We are starting a new year as the old one ended with a stark warning from Tedros Ghebreyesus, the WHO director-general. “We cannot delay action on climate change. We cannot sleepwalk through this health emergency any longer.”
A Lancet Countdown on Health and Climate Change reports that global warming is affecting every aspect of human life, not only in terms of extremes of weather but in terms of falling food security and access to safe drinking water and clean air.
In our region, where people are highly dependent on agriculture, vulnerable to drought and flooding and already facing a deficit in food security, safe water and clean energy, the impact is reported to be increasing already intense social inequality. WHO estimates that almost one in four premature deaths in Africa have environmental causes, and that climate change is likely to increase the number of health emergencies and disease outbreaks.
In November this year, African ministers for health and environment adopted a ten-year framework to direct funds toward joint health and environment initiatives. The Strategic Action Plan to Scale Up Health and Environmental Interventions in Africa 2019-2029 is expected to promote government investment in addressing environmental problems that affect human health, such as air pollution, contamination of water sources, and ecosystem damage.
These are important commitments. But in our region most governments are not yet fulfilling the commitment they made in 2011 to allocate 15% of domestic government spending on health. Underfunded health sectors struggle to balance the demand for promotion, prevention and medical care and often retreat into the latter.
Climate change demands global co-operation and resources. During the COP 16, the world's high income countries agreed to mobilize 100 billion US dollars per year by the year 2020 for adaptation and mitigation in low income countries, through a Green Climate Fund (GCF). We are nearly at 2020 and it is reported by IPS that only 10 billion US dollars has been mobilized so far since the establishment of the Fund in 2006.
Raising the health consequences of climate change is an important lever for attention and action on these concerns. It should also be a means to put people, social justice and solidarity at the centre of this. The opposite is feared to be happening. For example, at the November World Innovation for Health Summit it was noted that effects such as ‘environmental migrancy’, as people move away from harsh conditions, and the competition for resources can generate self-protection and discrimination. Vandana Singh, author and professor urges that these challenges not make us surrender “our imaginations, our creativity, our wonderful human capacity to work together, to negotiate and argue and brainstorm—on the altar of fear”. The solutions to these complex issues are not simply technical. They are inherently social and thus political.
So on this and the many other challenges that will certainly confront us in 2019, we wish you righteous anger, imagination and creativity and deepening opportunities to work together, negotiate, argue and brainstorm in the interest of our collective health and wellbeing.
1. Editorial
2. Latest Equinet Updates
TARSC as cluster lead of the “Equity Watch” work in EQUINET has been exploring these questions in east and southern African (ESA) countries, gathering diverse forms of evidence from literature review, analysis of quantitative data, internet searches on practices and a participatory validation amongst different social groups of youth in Harare and Lusaka. In Harare, TARSC worked with Civic Forum on Human Development (CFHD) and youth living in low density, medium income suburbs; in formal employment; in tertiary education; unemployed youth; youth in informal employment and in informal settlements. Briefs and reports capturing some of this work are available on the EQUINET website. This report compiles in one document the several rounds of participatory review and validation carried out in Harare with young people from low density, medium income suburbs; youth in formal employment; youth in tertiary education; unemployed youth; youth in informal employment and youth in informal settlements on their perceptions of health and wellbeing, the drivers of wellbeing in their areas, the approaches and practices that are and could be implemented to improve their wellbeing and the implications for urban services, including for health systems.
This review paper examines the extent to which the core, public health capacities developed for the 2005 International Health Regulations (IHR) are also being applied in a manner that supports health systems strengthening (HSS). Produced under the Regional Network for Equity in Health in East and Southern Africa (EQUINET), the paper reviews evidence on the IHR 2005 design, capacities and implementation on HSS in east and southern African countries, particularly in relation to: a. Capacities of community health and primary-level health personnel and service capacities, including health information systems to this level; b. Public health system capacities and functioning relevant to food safety; and c. Ensuring laboratory and pharmaceutical personnel capacities. The paper explores the synergies and opportunities being generated, or not, between investments in IHR implementations and these three areas of HSS in the 16 ESA countries covered by EQUINET. It identifies key weaknesses and challenges and highlights case studies of good practice within the region.
