EQUINET NEWSLETTER 210 : 01 September 2018

1. Editorial

A tribute to those who provoke us to think again
Editor, EQUINET News

While working on this month's issue we got news of the passing of an inspiring African thinker, Samir Amin, and then later in the month of the previous UN Secretary General Kofi Annan and pay our respects to both. In different ways and forums they challenged thinking and agendas from an African and southern lens. From Dakar, Senegal, where Samir Amin led the Third World Forum, Vijay Prashad notes that Amin explored and wrote about both the dangers and possibilities of our current world. In the face of a "world system with finance in dominance and people whipping from one precarious job to another" he pointed to both the need and possibility of Africa making different choices and creating and advancing an alternative. "As long as we are resisting, he would say, we are free." We include one of the many articles published on his work and ideas in this issue.

Back to our editorial this month on waiting mother shelters. Papers included in this issue point to a continuing research debate on their effectiveness, with one review finding no evidence of this from randomised control trials. Yet the evidence from experience of their use in Zimbabwe in the editorial suggests a need to think beyond measured service and morbidity outcomes to understand their value for improving wellbeing, and to understand how, beyond individual interventions, different elements of comprehensive primary health care come together to improve health and wellbeing.

Waiting mothers homes save lives: what we have learned from Zimbabwe
Nonjabulo Mahlangu, Mandy Mathias, Mongi Khumalo, Thabiso Sibanda, Zimbabwe

Silothemba looks lovingly at the little bundle nestled in her arms and beams with pride. “It wasn`t easy,” she says. “I nearly lost this baby. I bled a lot and had I not been here the nurses say I may not have made it too. I wasn`t eager to come to the waiting mothers home because my friends said the nurses keep you there for long and I have two small children at home. Actually I didn’t go to the home on the day the nurses said as I decided to go to the clinic when I felt labour pains. My local village health worker encouraged me to take their advice, however, and I am so happy that I did. My delivery was very difficult. It started at night and had I not been at the clinic my baby and I might not have survived”.

Silothemba is one of the many mothers in Zimbabwe who have benefited from waiting mothers homes. These facilities help to reduce home deliveries as they enable mothers to be at health facilities when labour begins. Nutrition gardens at clinics managed by health centre committees provide vegetables for pregnant women, and boost food security for those from poor households.. Kumbudzi clinic in Umzingwane district also has a kitchen project to support and promote nutrition amongst pregnant women.

In Zimbabwe currently 525 mothers die in every 100 000 live births, one of the highest maternal mortality rates in the world. Mother and newborn survival in Zimbabwe is affected by the ‘3 delays’, that is a delay in making a decision to seek health services, a delay in reaching a health facility and a delay in receiving quality services and care upon reaching a health facility. These delays and the deaths from them are greater in rural areas.

Before the waiting mothers homes were introduced, rural women often gave birth at home with the aid of traditional birth attendants. While convenient, these home births may expose women to risks from unhygienic conditions or limited ability to manage complications. Waiting mothers` homes increase mothers’ access to skilled birth attendants and emergency specialized care.

Women who deliver at home often lack adequate information on the risks associated with pregnancy and childbirth. Health monitors at community level indicate that the delay in deciding to seek health care is a major contributor to maternal deaths, as women decide to seek appropriate health care when it is too late. This delay is exacerbated by the fact that many women do not make these decisions themselves but defer to spouses or relatives, who may also lack knowledge on maternal and child health. Pregnant women also face barriers from long distances to health facilities, poor road networks, slow transport methods. They may thus deliver before they even reach the clinic. Women in many remote rural and resettlement areas live more than 25 kilometers away from health facilities, above the 10km maximum recommended by government. Going by ox drawn cart is not an option when there are pregnancy related complications have developed and many transport operators fear the risk associated with ferrying such passengers.

A waiting mother home reduces the stress of these barriers, giving time to travel to facilities, and reducing costs from different transport options. It brings mothers closer to the skilled health workers they need to manage normal deliveries or obstetric complications.

This puts the focus on the third delay, the delay in receiving adequate health care. With postpartum hemorrhage; obstructed labor and hypertensive disorders common causes of maternal death in Zimbabwe, health services need, but often lack, the staff, training, medicines and equipment to effectively respond to a mother’s needs. Most rural clinics have at least 2 trained nurses/midwives, but these health workers often face burnout due to overwork and lack electricity, running water and adequate medicines. Higher level referral services may themselves lack skilled personnel. Antenatal care services and waiting mothers homes allow health workers to monitor the mother before their labour and make early referrals to the next level of care for caesarians, vacuum extraction and induction if this is needed. Referral to these services may also face challenges in some areas from poor road networks, flooding rivers, a shortage of ambulances and poor communication channels. While waiting mother homes cannot solve these referral problems, they can give health workers more time to arrange options to address them.

To overcome the three delays, waiting mothers homes need to be backed by other service improvements. Primary health care services need to be available in remote and hard to reach areas, skilled obstetric care needs to be brought closer to rural women through regular visits to health facilities by doctors and stock-outs of relevant medicines avoided. Village Health Workers should be supported by strengthening their knowledge on maternal and child health and support for community led health promotion. Communities especially men should be involved and educated on the risks associated with maternity and the benefits of delivering at health services to encourage their partners to use and benefit from waiting mothers homes, to promote institutional deliveries and to argue for effective primary care and referral services.

