EQUINET NEWSLETTER 213 : 01 December 2018

1. Editorial

The African Continental Free Trade Agreement – what will it mean for our health?
Rangarirai Machemedze, SEATINI

In March 2018, when African Union leaders in Rwanda signed the African Continental Free Trade Agreement (AfCFTA), there was much talk about it being a new chapter for the continent in furthering the socio-economic integration enshrined in the 1991 Abuja Treaty. It’s important therefore to ask- what implications does it have for health equity?

The agreement establishes a free trade area between African countries, liberalising 90% of trade in goods between countries, removing import duties on goods originating from African countries to enhance trade between them. On the one hand this can potentially promote sustained economic progress, with potential health gains if it offers benefits to all local producers, including small scale producers, and if the economic benefits are equitably distributed. On the other hand it can lead to risks to health if the laws and institutional mechanisms protecting health in cross border trade are not adequate.

One way to predict what the impacts of the AfCFTA may be on health is to examine what happened in previous trade liberalization experiences, specifically those in the International Monetary Fund and World Bank led Structural Adjustment Programmes. These trade liberalisation policies were implemented across Africa in a context of weak safety nets and protection of public sector services, including in health, education and agriculture. The decline of these services and economic inequality that arose after that experience raise questions on how the AfCFTA will be implemented.

Supporting a health sector calls for a range of areas of value-added production, such as for medicines and technologies. Our economies have still weak development of these areas of production and tend to import them, while exporting more or less the same products. So will the AfCFTA be accompanied by measures to promote investment for value added production in an organised collaborative manner, such as for infrastructures, equipment, technology and medicines for the health sector? Given that prior liberalisation policies have been accompanied by cost escalation for the ordinary person, will it assess and take as a measure of its progress a fall for the population in the price of essential medicines, commodities and services for health?

Most African countries have porous borders and many have weak capacities to check the quality and safety of goods crossing borders. When unsafe food products, chemicals, alcohol and other products that could harm health are poorly checked at borders there is a risk to public health. So too is the risk to health of cross border movement of substandard medicines. There are already reports by WHO of such medicines appearing in markets in some of our countries. Competition and wider markets provide a potentially health incentive for reducing prices of goods, so the AfCFTA could enhance access to low cost generic drugs from efficient producers within the continent. This benefit and the control of public health risk from harmful products and unsafe foods calls, however for significantly improved port health capacities in all our countries to accompany the flow of goods. Will the AfCFTA thus include specific measures to enhance these capacities in line with the International Health Regulations, and apply them at all the various points where goods cross borders?

If the AfCFTA promotes the freer movement of personnel, it could enhance availability and possibly accessibility of skilled personnel, including health workers, especially for countries experiencing acute shortages. But it could also do the opposite, as we have already experienced in our countries, where skilled health professionals are pushed or pulled to higher income areas and services, further deepening existing inequalities in their distribution. And the movement of people itself has the potential to spread disease across countries. So will the AfCFTA be introduced together with measures for training and resourcing personnel to manage the cross border spread of infection and to enhance equity within the continental access to skilled health workers?
The liberalisation of trade holds the promise of wider access to new goods and services, and to the spread of innovation across the continent. This can be very positive for health. At the same time changes in dietary patterns, employment conditions, physical environments and lifestyles can change consumption patterns in ways that are not always healthy. We have seen the consequences of this in the negative effect of consumption of processed foods and sweetened products in levels of obesity and diabetes for example. Our countries need strong public health laws and capacities and good communication capacities to manage such issues and avoid the epidemic of non-communicable diseases that has been witnessed in other regions.

The AfCFTA will certainly lead to changes in production and industries with implications for incomes and public revenues. As tariffs that protect domestic industries are removed, they are exposed to competition. If they have the capital and capacity to manage the change they may succeed, but if not they may close. For the public the question may thus be “what will happen to my job and my income?” Without adequate social security schemes in the continent, any significant negative shifts in jobs and incomes for countries who become net importers rather than net producers could be very harmful for health.

Given that import duties will be eliminated on 90% of goods traded between countries the public sector will lose the revenues generated from these import duties. Countries will thus need to diversify their sources of revenue. For some the growth in production may generate new tax revenue, for others that do not see the same production growth, their tax revenues may fall. As we have seen in the structural adjustment programmes, when this happens public health budgets are cut, with increasing dependency on external funders for the right to health care. As our countries intend to mobilise domestic financing for universal health coverage, what plans are there associated with the AfCFTA to make sure that it doesn’t lead to widening inequality in achieving this across the continent?

