EQUINET NEWSLETTER 209 : 01 August 2018

1. Editorial

Safeguarding the principles of the Alma Ata Declaration on PHC
Editor, EQUINET Newsletter

For forty years the 1978 Declaration of Alma Ata on Primary Health Care has inspired and galvanised understanding, analysis and action on health. In our region, the aspirations and content that were included in the 1978 declaration were embedded in liberation movement goals and post- independence policies and informed the organisation and transformation of health services. Indeed a context of growing movements for social justice and emergent national health systems in the South was one source of the political momentum, values and practice that fuelled the Declaration. In various declarations over the past 40 years, African governments and communities have recognised the contribution of PHC to improved health equity in the region and voiced a need to accelerate efforts to implement it, even while resources bled out of public sector services.

In preparation for a Global conference in Astana in 2018 to commemorate 40 years of PHC a new declaration is being drafted: “the Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals”. The text can be found at http://www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf. It notes a “renewed commitment to health and well-being for all based on universal health coverage (UHC)” and locates PHC as “a necessary foundation to achieve UHC”. Its focus is thus on UHC as the end and PHC as the means. It makes reference to the work of other sectors to address other health determinants in line with the Sustainable Development Goals, “ avoiding political and financial conflicts of interest”.

But the Alma Ata declaration was so much more ambitious and comprehensive in its vision and scope! It called for an economic order that would serve the attainment of health and reduce inequalities in health globally, while also recognising that the promotion and protection of people’s health is essential for socio-economic development. Its language on state duties and public rights is unambiguous. Its principles are no less relevant today than in 1978, even if changing contexts, health profiles and knowledge demand creativity in how it is applied.

As new statements and declarations circulate, let’s remind ourselves of key features of what the Alma Ata Declaration says:

“ I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.

IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.

VI Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”.

There is more, and the full declaration can be found at http://www.who.int/publications/almaata_declaration_en.pdf

Those engaging on statements and processes on PHC should carefully compare with the Alma Ata Declaration and ensure that we do not lose or blur its clarity of principles and content.

Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the Global conference on PHC see http://www.who.int/primary-health/conference-phc/en/

2. Latest Equinet Updates

Responding to inequalities in health in urban areas in east and southern Africa: Brief 3: What do Harare urban youth say?
TARSC; CFHD; Harare youth: TARSC, CFHD EQUINET, Harare, 2018

By 2050, urban populations will increase to 62% in Africa. 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. We thus integrated many forms of evidence, including a review of literature, analysis of quantitative indicators, internet searches of evidence on practices, thematic content analysis and participatory validation by those more directly involved and affected. This brief covers the participatory validation by youth from six different suburbs in Harare facilitated by TARSC and the Civic Forum on Human Development (CFHD). The six groups of young people involved in the participatory validation came from youth living in northern higher income suburbs; youth in formal jobs (although noting that they may also be in insecure jobs); young people in tertiary education; young people in Epworth, as a suburb with informal settlements.; unemployed youth and youth in informal jobs. In this brief we summarise the findings of the participatory validation in the two meetings in 2016. We present how the views of the Harare youth related to the areas of health and wellbeing identified in the literature, and how far their experiences varied in the different groups. The findings indicate that there is diversity between young people in different parts of the city and different social contexts that affect which dimensions of wellbeing they perceive to be most important. It was evident, however, that the question preoccupying young people was not ‘how big is the gap between us?’ but ‘how, collectively do we close the gap’? The brief points to the policies for youth wellbeing in Harare that would be important to closing the gap.

Responding to inequalities in health in urban areas in east and southern Africa: Brief 4: What did we learn from experiences and innovations in other countries to improve youth health and wellbeing?
Loewenson R; Masotya M; CFHD and Harare youth: TARSC, EQUINET, 2018

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 covers the main features of practices found to be important for urban youth wellbeing from the literature, data and participatory validation reported in Briefs 1-3. In particular it explores practices relating to education, and ensuring access and responsiveness of the curriculum to youth needs; job creation and the measures to support job creation for youth; enterprise creation, and support of how health promoting activities support youth entrepreneurship; the creative and green economy, how it is being developed and organised to support youth employment and wellbeing; shelter/social conditions, including youth access to shelter and non-violent enabling community environments; information and communication, how youth are influencing debates, norms and practices and using social media to promote wellbeing, gender equality and solidarity and participatory government. The brief discusses what these findings suggest for urban primary health care systems to promote health and address the health and wellbeing of urban youth.

