Although half of the world population lives in rural and remote areas, these areas are serviced by only a quarter of the world’s nurses and less than a quarter of the doctors. In our region the ratios are even worse, where only 16 doctors service every 100 000 people living in remote rural areas.
The global shortage of health workers, estimated by World Health Organisation to reach 18 million by 2030, has motivated resolutions in the World Health Assembly and other fora for member states to find ways of retaining their health workers, through incentives and working environments that encourage people to stay in rural areas. Most recently in 2016, a High-level Commission on Health Employment and Economic Growth recommended investing in rural education and creating decent jobs in the rural health sector, particularly recognising the contributions of nurses and midwives to improved health.
Notwithstanding these calls, rural and remote areas continue to fail to attract and retain health workers. So beyond statements of good intention, what practical measures should we be implementing to improve the retention of health workers in our rural areas?
It begins with how health workers are enrolled and trained. Our training institutions need to review their admission policies to enrol students from rural backgrounds. They need to include information on rural health care in the curriculum and to integrate rural community experiences to expose students to these environments. Our undergraduate and postgraduate curricula and continuing education programmes should be oriented to building competencies for the shift from hospital-based approaches to preventive, affordable, integrated community-based, people-centred primary and ambulatory care in rural areas, as well as in building capacities for public health and preventing and managing epidemics.
Financial incentives have commonly been used to attract and retain health workers in rural areas. In addition to allowances, they may be given as bursaries for further education, study loans and occupation-specific dispensations. There is evidence that these measures have motivated health workers to remain in rural areas. But they can also be eroded if they lose value over time.
This makes the living conditions, availability of electricity, proper sanitation, access to schools, telecommunication and internet equally important to enhance retention, together with support for career development and advancement, such as by creation of senior positions in rural institutions. There are new opportunities in using information technologies to enhance rural practice and avoid professional isolation. Providing scholarships, bursaries or other education subsidies and improving living and working conditions can have a more positive effect than compulsory service requirements. Health workers, like others, appreciate their jobs when treated with dignity and respect.
From our review of the literature in a new EQUINET discussion paper 115, we found that many such strategies are being used. There were some cautions on how we apply these strategies. For example, compulsory measures appear to be best accompanied by relevant support and incentives. Mitigatory strategies such as task shifting should not become ‘task dumping’ and replace more substantive solutions. Ad hoc financial incentives should not be applied so selectively that they motivate some workers, while demotivating others. They should also not be used as a substitute for a more substantive review of working conditions and of disparities in salaries between different health professionals.
It is evident that there is no single approach. There are options, and countries need to choose strategies that are relevant for their own context and in consultation with key stakeholders. This needs to be embedded in the strategic processes for national health planning and financing. Addressing this issue calls for robust management and communication processes and skills, backed by credible evidence from monitoring and evaluation systems, to ensure that the chosen strategies are relevant, appreciated and continually updated.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: email@example.com. Please visit the EQUINET website to read the publications on health worker retention.
Although half of the world population lives in rural and remote areas, these areas are serviced by only a quarter of the world’s nurses and less than a quarter of the doctors. In our region the ratios are even worse, where only 16 doctors service every 100 000 people living in remote rural areas.
2. Latest Equinet Updates
This literature review, implemented within an EQUINET programme of theme work on health workers at the University of Limpopo, presents published evidence on the recruitment and retention of skilled healthcare workers in rural areas of east and southern Africa. It reviewed published documents in English with a focus on east and southern Africa from 2000-2017. From the literature reviewed the following strategies emerged as key for health worker retention: Education and training of healthcare workers; review of regulations and policies regarding provision of healthcare services in rural areas; provision of financial incentives; and personnel and professional support of healthcare workers. The report identified strategies relating to: Reviewing admission policies and criteria for health worker education; including rural practice issues and skills in health worker training and exposing students to rural areas during training; improving access to continuing professional development (CPD) in rural areas; ensuring that compulsory measures are accompanied by relevant support and incentives; ensuring that mitigatory strategies such as task shifting are not ‘task dumping’, do not replace more substantive solutions and that they are accompanied by suitable regulatory systems, training and management support; using financial and non-financial incentives to address issues prioritised by health workers, in a way that does not motivate some while demotivating others, and not as a substitute for a more substantive review of working conditions of healthcare workers and strategies to reduce the disparities in salaries between different health professionals; and improving health worker management and support, and the skills of HRH managers.
