We have a shorter newsletter and no editorial this month as we carry out essential review and maintenance work on our site. We hope the papers and content included still provide you with interesting materials for your work and analysis in and beyond the region. We have appreciated editorial contributions from a range of experiences and invite you to send us editorials written by you, and any links to videos, blogs, papers or other online resources you want to share on your perspective on the opportunities that we should be tapping in east and southern Africa for making immediate or longer term advances in equity in health.
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1. Editorial
2. Latest Equinet Updates
By 2050, urban populations in Africa will increase to 62%. The World Health Organisation (WHO) and UN Habitat in their 2010 report ‘Hidden Cities’ note that this growth constitutes one of the most important global health issues of the 21st century. TARSC as cluster lead of the ‘Equity Watch’ work in EQUINET implemented a multi-methods approach to gather and analyse diverse forms of evidence and experience of inequalities in health and its determinants within urban areas, and on current and possible responses to these urban conditions, from the health sector and the health-promoting interventions of other sectors and communities. We aimed to build a holistic understanding of the social distribution of health in urban areas and the responses and actions that promote urban health equity. The different stages and forms of evidence are presented in a set of reports and briefs and a final synthesis document. This report presents the findings of the separate search on holistic paradigms relevant to urban wellbeing, and an analysis of statistical evidence on health and wellbeing in east and southern Africa (ESA) countries using indicators drawn from these approaches. The findings indicated that ESA countries face a challenge if they seek to track progress in the multiple dimensions of wellbeing or to build an understanding from the quantitative data gathered. First, there are no data measured across the 16 ESA countries for many dimensions of a more holistic approach to wellbeing. Second, in ESA countries, the indicators that are measured are more commonly those of negative rather than positive wellbeing outcomes. This turns the focus away from the assets in society. It points out where the problems are, but not the progress in achievement of positive or affirmative goals. Third, where data do exist, they are poorly disaggregated to show urban areas separately or to show intro-urban inequalities or levels in specific social groups. Finally and importantly, the subjective views of people on their life satisfaction do not always match measured data, and needs to be elicited and taken into account more directly in planning for urban wellbeing, including for interpreting, validating, adding to or even challenging quantitative data.
3. Equity in Health
On 16 March 2018, Botswana became one of a dozen countries in East and Southern Africa that have launched its national demographic dividend study. A demographic dividend is not only contingent on a rapid decline in fertility and mortality. It also requires strategic investments in promoting equality, health and family planning, education and skills development, and job creation. When countries harness the demographic dividend, their young people are argued to become more empowered, healthier, better educated and have more equal access to opportunities. At the launch of Botswana’s demographic dividend report, President Mokgweetsi EK Masisi acknowledged “the right investments have to be made in Botswana for us to tap into the potential and skills of young people. Our return on investments isn’t commensurate with the expectations we have for Botswana.” The author argues that this is a golden moment for Botswana and other African countries to reprioritise their investments and tap into the potential of their young people – and for Botswana to plan for its second demographic dividend.
4. Values, Policies and Rights
South Africa’s GDP is reported to have risen from US $3445 in 1994 to US $5284 in 2016, but far from ushering in overall improvement in health or well-being, the author notes that rising white collar crime, violence, small business failure , un- and underemployment and the flight of skills signpost an unhappy place. He notes that South Africa “… had the highest number of drunk driving incidents at 58 percent” in the world …”. Alcohol is said to account for 40 percent of violent crime. The author calls more regulations to ensure that alcohol companies pays for the consequences that come with heavy drinking in the country.
Botswana Labour Migrants Association and its members from all the four corners of Botswana, present a press release reporting the news of the finalization of the TB/Silicosis class action, by way of a settlement agreement between mineworkers and the mining companies. The settlement ceremony which was held on the 3 May 2018 in South Africa, was reported in the press release to be groundbreaking and a vindication of the dues, sweat and rights of ex-miners in the region, their spouses and children and especially the efforts of the Association and its leadership..
Uganda is at the centre of current debate on urban refugees. The country’s Refugees Act 2006, which establishes refugees’ rights to live, work and own land in urban areas, has been hailed as exemplary and a global model for humanitarian responses. However, new evidence on refugee livelihoods in Kampala suggests that the rights to work and move freely, and without fear, are often unmet in urban areas. In the absence of financial assistance, urban refugees often struggle to find gainful employment and report frequent cases of discrimination by both the Ugandan state and the public. This briefing outlines the barriers faced in upholding the rights of urban refugees in Uganda, and recommends ways in which these may be overcome.