3. Equity in Health

Multimorbidity: a priority for global health research
The Academy of Medical Sciences: AMS, London, 2018.

This report summarises available evidence on multimorbidity and highlights key evidence gaps which must be addressed to better understand the issue, and improve care and outcomes globally. The report calls for a standardised definition and reporting system for multimorbidity. It recommends a need to better understand the trends and patterns of multimorbidity across countries; the determinants of and burden caused by common clusters of conditions and how best to prevent and manage multimorbidity. The report draws on insights from a number of workshops, one of which was held in Johannesburg, South Africa. It raises that many populations in high, middle and low income countries are experiencing multimorbidity on a massive scale but that the available evidence about the burden, determinants, prevention and treatment of patients with multimorbidity is inadequate.

The increasing prevalence of non-communicable diseases in low-middle income countries: the view from Malawi
Gowshall M; Taylor-Robinson: International Journal of General Medicine, 2018(11), 255-264, 2018

As a low-income African country that consistently ranks amongst the world’s poorest nations, Malawi as a case study demonstrates how transition due to societal change and increasing urbanization is often accompanied by a rise in the rate of non-communicable diseases (NCDs). Other factors apart from changing lifestyle factors can explain at least some of this increase, such as the complex relationship between communicable and NCDs and growing environmental, occupational, and cultural pressures. Malawi and other LMIs are struggling to manage the increasing challenge of NCDs, in addition to an already high communicable disease burden. However, the author proposes that health care policy implementation, specific health promotion campaigns, and further epidemiological research may be key to attenuating this impending health crisis, both in Malawi and elsewhere.

WHO Global Ambient Air Quality Database
World Health Organisation: WHO Geneva 2018

More than 80% of people living in urban areas that monitor air pollution are exposed to air quality levels that exceed the World Health Organization (WHO) limits. While all regions of the world are affected, populations in low-income cities are the most impacted. According to the latest air quality database, 97% of cities in low- and middle income countries with more than 100 000 inhabitants do not meet WHO air quality guidelines. However, in high-income countries, that percentage decreases to 49%. In the past two years, the database – now covering more than 4000 cities in 108 countries – has nearly doubled, with more cities measuring air pollution levels and recognizing the associated health impacts. As urban air quality declines, the risk of stroke, heart disease, lung cancer, and chronic and acute respiratory diseases, including asthma, increases for the people who live in them.

4. Values, Policies and Rights

DRAFT Astana Declaration on Primary Health Care
WHO: Draft for review for the Global Conference on Primary Health Care, World Health Organisation, Geneva, 2018

On 25-26 October 2018, the world will come together to renew a commitment to strengthening primary health care to achieve universal health coverage and the Sustainable Development Goals. The World Health Organisation (WHO) have received over 500 comments on the Draft Declaration on Primary Health Care and incorporated them in this updated draft. This draft describes the need for Primary Health Care to address today’s health challenges. WHO are reopening the public consultation to ensure that voices of a broad range of stakeholders are included and has circulated a draft declaration for comment. It goes to in-person member state consultation in early August. The proposed text is provided at the website.

From health for all to universal health coverage: Alma Ata is still relevant
Raj Pandey K: Globalization and Health 14(62), doi: https://doi.org/10.1186/s12992-018-0381-6, 2018

With increasing adoption of universal health coverage (UHC), the health for all agenda is resurgent globally. This commentary discusses the origin of the health for all agenda in the 1970s and the influence of global politico-economic forces in shaping that agenda and its demise. The author proposes that it has resurged in the form of UHC in the twenty-first century, but also discusses UHC’s focus on finances and the increasing role of market economy in health care, and the need to regulate the market based provision of healthcare, and incorporate more of the people and community centred ethos of the PHC of 40 years ago.

