The World Health Organisation has its first ever director-general from Africa, after the election of Dr Tedros Adhanom Ghebreyesus, the former Ethiopian health minister, who will begin his term in July 2017. In a speech to the World Health Assembly Dr Tedros Adhanom talked about growing up in Ethiopia, saying he comes from a background of “knowing survival cannot be taken for granted, and refusing to accept that people should die because they are poor.” He spoke about the need for universal access to health care, a better response to health emergencies and the need to tackle gender-based violence, as well as threats to global health like climate change. He wrote in his application "“I envision a world where everyone can lead healthy and productive lives, regardless of who they are or where they live.” We look forward to contributing to what this implies for health equity, globally and in our region.
1. Editorial
In front of us in one of our rural districts is a road accident with injured passengers including children. They are distressed - the local public hospital has no ambulance and they are trying to find enough money to assure the private ambulance service that they will be able to pay the fee before they will send the ambulance. The fee is more than they can afford, but if they don’t find someone to pay and get people to care quickly the injured people could have complications or suffer avoidable deaths.
This is not the only problem people who have emergencies face. Ambulances can take long to respond. Many ambulances too do not have basic equipment or adequately trained staff to take care of patients during transit, also complicating their recovery or risking fatalities in transit. Emergency departments are under resourced, without adequate equipment and staff to cope with the critically ill patients coming to them, including patients who have delayed seeking care until they have an acute emergency. In some countries in our region, a critical shortage of doctors and other skilled health workers has affected the quality of the response to emergencies. Yet in others, like South Africa and Uganda, ambulances are better equipped and staffed, and people arriving at emergency facilities find doctors and nurses on stand-by and ready to receive patients and give them prompt care.
This situation is compounded by conditions that increase the risk of traumatic injury. For example, the state of our roads in Zimbabwe’s road network raises concern, especially when they are further damaged by heavy rains and other climate disasters. Poor roads not only raise the risk of accidents, but also mean that ambulances cannot easily access patients in need. During the rainy season, rural roads become even more impassable, making access for emergency services even more difficult. While communities assist with emergencies where they can, local transport operators sometimes take advantage of poor conditions to overcharge desperate patients in need of acute care, including pregnant women, carers of sick children and elderly people. In the absence of adequate investment in roads and services, poor people pay the price. Allocating funds to improve road systems will prevent accidents and also make it easier for ambulances to reach emergencies. Yet in 2017, of the US$15 million that the Harare City Council said it needed to improve the road network in Harare alone, it received only US1.2m from the Zimbabwe National Road Administration (Zinara).
The situation may be even worse when air rescue emergency services are needed, as a key component of an effective emergency care system. Yet air rescue emergency services are an even more scarce healthcare resource, and as in Zimbabwe, the only public service for this may be the Air Force. There are private services for those able to afford the costs of private insurance or providers, but these are unaffordable for the majority, and thus only used by a minority of people.
In the common discussions on universal health coverage and emergency responses, it is important that we at minimum ensure availability, accessibility and affordability of effective and good quality emergency medical services for everyone in the public. Good quality emergency medical services provide an immediate response to a variety of illnesses and injuries and the treatment and transportation of people in health situations that may be life threatening. They should provide universal quality care to all those who need it at the time they need it to save their lives, prevent suffering or disability. Although the current situation varies from country to country in the region, for many this is not yet delivered.
The situation contradicts the fact that in Zimbabwe, as for seven other countries of the region, according to EQUINET policy brief 27, the constitution guarantees citizens the right to health care, including emergency medical services. Section 76 (3) of Zimbabwe’s Constitution states this as, “No person may be refused emergency medical treatment in any health care institution.” Of course no service would refuse care, but a situation of inadequate investment in affordable, accessible and good quality emergency services, including ambulances can be understood to be a form of denial, or refusal. The Zimbabwe Constitution makes this clear in stating that the state must take reasonable legislative and other measures, within the limits of the resources available to it, to achieve the progressive realization of this right. Whilst public emergency services offered by state-owned health institutions, the air force, the police and fire brigade are weak and poorly resourced, people’s rights are violated and they are exposed to high payments for private services, or worse still disability or death.
It is evident that this is a core duty of the state and must be adequately funded. When public emergency care services are not adequately funded, staffed or provided, it leads to a growth of commercial and privatized services. While this is a private sector response to demand, and can help to minimize morbidity and mortality if of good quality and properly regulated and monitored, it is not appropriate to rely on the private sector for this service, and leads to inequities in access to care. The driving force of private provision is maximizing profits and not the needs of the most disadvantaged members of society. A trend towards privatization of emergency medical services thus has highest burdens for the poorest, adding to the stresses in often tough economic environments of accessing services and meeting medical bills. A 2016 study by the Zimbabwe Coalition on Debt and Development on a public-private partnership in one major central hospital in Zimbabwe found that residents faced challenges in realizing their right to health care, due to the high cost of services, unfair treatment of those who cannot pay, ‘…deepening inequality between the haves and have-nots’ and report of corruption in the demand by staff for differing levels of cash payments. They attributed this violation of rights to health care to the ‘private vendor profit motive’ and diminished public control.