3. Equity in Health
South Africans are likely to live, on average, seven years longer in 2040 than they do now, but the country will see only modest improvement in its global ranking as longevity increases worldwide, according to a study published in the Lancet. SA had an average life expectancy of 62.4 years in 2016, and ranked 171 among 195 countries. If recent health trends continue, SA could see life expectancy increasing to 69.3 years. But it will only rise two places in the global rankings, to 169, as life expectancy is expected to increase in most countries. The authors of the study forecast a range of scenarios for each country, which for SA show that life expectancy could increase by as much as 12.9 years to 75.3 years if the country stepped up its efforts to improve the health of the nation. But in the worst-case scenario, life expectancy could fall by as much as 8.1 years. The study forecast a large global shift in deaths from infectious diseases to deaths from noncommunicable diseases such as diabetes, chronic obstructive pulmonary disease, kidney disease and lung cancer. The top 10 causes of death in SA in 2016 were HIV/Aids, lower respiratory infections, road injuries, interpersonal violence, tuberculosis, diabetes, ischemic heart disease, diarrhoeal diseases, stroke and premature birth complications. By 2040, however, diabetes will be the leading cause of death, followed by road injuries, lower respiratory infections, HIV/AIDS, interpersonal violence, ischemic heart disease, tuberculosis, chronic kidney disease, stroke and diarrhoeal diseases.
4. Values, Policies and Rights
The author outlines a court case in which the judgment raises concerns that some judicial officers hold deeply misguided notions regarding people with mental health issues, which deprives them of access to justice. Such attitudes are noted to not be restricted to judicial practitioners and discrimination to be nationwide. The judiciary as protectors of the rule of law are argued to be held to a higher standard. In 2014, Mental Health Uganda and Validity (formerly the Mental Disability Advocacy Centre – MDAC) published research uncovering widespread abuse, ill-treatment and appalling conditions in Uganda’s regional mental health facilities as well as Butabika. The research also investigated the experiences of people in their communities. The report found that most people with mental health issues experience high levels of violence and neglect at the hands of community members and public officials. The lack of local community mental health and psychosocial support services meant that many found themselves pushed towards unregulated traditional and faith-based healers. Many people recounted having endured unspeakably cruel practices including chaining, cutting the skin, being tied to trees, beatings and daily, casual prejudice. The author argues that the law needs to ensure people can access consensual mental health treatment in the community, with the aim of supporting independence and social inclusion.
5. Health equity in economic and trade policies
The workplace is an important setting for the prevention of non-communicable diseases (NCDs). Policies for transformation of the workplace environment for occupational health and safety in South Africa have focused more on what to do and less on how to do it. There are no guidelines and little evidence on workplace-based interventions for NCDs. This study aimed to learn how to transform the workplace environment in order to prevent and control cardio-metabolic risk factors for NCDs amongst the workforce at a commercial power plant in Cape Town, South Africa. The study used participatory action research in the format of a cooperative inquiry group (CIG). The researcher and participants engaged in a cyclical process of planning, action, observation and reflection over a two-year period. The group used outcome mapping to define the vision, mission, boundary partners, outcomes and strategies required. At the end of the inquiry the CIG reached a consensus on their key learning. Substantial change was observed in the boundary partners: catering services (78% of progress markers achieved), sport and physical activities (75%), health and wellness services (66%) and managerial support (65%). Highlights from a 10-point consensus on key learning included the need for: authentic leadership; diverse composition and functioning of the CIG; value of outcome mapping; importance of managerial engagement in personal and organizational change; and making healthy lifestyle an easy choice. Transformation included a multifaceted approach and an engagement with the organization as a living system.
6. Poverty and health
Just four months ago, the fishing harbour at Kachulu on the western shores of Lake Chilwa in Malawi was bustling with fishermen and traders haggling over the catch of the day. Today hundreds of fishing boats sit marooned on cracked, dry mud as vultures fly above the shores of the once productive fishing zone 30 kilometres (19 miles) east of the southern African country's old capital Zomba. Julius Nkhata, a local villager, says the increasingly dramatic seasonal dry-out of the lake -- blamed by experts on man-made climate change -- has displaced local people and increased joblessness. One-and-a-half million people live in the areas on the Lake Chilwa basin, which is one of the most densely populated areas in southern Africa. Nixon Masi, a government fishery official at Chilwa, said a women's fish-drying cooperative that depends on the lake had been devastated. "There is no fish. This has resulted in a big problem as the women from the cooperative have no source of income," he said. Of the initial 38 members, 21 have left to rebuild their lives elsewhere.
