EQUINET NEWSLETTER 212 : 01 November 2018

1. Editorial

Breathing life into constitutional rights to health in Uganda
Jacqueline Nassimbwa and Mulumba Moses, CEHURD, Uganda

In 2011 civil society petitioned the Uganda Constitutional Court (Petition 16 of 2011) for its failure to put in place systems to prevent maternal deaths in public health facilities. This failure was argued to be a violation of the right to the highest attainable standard of health guaranteed in the country’s constitution.

In response the judgement stated

“…Much as it may be true that government has not allocated enough resources to the health sector and in particular the maternal health care services, this court is………reluctant to determine the questions raised in this petition. The Executive has the political and legal responsibility to determine, formulate and implement polices of Government……….. This court has no power to determine or enforce its jurisdiction on matters that require analysis of the health sector government policies…”

The court argued that it had no role in reviewing or commenting on government policies or on how they are operationalized. It stated that judging on the issues raised in the petition implied taking over the role of the government executive, and that the injustice was not a constitutional but a political issue.

The Constitutional court thus dismissed the case. However, in an appeal to Uganda’s High Court the dismissal was struck down, with a ruling that the Constitutional Court had erred and that it indeed had a mandate to hear the case. The case has since gone back to the Constitutional court with a date for the hearing still pending.

The to and fro on this case reflects the challenges arising when claiming a right to health that is implicit within a national constitution. Clearly stating the right to health in the constitution is important for it to be promoted, enforced and safeguarded. If not stated in the constitution, its implementation depends on the actions of politicians, state officials, the courts and civil society. In particular, the preamble, “We the people…” in the constitution mandates the citizenry to advance these provisions.

While some countries in east and southern Africa do explicitly provide the right to health care, the right to health is often not explicitly stated. In Uganda, the 1995 Constitution, currently in force, has provisions on rights to life, privacy, freedom from torture and education amongst others. It does not, however, explicitly provide for the right to health. This right is rather found in the national objectives and directive principles of state policy. It thus depends on a mix of political, judicial and social action.

In an EQUINET case study by CEHURD (https://tinyurl.com/y6uppusb), we reviewed how this less explicitly provided right to health in the Uganda Constitution is being implemented through political, judicial and popular mechanisms.

Politically, the government executive has made international commitments to the Sustainable Development Goals in line with a Uganda Vision 2040. This policy vision aligns government initiatives to fulfilling duties and responsibilities, including for health care. It commits government to ensure policies and laws and build state capacities to implement programmes to realise health rights. In the health sector, for example, the ministry of health has a policy commitment and plans to ensure universal health coverage to realise the right to health care.

Such positive political intentions draw attention to how far they are being implemented. Parliamentarians as political actors have passed progressive laws to reflect changing social perspectives on health rights. However, there are gaps that need to be addressed. For example, old, colonial laws are still in force that do not reflect human rights principles, such as those governing the control of sexually transmitted diseases (termed ‘venereal diseases’ in the law).

Further, a gap in delivery on political intentions can be seen through the disparities in service coverage for particular social groups and lack of a clear co-ordinating mechanism for different sectors to address health determinants. It can also be assessed from how far policies are being framed for and services delivered to address controversial issues, such as abortion, access to contraceptives and education on sexuality for sexually active adolescents.

Beyond these political measures, there is an option for judicial implementation of the right to health. Indeed, there has been some increase in litigation on the right to health in Uganda, although with still few cases filed, and even less with favourable judgements. In a 2009 case the court dismissed a petition on the potential toxicity of chemicals sprayed for malaria prevention as not violating constitutional provisions on the right to health. In contrast in 2010 the court declared female genital mutilation, being practiced in certain Ugandan cultures, as a violation of the constitution, and specifically a violation of the rights of women and the right to health.

These poor outcomes could be explained by a lack of understanding of the human rights doctrine amongst judicial officers and lawyers. This may, for example, be a reason for the dismissal of Petition 16 cited earlier, later overturned by the High Court. It could explain the caution in the courts over litigation on social rights. This suggests a need for advocacy and capacity building with these key judicial stakeholders on their role in taking forward the right to health and the use of appeal processes to take up cases where the outcome may be seen to be unfair.

Beyond the political and judicial routes to implementation of the right to health, there is also the possibility of social action advancing these rights. There has been a rise in popular implementation of the right to health as implicitly provided in the Constitution in Uganda, more commonly through the actions of organized groups. In our review, we found experiences of campaigns, demonstrations, coalition formation and industrial action.

For example, in the ‘Walk to Work’ campaign in 2011, people were encouraged to walk to work daily to protest increasing prices of fuel, food, and transportation and poor social service delivery. The campaign, identified as political opposition due to its leadership, met police suppression and incarceration of campaigners and was banned in 2012.