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

2. Latest Equinet Updates

Advancing the right to health in east and southern Africa
CEHURD: EQUINET Regional workshop report, Garuga Country Lake Resort, Entebbe, 30 August 2017

In 2015-2018, CEHURD, under the Regional Network for Equity in Health in East and Southern Africa (EQUINET) conducted a desk review of the implementation of constitutional provisions on the right to health in east and southern Africa. The objective of the workshop was to introduce the OPERA framework in the region, using evidence from Uganda. It aimed to 1. identify the main bottlenecks in implementing the right to health; 2. devise a common advocacy strategy that aims at removing the bottlenecks;. and 3 explore opportunities for applying this within the region. The workshop built on the previous validation of the Ugandan draft report on constitutional implementation of the right to health.

EQUINET Call for applicants: Desk review on “A critical assessment of different health financing options in east and southern African countries”
Call closes 5pm September 8 2018

This critical assessment of different health financing options in east and southern African countries is being commissioned by the Regional Network for Equity in Health in East and Southern Africa (EQUINET) through and in collaboration with key regional partners. It aims to inform policy makers on the positive and negative implications and issues to consider in applying the different domestic public health financing options current being explored, advocated and implemented in east and southern Africa - including mandatory national health insurance; social health insurance, community based health insurance, voluntary insurance, earmarked taxes, wealth taxes, other direct/ indirect taxes and other sources. Read more at the link shown.

Further details: /newsletter/id/63573
Participatory meeting in Lusaka on health and wellbeing of urban youth
Lusaka District Health Office(LDHO); Training and Research Support Centre (TARSC); Civic Forum on Human Development (CFHD): Meeting report 26-27 June 2018, EQUINET, Lusaka, Zambia

TARSC as cluster lead of the “Equity Watch” work in EQUINET has been exploring urban health in east and southern African (ESA) countries, gathering diverse forms of evidence from literature review, analysis of quantitative data, internet searches on practices and a participatory validation amongst different social groups of youth. Lusaka District Health Authority (LDHO) has a history of over a decade of using participatory reflection and action (PRA) approaches to strengthen health literacy, working with TARSC and other organisations in EQUINET. In 2018, TARSC and LDHO colleagues involved with the Zambian health literacy programme identified that it would be important to explore the views of youth in the city on their health and wellbeing to better integrate this group within the health literacy programme. Involving Lusaka youth in a similar process as in Harare of identifying their experiences, perceptions and proposals on health and wellbeing added further grounded evidence in the work in EQUINET. Further, the Harare youth were interested in sharing experience with youth in Lusaka. A two day participatory process was thus held with young people from various social settings in Lusaka on 26-27 June 2018 hosted by LDHO and TARSC, with the objectives to: a. Hear from different groups of Lusaka urban youth their perceptions and experiences on urban health and wellbeing. b. Facilitate exchanges between Lusaka and Harare youth on urban health and wellbeing, and identify their similar and different experiences and priorities. c. Identify what implications the information gathered have for urban health literacy and urban primary health care, and share this with relevant authorities involved in health and wellbeing of urban youth in Lusaka. This report presents the proceedings of the meeting.

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(1):52, 1-15, 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 Southern African Development Community (SADC) countries. Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only statistically significant for South Africa, and marginally significant for Zambia and Zimbabwe. Smoking and inadequate fruit and vegetable consumption were significantly concentrated among poor people. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among poor. people 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 for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. Because some of the determinants of ill-health lie outside the health sector, they also indicate that inter-sectoral action is required

4. Values, Policies and Rights

A Rebel in the Marxist Citadel: Tributes to Samir Amin
Shivji I; Lawrence P; Saul J; et al: Review of African Political Economy, August 2018

In this journal feature, Issa Shivji, Peter Lawrence, John Saul, Natasha Shivji, Ray Bush and Ndongo Samba Sylla pay tribute to the late Samir Amin. Issa Shivji writes of Amin’s support for younger generations, ‘His intellectual works, scholarly contributions and political interventions have been sufficiently covered in dozens of tributes that are pouring in every day. I will not go over them. I wanted specifically to capture Samir’s attitude and treatment of younger generations, done as a matter of course and without pretense.’ Peter Lawrence highlights one of Amin’s key ideas, ‘Amin rejected the prevailing view in both the capitalist ‘West’ and the socialist ‘East’ that development entailed catching up with the developed capitalist countries. … The history of the world was not about followers catching up with leaders but about dominant civilizations being ‘transcended’ by peripheral ones as the former decline and the peripheral overtake them with different social organizations.’ John Saul illuminates Amin’s concept of ‘an actual and active ‘delinking’ of the economies of the Global South from the Empire of Capital that otherwise holds the South in its sway. For Amin, delinking was best defined as ‘the submission of external relations [to internal requirements], the opposite of the internal adjustment of the peripheries to the demands of the polarizing worldwide expansion of capital’. Amin saw it as being ‘the only realistic alternative [since] reform of the [present] world system is utopian.’ Ndongo Samba Sylla concludes by writing on Amin’s notion of ‘daring’ in coordinated struggles, ‘by the emergence of an anti-monopolies front [in the Global North] and in the Global South by that of an anti-comprador front' challenging subservience to neoliberal globalisation. The authors collectively highlight how through his writings, his interventions and engagement Amin profiled the perspective of the Global South 'and the wretched of the earth.’

