In social theory, the dominant state is known as the hegemon. In the 19th century, hegemony came to denote the ‘Social or cultural predominance or ascendancy; predominance by one group within a society or milieu’. However, commentators on power have also used the term to describe the power of discourse - particularly in the field of governance. In this note we wish to draw attention to, and challenge, what we fear is an emerging hegemonic discourse in the field of health policy and systems work - the discourse of resilience.
In the past five years ‘resilience’ has been increasingly applied in health policy and systems research (HPSR) to refer to the need for distressed health systems (micro or macro) to ‘bounce back’ from shocks. Often implicit in this discourse, is the assumption that such systems were ‘there’ in the first place, or at the very least, that with a concerted effort they can get there. What a resilient health system means in this context is not clear - but we contend that, in a form of technocratic reductionism, resilience strategies and solutions are often divorced from meaningful assessment of the political economy and power dynamics that produced the health system crises in the first place.
Health systems in crises suffer from chronic deficiencies in many things - material and human resources central-level planning and coordination capacity and domestic financing to name but a few. The populations and communities seeking services from these deficient systems are more likely to have low levels of education, weak citizen engagement and to experience deep class inequity. Much of the technocratic discussion around ‘building resilience’ appears to bypass these issues, however, often focusing on tweaking inputs or health system components, and frequently emphasising self-reliance and behaviour change. This technocratic and formulaic approach to building resilience is at odds with the complex reality of health systems in each country.
‘Building resilience’ rarely seems to involve a direct examination of, or challenge to, the structural conditions that contribute to overarching health system dysfunction, including historical colonial legacies, current trade and aid structures, tax and health insurance structures. We are concerned that the discourse of resilience will follow the trend of global health policy reforms being fuelled by the perceived immediacy of a problem instead of careful analysis of root causes and strategies likely to prevent recurrence in the long-term. Recent examples include the Ebola epidemic and now Zika, in which resilience discourse is getting close to that of the global health security agenda in which the main concern is transnational epidemics from the south to the north. The rise of hegemonic resilience discourse has effectively enabled global health stakeholders to replace the conversation about systemic failures at multiple levels which supports a far more long term vision, with an action-oriented discourse that implies much shorter time-frames.
A conscious discussion is needed to reframe what the health system community means when we use the term ‘resilience’. Resilience and the linked concept of sustainability of health programming have value, as long as they are not divorced from the material changes that need to occur to support them and the requirement for a more balanced relationship among national states (trade, flow of resources, and others). Use of these terms should build on previous work and consensus around social determinants of health, right to health and people-centered health systems. This means resilience should be situated on a continuum rather than replacing important advances around health systems and its relation with equity, fairness and human rights.
Ultimately, we contend that a more ambitious and nuanced application of the term ‘resilience’ is required if the term is to contribute to improving LMIC health systems’ capacity to withstand political, financial, epidemiological and environmental shocks. We must also do everything possible to prevent such shocks in the first place. But at the very least, we in the health policy and systems community need to start acknowledging the dangers of using ‘resilience’ as part of a de-politicised and technocratic discourse.
This piece was first posted as a blog for Health Systems Global (HSG) http://tinyurl.com/j968dqc. The authors are thematic leads of the cluster on Power in Health Systems in the SHaPeS Technical working group of HSG. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
1. Editorial
2. Latest Equinet Updates
When the International Health Regulations (IHR) were adopted in 2005 by member states of the World Health Organisation (WHO), State Parties were given up to June 2012 to have developed minimum core public health capacities to implement them. This included having surveillance, reporting and response systems for public health risks and emergencies and measures for disease control at designated airports, ports and ground crossings. In East and Southern Africa (ESA), the IHR are being implemented within an Integrated Disease Surveillance and Response (IDRS), which is a comprehensive, evidence-based strategy for strengthening national public health surveillance and response systems in African countries. This policy brief outlines the progress made and deficits in ESA countries in achieving the core capacities to implement the IHR. It proposes national measures to strengthen public health systems to both meet gaps in the implementation of the IHR and to link responses to health emergencies and outbreaks to health systems strengthening in ESA countries.
3. Equity in Health
Evidence on trends and determinants of disability-free life expectancies (DFLEs) are available in high-income countries but less in low and middle-income countries (LMICs). This study examines the levels of and inequalities in life expectancy(LE), disability and DFLE between men and women across different age groups aged 50 years and over in six countries with developing economies. This study utilised the cross-sectional data (n=32 724) from the WHO Study on global AGEing and adult health in China, Ghana, India, Mexico, the Russian Federation and South Africa in 2007–2010. Disability was measured with the activity of daily living instrument.. The disability prevalence ranged from 13% in China to 54% in India. Women were more disadvantaged with higher prevalence of disability across all age groups. Though women had higher LE, their proportion of remaining LE free from disability was lower than men. There are inequalities in the levels of disability and DFLE among men and women in different age groups among people aged over 50 years in these six countries. Countermeasures to decrease intercountry and gender gaps in DFLE, including improvements in health promotion and healthcare distribution, with a gender equity focus, are needed.