More specifically focused on the health sector, in late 2017 the Uganda Medical Association (UMA), launched an industrial action over poor salaries, poor working and living conditions and inadequate medical supplies preventing medical personnel from performing their duties. This too met an immediate government response in a court challenge to the legality of UMA, an order by the Minister of Health for the workers to return to work and deployment of military doctors to hospitals. Later, however, government negotiated with the medical workers, improving their welfare and salaries. This measure for popular implementation yielded more positive results on health rights, perhaps given its less partisan political nature.

These diverse experiences found in Uganda, further detailed in the case study report, point to the fact that applying a right to health that is not explicitly provided in the constitution is possible. It calls for and generates political, judicial and popular measures, and possibly demands a mix of all.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. Please visit the EQUINET website to read the case study report and other publications on health rights.

2. Latest Equinet Updates

EQUINET Case study: Review of Constitutional Provisions on the Right to Health in Uganda
Centre for Human Rights and Development (CEHURD)

This case study is produced by the Centre for Human Rights and Development (CEHURD) in the theme work on health rights and law of the Regional Network for Equity in Health in East and Southern Africa (EQUINET). It examines how the right to health is enforced in Uganda, how it was implemented, and how health rights advocates have suggested the provision be constitutionally interpreted. It is a follow up on the results of work on the right to health that highlighted a need to do further studies in countries that do not have expressed provision on the rights to health. While the right to health is yet to be explicitly incorporated in the Ugandan constitution, the case study points to a number of ways to implement it within judicial, political and popular measures. Several issues merit future attention to support this, including: developing increased measures and capacities for accountability; integrating a rights based approach in a multi-sectoral response; ensuring adequate resources to the health system; strengthening judicial understanding and implementation of health rights; and strengthening issue based civil society groups and processes that are focused on advancing the right to health with the intention to realize positive public and policy outcomes.

3. Equity in Health

Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys
Benova L; Dennis M; Lange I; et al: BMC Health Services Research 18(758) 1-14, 2018

The authors present a repeated cross-sectional study using four Uganda Demographic and Health Surveys of evidence on births with ANC, facility delivery, caesarean sections and complete maternal care. The authors assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone in the 1995 and 2011 surveys. ANC coverage with remained high over the study period but < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components. The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care. Providers in both sectors require quality improvements. The authors suggest that achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women, despite competing priorities for financial and human resources.

4. Values, Policies and Rights

Alternative Civil Society Astana Statement on Primary Health Care
Public interest civil society organisations and social movements: open for endorsements up to 15 November

Members of public interest civil society organisations and social movements, some of whom are participants at the Global Conference on Primary Health Care, produced this statement to re-affirm a commitment to primary health care (PHC) in pursuit of health and well-being for all, aiming to achieve equity in health outcomes. The statement is a re-affirmation of the Alma Ata declaration, which to PHM and others remains the ultimate declaration on primary health care; the principles are clear and remain relevant. This authors invite organisations who agree with the views expressed to sign on to the statement.

How a change in US abortion policy reverberated around the globe
Bearak M; Morello C: The Washington Post, October 2018

In January 2017, President Trump signed an executive order that denied U.S. assistance to any foreign-based organization that performs, promotes or offers information on abortion. A similar policy was in effect under past Republican presidents. In 2017 it was expanded exponentially to apply not just to around $600 million in overseas family-planning funds, but to the entire $8.8 billion in annual U.S. global health aid. It will take years to gauge the full impact of the policy, which will affect aid groups as they renew grants or seek new U.S. funding. More broadly, the policy has created a wave of uncertainty in aid-dependent countries. For the first time, groups that treat HIV, malaria and other illnesses will also have to pledge to have no role in promoting abortion — or forgo American aid. Academics have questioned whether the policy effectively decreases abortions. A 2011 study by Stanford University researchers suggested the policy has actually been “associated with increases in abortion rates in sub-Saharan African countries.” One possible reason the researchers gave for this was that some organizations that had provided contraceptives lost funding, which may have led to more unwanted pregnancies. While most foreign health groups have committed to following the new rules., a small group , including the International Planned Parenthood Federation and Marie Stopes, have refused to sign.

