EQUINET NEWSLETTER 215 : 01 February 2019

1. Editorial

Include a gender and equity lens to effectively tackle antimicrobial resistance
Sarah Simpson and Victoria Saint

Antimicrobial resistance (AMR) is one of the most serious current threats to global public health, food security and thus development. It may make standard treatments ineffective for many communicable diseases, including pneumonia, tuberculosis, malaria and HIV/AIDS. Without effective antibiotics, chemotherapy and everyday dental and surgical procedures become increasingly dangerous, due to the risk of complications from infection.

AMR refers to the ability of microorganisms such as bacteria, viruses, and some parasites to stop antimicrobial medicines such as antibiotics, antivirals and antimalarials from controlling them.

One of the reasons for this resistance across all countries is the overuse of antimicrobials, or use when they are not needed or suitable. This may happen in various sectors beyond the use of medicines in health services. It may happen, for example, in agriculture and aquaculture, such as to prevent infection and increase growth in chickens, cows or fish, and in the environment, where antibiotic residues may be found in waste water from humans and farms, together with unused medicines that are not properly disposed of.

Supporting this drive for change, a global action plan to tackle AMR was endorsed in 2015. The 2015 World Health Assembly set the goal of this global action plan as “to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them.”

There is an urgent need for the world to change the way it prescribes and uses antibiotics to address AMR, rather than only relying on the development of more powerful antimicrobials. AMR is often talked about in terms of ‘drugs and bugs’. We need to move beyond this focus to think about how AMR and interventions to address it affect people in their day to day lives, at home, at work and in their communities. This is important if we are to ensure the reach, effectiveness and impact of the strategies used, so that they leave no one behind. We need to understand how men, women and different groups in society may have different levels of exposure to and risk of AMR, or different levels of impact from AMR, to identify ways of addressing them.

For example, increasing antibiotic resistance and inadequate safe water and sanitation in health care institutions may raise women’s risk during pregnancy and childbirth. Women and men may have different levels of exposure and vulnerability to diseases that have already shown signs of AMR, such as tuberculosis, HIV, malaria, gonorrhea and urinary tract infections. The World Health Organization (WHO) observed that men who have sex with men may be at greater risk of getting drug-resistant strains of gonorrhea, as some may not seek treatment given the stigma they face.

Women make up 67% of the global health and social sectors workforce and are often concentrated in lower-level, lower-paid jobs, with unsafe working conditions. For example, health workers and cleaners may not be provided with gloves, masks and other protective clothing, leaving them exposed to resistant microbes through their work. Likewise in agricultural settings, people working without protective equipment or cleaning facilities with cattle, pigs and poultry that are infected with drug resistant bacteria may also be exposed to these strains. Workers infected with these resistant bacteria in their work may then spread them to family members and friends.

There are also different levels of knowledge and different attitudes and practices relating to the use of antibiotics amongst people, prescribers, policy makers and pharmacists. For example, younger people and those with less education may not have correct information and knowledge on what illnesses antibiotics work for. In 2014 in Spain, researchers found, for example, that young men were more likely to believe that antibiotics are effective against viruses such as flu (they are not) and to incorrectly seek prescriptions for antibiotics to manage such conditions.

Given that AMR is occurring everywhere in the world, it is critical to effectively cover all these negative effects. This means that in sectors with a known risk of AMR, there are measures to monitor which groups in the population may be experiencing higher exposures to and rates of AMR, or may not have sufficient access to quality-assured and affordable medicines when needed. Monitoring such health impacts thus needs not only to be undertaken by the health sector, but also by other sectors such as agriculture and environment.

As the examples in this editorial indicate, a strategy for effective coverage would need to pay attention to the differences in exposure, risk and impact between males and females and between different socioeconomic groups, taking features such as occupation and working conditions into account. It would need to analyse equity and gender differentials to ensure that no one is left behind.

A WHO working paper, ‘Tackling antimicrobial resistance (AMR) together – Working Paper 5.0: Enhancing the focus on gender and equity’ (https://tinyurl.com/yakxvzqo) addresses this issue. It explores how to include a focus on gender and equity in efforts to tackle AMR.

It highlights the need to better understand how gender and other social determinants affect the exposure and behavior of different groups in the population in relation to their use of antibiotics and to prescribing practices. For example, it points to use of existing studies to tailor health campaigns and messages to better reach key groups such as young men or doctors or to reach settings where antimicrobials are mis- or over-prescribed, making use of diverse media. These include, for example, social media, YouTube videos and an interactive game on AMR. These resources can be found at http://apps.who.int/world-antibiotic-awareness-week/activities/en. The WHO paper also provides some guidance for countries on how to explore and manage gender and equity considerations in AMR in their national action plans. The WHO secretariat is encouraging review, dissemination and feedback to the secretariat at whoamrsecretariat@who.int on this working paper, to support its use in practice.