5. Health equity in economic and trade policies
Tobacco farming is a pillar of Zimbabwe’s economy. Tobacco is the country’s most valuable export commodity—generating US$933.7 million in 2016—and the crop is particularly significant to Zimbabwean authorities’ efforts to revive the economy. However, Human Rights Watch research in 2016 and 2017 into conditions on tobacco farms in Zimbabwe revealed an industry tainted by child labour and confronted by other serious human rights problems as well. This report—based on extensive field research and interviews with 64 small-scale tobacco farmers, as well as 61 hired workers on tobacco farms in the largest tobacco-growing provinces in Zimbabwe—found several human rights problems in the tobacco sector. Children under 18 were found to work in hazardous conditions on tobacco farms in Zimbabwe, some performing tasks that threaten their health and safety or interfere with their education. Adults involved in tobacco production—both small-scale farmers and hired workers— were reported to face serious health and safety risks, with insufficient information, training, and equipment to protect themselves. Hired workers on some large-scale tobacco farms said they were pushed to work excessive hours without overtime compensation, denied their wages, and forced to go weeks or months without pay. The authors call on companies and government to prohibit children from any work involving contact with tobacco, as a policy that is both protective and straightforward for companies to communicate, implement, and monitor throughout the supply chain.
The tobacco industry has for a long time affected innocent lives world over through several ways including; advertising and encouraging direct smoking of cigarettes, secondhand smoke exposure, smoking of other combustible tobacco products , smokeless tobacco and electronic nicotine delivery systems (ENDS) among others. The WHO report on Global Tobacco Epidemic 2008, confirms that the global tobacco epidemic is one of the greatest public health threats of modern times as smoking causes so many deleterious health effects. Some of these health effects include; diminished health status, susceptibility to acute illnesses and respiratory symptoms, death, coronary heart disease, cancers of any organ of the body, chronic obstructive pulmonary disease or COPD, pre-mature births, among others. Uganda has taken a great leap in tobacco control interventions through ratification of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) and consequently the enactment of the Tobacco Control Act of 2016.
6. Poverty and health
This report explores the current nutrition status of countries in the WHO African Region in relation to the six primary outcomes achievable by 2025 and the other global nutrition monitoring framework indicators. The aim is to highlight where action is needed to drive progress on the global targets for 2025 and Sustainable Development Goal No. 2 that calls on countries to end hunger through achieving food security, improving nutrition and promoting sustainable agriculture. A complementary objective of the report was to evaluate existing data sources that countries use to monitor programme performance and track progress on the global targets. A key finding in this report is that undernutrition is still persistent in the WHO African Region, with major implications for health, particularly among poor and vulnerable population groups. It finds that persistent drought, famine, flooding, and civil crises will make it difficult for many countries to achieve the target of reducing and maintaining wasting at less than 5%. Along with persistent undernutrition, the prevalence of overweight among children under 5 years of age (as well as the overall number of children affected) is rising, whereas the target is to halt its increase. WHO AFRO assert that In the absence of survey data, properly functioning routine surveillance systems could provide invaluable real-time information for decision making in policy and programme design and implementation in this area.
7. Equitable health services
This study examined the context of access to healthcare experienced by men who have sex with men, female sex workers and people who use drugs in two South African cities: Bloemfontein in the Free State province and Mafikeng in the North West province. In-depth interviews were conducted to explore healthcare workers’ perceptions, beliefs and attitudes. Focus group discussions were also conducted with members of these groups exploring their experiences of accessing healthcare. Healthcare workers demonstrated a lack of relevant knowledge, skills and training to manage the particular health needs and vulnerabilities facing these social groups. Men who have sex with men, female sex workers and people who use drugs described experiences of stigmatisation, and of being made to feel guilt, shame and a loss of dignity as a result of the discrimination by healthcare providers and other community. members. The findings suggest that the uptake and effectiveness of health services amongst these three groups is limited by internalised stigma, reluctance to seek care, unwillingness to disclose risk behaviours to healthcare workers, combined with a lack of knowledge and understanding on the part of the broader community members, including healthcare workers.