3. Equity in Health
This paper explores community perceptions and experiences related to health and health inequality. The authors conducted 12 focus group discussions and 24 in-depth interviews with community stakeholder groups across six rural sites in Jimma Zone, Ethiopia. Participants described being healthy as being disease free, being able to perform daily activities and being able to pursue broad aspirations. Health inequalities were viewed as community issues, primarily emanating from a lack of knowledge or social exclusion. Poverty was raised as a contributor to poor health that could be overcome through community-level responses. Participants described formal and informal mechanisms for supporting disadvantaged people in form of safety net that provide information and emotional, financial and social support. Understanding community perceptions of health and health inequality can serve as an evidence base for community-level initiatives, including for maternal, new-born and child health.
4. Values, Policies and Rights
Despite 20 years of democracy, South Africa still suffers from profound health inequalities and gender roles and norms associated with vulnerability to ill-health. Gender inequality influences women’s access to health care and agency to make health-related decisions. This paper explores gender-awareness and inclusivity in organisations that advocate for the right to health in South Africa, and analyses how this knowledge impacts their work. Ten in-depth interviews were conducted with members of The Learning Network for Health and Human Rights (LN), a network of universities and Civil Society Organisations (CSOs) committed to advancing the right to health, but not explicitly gendered in its orientation. The results show that there is a discrepancy in knowledge around gender and gendered power relations between LN members. This suggests that gender is ‘rendered invisible’ within the LN, which impacts the way the LN advocates for the right to health. The authors thus suggest that even organizations that work on health rights of women might be unaware of the possibility of gender invisibility within their organisational structures.
In January 2015, South Africa ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR). The South African government submitted its initial report to the United Nations Committee on Economic, Social and Cultural Rights (CESCR) in April 2017, raising the steps and measures taken to comply with the provisions of the Covenant, noting its progressive Constitution that includes socio-economic rights. A coalition of civil society organisations called “South Africa’s Ratification Campaign of the ICESCR and its Optional Protocol” (the Campaign) submitted a parallel report to the United Nations CESCR. The Campaign’s Steering Group is comprised of the Socio-Economic Rights Institute of South Africa, Black Sash, the Dullah Omar Institute, the People’s Health Movement South Africa and the Studies in Poverty and Inequality Institute. The Campaign’s parallel report provided a civil society perspective on socio-economic rights realisation in South Africa, and raised questions about areas of the state’s record in fulfilling these rights in order to promote greater accountability. The Campaign's report noted that actions to address the binding constraints to realising socio-economic rights are increasingly urgent in the South African context of severe poverty and inequality. For this reason, the authors identified the need for the state to address forced evictions and displacement; to assess the causes of under-expenditure on informal settlement upgrading; to address a lack of investment in infrastructure maintenance and services provision, and to address intergovernmental cooperation issues that impacted severely in the management of the drought in the Western Cape.
The WHO guidelines for drinking-water quality provide recommendations to support countries in developing drinking-water quality regulations and standards, as well as the associated risk management strategies. The guidelines provide an authoritative basis for the effective consideration of public health in
setting national or regional drinking-water policies and actions; provide a comprehensive preventive risk management framework for health protection, from catchment to consumer, that covers policy formulation and standard setting, risk-based management approaches and surveillance; emphasize achievable practices and the formulation of sound regulations that are applicable to low-income, middle-income and industrialized countries alike; summarize the health implications associated with contaminants in drinking water, and the role of risk assessment and risk management in disease prevention and control; summarize effective options for drinking-water management; and provide guidance on hazard identification and risk assessment.
