EQUINET NEWSLETTER 218 : 01 May 2019

1. Editorial

It’s not enough to tweak old models: Urban health calls for new approaches
R Loewenson, M Masotya, Training and Research Support Centre (TARSC)

Isaac is a 20 year old with aspirations of a better life. He came to urban Harare a few years ago after finishing school to start a new life. In his life in the city he has done this in ways he didn’t predict. He lives as a lodger in a small, smoky backyard shack and earns money from gathering and selling plastic waste. His most prized possession is a smart phone that is his link to friends, humour and, when he can afford data, to social media and market ideas. Behind a ‘healthy’ appearance he hides stress, hunger, worry about his future and frustration that he cannot afford the food, services, entertainment and life that he sees around him in the city.

Our growing cities are full of such young people, in urban areas that concentrate opportunities, information, social connections, ideas, enterprise, wealth, technology and services together with substandard living environments, pollution, food and income insecurity, violence and exclusion.

Published evidence shows that these risks and benefits are unequally distributed amongst urban residents. Recent migrants, residents of informal settlements and those living in informal housing, as lodgers or ‘backyard shacks’ have a vastly different experience of urban life than wealthier, more secure groups. These urban conditions pose particular challenges for people at different stages of life, whether as children, adolescents, adults or elderly people. We have for decades measured and implemented measures to address the social gap between urban and rural areas, with the disadvantage in the latter. However the growth in poverty and disadvantage and rising inequality within urban areas now demand attention. Published evidence appears to chase, lag behind or miss the rapid, diverse changes taking place in urban areas and is often silent on the features of urbanisation and social assets that promote wellbeing.

In 2016-18 we gathered and analysed diverse forms of evidence and experience on the social distribution of health in urban areas and on the opportunities for promoting health and wellbeing. In Harare, with the Civic Forum on Human Development and Harare youth, and in Lusaka, with the District Health Office and Lusaka youth, we listened to the perceptions and experiences of young people (18-25 year olds) from diverse settings and socio-economic groups in these two cities. We explored how far their experiences were captured in the evidence we collect across the countries in the region.

For young people in Harare and Lusaka, ‘health’ was a biomedical concept, linked to ‘absence of disease’, and to the various problems they see their health services treating. Indeed, the ‘health’ data we routinely collect in our region also commonly focuses on mortality, morbidity and negative indicators such as suicide and obesity, and on immediate determinants of these diseases such as food, water, sanitation, education and health care. This is problematic for young people like Isaac. They appear to be in ‘good health’, despite lacking decent standards of many of these immediate determinants, but this hides the mental and social challenges they experience, and ignores conditions and determinants that have longer term effects across their lives, including for the rising burden of chronic conditions and the growing challenge this poses to our urban health services.

For young people in Harare and Lusaka, having secure incomes, opportunities for entrepreneurship, education, shelter, public spaces, participation in government decisions and self-esteem were important for them to be and remain healthy. They believed these issues would become more challenging in the future, envisaging that as the city grew, it would become more competitive and overcrowded, threatening resources for health, including green spaces. Cities would demand even more of young people’s capacities for innovation and entrepreneurship, with a diminishing, rather than an increasing level of social solidarity.

How ready are we to address these concerns? The indicators we collect across the countries of the region provide a picture of disconnected facets and fragments that weakly reflect the combined current and future impact of these features of urban life on the different groups in the city. Not surprisingly, therefore, the systems and services that respond to them are also segmented and silo’ed. In 2016, the World Health Organisation (WHO) and UN Habitat suggested that we need to reclaim a more multidimensional understanding of equity to address the challenges in urban areas.

