The 2017 World Health Assembly (WHA70) will be held in Geneva from 22 to 31 May 2017. The agenda and initial documents are being made available at http://apps.who.int/gb/e/e_wha70.html.
WHA70 has a wide ranging agenda, including the election of a new Director General; the management of emergency responses and antimicrobial resistance; research and development (R&D) for neglected diseases; the capacities for and evaluation of preparedness for the International Health Regulations (IHR) 2005, migrant health; and the Sustainable Development Goals (SDGs), amongst other items. It will discuss progress in the implementation of resolutions from prior WHAs and the governance and programmes of the World Health Organisation (WHO).
The WHA is being held at a time when military conflict has terrorized populations and forced displacement internally and across borders, disrupting lives, livelihoods and food supplies, and heightening the risk of epidemic outbreaks. African migrants leaving due to conflict or to seek economic opportunity face many health challenges, including physical and psychological stress and abuse, and poor access health services. Migrancy affects transmission of infectious diseases, including to northern countries now experiencing warmer temperatures due to climate change. WHO has proposed migrant-sensitive health policies that incorporate a public health approach, with universal, equitable access to quality health services that would also assist in surveillance, detection and control of infectious and other health problems and financial protection for migrants. However, there is a wide gap between this and the situation in practice.
Progress has been made in the development of a vaccine against Ebola and control of the yellow fever epidemic in central Africa. The accelerated process for use of the former as an experimental vaccines in health care and frontline workers has raised ethical and equity concerns, while non availability of yellow fever vaccine stocks in the latter case led to fractional dosing (of one fifth of the normal vaccine dose) to stretch resources as an emergency response, which, as indicated by WHO, does not confer longer term protection and is not a measure for routine vaccination. These issues and a Zika virus disease outbreak recently reported in Angola from the Aedes vector responsible for transmitting dengue fever, yellow fever and chikungunya virus infections points to the need for strengthened public health measures to prevent, detect and control communicable diseases, within and across countries. Although much attention has been given to acute infectious disease emergencies, the rising level of non-communicable diseases (NCDs) in ESA countries, including trauma/injuries and cancers represents a major immediate and long term challenge, driven largely by conditions and policies outside the health sector, with health systems that are poorly equipped to detect, prevent and manage them.
These health threats take place against the backdrop of underfunded health systems and inadequate skilled health workers and medicines in our region, particularly in areas of high health need. While 18 million workers are estimated to be needed globally to achieve Universal Health Coverage and maintain pace with SDGs, by 2030 Africa is projected to have a shortage of 6 million health workers. Inadequate and increasingly costly medicines and health technologies undermine equitable access, in a global environment of growing microbial resistance and one that still raises investment, technology transfer and intellectual property barriers to development and production in areas of high health need. This directly links measures to combat antimicrobial resistance to those that ensure community health literacy and equitable access at affordable cost to good quality old and new antibiotics, vaccines and diagnostic tools, and measures for public investment in R&D, local production, pooled procurement and the lifting in practice of intellectual property barriers affecting public health.
There has been progress, particularly in emergency responses. For example, the WHO has set up a Health Emergencies Programme to co-ordinate emergency prevention and response; a collaboration agreement with the Africa Centre for Disease Control (AU-CDC) has stimulated work to build a regional health workforce for emergencies. Incident Management Systems have been established in a number of African countries to strengthen coordination of responses to emergencies and nine African countries have implemented Joint External Evaluations of their IHR core capacities. The WHO Contingency Fund for Emergencies and the Africa Public Health Emergency Fund have been established and have enabled quick response to zika, cholera and yellow fever outbreaks, although with challenges to address, including their alignment to national resources and delays in operationalising and slow disbursement of these funds.
This investment in detection and control of epidemics is welcomed, but the concern in the region is also to prevent epidemics from occurring in the first place. This needs continuous strengthening of health information systems and population surveys to map disease risks and burdens and assess vulnerabilities in the region, to raise and ensure that African priorities are planned for and responded to at local, national, regional and global level.
An East Central and Southern African Health Community (ECSA HC) April 2017 meeting of senior officials and technical actors with input from Geneva-based diplomats in the Africa Group of Health Experts noted that this calls for a pooling of efforts, to respond to emergencies, to co-ordinate R&D and to share capacities and experience in building integrated health systems. Such comprehensive measures recognise that health systems are not simply technical in nature, but signal our social values, including for example in the way migrants are treated, or in how the health workers in conflict and emergency zones are cared for and protected.
Delegates at the ECSA HC meeting called for integrated systems and a one-health approach, rather than a proliferation of new silo’ed vertical programmes and committees. Health for population groups like mothers and children or for settings like urban health should not be treated as another vertical programme, but addressed through making clear linkages with comprehensive health systems and ‘health-in-all-policies’. After a long period of investment in specific disease programmes, investments are now seen to be needed in the institutional arrangements, processes and information systems that support coordination, collaboration and integration of actions within health systems, with other sectors and within and across countries.
A focus on prevention demands action upstream, to map and identify risk and vulnerability and to control vectors and risk environments, both for infectious and non-infectious risks, including those related to chemicals, radiation and food safety. Integration calls for resources and strategies for prevention and response to epidemics and emerging challenges such as NCDs to be linked to broader measures applied to build robust, competent and comprehensive health systems that enroll and involve their communities. It calls for measures to reduce the costs of health technologies and treatment programmes, and to strengthen the independent country and regional regulatory agencies, databases and public health agencies needed to inform and support responses within and across countries.
