EQUINET NEWSLETTER 208 : 01 July 2018

1. Editorial

Ensuring health and access to health care for migrants: A right and good public health practice
Ncumisa Willie: Research Advisor, South African Human Rights Commission, South Africa

According to the United Nation’s 2017 International Migration Report, South Africa is host to an estimated four million migrants. This figure is set against a backdrop of a history of migration into South Africa that was marked by exploitative labour arrangements between South Africa and its neighbouring countries. This history is often treated with a ‘historical amnesia’ of the contribution of migrants to the South African economy and society. Migrants and particularly African migrants are met with a distrust and hostility that appears as xenophobia.

This hostility is also reflected in South Africa’s public health system, which does not adequately incorporate the reality of migration and health, nor address the needs of migrants. The South African Immigration Act is silent on the health rights and needs of migrants, placing them in a vulnerable situation and often leading to their exclusion from the public health system. This situation is worse for undocumented migrants, given their insecure legal status.

In contrast, recent media reports have often focused on ‘how an influx of health migrants’ has placed a strain on the country’s ability to deliver health care to its nationals. Some provincial health departments have lamented the strain on their limited resources due to the demand for services from migrants. These media reports and official pronouncements create conditions for refugees, asylum seekers and undocumented migrants to be denied access to health care services in public hospitals and clinics on the basis of their nationality or legal status. This was described by Crush and Tawonzera in 2011 as a form of ‘medical xenophobia’.

Denying migrants access to health care constitutes a violation of the internationally recognized right to access health care services, a right that is also enshrined in South Africa’s national law. The Bill of Rights in the South African Constitution enshrines equal rights for all persons in the country and affirms values of human dignity, equality and freedom. Migrants are covered by these constitutional rights, including the right to life, to dignity, freedom and security, to access information and to just administrative action. Section 27 of the Constitution guarantees everyone the right to basic health care, affirming that “everyone has the right to have access to health care services, including reproductive health care” and that “no one may be refused emergency medical treatment”.

The violation of migrants’ rights to access health care has grave consequences. For example, in 2015, a migrant woman lost her premature baby, allegedly due to denial of access to health care. In another incident, a migrant woman was forced to give birth at a bus station after allegedly being denied access to two hospitals in Gauteng province. Such denials of care violate rights. They have a gendered, racial and class impact, with poor, black women bearing the brunt of this discrimination.

Beyond the state’s legal obligation to provide access to health care services, there are public health reasons for providing health care services to migrants. The difficult journeys undocumented migrants, asylum seekers and refugees have had to make from their countries to South Africa may have exposed them to health problems, including communicable diseases. Treating these conditions makes public health sense as we live in a shared social space. The health of the local population is linked to that of the migrant population, given their integration into the wider community.

I would therefore argue that the South Africa state should develop a comprehensive multi-sectoral approach to migration and health, beyond infectious diseases and border control. Both the National Health Act and the Immigration Act should explicitly provide for migrant health care. The Immigration Act needs to be amended to adequately reflect the health rights of documented and undocumented migrants. The law should be supported by a comprehensive national policy, that also details how undocumented migrants should be treated, and that is applied universally across all provinces.

We need to advocate for and train health workers to implement migrants’ health rights. Such training, as a collaboration of the South African Department of Health and the Health Professions Council of South Africa, should create and foster an understanding among healthcare professionals of migrants’ health rights and needs. It should also include health administrators, as they are a point of entry for migrants attempting to access health care services.

These measures are necessary as a public health care system that excludes migrants creates conditions for poor public health for all. It increases the vulnerability of migrants, generates and magnifies discrimination and inequalities in health and violates migrants’ constitutional rights to access health care.

This is not just a health and human rights issue. It is also a matter of social justice. Migrant labour, often low wage, has been integral to South Africa’s society and economy, raising the profitability and savings of local business and consumers. It is also a matter of good public health practice. Delivering equitable access to care for migrants can reduce the health and social costs of disease, improve social cohesion, protect public health and human rights and contribute to healthier migrants in healthier local communities.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.

2. Latest Equinet Updates

EQUINET Policy brief 43: The role of an essential health benefit in health systems in east and southern Africa
EQUINET, TARSC, IHI, et al.: EQUINET, Harare, May 2018

This brief presents evidence, learning and recommendations from a regional programme of work in 2015-2017 on the role of essential health benefits (EHBs) in resourcing, organising and in accountability on integrated, equitable universal health systems. It outlines from the regional literature reviews and the case studies implemented in Swaziland, Tanzania, Uganda and Zambia the context and policy motivations for developing EHBs; and how they are being defined, costed, disseminated and used in health systems. EHBs can act as a key entry point and operational strategy for realizing universal health systems, for making clear the deficits to be met and to make the case for improved funding of health systems. The brief points to areas where regional co-operation could support national processes and engage globally on the role of EHBs in building universal, equitable and integrated health systems.