7. Equitable health services
Global efforts to strengthen primary healthcare are observed by the authors to have generally not focused on the critical interface between provider and patient but rather on policy, financing and infrastructure. Over the past two decades the Knowledge Translation Unit at the University of Cape Town has worked with government, academic, and non-governmental organisation partners to develop and evaluate health systems innovations that empower frontline providers. The unit developed the Practical Approach to Care Kit (PACK), a programme that covers primary healthcare needs across the life course. At the centre of the programme are concise clinical decision support tools (guides) comprising standardised and user friendly algorithms and checklists that provide a comprehensive and integrated approach to screening, diagnosing, and treating common symptoms and chronic conditions in adults, adolescents, and children. The accompanying training programme uses case-based, short training sessions delivered by existing health staff to support frontline providers and their teams. PACK provides decision support tools and training to support frontline providers in low and middle income countries. It prompts primary care health workers to claim “system agency” based on an intervention that resonates with their primary identity as clinicians. The authors suggest that delivering on universal primary healthcare requires a change in investments to prioritise comprehensive approaches that can meet the changing burden of disease
In October 2016, the Mozambique Ministry of Health implemented a mass vaccination campaign using a two- dose regimen of the ShancholTM OCV in six high-risk neighborhoods of Nampula city, in Northern Mozambique. Overall 193,403 people were targeted by the campaign, which used a door-to-door strategy. During campaign follow-up, a population survey was conducted to assess oral cholera vaccine coverage, frequency of adverse events following immunization, vaccine acceptability and reasons for non-vaccination. In the absence of a household listing and clear administrative neighborhood delimitations, the authors used geospatial technology to select households from satellite images and used the support of community leaders. One person per household was randomly selected for interview. In total, 636 individuals were enrolled in the survey. The overall vaccination coverage with at least one dose was 69.5% and the two-dose coverage was 51.2%. The campaign was well accepted. Among the 185 non-vaccinated individuals, 83 did not take the vaccine because they were absent when the vaccination team visited their houses. Among the 451 vaccinated individuals, 47 reported minor and non-specific complaints, and 78 mentioned they did not receive any information before the campaign. In spite of overall coverage being slightly lower than expected, the use of a mobile door-to-door strategy remains a viable option even in densely-populated urban settings. The authors’ results suggest that campaigns can be successfully implemented and well accepted in Mozambique in non-emergency contexts in order to prevent cholera outbreaks.
8. Human Resources
In this paper, the authors investigated the comprehensibility and the internal reliability of Context Assessment for Community Health and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique. The cross-sectional survey using Context Assessment for Community Health, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique. Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the work culture, leadership, and Informal payment dimensions.
9. Public-Private Mix
This case study examined government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses 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 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: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship’s evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the “good will” of government actors, and 5) 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. The authors concluded that GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. 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.
10. Resource allocation and health financing
This investment case describes how a stronger, more efficient and results oriented WHO can serve and guide governments and partners in their efforts to improve the health of their populations and to achieve Sustainable Development Goal 3. The five years to 2023 will determine whether the world will achieve the health- related SDGs. WHO aims to achieve: One billion more people benefiting from Universal Health Coverage through improving access to quality essential health services, ensuring sustainable financing and availability of essential medicines, through qualified workforces, better governances and monitoring; One billion more people better protected from Health Emergencies through increasing preparedness, prevention, detection and response; One billion more people enjoying Better Health and Well-Being. Further, WHO commits to address specific health challenges through; improving human capital across the life course, noncommunicable disease prevention and mental health promotion, elimination and eradication of high-impact communicable diseases, tackling antimicrobial resistance and ensuring a healthy environment. WHO needs US$ 14.1 billion for 2019– 2023 to deliver on the Triple Billion target, and drive impact in countries. This includes 2.5 billion for humanitarian and emergencies, 1.6 billion for polio eradication and 10.0 billion for the WHO base budget. Over the last decade WHO has seen a rise of earmarked voluntary contributions. Partners are requested to increase flexible sources available to WHO, including funding for strategic priorities and regional funding.