In July 2018 a WHO survey found that 100 of 194 member state countries had national action plans for AMR in place and 51 countries had plans under development. There is demand, scope and information now available to improve how these action plans are designed and implemented so that no one is left behind.

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

2. Latest Equinet Updates

Mapping the constitutional provisions on the right to health and the mechanisms for implementation in Kenya
Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN): Case study report, KELIN, EQUINET, Kenya, 2018

This case study is produced by the Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN), working with Charles Dulo as a contributor, in the theme work on health rights and law of the Regional Network for Equity in Health in East and Southern Africa (EQUINET). This Paper’s objective is to answer the question, “What difference have constitutional rights to health made in practice and what have been the issues affecting the capacity to claim and deliver on the rights in Kenya?” 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. It is a desk review of literature that explores the historical background on the right to health before the current constitution that was promulgated in 2010. This is followed by a review of the legislative framework after 2010 and jurisprudence on the right health, and concludes by highlighting key challenges in the realization of the right to health in Kenya.

3. Equity in Health

Assessing changes in social determinants of health inequalities in South Africa: a decomposition analysis
Omotoso K; Koch S: International Journal for Equity in Health 17(181) 1 -13, 2018

This study examines how changes in the social determinants of health have impacted health inequalities in South Africa over the last decade, the second since 1994. Information collected on social determinants of health and on health status was obtained from the 2004, 2010 and 2014 questionnaires in the South African General Household Surveys. The health indicators considered include ill-health status and disability. Concentration indices and Oaxaca-Blinder decomposition of change in a concentration index methods helped to unravel changes in socio-economic health inequalities and their key social drivers over the studied time period. The results show that inequalities in ill-health are consistently explained by socio-economic inequalities relating to employment status. Provincial differences narrowed considerably over the studied periods. Relatedly, disability inequalities are largely explained by shrinking socio-economic inequalities relating to racial groups, educational attainment and provincial differences. The extent of employment, location and education inequalities suggests the need for improved health care management and further delivery of education and job opportunities.

4. Values, Policies and Rights

African Civil Society Statement on Universal Health Coverage
People’s Health Movement: PHM, December 2018

This statement from the People’s Health Movement (PHM) asserts a commitment to Comprehensive Primary Health Care and addressing the Social, Environmental and Economic Determinants of Health. To make health care accessible to all, African governments are considering or have implemented policy reforms with a focus on achieving Universal Health Coverage (UHC). Examples include, the Community Based Health and Planning Services (CHPS) and National Health Insurance Scheme in Ghana; National Health Insurance Scheme in Uganda, expansion of the National Hospital Insurance Fund in Kenya, National Health Insurance in South Africa and Health Financing Policy and Strategy in Zimbabwe. These policy reforms in different ways aim to provide health financing to protect populations from impoverishing health care costs. Despite this momentum, many African countries still provide limited access to quality health services and only a small percentage of the population is protected from financial risks associated with health care costs. PHM identify that the dialogue on UHC in Africa is strongly influenced by the World Bank and other multilateral and bilateral donors, which promote UHC as predominantly a health financing mechanism. Issues of health equity, including a focus on access for the ‘uncovered’ poor, community participation and the strengthening of public health systems are largely ignored. Where UHC is framed as a health financing issue, rather than a human right or public good, and supports charging the poor for health coverage and the creation of health markets (privatisation). Instead PHM assert that PHC is the key to achieving health for all. Efforts to achieve UHC should prioritise reviving and strengthening public health systems in African countries within the Primary Health Care framework which permeates all levels of health care including addressing social determinants of health. The statement identifies actions needed towards addressing the social determinants of health, including: that policies for UHC need to clearly prioritise PHC at the primary and community levels. They argue that a whole of government approach must be applied to support UHC, including Health in All Policies, so that all ministries and departments of government are coordinated in promoting healthier working and living conditions and healthy lifestyles, preventing causes of disease and mortality, and supporting equitable access to health services. Further, governments should increase health sector spending to at least 15% of national budgets, as agreed in the 2001 Abuja Declaration. The PHM call for increased fiscal space by expanding and improving current tax collection measures; as well as implementing new taxes that ensure progressiveness and sustainability and strengthening prepayment mechanisms that pool resources.