This resonates with the WHO 2030 agenda calling for a One World One Health approach, that involves strengthening health systems for universal health coverage and inter-sectoral action for health. However two years from the declaration of the SDGs, it is surely time to focus attention on moving from pronouncements to what actions have been taken to implement the SDGs, particularly in terms of the public health issues that are a priority for the region. These are issues for whoever is elected as the new DG, whether from Africa or not. How far are the necessary actions being financed and delivered? What progress has been made in equitable development of and access to research and innovation? What progress is WHO making in reclaiming its leading role in health within the United Nations system, backed by the necessary increase in fixed contributions from countries to ensure its autonomy as global public health authority? What progress have countries made in improving progressive financing and reducing dependence on out of pocket funding? How far have all countries put in place the integrated, comprehensive primary health care oriented systems and public health leadership and capacities needed to meet these challenges and to progressively meet the right to health, leaving no-one behind?
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
1. Editorial
2. Equity in Health
The Global Tuberculosis Report provides a comprehensive and up-to-date assessment of the TB epidemic, and of progress in prevention, diagnosis and treatment of the disease at global, regional and country levels. This global TB report provides an assessment of the TB epidemic and progress in TB diagnosis, treatment and prevention reports, as well as an overview of TB-specific financing and research. It also discusses the broader agenda of universal health coverage, social protection and other SDGs that have an impact on health. Data were available for 202 countries and territories that account for over 99% of the world’s population and TB cases. Six countries accounted for 60% of the new cases: India, Indonesia, China, Nigeria, Pakistan and South Africa. Global progress is argued to depend on major advances in TB prevention and care in these countries. Worldwide, the rate of decline in TB incidence remained at only 1.5% from 2014 to 2015. This needs to accelerate to a 4–5% annual decline by 2020 to reach the first milestones of the End TB Strategy. TB treatment averted 49 million deaths globally between 2000 and 2015, but important diagnostic and treatment gaps persist. US$ 6.6 billion was available for TB care and prevention in low and middle-income countries in 2016, of which 84% was from domestic sources. Nonetheless, national TB programmes in low-income countries continue to rely on international funders for almost 90% of their financing. The report notes that investments in low and middle-income countries fall almost US$ 2 billion short of the US$ 8.3 billion needed in 2016. This annual gap will widen to US$ 6 billion in 2020 if current funding levels do not increase. Despite some progress in the pipeline for new diagnostics, drugs and regimens, and vaccines, TB research and development is also argued to remain severely underfunded.
This study in South Africa investigated the association between multi-morbidity and disability among older adults; and whether hypertension (both diagnosed and undiagnosed) mediates this relationship. The authors consider whether the impact of the multi-morbidity on disability varies by socio-demographic characteristics. Data were drawn from Wave 1 (2007-08) of the South African Study on Global Ageing and Adult Health. Disability was measured using the 12-item World Health Organisation Disability Assessment Schedule (WHODAS) 2.0. Nearly half of the respondents had a hypertensive blood pressure when measured during the interview, but had not been previously diagnosed. A further third self-reported they had been told by a health professional they had hypertension. The logistic regression showed in comparison to those with no chronic conditions, those with one or two or more had significantly higher odds of severe disability. Hypertension was insignificant and did not change the direction or size of the effect of the multi-morbidity measure substantially. The interactions between number of chronic conditions with wealth were significant. The diagnosis of multiple chronic conditions, can be used to identify those most at risk of severe disability and to prioritise limited resources for such individuals for preventative, rehabilitative and palliative care.
3. Values, Policies and Rights
This joint UNDP-UNRISD report reviews recent trends in six areas that are fundamentally important to achieving the 2030 Agenda. These six “mega-trends” relate to (i) poverty and inequalities, (ii) demography, (iii) environmental degradation and climate change, (iv) shocks and crises, (v) development cooperation and financing for development, and (vi) technological innovation. The report explores whether these trends are having positive or negative effects on development and discusses policy implications for the implementation of the 2030 Agenda. The report raises that some of the trends displayed currently are positive and supportive, including in the reduction of absolute poverty and technological innovation. Yet negative trends in several of the other target areas pose a significant risk to the realisation of the SDGs. They suggest that evidence-generating processes should be designed so as to take interactions between areas into account, whether that be through the use of interdisciplinary teams who can bring different insights to research, or through modelling and simulations of complex interactions. The potential for policy coherence manifests itself in two ways in the 2030 Agenda. First, there is a need to pursue progress across goals at the same time (e.g. employment guarantee programmes that focus on the provision of the safeguarding of environmental goods and services), while recognising and minimising the negative interactions. Second, there is the issue of coherence at different levels of decision-making and implementation, primarily local, national, regional and global—for example, whether local policies on education service provision are supported by fiscal policies at the national level, especially the decentralisation of tax policy. All of the issues discussed in the report are argued to point to the need for collective action so as to maximise the positive dynamics in these areas and minimise risk, and for processes that build trust and inclusiveness of participation.
The Africa Mining Vision (AMV) signed in 2009 by African Ministers responsible for mineral resources development throughout the continent, and its accompanying policy framework, Minerals and Africa’s Development, provide a comprehensive strategy for mineral and other natural resource extraction to be used in manufacturing within the continent, rather than exported from Africa for the industrial development of other continents. The authors note that while comprehensive and bold, it does not incorporate the effects of such a development strategy on African women, even though extraction primarily affects rural populations and particularly women. They note the mounting drought in the continent and other consequences of climate change attributing it in part to excessive, worldwide extraction and combustion of minerals and fossil fuels. Showcasing seven community based studies in sub-Saharan Africa, this paper aims to fill this gap. The authors argue from the evidence in the case studies that mineral and oil-based development undervalues community wealth, food production systems and female labour. They make two policy recommendations: Firstly in order to enable meaningful public participation in the policy framework and vision provided in the AMV they call on the African Union to make public the number of displacements estimated for the African continent over the next half-century. They estimate that as many as 90 million displaced across the continent. Secondly, they call on African states to carry out national studies of the socioeconomic, environmental and thus human impacts of existing and abandoned mineral and oil-based development projects post-independence period, with active participation of women’s organisations, mining affected communities, policy think tanks, and academics in the fields of social and human development.