So what would such a more holistic, integrated and affirmative approach look like? One starting point may be to go back to the first principle of the WHO Constitution, that health is not merely the ‘absence of disease or infirmity’, it is “a state of complete physical, mental and social wellbeing. A concept of ‘wellbeing’ – or ‘buen vivir’ as applied in some countries – holds the potential to integrate psychosocial, social, time use, political, material, economic, service, governance and ecological determinants, all of which are affecting urban health.
By bringing them together, the concept draws attention to what balance (and imbalances) we are generating between these different dimensions of wellbeing and the current and future consequences of imbalances. The structural adjustment programmes exposed the inequalities that grow when economic strategies pursue growth at the cost of social deficits. The recent global student school strikes over climate justice point to young people’s concern that decisions made globally are dominated by certain economic interests to the cost of the degradation of nature and extinction of species. Achieving equity in wellbeing takes us beyond measuring and closing gaps between different groups of people to the strategies needed and assets we have to use to redress the imbalances that are generating these gaps and that have long term consequences.
The health sector has tried, through ‘health in all policies’ approaches, to persuade other sectors to adopt policies that promote health. To some extent this is still seen as a ‘health sector’ campaign, often taking place in parallel with increasingly biomedical personal care services and declining investment in public health capacities and authority.

In contrast, we found many integrated, collaborative approaches addressing these imbalances and the issues raised by Harare and Lusaka youth in different cities globally, from participatory urban planning in Kenya, to strengthening community safety in Honduras, environmental regeneration and urban agriculture in Brazil and urban youth collaborative engagement on school reforms in the USA. They point not only to the importance of public spaces for bringing together diverse services and interventions in area-based approaches, but also to the opportunities that exist in urban areas for encouraging local competencies and innovation and for facilitating the involvement of affected residents, like Isaac, as knowledge producers and participants in planning and action for health and wellbeing.

More detailed information on the evidence and processes referred to in this oped and the different people involved in this work can be found in EQUINET Discussion paper 117 Responding to inequalities in health in urban areas: Report of multi-method research in east and southern Africa, http://tinyurl.com/y3dv4pvm and other reports referred to in that document.

2. Latest Equinet Updates

EQUINET Discussion paper 117: Pathways to urban health equity: Report of multi-method research in east and Southern Africa
Loewenson R; Masotya M: TARSC, Working with Harare and Lusaka youth, Civic Forum on Human Development and Lusaka District Health Office, EQUINET, Harare, 2018

By 2050, urban populations in Africa will increase to 62%. The World Health Organization (WHO) and UN-Habitat in their 2010 report ‘Hidden Cities’ note that this growth in the urban population constitutes one of the most important global health issues of the 21st century. In 2016-2018, Training and Research Support Centre (TARSC) in the Regional Network for Equity in Health in East and Southern Africa (EQUINET) explored the social distribution of health in urban areas and the opportunities for and practices promoting urban health and well-being. It focused on youth 15-24 years of age as an important group for both current and future well-being. The paper synthesises and reports evidence from a programme of work that unfolded iteratively over two years. The work involved desk reviews of published literature and analysis of data from international databases for east and southern African countries, and international evidence on practices supporting urban well-being in areas prioritised by urban youth. The findings were subject to cycles of participatory review and validation by young people from diverse urban settings and socio-economic groups in Harare and Lusaka. These methods were applied with an intention to draw on different disciplines, concepts and variables from different sectors and on the lived experience and perceptions of the youth directly affected by different urban conditions. Separate publications produced in the project give more detail on particular methods, and findings and are cited in this paper. A series of dissemination and dialogue activities have been carried out with youth, local authority and policy actors, supported by shorter briefs and technical reports.

EQUINET Discussion paper 118: Comparative review: Implementation of constitutional provisions on the right to healthcare in Kenya and Uganda
Centre for Health, Human Rights and Development (CEHURD): CEHURD, EQUINET: Uganda and Harare, 2019

This discussion paper is produced by the Centre for Human Rights and Development (CEHURD) as part of the theme work on health rights and law of the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The paper examines the implementation of constitutional provisions on the right to healthcare in Kenya and Uganda, two countries in East Africa. It aims to identify factors and mechanisms that have facilitated implementation of constitutional provisions on the right to healthcare, including how the constitutions were developed and framed. It compares implementation in Kenya, where the right to healthcare is explicit in their 2010 Constitution, and in Uganda, where the right to healthcare is implicit in the National Objectives and Directive Principles of State Policy. The paper draws on two EQUINET case studies on implementation of constitutional provisions on the right to health, one each in Kenya and Uganda, published in 2018, a 2017 regional workshop that discussed the implementation of constitutional provisions on the right to health, and additional review of published literature. It presents a thematic analysis of the findings from the two case studies in terms of the judicial, political and popular implementation mechanisms, exploring further the factors and mechanisms that have facilitated or blocked their implementation. As the two constitutions address the right to healthcare differently, this analysis of their application provides insights into the factors and mechanisms for practice that may be useful in other settings.