By May 2016, tests conducted at Brazil’s national reference laboratory conclusively identified that a new mosquito-borne disease - Zika- had indeed arrived in the Americas, though no one knew what that might mean. Although the re-profiling of Zika from a benign disease to a global health emergency stimulated a flurry of research, the disease remains poorly understood at levels ranging from its virology and epidemiology to the clinical spectrum of complications it can cause. No one can answer questions about further international spread with certainty, though theories abound. As the virus has been detected in parts of Asia and Africa for several decades, some level of endemicity is assumed, though no one knows whether presence of the virus over time has resulted in widespread or low-level immune protection or possibly no protection at all. In April 2016, researchers in Ecuador and the northeastern part of Brazil reported the detection of Zika in monkeys, suggesting a new transmission cycle that could allow the virus to persist. In Brazil, the virus detected in monkeys was identical to the one circulating in humans. Researchers at a government laboratory in Mexico reported detection of the Zika virus in female Aedes albopictus mosquitoes collected in the wild, as opposed to experimentally infected – a first for the western hemisphere. As the mosquito can survive the winter in temperate climates, its ability to carry the Zika virus could expand the map of areas at risk of Zika virus transmission.
Decades of neglect and chronic underinvestment have had serious detrimental effects on the health and wellbeing of adolescents aged 10–24 years, according to a major new Lancet Commission on adolescent health and wellbeing. Two-thirds of young people are growing up in countries where preventable and treatable health problems like HIV, early pregnancy, unsafe sex, depression, injury, and violence remain a daily threat to their health, wellbeing, and life chances. Evidence shows that behaviours that start in adolescence can determine health and wellbeing for a lifetime. Adolescents today also face new challenges, including rising levels of obesity and mental health disorders, high unemployment, and the risk of radicalisation. Adolescent health and wellbeing is also a key driver of a wide range of the Sustainable Development Goals on health, nutrition, education, gender, equality and food security, and the costs of inaction are enormous, warn the authors. While efforts to improve the health of children under 5 have led to major improvements in younger ages, the leading causes of death for young people aged 10-24 years have changed remarkably little from 1990 to 2013, with road injuries, self-harm, violence, and tuberculosis remaining in the top five. Maternal disorders were the leading cause of death in young women in 2013, responsible for 17% of deaths in women aged 20–24 years and 11.5% in girls aged 15–19 years. The leading risk factors for death in young people aged 10–14 years have not changed in the past 23 years, with unsafe water, unsafe sanitation, and handwashing remaining in the top three. Diarrheal and intestinal diseases are still responsible for 12% of deaths in 10–14 year old girls. Injuries, mental health conditions, common infectious diseases, and sexual and reproductive health problems are the dominant health problems in young people. The two main contributors to health loss worldwide for both sexes are mental health disorders and road injuries.
An estimated 200 million children worldwide fail to meet their development potential due to poverty, poor health and unstimulating environments. Missing developmental milestones has lasting effects on adult human capital. Africa has a large burden of risk factors for poor child development. This paper identifies the scope for improvement at the country level in three domains – nutrition, environment, and mother–child interactions. It uses nationally representative data from large-scale surveys, data repositories and country reports from 2000 to 2014. Overall, there was heterogeneity in performance across domains, suggesting that each country faces distinct challenges in addressing risk factors for poor child development. Data were lacking for many indicators, especially in the mother–child interaction domain. The authors argue that there is a need to improve routine collection of high-quality, country-level indicators relevant to child development to assess risk and track progress.
4. Values, Policies and Rights
This paper provides a theoretical and political critique of how the concept of resilience has been applied to places. It is based upon three main points. First, the ecological concept of resilience is conservative when applied to social relations. Second, resilience is externally defined by state agencies and expert knowledge. Third, a concern with the resilience of places is misplaced in terms of spatial scale, since the processes which shape resilience operate primarily at the scale of capitalist social relations. The authors argue that resilience is fundamentally about how best to maintain the functioning of an existing system in the face of externally derived disturbance. Both the ontological nature of ‘the system’ and its normative desirability escape critical scrutiny. As a result, the existence of social divisions and inequalities tends to be glossed over when
resilience thinking is extended to society. Ecological models of resilience are thus argued to be fundamentally
anti-political, viewing adaptation to change in terms of decentralized actors, systems and relationships and failing to accommodate the critical role of the state and politics. In place of resilience, the authors offer the concept of resourcefulness as an alternative approach for community groups to foster.