5. Health equity in economic and trade policies
This study investigated the association between proximity to mine dumps and prevalence of chronic respiratory disease in people aged 55 years and older. Elderly persons in communities 1-2 km (exposed) and 5 km (unexposed), from five pre-selected mine dumps in Gauteng and North West Province, in South Africa were included in a cross-sectional study. Structured interviews were conducted with 2397 elderly people, using a previously validated questionnaire from the British Medical Research Council. Exposed elderly persons had a significantly higher prevalence of chronic respiratory symptoms and diseases than those who were unexposed., Results from the multiple logistic regression analysis indicated that living close to mine dumps was significantly associated with asthma, chronic bronchitis, chronic cough, emphysema, pneumonia and wheeze. Residing in exposed communities, current smoking, ex-smoking, use of paraffin as main residential cooking/heating fuel and low level of education emerged as independent significant risk factors for chronic respiratory symptoms and diseases. This study suggests that there is a high level of chronic respiratory symptoms and diseases among elderly people in communities located near to mine dumps in South Africa.
South Africa recently adopted a new Intellectual Property Policy, which seeks to align IP with the country’s national development plan. What works for the new SA policy is that it addresses the interface between IP and public health. In facilitating local production and export of pharmaceuticals in line with its industrial policy, the new policy recommends the following changes: introduction of substantive patent search and examination, introduction of patent opposition, strengthening of patentability criteria, incorporation of disclosure requirements, parallel importation, exceptions, provisions to regulate voluntary licensing, compulsory licences, use of IP and competition law. All these provisions use flexibilities provided in the TRIPS (Trade related aspects of IP Rights) Agreement to safeguard development objectives. The South African policy mentions that it must engender the ethos of the South African Constitution and also reflect the country’s broader social economic development objectives. In contrast, India’s IP policy fails to take notice of obligations under Fundamental Rights and Directive Principles of the right to health in its Constitution while promoting IP rights. Instead it focuses on enhancing the protection and enforcement of IP rights, which goes beyond its international obligations (referred as ‘TRIPS-plus’) without taking into consideration their negative implications. Despite being at the forefront of international fora in defending the TRIPS flexibilities, the author observes that India ignores their use for itself at the domestic level, and recommends following the South African approach.
6. Poverty and health
Childhood sexual abuse of boys was examined in a longitudinal cohort in South Africa, with data on abuse collected at six age points between 11 and 18 years. Potential personal and social vulnerability of male sexual abuse victims was explored and mental health outcomes of sexually abused boys were examined at age 22–23 years. Reports of all sexual activity – touching, oral and penetrative sex – increased with age and sexual coercion decreased with age. Almost all sexual activity at 11 years of age was coerced, with the highest rates of coercion occurring between 13 and 14 years of age; 45% of reports of coerced touching were reported at age 14, 41 percent of coerced oral sex at age 13, and 31% of coerced penetrative sex at age 14. Sexual coercion was perpetrated most frequently by similar aged peers and although gender of the assailant was less often reported, it can be presumed that perpetration is by males. Boys who experienced childhood sexual abuse tended to be smaller (shorter) and from poorer families. No relationships to measured childhood intelligence, pubertal stage, marital status of mother or presence of the father were found and there was no significant association between reports of childhood sexual abuse and mental health in adulthood.
Millions of children around the world do not have access to clean water or decent sanitation at school, putting their education – and those of girls in particular – at risk. The first ever global baseline report on drinking-water, sanitation and hygiene in schools – carried out by WHO and UNICEF – shows that 620 million children worldwide do not have access to decent toilets at school, and around 900 million children cannot wash their hands properly. Ensuring that children attend school and complete their education is crucial to a country’s social and economic development, yet a lack of decent hygiene facilities discourages children, particularly girls, from doing so. Nearly 570 million children lacked a basic drinking water service at their school. Nearly half of schools in sub-Saharan Africa had no safe drinking water and a third of schools in sub-Saharan Africa had no sanitation service.