Influence of the WHO framework convention on tobacco control on tobacco legislation and policies in sub-Saharan Africa
Wisdom J; Juma P; Mwagomba B: BMC Public Health 18(Suppl 1) 954, doi: https://doi.org/10.1186/s12889-018-5827-5, 2018

The World Health Organization’s Framework Convention on Tobacco Control, enforced in 2005, was a watershed international treaty that stipulated requirements for signatories to govern the production, sale, distribution, advertisement, and taxation of tobacco to reduce its impact on health. This paper describes the timelines, context, key actors, and strategies in the development and implementation of the treaty and describes how six sub-Saharan countries responded to its call for action on tobacco control. A multi-country policy review using case study design was conducted in Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo. It involved document review and key informant interviews. Multiple stakeholders, including academics and activists, led a concerted effort for more than 10 years to push the WHO treaty forward despite counter-marketing from the tobacco industry. Once the treaty was enacted, Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo responded in unique ways to implement tobacco policies, with differences associated with the country’s socio-economic context, priorities of country leaders, industry presence, and choice of strategies. All the study countries except Malawi have acceded to and ratified the WHO tobacco treaty and implemented tobacco control policy. Reviewing how six sub-Saharan countries responded to the treaty to mobilize resources and implement tobacco control policies provided insight for how to utilise international regulations and commitments to accelerate policy impact on the prevention of non-communicable diseases.

Press release on prosecution of SGBC in Uganda
Kwagala P: Centre for Health, Human Rights & Development, 2018

In August 2018, the Center for Health, Human Rights and Development (CEHURD), Nnamala Mary and Simon Kakeeto took the Government of Uganda to the Constitutional Court for failing to put in place shelters for women who have been raped or defiled. CEHURD challenged the unequal punishments that the law provides for sexual offenders as being unjust. Men charged with rape are liable to suffer a maximum penalty of death whereas the law provides for the offense of ‘defilement’ for persons between the ages of 14-17 and sexual offenders against girls of that category are only given a few years of a jail term. This difference in penalties towards perpetrators who commit the same offense was argued to be unjust and to offend the principle of equality and non-discrimination before the law. It was also observed to have an effect of increasing sexual violence against girls in that particular age group. Women who survive sexual violence need safe spaces, shelters and refuge. The Ugandan Constitution mandates the State to put in place facilities to enhance the welfare of women to enable them to realise their full potential and advancement. It was thus CEHURD's contention that failure by government to construct and finance these shelters is a clear violation of women’s rights guaranteed under article 33(2) of the 1995 Constitution of Uganda.

The future of health in Zimbabwe
Kidia K: Global Health Action 11(1496888) 1-5, 2018

The author presents the argument that Zimbabwe is at a critical juncture for health reform and argues that this reform should focus on repairing relationships with the international community by focusing on human rights and eliminating corruption; strengthening the health workforce through retention strategies, training, and non-specialist providers and strengthening community engagement to grow local leadership and ensure that interventions are socially and culturally sensitive.

This is 18: through girls’ eyes.
Bennett J; Strzemien A: New York Times, October, 2018

When Malala Yousafzai turned 18, she opened a school for Syrian refugee girls, calling on leaders from around the world to provide “books not bullets.” It was at 18 that Cleopatra became ruler of Egypt, in 51 B.C.E., and Victoria the queen of Great Britain, in 1837. By the time she was 18, Britney Spears had had two No. 1 albums on the Billboard chart, and Serena Williams had won the U.S. Open. Emma Gonzalez, 18 now, has become a global leader in the movement to end gun violence. No pressure, right? Eighteen is an age. But it’s also something more. It’s a moment, a rite of passage, a gateway to adulthood.In the United States, 18 means you can finally vote, sign a lease on an apartment, obtain a credit card and buy a Juul. In China and parts of Canada, 18 grants you entrance to a pub, while for most Israelis, it means a mandatory draft into the military. By 18, one in five women across the globe will be married. Millions will enter college or university. “This is 18” aims to capture what life is like for girls turning 18 in 2018 across oceans and cultures. The editors asked young women photographers to document girls in their communities — taking the photos and conducting the interviews themselves. Each photographer was paired with a professional mentor to guide them through the process. The result is a celebration of girlhood around the world — across 12 time zones and 15 languages, featuring 21 subjects and 22 photographers. #ThisIs18 — a look at girls’ lives, through girls’ eyes.

United States aid policy and induced abortion in sub-Saharan Africa
Brendavid E; Avila P; Miller G: Bulletin of the World Health Organisation 89(12) 853-928, 2011

This study explored the relationship between the reinstatement in 2001 of a US policy requiring all nongovernmental organizations operating abroad to refrain from performing, advising on or endorsing abortion as a method of family planning if they wish to receive federal funding and the probability that a sub-Saharan African woman will have an induced abortion. The authors used longitudinal, individual data on terminated pregnancies collected by Demographic and Health Surveys (DHS) to estimate induced abortion rates. The study found robust empirical patterns suggesting that the policy was associated with increases in abortion rates in sub-Saharan African countries. Several observations were identified to strengthen this conclusion. First, the association was strong: and second, there was broad agreement among the aggregate graphical analysis and both unadjusted and adjusted statistical analyses, robust across a variety of sensitivity analyses. Third, the timing of divergence between high and low exposure countries was coincident with the policy’s reinstatement: in high exposure countries, abortion rates began to rise noticeably only after the policy was reinstated in 2001 and the increase became more pronounced from 2002 onward.

