At this time last year we wished you progress towards health and justice in the year.
Our editorials in 2017 reflect some of the mountains that have to be moved for this: At several points of the year - in February and June - contributors highlighted preoccupations with emergencies, bio-security and migration that trigger discrimination and exclusion, rather than solidarity and shared responsibility. In March and in September we heard about the increasing privatisation of public spaces, public institutions and public health services, and in April about the extraction of minerals and other resources from our countries without fair benefit for local communities.
However, the 2017 contributions also point to ideas and forces that move these mountains: such as the news in February of thousands of people gathering at Habitat3 around people’s right to the city and to healthy urban life; the demand in March by civil society to open up a closed world of global policy making; the claim in April for regional economic communities to set health standards in mining that should apply across the region; the organisation of collective African voice May’s World health assembly to more strongly advance ideas and interests from the region; and examples raised in September and October of how recognising and nurturing people’s rights, evidence and power generates a critical resource for health systems. In the beginning of 2017 one editorial painted a scenario of a future world where inclusion and investment in wellbeing is recognised not only as a matter of rights and justice, but as vital for our collective survival. So it was inspiring in the end of the year to hear a group of young contributors share ideas of urban futures that would overcome the significant differences in opportunities for wellbeing that they seek to demand, contribute to and achieve.
These ideas and forces are all rooted in the challenging conditions described. But they are also challenging these conditions, envisaging both a direction for change and a power to transform that lies in people’s hands. A Sudanese proverb says that we desire to bequeath two things to the next generation; the first one is roots, the other one is wings. Let’s move forward into 2018 with both!
1. Editorial
2. Latest Equinet Updates
Stakeholders working with Health Centre Committees (HCCs) in East and Southern Africa (ESA) raised proposals in EQUINET policy brief 37 to improve the functioning and impact of HCCs as potential contributors to equitable, people centred health services. These proposals advocated for legal, institutional and social measures to support and clarify HCC roles, composition, powers and duties, to ensure the capacities and resources for them to function. They also proposed that HCCs strengthen their communication with the communities they represent backed up by wider measures for health literate and informed communities. Since then, institutions in EQUINET have followed up to act on the recommendations, building on existing work. This brief shares information on these developments. It reports some progress in legal recognition and setting of clearer constitutions for HCCs, clearer guidelines for the functioning, use of community based processes like photovoice to connect them with communities and their conditions in their dialogue with health services and efforts to share resources for capacity building of HCCs. It highlights that HCCs continue to play a role in improved frontline health systems. However the potential of HCCs still needs to be realised and the work continues.
The extractive (or mining) sector is a major economic actor in east and southern Africa. The mineral resources extracted are sought after globally, and how the sector operates affects the lives of millions of people. This brief aimed mainly civil society discusses the health impacts of the sector, how far these risks are recognised in policy and controlled in practice, and what civil society can do to ensure that health is protected in EI activity. It presents the proposals made at the 13th Southern Africa Civil society Forum in 2017 to advocate for regional health standards for EIs and a bottom up local to regional campaign for civil society to advocate for these harmonised standards for health in the mining (extractive) sector in SADC.
3. Equity in Health
The author raises that almost 100 million people are pushed into extreme poverty each year because of debts accrued through healthcare expenses. Citing a report, published by the World Health Organization and the World Bank, she highlights that the poorest and most vulnerable people are routinely forced to choose between healthcare and other necessities for their household, including food and education, subsisting on $1.90 (£1.40) a day. Researchers found that more than 122 million people around the world are forced to live on $3.10 a day, the benchmark for “moderate poverty”, due to healthcare expenditure. Since 2000, this number is reported to have increased by 1.5% a year. She cites Timothy Evans, senior director of health, nutrition and population at the World Bank Group: “Universal healthcare coverage is not just about better health. The reality is that as long as millions of people are being impoverished by health expenses, we will not reach our collective sustainable development goal of ending extreme poverty by 2030.”