Advancing Access to SRHRs - Commemoration of The International day for maternal health and Rights
Nkoobe F: Centre for Health, Human Rights & Development, 2018

On 11th April 2018, Uganda joined the rest of the world to commemorate the International Day for Maternal Health and Rights under the Theme: “Rights Based Approach to Maternal Health in Uganda: No Woman Should Die Giving Birth.” Civil Society, led by Center for Health, Human, Rights and Development (CEHURD), and other stakeholders including policy makers marched from the Independence Monument to Parliament where a dialogue with Members of Parliament was held to collectively find sustainable solutions to the alarming maternal mortality rate. Civil Society used dialogue to petition Parliament in demand for the implementation of the resolution that was passed by the house on December 15, 2011 urging Government to institute measures to address Maternal Mortality in Uganda. Among these included tasking government through the Ministry of Health to strictly enforce maternal health audits and take actions to the established causes, together with developing a policy of compensation to the families of all women who die as a result of maternal related cases through government facilities.

The Zimbabwe National Maternal and Neonatal Health Road Map 2007-2015
Ministry of Health and Child Welfare: Government of Zimbabwe, Harare, 2007

Zimbabwe's 2007 National Maternal and Neonatal Health Road Map provided an over- arching strategy for scaling up the national response to reduce the current levels of maternal and neonatal mortality and morbidity in line with the MDG health related targets, bringing together all national stakeholders to support one national MNH programme, one national MNH coordination mechanism, and one national MNH Planning, Monitoring and Evaluation Framework. The concept of the Four Pillars of Safe Motherhood describes comprehensively all prerequisites to be met in order for a woman to safely live through her life cycle, from informed teen age through supervised, healthy pregnancy, through safe delivery and childbirth, the safe-guarding of her newborn’s health start of life, and through a continued, problem free reproductive life. The MNH Road Map sets two clearly defined phases, a first phase of prioritisation on the supply issues of the interventions to make services available first, before fully focusing on a further creation of demand in the second phase.

World Intellectual Property Day: Are women in Uganda being priced out of life-saving medicine due to Intellectual Property Rights?
Lumbasi A: Centre for Health, Human Rights & Development, 2018

Although intellectual property (IP) Rights are intended to promote innovation and creativity, the author argues that they act as barriers for access to essential medicines as they create monopolies for pharmaceutical manufacturers who charge exorbitant prices, making these medicines out of reach for many especially in least developed countries. According to 2016 health data compiled by the Institute for Health Metrics and Evaluation , HIV was ranked number one cause for premature death in Uganda. Moreover women, in particular, were disproportionately affected in comparison to men. Many of the medicines they need are noted to be under patent protection and expensive for those who need them, as inventors seek to make a return on the high costs of research and development. The author proposes that the solution to this lies in the effective utilization of provisions incorporated in the WTO- Trade Related Aspects of Intellectual Property Agreement, commonly referred to as the TRIPS flexibilities. One flexibility is compulsory licensing which allows third parties to use an invention without the holders’ consent. Another is parallel importation which allows procurement of drugs at a lower price from another country without consent of a patent holder of a patented product that is on the market of the exporting country. A further flexibility is the exemption of least developed countries from enforcing pharmaceutical patents until 2033 which can be exploited to promote transfer of technology. The author regards it as imperative to think of those women who are unable to access essential medicines due to their high cost caused by the strict enforcement of IP Rights.

5. Health equity in economic and trade policies

6th Anniversary of the Marikana Massacre
Marikana Solidarity Collective; Review of African Political Economy, August 2018

This paper presents a case that six years after the Marikana Massacre, the London-based mining corporation involved (Lonmin) has decided to leave its platinum mining operation in South Africa by preparing to sell to Sibanye-Stillwater. The authors support the demands of women’s organisation Sikhala Sonke and victims’ representatives that Lonmin must fulfil a social covenant with the community, rather than to the banks. The paper reports the demands of social movements that Lonmin apologise to the South African nation and to the victims of the massacre and pay reparations to the affected parties. The authors also report the call that Lonmin join calls to release the miners in prison as a result of the massacre and to prosecute the police officers and authors of the massacre, take responsibility for the environmental destruction at Marikana and comply with the obligations of its social and labour plan and add its voice to those calling to review the Farlam Commission and finance the legal process. They reject the excuse that the company is now insolvent.

BRICS-Johannesburg simultaneously disappoints and threatens
Bond P: Pambazuka News, August 2018

The author asks whether the Brazil-Russia-India-China-South Africa (BRICS) bloc can rise to the talk in Johannesburg about counter-hegemonic prospects during the BRICS summit held in the last week of July. However he also notes that their ideological diversity means that an excellent opportunity for this was lost and that the unity came rather from a support for mercantilist-neoliberalism. This he notes points to progressive international reform being practically impossible at present. He noted that the BRICS further distorted the International Monetary Fund (IMF) during its 2015 vote restructuring. Four of the five countries took much greater shares for themselves (aside from South Africa which lost 21 percent of its vote) at the expense mainly of poorer countries. He argues that the main site to consider antidote analysis and news is “brics from below,” a tradition of counter-summit critique begun in Durban five years ago, and also witnessed in Fortaleza in 2014, Goa in 2016 and Hong Kong in 2017. and as found in a protest led by four Goldman Environmental Prize winners and their organisations and allies: Makoma Lekalakala of Earthlife Africa, Bobby Peek of groundWork, Thuli Makama of OilChange International and Des D’Sa of the South Durban Community Environmental Alliance. As one outcome the largest proposed mega-project made at prior BRICS summits in 2014 and 2015 on US $100 billion worth of nuclear energy reactors as a deal between former South African president Jacob Zuma and Putin, is now on indefinite hold.