Responding to inequalities in health in urban areas in east and southern Africa: Brief 1: What does the literature tell us?
Loewenson R; Masotya M: TARSC, EQUINET, Harare, May 2018

By 2050, urban populations will increase to 62% in Africa. 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. Cities concentrate opportunities, jobs and services, but they also concentrate risks and hazards for health (WHO and UN Habitat 2010). How fairly are these risks and opportunities distributed across different population groups but also across generations? How well are African cities promoting current and future wellbeing? How far are health systems responding to and planning for these changes? TARSC as cluster lead of the “Equity Watch” work in EQUINET explored these questions in 2016-7, for east and southern African (ESA) countries. This brief reports what we found from a review of published literature. It draws on an annotated bibliography of the literature can be found in Loewenson R, Masotya M (2015) Responding to inequalities in health in urban areas: A review and annotated bibliography, EQUINET Discussion paper 106, TARSC, EQUINET, Harare. The literature pointed to broad trends, but included less evidence on social inequalities in health within urban areas in ESA countries. The picture presented in the literature is not a coherent one- it is rather a series of fragments of different and often disconnected facets of risk, health and care within urban areas. There is limited direct voice of those experiencing the changing conditions. There is also very limited report of the features of urbanisation that promote wellbeing.

Responding to inequalities in health in urban areas in east and southern Africa: Brief 2: What does the data tell us?
Loewenson R; Masotya M: TARSC, EQUINET, Harare, May 2018

Cities concentrate opportunities, jobs and services, but they also concentrate risks and hazards for health. How fairly are these risks and opportunities distributed across different population groups but also across generations? How well are African cities promoting current and future wellbeing? How far are health systems responding to and planning for these changes? TARSC as cluster lead of the “Equity Watch” work in EQUINET explored these questions in 2016-7, for east and southern African (ESA) countries. This brief reports what we found from analysis of data on indicators of wellbeing. Detail on the methods, findings and analyses of data can be found in full in Loewenson R, Masotya M (2018) Inequalities in health and wellbeing in urban areas in east and southern Africa: what does the data tell us? EQUINET Discussion paper 114, TARSC, EQUINET, Harare. Available at ht tps://tinyurl.com/y9nwy9oh. A number of holistic frameworks were found in the literature. They challenge the equation of progress in development with economic growth, when this is at the cost of intense exploitation of nature and significant social inequality. They thus focus on basic needs, wellbeing and quality of life (material, social and spiritual) of the individual and community, and of current and future generations, as a common good. While context dependent and with different terms in different regions, the buen vivir paradigm, (‘living well’ or ‘wellbeing’) best captures their key features. The brief presents evidence from data in several online databases with comparable data across ESA countries to see how far they measured these dimensions of wellbeing. ESA countries face a challenge in tracking progress in wellbeing, with data missing for many of its dimensions, limited disaggregation by social group or area, and more common measurement of negative than positive outcomes.

3. Equity in Health

Inequalities in health and health risk factors in the Southern African Development Community: evidence from World Health Surveys
Umuhoza S; Ataguba J: International Journal for Equity in Health 17(52), doi: https://doi.org/10.1186/s12939-018-0762-8, 2018

This study investigates inequalities both in poor self-assessed health (SAH) and in the distribution of selected risk factors of ill-health among the adult populations in six SADC countries. Data come from the 2002/04 World Health Survey (WHS) using six SADC countries (Malawi, Mauritius, South Africa, Swaziland, Zambia and Zimbabwe) where the WHS was conducted. Poor SAH is reporting bad or very bad health status. Risk factors such as smoking, heavy drinking, low fruit and vegetable consumption and physical inactivity were considered, as were other environmental factors. Socioeconomic status was assessed using household expenditures. Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only significant for South Africa, and marginally significant for Zambia and Zimbabwe. Smoking and inadequate fruit and vegetable consumption were significantly concentrated among the poor. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among the poor. However, inequalities in heavy drinking and physical inactivity are mixed. Overall, a positive relationship exists between inequalities in ill-health and inequalities in risk factors of ill-health. The authors argue that there is a need for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. With some of the determinants of ill-health lying outside the health sector, inter-sectoral action is required.