3. Equity in Health

Association between the Human Development Index and Millennium Development Goals 6 Indicators in Sub-Saharan Africa from 2000 to 2014: Implications for the New Sustainable Development Goals
Mabaso M; Zama T; Mlangeni L; Mbiza S; et al: Journal of Epidemiology and Global Health 8(1-2), 77-81, 2018

It is important to assess whether regional progress toward achieving the Millennium Development Goals (MDGs) has contributed to human development and whether this has had an effect on the triple burden of disease in Africa. This analysis investigates the association between the human development index (HDI) and co-occurrence of HIV/AIDS, tuberculosis (TB), and malaria as measured by MDG 6 indicators in 35 selected sub-Saharan African countries from 2000 to 2014. The analysis used secondary data from the United Nations Development Programme data repository for HDI and disease data from WHO Global Health observatory data repository. Generalized Linear Regression Models were used to analyze relationships between HDI and MDG 6 indicators. HDI was observed to improve from 2001 to 2014, and this varied across the selected sub-regions. There was a significant positive relationship between HDI and HIV prevalence in East Africa and Southern Africa. A significant positive relationship was observed with TB incidence and a significant negative relationship was observed with malaria incidence in East Africa. Observed improvements in HDI from the year 2000 to 2014 did not translate into commensurate progress in MDG 6 goals.

Is the Urban Child Health Advantage Declining in Malawi? Evidence from Demographic and Health Surveys and Multiple Indicator Cluster Surveys
Lungu E; Biesma R; Chirwa M; Darker C: Journal of Urban Health 96(1) 131–143, 2019

Considerable evidence has emerged that some population groups in urban areas may be facing worse health than rural areas and that the urban advantage may be waning in some contexts. The authors used a descriptive study undertaking a comparative analysis of 13 child health indicators between urban and rural areas using seven data points provided by nationally representative population based surveys—the Malawi Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Rate differences between urban and rural values for selected child health indicators were calculated to denote whether urban-rural differentials showed a trend of declining urban advantage in Malawi. The results show that all forms of child mortality have significantly declined between 1992 and 2015/2016 reflecting successes in child health interventions. Rural-urban comparisons, using rate differences, largely indicate a picture of the narrowing gap between urban and rural areas albeit the extent and pattern vary among child health indicators. Of the 13 child health indicators, eight show clear patterns of a declining urban advantage particularly up to 2014. However, U-5MR shows reversal to a significant urban advantage in 2015/2016, and slight increases in urban advantage are noted for infant mortality rate, underweight, full childhood immunization, and stunting rate in 2015/2016. The findings suggest the need to rethink the policy viewpoint of a disadvantaged rural and much better-off urban in child health programming. Efforts should be dedicated towards addressing determinants of child health in both urban and rural areas.

4. Values, Policies and Rights

Landmark Jurisdiction case won by Zambian farmers at Supreme court
Foil Vedanta; Lusaka Times, April 2019

The Supreme Court in the United Kingdom announced in April a verdict in the landmark case of the Zambian communities consistently polluted by Konkola Copper Mines (KCM), a subsidiary of British miner Vedanta Resources Plc, allowing them to have their case against the parent company and its subsidiary tried in the UK. The ruling sets a strong legal precedent which will allow people with claims against subsidiaries of British multinationals to sue the parent company in the UK. The judgment by Chief Justice Lady Hale, and four further judges, re-affirms the rulings of the Court of Technology and Construction in 2016 and the Court of Appeal in 2017. Lady Hale refused Vedanta’s pleas in appealing the former judgments stating that, contrary to the claims of Vedanta’s lawyers the claimants do have a bona fide claim against Vedanta; the company does owe a duty of care to the claimants, especially in view of the existence of company-wide policies on environment and health and safety. The judgement noted that the size and complexity of the case, and the lack of funding for claimants at ‘at the poorer end of the poverty scale in one of the poorest countries of the world’ means that they do not have substantive access to justice in Zambia. This has wider implications for other communities affected by multinational mining.