SADC Member States participate in 16 Days of Activism Against Gender Based Violence Campaign
Dambuza K: SADC Secretariat Monthly Newsletter 12, December 2018

The Southern African Development Community (SADC) Member States joined the global community to raise their voices against gender based violence (GBV) during the 16 Days of Activism against GBV Campaign. This global Campaign runs from the 25 November to the 10 December of every year. For 2018, this Campaign was implemented under the global theme Orange Your World: #HearMeToo. The SADC Member States commemorated the 16 Days Campaign through localized themes and different activities involving stakeholders and the community. Key messages from some Members States are as follows: Botswana commemorated this Campaign day under the theme: “#HearMeToo; End Violence Against Women and Children”. His Excellency the President of Botswana Mokgweetsi Eric Keabetswe Masisi highlighted Botswana’s commitment to various gender instruments among which is SADC Protocol on Gender and Development. Namibia used this Campaign to bring to the forefront the voices of women and girls who have survived violence and those who are defending women’s rights. The Ministry of Family Affairs launched the 16 Days of Activism against GBV under a local theme of: “Orange Seychelles: Say NO to Gender-Based Violence”.

United Towards Achieving Health For All in Kenya
Kariuku S; Chatterjee S: Reliefweb, 2018

Of all the Sustainable Development Goals, few would rival good health as the definition of a country that has a sustainable, inclusive, peaceful and prosperous future. The authors observe that the launch in December 2018 of the pilot phase of Kenya’s journey towards Universal Health Coverage (UHC) heralds a major step towards that future. In Kenya, health-related expenses are driving about one million into poverty every year, and health care is second only in demand on family spending to food in family budgets. Kenya announced that UHC will involve scaling up immunization, prevention of water borne, vector borne, TB, HIV and sexually transmitted diseases, improving maternal and child health as well as nutrition of pregnant women. Kenya will also focus on prevention of non-communicable diseases like diabetes and hypertension. With Kenya’s Vision 2030 ambition of providing a high quality of life to all its citizens, the most urgent need is argued to be that of ensuring that everyone stays healthy to participate in economic development.

5. Health equity in economic and trade policies

Courts deliver big wins for environment
Sipho Kings: SangoNet Pulse, 2018

South Africa’s environment law has a strange loophole. In theory, every activity that would harm the environment falls under the National Environmental Management Act (Nema) and the Acts linked to it. This allows the government to uphold everyone’s constitutionally guaranteed right to a healthy environment. Nema is what should give the environment department teeth. But mining is exempt because of a 2014 takeover by the mineral resources department of most environmental oversight for mining. Now, far-reaching court decisions are pulling apart the way in which the mining department discharges its job of looking after the environment, and questioning how positive a development this has been. In a stinging rebuke last week, the high court ruled in defence of a wetland in Mpumalanga. This has created a precedent that rights groups say they will use to challenge other cases when mines threaten the environment. This decision follows a judgment earlier this month by the Constitutional Court in a case between residents of villages that fall under the Bakgatla Ba Kgafela tribal administration, near Rustenberg in the North West, and a would-be mining company. Read together, the environmental and land rights judgments are argued by the author to be a serious blow to the carte blanche attitude of the minerals department and its mandate to expand mining. Mining companies will now have to consult all residents. The minerals department will also have to do more than tick boxes based on information given by mines when it comes to looking after the environment.

Trade, investment and public health: compiling the evidence, assembling the arguments
Labonté B: Globalisation and Health 15(1), doi: https://doi.org/10.1186/s12992-018-0425-y, 2019

Trade has long been an axiomatic characteristic of globalization, although international rules governing trade are of more recent vintage. In the post-World War II period, an increasing number of countries began negotiating treaties to reduce, first, tariff barriers and, later, non-tariff barriers (government measures of any sort) that could impede the cross-border flow of goods. The rationale, in part, was that countries that became more entwined economically would be less likely to go to war with each other. It wouldn’t be in their own economic interests to do so, or at least that of the firms based within their borders but engaged in transnational trade and dependent upon global supply chains. At first primarily an undertaking in high-income countries, low and middle-income countries slowly enjoined in what, in 1995, became the World Trade Organization. The WTO locked in scheduled declines in tariffs (border taxes), albeit with lesser obligations on low income country members. Importantly, a slew of new agreements that coincided with the establishment of the WTO also sought to liberalize trade in services and not just goods in the General Agreement on Trade in Services, with new rules for agricultural trade, expanded intellectual property rights protections and other agreements ensuring that government food, health, or environmental regulations would not pose an unnecessary barrier to trade. Outside of the WTO system, bilateral or regional investment treaties grant special rights to foreign investors to sue governments for actions perceived to affect the value of their investment similarly exploded in number, dispute frequency, and the size of monetary claims. The breadth and depth of these post-1995 Agreements meant that few areas of general public health concern are potentially untouched. Given mounting evidence that trade and investment liberalization was creating and globally diffusing new health risks, public health researchers began focusing on the specific measures in trade and investment treaties that created such risks, primarily but not exclusively through constraining the ‘policy space’ for new public health regulations. Globalization processes affect health through multiple pathways and not simply through those more directly linked via changes in health systems. This issue explores the methods and issues that this poses for research on globalisation and health.