Zambia’s drive to eliminate malaria faces challenges
Loewenberg S: Bulletin of the World Health Organisation 96(5) 302–303, 2018

Zambia is one of eight southern African countries aiming to eliminate malaria in the next few years. Zambia has switched from the goal of its malaria control from reducing the number of cases to a very low level to elimination, defined as reducing the number of indigenous cases to zero. Supporters of the elimination agenda point to the success of the Maldives and Sri Lanka, which received World Health Organization certification for malaria elimination in 2015 and 2016, respectively. Some parts of Zambia such as the Southern Province have made huge progress in reducing the burden of malaria, but the country has not yet achieved overall control. Challenges include shortages of medicines, supplies and health workers with adequate training and supervision at the community level. However, community health workers are unpaid volunteers, leading to high turnover. While Zambia remains heavily dependent on external funding for its malaria elimination efforts, critics have questioned whether the disease can be successfully tackled without building stronger health systems first. Officials are worried by the challenge of mosquito resistance to insecticides and recent evidence this may be increasing, especially resistance to pyrethroids, the only insecticide class WHO recommends for use in insecticide-treated nets.

4. Values, Policies and Rights

Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage
Nelson E; Bloom G; Shankland A: Institute of Development Studies (IDS) Bulletin 49(2), doi: http://dx.doi.org/10.19088/1968-2018.127, 2018

In July 2017, IDS hosted a workshop on ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity’, with the aim of generating dialogue and mutual learning among activists, researchers, policymakers, and funders working towards more equitable health systems and a commitment to Universal Health Coverage (UHC). This issue of the IDS Bulletin is based around three principal themes that emerged from the workshop as needing particular attention. First, the nature of accountability politics ‘in time’ and the cyclical aspects of efforts towards accountability for health equity. Second, the contested politics of ‘naming’ and measuring accountability, and the intersecting dimensions of marginalisation and exclusion that are missing from current debates. Third, the shifting nature of power in global health and new configurations of health actors, social contracts, and the role of technology. For the first time in IDS Bulletin history, themes are explored not only in text but also through a selection of online multimedia content, including a workshop video, a photo story and a documentary. This expansion into other forms of communication is explicitly aimed at galvanising larger numbers of people in a movement towards UHC and the linked agenda of accountability for health equity. The articles and multimedia in this IDS Bulletin reflect the fact that while the desired outcome might be the same – better health for all – accountability strategies are as diverse as the contexts in which they have developed.

How to stop strikes from killing patients
Cullinan K: Health-e News, May 2018

How can patients and health workers be protected from becoming victims of a fight that is aimed an employer? Non-governmental organisations (NGOs) have asked the SA Human Rights Commission to investigate the violations of patients’ and health workers’ rights during a recent strike in South Africa and to offer guidance on how patients can be protected during future strike action. The human rights group Section 27 believes that such a solution lies in “determining essential services from non-essential services, or reaching agreement on the maintenance of some level of services during a legal dispute”. “Addressing the essential services issue is argued to have a two-fold effect. Firstly, those in the public health care system classified as non-essential services personnel would be able to exercise their right to strike. Secondly, patients’ rights would also be protected as they would be ensured of continued access to health care services as those staff properly designated as essential staff would not be striking,” according to a Section 27 opinion on strikes in the essential services.

Neglected Tropical Diseases and Equity in the Post-2015 Health Agenda
Taylor E; Smith J: Institute of Development Studies (IDS) Bulletin 49(2), doi: http://dx.doi.org/10.19088/1968-2018.141, 2018

The Millennium Development Goals’ focus on just three infectious diseases (HIV/AIDS, malaria, and belatedly, tuberculosis) configured the global health funding landscape for 15 years. Neglected tropical diseases (NTDs) are a group of 17 or so diseases that disproportionately afflict the world’s ‘bottom billion’. They are a symbol of global health inequities, in terms of prioritisation, research attention, and treatment. This article traces efforts to include NTDs in the Sustainable Development Goal (SDG) agenda and, having achieved that goal, lobby for an influential position in the post-2015 aid agenda. The SDGs herald a shift to a more expansive approach and there is a risk that NTDs will once again be left behind, lost in a panoply of new goals and targets. There is, however, an opportunity for NTDs to lever their ‘neglect’ and be recast as a tool of accountability, acting as both a target for and proxy indicator of health equity for the SDGs.