8. Human Resources
As part of efforts to implement the human resources capacity building component of the African Regional Strategy on Disaster Risk Management (DRM) for the health sector, the African Regional Office of the World Health Organization, in collaboration with selected African public health training institutions, followed a multistage process to develop core competencies and curricula for training the African health workforce in public health DRM. In this article, we describe the methods used to develop the competencies, present the identified competencies and training curricula, and propose recommendations for their integration into the public health education curricula of African member states. The authors identified 14 core competencies and 45 sub-competencies/training units grouped into six thematic areas: 1) introduction to DRM; 2) operational effectiveness; 3) effective leadership; 4) preparedness and risk reduction; 5) emergency response and 6) post-disaster health system recovery. These were defined as the skills and knowledge that African health care workers should possess to effectively participate in health DRM activities. To suit the needs of various categories of African health care workers, three levels of training courses are proposed: basic, intermediate, and advanced.
9. Public-Private Mix
A current wave of pharmaceutical industry investment in sub-Saharan Africa is associated with active African government promotion of pharmaceuticals as a key sector in industrialization strategies. The authors present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. The authors identify key policies that can ensure that local health systems benefit from the investments. They argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. This local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions.
10. Resource allocation and health financing
As growth in development assistance for health levels off, development assistance partners must make allocation decisions within tighter budget constraints. In the ‘financing gaps framework’, the authors propose a new approach for harnessing information to make decisions about health aid. The framework was designed to be forward-looking, goal-oriented, versatile and customisable to a range of organisational contexts and health aims. The framework brings together expected health spending, potential health spending and spending need, to orient financing decisions around international health targets. As an example of how the framework could be applied, a case study is developed, focused on global goals for child health. The case study harnesses data from the Global Burden of Disease 2013 Study, Financing Global Health 2015, the WHO Global Health Observatory and National Health Accounts. Funding flows are tied to progress toward the Sustainable Development Goal’s target for reductions in under-five mortality. The flexibility and comprehensiveness of the framework makes it adaptable for use by a diverse set of governments, donors, policymakers and other stakeholders. The framework can be adapted to short‐ or long‐run time frames, cross‐country or subnational scales, and to a number of specific health focus areas. Depending on donor preferences, the framework can be deployed to incentivise local investments in health, ensuring the long-term sustainability of health systems in low- and middle-income countries, while also furnishing international support for progress toward global health goals.
11. Equity and HIV/AIDS
This paper provided an estimated use and outcomes of the Malawian programme for the prevention of mother-to-child transmission of human immunodeficiency virus. In a cross-sectional analysis of 33 744 mother–infant pairs, the authors estimated the weighted proportions of mothers who had received antenatal human immunodeficiency virus testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or human immunodeficiency virus testing. The authors calculated the ratios of mother-to-child transmission at 4–26 weeks postpartum for subgroups that had missed none or at least one of these four steps. The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant human immunodeficiency virus testing was 53.2%. Estimated ratios of mother-to-child transmission were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed human immunodeficiency virus testing and infant prophylaxis than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis and infant testing than women who had. Most women used the Malawian programme for the prevention of mother-to-child transmission. The risk of mother-to-child transmission increased if any of the main steps in the programme were missed.
12. Governance and participation in health
The global health system has faced significant expansion over the past few decades, including continued increase in both the number and diversity of actors operating within it. However, without a stronger understanding of what the global health system encompasses, coordination of actors and resources to address today’s global health challenges will not be possible. This study presents a conceptually sound and operational definition of the global health system. Importantly, this definition can be applied in practice to facilitate analysis of the system. The study tested the analytical helpfulness of this definition through a network mapping exercise, whereby the interconnected nature of websites representing actors in the global health system was studied. Using a systematic methodology and related search functions, 203 global health actors were identified, representing the largest and most transparent list of its kind to date. Identified global health actors were characterised and the structure of their social network revealed intriguing patterns in relationships among actors. These findings are argued to provide a foundation for future inquiries into the global health system’s structure and dynamics that are critical to better coordinate system activities and ensure successful response to pressing global health challenges.