This study aimed to generate high-resolution estimates of under-5 and neonatal all-cause mortality across 46 countries in Africa. The authors assembled 235 geographically resolved household survey and census data sources on child deaths to produce estimates of under-5 and neonatal mortality at a resolution of 5 × 5 km grid cells across 46 African countries for 2000, 2005, 2010, and 2015. Amid improving child survival in Africa, there was substantial heterogeneity in absolute levels of under-5 and neonatal mortality in 2015, as well as the annualised rates of decline achieved from 2000 to 2015. Subnational areas in countries such as Botswana, Rwanda, and Ethiopia recorded some of the largest decreases in child mortality rates since 2000, positioning them well to achieve SDG targets by 2030 or earlier. Yet these places were the exception for Africa, since many areas, particularly in central and western Africa, must reduce under-5 mortality rates by at least 8.8% per year, between 2015 and 2030, to achieve the SDG 3.2 target for under-5 mortality by 2030. In the absence of unprecedented political commitment, financial support, and medical advances, the viability of SDG 3.2 achievement in Africa is argued to be precarious at best.
4. Values, Policies and Rights
In this statement civil society organisations call for a change to the business-as-usual approach to achieving UHC and raise following principles that need greater emphasis in national and global efforts: Health is a human right and the achievement of UHC should ensure that no one is left behind; Out-of-pocket payments should be progressively abolished and public financing for health should be significantly increased; and good governance, robust transparency, and sound accountability must be ensured.
Ensuring that all people can access the health services they need – without facing financial hardship – is key to improving the well-being of a country’s population. This report argues that universal health coverage (UHC) is more than that: it is an investment in human capital and a foundational driver of inclusive and sustainable economic growth and development. It is a way to support people so they can reach their full potential and fulfil their aspirations. However, the report indicates that despite some progress on UHC, at least half of the world’s population still cannot obtain essential health services. And each year, close to 100 million people are being pushed into extreme poverty because they must pay for health expenses out of their own pockets, pointing to the challenges in reaching the global goal of UHC by 2030.
5. Health equity in economic and trade policies
This report was prompted by tailings dams disasters and rising global concerns about the safety, management and impacts of storing and managing large volumes of mine tailings. The report laments that although the number of dam failures has declined over many years, the number of serious failures has increased, despite advances in the engineering knowledge that can prevent them. The report makes two recommendations that can help the industry to eliminate tailing dam failures. Firstly, it calls for a “safety-first” approach to tailings storage that should be reflected in both management actions and on-the-ground operations. The report also recommends establishing a UN Environment stakeholder forum to facilitate international strengthening of tailings dam regulation. These approaches could include establishing a database of mine sites, identifying best practice and developing technical solutions to the main causes of failure. The assessment also discusses how mining firms can adopt cleaner processes, new technologies and re-use materials in order to reduce waste.
This study aimed to identify how research organisations and partnerships could contribute to capacity strengthening for health technology assessment and priority-setting in Africa. A rapid scan was conducted of international formal and grey literature and lessons extracted from the deliberations of two international and regional workshops relating to capacity-building for health technology assessment. ‘Capacity’ was defined in broad terms, including a conducive political environment, strong public institutional capacity to drive priority-setting, effective networking between experts, strong research organisations and skilled researchers. Effective priority-setting requires more than high quality economic research. Researchers have to engage with an array of stakeholders, network closely other research organisations, build partnerships with different levels of government and train the future generation of researchers and policy-makers. In low- and middle-income countries where there are seldom government units or agencies dedicated to health technology assessment, they also have to support the development of an effective priority-setting process that is sensitive to societal and government needs and priorities. Research organisations were found to have an important role to play in contributing to the development of health technology assessment and priority-setting capacity. In Africa, where there are resource and capacity challenges, effective partnerships between local and international researchers, and with key government stakeholders, can leverage existing skills and knowledge to generate a critical mass of individuals and institutions. It is proposed that these would help to meet the priority-setting needs of African countries.