Opposition to Breast-Feeding Resolution by U.S. Stuns World Health Officials
Jacobs A: The New York Times, July 2018

A resolution to encourage breast-feeding was expected to be approved quickly and easily by the hundreds of government delegates who gathered in Geneva for the World Health Assembly. Based on decades of research, the resolution says that mother’s milk is healthiest for children and countries should strive to limit the inaccurate or misleading marketing of breast milk substitutes. The United States delegation was however reported to have embraced the interests of infant formula manufacturers and to have upended the deliberations. Health advocates scrambled to find another sponsor for the resolution, but at least a dozen countries, most of them poor nations in Africa and Latin America, backed off, citing fears of retaliation, according to officials from Uruguay, Mexico and the United States. In the end, the Russian delegation stepped in to introduce the measure — and the Americans did not oppose.

Teenager at centre of Kenyan court case over botched abortion has died
Ratcliffe R: The Guardian, July 2018

A teenager whose botched abortion was at the centre of a high court case in Kenya has died. The girl, who was raped aged 14 and then left with horrific injuries after a backstreet termination, had been the subject of a controversy over the liability of the Kenyan government in her case. The girl’s mother and a group of campaigners had filed a case against the government, claiming it had failed to offer the girl – known as JMM – adequate post-abortion care. They called for the government to reinstate guidelines on safe abortions. JMM’s mother, as well as the Federation of Women Lawyers-Kenya and two human rights advocates, filed the case in the Kenyan high court in 2015. Campaigners say that if successful it could save the lives of thousands of women a year. The hearings are expected to conclude in July 2018. Access to abortion was widened under Kenya’s 2010 Constitution, which allowed for the procedure in cases where the health or life of a pregnant woman is at risk, and in cases of emergency. But the government has since withdrawn standards and guidelines designed to make legal abortions safer and banned health workers from undergoing training on abortion. In 2012, nearly 120,000 women were admitted to public health facilities for abortion-related complications. The author reports that women seeking post-abortion services face stigma and discrimination in health facilities, particularly poor or young women. The court decision is expected before the end of the year.

5. Health equity in economic and trade policies

Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: A thematic document analysis of trade and health policy space
Barlow P; Labonte R; McKee M; et al.: PLOS Medicine, doi: https://doi.org/10.1371/journal.pmed.1002590, 2018

It has long been contested that trade rules and agreements are used to dispute regulations aimed at preventing noncommunicable diseases (NCDs). Yet most analyses of trade rules and agreements focus on trade disputes, potentially overlooking how a challenge to a regulation’s consistency with trade rules may lead to ‘policy or regulatory chill’ effects, whereby countries delay, alter, or repeal regulations in order to avoid the costs of a dispute. Systematic empirical analysis of this pathway to impact was previously prevented by a dearth of systematically coded data. In this paper, the authors report analysis of a newly created dataset of trade challenges about food, beverage, and tobacco regulations among 122 World Trade Organization (WTO) members from January 1, 1995 to December 31, 2016. The scope and frequency of trade challenges are thematically described, and economic asymmetries between countries are analysed, raising and defending them, and summarised through four cases of their possible influence. Between 1995 and 2016, 93 food, beverage, and tobacco regulations were challenged at the WTO. ‘Unnecessary’ trade costs were the focus of 16.4% of the challenges. Only one (1.1%) challenge remained unresolved and escalated to a trade dispute. Thirty-nine (41.9%) challenges focussed on labelling regulations, and 18 (19.4%) focussed on quality standards and restrictions on certain products like processed meats and cigarette flavourings. High-income countries raised 77.4% of all challenges raised against low- and lower-middle–income countries. The authors further identified four cases in Indonesia, Chile, Colombia, and Saudi Arabia in which challenges were associated with changes to food and beverage regulations. Data limitations precluded a comprehensive evaluation of policy impact and challenge validity. The authors observe that policy makers appear to face significant pressure to design food, beverage, and tobacco regulations that other countries will deem consistent with trade rules. They note that trade-related influence on public health policy is likely to be understated by analyses limited to formal trade disputes.