6. Poverty and health

Air pollution and child health: prescribing clean air
World Health Organisation: WHO, Geneva, 2018

This report summarizes the latest scientific knowledge on the links between exposure to air pollution and adverse health effects in children. It is intended to inform and motivate individual and collective action by health care professionals to prevent damage to children’s health from exposure to air pollution, a major environmental health threat. Exposure to fine particles in both the ambient environment and in the household causes about seven million premature deaths each year. Ambient air pollution alone imposes enormous costs on the global economy, amounting to more than US$ 5 trillion in total welfare losses in 2013. This public health crisis is receiving more attention, but one critical aspect is often overlooked: how air pollution affects children in uniquely damaging ways. Recent data released by the World Health Organization (WHO) show that air pollution has a vast and terrible impact on child health and survival. Globally, 93% of all children live in environments with air pollution levels above the WHO guidelines. More than one in every four deaths of children under 5 years is directly or indirectly related to environmental risks. Both ambient air pollution and household air pollution contribute to respiratory tract infections that resulted in 543 000 deaths in children under 5 years in 2016.

Temporal trends in the nutritional status of women and children under five years of age in sub-Saharan African countries: ecological study
Humbwavali J; Giugliani C; Silva I; Duncan B: Sao Paulo Medical Journal 136(5), 454-463, 2018

This paper seeks to describe obesity trends among women of childbearing age over recent decades, along with trends in over and under nutrition among children under five years of age, in sub-Saharan African countries. An ecological study with temporal trend analysis in 13 sub-Saharan African countries was carried out covering trends in nutritional status such as adult obesity, childhood overweight, low height-for-age, low weight-for-height, low weight-for-age and low birth weight. Publicly available data from repeated cross-sectional national surveys were used. The authors chose 13 sub-Saharan African countries from which at least four surveys conducted since 1993 were available. The authors investigated women aged 15-49 years and children under five years of age. In multilevel linear models, the prevalence of obesity increased by an estimated 6 percentage points over 20 years among women of childbearing age, while the prevalence of overweight among children under 5 years old was stable. A major decrease in stunting and, to a lesser extent, wasting accompanied these findings. The upward trend in obesity among women of childbearing age in the context of highly prevalent childhood undernutrition suggests that the focus of maternal and child health in sub-Saharan Africa needs to be expanded to consider both nutritional deficiencies and nutritional excess.

7. Equitable health services

Oral cholera vaccination in hard-to-reach communities, Lake Chilwa, Malawi
Grandesso F; Rafael F; Chipeta S; et al: Bulletin of the World Health Organization 96(12), doi: http://dx.doi.org/10.2471/BLT.17.206417, 2018

This study aimed to evaluate vaccination coverage, identify reasons for non-vaccination and assess satisfaction with two innovative strategies for distributing second doses in an oral cholera vaccine campaign in 2016 in Lake Chilwa, Malawi, in response to a cholera outbreak. The authors performed a two-stage cluster survey. The population interviewed was divided in three strata according to the second-dose vaccine distribution strategy: (i) a standard strategy in 1477 individuals (68 clusters of 5 households) on the lake shores; (ii) a simplified cold-chain strategy in 1153 individuals (59 clusters of 5 households) on islands in the lake; and (iii) an out-of-cold-chain strategy in 295 fishermen (46 clusters of 5 to 15 fishermen) in floating homes, called zimboweras. Vaccination coverage with at least one dose was 79.5%, on the lake shores, 99.3% on the islands and 84.7% on zimboweras. Coverage with two doses was 53.0% 91.1% and 78.8% in the three strata, respectively. The most common reason for non-vaccination was absence from home during the campaign. Most interviewees liked the novel distribution strategies. Vaccination coverage on the shores of Lake Chilwa was moderately high and the innovative distribution strategies tailored to people living on the lake provided adequate coverage, even among hard-to-reach communities. Community engagement and simplified delivery procedures were critical for success. Off-label, out-of-cold-chain administration of oral cholera vaccine should be considered as an effective strategy for achieving high coverage in hard-to-reach communities. Nevertheless, coverage and effectiveness must be monitored over the short and long term.