The Extractive Industries Transparency Initiative (EITI) Standard is in its fifth version since the first principles were agreed in 2003. The principles on which the EITI is based state that the wealth from a country’s natural resources should benefit all its citizens and that this requires high standards of transparency and accountability. Revenue transparency remains a fundamental aspect of the EITI. The requirements follow the extractive value chain order and cover: first oversight by the multi-stakeholder group, then legal and institutional frameworks, exploration and production, revenue collection, revenue allocation, and finally social and economic spending and outcomes. It encourages countries to make use of existing reporting systems for EITI data collection and make the results transparent at source, with recommendations on the actions to take and the plans for taking them. It raises that the identity of the real owners – the ‘beneficial owners’ – of the companies that have obtained rights to extract oil, gas and minerals will have to be disclosed from 2020. It introduces a new validation system which aims to better recognise efforts to exceed the EITI requirements and sets out fairer consequences for countries that have not yet achieved compliance.
Under the Millennium Development Goals (MDGs), United Nations Member States reported progress on the targets toward their general citizenry. This focus repeatedly excluded marginalised ethnic and linguistic minorities, including people of refugee backgrounds and other vulnerable non-nationals that resided within a States' borders. The Sustainable Development Goals (SDGs) aim to be applied to all, nationals and non-nationals alike. Global migration and its diffuse impact has intensified due to escalating conflicts and the growing violence in many countries. This massive migration and the thousands of refugees crossing borders in search for safety led to the creation of two-tiered, ad hoc, refugee health care systems that have added to the sidelining of non-nationals in reporting frameworks. The authors have identified four ways to promote the protection of vulnerable non-nationals' health and well-being in States' application of the post-2015 SDG framework: In setting their own post-2015 indicators states should explicitly identify vulnerable migrants, refugees, displaced persons and other marginalised groups in the content of such indicators. The authors’ recommend that communities, civil society and health justice advocates vigorously engage in country's formulation of post-2015 indicators and that the inclusion of non-nationals be anchored in the international human right to health, which in turn requires appropriate financing allocations as well as robust monitoring and evaluation processes that can hold technocratic decision-makers accountable for progress.
4. Health equity in economic and trade policies
Studies were carried out in Krugersdorp, South Africa, to evaluate the ecological and human health risks associated with exposure to metals and metalloids in contaminated soils in mine tailings from gold mining. Human health risk was assessed using Hazard Quotient (HQ), Chronic Hazard Index (CHI) and carcinogenic risk levels, where values of HQ > 1, CHI > 1 and carcinogenic risk values > 1×10−4 represent elevated risks. Values for HQ indicated high exposure-related risk for arsenic, chromium, nickel, zinc and manganese. Children were more at risk from heavy metal and metalloid exposure than adults. Cancer-related risks associated with metal and metalloid exposure among children were also higher than in adults. The authors identify that there is significant potential ecological and human health risk associated with metal and metalloid exposure from contaminated soils around gold mine tailings dumps. They note that this could be a potential contributing factor to poor health of residents in informal settlements in the mining area, particularly for those whose immune systems are already compromised by HIV.
As the demand for mineral resources and fossil fuels continues to grow worldwide, the impact of mining will be an increasingly important concern. In Africa, local communities have been exposed to the detrimental effects of contamination arising from mining and its effects on public health, agriculture and the environment. The legacy of mining has left thousands of sites in Africa contaminated by mining and associated mine dumps such as tailings and slag material. The number of studies focused on the impacts of mining on the environment and human health in Africa have increased during the last decade. This paper reports on a project designed to correlate and integrate the results of multidisciplinary studies carried out in contaminated sites and areas using the best contemporary procedures for statistical analysis, management and compilation of the geochemical data; to strengthen the capacity of African institutions in environmental geochemistry, to raise public awareness of the impacts of mining on the environment and human health and to facilitate cooperation among geoscientists and medical scientists.
This paper aimed to investigate the relationship between mining and tuberculosis (TB) in sub-Saharan Africa. The authors used multivariate regression to estimate the contribution of mining activity to TB incidence, prevalence, and mortality, as well as rates of TB among people living with HIV, with control for economic, health system, and population confounders. Mining production was associated with higher population TB incidence rates, with an increase of mining production of 1 SD corresponding to about 33% higher TB incidence or 760 000 more incident cases, after adjustment for economic and population controls. Similar results were observed for TB prevalence and mortality, as well as with alternative measures of mining activity. Independent of HIV, there were significant associations between mining production and TB incidence in countries with high HIV prevalence and between log gold mining production and TB incidence in all studied countries. The authors conclude that mining is a significant determinant of countrywide variation in TB among sub-Saharan African nations. Comprehensive TB control strategies should explicitly address the role of mining activity and environments in the epidemic.
Samir Amin is one of Africa's foremost radical thinkers. In this interview organised by African Research and Cooperation for Endogenous Development Support, Amin reflects on a life spent at the cutting edge of radical theory and practice and African politics. Amin questions what social progressive change means today. He argues that there needs to be a strengthening of socialist consciousness - instead of ‘moving up’ within capitalism, people need to orientate in the opposite direction, and intensify the contradictions between an anti-capitalist alternative and what capitalism can offer. He argues against the concept of a single ‘revolution’, preferring instead to talk about advances and changes which create the possibility of later, further advances. He also rejects the view that it is possible to produce change without political and state power. Amin notes that all the peoples of Africa are today facing a big challenge. African societies are integrated in a form of globalisation that is damaging for the continent. He argues that Africans must 'delink’ from it and reject the logic of unilateral adjustment to the needs of further capitalist and imperialist expansion, starting at national level.