5. Health equity in economic and trade policies

Chronic respiratory disease among the elderly in South Africa: any association with proximity to mine dumps?
Nkosi V: The Conversation, May 2018

There is increasing evidence that environmental factors such as air pollution from mine dumps increase the risk of chronic respiratory symptoms and diseases. This study investigated the association between proximity to mine dumps and prevalence of chronic respiratory disease in people aged 55 years and older. Elderly persons in communities 1-2 km (exposed) and 5 km (unexposed), from five pre-selected mine dumps in Gauteng and North West Province, in South Africa were included in a cross-sectional study. Structured interviews were conducted with 2397 elderly people, using a previously validated ATS-DLD-78 questionnaire from the British Medical Research Council. Exposed elderly persons had a significantly higher prevalence of chronic respiratory symptoms and diseases than those who were unexposed., Results from the multiple logistic regression analysis indicated that living close to mine dumps was significantly associated with asthma, chronic bronchitis, chronic cough, emphysema, pneumonia and wheeze. Residing in exposed communities, current smoking, ex-smoking, use of paraffin as main residential cooking/heating fuel and low level of education emerged as independent significant risk factors for chronic respiratory symptoms and diseases. The study suggests that there is a high level of chronic respiratory symptoms and diseases among elderly people in communities located near to mine dumps in South Africa and that new long term effective dust control measures should be researched and implemented. One possible intervention could be to put buffer zones in place between mining dumps and where people come to settle as a start to what needs to be concerted government efforts to address the problem.

6. Poverty and health

No end to cholera without basic water, sanitation and hygiene
Montgomery M; Jones M; Kabole I; et al: Bulletin of the World Health Organisation 96(66), doi: http://dx.doi.org/10.2471/BLT.18.213678, 2018

Safe water, sanitation and hygiene are crucial in protecting people from cholera. The oral cholera vaccine is perceived as an interim solution that can be deployed in advance of, or together with, investments in water sanitation and hygiene. Oral cholera vaccine comes at a cost. Efforts to improve water sanitation and hygiene, on the other hand, have a relatively high return: US$ 4.30 for every dollar invested in water and sanitation, in addition to prevention of most waterborne diseases and time saved from not having to fetch water. Furthermore, several water sanitation and hygiene interventions can be implemented quickly and cheaply, such as point-of-use water treatment and safe storage, community action to end open defecation, provision of soap and promotion of handwashing. The authors argue that the reasonable alternative would be to pursue both oral cholera vaccine and water sanitation and hygiene efforts in parallel as done in, for example, Zanzibar, the United Republic of Tanzania and in Zambia. They argue that three main actions need to be taken to ensure that such investments are prioritized as part of the renewed efforts to end cholera. First, when countries request oral cholera vaccine, they should engage in water sanitation and hygiene efforts. Second, efforts should be made to ensure that initiatives to strengthen health systems and provide quality care devote sufficient resources for providing and sustaining water and sanitation services, especially in cholera treatment centres. Third, external funders and partners must align behind national multisectoral cholera control plans, not simply invest in stand-alone interventions. A shared vision and unanimous agreement among Member States, partners and funders to prioritize broader social and environmental determinants of health, including water, sanitation and hygiene, is needed to end cholera. A proposed World Health Assembly resolution seeks to promote this consensus, ensure effective multisectoral collaborations and address cholera in tandem with other diarrhoeal diseases.

7. Equitable health services

Oral cholera vaccine in cholera prevention and control, Malawi
M’bangombe M; Pezzoli L; Reeder B; et al: Bulletin of the World Health Organisation 96(66), 2018

With limited global supplies of oral cholera vaccine, countries need to identify priority areas for vaccination while longer-term solutions, such as water and sanitation infrastructure, are being developed. In 2017, Malawi integrated oral cholera vaccine into its national cholera control plan. The process started with a desk review and analysis of previous surveillance and risk factor data. At a consultative meeting, researchers, national health and water officials and representatives from nongovernmental and international organizations reviewed the data and local epidemiological knowledge to determine priority districts for oral cholera vaccination. The final stage was preparation of an application to the global oral cholera vaccine stockpile for non-emergency use. Malawi collects annual data on cholera and most districts have reported cases at least once since the 1970s. The government’s application for 3.2 million doses of vaccine to be provided over 20 months in 12 districts was accepted in April 2017. By April 2018, over 1 million doses had been administered in five districts. Continuing surveillance in districts showed that cholera outbreaks were notably absent in vaccinated high-risk areas, despite a national outbreak in 2017–2018. Augmenting advanced mapping techniques with local information helped to extend priority areas beyond those identified as high-risk based on cholera incidence reported at the district level. Involvement of the water, sanitation and hygiene sectors is key to ensuring that short-term gains from cholera vaccine are backed by longer-term progress in reducing cholera transmission.