6. Poverty and health

"Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda
Keya K; Sripad P; Nwala E; et al: International Journal for Equity in Health 17(70) 1-10, 2018

This paper explored, through women’s, communities’, and providers’ perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking services for fistula. A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews with women affected by fistula including those awaiting repair, living with fistula, and after repair, their spouses and other family members, and health service providers involved in fistula repair and counseling. Focus group discussions with male and female community stakeholders and post-repair clients were also conducted. Women’s experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. Women in Uganda spend Ugandan Shilling 10,000 to 90,000 for two people for a single trip to a camp. Factors that influence women’s and families’ ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation. The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers were recommended.

7. Equitable health services

EAC Executive decries high number of East Africans seeking health services in India
East African Community Secretariat: Arusha, Tanzania, June, 2018

The Executive Secretary of the East African Health Research Commission (EAHRC), Professor Gibson Kibiki, has decried the high number of East Africans going to India to seek medical services which can be accessed in hospitals in the region. Prof. Kibiki attributed the huge exodus of patients to India to the lack of information on health services that were available at referral hospitals in the region. He revealed that East Africans may soon be able to access treatment across national borders in addition to enjoying portable health insurance across the region, adding that the Commission would soon undertake research to gauge the feasibility of a regional health insurance scheme before piloting the scheme. He described as counterproductive the tendency by health researchers and medics in the Partner States to work in silos since the region was one and that diseases did not know national borders.

Gendered health systems: evidence from low- and middle-income countries
Morgan R; Ayiasi R; Barman D; et al: Health Research Policy and Systems 16(58) 2-12, 2018

This paper synthesizes findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gender approach can be applied by researchers in a range of low- and middle-income settings to these domains and demonstrates that this can uncover new ways of viewing seemingly intractable problems. The studies used a combination of mixed, quantitative, qualitative and participatory methods, including photovoice and life histories, to prompt deeper and more personal reflections on gender norms. Five core themes that cut across the different studies were the intersection of gender with other social stratifiers, the importance of male involvement, the influence of gendered social norms on health system structures and processes, the reliance on unpaid carers within the health system and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis by researchers, policy-makers and health practitioners.

Socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over in China, Ghana, and India
Kailembo A; Preet R; Williams J; et al.: International Journal for Equity in Health 17(99) 1-14, 2018

This study measures and describes socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over, in China, Ghana and India. The prevalence of unmet need was 60, 80, and 62% in China, Ghana and India respectively. The adjusted relative index of inequality for education was statistically significant for China, Ghana, and India, whereas the adjusted relative index of inequality for wealth was significant only in Ghana. Male sex was significantly associated with self-reported unmet need for oral health services in India. Given rapid population ageing, the author argues that further evidence of socioeconomic inequalities in unmet need for oral health services by older adults in low to medium income countries are needed to inform policies to mitigate inequalities in the availability of oral health services.

8. Human Resources

How do gender relations affect the working lives of close to community health service providers? Empirical research, a review and conceptual framework
Steege R; Taegtmeyer M; McCollum R; et al: Social Science & Medicine 209 (2018) 1–13, 2018

This paper synthesises current evidence on gender and close-to-community (CTC) providers and the services they deliver. The review included 58 papers from literature to inform the development of a conceptual framework. The authors present a holistic conceptual framework to show how gender roles and relations shape CTC provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, family and intra-household dynamics are of importance. Important at the health systems level, are career progression and remuneration. The authors present suggestions for how the role of a CTC provider can, with the right support, be an empowering experience. Key priorities for policymakers to promote gender equity in this cadre include: safety and well-being, remuneration, and career progression opportunities.

Postgraduate training for trauma prevention, injury surveillance and research, Uganda
Bachani A; Paichadze N; Bentley J; et al: Bulletin of the World Health Organisation; 96(6):423–427, 2018

This paper addressed the gaps in shortage of trained people and lack of national data on non-communicable diseases and their risk factors in Uganda. The authors developed and implemented a new track within an existing master of public health programme, aimed at developing graduate-level capacity and promoting research on key national priorities for trauma and injuries. They also offered training opportunities to a wider audience and set up a high-level national injury forum to foster national dialogue on addressing the burden of trauma, injuries and disability. Over the years 2012 to 2017 there were four cohorts of master’s students, with a total of 14 students. Over 1300 individuals participated in workshops and seminars of the short-term training component of the programme. The forum hosted three research symposia and two national injury forums. The authors note that institutional support and collaborative engagement is important for developing and implementing successful capacity development programmes, and that integration of training components within existing academic structures is key to sustainability and appropriate mentorship for motivated and talented students.