Countries Pressured to Drop Language on Protecting Access to Affordable Meds from TB Summit Declaration Negotiations
Medicins Sans Frontieres; Doctors Without Borders: July 2018

Countries negotiating the final declaration text for the first-ever UN High-level Meeting on Tuberculosis in September were put under significant pressure to drop references to protecting countries’ rights to take fully-legal actions to access affordable medicines for their people, Médecins Sans Frontières reports. One of the final sticking points in the negotiations in New York was language on public health safeguards enshrined in the World Trade Organization’s (WTO) Agreement on Trade-related Aspects of Intellectual Property Rights (TRIPS). This allows governments, among other things, to issue ‘compulsory licenses’ to override patents in the interest of public health, so that they can allow generic versions to be produced or imported and more people can receive needed treatment. The ‘Group of 77’ bloc of developing countries has been under pressure to drop all references to the WTO’s 2001 Doha Declaration that enshrined public health flexibilities and safeguards in the TRIPS agreement. This led to a call by Leena Menghaney, South Asia Head for MSF’s Access Campaign for all countries, including those in the Group of 77, and Brazil, Russia, India, China and South Africa, that have a high burden of TB, to urgently stand up right now against what they refer to as 'bullying', that aims to keep medicines out of the hands of people who need treatment.

Social support under siege: An analysis of forced migration among women from the Democratic Republic of Congo
Wachter K; Gulbas L: Social Science & Medicine (208) 107-116, 2018

The authors aimed to develop theory to explain how women who migrated from the Democratic Republic of the Congo recreate social support post-resettlement in the United States. An interpretive approach informed by postcolonial feminist perspectives guided the grounded theory methodology. Upon arrival to the United States, women experienced partitioned lives through changing relationships in space and time, which contributed to women being alone and impacted on their well-being. Converging processes propelled women towards learning to stand alone, through which they developed a sense self-reliance, but not without consequences for themselves and their relationships. The analysis contributes to the knowledge of how resettlement is a life altering event that sets into motion psychosocial processes with implications for well-being and health.

6. Poverty and health

Home is best: Why women in rural Zimbabwe deliver in the community
Dodzo M; Mhloyi M: PLOS One 12(8) e0181771, doi: 10.1371/journal.pone.0181771, 2017

Maternal mortality in Zimbabwe has unprecedentedly risen over the last two and half decades although a decline has been noted recently. Many reasons have been advanced for the rising trend, including deliveries without skilled care, in places without appropriate or adequate facilities to handle complications. The recent decline has been attributed to health systems strengthening. On the other hand, the proportion of community deliveries has also been growing steadily over the years and in this study the authors investigate why. Twelve focus group discussions with child-bearing women and eight key informant interviews (KIIs) were conducted. Four were traditional birth attendants and four were spiritual birth attendants. The study shows that women prefer community deliveries due to perceived low economic, social and opportunity costs involved; pliant and flexible services offered; and diminishing quality and appeal of institutional maternity services. The authors conclude that rural women are very economic, logical and rational in making choices on place of delivery. Delivering in the community offers financial, social and opportunity advantages to disenfranchised women, particularly in remote rural areas. The authors recommend increased awareness of the dangers of community deliveries; establishment of basic obstetric care facilities in the community and more efficient emergency referral systems. In the long-term, they argue that there should be a sustainable improvement of the public health delivery system to make it accessible, affordable and usable by the public.

7. Equitable health services

Maternity waiting facilities for improving maternal and neonatal outcome in low- resource countries
van Lonkhuijzen L; Stekelenburg J; van Roosmalen J: University of Groningen, 2011

A Maternity Waiting Home (MWH) is a facility, within easy reach of a hospital or health centre which provides Emergency Obstetric Care (EmOC). The aim of the MWH is to improve accessibility and thus reduce morbidity and mortality for mother and neonate should complications arise. This study assessed the effects of a maternity waiting facility on maternal and perinatal health. The authors searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009), CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHL (1982 to April 2009), African Journals Online (AJOL) (April 2009), POPLINE (April 2009), Dissertation Abstracts (April 2009) and the National Research Register archive (March 2008) for conducted randomised controlled trials that compared perinatal and maternal outcome in women using a MWH and women who did not. There were no randomised controlled trials or cluster-randomised trials identified from the search. They found from this evidence that there is insufficient evidence to determine the effectiveness of Maternity Waiting Facilities for improving maternal and neonatal outcomes.

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi
Angwenyi V; Aantjes C; Kajumi M; et al: Public Library of Science ONE 13(7) 1-17: 2018

This study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource constrained setting in Malawi. A qualitative study was conducted which involved patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients, 14 in-depth interviews, and four focus-group discussions with patients. Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included ability to acquire appropriate disease knowledge, poverty level, the presence of support from family caregivers and community-based support initiatives, the nature of one’s social relations; and the ability to deal with stressors and stigma. Non-communicable diseases and HIV co-infected people were more disadvantaged in their access to care, as they experienced frequent drug stockouts and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of care challenges. The authors’ findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. They recommended expanding current peer-patient and support group initiatives to patients with non-communicable diseases, and further investments in the decentralization of integrated health services to primary care level in Malawi.

The role of maternity waiting homes as part of a comprehensive maternal mortality reduction strategy in Lesotho
Satti H; McLaughlin M; Seung K: Partners In Health Reports 1(1) 1-24, 2013

Lesotho has one of the highest maternal mortality rates in the world, Partners In Health (PIH) has included maternity waiting homes since 2009 as part of a comprehensive effort to increase facility-based deliveries and reduce maternal mortality. The maternity waiting homes are located at seven PIH-supported health centres in some of the most remote, underserved areas of rural Lesotho. The homes provide food and shelter for women who live far away from the health centre or have risk factors for potential obstetric complications, and are well-regarded by both health centre staff and pregnant women. Since the implementation of the Maternal Mortality Reduction Project, PIH has seen waiting home admissions and the number of monthly deliveries at health centres increase dramatically. The authors suggest that failure of previous studies to demonstrate a positive impact of maternity waiting homes may reflect the failure to successfully implement other supporting components of a larger, comprehensive strategy to increase access to maternal health services.