5. Health equity in economic and trade policies

'You often get sick': the deadly toll of illegal gold mining in South Africa
Clark C: The Guardian, April 2019

According to a 2015 report by the South African Human Rights Commission, South Africa’s burgeoning illicit gold trade has been fuelled by the formal mining industry’s decline combined with the failure of government to regulate the informal mining sector. The report estimated 30,000 illegal miners were operating across South Africa; about 75% are believed to be undocumented migrants, primarily from Zimbabwe, Mozambique and Lesotho. The authors indicate that hundreds have died due to collapsing mine shafts, gas explosions and turf wars between the criminal syndicates that have seized control of the illegal industry. On Johannesburg’s outskirts, cut off from support networks and services, women are bearing the brunt of the violence and lawlessness associated with illicit mining. With the vast majority of people in the area living off the proceeds of illicit mining, fear of arrest or deportation prevents many women from going to the police or seeking help at overstretched local medical clinics.

Commercial determinants of health: advertising of alcohol and unhealthy foods during sporting events
Ireland R; Bunn C; Reith G; Philpott M; et al: Bulletin of the World Health Organisation 97(4), 290-295, 2019

Tobacco, alcohol and foods that are high in fat, salt and sugar generate much of the global burden of noncommunicable diseases. A better understanding is needed of how these products are promoted. The promotion of tobacco products through sporting events has largely disappeared over the last two decades, but advertising and sponsorship continues by companies selling alcohol, unhealthy food and sugar-sweetened beverage. The sponsorship of sporting events such as the Olympic Games, the men’s FIFA World Cup and the men’s European Football Championships in 2016, has received some attention in recent years in the public health literature, as have global football events with which transnational companies are keen to be associated, to promote their brands to international markets. Despite this the marketing and sponsorship portfolio of these events have received very little scrutiny from public health advocates. The authors call for policy-makers and the public health community to formulate an approach to the sponsorship of sporting events, one that accounts for public health concerns.

Local solutions can boost healthier food choices in South Africa
Ndlovu N: The Conversation, March 2019

In this article, Ndlovu asks, how should countries like South Africa go about making sure that people – particularly poor people where the burden of non-communicable diseases is highest – have access to healthy food? Recent research from the Wits School of Public Health, the Health Systems Trust and the University of KwaZulu-Natal sheds fresh light on the problem, showing a proliferation of unhealthy food, particularly in poorer communities. The research set out to assess differences in food environment based on socio-economic status. It focused on grocery stores and fast-food restaurants only, with full service restaurants excluded. The analysis used a tool called the “modified retail food environment index” and show the proportion of food retailers in Gauteng that were “healthy” and what proportion were “unhealthy”. The results showed how fast-food outlets and the unhealthy foods they serve, vastly outnumbered formal grocery stores. In November 2016, there were 1559 unhealthy food outlets in Gauteng compared to only 709 healthy food outlets. Strikingly, the distribution of these outlets are income-based. Most of the poorer wards had only fast-food retailers with no healthy food outlets. Conversely, grocery stores are concentrated in wealthy areas. The research shows that many wards in Gauteng have high concentrations of unhealthy food – in other words, they have “obesogenic” food environments. This means the type of food available in this environment promote obesity, leaving their residents little choice. Local as well as national government structures have the authority to license and control food retailers. Alternatively, national level policies can better guide implementation at a local level. This would require governments to adapt existing business licensing and planning frameworks to take into account the lack of healthy food retailers in a particular area. Additionally, municipalities could streamline the process for licensing healthy food retailers, making it easier and faster for them to open in areas most in need. The authors indicate that there is a plethora of options to select from if municipalities want to improve their food environments and can facilitate the right to access to healthy foods for the poorest and most vulnerable.

6. Poverty and health

Clean water and sanitation: Why it matters
NGO pulse, Sangonet, March 2019

Worldwide, more than two million people die every year from diarrhoeal diseases. Poor hygiene and unsafe water are responsible for nearly 90 per cent of these deaths and mostly affect children. A study by the World Bank Group, UNICEF and the World Health Organization estimates that extending basic water and sanitation services to unserved households would cost US$28.4 billion per year from 2015 to 2030, or 0.1 per cent of the global product of the 140 countries included in its study. The economic impact of not investing in water and sanitation costs 4.3 per cent of sub-Saharan African GDP. The paper recommends that civil society organizations work to keep governments accountable, invest in water research and development, and promote the inclusion of women, youth and indigenous communities in water resources governance.