Internationally, the involvement of women working underground is a relatively new phenomenon. In South Africa, women were recently allowed to work in the underground mines. However, the challenges of women and men are different and their coping mechanisms are not the same. This research investigated how women cope under the occupational and labour culture, and health and physical demands inherent to this type of work. By means of the non-probability sampling method, ten (10) women were purposively selected and a qualitative collective case study design was used. The findings illustrate that women in the mining industry experience challenges with regard to labour, health, occupational challenges, work-life balance, sanitation facilities and sexual harassment. They were found to use different mechanisms to cope with the challenges they face on a daily basis. The authors call for the mining industry management to devise ways to meet the needs of women and offer support in response to their daily challenges.
5. Poverty and health
Close-to-client community-based approaches are argued by the authors to be a low-cost way of providing basic care and social support for elderly populations in such resource-constrained settings and that family caregivers play a crucial role in that regard. However, family caregiving duties are often unpaid and their care-related economic burden is often overlooked, despite this knowledge being important in designing or scaling up effective interventions. This study, therefore, estimated the economic burden of family caregiving for the elderly in southern Ghana. It used a retrospective cross-sectional cost-of-care design in 2015 among family caregivers for elderly registered for a support group in a peri-urban district in southern Ghana. A simple random sample of 98 respondents representative of the support group members completed an interviewer-administered questionnaire. Costs were assessed over a 1-month period. Direct costs of caregiving (including out-of-pocket costs incurred on health care) as well as productivity losses (i.e. indirect cost) to caregivers were analysed. The estimated average cost of caregiving per month was US$186.18, 66% of which was a direct cost. About 78% of the family caregivers in the study reported a high level of caregiving burden with females reporting a relatively higher level than males. Further, about 87% of the family caregivers reported a high level of financial stress as a result of caregiving for their elderly relative. The study shows that support/caregiving for elderly populations imposes economic burden on families, potentially influencing the economic position of families with attendant implications for equity and future family support for such vulnerable populations.
Informal settlement upgrading is widely recognised for enhancing shelter and promoting economic development, yet its potential to improve health equity is usually overlooked. Slum upgrading is the process of delivering place-based environmental and social improvements to the urban poor, including land tenure, housing, infrastructure, employment, health services and political and social inclusion. The processes and products of slum upgrading can address multiple environmental determinants of health. This paper reviewed urban slum upgrading evaluations from cities across Asia, Africa and Latin America and found that few captured the multiple health benefits of upgrading. With the Sustainable Development Goals focused on improving well-being for billions of city-dwellers, slum upgrading should be viewed as a key strategy to promote health, equitable development and reduce climate change vulnerabilities. The authors conclude with suggestions for how slum upgrading might more explicitly capture its health benefits, such as through the use of health impact assessment and adopting an urban health in all policies framework. Urban slum upgrading must be more explicitly designed, implemented and evaluated to capture its multiple global environmental health benefits.
6. Equitable health services
In this article, a photo story is used to describe some of WHO’s recommendations on how countries can improve quality of care in their health facilities and prevent maternal and newborn deaths, based on its standards for improving quality of maternal and newborn care in health facilities. The photo story shows that health facilities must have an appropriate physical environment and that communication with women and their families must be effective and respond to their needs. The story shows further that women and newborns who need referrals should obtain them without delay, no woman should be subjected to harmful practices during labour, childbirth and the early postnatal period, and that health facilities need well-trained and motivated staff consistently available to provide care. Lastly, the story presents images showing that every woman and newborn should have a complete, accurate, and standardised medical record.
Antimicrobial resistance is one of the most complex global health challenges today. Worsening antimicrobial resistance could have serious public health, economic and social implications around the world and could cause as much damage to the global economy as the 2008 financial crisis. Since May 2015, progress has also been made in the implementation of global commitments in this area. Over one hundred countries have completed, or are about to complete, their national multi-sectoral action plans. WHO has established a global antimicrobial resistance surveillance system to track which drug-resistant pathogens are posing the biggest challenge. Based on a review and analysis of national guidelines and prescribing practices for 20 common syndromes, WHO is revising the antibiotics included in the WHO model list of essential medicines. The organisation has also rolled out a global awareness-raising campaign targeting policy-makers, health and agriculture workers and communities. To scale up activities, the authors suggest that governments can build on existing regulatory frameworks, surveillance systems, laboratory and infection control infrastructure and human resources that are already in place to manage drug resistance in tuberculosis, HIV and malaria. Both at global and country level, much more still needs to be done. An ad hoc interagency coordination group is being established by the United Nations (UN) Secretary-General, in consultation with WHO, the Food and Agriculture Organisation of the UN and the World Organisation for Animal Health. WHO is preparing proposals for a global development and stewardship framework to support the development, control, distribution and appropriate use of new antimicrobial medicines, diagnostic tools, vaccines and other interventions. By May 2017, all countries should have their national action plans ready, as called for by World Health Assembly resolution 68.7. To see tangible progress, the authors argue that these global commitments must be translated into coherent regional and national action across the entire spectrum of diseases and pathogens.
Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. The authors performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care. The study found for women in rural Uganda with postpartum fever, a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. They recommend that increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities.