8. Human Resources

Community health workers and accountability: reflections from an international “think-in”
Schaaf M; Fox J; Topp S; et al: International Journal for Equity in Health 17(66) 1-5, 2018

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and as a means for improvement in health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from the authors’ deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. Several propositions were made for further conceptual development and research related to the question of CHWs and accountability.

Community-based training of medical students is associated with malaria prevention and treatment seeking behaviour for children under 5 years in Uganda: a study of MESAU-MEPI COBERS in Uganda
Obol J; Akera P; Ochola P; et al: BMC Medical Education 18(131), doi: https://doi.org/10.1186/s12909-018-1250-y, 2018

This paper seeks to assess if targeted community-based medical education programme is associated with better prevention and treatment seeking behaviours in the management of malaria, a leading cause of morbidity and mortality of children under five in Uganda. A cross-sectional survey was done to compare communities around health facilities where medical students were placed at community-based education and Research Service (COBERS) sites with communities around similar health facilities where medical students were not placed (non-COBERS sites). The authors randomly selected two villages near each health facility and consecutively selected 10 households per village for interviews using nearest-neighbour method. The authors used a structured questionnaire to interview household heads on malaria prevention and treatment seeking behaviour for children under 5 years. The authors performed univariate analysis to determine site and demographic characteristics and performed a multivariate logistic regression to assess association between dependent and independent variables. Five hundred twenty-three of the children under 5 years in COBERS communities slept under insecticide treated nets the night before survey compared with 1451 in non-COBERS communities. 100 of children under 5 years in COBERS communities sought care for fever within 24 h of onset compared with 268 in non-COBERS communities. The presence of COBERS in communities is associated with improved malaria prevention and treatment-seeking behaviour for parents of children under 5 years. Further study needs to be done to determine the long-term impact of COBERS training program on malaria control and prevention in Uganda, along with its other effects.

Grandmothers help to scale up mental health care
Fleck F, Chibanda D: Bulletin of the World Health Organisation 96(66), doi: http://dx.doi.org/10.2471/BLT.18.020618, 2018

Dixon Chibanda developed the Friendship Bench approach to mental health care in Zimbabwe. In this interview he tells Fiona Fleck how he is taking the innovative approach to other countries. The idea of the Friendship Bench arose when he lost a patient to suicide in 2005. After identifying a large burden of mental health conditions, Chibanda talked to the authorities, but they had no money, staff or facilities to offer. So in 2007 he worked with 14 grandmothers in Mbare, a suburb of Harare that was badly affected by the clearance operation of informally built suburbs in the city. The grandmothers were from the community and already doing community work and the friendship bench formalized their role. The first four years were focused on developing a culturally appropriate evidence-based intervention that they could deliver. They developed a problem-solving therapy in the local language drawing on familiar concepts in the local culture while incorporating elements of cognitive behavioural therapy. Together with the grandmothers, they came up with key terms – kuvhura pfungwa, which means opening the mind, kusimudzira, (uplifting), and kusimbisa(strengthening) – that formed the basis of the Friendship Bench approach. The benches are outside each health facility, initially they were set apart, but now they are quite public, because the programme is widely accepted in the communities. Harare has more than 53 primary health care facilities, each with one to four of these benches. When people come to these facilities seeking mental health services, they are screened with the Shona Symptoms Questionnaire 14 to determine the level of mental health disorders and referred to the grandmothers –lay health workers who have been trained and who are supervised by health professionals. Chibanda’s own grandmother lived in Mbare and – although she was not one the therapists – she was instrumental in coming up with the income generating component of the approach, which is an important part of the group peer support. After finishing sessions on the bench, the grandmothers sit in a circle and share the challenges they face with their colleagues, while crocheting bags with recycled plastic to sell. Now, after completing therapy, the grandmothers give their patients further support and show them how to make the bags, as a forum for problem solving and income generation. In Zimbabwe, the approach has been scaled up in more than 70 communities in Harare, Chitungwiza and Gweru and further roll out is taking place, with a component for adolescents under development. The approach is being rolled out in Tanzania, the USA, Canada, Australia and New Zealand.