This article reviews trends and patterns of government spending in the East and Southern Africa region. It points out methodological challenges with interpreting data from the World Health Organization’s (WHO) Global Health Expenditure Database (GHED) and other sources. Government expenditure for health has increased for most countries, albeit at a slower rate than gross domestic product (GDP). In most countries there has been a prioritization away from health in government budgets, putting the onus on the private sector and external funders to fill the gap. Reliance on external funding is important in the region but argued to be inconsistent with countries’ stated ambitions of universal health coverage. A number of methodological challenges with estimating health expenditures are identified. Capturing health expenditures adequately across agencies and levels of decentralization can be challenging, and off-budget funds and arrears are evasive. Measurement error can be significant because actual expenditure information can be hard to come by and is often dated and unreliable. Furthermore, how external financing is captured will affect government health expenditure estimates. These factors have contributed to differences in expenditure estimates between WHO and country-specific public expenditure reviews and complicate interpretation. The article concludes that it is critical to strengthen national data capacity and international efforts to promote quality and consistency of data.
11. Equity and HIV/AIDS
In this longitudinal study from 2013 to 2015 the authors sought to establish how World Health Organization (WHO) HIV guidelines changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities. National HIV programme policy guidelines published between 2003 and 2013 and 2014 and 2015 were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015. High levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013–2015. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, prevention of mother-to-child transmission and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities. Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased. Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services. Good progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. The authors suggest that further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility.
12. Governance and participation in health
At the recent HSR2018 Symposium delegates explored how to challenge embedded power dynamics in health systems research through participatory methodologies. One of the innovations that the Local Organising Committee (LOC) introduced for HSR2018 was the inclusion in the programme of a multi-project Photovoice exhibition. Photovoice is a participatory action research methodology that involves the taking of images by individuals, the discussion and analysis of these images and the use of the images to communicate the lived experiences, strengths and challenges of the photographers. Colleagues commented that this was the largest health based Photovoice exhibition to date but more significant was the scope of the material displayed. The author argues that Photovoice exhibition activities are a great representation of the strength and challenges of using this visual participatory methodology. Using photos can promote the voice of the less powerful seems such a laudable and simple aim but it is important not to overlook the underlying power shifting aims of the methodology.
13. Monitoring equity and research policy
This paper describes and evaluates health research priority-setting in Zambia from the perspectives of key stakeholders using an internationally validated evaluation framework. This was a qualitative study based on 28 in-depth interviews with stakeholders who had participated in the priority-setting exercises. An interview guide was employed. Emerging themes were, in turn, compared to the framework parameters. Although there is apparent commitment to health research in Zambia, health research priority-setting is limited by lack of funding, and consistently used explicit and fair processes. The designated national research organisation and the availability of tools that have been validated and pilot tested within Zambia provide an opportunity for focused capacity strengthening for systematic prioritisation, monitoring and evaluation. The authors observe that the utility of the evaluation framework in Zambia could indicate potential usefulness in similar low-income countries.
14. Useful Resources
Around 15% of the world’s population, or 1 billion people, live with some form of disability, with numbers continuing to rise over the coming decades. People with disabilities are often overlooked in national and international development, and can face widespread barriers in accessing services, including health and rehabilitation services, even though simple initiatives are available to enable access. This three week course aims to raise awareness about the importance of health and well-being of people with disabilities in the context of the global development agenda: Leaving no one behind.
15. Jobs and Announcements
Africa Health gathers innovations in healthcare, from state-of-the-art imaging equipment to the most cost-effective disposables; developments in surgery to advances in prosthetics, coming in from more than 40 countries. The show is free to visit if one registers before 28 May 2019. Accompanying the exhibition is a number of business, leadership and Continuing Professional Development (CPD) conferences and workshops providing the very latest updates and insights into cutting edge procedures, techniques and skills.
The current economic boom in many sub-Saharan countries is accompanied by an unprecedented increase in noncommunicable 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 at exploring 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.
Mandela Institute for Development Studies is looking for individuals with a Pan-African outlook, strong leadership potential and a track record of academic excellence. Applications must demonstrate these elements convincingly. Mandela Institute for Development Studies encourages applicants to consider universities that are outside of South Africa. There are two scholarships available for South African citizens wishing to study elsewhere in Africa for studies that relate to Actuarial Sciences, Business Sciences and Accounting. Applicants who wish to conduct such studies at any of the South African, Kenyan and Nigerian institutions that are on the preferred list are encouraged to apply. There is no deadline for submission. Applicants - who meet the criteria - should apply as soon as they have all supporting documents needed submit the application. Mandela Institute for Development Studies will review applications as they are submitted and aim to award scholarships per different university cycles on the continent.
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