Beyond improving public funding of emergency care services, we can also take advantage of technology advances. For example, health facilities have used mobile phones to alert ambulance services and to support those attending to patients whilst waiting for an ambulance or medical personnel, improving the possibility of improved outcomes for patients. A ‘Dial-a-Doc’ initiative by one mobile operator in Zimbabwe works with enlisted services of medical practitioners at a call center to respond to phone-in requests for information and help from the public. A similar service is available in South Africa, Zambia and Malawi.
At the same time, we cannot keep relying on the health services to manage growing risks in the environments we live and work in. Death and disability from traumatic injuries from road traffic accidents on poor roads, from climate disasters and other accidents, and acute health crises in pregnancy, for children and others, and due to unsafe working conditions are largely preventable and should not be filling our health services. We need to have a commitment from all sectors that play a role to identify and reduce their role in traumatic injury and illness.
As economies improve they should show marked reductions in such trauma, but even under challenging economic conditions, adequate, affordable and accessible public emergency care services must be secured.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
2. Latest Equinet Updates
This 2017 session within the Regional ECSA HC Best Practices Forum was convened by ECSA HC and EQUINET in line with HMC Resolution – ECSAHMC50/R2 and with proposals from the 2016 Regional meeting on GHD. The objectives of the meeting were to a. To share information on progress in the ECSA HC GHD programme and issues for policy dialogue and follow up work b. To present and discuss evidence supporting and proposals for harmonised regional standards on health in the extractive sector c. To review and discuss positions on selected agenda items in the 2017 World Health Assembly (WHA) agenda The meeting recommendations were further summarised and reviewed in the Best Practices Forum and then in the Directors Joint Consultative conference, where the outcome of what was formally recommended is separately reported by ECSA HC. Delegates were provided with specific background materials through distributed publications. The report is organised by theme, with the presentation and group discussions on each area shown together.
In a regional EQUINET programme led by Community Working Group on Health (CWGH) on health centre committees as a vehicle for social participation in health system in east and southern Africa, Lusaka DHO is building capacities and learning for the district and the wider country programme on policy and legal guidelines to support the effective interaction of communities in health centre committees (HCCs) that can be shared regionally. A workshop was held on 7th January 2016 in Lusaka to support and inform the objectives for the Zambia work, viz: 1.To compile and exchange information on the current laws and legal guidelines on the role and functioning of HCCs. 2.To develop through regional dialogue a model HCC guideline to be tabled and reviewed regionally. 3.To analyse and document how current laws compare to this guideline. 4.To advocate for strengthening of law and guidelines in regional and national policy forum.
3. Equity in Health
Indigenous people remain on the margins of society in high, middle and low-income countries, and bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators. The social determinants of health framework has enriched the understanding of the complex conditions that give rise to inequalities in indigenous health, including the structural and socio-political factors, and the intersecting conditions of poverty, social and political exclusion, discrimination and land loss that shape indigenous people’s health. The authors report in this paper the conditions of marginalisation that impact indigenous health from their work in Guatemala and argue for a citizen-led initiative for state accountability for the right to health in rural indigenous municipalities. The authors argue that the challenge of engaging with the conditions underlying inequalities and promoting transformational change means that equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilising networks of collective action.
Africa faces many health challenges despite sustained growth and development over the past decade. Contributory factors are the lack of financial resources, an inadequate health professional workforce, a high burden of communicable diseases and an increasing burden of non-communicable diseases. Rheumatology services are limited or non-existent in many parts of sub-Saharan Africa. Over the past decade, partnerships with international academic institutions have resulted in some progress in the training of rheumatologists and health professionals and development of rheumatology services in countries such as Kenya, Nigeria, and Zambia. Basic diagnostic tests, biological agents and arthroplasty are either unavailable or not affordable by the majority of the population. Urbanisation has resulted in a change in the epidemiology of rheumatic diseases with an increase in the prevalence of gout, rheumatoid arthritis, systemic lupus erythematosus, and scleroderma over the past four decades. Future growth of rheumatology services will depend on identifying committed individuals in underserved countries for training and supporting them to educate medical students, physicians, and health professionals in their home countries. The author raises that there is a need to develop models of care using all categories of health workers and identify prevention strategies and cost-effective management programs for low resource settings. Africa affords an opportunity for collaborative research, including genetic and epigenetic studies, to improve regional understanding of many of the rheumatic diseases.
4. Values, Policies and Rights
This presentation of the ECSA strategic plan provides a situation analysis of the trends in health affecting the region, and health services trends, including a continued inadequacy of human resources for health and high level of out-of-pocket expenditure on health, above 30% of total health expenditure in most countries in the region. The strategic plan seeks to contribute to the health status in the ECSA region by providing leadership towards attainment of the Sustainable Development Goals (SDGs). The plan covers six strategic areas. It includes measures to support and promote efforts to build human resources for health and human capacity development; to strengthen health systems towards Universal Health Coverage and to assist countries to develop capacity to implement reproductive and maternal and child health strategies. It seeks to reduce communicable and non-communicable diseases, chronic conditions, injuries and all forms of malnutrition, and to promote the generation, management and utilisation of knowledge to inform decision making and programming in health. A final objective for the ECSA health community in the plan is to set a regional health policy agenda and foster strategic partnerships and collaboration towards achieving of international commitments, including of the SDGs. Several enabling factors are identified, including continued support from the member states as shown through ownership of ECSA resolutions and activities and the remittance of subscriptions; and a diversified funding base through securing new funders and income generation activities such as training.