The AfCFTA could be a tool for fostering south-south cooperation on the continent, with a range of potential benefits for health. Countries could provide mutual support to strengthen areas of inadequacies and reduce inequalities across the continent. However, the issues raised above indicate that trade alone cannot achieve this without complementary measures to ensure wider benefits within and between countries, cooperation on production of health commodities and technologies, and strengthened capacities and measures to protect public health. As the negotiations to finalise the texts and implementation continue, it is imperative that the health sector takes an active role, not only to understand the implications of the AfCFTA, but to negotiate for measures in it that will safeguard the health of the people.

Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the AfCFTA text see https://www.tralac.org/documents/resources/african-union/1964-agreement-establishing-the-afcfta-consolidated-text-signed-21-march-2018-1/file.html

2. Latest Equinet Updates

New resources added to the PAR portal
EQUINET pra4equity network

New resources have been added to the Participatory Action Research Portal. The portal has resources on Participatory Action Research (PAR) with a growing number of resources on PAR related to training courses, training guides and reports of training activities; methods, tools and ethics; PAR work and journal publications on PAR. The portal is a resource for all those working with PAR and includes resources in any language. There is a form for people to send videos, photojournalism, organisations, journal papers, training guides and other resources for the portal. The url link shown here is in English but there is also a Spanish version at http://www.equinetafrica.org/content/portal-de-recursos-para-la-investigaci%C3%B3n-acci%C3%B3n-participativa-iap

3. Equity in Health

An analysis of the nutrition status of neighboring Indigenous and non-Indigenous populations in Kanungu District, southwestern Uganda: Close proximity, distant health realities
Sauer J; Berrang-Ford L; Patterson K; Donnelly B: Social Science & Medicine 217, 55-64, 2018

This paper analyzed the estimated prevalence, and modeled possible determinants of, moderate acute malnutrition and severe acute malnutrition (SAM) for Indigenous Batwa and non-Indigenous Bakiga of Kanungu District in Southwestern Uganda. The authors characterize possible mechanisms driving differences in malnutrition. Retrospective cross-sectional surveys were administered to 10 Batwa communities and 10 matched Bakiga Local Councils during April of 2014. Individuals were classified as moderate acute malnutrition and SAM based on middle upper-arm circumference for their age-sex strata. Malnutrition is high among Batwa children and adults, with nearly half of Batwa adults and nearly a quarter of Batwa children meeting moderate acute malnutrition criteria. SAM prevalence is lower than moderate acute malnutrition prevalence, with SAM highest among adult Batwa males. SAM prevalence among children was higher for Batwa males compared to Bakiga males. Models that incorporated community ethnicity explained the greatest variance in middle upper-arm circumference values. This research demonstrates inequality in malnutrition between the Indigenous Batwa and non-Indigenous Bakiga of Kanungu District, Uganda, with model results suggesting further investigation into the role of ethnicity as an upstream social determinant of health.

4. Values, Policies and Rights

Antibiotic resistance has a language problem
Mendelson M; Balasegaram M; Jinks T: Nature, May 2017

Clinicians have long known that microbes such as bacteria, viruses and fungi are becoming alarmingly resistant to the medicines used to treat them. But a global response to this complex health threat — commonly termed 'antimicrobial resistance' — requires engagement from a much broader array of players, from governments, regulators and the public, to experts in health, food, the environment, economics, trade and industry. The authors argue that people from these disparate domains are talking past each other. Many of the terms routinely used to describe the problem are misunderstood, interpreted differently or loaded with unhelpful connotations. In 2017, the United Nations formed an interagency group to coordinate the fight against drug resistance urging that, as one of its first steps, the group coordinate a review of the terminology used by key actors. They proposed that drug-resistant infection be the overarching term used (in English) to describe infections caused by organisms that are resistant to treatment, including those caused by bacteria that do not respond to antibiotics. They also noted that a blame narrative is unhelpful, failing to acknowledge symbiotic relationships with bacteria. Because terminology has geographic, disciplinary and societal variations that affect understanding and interpretation, research is argued to be needed to optimize the lexicon across different countries and languages.

Heads of State commit to lead response to beat noncommunicable diseases, promote mental health
World Health Organisation: WHO, Geneva, 2018

Heads of state and government in September 2018 committed to 13 new steps to tackle non-communicable diseases including cancers, heart and lung diseases, stroke, and diabetes, and to promote mental health and well-being. World leaders agreed to take responsibility themselves for their countries’ effort to prevent and treat NCDs. They also agreed that these efforts should include robust laws and fiscal measures to protect people from tobacco, unhealthy foods, and other harmful products, for example by restricting alcohol advertising, banning smoking, and taxing sugary drinks. They committed to implement a series of WHO-recommended policies to prevent and control of NCDs - such as public education and awareness campaigns to promote healthier lifestyles, vaccinating against HPV virus to protect against cervical cancer and treating hypertension and diabetes. WHO estimates that implementing all these policies could generate US$ 350 billion in economic growth in low and lower-middle-income countries between now and 2030. Other specific commitments focus on halting the rise of childhood obesity, promoting regular physical activity, reducing air pollution and improving mental health and wellbeing. The political declaration reaffirms WHO’s global leadership of the fight to beat NCDs and promote mental health, and urges the Organization to continue working closely with key partners, including government, civil society and the private sector. In particular, it calls on food manufacturers to take several actions. These include reformulating products to reduce salt, free sugars and saturated and industrially produced trans fats, using nutrition labelling on packaged food to inform consumers, and restricting the marketing of unhealthy foods and beverages to children.