The heads of state from Brazil, Russia, India, China and South Africa (BRICS) met in August for a two-day annual BRICS summit, with one of the issues that of energy related investments and their impact. The author notes that China and India are investing billions of dollars in coal-fired thermal-power generation in Africa while winning global applause for increasing their solar and wind power at home and suggests that this points to a contradiction and policy inconsistency. China is funding coal projects in Ghana, Kenya, Tanzania, Malawi, Zambia and Zimbabwe, yet is a global powerhouse in renewable energy. He suggests that Chinese state energy companies losing business due to government slowing of carbon emissions in China are turning to Africa, even while they have first-hand knowledge on the effects of coal on the environment and human health. The Indian Government is also being praised globally for taking steps to halt carbon emissions, but it too has made investments in Africa in coal-based energy. He describes protest against harmful approaches with pickets by activists raising issues and demands to address exploitation, climate change, pollution and the looting of Africa resources with inequality and social harm.
7. Equitable health services
During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. The authors describe the scope and characteristics of this contact tracing and assess its performance during the 2014–2015 epidemic in six counties. Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during the period covered, with a PPV of 1.4%. Potential cases were more likely to be detected early in the outbreak; to hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness, as compared to contacts who completed monitoring. Contact tracing was identified to be a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, the study data suggest there were limitations to its performance—particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies.
The month-old Ebola outbreak in the Democratic Republic of Congo, which rose quickly to over 100 cases appears to be fading. More than 3,500 contacts of known cases are being followed, more than 4,000 doses of vaccine have been given and officials reported feeling hopeful enough to allow schools in the area — North Kivu Province, on the eastern border with Uganda — to open as usual. Although five experimental treatments for infected patients recently won approval for emergency use, the author reports that so far too few patients have received them to draw conclusions about how well they may work. One reason experts are reluctant to declare the outbreak contained is that some remote towns have not been visited because of armed groups in the area. Ebola experts also said they would not let down their guard because they remembered a brief, deceptive lull in the early days of the 2014 West African outbreak before it reached three capital cities and exploded, killing more than 11,000 people. Medically, the most exciting prospect on the horizon is that, as of Aug. 22, DRC has approved the emergency use of five potential treatments: two antiviral drugs, remdesivir and favipiravir; and three cocktails of antibodies originally found in recovered patients, including ZMapp, mAb114 and Regn3450-3471-3479. Previously, only about half of Ebola patients were saved if they got supportive treatment, including fluid replacement and fever control, in time. Being consistently able to cure most patients is reported to be an important advance.
In low-and-middle-income countries (LMICs), epidemiologic transition is taking place very rapidly from communicable diseases to non-communicable diseases (NCDs). NCD mortality rates are increasing faster and nearly 80% of NCDs deaths occur in LMICs, with human and economic costs, increasing treatment costs and losses to productivity. At the same time, the increasing penetration of mobile phone technology and the spread of cellular network and infrastructure have led to the introduction of the mHealth. While mHealth offers a promising approach in prevention and control of NCDs, it is unclear how ready health systems are to adopt it for this. The authors raise a number of factors which determine health systems readiness and response for adoption of mHealth technology including preparedness of healthcare institutions, availability of the resources, willingness of healthcare providers and communities. They discuss these factors and suggest that they be dealt up-front through constant effort to improve health systems response for NCDs.
8. Human Resources
This paper examines and seeks to contribute to understanding of external multiple job holding practices in public health training institutions based in prominent public universities in three sub-Saharan Africa countries. A qualitative multiple case study approach was used. Data were collected through document reviews and in-depth interviews with 18 key informants. Data were then triangulated and analyzed thematically. External multiple job holding practices among faculty of the three public health training institutions were widely prevalent. Different factors at individual, institutional, and national levels were reported to underlie and mediate the practice. While the authors report that it contributes to increasing income of academics, which many described as enabling their continuing employment in the public sector, many pointed to negative effects. Similarities were found regarding the nature and drivers of the practice across the institutions, but differences exist with respect to mechanisms for and extent of regulation. Regulatory mechanisms were often not clear or enforced, and academics are often left to self-regulate their engagement. Lack of regulation is cited as allowing excessive engagement in multiple job holding practice among academics at the expense of their core institutional responsibility. This could further weaken institutional capacity and performance, and quality of training and support to students. The research describes the complexity of external multiple job holding practices, which is characterized by a cluster of drivers, multiple processes and actors, and lack of consensus about its implication for individual and institutional capacity. They argue that in the absence of a strong accountability mechanism, the practice could perpetuate and aggravate the fledgling capacity of public health training institutions.