Why indigenous medicine could play a role in rebuilding health systems
Falisse J; Masino S; Ngenzebuhoro R: The Conversation, June 2018

This study contributes to the health policy debate on medical systems integration by describing and analysing the interactions between health-care users, indigenous healers, and the biomedical public health system, in the so far rarely documented case of post-conflict Burundi. The authors adopted a mixed-methods approach combining (1) data from an existing survey on access to health-care, with 6,690 individuals, and (2) original interviews and focus groups conducted in 2014 with 121 respondents, including indigenous healers, biomedical staff, and health-care users. The findings reveal pluralistic patterns of health-care seeking behaviour, which are not primarily based on economic convenience or level of education. Indigenous healers’ diagnosis is shown to revolve around the concept of ‘enemy’ and the need for protection against it. The authors suggest ways in which this category may intersect with the widespread experience of trauma following the civil conflict. They find that, while biomedical staff display ambivalent attitudes towards healers, cross-referrals occasionally take place between healers and health centres. The authors emphasise healers’ psychological support role in helping communities deal with trauma.

8. Human Resources

Brain Drain in Africa: The Case of Tackling Capacity Issues in Malawi's Medical Migration
The African Capacity Building Foundation: ACBF Occasional Paper No. 31, Zimbabwe, 2018

Malawi faces severe staffing shortages in the health sector and high migration of health workers. This paper suggests that, like most countries in Sub-Saharan Africa, local training of medical personnel has neither plugged these capacities deficits nor increased retention rates. Given the economic realities in Sub-Saharan Africa and the allure of countries in the Organization for Economic Cooperation and Development, many locally trained physicians migrate. The paper concludes that, like much of Sub-Saharan Africa, Malawi is victim of regional developments. Owing to growth in migration of physicians from South Africa to Organization for Economic Cooperation and Development countries, the paper raises that Malawi has turned to recruiting doctors from other African countries, exacerbating capacity constraints elsewhere in the region.

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) 1-13, 2018

This paper synthesises current evidence on gender and close-to-community providers and the services they deliver. The authors used a two-stage exploratory approach drawing upon qualitative research from six countries in the REACHOUT consortium in 2013 to 2014. This was followed by systematic review that took place in 2017, using critical interpretive synthesis methodology. This review included 58 papers. From this, the authors present the holistic conceptual framework to show how gender roles and relations shape close to community 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, influence of 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 close to community provider can, with the right support, be an empowering experience. They argue for policymakers to promote gender equity in this cadre through safety and well-being, remuneration, and career progression opportunities.

9. Public-Private Mix

Health Market Inquiry: ‘Nothing we don’t already know’, says Health Minister
Unnamed author: Medical Brief, South Africa, July 2018

This article raises that the four-year long Competition Commission Health Market Inquiry’s findings reveal what Health Minister Dr Aaron Motsoaledi says he already knew – that South Africa’s private healthcare has become so expensive that even those on medical aid can’t afford it. The article reports that the inquiry singled out the dominance of Discovery Health among medical schemes, and Netcare, Mediclinic and Life Healthcare among hospital groups, as illustrations of competitive market failure. The commission found that the market was characterised by high and rising costs of healthcare and medical scheme cover, by disempowered and uninformed consumers, and by a general absence of value-based purchasing. According to the inquiry’s chair, former Chief Justice, Sandile Ngcobo – who presented the executive summary of the report – the private healthcare sector market displayed consistently rising medical scheme premiums accompanied by increasing out-of-pocket payments for the insured, almost stagnant growth in covered lives and a progressively decreasingly range and depth of services covered by scheme options. Although there were 22 open schemes, two medical schemes constitute 70% of the total open scheme market and Discovery Health Medical Scheme comprised 55% of the open scheme market. The Government Employees Medical Scheme (GEMS) was the second largest restricted scheme. There were 16 medical scheme administrators and Discovery Health and Medscheme accounted for 76% of the market based on gross contribution income. The inquiry also found that there was a failure by practitioners to explore multi-disciplinary models of care and that the fee-for-service model of remuneration stimulated oversupply, and incentivised practitioners to provide more services than needed. The inquiry was also reported to raise the issue of an incomplete regulatory regime in the private healthcare sector: Medical facilities were not regulated beyond the requirement to have a licence to operate and practitioners licensed to practice by the Health Professions Council of SA but little more. The report is open for comments until 7 September 2018 and the final report is expected to be released on 30 November.