A judgment handed down in May 2016 in the South Gauteng High Court in the case of Bongani Nkala and 68 Others v Harmony Gold Mining Company Ltd and 31 Others is reported an important step toward providing just compensation for the many thousands of miners who contracted silicosis or tuberculosis on South Africa’s gold mines. The court certified two classes. The first and larger is gold miners and former gold miners who have contracted silicosis and the second is those who have contracted TB. The class requires that a person has worked underground in the mines for at least two years since 1965 and contracted either disease. The lawsuit, unless settled, will now proceed into trials in which common issues relevant to all class members will be determined. The court confirmed that for mineworkers, “it is class action or no action at all. Class action is the only realistic option open to mineworkers and their dependents. It is the only way they would be able to realise their constitutional right of access to court bearing in mind that they are poor, lack the sophistication to litigate individually, have no access to legal representatives and are continually battling the effects of two extremely debilitating diseases.” [para 100] The judgment is also important for all vulnerable people in South Africa. A class action is a powerful mechanism by which poor or vulnerable people can access justice. It is however not commonly used in South Africa. This judgment is argued to help those who do not have resources on their own to pool efforts in order to access justice. The authors argue that it recalibrates the balance of power to give the poor a better chance of holding the powerful to account.
5. Health equity in economic and trade policies
This synthesis paper offers a broad framing of the issues to consider in implementing the proposed African Agenda 2063. In doing so, it re-interprets the African historical experience to underscore the point that the core pillar and contribution of Agenda 2063 must be to help translate centuries of efforts to regain freedom, and to rebuild the self-reliance and dignity of Africans. The paper also identifies some of the possible challenges to which the Agenda must respond if it is to be effective and relevant, the existing policy and institutional pillars into which it fits and on which it must build, and a broad menu of issues which would need to be further reflected upon towards its full-fledged articulation. A set of background papers annexed to the synthesis offer a more in-depth assessment of some of these issues, as a foretaste of the kind of additional technical work required in the course of articulating a robust 2063 Agenda for the continent.
This Africa Progress panel Report argues that African policy makers have critical choices to make. They can either invest their natural resource revenue in people to generate jobs and opportunities for millions in present and future generations, or they can squander this opportunity, allowing jobless growth and inequality to take root. In many African countries, natural resource revenues are widening the gap between rich and poor. Although much has been achieved, a decade of highly impressive growth has not brought comparable improvements in health, education and nutrition. The Africa Progress Panel is convinced that Africa can better manage its vast natural resource wealth to improve the lives of the region’s people by setting out bold national agendas for strengthening transparency and accountability. The Panel consists of ten distinguished individuals from the private and public sector who advocate for equitable and sustainable development for Africa.
This paper examines the evidence for a 'resource curse' at subnational level. Natural resource extraction can have positive effects, generating profits, tax revenue for government, and economic linkages to other sectors. It can also have negative economic, environmental and social consequences, including changes in local relative prices that might crowd out other productive activities; deforestation; pollution and degradation; and the potential for social dislocation and displacement. This paper evaluates the evidence for how these effects accrue specifically to the subnational economy and whether government policy can lead to positive development impacts, while avoiding the challenge of unbalanced costs borne locally.
Sphiwe Mazibuko's 9 minute documentary exposes the intimidation and violence facing anti-mining activists on the Wild Coast and Zululand, in South Africa. Xolobeni residents have fought for 10 years to prevent an Australian company from mining their titanium rich dunes. The film documents how an unwavering response of the Pondo people to protect their traditional Wild Coast lands, where they have lived for over 1500 years, has been met by increasing intimidation and violence with activist lives threatened and attacked.
6. Poverty and health
Access to poor quality and inexpensive food that are high in fats and refined carbohydrates have the potential to expose children to obesity. Fighting obesity could translate into a decrease in the number of adults who suffer from non-communicable diseases such as diabetes, hypertension and heart disease. In this edition of NGO Pulse, Lauren Graham, a senior researcher at the University of Johannesburg’s Centre for Social Development for Africa, writes that with the current drought and increased food prices, it is becoming more expensive and difficult for families, especially those in poor communities, to afford and opt for healthier food baskets. Graham, who argues that it is easy and cost effective to prevent obesity and overweight, adds that: “Obesity is not necessarily driven by overeating, as is commonly thought.” She notes that children who grow up in poor communities are at high risk for obesity and ‘hidden hunger’ since they have no option but to consume food that lacks the right balance of nutritious meals.