6. Poverty and health
This article examines adaptation to climate change in view of changing humanitarian approaches in Isiolo County, Kenya. While humanitarian actors are increasingly integrating climate change in their international and national-level strategies, less is known about how this plays out at sub-national levels, which is key to tracking whether and how short-term assistance can support long-term adaptation. The article suggests that increasing attention to resilience and adaptation among humanitarian actors may not lead to reduced vulnerability because resources tend to be captured through existing power structures, directed by who you know and your place in the social hierarchy. In turn, this sustains rather than challenges the marginalisation processes that cause vulnerability to climate shocks and stressors. The article highlights the important role of power and politics both in channelling resources and determining outcomes.
7. Equitable health services
The timing of the first antenatal care visit is paramount for ensuring optimal health outcomes for women and children, and it is recommended that all pregnant women initiate antenatal care in the first trimester of pregnancy (early antenatal care visit). Systematic global analysis of early antenatal care visits has not been done previously. This study reports on regional and global estimates of the coverage of early antenatal care visits from 1990 to 2013. Data were obtained from nationally representative surveys and national health information systems. Estimates of coverage of early antenatal care visits were generated with linear regression analysis and based on 516 logit-transformed observations from 132 countries. The model accounted for differences by data sources in reporting the cutoff for the early antenatal care visit. The estimated worldwide coverage of early antenatal care visits increased from 40.9% in 1990 to 58.6% in 2013, corresponding to a 43.3% increase. Overall coverage in the developing regions was 48.1% in 2013 compared with 84.8% in the developed regions. In 2013, the estimated coverage of early antenatal care visits was 24% in low-income countries compared with 81.9% in high-income countries. Progress in the coverage of early antenatal care visits has been achieved but coverage is still far from universal. Substantial inequity exists in coverage both within regions and between income groups. The absence of data in many countries is of concern and the authors argue that efforts should be made to collect and report coverage of early antenatal care visits to enable better monitoring and evaluation.
The Ebola virus disease outbreak in west Africa and the rapid spread of other emerging viruses, such as the severe acute respiratory syndrome or the Middle East respiratory syndrome coronaviruses, showed how limited or non-existent infection prevention and control (IPC) programmes, combined with an inadequate water supply, poor sanitation, and a weak hygiene infrastructure in health facilities, can threaten global health security. In such outbreaks, instead of serving as points where disease was controlled, health-care facilities became dangerous places for outbreak amplification among staff and patients and transmission back to communities. The authors argue that it is now urgent to consider IPC capacity building and actual implementation as global health priorities. Among its efforts in this field, WHO coordinates the Global IPC (GIPC) Network. There are strong economic and ethical reasons to enhance IPC within the national and global health security agendas and efforts should capitalise upon evidence-based recommendations, proven and feasible implementation strategies, and awareness raised by AMR and epidemic-prone disease threats.
This study evaluates the service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Using existing data from service provision assessments of the health systems of the 10 study countries, the authors calculated a service readiness index for each of 8443 health facilities. This index represents the percentage availability of 50 items that the World Health Organization considers essential for providing health care. For the analysis, the authors used 37–49 of the items on the list. The mean values for the service readiness index were 77% for the 636 hospitals and 52% for the 7807 health centres/clinics. Deficiencies in medications and diagnostic capacity were particularly common. The readiness index varied more between hospitals and health centres/clinics in the same country than between countries. There was weak correlation between national factors related to health financing and the readiness index. Most health facilities in the study countries were insufficiently equipped to provide basic clinical care. The authors argue that if countries are to bolster health-system capacity towards achieving universal coverage, more attention needs to be given to within-country inequities.
8. Human Resources
This qualitative comparative study aimed at understanding similarities and differences in how relationships between community health workers, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and community health workers’ relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between community health workers and the health sector resulted in weaker relationships between community health workers and communities. The broader context and programme context in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust community health worker programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling community health workers to perform well and responding to the opportunities offered by their unique intermediary position.