Washing with hope: evidence of improved handwashing among children in South Africa from a pilot study of a novel soap technology
Burns J; Maughan-Brown B; Mouzinho Â: BMC Public Health 18(709), doi: https://doi.org/10.1186/s12889-018-5573-8, 2018

While regular handwashing effectively reduces communicable disease incidence and related child mortality, instilling a habit of regular handwashing in young children continues to be a challenging task, especially in low income countries. A randomised controlled pilot study assessed the effect of a novel handwashing intervention – a bi-monthly delivery of a colourful, translucent bar of soap with a toy embedded in its centre (HOPE SOAP©) – on children’s handwashing behaviour and health outcomes. Between September and December 2014, 203 households in an impoverished community in Cape Town, South Africa, were randomised (1:1) to the control group or to receive HOPE SOAP©. Of all children aged 3–9 years and not enrolled in early childhood development programmes, Two ‘snack tests’ (children were offered crackers and jam) were used to provide objective observational measures of handwashing. Through baseline and endline surveys, data were collected from caregivers on the frequency (scale of 1–10) of handwashing by children after using the toilet and before meals, and on soap-use during handwashing. Data on 14 illnesses/symptoms of illness experienced by children in the two weeks preceding the surveys were collected. At the end, HOPE SOAP© children were directly observed as being more likely to wash their hands unprompted at both snack tests (49% vs 39%) and were more likely to use soap when washing their hands. HOPE SOAP© children, in general, had better health outcomes, used the soap as intended and were less likely to have been ill. Results point towards HOPE SOAP© being an effective intervention to improve handwashing among children.

10. Resource allocation and health financing

Zimbabwe: Realising the right to health for mothers and children, a mutli-donor Health Transition Fund helps to revitalise Zimbabwe’s health system
UNICEF: UNICEF and MoHCC Zimbabwe 2018

The Health Transition Fund (HTF) is a $435 million, five-year programme (2011-2015) that aimed to revitalize Zimbabwe’s health sector by improving the lives of children and women. It was funded by multiple external funders from the European Union, Canada, Ireland, Norway, the United Kingdom and SIDA Sweden, and managed by UNICEF in cooperation with the Zimbabwean Ministry of Health. It has four pillars: 1) Improvement of maternal, newborn and child health as well as nutrition, 2) Provision of essential medicines, vaccines and technologies, 3) Human resources including assistance with health worker management, training and retention, 4) Health policy, planning and finance. It aimed to reduce maternal mortality by three quarters and under-5 mortality by two thirds (as stated in the Millennium Development Goals) and eliminate user fees for children under the age of five and pregnant and lactating women by 2015. It sought to support the halving of the number of underweight children under five and combating, halting and reversing trends in HIV/AIDS, malaria and other diseases. A steering committee, chaired by the permanent secretary of the Ministry of Health, oversees and directs the rollout of the fund and defines priority interventions within each of the four thematic areas, while funders provide support to monitoring, evaluation and technical expertise.

11. Equity and HIV/AIDS

Southern Africa HIV and AIDS Regional Exchange (SHARE) Research Digest, April—May 2018
Southern Africa HIV and AIDS Regional Exchange (SHARE), 2018

This digest offers article abstracts from peer-reviewed literature related to HIV and AIDS in Southern Africa and is designed to keep readers in touch with the rapidly expanding evidence base pertaining to HIV in the region. For example in this issue there are 72 abstracts published April through May 2018 that feature articles from Botswana (4), Lesotho (2), Malawi (7), Mozambique (5), South Africa (43), Swaziland (2), Tanzania (4), Zambia (2) and Zimbabwe (9). Articles include a mixed methods study on access to HIV care and treatment for migrants between Lesotho and South Africa; findings from a cross-sectional study on HIV status disclosure among postpartum women with varied intimate partner violence experiences in Zambia; and lessons learned from the ZENITH trial in Zimbabwe on the role of community health workers in improving HIV treatment outcomes in children. The articles are catered to advocates, health care providers, implementers, lay health workers, policy makers and researchers.

The impact of intimate partner violence on women's contraceptive use: Evidence from the Rakai Community Cohort Study in Rakai, Uganda
Maxwell L; Brahmbhatt H: Ndyanabo A; et al: Social Science & Medicine, (209) 25-32, 2018

A systematic review of longitudinal studies suggests that intimate partner violence is associated with reduced contraceptive use. The authors used seven waves of data from the Rakai Community Cohort Study in Rakai, Uganda to estimate the effect of prior year intimate partner violence at one visit on women's current contraceptive use at the following visit. The analysis included 7923 women interviewed between 2001 and 2013. Women who experienced any form of prior year intimate partner violence were 20% less likely to use condoms at last sex than women who had not. The authors did not find evidence that intimate partner violence affects current use of modern contraception, however, current use of a partner-dependent method was 27% lower among women who reported any form of prior-year intimate partner violence compared to women who had not. Women who experienced prior-year intimate partner violence were less likely to use condoms and other forms of contraception that required negotiation with their male partners and more likely to use contraception that they could hide from their male partners. Longitudinal studies in Rakai and elsewhere have found that women who experience intimate partner violence have a higher rate of HIV than women who do not. The finding in this paper that women who experience IPV are less likely to use condoms may help explain the relation between intimate partner violence and HIV.

12. Governance and participation in health

Governance and Equity-oriented Policies for Urban Health
Shakim C: ECSA HC Best Practices Forum, Arusha, Tanzania, 2018

This presentation given at the ECSA HC Best Practices Forum 2018 provides an overview of urban poverty and global commitments to equity oriented policies for urban health; urban health challenges in Sub-Saharan Africa; examples of how youth and community engagement could inform change and how to support the development of governance and equity oriented policies. The author notes that unmanaged urban growth is linked with rising social and economic inequities that benefit the well off and negatively impact health and well-being of the poor and disadvantaged; and that densely packed areas with low levels of sanitation services offer a petri dish for infectious diseases. This contributes to higher cost of living, high risk of school dropout and teenage pregnancy and high rates of crime and violence. Shakim provides evidence of youth as agents of change in urban Tanzania through the Tandale Health Centre.