This research assessed the extent to which the occupational safety and health act in Kenya safeguards the safety and health of workers in its coal mines. From a comparison with law in other countries, the author identifies gaps and recommends that Kenya should enact more comprehensive clauses for occupational safety and health of coal mine workers, should revise the compensation amounts provided for by the Work Injury Benefits Act; set guidelines and directions encompassing duties of employers and employees in mining and provide for medical services in coal mines.
At an official side event of the 34th Session of the Human Rights Council, panelists discussed how people’s sexual and reproductive health rights (SRHRs) around the world could be better protected and promoted. This report presents perspectives raised on challenges and good practices in ensuring full access to SRHRs, environmental dimensions of family planning, the linkages between a human rights-based social protection framework and access to these rights, and current global trends, and what these mean for implementation of the SDGs and their achievement by 2030. Men, women and gender non-conforming persons are all entitled to SRHRs and require these services. And while everyone is affected by limited access to these rights, individuals from already marginalized groups such as children and adolescents, lesbian, gay and trans persons, men who have sex with men, sex workers, drug users, indigenous peoples, and people living in poverty were reported to be the most affected, sometimes fatally.
5. Health equity in economic and trade policies
This study describes the status of occupational health and safety in Tanzania and the challenges in provision of occupational health services in an expanding economy, with growth being driven by communications, transport, finance services, construction, mining, agriculture, and manufacturing. The workers exposed to hazards from these activities are found suffer from illness and injuries, but to not access adequate occupational health services, with services limited to a few enterprises that can afford it. Existing laws and regulations are reported by the authors to not cover the entire population and implementation to be weak. The authors argue for an occupational health and safety services strategy, backed by legal review, training and the necessary skills, financial and technological resources to cover the whole working population, to match the growing economy.
Malawi is the world’s largest producer of burley tobacco and its population is affected by the negative consequences of both tobacco consumption and production. In producer countries, tobacco control involves control of the whole tobacco supply chain, rather than only control of consumption. The authors reviewed the impact of tobacco cultivation in Malawi to illustrate through this example the economic, environmental, health and social issues faced by low- and middle-income countries that still produce significant tobacco crops. The authors placed these issues in the context of the sustainable development goals (SDGs), particularly goal 3a, which calls on all governments to strengthen the implementation of the World Health Organisation Framework Convention on Tobacco Control. Other goals address the negative effects that tobacco cultivation has on development. The authors suggest that without external assistance, Malawi has relatively limited capacity to develop alternatives to tobacco production that are economically viable, but could benefit greatly from becoming a party to the FCTC to receive assistance through the incorporation of the FCTC into the SDGs.
6. Poverty and health
South Africa has piloted a new program, 'Safe and Sound' to reduce the common risk of violence against pregnant women in South Africa. Most women were found to not speak about the violence they endure. In addition to rape and sexual violence, coercive or controlling behaviour, such as a man refusing to use a condom or restricting other forms of birth control, is argued to increase the risk of contracting HIV. Women who are HIV-positive and experience intimate partner violence are reported by the author to be half as likely to take their HIV medications as women in nonviolent relationships, leaving them in much poorer health. The author urges that countries adopt programs like Safe and Sound because violence against women, including HIV positive women, can lead to a deterioration in their mental health, with some women stopping their medication and developing suicidal tendencies.
7. Equitable health services
As the sustainable development goals (SDGs) require country-level tracking of indicators related to contraception, including met need, a key question is “What can be done to support adolescents to prevent unintended pregnancy? To answer this question, the authors developed country-specific fact sheets describing adolescent contraceptive use and non-use in 58 low- and middle-income countries spanning all six World Health Organisation Regions. The authors report the top three reasons adolescent girls give for why they are not currently using contraception, even though they do not want to become pregnant in the next two years. The data are based on responses from 15–19 year old adolescent girls, and are presented separately for those unmarried and sexually active and those in a union. Reasons for non-use vary considerably but among the most common reported are, being “not married” and infrequent sexual relations for unmarried, sexually active adolescents. In contrast, currently breastfeeding or postpartum abstinence are among the most common reasons for non-use reported by adolescents in a union. Fear of side-effects or health concerns was commonly reported by both groups of adolescent girls.The authors report on the two most common sources from which adolescents who are currently using a modern method most recently obtained that contraceptive method. The sources are driven by the types of contraceptive methods available, as well as those that are easy for adolescents to access. In some settings most sources are in the formal sector, including government facilities, private facilities and pharmacies. In other settings most adolescents obtain contraceptive commodities in the informal sector, such as shops, kiosks or roadside stands, or from friends. The data from the fact sheets indicate where best to target investments to improve access to – and quality of – contraceptive services for adolescents. The data provided in these fact sheets are disaggregated by age and marital status to address the calls for ensuring that no one is left behind. These data can help policy-makers and programme planners reduce inequities in service provision and access, and to make evidence-based decisions about how to better address adolescents’ contraceptive needs.