In this paper the authors present a systematic review of empirical studies investigating the relationship between human resource management and performance in Sub-Saharan Africa hospitals, based on a total of 111 included studies that represent 19 out of 48 Sub-Saharan Africa countries. From a human resource management perspective, most studies researched human practices from motivation-enhancing, skills-enhancing, and empowerment-enhancing domains. Motivation-enhancing practices were most frequently researched, followed by skills-enhancing practices and empowerment-enhancing practices. Few studies focused on single human resource management practices. Training and education were the most researched single practices, followed by task shifting. Most studies report human resource management interventions to have positively impacted performance in one way or another. The authors found that specific outcome improvements can be accomplished by different human resource management interventions and conversely that similar human resource management interventions are reported to affect different outcome measures. The review also identified little evidence on the relationship between human resource management and patient outcomes and the evidence often fails to provide contextual characteristics which can affect the impact of human resource management interventions. The authors call for more coordinated research efforts.
The paper synthesizes the current understanding of how community-based health worker programs can best be designed and operated in health systems. The authors searched 11 databases for review articles published between January 2005 and June 2017. The authors identified 122 reviews, 83 from low- and middle-income countries, 29 from high income countries and 10 global. Community-based health worker programs included in these reviews are diverse in interventions provided, selection and training of community-based health workers, supervision, remuneration, and integration into the health system. Features that enable positive community-based health worker program outcomes include community embeddedness, supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of community-based health worker programs into health systems can bolster program sustainability and credibility, clarify community-based health worker roles, and foster collaboration between community-based health workers and higher-level health system actors. The authors found gaps in the review evidence, including on the rights and needs of community-based health workers, on effective approaches to training and supervision, on community-based health workers as community change agents, and on the influence of health system decentralization, social accountability, and governance.
9. Public-Private Mix
The South African private healthcare sector comprises a complex set of interrelated stakeholders that interact in markets that are not transparent and so not easily understood. This report highlights key features that describe how the private healthcare sector operates. The author identifies features of the private healthcare sector that, alone or in combination, prevent, restrict or distort competition. The report presents recommendations to remedy these adverse effects on competition. Overall, the market is characterised by high and rising costs of healthcare and medical scheme cover, highly concentrated funders’ and facilities’ markets, disempowered and uninformed consumers, a general absence of value-based purchasing, ineffective constraints on rising volumes of care, practitioners that are subject to little regulation and failures of accountability at many levels. An incomplete regulatory regime is attributed to a failure in implementation on the part of regulators and inadequate stewardship by the Department of Health over the years. Intrinsic and extrinsic incentives in the market have promoted over-servicing by medical practitioners which include increased admissions to hospitals, increased length of stay, higher levels of care, greater intensity of care or use of more expensive modalities of care than can be explained by the disease burden of the population. The report presents We evidence of supply induced demand. Various marketing choices are reported to leave consumers confused and disempowered, compounding their inability to use choice as a pressure on schemes. The market is characterized by a dominance of a few schemes and by an absence of effective direct competition between the three big hospital groups. The report recommends changes to the way scheme options are structured to increase comparability between schemes and increase competition in that market; a system to increase transparency on health outcomes to allow for value purchasing and a set of interventions to improve competition in the market through a supply side regulator.
The Health Market Inquiry (HMI) report published in South Africa is a result of widespread complaints about rising prices and declining benefits in 2014, and was set up by the Competition Commission as an inquiry into the private health care market. A panel of independent experts was appointed, chaired by former Chief Justice Sandile Ngcobo. According to the Competition Commission nearly nine million people in South Africa (16.9% of the population) are members of medical schemes. Many are reported to feel resentful of paying a lot to medical schemes and still having to pay more out of pocket when they need care. The HMI report confirms that premiums are rising and benefits are falling. Expenditure on private health, where R235-billion is spent on nine million people, overshadows the R201-billion the government spends on the other 44-million. Yet the two systems are tied at the hip: they have overlapping staff, overlapping regulatory institutions, and of course an overlapping population for whom healthcare is a right. The National Health Insurance (NHI) reform is raising a need for scrutiny of all providers. The HMI recommends regulations, systems for effective and fair price control and institutions to oversee the market. Scheme members are urged by the author to obtain the report and to challenge the Minister of Health to implement the recommendations.