8. Human Resources

Challenges to tuberculosis control in Angola: the narrative of medical professionals
Brady P; Vita D: Journal of Public Health 40(4) 820–826, 2018

This study interviewed healthcare workers involved in tuberculosis (TB) control on what they consider to be the drivers of the TB epidemic in Angola. Twenty four in-depth qualitative interviews were conducted with medical staff working in this field in the provinces of Luanda and Benguela. The healthcare professionals see the migrant working poor as a particular problem for the control of TB. Migrants are constructed as ‘Rural People’ and are seen as non-compliant and late-presenting. This is a stigmatized and marginal group contending with the additional stigma associated with TB infection. The healthcare professionals interviewed also see the interruption of treatment and self-medication generally as a better explanation for the TB epidemic than urbanization or lack of medication. The local narrative is in contrast to explanations used elsewhere. To be effective policy must recognize the local issues of the migrant workforce, interruption of treatment and the stigma associated with TB in Angola.

Coming Full Circle: How Health Worker Motivation and Performance in Results-Based Financing Arrangements Hinges on Strong and Adaptive Health Systems
Kane S; Gandidzanwa C; Mutasa R; et al: International Journal of Health Policy and Management 8(2), doi: 10.15171/ijhpm.2018.98, 2018

This paper presents findings from a study which sought to understand why health workers working under the results-based financing (RBF) arrangements in Zimbabwe reported being satisfied with the improvements in working conditions and compensation, but paradoxically reported lower motivation levels compared to those not working under RBF arrangements. A qualitative study was conducted amongst health workers and managers working in health facilities that were implementing the RBF arrangements and those that were not. Through purposeful sampling, 4 facilities in RBF implementing districts that reported poor motivation and satisfaction, were included as study sites. Four facilities located in non-RBF districts which reported high motivation and satisfaction were also included. Data was collected through in-depth interviews and analyzed using the framework approach. Findings reveal that insufficient preparedness of people and processes for this change, constrained managers and workers performance. Results based financing arrangements introduce explicit and tacit changes, including but not limited to, incentive logics, in the system. Findings show that unless systematic efforts are made to enable the absorption of these changes in the system: eg, through reconfiguring the decision space available at various levels, through clarification of accountability relationships, through building personnel and process capacities, before instituting changes, the full potential of the RBF arrangements cannot be realised. This study demonstrates the importance of analysing existing institutional, management and governance arrangements and capabilities and taking these into account when designing and implementing RBF interventions. Introducing RBF arrangements cannot alone overcome chronic systemic weaknesses. For a system wide change, as RBF arguably is, to be effected, explicit organisational change management processes need to be put in place, across the system. The authors argue that carefully designed processes, which take into account the interest and willingness of various actors to change, and which are cognizant of and constructively engage with potential bottlenecks and points of resistance, should accompany any health system change initiative.

Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi
Angwenyi V; Aantjes C; Kondowe K; Mutchiyeni J; et al: British Medical Journal Global Health 3(e000996) 1-10, 2018

This paper reviews Malawi’s strategy, with particular focus on the interface between health surveillance assistants (HSAs), volunteers in community-based programmes and the community health team. The authors analysis identified key challenges that may impede the strategy’s implementation inadequate training, imbalance of skill sets within community health team (CHT) and unclear job descriptions for community health volunteers (CHVs); proposed community-level interventions require expansion of pre-existing roles for most CHT members; and district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is argued to be needed on the appropriate CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload and strengthening coordination and communication across all community actors.

9. Public-Private Mix

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study
Suchman L: International Journal for Equity in Health 17(179) 1-18, 2018

This paper pulled together data collected from private providers, patients, and social health insurance (SHI) officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services? In-depth interviews were held with 204 providers over three rounds of data collection in Kenya and Ghana. The authors also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency and the Kenya National Hospital Insurance Fund across four rounds of data collection. Provider interviews covered reasons for enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. Focus Group Discussions covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system, providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

10. Resource allocation and health financing

Public Spending on Health: A Closer Look at Global Trends
Xu K; Soucat A; Kutzin J; et al: World Health Organisation, Geneva, 2018

The 2018 global health financing report presents health spending data for all WHO Member States between 2000 and 2016. It shows a transformation trajectory for the global spending on health, with increasing domestic public funding and declining external financing. This report also presents, for the first time, spending on primary health care and specific diseases and looks closely at the relationship between spending and service coverage. The report presents key messages: Global trends in health spending confirm the transformation of the world’s funding of health services; domestic spending on health is central to universal health coverage, but there is no clear trend of increased government priority for health. Primary health care is a priority for expenditure tracking but Government spending accounts for less than 40% of primary health care spending. Allocations across disease and interventions differ between external and government sources. External funding to combat HIV/AIDS does not have a clear relationship with national prevalence or income level. The report argues that the extent of financial protection of individuals is closely associated with government spending on health.