This paper explores telemonitoring/mhealth approaches as a promising real time and contextual strategy in HIV and TB interventions access and uptake, retention, adherence and coverage impact in endemic and prone-epidemic prevention and control in sub-Sahara Africa. A scoping review was applied to identify relevant articles on the theme. The authors found tele monitoring/mhealth approach as a more efficient and sustained proxy in HIV and TB risk reduction strategies for early diagnosis and prompt quality clinical outcomes. It was found to significantly contribute to decreasing health systems/patients cost, long waiting time in clinics, hospital visits, travels and time off/on from work. Improved integrated HIV and TB telemonitoring systems sustainability are thus argued to hold promise in health systems strengthening, including patient-centred early diagnosis and care delivery systems, uptake and retention to medications/services and improving patients’ survival and quality of life. Tele monitoring/mhealth (electronic phone text/video/materials messaging) acceptability, access and uptake are reported to be crucial in monitoring and improving uptake, retention, adherence and coverage in both local and national integrated HIV and TB programs and interventions. Telemonitoring is also argued to be crucial in patient-providers-health professional partnership, real-time quality care and service delivery, antiretroviral and anti-tuberculous drugs improvement, susceptibility monitoring and prescription choice, reinforcing cost effective HIV and TB integrated therapy model and survival rate.
Fever in malaria endemic areas, has been shown to strongly predict malaria infection and is a key symptom influencing malaria treatment. WHO recommended confirmation testing for Plasmodium spp. before initiation of antimalarials due to increased evidence of the decrease of morbidity and mortality from malaria, decreased malaria associated fever, and increased evidence of high prevalence of non-malaria fever. To immediately diagnose and promptly offer appropriate management, caretakers of children with fever should seek care where these services can be offered; in health facilities. This study was conducted to describe healthcare seeking behaviours among caretakers of febrile under five years, in Tanzania, and to determine children’s, household and community-level factors associated with parents’ healthcare seeking behaviour in health facilities. Of the 8573 children under the age of five years surveyed, 19.5% had a history of fever two weeks preceding the survey. Of these, 56.8% sought appropriate healthcare. Febrile children aged less than a year have 2.7 times higher odds of being taken to the health facilities compared to children with two or more years of age. Febrile children from households headed by female caretakers have almost three times higher odds of being taken to the health facilities compared to households headed by men. Febrile children with caretakers exposed to mass media (radio, television and newspaper) have more than two times higher odds of being taken to health facilities compared to those not exposed to mass media. Febrile children from regions with malaria prevalence above national level have 41% less odds of being taken to health facilities compared to those febrile children coming from areas with malaria prevalence below the national level. Furthermore, febrile children coming from areas with higher community education levels have 57% higher odds of being taken to health facilities compared to their counterparts coming from areas with low levels of community education. To effectively and appropriately manage and control febrile illnesses, the authors propose that the low proportion of febrile children taken to health facilities by their caretakers should be addressed through frequent advocacy of the importance of appropriate healthcare seeking behaviour, using mass media particularly in areas with high malaria prevalence. They recommend that a multifaceted approach be used in malaria control and eradication as multiple factors are associated with appropriate healthcare seeking behaviour.
Millie Balamu goes from door to door providing life-saving health care for about 200 households in the Wakiso district of Uganda. Villagers call her masawu (“doctor” in the local Luganda language), but she is a community health worker. She has tests and drugs with her to diagnose and treat malaria, diarrhoea and pneumonia and uses her mobile phone to diagnose these diseases and register pregnant women for follow up. This paper reports on the Social Innovation in Health Initiative. The concept of social innovation is taken from economics and business studies and refers to efforts to mobilise and incentivise communities. In health, social innovation may refer to low-fee private delivery of health care, using mobile phone applications – such as the one Balamu uses to diagnose common childhood diseases – and other novel ways to make health-care delivery more accessible and affordable in low-income communities. According to a working paper presenting the results of a randomised controlled trial in Uganda of more than 8000 households, published in 2016 the social innovation project helped to reduce child mortality across those households by 27% between 2011 and 2013.
8. Human Resources
In 2010, South Africa’s National Department of Health launched a national primary health care initiative to strengthen health promotion, disease prevention, and early disease detection. The strategy, called Re-engineering Primary Health Care, aims to provide a preventive and health-promoting community-based Primary Health Care model. A key component is the use of community-based outreach teams staffed by generalist community health workers. The authors conducted focus group discussions and surveys on the knowledge and attitudes of 91 Community Health Care Workers working on community-based teams in Eastern Cape Province. The community health workers who were studied enjoyed their work and found it meaningful, as they saw themselves as agents of change. They also perceived weaknesses in the implementation of outreach team oversight, and desired field-based training and more supervision in the community. The authors propose providing community health workers with basic resources like equipment, supplies and transport to improve their acceptability and credibility to the communities they serve.