10. Resource allocation and health financing
Uganda has increased its allocation to the health sector from Ush1.8 trillion ( US $470.6 million) in the 2017/18 financial year to Ush2.3 trillion ($595.6 million), in what the author indicates that some see as an a response to a backlash in 2017 from external funders when the government reduced the nominal value of Ministry of Health’s funding by Ush6 billion ($1.5 million). Officials at the ministry note the increased allocation aims to support the country on a journey to universal health coverage and reduce dependence on external funding. In the 2018/19 financial year, Dr Sarah Byakika, the acting planning commissioner in the Ministry of Health, said the increased allocation will among other things target universal health coverage, recruit community health workers, cover recurrent expenditures at specific hospitals and for the national blood bank. Money is also being provided to avert the perennial strikes of interns and for the drafting of regulations for a new national health insurance law, with national health insurance seen as key for improved domestic financing.
Zimbabwe's Health Financing Policy and strategy launched in June 2018 was informed by WHO guidelines on health financing embedded in a health systems framework. The policy and strategy acknowledge that the way funds are raised and allocated and the way services are paid for influences how services are accessed by the population. It focuses on better use of available resources, and increased Government allocation to health leading to reduced direct out of pocket payments by households, which will in turn reduce financial barriers to access for the poor. It also brings in innovation in exploring more options to raise funding for health, and the creation of a pool of funds to ensure better management of health funds. Emphasis on achieving sustainable health financing is explicit in the Health Financing Strategy so that gains can be sustained. The financing seeks to ensure that the current National Health Strategy (2016-2020) is well financed and implemented to take steps towards financial risk protection and ultimately universal health coverage.
11. Equity and HIV/AIDS
This was a qualitative study was conducted in Central Uganda between February and March 2017 through 32 in-depth interviews to document women and men’s perceptions about HIV self-testing (HIVST) strategies used by women in delivering the kits to their male partners, male partners’ reactions to receiving kits from their female partners, and positive and negative social outcomes post-test. Women were initially anxious about their male partners’ reaction if they brought HIVST kits home, but the majority eventually managed to deliver the kits to them successfully. Women who had some level of apprehension used a variety of strategies to deliver the kits including placing the kits in locations that would arouse male partners’ inquisitiveness or waited for ‘opportune’ moments when their husbands were likely to be more receptive. A few women lied about the purpose of the test kit while one woman stealthily took a mucosal swab from the husband. Most men initially doubted the ability of oral HIVST kits to test for HIV, but this did not stop them from using them. Both men and women perceived HIVST as an opportunity to learn about each other’s HIV status. No serious adverse events were reported post-test. The author’s findings lend further credence to the feasibility of female-delivered HIVST to improve male partner HIV testing in sub-Saharan Africa. They suggest that women need support in challenging relationships to minimize potential for deception and coercion.
12. Governance and participation in health
In July 2018 i-CMiiST, a Nairobi based organisation held an Urban Dialogue for to discuss the development of two key areas of the city - Yaya junction and Luthuli avenue. The aim of the dialogue was to engage the general public on issues affecting Nairobi streets, transit and mobility to feed into future interventions and approaches in the development of these areas. The theme of the dialogue was ‘safety on our streets’ looked at from different perspectives: pedestrians, commuters, drivers and cyclist safety. The dialogue involved about 30 people from different professions and backgrounds – engineers, planners, cyclists, urban designers, state actors, NGOs, business people etc. It was also live streamed on various social media platforms to involve a wider public, viz: KPF, Naipolitans and Placemaking Network Nairobi pages. Views and contributions came from people watching locally and from other countries while the inputs were recorded and an illustrator documented what participants were saying in a visual form.