Within a rights-based paradigm, wheelchairs are essential in the promotion of user autonomy, dignity, freedom, inclusion and participation. This paper described a group of 94 Zimbabwean wheelchair users’ satisfaction with wheelchairs, wheelchair services and wheelchair function in a mixed method, descriptive study using the Quebec User Evaluation of Satisfaction with Assistive Technology for adults and children and Functioning Every day with a Wheelchair questionnaire. Qualitative data were collected through two focus group discussions (22 participants) and two case studies with participants purposively sampled from those who participated in the quantitative phase. More than 60% of participants were dissatisfied with the following wheelchair features: durability (79%), weight (76%), ease of adjustment (69%), effectiveness (69%), safety (67%), reliability (67%), and meeting user needs (61%). Similarly, more than 66% of participants were dissatisfied with various services aspects: professional services (69%), follow-up (67%), and service delivery (68%). Although 60% of participants agreed that the wheelchair contributed to specific functions, more than 50% of participants indicated that the features of the wheelchair did not allow in- (53%) and outdoor (53%) mobility. Findings indicate high levels of dissatisfaction with wheelchair features and services, as well as mobility. It is recommended that minimum service standards are set incorporating evidence and good practice guidelines for wheelchair services and management of wheelchair donations in Zimbabwe.
The Commission for Social Development concluded its fifty-fourth session approving three draft resolutions for adoption by the Economic and Social Council. One on Africa’s development, while traditionally endorsed by consensus, required a rare vote to address the United States’ concerns over language around trade issues, and more generally, “the right to development”. The Commission approved a draft on “Social dimensions of the New Partnership for Africa’s Development” by 29 in favour, to 12 against, with no abstentions (document E/CN.5/2016/L.5). This emphasizes that “increasingly unacceptable” poverty, inequality and social exclusion in most African countries requires social and economic policies to be devised through a comprehensive approach. African countries are encouraged to prioritize structural transformation, modernize smallholder agriculture, add value to primary commodities and improve public and private governance institutions.While the United States’ delegate, whose delegation had requested the vote, said her Government would vote against the text, as it viewed the World Trade Organization (WTO) as the main venue for trade negotiation, and could not support a text calling on WTO members to conclude the Doha Round of trade negotiations and improve market and duty-free access, South Africa’s representative, associating with the Group of 77, said South Africa would continue to advocate for social development as part of the global agenda.
7. Equitable health services
In this blog, the author reports that in Tanzania, less than one in 10 (9%) of sexually active youth who want to avoid pregnancy use modern contraceptives and that 22.8% of young women between the ages of 15 and 19 are mothers, according to the Tanzania Demographic and Health Survey 2010. Tanzanian women, the survey shows, have an average of 5.4 children each. Early childbearing and high rates of fertility put stress on the health and education systems, on the availability of food and clean water, and on natural resources, according to the country's National Family Planning Costed Implementation Plan. Tanzania has committed to Family Planning 2020 (FP2020), to ensure that, in line with the United Nations secretary general's global strategy for women, children, and adolescent health, all women have access to contraceptives by 2020. The aut5hor indicates that its needed: 47% of Tanzania's population is 15 years or younger. In Tanzania, family planning has been synonymous with child spacing for married men and women, as typified by posters and brochures featuring monogamous couples with their three distinctly spaced children. But the term "family planning" doesn't resonate with young people because they are not yet ready to start families. He notes therefore that as a result, the global health workers' advocacy and support group, IntraHealth International, has started referring to it as "future planning."
This in-depth country case study aimed to explain Malawi's success in improving child survival. The authors estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. They documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing. The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths per 1000 livebirths in 1990 to 71 deaths in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly, representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280 000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The funding allocated to the health sector increased substantially, particularly to child health and HIV and from external sources, albeit below internationally agreed targets. This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. The authors’ findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth.
Every year, nearly 200,000 women die during childbirth in sub-Saharan Africa in part due to poor access to basic reproductive and maternal health services. The author argues that Over 80 percent of these deaths could have been prevented with the assistance of a midwife. This campaign, Stand Up for African Mothers. aims to ensure that more African women can count on the assistance of a trained midwife during pregnancy and childbirth, and promotes reproductive rights and education to help women and their partners make informed choices about family planning. Through campaign, Amref is training 15,000 midwives to reduce the high rate of maternal mortality in sub-Saharan Africa through both traditional classroom-based teaching, and innovative methods such as distance learning and mLearning, which allows midwives to study using basic mobile phone technology. With a skilled midwife providing care to 500 mothers annually, over seven million African women each year could benefit from this campaign in 13 African countries. By 2016, almost 7,000 midwives had been trained since the campaign began in 2010.