In low- and middle-income countries, scaling essential health interventions to achieve health development targets is constrained by the lack of skilled health professionals to deliver services. The authors take a labour market approach to project the future health workforce demand using an economic model based on projected economic growth, demographics, and health coverage, and using health workforce data (1990–2013) for 165 countries from the WHO Global Health Observatory. The demand projections are compared with the projected growth in health worker supply and the health worker “needs” as estimated by WHO to achieve essential health coverage. The model predicts that, by 2030, global demand for health workers will rise to 80 million workers, double the current (2013) stock of health workers, while the supply of health workers is expected to reach 65 million over the same period, resulting in a worldwide net shortage of 15 million health workers. Growth in the demand for health workers will be highest among upper middle-income countries, driven by economic and population growth and ageing. This results in the largest predicted shortages which may fuel global competition for skilled health workers. Middle-income countries will face workforce shortages because their demand will exceed supply. By contrast, low-income countries will face low growth in both demand and supply, which are estimated to be far below what will be needed to achieve adequate coverage of essential health services. In many low-income countries, demand may stay below projected supply, leading to the paradoxical phenomenon of unemployed (“surplus”) health workers in those countries facing acute “needs-based” shortages. Opportunities exist to bend the trajectory of the number and types of health workers that are available to meet public health goals and the growing demand for health workers.
The shortage of formal health workers has led to the utilisation of Community-Based Health Volunteers to provide health care services to people especially in rural and neglected communities. This study explored factors affecting retention and sustainability of community-based health volunteers’ activities in a rural setting in Northern Ghana, through a qualitative study with thirty-two in-depth interviews with health volunteers and health workers overseeing their activities. Study participants reported that the desire to help community members, prestige and recognition as doctors in the community were key motivations for the health volunteers. Lack of incentives and logistical supplies such as raincoats, torch lights, wellington boots and transportation in the form of bicycles to facilitate the movement of health volunteers affected their work and discouraged them. Most of the dropout volunteers said lack of support and respect from community members made them to stop working as health volunteers. They recommended that community support, incentives and logistical supplies such as raincoats, torch light, wellington boots and bicycles can help retain community-based health volunteers and also sustain their activities at community level.
9. Public-Private Mix
A mobile app in Senegal helps families save money and reduce waste through a "virtual pharmacy" where users can exchange leftover medication for new prescriptions. JokkoSante is scaling up after a two-year pilot phase in one Senegalese town. It aims to reach 300,000 families in the West African nation by the end of the year. The app allows users to trade in unused, packaged medicine for points which can go toward the purchase of new medicine when they need it. All of the exchanges are done at health centres or pharmacies by licensed professionals. Users can send points to family members and friends, and donors can buy points for people in need. The project has been driven by telecoms companies. It reaches a certain demographic, such as women in their thirties, and if a matching user doesn't have enough points to pay for a prescription she will receive a text saying which company donated to complete her purchase.
An open letter was submitted by the authors on behalf of 61 signatories for the election of the new WHO Director General (DG) to take into account how the new leadership will ensure appropriate interactions with alcohol, food, pharmaceutical, and medical technology industries. In May 2016, WHA adopted the Framework of Engagement with Non-State Actors (FENSA), a policy due to be fully operational by May, 2018. While FENSA envisages that WHO will “exercise particular caution…when engaging with private sector entities …whose policies or activities are negatively affecting human health..”, the rhetoric and direction of WHO's reform process as well as WHO's chronic funding challenges are argued to have left the signatories concerned rather than reassured. They fear that instead of protecting WHO's mandate, FENSA risks relegating WHO to a limited role, unable to stand up for human rights and democratic decision making. The signatories draw attention to the conflict of interest statement signed by more than 175 NGOs and networks representing more than 2000 groups and first launched at the UN High-Level Meeting on Non-communicable Diseases in 2011: “The policy development stage should be free from industry involvement to ensure a ‘health in all policies’ approach, which is not compromised by the obvious conflicts of interests associated with food, alcohol, beverage and other industries, that are primarily answerable to shareholders.” They indicate that alcohol, food, pharmaceutical, and medical technology industries should comply with policies developed by WHO and its Member States, and that their role is not in public health policy formulation, risk assessments, risk management, or priority setting, nor in determining normative quality standards and legally binding regulations to protect and promote public health. These processes, it is argued, must be undertaken in an environment free of commercial influence. The signatories believe that only a WHO that protects its independence and integrity of decision making will have the ability to fulfil its constitutional mandate.
Zimbabwe's health sector has been under-funded for some time causing public health service providers, including Chitungwiza Central Hospital (CCH), to operate below capacity despite the increasing patient demand. CCH entered into a Public Private Partnership (PPP) agreement, now a Joint Venture Partnership, to upgrade quality and availability of health services. However, in this report the authors argue that the intended benefits of the PPP are not being realised because the poor people face increasing fee barriers due to the demand for upfront payment. A survey in 2016 included key informant interviews, client interviews and focus group discussions. It found that the majority of respondents have below poverty monthly household incomes. Most users did not understand the PPP model, and indicated that the hospital did not consult residents on the adoption of the PPP model. Two thirds of respondents felt that services were better before the adoption of the PPP model. Poorer respondents mainly raised the fact that they could not afford services after the PPP due to fee charges, while those with higher incomes felt services had improved due to improved availability of medicines and other supplies. The respondents perceived that not accessing services due to cost barriers for example violated their right to health. The authors note that while there are opportunities to adopt PPP models in sectors such as transport for the construction of roads, rails, and toll gates, these models should not be used in health sectors and other essential services where commoditisation of public services affects access.