13. Monitoring equity and research policy

Community-based indicators for HIV Programmes
MEASURE Evaluation: Online, USA 2018

Community-based information systems (CBIS) are key to understanding how HIV programs are working to control the epidemic at the local level in countries with high burden. MEASURE Evaluation developed this collection of indicators to guide community-based HIV programs in monitoring their performance and thereby enhance informed decision making by governments, major donors, and implementing partners. The indicators cover the following themes: vulnerable children, prevention of mother-to-child transmission, key populations, HIV prevention, home-based care and data use cases. The site also provides useful resources and a summary list of indicators.

What is Zimbabwe’s real maternal mortality rate?
Mkudu M; van Wyk A: Africa Check, 2015

The authors report on conflicting figures for pregnancy and childbirth related deaths in Zimbabwe from 525 to 960 maternal deaths for every 100,000 live births. It would seem to be a relatively straightforward task to measure maternal mortality, but they note that in reality, that is not the case. Ideally, you would analyse death certificates, but even in countries with well-functioning birth and death registration systems, they report that the number of maternal deaths is routinely undercounted. This is because death certificates are not always complete and in some cases, the person signing a death certificate may not be aware that the woman was pregnant or that her pregnancy contributed in some way to her death. In some instances, health facilities have been known to try and conceal maternal mortalities because of political pressure to reduce the numbers. Zimbabwe is classified as a country with incomplete birth and death records by the UN. Researchers therefore rely on censuses and surveys to estimate maternal deaths. Household surveys reported 614 deaths / 100,000 live births for the period between 2007 and 2014, and 581 / 100 000 for 2009 to 2014, within the range of global organisations’ estimates.

14. Useful Resources

2018 Africa Scorecard on Domestic Financing for Health
African Union Commission: AU 2018

The Africa Scorecard on Domestic Financing for Health is a health financing management tool for governments on the African continent. AidSpan, the independent observer of the Global Fund, describes the scorecard as a tool intended to help with financial planning for the health sector and with monitoring government domestic health spending performance against key global and regional health financing benchmarks. It is also intended to help governments compare their performance with each other. The 2018 Africa Scorecard on Domestic Financing for Health was adopted by the African Union Heads of State and Government Assembly on 2 July 2018 during the Summit in Nouakchott, Islamic Republic of Mauritania. The Scorecard can be accessed in English, French and Portuguese.

Outbreaks: Behind the headlines
World Health Organisation: WHO, Geneva, 2018

At any one time, dozens of infectious disease outbreaks are happening around the world. Those on the frontlines are often more visible, but behind the scenes, many activities are taking place to control the spread of these diseases. In this special feature, the World Health Organisation highlights a series of recent health emergencies, telling the stories behind the headlines and exploring the many different dimensions of an outbreak response. Humanitarian crises, forced migration, environmental degradation, climate change, reduced access to health services and prolonged conflict often provide exactly the right conditions for an outbreak to occur. Diphtheria - a bacterial disease that is preventable through a simple inexpensive vaccine – is one such example. Dr. Khadimul Anam Mazhar working in the Rohingya refugee camps in Cox’s Bazar, Bangladesh, found diptheria to be the main focus of his work. The outbreaks of Ebola in DRC and diphtheria among the Rohingya refugees have starkly different profiles. One was a naturally occurring zoonosis in a remote area, the other the result of a major migration of a highly stressed population. For all the differences, however, they also share similar traits: prolonged conflict, inadequate water and sanitation systems, and struggling health systems. The cases highlight two critical and often overlooked issues: 1) multiple countries around the world are facing severe health crises, and 2) many of these countries have several health crises occurring at the same time. While it is critical to treat patients affected by epidemic diseases, the response is much more than purely medical. The range of necessary expertise includes epidemiologists, logisticians, clinicians, data managers, anthropologists and planners.

15. Jobs and Announcements

3rd National Antimicrobial Resistance (AMR) Conference 2018, Makerere University College of Health Sciences 21-22 November 2018
Deadline for Submission of Abstracts: 30 September 2018

The World Health Organization (WHO) World Antibiotic Awareness Week takes place every year in November, and this year will be 12-18 November, with national events for awareness about antimicrobial resistance. Towards this, the 3rd National Antimicrobial Resistance (AMR) Conference 2018 for Uganda is being hosted by Makerere University College of Health Science (CHS) in partnership with One Health Central and Eastern Africa (OHCEA, http://ohcea.org), an international network of universities in eight African countries and 16 Universities including Makerere University. This year’s conference will be held at Hotel Africana in Kampala on November 21 – 22 and the theme will be Understanding Drivers and Collective Action against Antimicrobial Resistance. At the conference, the National One Health Platform will launch the National Action Plan (NAP) against Antimicrobial Resistance and it will also one health initiatives in the country.

4th People’s Health Assembly
Dhaka, Bangladesh, 15-19 November 2018

The Fourth People’s Health Assembly (PHA 4), will draw on civil society organizations and networks, social movements, academia and other actors from around the globe. PHA4 will provide a space for strengthening solidarity, sharing experiences, mutual learning and joint strategizing for future actions. The Assembly and associated activities aim to: evaluate and critically analyze current processes and policies that impact on health and healthcare at global, regional and local levels; undertake a collective assessment of PHM’s organizational and programmatic activities and to provide a renewed mandate for the years to come. They also seek to enhance the capacity of health civil society activists to engage with and intervene in the policy making process, to monitor and drive policy implementation and to ensure accountability in the functioning of health systems; to foster and support constructive dialogue, planning and mobilization around health and the broader social determinants of health, involving the widest possible range of practitioners; and to launch renewed sustainable structures and dynamics, both within and outside the health sector, that will continue to drive coordinated action to secure universal and equitable access to health and health care.

