidence influenced policy formulation for iCCM in Niger, Kenya and Mozambique, and explains the use of evidence in these contexts. Findings indicate that all three countries used national monitoring data to identify the issue of children dying in the community prior to reaching health facilities, whereas international research evidence was used to identify policy options. Nevertheless, policymakers greatly valued local evidence and pilot projects proved critical in advancing iCCM. World Health Organisation and United Nations Children's Fund (UNICEF) functioned as knowledge brokers, bringing research evidence and experiences from other countries to the attention of local policymakers as well as sponsoring site visits and meetings. Both Mozambique and Kenya exhibit Problem-Solving research utilisation with different outcomes.
13. Useful Resources
In this online interview with Edward Paice, Director of Africa Research Institute, Zhong Jianhua, China’s Special Representative on African Affairs, responds to common criticisms of China’s policy and conduct in Africa. He rejects any analogy between China-Africa trade patterns and those of the colonial era but agrees that Africa must regard China as a competitor pursuing its own interests. Ambassador Zhong observes many similarities between the policy choices facing African governments in the 2000s and those confronted by China during the 1980s and 1990s. He emphasises that China itself is still a developing country – and one which has a great deal to learn about Africa. He insists that it is China’s responsibility to help African nations compete in the global economy. While acknowledging the imperative shared by all developing economies to maximise agricultural potential, attract capital, create a more skilled workforce and industrialise, he concludes that “finally the chance has come” to Africa.
The world has committed to end the AIDS epidemic by 2030 as part of the Sustainable Development Goals. This ambitious yet wholly attainable objective represents an unparalleled opportunity to change the course of history for ever - something our generation must do for the generations to come. If the world is to end the AIDS epidemic by 2030, rapid progress must be made by 2020. Quickening the pace for essential HIV prevention and treatment approaches will limit the epidemic to more manageable levels and enable countries to move towards the elimination phase. This graphic shows visually in a map the content and geographical areas for scale up to achieve global targets.
14. Jobs and Announcements
Gathering 250+ senior representatives and advisors from regional governments, UN agencies, international and regional NGOs, CBOs, investors and donors, research institutes and the private sector, this summit looks at how technological innovations and best practice can improve aid delivery and development strategy in East Africa. The summit demonstrates best practice approaches, current initiatives and latest innovations, offering trans-disciplinary discussions with participants from all relevant stakeholder groups. The agenda has been developed in consultation with UN organisations. The specific objectives of this summit are: to showcase expertise, approaches and innovations by different global stakeholders, to discuss best practice, guidelines and policy that support technological innovations and to provide an opportunity for knowledge exchange and networking amongst public, private and civil society stakeholders.
The abstract reviewers are looking forward to receiving outlines for oral and poster presentations demonstrating innovations and good practice in Primary Health Care projects and programmes. Knowledge sharing and skills transfer are an important component of the Conference. To this end, the organisers also invite abstract submissions for the pre-conference workshops which should include interactive participation and offer practical outcomes to the delegates. Through the media of storytelling, drama, film, music or art, the organisers aim to create a platform for thought-provoking discussions through a non-conventional Conference experience. The organisers would like to hear from all those who work in and around South Africa’s health system, especially: district- and facility-based healthcare workers and community members of facility governance structures; development partners; universities; district, provincial and municipal structures; the National Department of Health; AIDS councils; private health sector; non-governmental and community-based organisations; health communicators; film producers; and artists.
The African Population and Health Research Center (APHRC), in partnership with the International Development Research Centre (IDRC), is pleased to announce the ninth call for applications for the African Doctoral Dissertation Research Fellowships (ADDRF). The ADDRF Fellowship Program seeks to facilitate more rigorous engagement of doctoral students in research, strengthen their research skills, and provide them an opportunity for timely completion of their doctoral training. The Program targets doctoral students with strong commitment to a career in training and/or research. The overall goal of the ADDRF Program is to support the training and retention of highly-skilled, locally-trained scholars in research and academic positions across the region. The ADDRF will award about 20 fellowships in 2016 to doctoral students who are within two years of completing their thesis at an African university. In this phase of funding and in consideration of IDRC’s health programming priorities, candidates whose dissertation topics address health policy or health systems issues will be given special consideration. The application form and supporting documents (attached) must be submitted on email (see website for details).
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