South Africa: Health workers say they are undervalued and poorly equipped
Mutandiro K: GroundUp, July 2018

Representatives from the Democratic Nursing Organization of South Africa (Denosa), a trade union that represents nurses and professional midwives, say that nursing staff work under bad conditions. A Denosa spokesman said South African nurses and nursing staff were seeking work out of the country where they were appreciated and would get better salaries. “People who rely on the services of public healthcare workers are disadvantaged when public health workers are understaffed or strike due to unresolved grievances,” said Ashwell Jenneker of Statistics South Africa. In a dialogue, the South Africa Minister of Health, Aaron Motsoaledi said, “We will do our best to ensure that all health workers are given better working conditions. We will also work on making sure that the minimum service level of health workers is implemented.” Those attending the dialogue agreed that a formal investigation was needed into the working conditions of all health workers.

9. Public-Private Mix

Leveraging the power of partnerships: spreading the vision for a population health care delivery model in western Kenya
Mercer T; Gardner A; Andama B; et al.: Globalization and Health 14(44), doi: https://doi.org/10.1186/s12992-018-0366-5, 2018

This paper describes an academic partnership to support the public-sector health care system, with a major focus on scaling up HIV care in western Kenya to build a system able to take responsibility for the health of an entire population. The population health care delivery model involved comprehensive, integrated, community-centred, and financially sustainable services, with a path to universal health coverage. The authors share information on the partnership with strategic planning and change management experts from the private sector to use a ‘Learning Map®’ to collaboratively develop and share a vision of population health, and achieve strategic alignment with key stakeholders at all levels of the public-sector health system in western Kenya. The authors describe how the model has leveraged the power of partnerships to move beyond the traditional disease-specific silos in global health to a model focused on health systems strengthening and population health.

10. Resource allocation and health financing

Examining equity in health insurance coverage: an analysis of Ghana’s National Health Insurance Scheme
Dake F: International Journal for Equity in Health 17(85) 1-10; 2018

This paper examines equity in coverage under Ghana’s National Health Insurance Scheme. Secondary data from the 2008 Ghana Demographic and Health Survey based on an analytical sample of 4821 females and 4568 males were analysed using descriptive, bivariate and multivariate methods. As at 2008, more than 60% of Ghanaians aged 15–59 years were not covered under the National Health Insurance Scheme with slightly more females than males covered. Coverage was highest among the highly educated, professionals, those from households in the richest wealth quintile and urban residents. Lack of coverage was most concentrated among poor people. The author calls for deliberate action to enrol the poor under the National Health Insurance Scheme.

Saving lives, spending less: a strategic response to NCDs
World Health Organisation: WHO, Geneva, 2018

This report reveals the financing needs and returns on investment of WHO’s cost-effective and feasible “best buy” policies to protect people from noncommunicable diseases (NCDs), the world’s leading causes of ill health and death. It shows that for every US$1 invested in scaling up actions to address NCDs in low- and lower-middle-income countries (LLMICs), there will be a return to society of at least US$7 in increased employment, productivity and longer life. If all countries use these interventions, the world would move significantly closer to achieving Sustainable Development Goal 3.4 to reduce premature death from NCDs by one-third by 2030. Among the most cost-effective “best buy” interventions are increasing taxes on tobacco and alcohol, reducing salt intake through the reformulation of food products, administering drug therapy and counselling for people who have had a heart attack or stroke, vaccinating girls aged 9─13 years against human papillomavirus and screening women aged 30─49 years for cervical cancer. LLMICs currently bear the brunt of premature deaths from NCDs: almost half (7.2 million) of the 15 million people who die globally every year between the age of 30 and 70 are from the world’s poorest countries. Yet global financing for NCDs is severely limited, receiving less than 2% of all health funding. The report indicates that taking effective measures to prevent and control NCDs costs just an additional US$ 1.27 per person per year in LLMICs. The health gains from this investment will, in turn, generate US$350 billion through averted health costs and increased productivity by 2030, and save 8.2 million lives during the same period. Saving lives, spending less: a strategic response to NCDs issues a clear call for funding for scaling up the “best buy” policies which would save millions of lives.