5th Global Symposium on Health Systems Research
Programme now online: Liverpool, UK, 8-12 October 2018

The Global Symposium on Health Systems Research is organized every two years by Health Systems Global to bring together the full range of players involved in health systems and policy research and practice. Beginning with the First Global Symposium in Montreux in 2010, the Symposia have played a crucial, catalytic role in convening a global community dedicated to strengthening health systems and building the field of health systems research. The Fifth Global Symposium on Health Systems Research (HSR2018) will take place at the ACC in Liverpool, UK from 8 to 12 October, 2018, bringing together approximately 2,000 health systems researchers, policymakers and practitioners from around the world. The full programme for the symposium is now online at the website.

Adolescent Girls and Young Women (AGYW) Grant to Influence Policy In Your Country
Application deadline: 30 November 2018

HER Voice Fund is giving out grants amounting to USD 2000 for activities meant to influence policy processes. The funds are to address the financial access barriers limiting community based organisations (CBOs) working on AGYW issues to fully participate in various stages of Global Fund processes in the 13 target countries. Relevant processes include Global Fund country dialogues across the various stages of the cycle (concept note development, grant-making, grant implementation and grant monitoring); and meaningful participation in related processes including but not limited to: HIV national strategic plans, frameworks, policies, guidelines- development and reviews and their accompanying or related monitoring and evaluation and operational plans; as well as strategies, policies and guidelines related to adolescent health and their well-being. These funds can be used to support short-term key activities including but not limited to: Transport to attend meetings related to Global Fund processes; meeting arrangements to facilitate dialogue processes by community based organisations and communication processes related to participation in key discussions and forums, among others. Applications can be submitted online or by email

Call for Abstracts: Federation of African Medical Students’ Associations (FAMSA) Conference, Ibadan, Nigeria, November 18th – 24th , 2018
Deadline 30 September 2018

The FAMSA General Assembly and Scientific Conference will bring together young vibrant minds as well as professionals and relevant stakeholders in both the public and private sectors from across Africa and beyond to discuss ideas and initiate steps to position Africa on the path to sustainable development in health and by extension in every other sphere of human development. The Conference invites medical students, healthcare professionals and researchers to submit abstracts for oral or poster presentations. Abstracts are to be submitted under any of the two categories; Research or Project. Abstract topics should fall under the subthemes or any other topic of relevance to the theme of the conference.

CODESRIA Humanities Institute: The essence(s), diversity and economies of the (Pan)-African arts - (Re)making and confronting memories and futures, Ouagadougou, Burkina Faso
Deadline for Applications: 30 September, 2018

To mark the 50th anniversary of the bi-annual Pan-Africa Film and Television Festival CODESRIA is organising the Humanities Institute in Ouagadougou on February 25- March 1, 2019. The theme will be ‘The essence(s), diversity and economies of the (Pan)-African arts: (Re)making and confronting memories and futures.’ The theme intends to promote contemplation of the structural conditions that hinder and facilitate involvement in shaping the future of the African arts and the event seeks to bring together a mixed group of scholars and artists.

Emerging Public Health Practitioner Award: manuscript submissions open
November 18th – 24th, 2018, Ibadan, Nigeria

The FAMSA General Assembly and Scientific Conference will bring together young vibrant minds as well as professionals and relevant stakeholders in both the public and private sectors from across Africa and beyond to discuss ideas and initiate steps to position Africa on the path to sustainable development in health and by extension in every other sphere of human development. The conference will feature keynote addresses, plenary sessions, workshops, trainings, hackathon sessions, and scientific presentations on carefully selected subthemes all related and contributory to the goal of repositioning healthcare in Africa for Sustainable Development. Sub themes for the conference include ‘The African Medical Student and the SDGs’, ‘Medical Education in Africa’, ‘Maternal and Child Health in Africa’, ‘The Burden of NCDs’, ‘Infectious Diseases in Africa’, ‘Sustainable Vaccination Schemes’, ‘Outbreak and Disaster Management’, ‘Mental Health’, ‘Health Policy and Financing’ and ‘Social Determinants of Health’.

Register for the Shaping health session: Grounding health action in community cultures and systems
9 October 1330-1700 Global Symposium on Health Systems Research Liverpool Conference Room 11C

Join us in this participatory satellite session at the Global Symposium on Health System Research where we will be sharing experiences from diverse countries globally on how social participation and power can make health systems more holistic, responsive and inclusive, and how to facilitate such practice. In this session we will share evidence and learning from a multi-country Shaping health consortium on social participation in local health systems, and use participatory approaches to draw also on the experiences of those participating. These experiences show how social participation and power can make health systems more holistic in approach, more responsive and more inclusive. We 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. For more information see the website below and sign up at admin@tarsc.org.

WHOs First Global Conference on Air Pollution and Health
30 October – 1 November 2018, World Health Organisation, Geneva

The Global Conference on Air Pollution and Health is the first-ever global event to focus on both air pollution and health. As a contribution towards achieving the Sustainable Development Goals, the Conference will feature a “Call for Urgent Action” where delegates will reach agreement on a target for 2030 to reduce the 7 million deaths caused by air pollution each year, Countries, urban mayors and civil society will be invited to make commitments to the global advocacy campaign www.BreatheLife2030.org to meet WHO Air Quality Guidelines and reduce climate emissions. The Conference will underline the links between air pollution and the global epidemic of noncommunicable diseases (NCDs), and position the health sector to catalyse actions for health-wise policies on clean household energy, transport and waste.


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