New Global Commitment to Primary Health Care for all at Astana Conference
Fernandez M: UNICEF, New York, 2018

In October 2018, United Nations Member States unanimously agreed to the Declaration of Astana, vowing to strengthen their primary health care systems as an essential step toward achieving universal health coverage. The Declaration of Astana reaffirms the historic 1978 Declaration of Alma-Ata, the first time world leaders committed to primary health care. The Declaration of Astana comes amid a growing global movement for greater investment in primary health care to achieve universal health coverage. Health resources have been overwhelmingly focused on single disease interventions rather than strong, comprehensive health systems – a gap highlighted by several health emergencies in recent years. The author reports that UNICEF and WHO will help governments and civil society to act on the Declaration of Astana and encourage them to back the movement and will support countries in reviewing the implementation of this Declaration, in cooperation with other partners.

UN International Day For Older Persons Celebrated In Marondera, Zimbabwe
263 Chat: Marondera, Zimbabwe, November 2018,

The United Nations International Day for Older Persons falls on 1 October every year. This year it was commemorated under the theme celebrating older human rights champions. Belated commemorations were held on Friday 23 November 2018 at Mahusekwa district hospital in Marondera, Zimbabwe. Representatives from the District Administrator’s office, the Ministry of Public Service Labour and Social Services, Ministry of Health and Child Care, the National Age Network of Zimbabwe (NANZ), chiefs, the private sector, NGOs, older people representative organisations and older people champions among others were in attendance. In line with celebrating older human rights champions the event was run and owned by older persons with Gogo Mufuta and Gogo Nyamande sharing the master of ceremonies platform. Speeches centred on the important role that older people play in society emphasising their role as custodians of culture. Older people were also noted to be key carers of orphaned and vulnerable children. Dr Guvheya, the former chairman of the Zimbabwe Older Persons Association (ZOPO) praised the constitution which enshrines the rights of older people. He challenged government to operationalize provisions of the constitution and other pieces of legislation to enable older people to enjoy their rights. Dr Guvheya also spoke about the challenges faced by older people, including witchcraft accusations and property grabbing. He lamented on the current environment where pharmacies are demanding payment in foreign currency for medicines. This point was emphasised throughout the day as older people are in need of holistic health care and support as many are living with diseases including HIV, cancer, diabetes and dementia yet they have lost the capacity to generate income to access health services.

5. Health equity in economic and trade policies

Calling for a New Global Economic Order
PHM, Wemos: Astana, November 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.” In Astana at the Cafe Session this video shares why this call is still relevant today and why it should be recalled and renewed now the world celebrates the 40th Anniversary of the Alma-Ata Declaration at the Global Conference on Primary Health Care in Astana, on 25-26 October. The film reminds that Primary Health Care is more than basic health care and some sort of financial protection but rather a radical comprehensive concept based on economic justice. The video calls for a new economic global order as was called for in 1978.

Seeds of Resistance, Harvests of Hope: Farmers halt a land grab in Mozambique
Wise T: Food Tank, 2018

On July 26, 2018, farmers in Xai-Xai, Mozambique, achieved a milestone. They met to formalize their new farmers’ association, elect leaders, and prepare a petition to the local government for land. The association, christened Tsakane, which means “happy” in the local Changana language, was the culmination of six years of resistance to a Chinese land grab that had sparked protest and outrage. The association now has a request pending for its own land. The difference between a large-scale agricultural development project and a land grab is consultation and consent, and this one had neither. Some 7,000 farmers had moved onto the irrigated lands along the Lower Limpopo River in the 1980s after a state farm ceased operations. Farmers reported that they were encouraged to do so by the local government. Mozambique’s Land Law is one of the most progressive in Africa, recognizing the land rights of peasant farmers whether or not they can show formal title, as long as they have been farming the land for 10 years or more. That applies not only to community or village land, it applies to estate land for which the government holds the formal land title. Instead of giving all the best land and infrastructure—particularly irrigation—to foreign investors who then displace local farmers, they ask why not give the land to those farmers? Help them organize into marketing cooperatives, water use associations, and credit unions. With the formal recognition of the Tsakane Farmers’ Association, the Xai-Xai farmers are planning to do just that. They hope to get collective land title to 750 acres of good land for their 300 members.