5. Health equity in economic and trade policies

Calling for a New Global Economic Order
Peoples Health Movement; Medicus Mundi International; G2H2: Astana 2018

In 1978, the Alma-Ata International Conference on Primary Health Care stated, in its final declaration, that “economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all.” This video raises why this call is still relevant today and why it should be recalled and renewed now we celebrate the 40th Anniversary of the Alma-Ata Declaration at the Global Conference on Primary Health Care in Astana, on 25-26 October 2018.

The causes of the growth of 'populism'
Navarro V: Other News, October 2018

In this article (original in Spanish) the author analyses current movements termed 'populist'. He notes that they have some points in common. One of them is their clear opposition to globalization and economic integration and to the cultural and political homogenization that they entail and that is perceived as a threat to their national identity. A desire to recover identity and national control conditions is a nationalist sentiment based primarily (though not exclusively) on globalization being identified with a decline in the quality of life and well-being of the social classes behind this populism, even while this was due to the enormous increase in the wealth and welfare of wealthy minorities at the expense of the great decline in welfare and standard of living of the majority of the population The author asserts that socialist movements that have an opposition and alternative to a neoliberal conservative establishment differs from most populisms, which have an anti-establishment dimension but lack a proactive dimension . At the same time he argues that the failure of socialist or social democratic parties to develop an effective response to neoliberalism has been one of the main causes of the growth of right wing populist movements. The author argues for responses that recognise that the different sectors of the population have elements and conditions in common, that also provides more radical proposals for how to address these conditions.

6. Poverty and health

How do gender and disability influence the ability of the poor to benefit from pro-poor health financing policies in Kenya? An intersectional analysis
Kabia E; Mbau R; Muraya K; et al: International Journal for Equity in Health 17(149) 1-12, 2018

This study employed an intersectional approach to explore how gender disability and poverty interact to influence how poor women in Kenya benefit from pro-poor financing policies that target them. The authors applied a qualitative cross-sectional study approach in two purposively selected counties in Kenya. The authors collected data using in-depth interviews with women with disabilities living in poverty who were beneficiaries of the health insurance subsidy programme and those in the lowest wealth quintiles residing in the health and demographic surveillance system. Women with disabilities living in poverty often opted to forgo seeking free healthcare services because of their roles as the primary household providers and caregivers. Due to limited mobility, they needed someone to accompany them to health facilities, leading to greater transport costs. The absence of someone to accompany them and unaffordability of the high transport costs, for example, made some women forgo seeking antenatal and skilled delivery services despite the existence of a free maternity programme. The layout and equipment at health facilities offering care under pro-poor health financing policies were disability-unfriendly. The latter in addition to negative healthcare worker attitudes towards women with disabilities discouraged them from seeking care. Negative stereotypes against women with disabilities in the society led to their exclusion from public participation forums thereby limiting their awareness about health services. Intersections of gender, poverty, and disability influenced the experiences of women with disabilities living in poverty with pro-poor health financing policies in Kenya. Addressing the healthcare access barriers they face could entail ensuring availability of disability-friendly health facilities and public transport systems, building cultural competence in health service delivery, and empowering them to engage in public participation.

7. Equitable health services

Feasibility, acceptability and potential sustainability of a ‘diagonal’ approach to health services for female sex workers in Mozambique
Lafort Y; de Melo M; Lessitala F; et al: BMC Health Services Research 18(752) 1-11, 2018

Female sex workers in many settings have restricted access to sexual and reproductive health services. This paper tested a diagonal intervention which combined strengthening of female sex workers targeted services with making public health facilities more female sex worker-friendly. It was piloted over 18 months and then its performance assessed. The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure that female sex workers have access to sexual reproductive health services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by the national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.

Healthcare service delivery to refugee children from the Democratic Republic of Congo living in Durban, South Africa: a caregivers’ perspective
Meyer-Weitz A; Oppong Asante K; Lukobeka B: BMC Medicine 16(163), doi: https://doi.org/10.1186/s12916-018-1153-0, 2018

This study explored refugee caregivers’ perceptions of their children’s access to quality health service delivery to their young children in Durban, South Africa. This study used an explanatory mixed methods design, purposively sampling 120 and 10 participants for the quantitative and qualitative phases, respectively. The majority (89%) of caregivers were women, with over 70% of them aged between 30 and 35 years. Over 74% of caregivers visited public clinics for their children’s healthcare needs. The majority of caregivers (95%) were not satisfied with healthcare services delivery to their children due to the long waiting hours and the negative attitudes and discriminatory behaviours of healthcare workers, particularly in public healthcare facilities. These findings underscore the need to address health professionals’ attitudes when providing healthcare for refugees. The authors suggest that attitudinal change may improve the relationship between service providers and caregivers of refugee children in South Africa, which may improve the health-related outcomes in refugee children.