9. Public-Private Mix
This study explored the perceptions and experiences of seeking treatment and advice from pharmacists and drugstore workers in Dar es Salaam, Tanzania, by men who have sex with men (MSM) with regards to their sexual health and STI-related problems. Fifteen in-depth interviews were conducted with MSM with experience of seeking assistance relating to their sexual health at pharmacies and drugstores in Dar es Salaam in 2016. Four themes related to different aspects of MSM’s perceptions and experiences of pharmacy care emerged from the analysis: Balancing threats against need for treatment reflected informants’ struggles concerning risks and benefits of seeking assistance at pharmacies and drugstores; Identifying strategies to access required services described ways of approaching a pharmacist when experiencing a sexual health problem; Seeing pharmacists as a first choice of care focused on informants’ reasons for preferring contact with pharmacies/drugstores rather than formal healthcare services; and lacking reliable services at pharmacies indicated what challenges existed related to pharmacy care. MSM perceived the barriers for accessing assistance for STI and sexual health problems at pharmacies and drugstores as low, thereby facilitating their access to potential treatment. However, the results further revealed that MSM at times received inadequate drugs and consequently inadequate treatment.
10. Resource allocation and health financing
In the Democratic Republic of Congo, recognising the need for reliable health workforce information, the government has worked to implement iHRIS, an open source human resources information system that facilitates health workforce management. In Kasaï Central and Kasaï Provinces, health workers brought relevant documentation to data collection points, where trained teams interviewed them and entered contact information, identification, photo, current job, and employment and education history into iHRIS on laptops. After uploading the data, the Ministry of Public Health used the database of over 11 500 verified health worker records to analyse health worker characteristics, density, compensation, and payroll. Both provinces had less than one physician per 10 000 population and a higher urban versus rural health worker density. Most iHRIS-registered health workers (57% in Kasaï Central and 73% in Kasaï) reported receiving no regular government pay of any kind (salaries or risk allowances). Payroll analysis showed that 27% of the health workers listed as salary recipients in the electronic payroll system were ghost workers, as were 42% of risk allowance recipients. As a result, the Ministries of Public Health, Public Service, and Finance reallocated funds away from ghost workers to cover salaries and risk allowances for thousands of health workers who were previously under- or uncompensated due to lack of funds. The reallocation prioritised previously under- or uncompensated mid-level health workers, with 49% of those receiving salaries and 68% of those receiving risk allowances representing cadres such as nurses, laboratory technicians, and midwifery cadres. The authors observe that assembling accurate health worker records can help governments understand health workforce characteristics and use data to direct scarce domestic resources to where they are most needed.
Direct payments by patients at the point of health care delivery, commonly known as user fees, lead to low utilisation of or exclusion from available health care services and impoverish households. Vulnerable groups are particularly affected. Over the past decade, many countries transitioned away from their user fee policies in favour of health care free at point of care for all or for specific population groups, such as pregnant women, children, and people with certain illnesses. Médecins Sans Frontières teams report in this paper witnessing evidence which starkly contrasts the discourse around UHC. Instead of improved access to care, they report a trend towards the reintroduction of user fees and other direct payments within national health financing strategies. They also report a lack of commitment and support to implement free care policies that secure access and sufficient coverage for the population’s health needs. The authors argue that if the global health community is serious about making UHC a reality and ‘leave no one behind’, removal of user fees for essential medicines and services must be tackled as a priority.