6. Poverty and health

The problem or the solution? Early fertility and parenthood in the transition to adulthood in Khayelitsha, South Africa
Swartz A; Christopher C; Harrison A: Reproductive Health Matters 16(32), doi: https://doi.org/10.1080/09688080.2018.1537417, 2018

This article draws on ethnographic data collected between 2014 and early 2016 with young adults (17-25 years) in Town Two, Khayelitsha. Participant observation was the primary data collection method. Narratives and experiences of 15 young people are presented here. The authors argue that in addition to immediate fertility desires, young people’s contraceptive decision-making was significantly shaped by gendered ideals and social norms. Young women’s fertility operated as both an aspiration and a threat within partnerships. Some couples partially achieved relationship stability or longevity through having a child. Entering parenthood in the context of a seemingly stable relationship was perceived as a movement towards an accepted, albeit tenuous, form of social adulthood. Although living up to the ideal of good parent was challenging, it was partially achieved by young mothers who provided care and young fathers who provided financially for children. The authors argue that in the absence of other accepted markers of transition to adulthood and within a context of deprivation and exclusion, early fertility, though clearly a public health problem, can become a solution to social circumstances.

7. Equitable health services

Data value and care value in the practice of health systems: A case study in Uganda
Hutchinson E; Nayiga S; Nabirye C; et al: Social Science & Medicine (211) 123-130, 2018

This paper interrogated the relationship between data collection and the delivery of patient care in Kayunga, Uganda in five public health centres. The authors undertook ethnographic research from July 2015 to September 2016 in health centres, at project workshops, meetings and training sessions. This included three months of observations by three fieldworkers, in-depth interviews with health workers and stakeholders and six focus group discussions with health workers. The authors observed that the attempt to improve data collection within health facilities transferred data-value into health centres with little consideration among project staff for its impact on care, and noted both acquiescence and resistance to data-value by health workers. The authors also described the rare moments when senior health workers reconciled these two forms of value, where care-value and data-value were enacted simultaneously. The authors suggest that those seeking to make changes in health systems must take into account local forms of value and devise health systems interventions that reinforce and enrich existing ethically driven practice.

Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990–2015: a literature review
Chol C; Negin J; Garcia-Basteiro; et al: Global Health Action 11(1), doi: https://doi.org/10.1080/16549716.2018.1517931, 2018

Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades – including 13 wars during 1990–2015 – than any other part of the world, and this has had an adverse effect on health systems in the region. This study aimed to understand the best health system practices in five SSA countries that experienced wars during 1990–2015, and yet managed to achieve a maternal mortality reduction – equal to or greater than 50% during the same period – according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). The study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms. Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars.

Role of maternity waiting homes in the reduction of maternal death and stillbirth in developing countries and its contribution for maternal death reduction in Ethiopia: a systematic review and meta-analysis
Dadi T; Bekele B; Kasaye H; et al: BMC Health Services Research 18(748)1-10, 2018

This study synthesised the best available evidence on effectiveness of maternity waiting homes on the reduction of maternal mortality and stillbirth in developing countries. In developing countries, maternity waiting homes users were 80% less likely to die than non-users and there was 73% less occurrence of stillbirth among users. In Ethiopia, there was a 91% reduction of maternal death among maternity waiting homes users unlike non-users and it contributes to the reduction of 83% stillbirth unlike non-users. Maternity waiting home contributes more than 80% to the reduction of maternal death among users in developing countries and Ethiopia. Its contribution for reduction of stillbirth is good. More than 70% of stillbirth is reduced among the users of maternity waiting homes. In Ethiopia maternity waiting homes contributes to the reduction of more than two third of stillbirths.

8. Human Resources

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

This paper explores the differential roles of male and female Community health workers (CHWs)in rural Wakiso district, Uganda, using photovoice, a community-based participatory research approach. The authors trained ten CHWs on key concepts about gender and photovoice. The CHWs 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 CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs 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 CHWs 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 CHWs more available to address local problems. CHWs 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 CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.

The use of low-cost Android tablets to train community health workers in Mukono, Uganda, in the recognition, treatment and prevention of pneumonia in children under five: a pilot randomised controlled trial
O’Donovan J; Taylor C; Chukhina M; et al: Human Resources for Health 16(49) 1-9, 2018