7. Equitable health services

Health System Factors Constrain HIV Care Providers in Delivering High-Quality Care: Perceptions from a Qualitative Study of Providers in Western Kenya
Genberg B; Wachira J; Kafu C: Journal of the International Association of Providers of AIDS Care 18, 1-10, 2019

This study examined the experiences of sixty HIV care providers in a high patient volume HIV treatment and care program in eastern Africa. The authors conducted in-depth interviews focused on providers’ perspectives on health system factors that impact patient engagement in HIV care. Results from thematic analysis demonstrated that providers perceive a work environment that constrained their ability to deliver high-quality HIV care and encouraged negative patient–provider relationships. Providers described their roles as high strain, low control, and low support. The authors suggest that health system strengthening must include efforts to improve the working environment and easing burden of care providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.

Prevention and control of noncommunicable diseases: lessons from the HIV experience
Abimbola S; Thomas E; Jan S; McPake B; et al: Bulletin of the World Health Organisation 97(3), 169-244, 2019

In many low- and middle-income countries, the challenges of scaling up successful localized projects to achieve national coverage are well recognized. The wide success of efforts to scale up interventions to prevent and control human immunodeficiency virus (HIV) infection mean that it is now managed as a chronic condition. Lessons from the HIV experience may thus be transferable to the rollout and scale-up of effective interventions for noncommunicable diseases in low- and middle-income countries. WHO’s best buys for reducing noncommunicable diseases in low-resource settings suggest several such interventions. They include measures to improve tobacco control, increase public awareness of the health benefits of physical activity, multidrug therapy for people at high risk of cardiovascular disease and the screening and treatment of cervical cancer. While there is much to learn from the HIV experience, noncommunicable diseases have peculiarities that may limit the transferability of learning or require significant adaptation of such learning, while there are also issues to address in transfering learning on noncommunicable disease prevention and control between high-income and low- and middle-income countries. The authors call for the development of research and practice platforms that allow for progressive and systematic accumulation and sharing of field learning from scale-up efforts of HIV interventions and from the scale-up of noncommunicable disease interventions between settings

8. Human Resources

Gender equity in the health workforce: Analysis of 104 countries
Boniol M; McIsaac M; Xu Lihui; Wuliji T; et al: Health Workforce Working paper 1, World Health Organisation, 2019

The health and social sector, with its 234 million workers, is one of the biggest and fastest growing employers in the world, particularly of women. Women comprise seven out of ten health and social care workers and contribute US$ 3 trillion annually to global health, half in the form of unpaid care work. While gender issues have been at the top of the global agenda, few comprehensive studies on gender in the health and social workforce have been conducted at the global level. This brief is based on an analysis of WHO NHWA data5 for 104 countries over the last 18 years. The analysis confirms previous findings that women’s share of employment in the health and social sector is high, with an estimated 67% of the health workforce in the 104 countries analysed being female. Analysis based on median wages from 21 countries showed health workers face gender-related gaps in pay, with female health workers earning, on average, 28% less than males. This is slightly greater than global estimates of gender pay gap data, showing that women are paid approximately 22% less than men. Data from 56 countries showed higher average working hours per week for men than women for most occupations and regions. This likely reflects different type of contracts, with more part-time jobs occupied by women. Women represent around 70% of the health workforce, but earn on average 28% less than men. Occupational segregation (10%) and working hours (7%) can explain most of this gap, but even when considering “equal work” an “equal pay” gap of 11% remains. The authors note that it must be recognized that much of the work in health done by women is unpaid work and that investments in creating decent work in the health sector are needed to support the translation of informal work into formal sector employment.

9. Public-Private Mix

Determinants of paying national health insurance premium with mobile phone in Ghana: a cross-sectional prospective study
Boaheng J; Amporfu E; Ansong D; Osei-Fosu A: International Journal for Equity in Health 18 (50) 1-9, 2019

This study investigated the determinants of renewing membership and paying the National Health Insurance Scheme premium through a mobile phone. The prospective cross-sectional survey was used to solicit information from 1192 respondents living in Kumasi Metropolis, Atwima Nwabiaya and Sekyere Central Districts of Ghana to estimate the determinants of paying the National Health Insurance Scheme premium with the mobile phone. The study found that residing in an urban area, senior high education, tertiary education and informal employees are the determinants of paying the NHIS premium with the mobile phone. It was recommended that the NHIS consider making the mobile payment as simple as possible for the less educated and for rural members to access it.