Is healthcare really equal for all? Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians
Dei V; Sebastian M: International Journal for Equity in Health 17(86)1-12, 2018

This paper aimed to assess whether horizontal and vertical equity were being met in the healthcare utilisation among adults aged 50 years and above. The paper was based on a secondary cross-sectional data from the World Health Organization’s Study on global AGEing and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Horizontal and vertical inequities were found in the use of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The paper reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access.

8. Human Resources

Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya
Aseyo R; Mumma J; Scott K; et al: Human Resources for Health 16(53) 1-12, 2018

This study examines the behaviour change-related activities of community health volunteers (CHVs) community health workers affiliated with the Kenyan Ministry of Health in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation. This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement. Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs’ low motivation to encourage behaviour change in local communities. In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. The authors argue that more resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.

9. Public-Private Mix

Towards universal health coverage: a mixed-method study mapping the development of the faith-based non-profit sector in the Ghanaian health system
Grieve A; Olivier J: International Journal for Equity in Health 17(97)1-20, 2018

This paper presents a mapping of faith-based health assets in Ghana using both qualitative and quantitative evidence to provide a visual representation of changes in the spatial footprint of the faith-based non-profit (FBNP) health sector. The geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts. The sector has had a long-standing role in the provision of health services and remains a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. The authors observe that collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of universal health coverage.

10. Resource allocation and health financing

HIV partner services in Kenya: a cost and budget impact analysis study
Cherutich P; Farquhar C; Wamuti B; et al: BMC Health Services Research 18(721) 1-11, 2018

This paper focuses on elicitation of contact information, notification and testing of sex partners of HIV infected patients (aPS). Using study data and time motion studies, the authors constructed an Excel-based tool to estimate costs and the budget impact of aPS in selected facilities in Kisumu County. The authors report the annual total and unit costs of HTS, incremental total and unit costs for aPS, and the budget impact of scaling up aPS over a 5-year horizon. The average unit costs for HIV testing among HIV-infected index clients was US$ 25.36 per client and US$ 17.86 per client using nurses and CHWs, respectively. The average incremental costs for providing enhanced aPS in Kisumu County were US$ 1 092 161 and US$ 753 547 per year, using nurses and CHWs, respectively. The average incremental cost of scaling up aPS over a five period was 45% higher when using nurses compared to using CHWs. Over the five years, the upper-bound budget impact of nurse-model was US$ 1,8mn, 63% and 35% of which were accounted for by aPS costs and ART costs, respectively. The CHW model incurred an upper-bound incremental cost of US$ 1,3mn which was 71% lower than the nurse-based model. The budget impact was sensitive to the level of aPS coverage and ranged from US$ 28 547 for 30% coverage using CHWs in 2014 to US$ 1,3mn for 80% coverage using nurses in 2018. Scaling aPS using nurses has minimal budget impact but not cost-saving over a five-year period. Targeting aPS to newly-diagnosed index cases and task-shifting to community health workers is recommended by the authors.

11. Equity and HIV/AIDS

Associations between health systems capacity and mother-to-child HIV prevention program outcomes in Zambia
Price J; Chi B; Phiri W: PLOS ONE 13(9), doi: https://doi.org/10.1371/journal.pone.0202889, 2018

In this study, the authors investigated the association between health system capacity and use of prevention of mother-to-child HIV transmission (PMTCT) services in Zambia. They analyzed data from two studies conducted in rural and semi-urban Lusaka Province in 2014–2015. Among 29 facilities, the median overall facility score was 72. Median domain scores were: patient satisfaction 75; human resources 85; finance 50; governance 82; service capacity 77; service provision 60. The programmatic outcome was measured from 804 HIV-infected mothers. Median community-level antiretroviral use at 12 months was 81%. Patient satisfaction was the only domain score significantly associated with 12-month maternal antiretroviral use. When the authors excluded the human resources and finance domains, a positive association between composite 4-domain facility score and 12-month maternal antiretroviral use in peri-urban but not rural facilities was found. In these Zambian health facilities, patient satisfaction was positively associated with maternal antiretroviral 12 months postpartum. The association between overall health system capacity and maternal antiretroviral drug use was stronger in peri-urban versus rural facilities.