9. Public-Private Mix

Experimental vaccine to be used against Ebola outbreak in the DRC
Branswell H: Stat, 2018

A campaign to vaccinate people at risk of developing Ebola in the latest outbreak in the Democratic Republic of the Congo began in May 2018. The government of the DRC has formally asked to use an experimental vaccine being developed by Merck. The WHO has a stockpile of 4,300 doses of the vaccine in Geneva and the company has 300,000 doses of the vaccine stockpiled in the United States. Merck has given its permission for the vaccine to be used in this outbreak. As the vaccine — provisionally called V920 — is not yet licensed, the government deployed it under a compassionate use protocol. At this stage, it can only be used in the context of a clinical trial, plans for which are already in the works. The WHO director-general noted that DRC has lots of experiencing combating Ebola, since the first known outbreak in 1976 happened there. The 2018 outbreak marks the ninth known time Ebola has broken out in the DRC.

Use of family planning and child health services in the private sector: an equity analysis of 12 DHS surveys
Chakraborty N; Sprockett A: International Journal for Equity in Health 17(50) 1-12, 2018

This paper seeks to explore improved access to healthcare while minimizing financial hardships or inequitable service delivery. The authors analyzed Demographic and Health Survey data from Bangladesh, Cambodia, DRC, Dominican Republic, Ghana, Haiti, Kenya, Liberia, Mali, Nigeria, Senegal and Zambia. They conducted weighted descriptive analyses on current users of modern family planning and the youngest household child under age 5 to understand and compare country-specific care seeking patterns in use of public or private facilities based on urban/rural residence and wealth quintile. The modern contraceptive prevalence rate ranged from 8.1% to 52.6% across countries, generally rising with increasing wealth within countries. For relatively wealthy women in all countries except Ghana, Liberia, Mali, Senegal and Zambia, the private sector was the dominant source. Source of family planning and type of method sought across facilities types differed widely across countries. Across all countries women were more likely to use the public sector for permanent and long-acting reversible contraceptive methods. Wealthier women demonstrated greater use of the private sector for family planning services than poorer women. Overall prevalence rates for diarrhoea and fever/ARI were similar, and generally not associated with wealth. Over 40% of children with cough or fever did not seek treatment in DRC, Haiti, Mali, and Senegal. Of all children who sought care for diarrhoea, more than half visited the public sector and just over 30% visited the private sector; with differences more pronounced in the lower wealth quintiles. Use of the private sector varies widely by reason for visit, country and wealth status. Given these differences, the authors suggest that country-specific examination of the role of the private sector furthers an understanding of its utility in expanding access to services across wealth quintiles and providing equitable care.

10. Resource allocation and health financing

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014
Obare F; Abuya T; Matanda D; et al.: International Journal for Equity in Health 17(65), doi: https://doi.org/10.1186/s12939-018-0774-4, May 2018

This paper examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys. In 2004, the Ministry of Health implemented the “10/20 policy” for maternal health services in public facilities, that removed user fees at the lowest levels of care. In 2007, the 10/20 policy was removed and a policy of no user fees for deliveries in public facilities was declared. However, no alternative source of funding was offered and the reality of informal fees remained in place for many service users. Government announced
free maternity services in all public health facilities in June 2013. Data was gathered from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy and a statistically significant increase in public facility deliveries among women from the two top quintiles, and a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time. The findings provided empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: a systematic review
Owusu-Addo E; Renzaho A; Smith B: Health Policy and Planning 33(5) 675–696, 2018

This paper synthesises the evidence on cash transfers (CTs) impacts on social determinants of health and health inequalities in sub-Saharan Africa, and to identify the barriers and facilitators of effective CTs. Twenty-one electronic databases and the websites of 14 key organizations were searched in addition to grey literature and hand searching of selected journals for quantitative and qualitative studies on CTs’ impacts on social determinants of health and health outcomes. Out of 182 full texts screened for eligibility, 79 reports that reported findings from 53 studies were included in the final review. The review found that CTs can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration. CTs modify intermediate determinants such as nutrition, dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage. In conjunction with their influence on social determinants of health, there is moderate evidence from the review that CTs impact on health and quality of life outcomes. Many factors relating to intervention design features, macro-economic stability, household dynamics and community acceptance of programs influence the effectiveness of CTs.