10. Resource allocation and health financing

Large-scale health insurance for the informal sector in Sub-Saharan Africa: Six years field experience on creating a large scale health insurance in rural Senegal
Docrat S; Lund C; Chisholm D: International Journal of Mental Health Systems 13(4) https://doi.org/10.1186/s13033-019-0260-4, 2019

From 2012 to 2017, the Belgian governmental cooperation and the Senegalese authorities implemented a project aimed at organising health insurance for rural poor people (‘PAODES’) to fund basic health care services at local and district level. It aimed to develop a health insurance model that had been tested long enough on a large enough scale to scale it up. PAODES intervened in four health districts with 480 000 people. The report found that health insurance coverage after two years was at 64% (more than 300,000 people). The health insurance scheme was reported to be financially viable at 30% coverage. Utilisation of primary care was up from 0.6 to 1.2 consultations per person per year for insured people. The authors report that large-scale health insurance for the informal sector can be efficient if it is operated by professional teams, if it is significantly subsidised by government so as to allow poor people to adhere, and if it is embedded in a nation-wide institution with a public purpose. The authors report that the credibility of a health system depends on the quality and packages of care offered. It is argued that large-scale health insurance cannot exist and function without the government addressing at least technical and procedural matters with regard to governance, such as a uniform and government-regulated fee-paying system and a digitalised accounting system for all health facilities and districts.

Public Spending on Health: A Closer Look at Global Trends
Xu K; Soucat A; Kutzin J; Brindley C; 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 based on the SHA 2011 methodology. It shows a transformation trajectory for the global spending on health, with increasing domestic public funding and declining external financing. This report 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 key messages include that 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. The report further shows that primary health care is a priority for expenditure tracking. Further, allocations across disease and interventions differ between external and government sources. The report indicates that performance of government spending on health can improve.

11. Equity and HIV/AIDS

Implementing prevention policies for mother-to-child transmission of HIV in rural Malawi, South Africa and United Republic of Tanzania, 2013–2016
Jones H; Wringe A; Todd J; Songo J; et al: Bulletin of the World Health Organisation 97(3) 200–212, 2019

This study assessed the adoption of World Health Organization guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus and monitored implementation of the guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania. The authors summarized national PMTCT policies and World Health Organization guidance for 15 indicators across the cascades of maternal and infant care over 2013–2016. Two survey rounds were conducted in 46 health facilities serving five health and demographic surveillance system populations. Structured questionnaires were administered to facility managers to describe service delivery. In all countries, national policies influencing the maternal and infant prevention of mother-to-child transmission cascade of care aligned with World Health Organization guidelines by 2016; most inter-country policy variations concerned linkage to routine human immunodeficiency virus care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy initiation, antenatal care and antiretroviral therapy provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock-outs of human immunodeficiency virus test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds. Progress has been made in implementing prevention of mother-to-child transmission policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant human immunodeficiency virus elimination goals.

Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis of HIV-treatment outcomes in Kenya, 2003-2013
Achwoka D; Waruru A; Chen T; Masamaro K; et al: Biological Medical Central Public Health 19(372) 1-10, 2019

This paper sought to estimate the burden of noncommunicable diseases (NCDs) among people living with HIV (PLHIV) enrolled in HIV care and treatment in Kenya between 2003 and 2013. The authors conducted a nationally representative retrospective medical chart review of HIV-infected adults aged ≥15 years enrolled in HIV care in Kenya from October 1, 2003 through September 30, 2013. The authors estimated proportions of four NCDs categories among PLHIV at enrolment into HIV care, and during subsequent HIV care visits from 3170 records of PLHIV, 2115 of whom were women and just over half from PLHIVs aged above 35 years. Close to two-thirds of PLHIVs were on ART. The proportion of any documented NCD among PLHIV was 11.5%, with elevated blood pressure as the most common NCD. Despite this observation, only 17 patients had a corresponding documented diagnosis of hypertension in their medical record. Overall NCD incidence rates for men and women were and 31.6%, slightly more in men than in women but with no differences in NCD incidence rates by marital or employment status. At one year of follow up 43.8% of PLHIV not on ART had been diagnosed with an NCD compared to 3.7% of patients on ART; at five years the proportions with a diagnosed NCD were 88.8 and 39.2%, respectively. PLHIV in Kenya are thus noted to have a high prevalence of NCD, but in the absence of systematic, effective screening, the NCD burden is likely to be underestimated in this population. The authors recommend that systematic screening and treatment for NCDs using standard guidelines be integrated into HIV care and treatment programs in sub-Saharan Africa.