8. Human Resources
In 2015, the One Million Community Health Workers (1mCHW) Campaign and mPowering Frontline Health Workers (mPowering) conducted a series of interviews and held an online discussion, hosted on the Healthcare Information for All forum, on the need for improved data on community health workers (CHWs) to help achieve the Sustainable Development Goals. The key findings showed that CHWs deliver life-saving health care services than can address health issues in poor rural communities. They help keep track of disease outbreaks and overall public health, and offer a vital link between underserved populations and the primary health care system. CHWs have been recognised for their success in reducing morbidity and averting mortality in mothers, newborns and children. While they have proven crucial in settings where the primary health care system is weak, or where there are health workforce shortages, they are most effective when properly supported and deployed within the context of an appropriately financed health system.
An understanding of rural communities is fundamental to effective community-based rehabilitation work with persons with disabilities. The authors argue that insufficient attention has been paid to the challenges that rural community disability workers face. This qualitative interpretive study, involving in-depth interviews with 16 community disability workers in Botswana, Malawi and South Africa, revealed the complex ways in which poverty, inappropriately used power and negative attitudes of service providers and communities combine to create formidable barriers to the inclusion of persons with disabilities in families and rural communities. The paper highlights the importance of understanding and working with the concept of ‘disability’ from a social justice and development perspective. It stresses that by targeting attitudes, actions and relationships, community disability workers can bring about social change in the lives of persons with disabilities and the communities in which they live.
9. Public-Private Mix
This issue of the African Newsletter on Occupational Health and Safety examines infectious disease and occupational health. Marie-Paul Kelly explores governance and leadership, both at regional and global levels in preventing health emergencies. The issue explores guidance to workplaces and occupational health professionals in prevention of occupational infections and examines the workplace as an arena for raising awareness on infectious diseases. Further papers look at protecting front-line health care workers and enterprise workers from Ebola. Jeanneth Manganyi and Kerry Wilson author a paper on the importance of respirator fit testing and proper use of respirators. Further articles in the issue explore food-borne illnesses at workplaces, the effectiveness of personal protective equipment to prevent Ebola transmission and the use of blunt suture needles to halve the risk of needle stick injuries among surgeons.
10. Resource allocation and health financing
This article argues that an assessment of progressivity over time can provide an indication of progress towards a ‘more’ progressive or a ‘less’ regressive health financing system and can be useful to policymakers. It introduces a framework to characterize ‘shifts’ in progressivity in health financing between two time periods using the popularly known Kakwani index of progressivity and other associated indices. It also decomposes the ‘shifts’ in progressivity into the relative contributions of the changes in income distribution and the changes in the distribution of health payments. Further, it proposes graphics that statistically analyses how the ‘shifts’ in progressivity vary along the distribution of income. A pro-poor (pro-rich) shift implies that the health financing mechanism is becoming more (less) progressive or less (more) regressive between two time periods. A proportional shift means that progressivity is constant between the two periods. This framework is applied to nationally representative household data from South Africa. It emerged that such characterization is a very useful tool for policy in assessing progress towards equitable health financing.
Health financing reforms in low- and middle- income countries (LMICs) over the past decades have focused on achieving equity in financing of health care delivery through universal health coverage. This systematic review assesses progress towards equity in health care financing in LMICs through the use of benefit incidence analysis (BIA) and financing incidence analysis (FIA). A total of 512 records were obtained and 24 were judged appropriate for inclusion. Twelve of the 24 studies originated from sub-Saharan Africa. The evidence points to a pro-rich distribution of total health care benefits and progressive financing in sub-Saharan Africa. In the majority of cases, the distribution of benefits at the primary health care level favoured the poor while hospital level services benefit the better-off. Studies evaluated in this systematic review indicate that health care financing in LMICs benefits the rich more than the poor but the burden of financing also falls more on the rich. There is some evidence that primary health care is pro-poor suggesting a greater investment in such services and removal of barriers to care can enhance equity. The results overall suggest that there are impediments to making health care more accessible to the poor and this must be addressed if universal health coverage is to be a reality.
This paper aimed to measure the impact of user fee reforms on the probability of giving birth in an institution or receiving a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population. The authors analysed data from consecutive surveys in five countries: two case countries that experienced reforms (Ghana and Burkina Faso) in contrast to three that did not experience reforms (Zambia, Cameroon, Nigeria). User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest) and non-educated women and those in rural areas benefited the most from the reforms. Findings show a clear positive impact on access when user fees are removed but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform.