This pilot study compares traditional training with using locally made videos loaded onto low-cost Android tablets to train community health workers (CHWs)on the pneumonia component of Integrated Community Case Management (iCCM). The authors conducted a pilot randomised controlled trial with CHWs in the Mukono District of Uganda. The unit of randomisation was the sub-county level, and the unit of analysis was at the level of the individual CHW. Eligible CHWs had completed basic iCCM training but had not received any refresher training on the pneumonia component of iCCM in the preceding 2 years. CHWs in the control group received training in the recognition, treatment, and prevention of pneumonia as it is currently delivered, through a 1-day, in-person workshop. CHWs allocated to the intervention group received training via locally made educational videos hosted on low-cost Android tablets. The primary outcome was change in knowledge acquisition, assessed through a multiple-choice questionnaire before and after training, and a post-training clinical assessment. The secondary outcome was a qualitative evaluation of CHW experiences of using the tablet platform. In the study, 129 CHWs were enrolled, 66 and 63 in the control and intervention groups respectively. CHWs in both groups demonstrated an improvement in multiple choice question test scores before and after training; however, there was no statistically significant difference in the improvement between groups. There was a statistically significant positive correlation linking years of education to improvement in test scores in the control group, which was not present in the intervention group. The majority of CHWs expressed satisfaction with the use of tablets as a training tool; however, some reported technical issues. The authors note that tablet-based training is comparable to traditional training in terms of knowledge acquisition. It also proved to be feasible and a satisfactory means of delivering training to CHWs. They argue that further research is required to understand the impacts of scaling such an intervention.

9. Public-Private Mix

Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation
Maluka S; Chitama D; Dungumaro E; et al: International Journal for Equity in Health 17(118) 1-13, 2018

This paper reports on the design and implementation of service agreements between local governments and non-state providers for the provision of primary health care services in Tanzania. The authors used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. The institutional frameworks shaping the engagement of the government with non-state providers are rooted in Tanzania’s long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage non-state providers facilities. Development partners provided significant technical and financial support, signalling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with non-state providers, financing the contracts remained largely dependent on external funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements. The authors indicate that Tanzania’s central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with non-state providers for primary health care services; and that forums for continuous dialogue between the government and contracted non-state providers be fostered to clarify the expectations of all parties and resolve any misunderstandings.

Government resource contributions to the private-not-for-profit sector in Uganda: evolution, adaptations and implications for universal health coverage
Ssennyonjo A; Namakula J; Kasyaba R; et al: International Journal for Equity in Health 17(130) 1-12, 2018

In this paper, the authors examine government resource contributions (GRCs) to providers in Uganda focusing on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for government resource contributions (GRCs) and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study’s findings were validated during two meetings with a broad set of stakeholders. Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB initiation, rapid increase in GRCs, and declining GRCs. The main factors affecting the relationship’s evolution were: financial deficits at private-not-for-profit (PNFP) facilities, advocacy by PNFP network leaders, changes in the government financial resource envelope, variations in the “good will” of government actors, and changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The authors argue that the Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. They further suggest that governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.

Moving towards universal health coverage: engaging non-state providers
Rao K; Paina L; Ingabire M; et al: International Journal for Equity in Health 17(127) 1-9, 2018

This paper provides a unique opportunity to understand the dynamics of non-state providers (NSP) engagement in different contexts. A standard template was developed and used to summarize the main findings from the country studies. The summaries were then organized according to emergent themes and a narrative built around these themes. Governments contracted NSPs for a variety of reasons – limited public sector capacity, inability of public sector services to reach certain populations or geographic areas, and the widespread presence of NSPs in the health sector. Underlying these reasons was a recognition that purchasing services from NSPs was necessary to increase coverage of health services. Yet, institutional NSPs faced many service delivery challenges. Like the public sector, institutional NSPs faced challenges in recruiting and retaining health workers, and ensuring service quality. Properly managing relationships between all actors involved was critical to contracting success and the role of NSPs as strategic partners in achieving national health goals. Further, the relationship between the central and lower administrative levels in contract management, as well as government stewardship capacity for monitoring contractual performance were vital for NSP performance. The authors suggest that for countries with a sizeable NSP sector, making full use of the available human and other resources by contracting NSPs and appropriately managing them, offers an important way for expanding coverage of publicly financed health services and moving towards universal health coverage.

10. Resource allocation and health financing

Results-based financing in health: from evidence to implementation
McIsaac M: Kutzin J: Dale E; Soucat A: Bulletin of the World Health Organization 96(11), 729-796, 2018