12. Governance and participation in health

A panel discussion how to base country health priorities on the Sustainable Development Goals. Zambia and other country cases.
Byskov J; Zulu J; Silumbwe A; et al: Summary of presentation in International Conference on Priorities in Health, Linköping, September 2018

The ever increasing evidence and technical developments supporting population health have not yet reached the goal of health for all. The decision making for population health has not led to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. This presentation discusses Zambia as a case study country, finding that national governance results in policy based choices are not necessarily helpful at implementation and community levels. The authors present evidence that if one comprehensively addresses a particular disease burden it does decrease, but limits other action. The Sustainable Development goals included democratic cross sector processes in their formulation, but the targets applied in health still tend to receive funding from competing sectors and programs.

Climate change adaptation in South Africa: a case study on the role of the health sector
Chersich M; Wright C: Globalisation and Health 15(22), doi: https://doi.org/10.1186/s12992-019-0466-x, 2019

In this systematic review the authors assessed progress with climate change adaptation in the health sector in South Africa, providing useful lessons for other African countries. Very few of the studies found presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country’s preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers. Overall, the authors note that the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. They suggest that more effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as a health issue, one necessitating an urgent, adequately-resourced response.

13. Monitoring equity and research policy

Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems
Edwards A; Zweigenthal V; Olivier J: Health Research Policy and Systems 17(16) 1-14, 2019

This paper provides a systematic overview of the literature on knowledge translation strategies employed by health system researchers and policy-makers in African countries. An evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of knowledge translation strategies, outcomes, facilitators and barriers.The knowledge translation literature in African countries is found to be widely distributed, problematically diverse and growing. Significant disparities exist between reports on knowledge translation in different countries, and there are many settings without published evidence of local knowledge translation characteristics. Commonly reported knowledge translation strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct knowledge translation activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited knowledge translation outcomes reflect persisting difficulties in outcome identification and reporting.

Repositioning Africa in global knowledge production
Fonn S; Ayiro L; Cotton P; Habib et al: The Lancet 392(10153), 1163-1166, 2018

Sub-Saharan Africa accounts for 13·5% of the global population but less than 1% of global research output. In 2008, Africa produced 27 000 published papers—the same number as The Netherlands. Informed by a nuanced understanding of the causes of the current scenario, the authors propose action that should be taken by African universities, governments, and development partners to foster the development of research-active universities on the continent. Since the 1990s, African universities have sought to regain their role as agents of transformation. On a per capita basis, African universities remain severely underfunded in view of increasing enrolment, the establishment of new universities, and the declining purchasing power of African currencies. Part of the explanation is that Africa contributes less than 1% of the global expenditure on research and development. By comparison, Latin America and the Caribbean account for 3%; Europe for 27%; Asia for 31%, and North America for 37%. Sub-Saharan Africa depends greatly on international collaboration and visiting academics for its research output. In 2012, southern Africa, east Africa, and west and central Africa produced 79%, 70%, and 45% of all their research output, respectively, through international collaborations. African Education ministers have met several times recently to address challenges in higher education. The authors argue that research-intensive universities across sub-Saharan Africa need to be identified, recognised, strengthened, and invested in through new sources of funding. Creating and maintaining research-intensive universities will require consistent investment in human capital, research equipment, and relevant administrative support, at far higher levels than is available under current conditions. To ensure that designated research-intensive universities do not become complacent and to allow for the entry of upcoming high-achieving universities, the authors propose on-going peer review every 3–5 years. At a minimum, the authors propose that research-intensive universities commit their own resources to research and that African governments increase their support for research in general and provide targeted funding for research-intensive universities—in addition to the usual operational funds and tuition income currently available to these institutions.