11. Equity and HIV/AIDS

HIV infection in patients with sexually transmitted infections in Zimbabwe – Results from the Zimbabwe STI etiology study
Kilmarx P; Gonese E; Lewis D; et al.: PLoS One, doi: https://doi.org/10.1371/journal.pone.0198683, 2018

HIV and other sexually transmitted infections (STI) frequently co-occur. The authors conducted HIV diagnostic testing in an assessment of the etiologies of major STI syndromes in Zimbabwe. A total of 600 patients were enrolled at six geographically diverse, high-volume STI clinics in Zimbabwe in 2014–15: 200 men with urethral discharge, 200 women with vaginal discharge, and 100 men and 100 women each with genital ulcer disease (GUD). Patients completed a questionnaire, underwent a genital examination, and had specimens taken for etiologic testing. Patients were offered, but not required to accept, HIV testing using a standard HIV algorithm in which two rapid tests defined a positive result. A total of 489 participants accepted HIV testing; 201 tested HIV-1-positive, including 16 of 134 participants who reported an HIV-negative status at study enrollment, and 58 of 206 participants who reported their HIV status as unknown. Of 147 who self-reported being HIV-positive at study enrollment, 21 tested HIV negative. HIV infection prevalence was higher in women than in men, and was 28.5% in men with urethral discharge, 40.5% in women with vaginal discharge, 45.2% in men with GUD, and 59.8% in women with GUD. The high prevalence of HIV infection in STI clinic patients in Zimbabwe is argued by the authors to underscore the importance of providing HIV testing and referral for indicated prevention and treatment services for this population. The discrepancy between positive self-reported and negative study HIV test results highlights the need for operator training, strict attention to laboratory quality assurance, and clear communication with patients about their HIV infection status.

12. Governance and participation in health

Digital Democracy, Analogue Politics
Nanjala N: Zed Books, 2018

From the upheavals of recent national elections to the success of the #MyDressMyChoice feminist movement, digital platforms have already had a dramatic impact on political life in Kenya – one of the most electronically advanced countries in sub-Saharan Africa. While the impact of the Digital Age on Western politics has been extensively debated, there is still little appreciation of how it has been felt in developing countries such as Kenya, where Twitter, Facebook, WhatsApp and other online platforms are increasingly a part of everyday life. Written by a respected Kenyan activist and researcher at the forefront of political online struggles, this book presents a unique contribution to the debate on digital democracy. For traditionally marginalised groups, particularly women and the disabled, digital spaces have allowed Kenyans to build new communities which transcend old ethnic and gender divisions. But the picture is far from wholly positive. Digital Democracy, Analogue Politics explores the drastic efforts being made by elites to contain online activism, as well as how ‘fake news’, a failed digital vote-counting system and the incumbent president's recruitment of Cambridge Analytica contributed to tensions around the 2017 elections. Reframing digital democracy from the African perspective, Nyabola’s work opens up new ways of understanding our current global online era.

Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries
Waldman L; Theobald S; Morgan R: Institute of Development Studies (IDS) Bulletin 49(2), doi: http://dx.doi.org/10.19088/1968-2018.137, 2018

This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability and there is a need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. The authors suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.

Ugandan citizens unite against social media tax
Agence France Press: News24, July 2018

Politicians, clerics, feminists and others have formed a broad coalition of Ugandans calling for an end to a social media tax. In July, Uganda's communications regulator blocked access to social media including WhatsApp, Facebook and Twitter, as well as dating sites Tinder and Grindr, unless users pay a Shs200 ($0.05) daily tax. Mobile internet users now have to input a telephone code to pay the tax before they are able to access most social media sites, although implementation has proved patchy with some blocked services still available. Some have turned to virtual private networks (VPNs) to disguise their location and avoid the levy, a trick learned during elections two years ago when the government tried to shut down social media. President Yoweri Museveni - a Twitter user with 855 000 followers - is reported to have urged the imposition of the tax earlier this year, to put an end to "gossip". The protesters are resisting the measure and calling for it to be lifted.