The scale-up of antiretroviral therapy (ART) for HIV-infected people in sub-Saharan Africa (SSA) over the past 15 years is one of the most remarkable achievements in public health. With approximately 12 million people on treatment in 2015, life expectancy on the subcontinent has vastly improved. Nevertheless, ART coverage in SSA is still suboptimal, HIV incidence remains high, and improved survival due to ART implies ever increasing numbers of people on treatment. Substantial additional resources are needed to further scale up ART, yet funding has recently levelled off, increasing the need to optimise the allocation of limited resources. This presents local policy makers with complex dilemmas. The authors argue that the current evidence base for prioritising ART scale-up strategies leads to recommendations that are theoretically optimal but practically infeasible to implement. They argue that cost-effectiveness analyses of scaling up ART in SSA take into account the local health system by integrating supply- and demand-side constraints in mathematical models and improving the dialogue between researchers and policy makers.
The District Health Barometer (DHB) 2015/16, in its 11th edition, seeks to highlight, health system performance, inequities in health outcomes, and health-resource allocation and delivery, and to track the efficiency of healthcare delivery processes across all provinces and districts in South Africa. It has become a planning and management resource for health service providers, managers, researchers and policy-makers. This DHB contains 44 indicators, with trend illustrations and health profiles across South Africa’s nine provinces and 52 health districts. It includes a chapter on the burden of disease, as well as seven additional indicators, including: inpatient under 5 years death rate, percentage of ideal clinics, percentage of assessed PHC facilities with patients who have access to a medical practitioner and the MDR-TB treatment success rate.
7. Human Resources
This is a time of unprecedented change in medical education globally. Medical schools, postgraduate bodies and other organisations are responding to rapid advances in medicine and changes in health care delivery. New education approaches are being adopted to exchange information. This enables the institutions to produce relevant health professionals. There are a number of innovations and models that are being explored to improve the learning of students studying medicine and public health. This Kenyan case study reports on how partnerships between the higher education institution and the community are working. It gives an account of the Moi University community programme that uses adaptive instruction for health trainees in the schools of medicine and public health. Adaptive instruction is a student centred approach where they are given real life cases to solve health problems theoretically as tutorial cases. This discussion, with the guidance of a tutor, promotes active learning. The model encourages active learner participation in the provision of health services. It introduces the students to a community health framework where they work in rural health facilities as part of their continuous assessment. It means that graduates entering the profession are able to apply and practise knowledge and skills beyond the theory learnt at the university. The students diagnose issues affecting the local community, develop a research proposal, work with district health management teams and implement activities. They conduct surveillance and monitor diseases and in the event of an epidemic, they are expected to respond effectively. They master the principles of how rural health facilities are run. The programme is divided into five phases: Introduction to the community, Community diagnosis, Writing a research proposal, Investigation executing the research plan, District health service attachment. The research projects designed and implemented in phase three and four have produced fascinating reports with research topics that address issues affecting the communities. It takes 20% to 30% of curriculum content and makes the graduand socially responsible and accountable team players in health care delivery. The authors hope that other tutors in Kenya, Eastern Africa and beyond the continent will benefit from this model. The experience provides tutorial guidance towards building a resilient and experienced crop of health professionals at par with global health training standards.
The South African Department of Health publishes annual guidelines identifying priority groups, including immunosuppressed individuals and healthcare workers (HCW), for influenza vaccination and treatment. How these guidelines have impacted HCW and their patients, particularly those infected with HIV, remains unknown. The authors aimed to describe the knowledge, attitudes and practices regarding influenza and the vaccine among South African HCW. Surveys were distributed by two local non-governmental organisations in public health clinics and hospitals in 21 districts/municipalities (5 of 9 provinces). There were 1164 respondents. One-third (34%) of HCW reported getting influenza vaccine and most (94%) recommended influenza vaccine to patients infected with HIV. The ability to get vaccine free of charge and having received influenza government training were significantly associated with self-reported vaccination in 2013/2014. Self-reported vaccination and availability of influenza vaccine during the healthcare visit were significantly associated with recommending influenza vaccine to patients infected with HIV/AIDS. Free and close access to influenza vaccine were associated with a higher likelihood of getting vaccinated. HCW who reported getting the influenza vaccine themselves, had vaccine to offer during the patient consult and were familiar with guidelines and training were more likely to recommend vaccine to HIV-infected patients.
8. Public-Private Mix
To attract greater levels of foreign direct investment into their gold mining sectors, the authors observe that many mineral-rich countries in sub-Saharan Africa have been willing to overlook serious instances of mining company non-compliance with environmental standards, and that these lapses in regulatory oversight and enforcement have led to high levels of pollution in many mining communities. This is argued to raise the risk of pollution-related sicknesses, such as skin infections, upper and lower respiratory disorders, and cardiovascular diseases, will necessitate increasingly high healthcare expenditures in affected communities. In this study, the authors propose and estimate a model that relates healthcare expenditure to the degree of residents’ exposure to mining pollution using data obtained on gold mining in Ghana. The empirical results confirm that, after controlling for factors such as current and long-term health status, increased mining pollution leads to higher healthcare expenditure.