11. Equity and HIV/AIDS

How antiretrovirals have cut the HIV/AIDS burden on SA's economy
Mahlakoana T: Business live, May 2018

Lost earnings attributable to HIV and AIDS as a result of either death or inability to work have declined significantly globally as countries scale up antiretroviral therapy. In 2005 HIV and AIDS were believed to have resulted in about $17bn in lost income, but the figure is projected to fall to $7.2bn in 2020. A study released by the International Labour Organisation shows that the number of employees living with the virus and unable to work has fallen "dramatically" since 2005. South Africa has the biggest HIV epidemic in the world with more than 7-million people living with the virus in 2016 and a stubbornly high rate of new infections. The country also has the largest antiretroviral treatment programme, which has increased life expectancy from 61 years in 2010 to 67 in 2015. The Employee Assistance Professionals Association’s Dr Dennis Cronson said there had been a great improvement in the effect of the virus on workers, especially in South Africa. "Hundreds of thousands of people are on ARVs and corporate managed programmes, and it’s a major success story …. the impact on productivity and other factors have improved," Cronson said.

12. Governance and participation in health

Inverted State and Citizens’ Roles in the Mozambican Health Sector
Dias J; Tomé T: Institute of Development Studies (IDS) Bulletin 49(2), doi: http://dx.doi.org/10.19088/1968-2018.134, 2018

This article explores the inversion of roles between the state and citizens, by exploring its historical roots and current implications for processes of social accountability in Mozambique, particularly in the health sector. This is a practice-based reflection grounded in the evidence collected through the implementation of community scorecards in the health sector in 13 districts of Mozambique. The evidence reveals a transfer of responsibilities from local governance institutions and service providers to the communities; diluting the frontiers between the state and citizens’ duties and rights, resulting in the inversion of roles. This inversion results in the minimisation of the state’s performance of its duties and accountability in the health sector to respond to local communities’ needs, allegedly due to the lack of financial resources. The authors suggest that it leads to the overburdening of local communities, who assume the responsibility of meeting their own demands, risking participation fatigue.

13. Monitoring equity and research policy

Evaluating efforts that build social power and participation in health systems: Introduction to the briefs
Loewenson R; Mastoya M; Beznec P; Frenz P; Mbwili Mueya C; Obando F: TARSC Shaping health, 2018

These four briefs (separately shown on this site) provide information on evaluation of social participation and power in health to support capacity and practice. They are intended primarily for those working directly with social participation and power in health systems, but also for managers, funders and others who engage with them. They intend to inform thinking and approaches and provide links to deeper resources and do not intend to prescribe or be a ’how to’ toolkit. The four briefs address:
BRIEF 1: The concepts and approaches applied in ‘monitoring and evaluation processes at www.tarsc.org/publications/documents/Shapinghealth%20eval%20brief%201%20May2018.pdf
BRIEF 2: Approaches to assessing change in social participation and power in health at www.tarsc.org/publications/documents/Shaping%20health%20eval%20brief%202%202018.pdf
BRIEF 3: The methods used for participatory evaluation at www.tarsc.org/publications/documents/Shaping%20health%20eval%20brief%203%202018.pdf
BRIEF 4: Engaging funders and formal systems on evaluations of social power in health at www.tarsc.org/publications/documents/Shaping%20health%20eval%20brief%204%202018.pdf

Trials and tribulations: cross-learning from the practices of epidemiologists and economists in the evaluation of public health interventions
Powell-Jackson T; Davey C; Masset E; et al.: Health Policy and Planning 33(5) 702–706, 2018

The authors propose that there are some underlying differences between the disciplines of epidemiology and economics how trials are used and conducted and how their results are reported and disseminated. They hypothesize that evidence-based public health could be strengthened by understanding these differences, harvesting best-practice across the disciplines and breaking down communication barriers between economists and epidemiologists who conduct trials of public health interventions. Differences between disciplines suggests that more can be done to incorporate behavioural theory into trials and to improve the reporting of trial results and share data. The authors hypothesize that evidence-based public health can be strengthened by understanding differences in how economists and epidemiologists conduct trials of public health interventions and harvesting best-practice across the disciplines.

14. Useful Resources

World Health Statistics 2018: Monitoring health for the SDGs
World Health Organisation, Geneva, 2018

The World Health Statistics series is WHO’s annual snapshot of the state of the world’s health. This 2018 edition contains the latest available data for 36 health-related Sustainable Development Goal (SDG) indicators. It also links to the three SDG-aligned strategic priorities of the WHO’s 13th General Programme of Work: achieving universal health coverage, addressing health emergencies and promoting healthier populations. The latest data available shows that less than half the people in the world today get all of the health services they need. In 2010, almost 100 million people were pushed into extreme poverty because they had to pay for health services out of their own pockets. 13 million people die every year before the age of 70 from cardiovascular disease, chronic respiratory disease, diabetes and cancer – most in low and middle-income countries.