The authors describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. The authors conducted a process evaluation of HSSF implementation. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. They found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need.
11. Equity and HIV/AIDS
The high prevalence of chronic diseases in Tanzania is putting a strain on the already stretched health care services, patients and their families. This study sought to find out how health care for diabetes and HIV is perceived, practiced and experienced by patients and family caregivers, to inform strategies to improve continuity of care. Thirty two in-depth interviews were conducted among 19 patients (10 HIV, 9 diabetes) and 13 family caregivers (6 HIV, 7 diabetes). The innovative care for chronic conditions framework informed the study design. Three major themes emerged; preparedness and practices in care, health care at health facilities and community support in care for HIV and diabetes. In preparedness and practices, HIV patients and caregivers knew more about aspects of HIV than did diabetes patients and caregivers on diabetes aspects. Continued education on care for the conditions was better structured for HIV than diabetes. On care at facilities, HIV and diabetes patients reported that they appreciated familiarity with providers, warm reception, gentle correction of mistakes and privacy during care. HIV services were free of charge at all levels. Costs involved in seeking services resulted in some diabetes patients to not keep appointments. There was limited community support for care of diabetes patients. Community support for HIV care was through community health workers, patient groups, and village leaders. Diabetes and HIV have socio-cultural and economic implications for patients and their families. The HIV programme is successfully using decentralization of health services, task shifting and CHWs to address these implications. For diabetes and NCDs, decentralization and task shifting are also important and, strengthening of community involvement is warranted for continuity of care and patient centeredness in care. While considering differences between HIV and diabetes, the authors show that Tanzania's rich experiences in community involvement in health can be leveraged for care and treatment of diabetes and other NCDs.
‘Treatment as prevention’ has become the cornerstone of UNAIDS’s post-2015 global strategy to end AIDS by 2030. As the expansion of treatment provision continues, and access improves, adherence becomes a determining factor in the impact of ART for both treatment and prevention. HEARD are conducting a number of small scoping studies on challenges to ART adherence in men who have sex with men (MSM) and lesbian, gay, bisexual, transgender, and intersex (LGBTI) communities living with HIV in East and Southern Africa (ESA), as key populations in the AIDS response. This report presents findings from a scoping study carried out in Kampala, Uganda, in December 2015. The findings suggest that (double) stigma and criminalisation of behaviour of people living with HIV (PLHIV) in MSM and LGBTI communities cut across almost every perceived challenge to ART adherence as a driving or contributory factor. As a result, indications suggest MSM and LGBTI experience challenges that are similar in type to the general population, but that these population groups experience the challenges more often, more acutely, and with less opportunity to overcome the challenges.
Although stigma and its relationship to health and disease is not a new phenomenon, it has not been a major feature in the public discourse until the emergence of HIV. The range of negative responses associated with the epidemic placed stigma on the public agenda and drew attention to its complexity as a phenomenon and concept worthy of further investigation. Despite the consensus that stigma is one of the major contributors to the rapid spread of HIV and the frequent use of the term in the media and among people in the street, the exact meaning of ‘stigma’ remains ambiguous. This paper re-visits some of the scholarly deliberations and further interrogates their relevance in explaining HIV-related stigma evidenced in South Africa. In conclusion a model is presented. Its usefulness – or explanatory potential – is that it attempts to provide a comprehensive framework that offers insights into the individual as well as the social/structural components of HIV-related stigma in a particular context. As such, it is argued by the authors to have the potential to provide more nuanced understandings as well as to alert us to knowledge-gaps in the process.
12. Governance and participation in health
Sustainable, effective and successful partnerships need to be built on mutual trust, on an explicit programme, clearly defined responsibilities, champion figures and financial resources. In this article, Dr. Kakonge outlines positive and negative factors that influence development assistance partnerships in Africa. The article notes that partnership demands creativity, compromise, commitment, consistency, flexibility and fairness. Some scholars argue that partnerships do not work when there is poor coordination relating to external assistance. . The author reviews factors that are critical in making development assistance partnerships successful in Africa.
Ban Ki-Moon’s term as UN Secretary General ends this year and already political jostling is underway ahead of the selection of the new head of the world body. There are strong indications that favour a woman candidate. And how has Africa positioned itself for the unfolding contest? A number of African female candidates with the right credentials fit to lead the UN exist. The author discusses which African candidates could be in the running and whether a candidate from Kenya might have the diplomatic weight to lobby and get elected.