The paper seeks to investigate the effect of using volunteer screeners in active tuberculosis case-finding in South Kivu, the Democratic Republic of the Congo, especially among groups at high risk of tuberculosis infection. In order to identify and screen high-risk groups in remote communities, the authors trained volunteer screeners, mainly those who had themselves received treatment for tuberculosis or had a family history of the disease. A non-profit organization was created and screeners received training on the disease and its transmission at 3-day workshops. Screeners recorded the number of people screened, reporting a prolonged cough and who attended a clinic for testing, as well as test results. Data were evaluated every quarter during the 3-year period of the intervention (2014–2016). Acceptability of the intervention was high. Volunteers screened 650 434 individuals in their communities, 73 418 of whom reported a prolonged cough; 50 368 subsequently attended a clinic for tuberculosis testing. Tuberculosis was diagnosed in 1 in 151 people screened, costing 0.29 United States dollars per person screened and US$ 44 per person diagnosed. Although members of high-risk groups with poorer access to health care represented only 5.1% of those screened, they contributed 19.7% of tuberculosis diagnoses. The intervention resulted in an additional 4300 sputum-smear-positive pulmonary tuberculosis diagnoses, 42% of the provincial total for that period. Patient-led active tuberculosis case-finding represents a valuable complement to traditional case-finding, and should be used to assist health systems in the elimination of tuberculosis.
Twenty years ago, a group of activists came together to demand access to treatment for all people living with HIV. The introduction of highly effective combination antiretroviral (ARV) therapy offered hope. Yet their high price meant that they were entirely unavailable in the public health system and out of reach for millions of people. In 1998, ARVs cost US$10 000 per year. Demanding access to treatments, activists from the Treatment Action Campaign (TAC), Médecins Sans Frontières (MSF) and the AIDS Law Project, later incorporated as SECTION27 helped to spur a global movement that radically reduced the prices of HIV medicines. Using skilled legal advocacy, high-quality research, social mobilisation, and public education, these activists transformed the global conversation on drug pricing, making it possible for millions of people to access treatment. Yet despite the remarkable success in increasing access to HIV medicines, this paper notes that systemic problems remain entrenched. New medicines to treat drug-resistant TB, cancers, and many other conditions remain far too expensive. As South Africa develops its intellectual property framework, they argue that it is worth revisiting the strategies, successes, and shortcomings of the access to medicines movement for the insights they may offer. The authors observe that a battle that began nearly twenty years ago engaging pharmaceutical giants and recalcitrant governments continues today. This interactive website showcases their story.
13. Monitoring equity and research policy
An article published in the journal Nature on July 5 puts forward a new technique for the evaluation of research on development. It marks a departure from conventional approaches that, according to the author, have significant weaknesses. This new method for the evaluation of development research — known as RQ+ or Research Quality Plus — emphasises the crucial importance of context, local knowledge and the views of the populations whose lives the research aims to improve. Conventional approaches to evaluating scientific endeavours are argued by the author to have a number of inbuilt constraints. For example, they focus primarily on peer assessment or bibliometrics but don’t explicitly pass judgement on the originality or usefulness of the research, nor do they look at the degree of respect for local knowledge. The RQ+ approach goes beyond an evaluation focused solely on the scientific merit of research outputs and includes other dimensions that are essential to measuring the value and quality of research. RQ+ takes account of what evaluators have to say, but their views should be evidence-based, rather than a simple opinion. Those carrying out the evaluation should take into consideration external points of view — for example those of users targeted by the research or of the communities it is supposed to benefit — as well as the perspectives of other researchers working in the same field.
14. Useful Resources
The World Health Organisation hosts this global open-access tripartite antimicrobial resistance database that provides access to information on the status of countries’ regarding the implementation of the global action plan and actions to address antimicrobial resistance across all sectors. Country responses are visualized through maps and can be sorted by regions and by income groups. Information captured in this database is a result of a country self-assessment questionnaire reporting on progress in: developing national antimicrobial resistance action plans; working with multiple sectors; and implementing key actions to address antimicrobial resistance. The database currently contains data for the reporting year 2016-17 and 2017-18.