This brief observes that equity and shared prosperity calls for a closer look at the working and living conditions of millions of mine workers in Africa, where tuberculosis (TB) imposes a high burden on mining economies and constitutes a regional public health crisis. Health hazards are reported to be perpetuated by poor enforcement of mining legislation, limited application of best international practices, weak institutions, and inadequate equipment and skills. In uncontrolled mining operations and communities of the type common in Africa, several factors are argued to combine to form a perfect storm for TB infection and transmission. They argue that the practice of allowing mining companies to self-report on health issues should be eliminated and that legislation on the health aspects of mining operations in Africa must be developed in line with international standards and best practices. The continent’s regional development communities should act urgently to establish public-private partnerships capable of ensuring that mining in fact benefits the region’s people in their path toward sustainable development. The goal should be the adoption of preventive measures to avoid further damage to the region’s health and skilled human capital.
10. Resource allocation and health financing
In February 2017, the Committee on Economic, Social and Cultural Rights – a UN human rights body – held a discussion of its draft General Comment on State obligations in the context of business activities. This General Comment – as an authoritative interpretation of States’ duties under the International Covenant on Economic, Social and Cultural Rights (ICESCR) – will fill an important gap in applying human rights law to situations of business-related abuses of these rights occurring within States’ territory as well as overseas. Corporate taxation remains an under-explored yet critical piece of the business and human rights puzzle, as confirmed by various participants in the discussion. Alongside the more direct ways businesses can adversely impact human rights (such as labor abuses, water pollution, etc.), the amount of tax corporations pay, and where they pay them, has profound human rights implications. As detailed in a factsheet co-authored by CESR, tax dodging by multinational copper firms in Zambia are estimated to amount to as much as $326 million annually, equivalent for example to about 60 percent of the country’s health budget. This raises governments’ responsibilities as State parties to international human rights treaties such as the ICESCR, and the phenomenon of tax avoidance and evasion. The ICESR General Comment early draft states that raising revenue through corporate taxation is an important part of the State’s duty to fulfil ESCR in its territory as the realisation of ESCR is dependent upon public resources that can, for example, pay for hospitals, schools and water systems. These resources will be raised from a variety of sources (including aid in some countries), but in all contexts progressive taxation is a lynchpin of public revenue raising. The report argues that those who can most afford to pay (including profitable multinational corporations and their executives and shareholders) must pay their fair share, and loopholes which allow them to escape tax should be closed.
This study describe how quality of care is incorporated into performance-based financing (PBF) programmes, what quality indicators are being used, and how these indicators are measured and verified. An exploratory scoping methodology was used to characterise the full range of quality components in 32 PBF programmes, initiated between 2008 and 2015 in 28 low- and middle-income countries, totalling 68 quality tools and 8,490 quality indicators. The programmes were identified through a review of the peer-reviewed and grey literature as well as through expert consultation with key funder representatives. Most of the PBF programmes were implemented in sub-Saharan Africa and most were funded primarily by the World Bank. On average, PBF quality tools contained 125 indicators predominately assessing maternal, newborn, and child health and facility management and infrastructure. Indicators were primarily measured via checklists which largely (over 90%) measured structural aspects of quality, such as equipment, beds, and infrastructure. Of the most common indicators across checklists, 74% measured structural aspects and 24% measured processes of clinical care. The quality portion of the payment formulas were in the form of bonuses (59%), penalties (27%), or both (hybrid) (14%). The median percentage (of a performance payment) allocated to health facilities was 60%, ranging from 10% to 100%, while the median percentage allocated to health care providers was 55%, ranging from 20% to 80%. Nearly all of the programmes included in the analysis (91%) verified quality scores quarterly (every 3 months), typically by regional government teams. PBF is argued by the authors to be a potentially appealing instrument to link verified performance measurement with strategic incentives and could ultimately help meet policy priorities. They also raise substantial variation and complexity in how PBF programmes incorporate quality of care considerations suggesting a need to further examine whether differences in design are associated with differential programme impacts.
11. Equity and HIV/AIDS
The authors conducted a systematic review of studies evaluating HIV testing services (HTS) by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. The authors also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomised trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity between them. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.
12. Governance and participation in health
This article reports on the work of HealthNewsReview.org to monitor the quality of health and medical news coverage. To combat inaccuracies, HealthNewsReview requires three reviewers to assess each article, applying 10 criteria. These include whether the journalists have adequately considered the cost of the intervention, its potential harms and benefits, whether they had compared new ideas with existing alternatives, and whether they solely relied on a press release or used independent sources. Projecting forward, the author observes that there should be room for promoting health literacy, for example, explaining that people should focus on absolute not relative risk reduction. People should not be amazed by claims that a drug reduced the risk of a problem by 50% (relative risk reduction) when that may mean that the absolute risk reduction was only from 2 in 100 in the untreated group to 1 in 100 in the treated group – a 1% absolute risk reduction.