11. Equity and HIV/AIDS

HIV prevalence in young people and children living on the streets, Kenya
Braitstein P; Ayuku D; DeLong A; Makori D; et al: Bulletin World Health Organisation 97(1) 33–41, 2019

This paper seeks to obtain an estimate of the size of and human immunodeficiency (HIV) prevalence among, young people and children living on the streets of Eldoret, Kenya. The authors counted young people and children using a point-in-time approach, ensuring the authors reached a target population by engaging relevant community leaders during the planning of the study. The authors acquired point-in-time count data over a period of 1 week between the hours of 08:00 and 23:00, from both a stationary site and by mobile teams. Participants provided demographic data and a fingerprint and were encouraged to speak with an HIV counsellor and undergo HIV testing. Of the 1419 eligible participants counted, 1049 were male with a median age of 18 years. Of the 1029 who spoke with a counsellor, 1004 individuals accepted HIV counselling and 947 agreed to undergo an HIV test. Combining those who were already aware of their HIV-positive status with those who were tested during this study resulted in an overall HIV seroprevalence of 4.1%. The seroprevalence was 2.7% for males and 8.9% for females. The authors observed an increase in seroprevalence with increasing age for both sexes, but of much greater magnitude for females. By counting young people and children living on the streets and offering them HIV counselling and testing, the authors could obtain population-based estimates of HIV prevalence.

12. Governance and participation in health

Treatment Action Campaign celebrates two decades of fighting against the odds — and winning
Ho U: Daily Maverick, December 2018

December 2018 marked the 20th anniversary of the birth of the Treatment Action Campaign (TAC); a story that began with a T-shirt with the slogan “HIV-positive” and came to be a thorn in government’s side, a symbol of hope for people dying from HIV/Aids and an icon of activism still needed in an age of democracy. Days before the protest that founded the TAC, co-founder Zackie Achmat had spoken at the funeral of Aids activist Simon Nkoli. He vowed to fight for access to treatment, knowing from his own experience that if the right medicines were affordable and accessible people would not be dying. Four days after that protest action, activist Gugu Dlamini, who had disclosed her HIV status publicly, speaking on radio in Zulu on World Aids Day, was beaten to death in KwaMashu. “Those two events created the anger and passion that would become the momentum for organising and mobilising,” says co-founder Mark Heywood. As one more person put on an “HIV-positive” T-shirt and stood to challenge HIV stigma, more people joined. Recruitment and empowerment came through a strong treatment literacy programme rooted in spreading the word from neighbour to neighbour, patient to patient. This patient-driven, community activism would become a hallmark of the movement. It meant that people could see the power and the purpose in marching to the opening of Parliament each year, taking part in in civil disobedience campaigns and joining rallies for AZT for pregnant women and pushing big pharmaceutical companies to make drugs available.

Using Health Committees to Promote Community Participation as a Social Determinant of the Right to Health: Lessons from Uganda and South Africa
Mulumba M; London L; Nantaba J; Ngwena C: Health and Human Rights Journal 20(2), PMID: 30568398, 2018

This paper provides perspectives from a three-year intervention whose general objective was to develop and test models of good practice for health committees in South Africa and Uganda. It describes the aspects that the authors found critical for enhancing the potential of such committees in driving community participation as a social determinant of the right to health. Interventions in South Africa and Uganda indicate that community participation is not only a human right in itself but an essential social determinant of the right to health. The interventions show that health committees provide a mechanism that enables communities to be active and informed participants in the creation of a responsive health system that serves them efficiently. The results are argued to confirm the effectiveness of rights-based trainings and exchanges in strengthening committee members’ sense of agency, their capacity to engage the health system, and their ability to exercise claims to health rights. They also contribute evidence of health committees’ potential to play a critical role in advancing community participation as a social determinant of the right to health.
These participatory spaces are observed to bridge the gap between communities and health facilities, making services responsive to community needs and contributing to the realization of health as a human right.