13. Monitoring equity and research policy
This paper assessed, whether and how, two knowledge translation platforms housed in government-affiliated institutions in Cameroon and Uganda have influenced health system policy-making processes and decisions aiming at supporting achievement of the health millennium development goals and the general climate for evidence-informed health system policy-making. The authors conducted an embedded comparative case study of four policy processes in which Evidence Informed Policy Network Cameroon and Regional East African Community Health Policy Initiative Uganda were involved between 2009 and 2011. The authors combined a documentary review and semi structured interviews of 54 stakeholders. A framework-guided thematic analysis, inspired by scholarship in health policy analysis and knowledge utilization was used. The coproduction of evidence briefs combined with tacit knowledge gathered during inclusive evidence-informed stakeholder dialogues helped to reframe health system problems, unveil sources of conflicts, open grounds for consensus and align viable and affordable options for achieving the health millennium development goals thus leading to decisions. New policy issue networks have emerged. Knowledge translation platforms were perceived as change agents with positive impact on the understanding, acceptance and adoption of evidence-informed health system policy-making because of their complementary work in relation to capacity building, rapid evidence syntheses and clearinghouse of policy-relevant evidence. The authors indicate that this embedded case study illustrates how two knowledge translation platforms influenced policy decisions through pathways involving policy issue networks, interest groups interaction and evidence-supported ideas and how they influenced the general climate for evidence-informed health system policy.
14. Useful Resources
IHS, the Institute for Housing and Urban Development Studies of Erasmus University Rotterdam is launching their 1st MOOC (Massive Open Online Course): “Planning for Climate Change in African Cities”. Developed in collaboration with the African Local Governments Academy (ALGA), United Cities and Local Governments of Africa (UCLG) and Erasmus University Rotterdam, this free MOOC is 5 weeks and it offers the basics of urban resilience and adaptation, climate change planning, and policy assessment tools. The course is open to students and professionals in the fields of urban planning, environmental science, climate change, and other related fields.
15. Jobs and Announcements
The International AIDS Conference, first convened during the peak of the AIDS epidemic in 1985, continues to provide a unique forum for the intersection of science, advocacy, and human rights, as an opportunity to strengthen policies and programmes that ensure an evidence-based response to the epidemic. The theme of AIDS 2018 is “Breaking Barriers, Building Bridges”, drawing attention to the need of rights-based approaches to more effectively reach key populations, including in Eastern Europe and Central Asia and the North-African/Middle Eastern regions where epidemics are growing.
The African Capital Cities Sustainability Forum (ACCSF) functions as a network for the mayors of capital cities across the continent to achieve the sustainable development goals that are common to all and, in the words of Solly Msimanga, executive mayor of Tshwane, “to establish commonalities and challenges faced by major cities in Africa while showcasing and sharing successful initiatives towards the emergence of truly African, original and appropriate answers in addressing the sustainability imperative at the urban scale.”
Since 2001 through the generosity of the late Professor Aubrey Sheiham 16 Cochrane researchers from low- and middle-income countries have been funded and supported to complete Cochrane Reviews on topics relevant to their region, and to cascade knowledge about Cochrane and evidence-based health care (EBHC) to their local networks. In 2014, the scholarship evolved into a new award focusing on leadership in EBHC - the Aubrey Sheiham EBHC in Africa Leadership Award, administered by Cochrane South Africa. With an updated and more concentrated focus, the fellowship is awarded annually to an individual based in Africa, and supports the conduct and dissemination of a high-impact Cochrane Review on a topic relevant to resource-constrained settings. The Cochrane Review should be registered with a Cochrane Review Group at the time of application. An update of an existing review is allowed if it will have high impact. The applicant should provide proof that relevant evidence is available for inclusion in the review. In addition to completing their chosen Cochrane Review and disseminating its findings, the award recipient will support capacity development by mentoring a novice author based in Africa through the review process. This continues the scholarship’s tradition of building knowledge and research networks, which will be actively supported by Cochrane South Africa.
At major meetings, advances in HIV management focuses mainly on either adults or children, leaving out this key group of individuals – the adolescents. To meet this need for international interchange in order to bring the field forward, the International Workshop on HIV & Adolescence: challenges and solutions seeks to redress this gap. This workshop is set up as an inclusive summit for multidisciplinary experts working with adolescents affected by HIV. The objective will be to share experiences, knowledge and best practices with the aim of defining a pathway forward for optimizing care for adolescents living with HIV. The program will cover the entire spectrum of developmental changes in adolescents including social, behavioural, physiological and biological aspects and the impact of an HIV positive status. Prevention programs, testing, treatment and support services among adolescents shall be discussed. The barriers encountered in delivering these services and ways to mitigate these barriers shall be key areas of discussion during the workshop.
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