The health sectors of most countries focus almost exclusively on health care services. The potential of multi-sectoral collaboration thus remains untapped in many low- and middle-income countries. Different sectors have different contributions to make towards solving specific health problems. The authors argue that in each case, the profile, interests, incentives, and relationships of key individuals and sectors must be mapped and analysed to inform the design of approaches and systems to tackle a shared problem. The authors argue that collaborative and distributed leadership is key for effective governance of multi-sectoral action, with a need to build leadership capacity across sectors and levels of government and cultivate champions in different sectors who can agree on common objectives. They present options for countries to take a multi-sectoral approach for health, including ensuring that the universal health coverage agenda addresses the capacity of the health sector to work with other sectors, learning from multi-sectoral efforts that do not involve the health sector, improving the capacity of global institutions to support countries in undertaking multi-sectoral action, and developing a clear implementation research agenda for multi-sectoral action for health.
PLOSBLOGS hosted a question and answer with the three final candidates for the World Health Organisation (WHO) Director General being directly elected by countries in the 2017 World Health Assembly. The article provides the questions and interview responses in full. The authors note in an analysis of the candidates’ responses that none of the candidates discussed issues of social justice in their responses regarding the societal determinants of health or mentioned the recommendations of the WHO Commission on Social Determinants of Health on global power asymmetries, specifically the need to “tackle the inequitable distribution of power, money, and resources.” In terms of the role of non-state actors in neutering public accountability at WHO, none of the candidates articulated the intrinsic differences in power and access between public-interest entities and corporate/philanthropic actors under the non-state actor rubric. All three seem to think FENSA will resolve the problems of private influence on the WHO agenda, which the authors of the article doubt. To improve health and health equity, all three candidates invoked Universal Health Coverage without specifying the role of public provision, comprehensive coverage, and equity in access, quality, and financing for health care systems. In relation to health equity and social determinants of health, all three candidates mentioned intersectoralism and social inclusion, partnerships, and WHO technical expertise, but did not give attention to the political context of these challenges.
In the past three decades in Ghana, the number of city dwellers has risen from four to 14 million; more than 5.5 million of whom live in slums. Urban growth exerts intense pressure on government and municipal authorities to provide infrastructure, affordable housing, public services and jobs. It has exacerbated informality, inequality, underdevelopment and political patronage. Some commentators warn of an impending urban crisis. Policymakers and international donors continue to prescribe better urban planning, slum upgrading, infrastructure investment and “capacity building” to “fix” African cities. While these are necessary, the authors argue that the success of any urban strategy depends on an informed appraisal of the political dynamics of urban neighbourhoods that define governance in Ghana’s cities and slums, in the interaction between politicians, entrepreneurs, traditional authorities and community leaders. The authors note that informal networks pervade formal political institutions and shape political strategy, and that political clientelism and the role of informal institutions are deepening alongside the strengthening of formal democratic institutions, but are often overlooked.
The author argues that destruction of the environment, human rights abuses and mass displacement have been ignored in the name of “development” that works to intensify neoliberal inequality. In response to legal attempts to hold it to account, the author argues that the World Bank has declared itself above the law. The latest attempt at accountability is a lawsuit filed in the U.S. federal court in Washington by EarthRights International, a human rights and environmental non-governmental organisation, charging that the World Bank has turned a blind eye to systematic abuses associated with palm-oil plantations in Honduras that it has financed. EarthRights International alleges that the World Bank has “repeatedly and consistently provided critical funding to Dinant, Honduran palm oil companies, knowing that Dinant was waging a campaign of violence, terror, and dispossession against farmers, and that their money would be used to aid the commission of gross human rights abuses.” The lawsuit reports that the International Finance Corporation’s ombudsman said the World Bank division “failed to spot or deliberately ignored the serious social, political and human rights context.” These failures arose “from staff incentives ‘to overlook, fail to articulate, or even conceal potential environmental, social and conflict risk’ and ‘to get money out the door.’ ” Despite this internal report, the suit says, the World Bank continued to provide financing and that the ombudsman has “no authority to remedy abuses.”
13. Monitoring equity and research policy
Partnerships are essential to deliver research and innovation for global health and partner development. Sustainable Development Goal 17 is all about this. Yet, COHRED argues that there is no framework, no benchmark, no standard of best practice on which to model governmental, corporate, non-profit, or academic collaborations, particularly not for international collaborative research and innovation involving low- and middle-income countries. This is where the Research Fairness Initiative intends to make a difference: to create a reporting system that encourages governments, businesses, organisations and funders to describe how they take measures to create trusting, lasting, transparent and effective partnerships in research and innovation. COHRED prioritises its application in global health because there are many urgent health-related issues, but it can be applied in any other setting also.
The first-ever, World Report on Health Policy and Systems Research, was launched recently by the Alliance for Health Policy and Systems Research. The report provides practical recommendations on how to reorient health research to more effectively address public health challenges on a national and global level. It describes the evolution of the field and provides figures on the number of publications produced, funding trends and institutional capacity in LMICs to conduct health policy and systems research. Low- and middle-income countries now have guidance for not only being users of research, but also producers. The report describes the state of the HPSR field in 1996, identifying three broad challenges to its progress that were clearly visible at that time. In the mid-1990s there were three principal challenges to the growth of the field of HPSR: (i) the fragmentation and lack of a single agreed definition of the field; (ii) the ongoing dominance of biomedical and clinical research; and (iii) a lack of demand for HPSR. Cross-cutting all these challenges was the problem of relatively limited capacity to undertake high-quality health policy and systems research. Subsequent sections then analyse how these challenges have been addressed over the intervening 20 years, resulting in greater recognition of and investment in HPSR. The report raises challenges to be addressed, including confronting the dominance of biomedical and clinical research as the primary channel for health research investments through a sustained advocacy campaign; seeking to clarify the scope and methods of the field; and finally nurturing closer collaboration with research users, in particular by capitalizing on the growth of interest in evidence-informed policy. It also collects together for the first time figures on various significant aspects of health policy and systems research: growth in the number of publications, collaboration between researchers in different parts of the world, funding trends and institutional capacities in low- and middle-income countries.