9. Resource allocation and health financing
In many developing countries where the majority of the population works in the informal sector, there are critical debates over the best financing mechanisms to progress towards UHC. In Kenya, government health policy has prioritized a contributory financing strategy (social health insurance) as the main financing mechanism for UHC. However, there are currently no studies that have assessed the cost of either social health insurance (SHI) as the contributory approach or an alternative financing mechanism involving non-contributory (general tax funding) approaches to UHC in Kenya. This study critically assessed the financial requirements of both contributory and non-contributory mechanisms to financing UHC in Kenya in the context of large informal sector populations, to provide estimates of financial resource needs for UHC over a 17-year period (2013-2030). The 17-year period was necessary because the Government of Kenya aims to achieve UHC by 2030. The results show that SHI is financially sustainable (that is expenditure does not outstrip revenue) within the first five years of implementation, but it becomes less sustainable with time. Modelling for a non-contributory scenario, on the other hand, showed greater sustainability both in the short- and long-term. The financial resource requirements for universal access to health care through general government revenue are compared with a contributory health insurance scheme approach. Although both funding options would require considerable government subsidies, given the magnitude of the informal sector in Kenya and their limited financial capacity, a tax-funded system would be less costly and more sustainable in the long-term than an insurance scheme approach. However, more innovative financing for health care as well as giving the health sector higher priority in government expenditure will be required to make the non-contributory financing mechanism more sustainable.
Health systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. Expansion of health insurance is being promoted in the quest for sustainable healthcare financing for many of the health systems in the region. However, the broader policy implications of expanding health insurance coverage have not been fully investigated and contextualised to many African health systems. The authors interviewed 37 key informants drawn from public, private and civil society organisations involved in health service delivery in Botswana. They aimed to determine the potential health system impacts that would result from expanding the health insurance scheme covering public sector employees. Study participants were selected through purposeful sampling, stakeholder mapping, and snowballing. The authors thematically synthesised their views, focusing on the key health system areas of access to medicines, efficiency and cost-effectiveness, as intermediate milestones towards universal health coverage. Participants suggested that expansion of health insurance would be characterised by increased financial resources for health and catalyse an upsurge in utilisation of health services particularly among those with health insurance cover. As a result, the health system, particularly within the private sector, would be expected to see higher demand for medicines and other health technologies. However, majority of the respondents cautioned that, realising the full benefits of improved population health, equitable distribution and financial risk protection, would be wholly dependent on having sound policies, regulations and functional accountability systems in place. It was recommended that, health system stewards should embrace efficient and cost-effective delivery, in order to make progress towards universal health coverage. Despite the prospects of increasing financial resources available for health service delivery, expansion of health insurance is reported to come with many challenges. They argue that decision-makers keen to achieve universal health coverage, must view health financing reform through the holistic lens of the health system and its interactions with the population, in order to anticipate its potential benefits and risks. Failure to embrace this comprehensive approach, would potentially lead to counterproductive results.
10. Equity and HIV/AIDS
Southern and eastern Africa, with 6.2% of the world’s population, bear a disparate half of the world’s HIV infection burden and would benefit greatly from inexpensive innovations aimed at curtailing the epidemic. A recent modelling study showed that introducing a partially (30%) effective vaccine for HIV in resource-limited settings such as southern Africa would result in an estimated 67% reduction in HIV incidence compared to a non-vaccine scenario. As sub-Saharan Africa has the highest incidence of HIV infection in the world, that the introduction of a vaccine with only partial efficacy could have such a dramatic effect, despite the existing availability of comprehensive prevention methods, is argued by the authors to be strongly persuasive for the pursuit of a vaccine-based approach. Whilst there is great optimism that increasing access to antiretroviral treatment in the region will reduce infection incidence, there is also recognition that epidemic control will not be achieved without a substantial and sustained scale-up of additional primary prevention resources. There are challenges to HIV prevention in resource-limited settings that a vaccine alone is seen to be well positioned to meet. These include the rate of HIV infections and the scale and complexity of the HIV epidemic in the region, juxtaposed with ailing health systems ill equipped to respond effectively. Challenges with antiretroviral drug therapy adherence, poor linkage to care following diagnosis, multiple and diverse vulnerable populations who require population-specific services (such as women, adolescents, and men who have sex with men, stigma, and discrimination, as well as generally limited health care facilities and health personnel impair the region’s capacity to manage the scale of the epidemic. Even with the success of pre-exposure prophylaxis demonstration projects and the encouraging results emerging, the extent of protection relies on fidelity to adherence, continuous uninterrupted access, and sustainable resources for provision. It is well documented that in resource-restricted areas, where education levels and access to health care are low, reliance on behavioural and structural support is also an enormous challenge. A vaccine, even if partially effective, is argued by the authors to be a way of filling these prevention gaps in a cost-effective manner. Whilst countries in this region must find ways to access all the available opportunities that the modern HIV prevention toolkit has on offer, such a vaccine is seen to potentially change the prevention landscape.
HIV related stigma and discrimination is a known barrier for HIV prevention and care. The authors aimed to assess the relationship between socio-economic status (SES) and HIV related stigma in Zimbabwe, using data from a project that examined the impact of community-based voluntary counselling and testing intervention on HIV incidence and stigma. A total of 2522 eligible participants responded to a psychometric assessment tool, which assessed HIV related stigma and discrimination attitudes on 4 point Likert scale. The tool measured three components of HIV related stigma: shame, blame and social isolation, perceived discrimination, and equity. Participants’ ownership of basic assets was used to assess the socio-economic status. Shame, blame and social isolation component of HIV related stigma was found to be significantly associated with medium and low SES indicating more stigmatising attitudes by participants belonging to medium and low SES in comparison to high SES.
11. Governance and participation in health
With the renewed call for community participation in health interventions after the Alma Ata Declaration, interest has been raised in volunteer community health workers (CHWs) acting as representatives of local communities. This study interrogates the dynamic interface between local communities and the government in the selection of CHW volunteers in a rural community. Data were collected through participant observation of community events, 35 in-depth interviews, 20 focus groups and 15 informal conversations and review of documents about Luwero district. Ambiguous national guidelines and poor supervision of the selection process enabled the powerful community leaders to influence the selection of village health teams (VHTs). Intended to achieve community involvement, the selection process was found to produce a disconnect in the local community where many members saw the selected VHTs as having been ‘taken away’. The authors argue that community involvement in the selection of VHTs took a form that, instead of empowering the local community, reinforced the responsibility of those in power and thus maintained the asymmetrical status quo.