13. Monitoring equity and research policy

Tracking SDG7: The Energy Progress Report
World Health Organisation: WHO, Geneva, 2018

Energy is crucial for achieving almost all of the sustainable development goals (SDGs), from eradication of poverty through advancements in health, education, water supply and industriali­zation to combating air pollution and climate change. This new report includes updated data from WHO on household air pollution showing that 3 billion people – or more than 40% of the world’s popula­tion – still do not have access to clean cooking fuels and technologies. Household air pollution from burning solid fuels and using kerosene for cooking alone are responsible for some 4 mil­lion deaths a year, with women and children being at greatest risk. The report provides a com­prehensive summary of the world’s progress towards the global energy targets on access to electricity, clean cooking fuels, renewable energy and energy efficiency. It was launched at the Sustainable Energy for All forum held on 2 May 2018 in Lisbon, Portugal.

14. Useful Resources

Managing epidemics: Key facts about major deadly diseases
World Health Organisation: WHO, Geneva, 2018

This manual provides concise and up-to-date knowledge on 15 infectious diseases that have the potential to become international threats, and tips on how to respond to each of them. The 21st century has already been marked by major epidemics. Old diseases - cholera, plague and yellow fever - have returned, and new ones have emerged - SARS, pandemic influenza, MERS, Ebola and Zika. These epidemics and their impact on global public health have convinced the world's governments of the need for a collective and coordinated defence against emerging public health threats and accelerated the revision of the International Health Regulations (2005), that entered into force in 2007. The diseases covered are: Ebola virus disease, lassa fever, Crimean-Congo haemorrhagic fever, yellow fever, Zika, chikungunya, avian and other zoonotic influenza, seasonal influenza, pandemic influenza, Middle-East respiratory syndrome (MERS), cholera, monkeypox, plague, leptospirosis and meningococcal meningitis. Although originally developed as guidance for WHO officials, this publication is available to a wide readership including all frontline responders - communities, government officials, non-state actors and public health professionals - who need to respond rapidly and effectively when an outbreak is detected.

15. Jobs and Announcements

African Network for Internationalization of Education (ANIE) 9th Annual Conference 2018: Africa in the global higher education landscape: the role of internationalization
3 – 5 October 2018, Nairobi, Kenya

ANIEs 10th Anniversary and 9th Annual Conference will debate contemporary trends in internationalization of higher education in Africa, the achievements that have been made over the last one decade, main challenges, and the implications of global internationalization of higher education in Africa. It is a timely opportunity to reflect on the crucial role of Africa in the global higher education and research landscape, especially towards the realization of the Sustainable Development Goals (SDGs).The conference ties in with the goals of Agenda2063; a blueprint for the growth of all the nations of the African continent for coming five decades. It aims to critically consider where African universities find themselves at present in the global higher education landscape. In which ways are the colonial and post-colonial legacies of African higher education playing themselves out in internationalization processes? How has internationalization in Africa helped African universities to claim spaces in the African knowledge domain from their former subservient positions? Who are the narrators of African knowledge and how can internationalization reshape the landscape?

Applications for the 2nd Cohort of Tekano Fellows now open
Deadline for Stage 1 of applications: 31 August 2018

Tekano's mission to foster dynamic, visionary, value-based leaders working both individually and in catalytic communities of learning and action who articulate, convey and act to promote health equity by addressing the social and structural determinants of health. Tekano's programme is built around annual fellowships for mid-career people from diverse backgrounds and disciplines who have already shown leadership in addressing the determinants of health equity. The programme is composed of 6 face-to-face modules, held every two months from January to December 2019. Applicants must be a South African citizen or valid permit holders between 25- 45 of age with evidence of showing leadership and commitment to social justice in South Africa, linked to health equity. Applicants must commit to all program activities of the Fellows Programme in 6 modules in 2019 and either be employed or volunteer with a sending organisation/s.