14. Useful Resources
Docubox was launched in 2012 as a documentary film fund that “supports intimate, character-driven storytelling and encourages new forms of ownership and authorship in East Africa because we believe that true stories well told make the world a better place to live”. Docubox exists to enable talented, driven, focused and accountable East African artists to produce unique films that unearth new realities and cross trans-national boundaries. Through training, development and production grants, screenings for people who love documentary films, it promotes East African filmmakers to share their stories with the world through creative documentary. Docubox believe good documentaries are intimate observations of the world’s identities and people captured by talented, driven, creative filmmakers –films able to uncover new realities because they are authored by authentic local voices, films that offer viewers new perspectives of society. Docubox want to create an authentic body of work that provides personalised glimpses into world, issues and lives that would ordinarily remain undocumented. They want to create a movement that will challenge ideas and assumptions about the world as it is known and provoke healthy, democratic dialogue and debate between our fellow citizens. Docubox believe that to change and inspire society, there is a need to support films that can spark off debate, films that get talked about, films that contribute to the formation of a vibrant documentary film movement across eastern Africa. Docubox want to do this because they believe that stories well told can make the world a better place to live.
On World Malaria Day the World Health Organisation (WHO) released a publication entitled "Malaria Prevention Works". Filled with eye-catching infographics, it presents WHO's recommended malaria prevention tools in a simple and digestible manner. It is divided into two parts: the first chapter focuses on core vector control measures, and the second on preventive treatment strategies for the most vulnerable groups. It touches on a key biological threat, mosquito resistance to insecticides and highlight the need for new anti-malaria tools.
15. 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.
With funding support from the Andrew W. Mellon Foundation, the Council for the Development of Social Science Research in Africa, CODESRIA, announces a call for proposals for a new intervention targeting support to doctoral schools and rebuilding scholarly communities in the social sciences and humanities in African universities. The overall goal is to engender a generation of academics and knowledge that can enable the people of the continent critically (re) imagine and (re) create better, freer, more sustainable, and more inclusive communities and worlds. Proposals to be supported under this call are those submitted by individual/ groups of graduate/doctoral schools, SSH faculties, including research and teaching units dealing with higher education studies. Proposals should focus on issues to do with curricular reform, doctoral student supervision practices and mentoring of faculty in graduate supervision; interventions to rebuild/recreate scholarly infrastructures and academic communities through holding faculty seminars, strengthening faculty journals and conferences, systems to recreate strong workshop and seminar cultures; support for scholarly writing and academic publishing workshops especially targeting doctoral students and early career academics.
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.
Health Policy Analysis (HPA), seeks to understand and explain the policy process. The Alliance for Health Policy and Systems Research is supporting a fellowship programme in HPA for 2017-18, for PhD students, or those registered for an equivalent degree, based in LMICs who seek to research the politics of health policy change – focussed, for example, on agenda setting, an aspect of policy formulation, an experience of policy implementation, the politics of policy evaluation/learning, or another, relevant, area. The PhD ideas must also be nested in relevant policy, political science, public administration and/or organisational theory. Proposed applicants must be a national of an LMIC already registered or be currently finalising registration for a PhD, or equivalent, in an LMIC university, and at a stage where they have NOT yet finalised their study protocol or started data collection. Those selected as HPA fellows under this programme will be supported to conduct their PhD research and will be required to attend 2 week-long thesis workshops during this time – broadly, to support the finalisation of their protocol (year 1) and a related paper (year 2). HPA fellows will receive distance learning support between workshops and receive bursary support for their PhD research, linked to the preparation and completion of workshop-related outputs. Applicants must submit the following: a full and complete CV, with copies of all post-graduate university level academic certificates; a 1-2 page motivational statement for your application, indicating how this programme will fit with their existing PhD plans and timelines; a 4-5 page note outlining the work which they hope/plan to do, the theoretical base and methodology and justifying its significance in terms of current HPA work in LMICs; a letter of support from their supervisor (on their university letterhead), and a brief CV of their supervisor; evidence of registration (completed or in progress) for a PhD or equivalent, at an LMIC university, including the disciplinary area of study, year of entry, expected graduation data and current phase of studies; and the name and contact details of 3 referees, with clarification of their relationship to each; of whom at least 2 should have supervised the applicant an academic capacity. Preference will be given to women candidates, those under 40 years of age and to candidates from low income countries (LICs).
In the 8th Southern African Conference delegates will find the latest advances in basic sciences alongside an emphasis on how to be part of lasting change to prevent new infections. South Africa’s National Strategic plan includes whole sections on prevention and structural change policies such as the National Liquor Norms and Standards, the National AIDS Council of the National Sex Worker HIV Plan, will be discussed with other measures to take control of the epidemic.
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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