During a recent civil society consultative meeting held in Karamoja sub-region in North Eastern Uganda to discuss with locals the review of mining law and policy in Uganda, participants from the community made statements about mining operations in the region: One participant stated; “As we talk here trucks and trucks ferry marble and the people of Rupa swallow dust.” Another participant said; “ they come here and cordon off large pieces of land beyond what is allowed under their licenses and the locals have nowhere to graze their cattle. They forget we are a pastoralist community. No one asks us whether we want the mining in the first place. We just see companies show up in our midst.” Karamoja sub-region in Uganda is endowed with a number of minerals including gold, marble limestone, gemstones and silver among others, and plays host to roughly 20 companies involved in the mining sector at different stages. However, this report suggests that there is a disconnect between local communities and the mining companies. Community members said they had very limited information about the sector, and complained of lack of consultation, exploitation and human rights abuses by the mining companies. The authors argue that local communities and indigenous people have the right to be consulted about mining projects because they bear the brunt of the negative impacts of mining, and as prior, informed consent is now a well recognised international best practice. This should, they propose, be included in law. They point, for example, to the Tanzania Mining Act 2010 that ensures that no discussions of mining can be engaged in without the representation of civil society and local small scale miners. In Ghana, New Mont Gold Company has adopted the use of community agreements, while the World Bank has published a Source Book – Mining Community Development Agreements, 2012 on how to develop and implement such community agreements.
Effective district management, particularly leadership is considered to be crucial element of the district health system. Internationally, the debate around developing leadership competencies such as motivation or empowerment of staff, managing relationships, being solution driven as well as fostering teamwork are argued to be possible through formal and informal training. This paper reports findings on the significance of informal learning and its practical value in developing leadership competencies. A qualitative case study was conducted in one district in the Gauteng province, South Africa. Purposive and snowballing techniques yielded a sample of 18 participants, primarily based at a district level. Primary data collected through in-depth interviews and observations (participant and non-participant) were analysed using thematic analysis. Results indicate the sorts of complexities, particularly financial management challenges which staff face and draws attention to the use of two informal learning strategies—learning from others (how to communicate, delegate) and fostering team-based learning. Such strategies played a role in developing a cadre of leaders at a district level who displayed essential competencies such as motivating staff, and problem solving. It is crucial for health systems, especially those in financially constrained settings to find cost-effective ways to develop leadership competencies such as being solution driven or motivating and empowering staff. The authors note that the study illustrates that it is possible to develop such competencies through creating and nurturing a learning environment (on-the-job training) which could be incorporated into everyday practice.
In 2015 Good Governance Africa (GGA), in conjunction with specialist researchers MarkData, conducted a survey to test public attitudes towards key aspects of governance in South Africa. In 2016 GGA commissioned MarkData to conduct a Voter Sentiment Survey. Respondents were selected using a random multistage sampling process. The survey findings are to some extent in line with the 2011 South African Reconciliation Barometer. The survey showed that in cases relating to government performance, the widely held view was that all areas (administration, economic development and service delivery) required attention and improvement. Participants suggested that service delivery is the priority, followed by economic development and then administration. It was also found that more voters are deploying their vote strategically in relation to their perceptions of governance, despite feeling that they have little say in how they are governed. The authors argue that this reinforces the need for further research and for greater engagement with the voters on the ground, particularly in areas where poor local government performance has been detected.
12. Monitoring equity and research policy
Participatory action research seeks to understand and improve the world by changing it. At its heart is collective, self-reflective enquiry that researchers and participant’s undertake so they can understand and improve upon the practices in which they participate and the situation in which they find themselves. This article describes that ways PAR has been applied to a wide range of issues in public health, including in community asset mapping, participatory evaluation of public health programs, community monitoring of health service quality, research documenting and advocating to remove threats to health including poor water and sanitation and environmental pollution and participatory health policy research. A systematic review indicated most health service PAR has been conducted in low and middle income countries. In high income countries it is often used as a method to empower groups who are excluded and hold little power including Roma peoples in Europe and Indigenous peoples in Canada and Australia. PAR is often not reported in the academic literature despite its application in local projects. The most important aspect of PAR is that it relies on a cycle of reflection, planning, acting, further observing and reflection, then new plans and action. This reflexivity is central and is deeply relational in that the researchers and the other actors (community members or service or policy players) are engaging together in these processes. The author observes that PAR holds great, and as yet largely unrealised promise, to create greater mobilisation and community interest and action on health inequities and action on the social determinants of health.