11. Equity and HIV/AIDS
This study seeks to understand the various factors influencing HIV-related risk behaviours and the resulting HIV positive status of Mozambican miners employed by South African mines to inform a broader and more effective HIV preventive framework in Mozambique. It used data sourced from the first integrated biological and behavioural survey among Mozambican miners earning their living in South African mines. The odds of reporting one sexual partner were roughly three times higher for miners working as perforators as opposed to other types of occupation. The odds of condom use – always or sometimes – for miners in the 31-40 age group were three times higher than the odds of condom use in the 51+ age group. Miners with lower education levels were less likely to use condoms. The odds of being HIV positive when the miner reports use of alcohol or drugs is 0.32 times lower than the odds for those reporting never use of alcohol or drugs. And finally, the odds of HIV positive status for those using condoms were 2.16 times that of miners who never used condoms, controlling for biological and other proximate determinants. In Mozambique, behavioural theory emphasising personal behavioural changes is the main strategy to combat HIV among miners. The findings suggested that there is a need to change thinking processes about how to influence safer sexual behaviour. This only stresses the need for HIV prevention strategies to exclusively transcend individual factors while considering the broader social and contextual phenomena influencing HIV risk among Mozambican miners.
12. Governance and participation in health
Mobile instant messaging (MIM) tools, such as WhatsApp, have transformed global communication practice. In the field of global health, MIM is an increasingly used, but little understood, phenomenon. It remains unclear how MIM can be used by rural community health workers (CHWs) and their facilitators, and what are the associated benefits and constraints. To address this gap, WhatsApp groups were implemented and researched in a rural setting in Malawi. The multi-site case study research triangulated interviews and focus groups of CHWs and facilitators with the thematic qualitative analysis of the actual conversations on WhatsApp. The use of MIM was differentiated according to instrumental (e.g. mobilising health resources) and participatory purposes (e.g. the enactment of emphatic ties). The identified benefits were centred on the enhanced ease and quality of communication of a geographically distributed health workforce, and the heightened connectedness of a professionally isolated health workforce. Alongside minor technical and connectivity issues, the main challenge for the CHWs was to negotiate divergent expectations regarding the social versus the instrumental use of the space. Despite some challenges and constraints, the implementation of WhatsApp was received positively by the CHWs and it was found to be a useful tool to support distributed rural health work.
Campaigners for Universal Health Coverage (UHC) camped at Mwananyamala Regional Hospital in Dar es Salaam in December 2017, raising voices for people who fail to access healthcare services due to financial constraints. Campaigns went out of the hospital as Kinondoni District residents and some health activists carried out peaceful demonstrations as a sign of solidarity for the UHC movement. The Universal Health Coverage Day, marked December 12 every year, is a time when health advocates around the globe join forces to demand action and results in healthcare access in every country.
13. Monitoring equity and research policy
This study seeks to develop a systematic approach to obtain the best possible national and subnational statistics for maternal and child health coverage indicators from routine health-facility data. The approach aimed to obtain improved numerators and denominators for calculating coverage at the subnational level from health-facility data. This involved assessing data quality and determining adjustment factors for incomplete reporting by facilities, then estimating local target populations based on interventions with near-universal coverage. The authors applied the method to Kenya at the county level, where routine electronic reporting by facilities is in place via the district health information software system. Reporting completeness for facility data were well above 80% in all 47 counties and the consistency of data over time was good. Coverage of the first dose of pentavalent vaccine, adjusted for facility reporting completeness, was used to obtain estimates of the county target populations for maternal and child health indicators. The country and national statistics for the four-year period 2012/13 to 2015/16 showed good consistency with results of the 2014 Kenya demographic and health survey. The results indicated a stagnation of immunization coverage in almost all counties, a rapid increase of facility-based deliveries and caesarean sections and limited progress in antenatal care coverage. While surveys will continue to be necessary to provide population-based data, web-based information systems for health facility reporting provide an opportunity for more frequent, local monitoring of progress, in maternal and child health.
14. Useful Resources
The Academy for African Urban Diversity (AAUD) was launched at the African Centre for Migration & Society (ACMS) in November 2017. AAUD is a joint initiative of ACMS; the African Centre for Cities; and the Max Planck Institute for the Study of Religious and Ethnic Diversity. It brings together a cohort of post-fieldwork doctoral students exploring diversity in African cities to debate and theorize the political, social and economic processes surrounding Africa’s growing and diversifying cities. The initiative creates interdisciplinary engagement among young and senior scholars working on urban studies on the African continent and the collaboration will play a role in supporting the development of skills and knowledge of a new generation of Urban African scholars. The next workshop will be held in Göttingen, Germany in 2018. PhD applications are considered on a rolling basis throughout the year.