Call for expressions of interest on Heightening Institutional Capacity for Government Use of Health Research Award
Deadline: 15 August 2018

Applications are open for Heightening Institutional Capacity for Government Use of Health Research (HIGH-Res) Award. This is a joint call for proposals from the Alliance for Health Policy and Systems Research and Wellcome to enhance the capacity of ministries of health in lower-middle and low-income countries to use health research evidence in policy-making. This call will fund one consortium up to US$ 1,000,000 for a maximum duration of 36 months. The collaborating research or academic teams must be based at recognized institutions with the capacity to undertake high-quality research. This means an institution that possesses an existing in-house capacity to host a grant and can demonstrate an independent capability to undertake and lead on research programmes. Ministries of health must engage as implementing partners and are required to co-lead the consortium. Applications that include capacity building and comparison across several different institutions and/or countries are encouraged. The primary applicants must be based in at least developed, lower-income or lower-middle income country.

Child Rights and Child Law Short Course for Health and Allied Professionals
3 - 7 December 2018 Cape Town

Every year the Children’s Institute runs a short course on child rights and child law for health and allied professionals. This five-day intensive course provides an opportunity for doctors, nurses, social workers and allied professionals to explore how to better support children’s rights in practice. The course aims to build a network of health and allied professionals interested in promoting children’s rights and sharing best practice, and will: deepen understandings of child rights and child law in South Africa; enable participants to apply this understanding in daily practice; enable participants to advocate for children’s health both within and outside the health care system. The course is accredited by both the Health Professions Council of South Africa and the SA Council for Social Service Professions, and is targeted at doctors, nurses, educators, social workers and allied professionals who are responsible for child health at all levels of the health care system.

Emerging Public Health Practitioner Award: manuscript submissions open
Deadline: 30 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. Individuals seeking to publish a paper dealing with any of the following issues are encouraged to apply: Health workers (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.; Progress and challenges towards implementing universal health coverage. The South African Health Review's Emerging Public Health Practitioner Award is offered to South African citizens or permanent residents who are under the age of 35 on 3 August 2018. See website for further details.

Public Health Association of South Africa Annual Conference: Health for All- Thinking Globally, Acting Locally
10-12 September 2018, Khaya iBhubesi, Parys, South Africa

The Public Health Association of South Africa extends a warm invitation to their 14th annual conference in Parys, North West Province. The conference program features expert plenaries and panel discussions, oral and poster research presentations, skills development workshops, and the opportunity to engage with special interest groups. In commemoration of the World Health Organization’s 70th anniversary celebration, the theme for this year’s conference is “Health for All- Thinking Globally, Acting Locally.” Since its establishment in 1948, “Health for All” has been an underlying objective of the World Health Organization’s 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. This theme aims to 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.

Robert Carr Fund Request For Proposals (RFP) for 2019-2021
Deadline for applications: 13 August 2018 at 12:00 (noon) CET.

The Robert Carr Fund is inviting proposals from global and regional civil society networks addressing critical factors protecting the rights of inadequately served populations (ISPs); scaling up access to HIV prevention, treatment, care and support; and assuring that resources are mobilized and utilized appropriately to respond to the global HIV epidemic. The goal of the Fund is to contribute to improved health, inclusion and social wellbeing for inadequately served populations (ISPs). To reach this goal, the Robert Carr Fund provides core funding to strengthen the institutional and advocacy capacity of regional and global ISP and civil society networks and/or their consortia. Global and regional networks and consortia of networks which meet the definitions and criteria set by this RFP are invited to apply for a grant to support core funding and/or activity needs of the networks and/or consortia for up to three years (2019-2021).

Shaping health participatory satellite session, Global Symposium for Health Systems Research, 9 October 2018, Liverpool UK
Session open for registration

In this session at the Global Symposium for Health Systems Research participants will share evidence and learning from a multi-country Shaping health consortium on social participation in local health systems. The session will also use participatory approaches to draw on the experiences of those participating. Experiences in Shaping Health show how social participation and power can make health systems more holistic in approach, more responsive and more inclusive. Participants will discuss and draw recommendations on practices that ground health action and services within community cultures and systems, what challenges they face, and how to facilitate and encourage such practice. The session is open for registration, but there are a limited number of places. See the website for further details on how to register .


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