High rates of smoking in people with HIV in sub-Saharan Africa
Carter M: Aidsmap, September 2018

This research analysed data from the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) from 25 sub-Saharan African countries to determine prevalence of cigarette smoking and use of smokeless tobacco according to HIV status. Cross-sectional data were collected between 2005 and 2015 from adults aged between 15 and 59 years. As well as HIV status, data were also collected on gender, marital/relationship status, level of education, income, area of residence (rural/urban) and employment status. These factors were taken into account in statistical analyses of the association between HIV status and tobacco use. Turning to HIV, the prevalence of smoking was higher among HIV-positive than HIV-negative individuals (10.6% vs 8.1%). Analysis by gender showed that 25.9% of HIV-positive men and 1.2% of HIV-positive women smoked, significantly higher than the 16.1% and 0.7% prevalence seen in HIV-negative men and women, respectively. Country-level analyses showed considerable variability in tobacco use between individual countries. The prevalence of smoking ranged from 2.4% in Ghana to 19.9% in Lesotho. Over half of countries (14 of 25) showed a higher smoking prevalence among people with HIV. The difference was significant in five countries: Gambia, Niger, Swaziland, Zambia and Zimbabwe. But in Ethiopia and Namibia, HIV-positive participants were less likely to smoke than HIV-negative ones. The investigators acknowledge a number of limitations, including the cross-sectional design of their study, failure to collect data on frequency and intensity of tobacco use and a lack of data on use of antiretroviral therapy.

12. Governance and participation in health

Gendered norms of responsibility: reflections on accountability politics in maternal health care in Malawi
Lodenstein E; Pedersen K; Botha K; et al: International Journal for Equity in Health 17(131) 1-15, 2018

This paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws that are local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed, in a qualitative study in five health centre catchment areas in Northern Malawi. In the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres’ and some community members contest them, in particular, the principles of individual responsibility and universality. The study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, the authors argue that women bear the full responsibility for failures in maternal health care, suggesting a form of ‘reversed accountability’ of women towards global maternal health goals. This can negatively impact on women’s reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. It is suggested that contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.

Reflecting strategic and conforming gendered experiences of community health workers using photovoice in rural Wakiso district, Uganda
Musoke D; Ssemugabo C; Ndejjo R; Ekirapa-Kiracho E; et al: Human Resources for Health 16(41) 1-9, 2018

This paper explores the different roles of male and female community health workers in rural Wakiso district, Uganda, using photovoice, as a community-based participatory research approach. The authors trained ten community health workers on key concepts about gender and photovoice. The community health workers took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis. Although responsibilities were the same for both male and female community health workers, they reported that in practice, community health workers were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male community health workers and females turning to female community health workers. Due to their privileged ownership and access to motorcycles, male community health workers were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male community health workers were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female community health workers more available to address local problems. Community health workers reflected both strategic and conformist gendered implications of their community work. The authors argue that the differing roles and perspectives about the nature of male and female community health workers while performing their roles should be considered while designing and implementing community health workers programmes, without further retrenching gender inequalities or norms.

Universal health coverage and community engagement
Odugleh-Kolev A; Parrish-Sprowl J: World Health Organisation 96(9)660-661, 2018

In this article, the authors reflect on how efforts towards UHC could offer an opportunity to address those aspects within health systems that continue to hinder efforts to meaningfully engage with patients, their families and local communities. The backbone of these efforts should be a health workforce that is skilled in engagement, responsive to local context and to the needs and expectations of those using their services. Community engagement was introduced in the 2013–2016 Ebola virus disease outbreak in recognition of the important role of response staff and their ability to engage with communities, in contrast to social mobilization or behaviour-change interventions. Engagement and empowerment of health service users and community members also re-emerged as a core strategy in the WHO Framework on Integrated People-Centred Health Services, which was formally adopted by Member States in 2016. To move towards a more meaningful understanding of what community engagement is and how it works, the authors suggest that several changes need to take place. First, to recognize that health systems have a fundamental responsibility and obligation for engaging with patients, their families, local communities, as well as a range of stakeholders, partners and sectors, recognising the physiological, emotional, mental and social interconnection of people. Health systems and communities are observed to be in continuous and interdependent action. If community engagement becomes a focus for UHC efforts, it could promote approaches that recognize that health and well-being are co-produced, and that empowers both health-care providers and communities.