15. Jobs and Announcements
Now in its 3rd year, the Aid & Development Africa Summit returns to Nairobi, Kenya on 27-28 February 2018, uniting humanitarian and development leaders, decision makers and advisors from NGOs, government and UN agencies and the private sector. The Summit will look into latest policy and project updates, best practice and innovations to improve humanitarian aid operations and infrastructure resilience in sub-Saharan East Africa. Participants will gain first hand insights from development banks, donors and government agencies into their financing priorities and funding guidelines as well as benefit from networking opportunities. The agenda is being developed in consultation with key organisations, such as WFP, IRFC, World Vision, USAID, UNICEF, World Bank, Save the Children, UN Habitat, CRS, FHI360, Oxfam, Habitat for Humanity International, IRD and will include case studies, panel discussions, workshops, and interactive roundtable sessions.
The Community Chest and Cornerstone Institute invite activist and development practitioners to apply for a scholarship to undertake a Bachelor of Arts Honours in Community Development at Cornerstone Institute. The scholarship provides for 70% of the tuition fee for the programme. Applicants are encouraged to secure the remainder of the fees from non-governmental organisations working in social development.
Theorising Africa seeks to explore what it means to be human, to be a member of society, through the exploration of identity, aesthetics, and politics by placing cultural theory and African epistemic frameworks in dialogue. For this seminar series, conveners at The University of Leeds are interested in looking to Africa for its history of ideas: How has African thought transcended boundaries and how can it continue to do so? What can African thought contribute to the many blind spots in the fields of cultural theory? How can these contributions account for the work of knowledge-making? In what ways are these contributions necessary? The conveners seek papers and proposals on topics including, but not limited to: African literary theory; Reframing the history of ideas – philosophical interrogations; Cultural analysis; Psychoanalysis; African Futures; Law; Politics and bio-violence; Feminisms and policy; Community building; The creaturely; Animism; Theology; Art History; Challenges to the legacy of the writer; Any non-conforming inquiry which doesn’t fall into a field. Proposals (max 300 words + bio) in Word format are to be sent to findingpocoafrica@gmail.com
The Nordic Africa Institute’s African Scholar Program is targeted at researchers based in Africa who need time and a conducive environment for finishing and writing up their ongoing research. It offers a Senior Researcher position at the Nordic Africa Institute for 12 months. The Institute is looking for a qualified researcher from African universities and research institutions with demonstrable research interest. The successful candidate might use the period of his/her employment to complete on-going research, develop new research projects, or complete articles, books or monograph manuscripts. The scholar-researcher should take advantage of the intellectual and logistical resources of the institute and is expected to contribute meaningfully towards actualizing its vision and mandate in return.
The South African Health Review (SAHR) is an accredited peer reviewed publication, widely respected as an authoritative source of research, analysis and reflection on health systems.
The editorial team of the 2018 SAHR is currently seeking abstracts that give consideration to advances made in the health system over the past 21 years, and reflect on areas of improvement for the future. In particular, abstracts that address the following range of topics are requested: Human resources for health, responses to the prevention and management of non-communicable diseases; and progress and challenges towards implementing universal health coverage. Preference will be given to manuscripts that offer critical review of the implementation of policies and programmes in the health sector and that give examples of good practices and multisectoral partnerships with demonstrated effectiveness, or of implementation and scale-up of initiatives designed to strengthen the health system. Abstracts should be submitted to: sahr@hst.org.za
The United Nations University (UNU) is offering sustainability scholarship for outstanding applicants from developing countries undertaking the MSc programme at UNU. The Japan Foundation for UNU (JFUNU) Scholarship is available for outstanding applicants from developing countries who can demonstrate a need for financial assistance. Candidates should have completed a bachelor’s degree (or equivalent) from a recognized university or institution of higher education in a field related to sustainability.
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