Results-based financing for health programmes are being piloted in many low- and middle-income countries. While the term results-based financing refers to demand- and supply-side incentives to increase output – that is, improved access to and quality of health care – this editorial focuses on the incentives that target service providers, also referred to as performance-based financing or pay-for-performance. A study in Zambia concluded that the pay-for-performance intervention was cost–effective. However, cost–effectiveness is not the most interesting point of this study, as four policy relevant lessons emerge. First, any output-based provider payment method requires some method of verification. In Zambia, setting up verification mechanisms required new investments, as before the pilot, providers were paid based on inputs. The estimates of the costs of the programme in Zambia, although annualized, are based on only 2.3 years of experience. Given that it is a new programme, one would expect that pay-for-performance verification costs would decline over time. Second, approaching pay-for-performance as an either-or choice of financing is no longer the only frame of reference. The substantive question is how to integrate elements of performance into the mixed provider payment system. Third, as described in the overall evaluation of the project, the direct disbursement of funds to facility bank accounts in the pay-for-performance group was a key ingredient for ensuring better service delivery. Fourth, facility financial autonomy supported by pay-for-performance was found to be key for ensuring progress towards strategic purchasing in Zambia. If balanced with clear accountability for both good results and the use of funds, it should be promoted. In shifting towards mixed provider payment methods with timely disbursement of funds and greater financial autonomy by front-line providers, the budgeting processes need to be considered. In countries such as Zambia, where budgets are mainly formulated, approved and executed based on detailed input lines, the authors argue that shifting to payments based on performance could be challenging.

Willingness to Pay for Condoms in Five Countries Kenya, Nigeria, South Africa, Zambia, and Zimbabwe
Ramakrishnan G; Tuchman J; Hartel L: Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project, 2018

Though condom use is now higher than ever before, key gaps remain in countries and in certain populations, where use has stagnated or even decreased. This survey comprised five standalone national cross-sectional surveys carried out in randomly selected geographical areas. Quantitative data were collected from adult men who purchased or obtained a condom in the three months preceding the surveys. A minimum of 1,200 participants was enrolled for each country, with quotas for urban and rural respondents; and brand types that a user most often used (i.e., free, socially marketed (SM), and commercial). The AIDSFree team identified important differences in each of the countries’ condom markets. The team noted many overarching themes: Supplies of free condoms appear to significantly exceed use of such condoms; SM brands should set prices based ability-to-pay trends in country, rather than on trends in costs or available subsidies; It is not just price—brand appeal and availability are important factors in men’s choice of condom brands; Low-priced commercial condom brands are emerging, at the same or lower price than SM brands. However, lower awareness and availability appear to limit their market share.; Introducing a single pack of condom brands does not appear to change the market structure significantly.

11. Equity and HIV/AIDS

Who are the male partners of adolescent girls and young women in Swaziland? Analysis of survey data from community venues across 19 DREAMS districts
Reynolds Z; Gottert A; Luben E; et al: PLOS One, doi: https://doi.org/10.1371/journal.pone.0203208, 2017

Adolescent girls and young women (AGYW, ages 15–24) are at high risk of HIV in Swaziland and understanding more about their male sexual partners can inform HIV prevention efforts for both. Using the PLACE methodology across all 19 DREAMS implementation districts, 843 men ages 20–34 were surveyed between December 2016-February 2017. Surveys were conducted at 182 venues identified by community informants as places where AGYW and men meet/socialize. In multivariate analyses, men who reported three or more AGYW partners in the last year were more likely to be HIV-positive. Men were also less likely to disclose their HIV status to adolescent versus older partners and partners more than 5 years younger than themselves. Results also revealed relatively high unemployment and mobility, substantial financial responsibilities, and periodic homelessness. Most men identified through community venues reported relationships with AGYW, and these relationships demonstrated substantial HIV risk. Challenging life circumstances suggest structural factors may underlie some risk behaviours. Engaging men in HIV prevention and targeted health services is argued to be critical, and informant-identified community venues are suggested to be promising intervention sites to reach high-risk male partners of AGYW.

12. Governance and participation in health

Botswana Labour Migrants Association (BoLAMA)
BoLAMA: Botswana, 2018

Botswana Labour Migrants Association (BoLAMA) is a non-profit organization registered in accordance with the laws of Botswana. The organization is comprised of former migrant mineworkers and their beneficiaries. The organization provides assistance to ex-miners and their beneficiaries by facilitating their access to social security benefits most of which involves occupational compensation from mines. Among other issues BoLAMA works to address social determinants of TB in mining communities. TB is the leading cause of death among ex-miners and it contributes to the socio-economic status of ex-miners. BoLAMA’s mandate is in line with various prescribes and targets set in global, continental, regional and national mining sector related instruments, protocols and frameworks. BoLAMA carries out its work under three (3) thematic areas:- extractives, labour migration and economic empowerment.

Policy brief on the implementation of devolution in Zimbabwe: recommendations on the structure / composition, functions and funding of Provincial and Metropolitan Councils (PMCs)
Centre for Community Development In Zimbabwe, Harare Residents Trust: Harare, November 2018

This brief was developed in consultation with key local government stakeholders. It provides an outline of key concerns and issues regarding devolution and proffers recommendations for consideration by government and parliament in crafting the new legislation to guide the implementation of devolution in Zimbabwe. The issue of devolution is topical and government has indicated its commitment to implementing it. However, the delay in the crafting of legislation to guide devolution is a serious cause for concern for citizens and other local government stakeholders. The devolution of power to local and provincial councils helps to achieve fair and balanced development through provincial and metropolitan councils, which are allowed by the Constitution to set local development priorities. The authors argue that governmental powers must be devolved to the local people so that there is increased transparency and accountability in governance and decision-making as well as management of public affairs and resources by local authorities. Provincial governments must be fully in control of their local authorities whilst central government plays an oversight role to ensure that public resources are used in a transparent manner.