13. Monitoring equity and research policy

Identifying health policy and systems research priorities for the sustainable development goals: social protection for health
Mary Qiu M; Jessani N; Bennett S: International Journal for Equity in Health 17(155) 1-14, 2018

This paper sought to identify potential research priorities concerning social protection and health in low and middle-income countries, from multiple perspectives. Priority research questions were identified through research reviews on social protection interventions and health, interviews with 54 policy makers from Ministries of Health, multi-lateral or bilateral organizations, and NGOs. Data was collated and summarized using a framework analysis approach. The final refining and ranking of the questions were completed by researchers from around the globe through an online platform. The overview of reviews identified 5 main categories of social protection interventions: cash transfers; financial incentives and other demand side financing interventions; food aid and nutritional interventions; parental leave; and livelihood/social welfare interventions. Policy-makers focused on the implementation and practice of social protection and health, how social protection programs could be integrated with other sectors, and how they should be monitored/evaluated. A collated list resulted in 31 priority research questions. Scale and sustainability of social protection programs ranked highest. The top 10 research questions focused heavily on design, implementation, and context, with a range of interventions that included cash transfers, social insurance, and labour market interventions. The authors observe that there is potentially a rich field of enquiry into the linkages between health systems and social protection programs, but research within this field has focused on a few relatively narrowly defined areas. The SDGs provide an impetus to the expansion of research of this nature, with priority setting exercises such as this helping to align funder investment with researcher effort and policy-maker evidence needs.

Towards a global monitoring system for implementing the Rio Political Declaration on Social Determinants of Health: developing a core set of indicators for government action on the social determinants of health to improve health equity
Working Group for Monitoring Action on the Social Determinants of Health: International Journal for Equity in Health 17(136) 1-27, 2018

In the 2011 Rio Political Declaration on Social Determinants of Health, World Health Organization Member States pledged action in five areas crucial for addressing health inequities. Their pledges referred to better governance for health and development, greater participation in policymaking and implementation, further reorientation of the health sector towards reducing health inequities, strengthening of global governance and collaboration, and monitoring progress and increasing accountability. The authors describe the selection of indicators proposed to be part of the initial World Health Organization global system for monitoring action on the social determinants of health. The authors describe the processes and criteria used for selecting social determinants of health action indicators that were of high quality and the described the challenges encountered in creating a set of metrics for capturing government action on addressing the Rio Political Declaration’s five Action Areas. The authors developed 19 measurement concepts, identified and screened 20 indicator databases and systems, including the 223 Sustainable Development Goals indicators, and applied strong criteria for selecting indicators for the core indicator set. They identified 36 suitable existing indicators, which were often Sustainable Development Goals indicators.

Towards an interdisciplinary approach to wellbeing: Life histories and Self-Determination Theory in rural Zambia
White S; Jha S: Social Science & Medicine (212)153-160, 2018

This paper implemented a qualitative analysis of wellbeing in life history interviews in Chiawa, rural Zambia. The enquiry goes beyond simply reading across methods, disciplines and contexts, to consider fundamental differences in constructions of the human subject, and how these relate to understandings of wellbeing. Field research took place in two periods, August–November, 2010 and 2012. Analysis drew on 46 individual case studies, conducted through open-ended interviews. These were identified through a survey with an average of 390 male and female household heads in each round, including 25% female headed households. As social determinants theory predicts, the interviews confirm elements of autonomy, competence and relatedness as vital to wellbeing. However, these are expressed in ways that highlight material and relational, rather than psychological, factors. The authors endorsed social determinants theory’s utility in interdisciplinary approaches to wellbeing, but only if it admits its own cultural grounding in the construction of socially and culturally distinctive questions on basic psychological needs.

14. Useful Resources

Mental Health Atlas 2017
World Health Organisation: WHO, Geneva, 2018

WHO's Mental Health Atlas 2017 reveals that although some countries have made progress in mental health policy-making and planning, there is a global shortage of health workers trained in mental health and a lack of investment in community-based mental health -based mental health facilities. The inclusion of mental health in the Sustainable Development Agenda, which was adopted at the United Nations General Assembly in September 2015, is likely to have a positive impact on communities and countries where millions of people will receive much needed help. Data included in Mental Health Atlas 2017 demonstrates that progressive development is being made in relation to mental health policies, laws, programmes and services across WHO Member States. However extensive efforts, commitment and resources at global and country level are needed to meet the global targets.

15. Jobs and Announcements

African Health Economics and Policy Association (AfHEA) conference, 11-14 March, Accra Ghana
October 31, 2018 is final deadline for individual abstract submission

The co-chairs of the Scientific Committee and Management of African Health Economics and Policy Association (AfHEA) take this opportunity to politely remind practitioners and researchers in the areas of health economists and financing, health systems and policy, public health, implementation science, including policy makers and advocates etc. that the deadline for individual abstract submissions to AfHEA’s 5th scientific conference (to take place from 11-14 March 2019 in Accra, Ghana) will expire on 31st October 2018 at midnight. The broad theme : Securing Primary Health Care (PHC) for all: the foundation for making progress on Universal Health Coverage (UHC) in Africa. Sub-Themes are: Health system strengthening; The effectiveness of aid in the building of health systems; PHC and Healthcare financing; Factors affecting access to healthcare and efforts/challenges in securing PHC; Key methodological changes in health economics and policy analysis specific to Africa; The role of research institutions and donors in building capacity in health economics and policy analysis. Abstracts may be submitted in English or French . Authors should submit individual abstracts online by October 31 at http://afhea.org/en/conferences/afhea-2019/submit-individual-abstracts. Proposals for organised sessions can be submitted by November 30 at http://afhea.org/en/conferences/afhea-2019/organised-session-abstract.