In February 2016, the World Health Organisation (WHO) declared the Zika virus-related cluster of microcephaly cases and other neurological disorders reported in Brazil, a Public Health Emergency of International Concern (PHEIC). Following the declaration, over 30 global health bodies issued a joint statement committing to data sharing to ensure that the global response to the Zika virus and future emergencies, could be informed by the best and most current evidence. The statement represented a concerted effort by those involved to address past failures of timely access to relevant data. It also highlighted the lack of a clear path to implementation for data sharing during public health emergencies. In March 2016, the Global Research Collaboration for Infectious Disease Preparedness established a data-sharing working group which has been working in coalition with other stakeholders including WHO, scientists, nongovernmental organisations, journals and other agencies. This group is working to identify barriers to data sharing in public health emergencies that should be addressed to better prepare for any future epidemic. The experiences from the 2013–2016 Ebola virus disease outbreak and the 2015 Zika virus outbreak demonstrated the importance of research in public health emergencies and the difficulties associated with sharing research findings rapidly and outside of conventional scientific publications. The WHO consensus and policy statements called for a paradigm shift in information sharing in public health emergencies and described the particularities to consider in dealing with different data types. Despite these efforts, rapid data sharing during public health emergencies remains challenging for various reasons. First, there are limited incentives for researchers and other people responding to the emergency to share data. Second, there is a lack of appropriate infrastructure for data sharing such as repositories and information technology platforms. Such rapid data sharing requires a clear governance structure that ensures a balance between privacy and access, as well as adheres to national and international ethical and legal requirements. The GloPID-R working group has developed, and requests comment on, a set of principles to underpin future implementation of timely data sharing. These new principles draw on others, such as the FAIR Guiding Principles for scientific data management and stewardship, and are intended to provide an initial framework for discussion. The collective work is intended to support WHO’s Research and Development Blueprint and include other stakeholders, such as the Global Outbreak Alert and Response Network and the Coalition for Epidemic Preparedness. Effective data sharing requires flexibility by all stakeholders to adapt to unforeseen events and challenges. A data-sharing system needs to allow collaboration between stakeholders in the absence of pre-existing relationships and all collaborators need to adhere to fundamental ethical principles of data use. Above all, it must ensure that people in all affected countries benefit from timely access to evidence-based interventions in emergencies.
13. Useful Resources
The first e-learning course on health financing policy for universal health coverage has now been launched. This e-learning course comprises six modules which cover the core functions of health financial policy as conceptualised by WHO. Each module is divided into a number of sub-topics. This is a foundational course which targets participants of various levels of experience and expertise. The course is designed to be used in a variety of ways: as preparation for those who will attend a WHO face-to-face course, for those who are for various reasons unable to attend a face-to-face course, and for those who have already attended courses and wish to refresh their knowledge. Individual modules can also be used as part of a programme of blended capacity building. The course will work on a range of devices, operation systems and browsers. The introductory module covers the goals of UHC and health financing. Module 2 addresses revenue raising and module 3 discusses the desirable characteristics of pooling revenues. Module 4 addresses the purchasing of health services and module 5 discusses benefit package design including coverage choices and how to promote UHC through benefit package choices.
This year's Stop TB Partnership campaign runs under the tagline "Unite to End TB!". This campaign draws on the goals set out in the Global Plan to End TB, the roadmap to accelerating impact on the TB epidemic and reaching the targets of the WHO End TB Strategy. To amplify the message the Stop TB Partnership has developed a set of campaign materials, which are free to use. The campaign materials include a ‘Call to Action’ logo, a ‘World TB Day’ logo, social media tiles and e-cards, posters, t-shirts and pin templates and identity guidelines for communities.
14. Jobs and Announcements
Stellenbosch University and the Human Sciences Research Council will jointly host the 13th AIDSImpact Conference at the Century City Conference Centre, Cape Town South Africa. Each AIDSImpact meeting attracts delegates new to the field as well as a core group of loyal psychosocial and behavioral researchers, prevention workers, community members and policy makers from universities and institutes across all five continents who use the biannual meeting to present their studies, interventions and prevention schemes. AIDSImpact has evolved as one of the leading platforms for understanding, updating and debating the behavioral, psychosocial and community facets of HIV in light of changing social conditions and medical advances. A review of past AIDSImpact scientific programs reveals the evolution of the psychosocial and behavioral response to the HIV epidemic over the past 25 years. The 2017 Cape Town conference will promote pioneering work on understanding the dynamics of a changing epidemic. A key focus will be consideration of new choices for HIV - for prevention, treatment, care and strategic planning.
This is an opportunity for activists and scholars to contribute to a series of three linked workshops in Africa. Each two-day meeting will debate current challenges and prospects for Left analysis and action. The organisers are seeking both key speakers and offers of papers, with a plan to publish a selection in the Review of African Political Economy. The workshops are scheduled in November 2017 in Accra, Ghana; April 2018 in Dar es Salaam, Tanzania; June 2018 in Johannesburg, South Africa; September 2018 at the African Studies Association in the UK. These workshops will link analysis and activism in contemporary Africa from the perspective of radical political economy, and will be organised around three linked themes: Africa in a ‘post-crisis’ world, economic strategy, industrialisation and the agrarian question and resistance and social movements in Africa.
IPRI-Africa has announced partial scholarship opportunities for three upcoming courses: 1. "Negotiations, Drafting and Management of Contracts"- July 10-14, 2017; 2. “Intellectual Property Law and Practice in the World Today" - Aug 1-5, 2017; and 3. "Mediation, Arbitration and ADRs" - Aug 7-11, 2017. The courses are being held in Kampala, Uganda and cover up to half of the full $1200 tuition fees including lunch, tea, refreshments, receptions, IPRI-Africa certification, course materials (soft and hard copy), and links to legal updates. It does not include airfare or accommodation.
The Shuttleworth Foundation offers fellowships to individuals to implement their innovative idea for social change. They are most interested in exceptional ideas at the intersection between technology, knowledge and learning, with openness being the key requirement. Applications are invited from people from all over the world regardless of gender, age, nationality or experiences. The Foundation invite individuals with a fresh approach to solving a social challenge, using openness, to apply.
IXminusY supports social movements, action groups and change makers who are fighting for a fair, democratic, sustainable and tolerant world. Projects that are supported by XminusY can take place on a broad variety of topics. But more important than the topic, is that the people involved take action themselves to change their own society. An application needs to have background information, concrete data, your planned activities and a detailed budget up to 3,000 euros. XminY doesn't support conferences, seminars, debates or other meetings unless they clearly aim to prepare for actions. In Africa, XminY only supports groups that can supply at least two references from other organisations or individuals.
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