The Global strategy for women’s, children’s and adolescents’ health (2016–2030) recognizes that people have a central role in improving their own health. The authors propose that community participation, particularly communities working together with health services (co-production in health care), will be central for achieving the objectives of the global strategy. Community participation specifically addresses the demand to transform societies so that women, children and adolescents can realize their rights to the highest attainable standards of health and well-being. This paper examines what this implies in practice. The authors discuss three interdependent areas for action towards greater participation of the public in health: improving capabilities for individual and group participation; developing and sustaining people-centred health services; and social accountability. They outline challenges for implementation, and provide policy-makers, programme managers and practitioners with illustrative examples of the types of participatory approaches needed in each area to help achieve the health and development goals.
WHO Watch is a civil society project, coordinated by People’s Health Movement (PHM) and Medicus Mundi International, directed both to supporting WHO and holding it accountable. WHO Watch involves a team of ‘watchers’ attending WHO governing body meetings, lobbying delegates, speaking from the floor, documenting and reporting on the debate and the decisions, and preparing commentaries on each of the agenda items. These commentaries are designed to support progressive delegations (in particular from smaller countries who have only limited human resources to devote to these issues) as well as arguing for progressive outcomes. The Sixty Ninth World Health Assembly (WHA69) convened in Geneva from 23 – 28 May 2016. The Watch reports on the debates on various items, including: managing conflicts of interest in global health; maternal, infant and young child nutrition; ending childhood obesity; ageing; air pollution; the ‘sound’ management of chemicals; antimicrobial resistance; polio; managing global health emergencies; the health of migrants; lessons from Ebola in West Africa; HIV, viral hepatitis, STIs; vaccination; global health workforce issues; medicines and intellectual property.
In this article the authors argue that the World Health Organisation (WHO) Secretariat, Member States and observers should honestly admit that they have so far fallen very short of the WHO Mission. The authors argue that the organization has become a huge bureaucratic structure while at the same time under-resourcing its needs has made it incapable of providing a timely response to the urgent health needs happening in the world. The organization is argued to be being privatized with influence from small group of private funders. This authors observe that the limited participation sometimes turns into an uncomfortable position for many, when faced with the lack of progress in the debates or with the endless diplomatic language that is used without reaching any concrete agreements and with resolutions and decisions where that make it almost impossible to identify the substance and therefore difficult to see their real value. In the meantime millions of diseases and preventable deaths are happening far away from what is being discussed at “the highest levels” of international public health policy arena.
The 69th World Health Assembly (WHA) adopted the Framework of Engagement with Non-State Actors (FENSA) on the concluding day of Assembly. The adoption of FENSA is the conclusion of a process initiated as part of the WHO reform in 2011. FENSA consists of an overarching framework of engagement with Non-State Actors (NSAs) and four separate policies for governing the engagements with four categories, i.e. Non-Governmental Organisations (NGOs), private sector, philanthropic foundations and academic institutions. The overarching principles set out the common rules for all NSAs and treat all NSAs on an equal footing. The separate policies provide certain customised aspects of the overarching principles to the respective categories of NSAs. The framework regulates five types of engagements: participation, resources, advocacy, evidence, and technical collaboration. The WHA resolution that adopts the FENSA decides to replace the two existing policies governing WHO engagements with NGOs and the private sector. Further, the resolution requests the Director-General to start the implementation immediately and take all necessary measures to fully implement FENSA. Further, it requests the Director-General to expedite the full establishment of WHO’s NSA register.
13. Monitoring equity and research policy
The EAC Sectoral Council of Health Ministers Regional Health Sector Strategic Plan (2015-2020) is a roadmap for improving and strengthening of the regional health sector through implementation of the various approaches, interventions and innovation in the region. The 5th EAC Health and Scientific Conference contributes to and is a catalyst for strengthening regional cooperation in the health sector especially with regard to the improvement of health care service delivery and patient care outcomes. It is a platform for synthesizing, sharing and dissemination of research findings to inform policy makers, scientists and programmers on evidence-based decision-making and mobilization of political will and resources for the Health Sector.
The authors outline a comprehensive approach for developing a cross-sectoral, multi-dimensional and dynamic understanding of resilience. This underpins the message of the Sustainable Development Goals (SDGs) that development is multi-faceted and the achievement of many of the individual development goals is dependent on the accomplishment of other goals. It also acknowledges that shocks and stresses can reverse years of development gains and efforts to eradicate poverty by 2030. The authors argue that this approach to understanding resilience draws on data that countries will collect for the SDGs anyway and entails only a small additional burden.