15. Jobs and Announcements

13th International Conference on ICT for Development, Education and Skills
26-28 September 2018, Kigali, Rwanda

eLearning Africa 2018 is the 13th International Conference on ICT for Development, Education and Skills, in September in Kigali, Rwanda. The programme includes core dialogues, debates, discovery demos, knowledge exchange sessions, knowledge factories, networking meet-ups, panel talks, plenary sessions and poster presentations on specific topics and informal networking opportunities in which practitioners share their experiences, ideas, new information and perspectives. In the exhibition area, leading international eLearning manufacturers, suppliers and service providers present their latest products and services. eLearning Africa will hold a ministerial round table, an annual meeting of African ICT and Education ministers, who take part in a day-long discussion of key issues affecting education, training, skills and technology before the official opening of the main conference. The sub-themes for the conference include: Creating opportunities through education; transforming the continent; boosting competitiveness and ICT-centric growth; matching skills demand and supply in the African and global context; overcoming barriers; integrating Africa; ensuring inclusiveness diversity matters and digital transformation.

22nd International AIDS Conference (AIDS 2018)
23-27 July 2018, Amsterdam, the Netherlands

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.

Cochrane South Africa invites applications for the Aubrey Sheiham Evidence-based Health Care in Africa Leadership Award 2018
Applications close: 31 July 2018

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.

Emerging Public Health Practitioner Award: manuscript submissions open
Deadline for Applications: 3 August 2018

The South African Health Review's Emerging Public Health Practitioner Award (EPHPA) is open to young public health practitioners or student researchers in the fields of health sciences, medicine or public health who are currently studying for their Masters or Honours degree, or are in the final year of their Bachelor's degree. It is offered to South African citizens or permanent residents who are under the age of 35 on 3 August 2018. To apply, please submit your complete chapter along with a copy of your South African ID and EPHPA Entry form. Individuals seeking to publish a paper dealing with any of the following issues are encouraged to apply: human resources for health (e.g. community health workers, production and distribution of healthcare workers, planning and forecasting, task-shifting, etc.); responses to the prevention and management of non-communicable diseases; and progress and challenges towards implementing universal health coverage.

HIV Adolescence Workshop
10-12 October 2018, Cape Town, 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.

International Conference on Community Nursing and Public Health
19-21 November 2018, Cape Town, South Africa

This conference on 'Advancement in Public Health by integration of Community Nursing Practices' aims to bring together individuals and organizations from varied fields of healthcare and provide a global platform for the exchange of innovative ideas. Community Nursing 2018 provides an unmatched opportunity for nursing practitioners, healthcare experts, public health organizations, clinical researchers, academics, physicians and students to meet and network with famous individuals and organizations from their respective fields and to get useful insights in the latest clinical researches.

Public Health Association of South Africa (PHASA) 14th annual conference
10-12 September, Parys, South Africa

In commemoration of the World Health Organization’s (WHO) 70th anniversary celebration, the theme for this year’s Public Health Association of South Africa (PHASA) conference is “Health For All- Thinking Globally, Acting Locally.” Since its establishment in 1948, “Health For All” has been an underlying objective of the WHO and its member states; traversing strategic milestones from the Alma Ata Declaration in 1978 and the Millennium Development Goals in 2000, to the Sustainable Developmental Goals in 2015. The organisers hope that this theme will stimulate robust discussions on progress made, critical reflections on the challenges encountered, and vibrant dialogue on how to move closer to a world where all people are able to attain a state of health that enables them to lead socially and economically productive lives.

The 11th ECSA Best Practices Forum and 27th Directors Joint Consultative Committee Meeting
26th to 28th June 2018, Arusha, Tanzania

The East, Central and Southern Africa Health Community (ECSA-HC) will host the 11th Best Practices Forum and 27th Directors Joint Consultative Committee from 26 to 28 June 2018 in Arusha, Tanzania. The meetings bring together senior officials from Ministries of Health, Health Research Institutions and Heads of Health Training Institutions from Member States; diverse collaborating Partners and Experts from the region and beyond. The BPF and DJCC will be convened at a time, when ECSA Member States continue with efforts in pursuit of Universal Health Coverage, which forms part of the 2030 global development agenda. Deliberations of the 2018 conference will therefore focus on the theme Universal Health Coverage: Addressing Health Needs of the Underserved.


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