The health system accountability impact of prison health committees in Zambia
Topp S; Sharma A; Chileshe C; et al: International Journal for Equity in Health 17(74) 1-13, 2018

From 2013, the Zambian Corrections Service (ZCS) worked with partners to strengthen prison health systems and services. One component of that work led to the establishment of facility-based Prison Health Committees (PrHCs) comprising of both inmates and officers. The authors present findings from a nested evaluation of the impact of eight PrHCs 18 months after programme initiation. In-depth-interviews were conducted with 11 government ministry and Zambia Corrections Service officials and 6 facility managers. Sixteen focus group discussions were convened separately with Prison Health Committees members and non-members in 8 facilities. Memos were generated from participant observation in workshops and meetings preceding and after implementation. The authors sought evidence of Prison Health Committees impact, refined with reference to Joshi’s three domains of impact for social accountability interventions in state, society, and state-society relations. Further analysis considered how project outcomes influenced structural dimensions of power, ability and justice relating to accountability. Data pointed to a compelling series of short- and mid-term outcomes, with positive impact on access to, and provision of, health services across most facilities. Inmates reported being empowered via a combination of improved health literacy and committee members’ newly-given authority to seek official redress for complaints and concerns. Inmates and officers described committees as improving inmate-officer relations by providing a forum for information exchange and shared decision making. Contributing factors included more consistent inmate-officer communications through committee meetings, which in turn enhanced trust and co-production of solutions to health problems. Nonetheless, long-term sustainability of accountability impacts may be undermined by permanently skewed power relations, high rates of inmate turnover, variable commitment from some officers in-charge, and the anticipated need for more oversight and resources to maintain members’ skills and morale. The authors showed that Prison Health Committees do have potential to facilitate improved social accountability in both state and societal domains and at their intersection, for an extremely vulnerable population. However, sustained and meaningful change will depend on a longer-term strategy that integrates structural reform and is delivered through meaningful cross-sectoral partnership.

13. Monitoring equity and research policy

Establishing Standards to Evaluate the Impact of Integrating Digital Health into Health Systems
Labrique A; Vasudevan L; Weiss W; et al: Global Health: Science and Practice 6(Supplement 1) S5-S17, 2018

In this commentary, the authors summarize the key milestones in the rise of digital health, illustrating efforts to bridge gaps in the evidence base, a shifting focus to scale-up and sustainability, growing attention to the precise costing of these strategies, and an emergent implementation science agenda to better characterize the necessary ecosystem of scale—the social, political, economic, legal, and ethical context that supports digital health implementation. In 2016, WHO established a guidelines development group to assess current evidence and recommendations for digital strategies. The guidelines development process recommends strategies that are adequately supported by sufficient evidence but also highlights promising strategies that currently have a low threshold of evidence that require future research, with a particular eye toward health system integration of these strategies. The evidence base of digital health approaches that have been successfully scaled up is growing, and new technology and shared standards provide a framework that can decrease the risk and amplify the promises of digital health investments. The authors argue that digital health innovations are increasing accessibility, promoting transparency, and have the capacity to increase accountability—all necessary facets of lasting health systems strengthening.

14. Useful Resources

Rees-Roberts D; Cooke P: 2016

CATCH is a fictional short film about a father and daughter quarantined in their home in a post-antibiotic world. CATCH is set in a near future world where antibiotic resistance has made antibiotics useless. Although that is a real potential future, the producers argue that it is possible to work now to stop that future from happening. There are lots of simple things people can all do to try to avoid the post-antibiotic future portrayed in CATCH: Always wash hands when handling and preparing food to avoid cross-contamination, especially between raw and ready-prepared food. Never pressure a doctor for antibiotics, as antibiotics can only treat bacterial infections. Never take unprescribed antibiotics. Always finish a prescribed course of antibiotics. Never stop taking antibiotics before the course is finished as prescribed - even if one starts feel better, see it through to the end. Raise awareness about the issue of antibiotic resistance, and what communities can do to combat it. Talk to friends, family, colleagues, and local politicians!

Toolkit for International Universal Health Coverage Day
UHC2030 & 12.12 Coordination Group: December 2018

Universal health coverage (UHC) ensures all people, everywhere, can access the quality health services they need without suffering financial hardship. World leaders have agreed: every person—no matter who they are, where they live, or how much money they have—should be able to access quality health services without suffering financial hardship. To achieve this vision of universal health coverage by 2030, there is a need for collective action now to build strong, equitable health systems in every country. The UHC2030 & 12.12 Coordination Group have built a toolkit to use to promote these goals. It provides actions for policy makers, civil society and individuals, resources to share in communities around the world and key messages to share on social media.