13. Monitoring equity and research policy

A health policy analysis reader: The politics of policy change in low- and middle-income countries
Gilson L; Orgill M; Shroff Z: Alliance for Health Policy and Systems Research, 2018

This reader aims to encourage and deepen health policy analysis work in low- and middle-income countries (LMICs). It presents the range of health policy analysis studies that have been conducted in LMICs, highlights relevant theory, and points to new directions for such work. It also includes methodological and analytical pointers, and considers how to use health policy analysis prospectively to support health policy change. The Reader’s primary audience includes all those with an interest in understanding and influencing health policy change, including researchers and educators, as well as policy advocates, managers, and policy-makers. The Reader will also be of interest to those who have specialist policy studies or public administration backgrounds, and also to those with limited prior engagement with relevant social science perspectives.

New research chairs program will expand research and innovation in Africa
International Development Research Centre, South Africa’s National Research Foundation (NRF): IRDC, December 2018

IDRC and South Africa’s National Research Foundation (NRF) have announced a new research chairs initiative. The OR Tambo Africa Research Chairs Initiative, named after Oliver Reginald Tambo, the pre-eminent South African leader and advocate of science and technology, will support up to 10 top researchers from across Africa over the next five years. Through international and regional strategic partnerships, the Chairs will contribute to the development of long-term mutually beneficial research collaborations on the continent. They will focus on world-class research in diverse fields and on training graduate students at leading universities in the 15 sub-Saharan African countries that make up the Science Granting Councils Initiative (SGCI), a collaboration between IDRC, NRF, the Swedish International Development Cooperation Agency, and the UK’s Department for International Development. The application and selection process will be conducted using a two-phase approach coordinated by NRF, which will also manage the Chairs once awarded. The call for institutional expressions of interest was launched in December 2018 and the call for detailed chair-holder applications will be launched in May/June 2019. Councils participating in SGCI are expected to play a key role in the research and grants management, implementation, and sustainability of the Chairs.

14. Useful Resources

Housing impacts health: New WHO Guidelines on Housing and Health
World Health Organisation: WHO, Geneva, 2018

The quality of housing has major implications for people’s health. Poor housing is associated with a wide range of health conditions such as respiratory diseases including asthma, cardiovascular diseases, injuries, mental health and infectious diseases including tuberculosis, influenza and diarrhoea. Housing is becoming increasingly important to public health due to demographic and climate changes, according to the latest WHO Housing and health guidelines re¬leased today. The guidelines provide new evidence-based recommendations on how to reduce major health risks associated with poor housing conditions in 4 areas: Inadequate living space (crowding); low and high indoor temperatures; injury hazards in the home; and accessibility of housing for people with functional impairments.

15. Jobs and Announcements

Africa Health Agenda International Conference 2019, 2030 Now: Multi-sectoral Action to Achieve Universal Health Coverage in Africa
Youth Pre-Conference 3-4 March 2019, General Admission 5-7 March 2019, Kigali, Rwanda

Every iteration of AHAIC builds on the success of the previous one to bring more nuance and action to conversations on health in Africa. The 2017 conference, which was held in Nairobi, Kenya, brought together over 1000 stakeholders to discuss systems and innovations needed to enable Africa to achieve the Sustainable Development Goals. AHAIC 2019 will convene stakeholders from across sectors and around the world to take forward critical conversations initiated in Nairobi to explore what it will take for Africa to achieve Universal Health Coverage (UHC) by 2030. Confirmed speakers include Dr Diane Gashumba, Minister of Health, Republic of Rwanda, Dr. Githinji Gitahi, Group CEO, Amref Health Africa and Dr. Matshidiso Moeti, Regional Director for Africa, World Health Organization.

Call for contributions to the journal Justice Spatiale | Spatial Justice
Deadline for Applications: 15 May 2019

As part of its editorial programming for 2019-2021, the journal Justice Spatiale | Spatial Justice is opening a permanent call for contribution to its different sections : 1) Focus for peer review papers ; 2) Public Spaces for general interventions, interviews or position papers on issues related to spatial justice; 3) JSSJ Reviews for books reviews. Justice Spatiale | Spatial Justice is an international electronic journal whose concept was born in Nanterre, France, precisely where Henri Lefebvre taught, and this is in no way a coincidence as there is a strong relation between the concept of spatial justice and the Lefebvrian concepts of production of space (“production de l’espace”) and right to the city (“droit à la ville”). The journal Justice Spatiale | Spatial Justice is committed to interdisciplinary approaches and encourages cross-cutting research. Another primary objective is to create sustained linkages between the English-speaking and the French-speaking scientific communities. The journal is therefore completely bilingual. The electronic medium also has the potential to expand the traditional definition of the academic article since it enables the combination of text, images (static and animated) and sounds.