Beyond Familiar Territories: 5th South Africa International Conference on Educational Technologies 2019
Deadline for submission of abstracts: 15 January 2019

The South Africa International Conference on Educational Technologies from 7 – 9 April 2019 (SAICET) 2019 is an international refereed conference that is dedicated to the advancement of research on Educational Technologies. The conference is organised by an African Academic Research Forum under the auspices for Association of Academics and Researchers in Africa. SAICET 2019 aims to offer a platform for academics and researchers in educational technologies to deliberate, network and present a wide range of perspectives, scholarship, and expertise in the pursuit of excellence in education.

COPASAH Global Symposium on Citizenship, Governance and Accountability in Health
15-18 October 2019, New Delhi, India

The practitioner centred COPGS 2019 on Citizenship, Governance and Accountability in Health is designed as meeting point of practice, think-tanks and policy in community centred health systems. Participating in COPGS 2019 will provide a unique opportunity for researchers, policy makers, donors, development and policy experts to interact and dialogue with the 'foot-soldiers' of community-centred accountability practice from around the world. As a participant one will get the opportunity to witness, engage with and experience the following: open sharing and learning on diverse social accountability practices and approaches through practical examples; debates on evolving paradigms and political economy of policy making in global health and its impact on the accountability ecosystem; new insights around the principles and practice of social accountability to achieve global health goals, especially as articulated in SDGs. There are five over-arching themes to the symposium; community action, indigenous people, reproductive health, private health sector and health care workers.

Managing Editor: Health-e News Service
Health-e News Service

Health-e News Service is looking for a dynamic Managing Editor to lead Africa's first independent health news agency. The successful candidate must have vision about how to develop a multimedia organization; experience in managing a non-profit organization; ability to fundraising; commitment to social justice and a well-functioning public health system. Key performance areas include: managing a diverse multimedia organisation, including editorial oversight over an award-winning team of journalists; overseeing the development and implementation of an annual strategic plan; fundraising and donors relations; managing client relations and expanding the client base. The candidate needs to have at least eight years management experience, extending fundraising experience, editorial management skills and at least a bachelor’s degree. The position is located in Johannesburg although consideration will be given to Cape Town-based candidates. Salary is in line with experience. Preference will be given to candidates from previously disadvantaged groups.

Public Health approach to hearing across the life course: A call for papers
Deadline for submissions: 30 November 2018

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.

The 7th East African Health and Scientific Conference
27-29 March 2019, Dar es Salaam, Tanzania

The main theme for this conference will be ‘Technology for health systems transformation and attainment of the UN-Sustainable Development Goals’. The key note speech will be on 'Invest in Digital Health to catalyse East Africa to attain the UN-Sustainable Development Goals’. Various sub-themes will be presented and discussed during the first two days of the conference. Each sub-theme will start with a state-of-the-art presentation, after which evidence-based scientific material will be presented. The presentations will lead to recommendations on technologies for health system decision making, diseases and the improvement of healthcare service delivery and health outcomes. Further sub-themes relate to the health financing and health knowledge management through digital technologies and solutions.

Wellcome Photography Prize 2019
Deadline for entries: 17 December 2018

The Wellcome Trust invite photographers and other image makers from all disciplines to enter the Wellcome Photography Prize, which celebrates compelling imagery that captures stories of health, medicine and science. Wellcome are looking for entries that can captivate people with stories of science and medicine, and start conversations about some of the health challenges people face. The winner of each category will receive £1,250, with the overall winner receiving a prize of £15,000. Prizes will be presented at an awards ceremony in London on 3 July 2019. All the winning and shortlisted entries will go on show in a major public exhibition at Lethaby Gallery, Central Saint Martins, University of the Arts London, from 4-13 July 2019. If you’re a winner, Wellcome will also offer opportunities to take part in events to showcase your work to a range of audiences. The winning images receive extensive international media coverage each year. There are four categories in the competition: Social perspectives – explore how health and illness affect the way we live; Hidden worlds – reveal details hidden to the naked eye; Medicine in focus – show health and healthcare up close and personal; Outbreaks (2019 theme) – capture the impact of disease as it spreads.


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