15. Jobs and Announcements

Call for contributions "Pesticide Politics in Africa"
Conference 29th-31st May 2019, Tropical Pesticide Research Institute (TPRI), Arusha, Tanzania

The current economic boom in many sub-Saharan countries is accompanied by an unprecedented increase in non-communicable diseases (NCDs) due to industrial pollution, including pesticides. While local and international mobilizations call for more stringent pesticide control measures, African governments often refrain from adopting and enforcing strict regulations – considered as potential obstacles to “development”. This interdisciplinary conference aims at laying the foundations for a long-term scientific cooperation between African and European scholars on the management of pesticide-related occupational and environmental health hazards in Africa. It aims to explore the trade-offs between production and prevention that underlie the expansion of chemical-intensive agriculture on the continent, to understand the relations between technique, knowledge and power that condition the inclusion of African populations in the globalized economy, and to grasp the resulting health and environmental inequalities.

CODESRIA 15th General Assembly. Theme: Africa And the Crisis of Globalization
17–21 December,2018, Dakar, Senegal

The CODESRIA General Assembly is a triennial gathering of scholars and academics drawn from the Social Sciences and Humanities in Africa and its Diaspora. On the back of the scientific sessions of the Assembly, a meeting of members who are in good standing will be held to review the functioning of the Council in the period since the 14th Assembly and decide the broad agenda to be pursued for the subsequent three years. Broad themes for the General Assembly include: Globalisation, its itinerary and iterations, Africa in the iterations of globalisation, Pan-Africanism and African regional integration, The African nation-state and globalization, Peace, security and Africa’s geopolitics, Planning, policy processes and Africa’s globalization, Globalisation and Africa’s economic transformation and Globalization and Africa’s changing ecology, amongst others.

IIEP-UNESCO Call for Expressions of Interest for National Researchers in Sub-Saharan Africa
Deadline for applications: 31 December 2018

IIEP, UNESCO’s International Institute for Educational Planning, has issued a call for expressions of interest for national researchers in Sub-Saharan Africa to collaborate in a research project on Use of Learning Assessment Data in the Planning Cycle. The project will explore how countries in this region use learning data produced by large-scale international, regional and national assessments; see how they are used in different phases of the education planning cycle; examine the intended use of these data as foreseen in regulatory documents and the discrepancies between this and observed uses; and explore factors that influence the use of assessment data with a particular focus on elements linked to the political economy of actors. It will take a wider look at the information ecosystem that surrounds learning data, analysing how it is interpreted and considered together with other evidence. IIEP-UNESCO will conduct a number of case studies in Sub-Saharan Africa countries to provide a qualitative comparative analysis and to generate knowledge and recommendations that would inform the work of national officers and international partners. The Institute has put out a call for expressions of interest to work with national researchers from Sub-Saharan Africa universities and institutes in the implementation of this project in conducting a case study in one of the countries in the region.

South African Health Review 2019 Call for Abstracts
Deadline for submission of abstracts: 14 December 2018

The South African Health Review (SAHR) is an accredited peer reviewed publication. The aims of the SAHR are to advance the sharing of knowledge, to feature critical commentary on policy implementation, and to offer empirical understandings for improving South Africa's health system. The editors are pleased to announce that the call for abstracts for the 2019 edition of the SAHR is now open. Abstracts providing fresh insights into health systems strengthening efforts supporting the realisation of universal health coverage in South Africa are particularly sought. Preference will be given to manuscripts that take cognisance of the World Health Organization's six building blocks for an effective, efficient and equitable health system. In addition to a primary call for abstracts, there are two other opportunities for potential authors. The first is the launch of the inaugural Healthcare Workers Writing Development Programme offering writing skills training and ongoing coaching throughout the publication process for identified first time authors. Healthcare workers who are interested in contributing to the SAHR and sharing their insights into the challenges and successes of implementation are encouraged to submit an abstract. Further details about this call will be available in January 2019. The second is the annual Emerging Public Health Care Practitioner Award (EPHPA) which is open to South African citizens under the age of 35, who are at Masters' level or below. Applications for this award will open in February 2019.


Contact EQUINET at admin@equinetafrica.org and visit our website at www.equinetafrica.org
Website: http://www.equinetafrica.org/newsletter

SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to admin@equinetafrica.org Please forward this to others.

SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit http://www.equinetafrica.org/content/subscribe
The information on subscribers is used only to email the newsletter to subscribers.

This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact admin@equinetafrica.org immediately regarding any issues arising.