This report explores evidence of success in environmental justice (EJ) activism on socio-environmental mining conflicts by applying a collaborative statistical approach, combining qualitative and quantitative methods. The empirical evidence covers 346 mining cases from around the world in the EJOLT Atlas of Environmental Justice, and is enriched by an interactive discussion of results with activists and experts. The authors used a social network analysis to study the nature of the relationships both among corporations involved in the mining activity, on the one hand, and among EJ organisations, on the other. Multivariate analysis methods were used to examine the defining factors in achieving EJ success and qualitative analysis, based on descriptive statistics, was conducted to investigate factors that configure the perception of success for EJ and incorporate activist knowledge into the theory of EJ. The authors argue that overall, such analytical exercises, coproduced with activists, should be seen as a source of engaged knowledge creation, which is increasingly being recognised as a pertinent method to inform scientific debate with policy implications, and that it can also be insightful and relevant for activism.
14. Useful Resources
The HST Conference 2016 programme included 90 oral and poster presentations from a wide range of presenters in the South African public health policy, research and implementation field. Presentations range from health governance and health financing to health counselling and electronic medical records. The presentations are available at this site..
The KEYSTONE open access teaching and learning materials on Health Policy and Systems Research (38 videos and 43 slide presentations across 13 modules) are now live online. These teaching and learning resources were developed for the inaugural KEYSTONE India short course on Health Policy and Systems Research. They include 38 videos and 43 slide presentations organized across 13 modules and cover a range of foundational concepts and common approaches used in HPSR. This suite of teaching and learning materials was developed in the process of delivering the inaugural KEYSTONE course, and is being made available as an open access resource under the Creative Commons license.
15. Jobs and Announcements
The Banting Postdoctoral Fellowships program provides funding to the very best postdoctoral applicants, both within Canada and internationally, who will positively contribute to the country's economic, social and research-based growth. The fellowship covers health research, natural sciences and/or engineering and social sciences and/or humanities.
This call for papers entitled ‘Gender and health inequalities: intersections with other relevant axes of oppression’ aims to generate knowledge about how gender inequalities in health/disease/mortality/and access to health care systems interact with other important axes of oppression (race/ethnicity, social class, religion, and/or migratory status, among others) through different levels of power (from the global to the local) at different lifetime stages for a population. It aims to contribute to a better understanding of the relationship between gender (in)equalities and health (inequalities). The editors welcome different types of contributions: empirical research, theoretical papers, methodological papers, and reviews. The editors also welcome papers that address not only issues of dominance and/or suffering but also those about resistance, agency, resilience, and/or empowerment. Submissions are encouraged from researchers working in low-, middle-, and high-income countries.
The International AIDS Conference is a gathering for those working in the field of HIV, as well as policy makers, persons living with HIV and other individuals committed to ending the pandemic. It is a chance to assess state of affairs, evaluate recent scientific developments and lessons learnt, and collectively chart a course forward. The AIDS 2016 programme will present new scientific knowledge and offer many opportunities for structured dialogue on the major issues facing the global response to HIV. A variety of session types – from abstract-driven presentations to symposia, bridging and plenary sessions – will meet the needs of various participants. Other related activities, including the Global Village, satellite meetings, exhibitions and affiliated independent events, will contribute to an exceptional opportunity for professional development and networking.
This programme’s objective is to improve the skills and competences of students and staff through enhanced intra-African mobility and cooperation between Higher Education Institutions (HEIs) in Africa to encourage and enable African students to undertake postgraduate studies in the African continent. The call is for partnerships between a minimum four and maximum six African HEIs including the applicant) and one technical partner from the EU. Eligible applicants and partners are HEIs registered in Africa that provide courses at postgraduate level (master’s and/or doctorate degree) of higher education leading to a qualification recognised by the competent authorities in their own country. Only HEIs accredited by relevant national authorities in Africa are eligible. Branches of HEIs from outside Africa are not eligible.
The University of the Western Cape (UWC) School of Public Health presents the 38th Short Course School in a series of Winter and Summer Schools held at UWC since 1992. These courses expose health and health-related workers to the latest thinking in Public Health and enable them to discuss and exchange ideas on improved planning and implementation of Primary Health Care in the changing environment of the developing world. To date, some 12,000 participants, mainly nurses and middle level managers have attended these courses, from all over South Africa and many other African countries. As many of these courses are also used as the teaching blocks of the UWC Master of Public Health degree, the highest academic and practical standards are maintained. Most courses are one week long to allow busy health workers to receive continuing education with minimal disruption of their services. Selection of subjects reflects the main public health priorities. This year UWC are offering courses covering a wide range of management, programme development and policy and planning issues. The cost of courses is kept to an absolute minimum, to allow for the fullest participation.
Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter
SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to admin@equinetafrica.org Please forward this to others.
SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org or send an email to admin@equinetafrica.org
This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact admin@equinetafrica.org immediately regarding any issues arising.