Clinton Health Access Initiative (CHAI) – South Africa, Programme Manager: Sexual and Reproductive Health and Congenital Syphilis Programs
Deadline for Applications: 28 February, 2019

The Clinton Health Access Initiative (CHAI) is seeking a highly motivated individual with outstanding technical and managerial capabilities to play a key role in either the Sexual and Reproductive Health and/or Congenital Syphilis programs in South Africa. The Program Manager will shape strategy, manage and provide technical input to a large and growing CHAI team. CHAI works in a fast-paced and results-driven environment. This individual would manage a growing team, at national and provincial levels, and shape CHAI’s engagement. Thus, they should have exceptional communication and analytical skills, be a strong strategic thinker and be able to adapt to differing program needs. CHAI places great value on commitment to excellence, resourcefulness, responsibility, tenacity, flexibility, independence, energy, work ethic and humility. The Manager will be based in Pretoria, South Africa and report to CHAI South Africa’s leadership team. The Manager’s key responsibilities include, but are not limited to support NDoH in all areas ranging from either sexual reproductive health and/or congenital syphilis; with respect to planning and implementation, ensuring CHAI’s ongoing alignment with the DoH strategic goals and priorities, oversee the translation of objectives provided by the government, donors, and other partner organizations into clear activity plans, and provide guidance to a team and DoH on prioritization of initiatives, manage and establish collaborative relationships with the DoH, suppliers, partner organizations and other relevant stakeholders. The qualifications and requirements for the position will include an advanced degree in a related field such as health economics, public health, financial management, business preferred, 5 to 7 years of professional experience in demanding, results-oriented environments in the public sector and/or private sector, excellent problem solving, analytical and quantitative skills, including attention to detail and experience in modeling using Microsoft Excel among others.

Clinton Health Access Initiative (CHAI) – South Africa, Senior Programme Manager: Sexual and Reproductive Health, Maternal and Neonatal Health (SRMNH)
Deadline for Applications: 28 February, 2019

The Clinton Health Access Initiative (CHAI) is seeking a highly motivated individual with outstanding technical and managerial capabilities to play a leadership role in the SRMNH program in South Africa. The Senior Program Manager will shape strategy, manage and provide technical input to a large and growing CHAI team across the areas of Sexual Reproductive Health, Maternal Neonatal Health. S/he will work with a range of partners and subject matter experts and report into CHAI South Africa’s leadership team. The Manager will be based in Pretoria, South Africa and report to CHAI South Africa’s leadership team. The key responsibilities will not be limited to the following supervise a team of CHAI staff working at the national and provincial level providing strategic direction, managerial and technical support as well as quality assurance for the portfolio, work with CHAI staff and the government in program areas ranging from sexual reproductive health and maternal and neonatal health, work with CHAI staff and the government in the scale-up of a health services including strategy and design, development and implementation of evidence-based strategic and operational plans, manage senior level stakeholder relationships; coordinate and participate in technical working groups. The qualifications and requirements for the position will include an advanced degree in a related field such as health economics, public health, financial management, business preferred; a clinical background is an added advantage but not required, 7-10 years of professional experience in demanding, results-oriented environments in the public sector and/or private sector, entrepreneurial mindset; demonstrated ability to work independently on complex projects and solve challenging problems, in a high-pressure, fast-paced environment among others.

The First FAO/WHO/AU International Conference on Food Safety: ‘The Future of Food Safety: Transforming knowledge into action for people, economies and the environment’
Addis Ababa, Ethiopia, 12-13 February, 2018

Ongoing changes in climate, global food production and supply systems affect consumers, industry and the planet itself. These changes can have an impact on food safety systems and pose sustainability and development challenges. This is a pivotal moment demanding urgent reflection on actions needed to bolster food safety -the impetus for the two international meetings. At the Addis Ababa Conference, priorities will be discussed so that food safety strategies and approaches can be aligned across sectors and borders, reinforcing efforts to reach the SDGs and supporting the UN Decade of Action on Nutrition. Strategic actions will be defined through Ministerial panels involving health, trade and agriculture officials and experts thematic sessions covering the topics of: the burden of foodborne diseases and the benefits of investing in safe food; safe and sustainable food systems in an era of accelerated climate change; science, innovation and digital transformation at the service of food safety; empowering consumers to make healthy choices and support sustainable food systems. The conference will result in a high-level political statement advocating for increased and better coordinated collaboration and support to improve food safety globally.


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