15. Jobs and Announcements
At major meetings, advances in HIV management focuses mainly on either adults or children, leaving out adolescents. To meet this need for international interchange in order to bring the field forward, Virology Education and partners have initiated the International Workshop on HIV & Adolescence: challenges and solutions. This workshop is for multidisciplinary experts working with adolescents affected by HIV. It aims to share experiences, knowledge and best practices in optimizing care for adolescents living with HIV. The program will cover the spectrum of developmental changes in adolescents including social, behavioral, physiological and biological aspects and the impact of an HIV positive status, and prevention programs, testing, treatment and support services among adolescents.
The Children’s Institute has developed a cutting-edge short course in child rights and child law for health and allied professionals - including training on consent to medical treatment and the reporting of child abuse and neglect as outlined in the new Children’s Act and amendments to the Sexual Offences Act. This five-day intensive course provides an opportunity for doctors, nurses, social workers and allied professionals to explore how best can better give effect to children’s rights in their practice, and is accredited with both the Health Professions Council of South Africa and the SA Council for Social Service Professions. 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.
This fellowship programme is aimed at African scholars who have obtained a doctoral degree within the preceding seven years and who hold an academic position at a university or research institution anywhere in Africa. Candidates should have established a research programme and have completed a post-doctoral fellowship or equivalent post-PhD programme. All disciplines are considered. Iso Lomso Fellowships provide an early career opportunity for Africa’s brightest minds in academia. Fellows will enjoy: a three-year attachment during which time they may spend a total of ten months in residence to develop and pursue a long-term research programme at a sister institute for advanced study in North America, Europe or elsewhere. The fellowship includes funding to attend up to two international conferences or training workshops; support to convene a workshop with collaborators and lecturer replacement subsidy for the fellow’s home institution during residency periods.
The International Lead Poisoning Prevention Week of Action will take place from 21–27 October 2018, with particular focus on eliminating lead paint in all countries by 2020. Lead poisoning is preventable, yet in 2016 lead exposure was estimated to account for 540 000 deaths and 13.9 million years lost to disability and death due to the long-term health effects, with the highest burden being in developing regions. Of particular concern is the role lead exposure plays in the development of intellectual disability in children. Even though this problem is widely recognised, it remains a key concern of healthcare providers and public health officials worldwide. The World Health Organisation has produced campaign materials for organisations to plan a local event with government, industry or civil society.
Hearing loss, especially disabling hearing loss, is associated with delayed cognitive development in children and early cognitive decline in older adults. Hearing loss was highlighted at the World Health Assembly in 2017, when Member States unanimously adopted a resolution to develop public health strategies to integrate ear and hearing care within countries’ primary health-care systems. Against this background, the Bulletin of the World Health Organization will publish a theme issue on the public health approach of hearing loss. Papers are welcomed which focus on identifying and filling the gaps in evidence across comprehensive hearing-care services, from promotion of ear and hearing care, to screening, hearing devices and rehabilitation. In particular, the papers should report on unmet needs, outcomes of services, and effective and sustainable initiatives to reach underserved groups. Submission of papers reporting on both the magnitude of diseases and conditions, such as ear infections, meningitis and rubella, that can affect hearing, are encouraged, as well as papers addressing health system issues and promoting an intersectoral approach to ear and hearing care, such as looking beyond health. As much as possible, papers should seek to integrate examples from low- and middle-income countries across life course.
CA Global Headhunters are recruiting for a a position of Director of a Secretariat for an international organisation implementing malaria control in sub-Saharan Africa. The organisation Ministerial Committee and Secretariat Board are now seeking a Director to continue the momentum that has been started, and to allow the organization to consolidate on the lessons and experiences of its start-up period to steer the next phase of the strategy towards malaria-free Regions. The Director will manage a successful transition from the previous head of the Secretariat, while supporting and guiding the regional partnership through a period of focused growth. He/she will work closely with member states, the Board and the Ministerial Committee to steer the organization to a more impactful and sustainable model for regional malaria elimination, including Ministers of Health, Permanent Secretaries, and Malaria Program Directors/Managers. The Director will facilitate negotiation and alignment between member states to allocate resources effectively for regional priorities, while also strengthening mechanisms for joint monitoring and accountability for the mutual elimination goal. The website provides information for submission of applications.
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