The future of African Studies: what we can do to keep Africa at the heart of our research
Nolte I: Journal of African Cultural Studies (Forthcoming Special Issue: Ethical Collaboration), doi: https://doi.org/10.1080/13696815.2019.1584552, 2019

Over the past two decades, Africa has returned to academic agendas outside of the continent. At the same time, the field of African Studies has come under increasing criticism for its marginalisation of African voices, interests, and agendas. This article explores how the complex transformations of the academy have contributed to a growing division of labour. Increasingly, African scholarship is associated with the production of empirical fact and socio-economic impact rather than theory, with ostensibly local rather than international publication, and with other forms of disadvantage that undermine respectful exchange and engagement. This article suggests ways of understanding and engaging with these inequalities.

14. Useful Resources

New app takes African short stories to the world
NGO pulse, Sangonet, March 2019

Anew local app hopes to give African writers global exposure by connecting them with literature fanatics in SA, US and the UK. Storytelling app BookBeak says it is the first African app-based platform to aggregate African short stories from published, unpublished and self-published writers and serve them to a global audience. The app, available on Android and iOS app stores, was founded by three young South Africans, Kamo Sesing, Cam Naidoo and Louis Enslin, and registered under their business Atheneum. Africans have been telling stories for centuries, passing nuggets of cultural knowledge and heritage from one generation to the next through fables, folktales and narrations. BookBeak aims to make it possible for those new and old African stories to be shared with the world in the form of e-books and audio books, while bridging the gap between traditional and digital reading experiences.

15. Jobs and Announcements

East, Central and Southern Africa Health Community Best Practices Forum Conference: ‘Theme: Innovation and Accountability in Health Towards achieving Universal Health Coverage’
19-21 June 2019, Arusha, Tanzania, Deadline for submission of abstracts: 3rd May 2019

The East, Central and Southern Africa Health Community (ECSA-HC) is an inter- governmental organisation, which was established to foster regional cooperation to address priority health problems, in order to attain the highest possible standards of health for the people of the region. In pursuit of its mandate, ECSA-HC facilitates the convening of regional meetings namely; the Best Practices Forum (BPF) and the Directors Joint Consultative Committee (DJCC). The aim of the BPF and DJCC meetings is to share best practices and research evidence, identify relevant health policy issues and making recommendations to the Health Ministers Conference, towards the improvement of health programming and outcomes in the region. The upcoming conference will provide a forum for health scientists, policy makers, development partners and other stakeholders in health, food and water and sanitation for health to present their best practices and research evidence that inform policies and programming in the ECSA region. The Conference will be organised in two parts as follows; The Regional Forum on Best Practices from 19 to 20 June 2019 and the Directors Joint Consultative Committee from 21 June 2019. The theme for the 12th BPF is Innovation and Accountability in Health Towards achieving Universal Health Coverage. The theme will be addressed through the following sub-themes: Efforts to improve adolescent and young people’s health; Opportunities for achieving water and sanitation health global target; Equity and access to eye healthcare in the ECSA region; Innovative approaches towards achieving food safety and improving quality of life; Prioritising substance use and mental health challenges in the ECSA Region; Tackling emerging and re-emerging health threats: A regional One Health approach to managing recurrent outbreaks in the region. ECSA-HC invites submission of abstracts for best practices and scientific papers that are relevant to the conference theme or sub themes.

Public Health Association of South Africa (PHASA) Conference 2019
16-18 September 2019, College of Cape Town, Athlone, Cape Town, South Africa

The 2019 Public Health Association of South Africa conference reflects on the intersections between democracy and health, and the progressive realisation of health care in South Africa. This year’s conference will focus on the status of health care since independence in South Africa and what can be done to move the country closer to achieving the targets of the National Development Plan, achieving equity within universal health coverage and the global Sustainable Developmental Goals by 2030. Through this Conference and its other activities, the Association is working to increase recognition of the importance of maintaining and improving the health of populations by 2030 that is based on the principles of social justice, human rights, equity, evidence-informed policy and practice, and addressing the underlying determinants of health.

South African Health Review (SAHR) 2019 Emerging Public Health Practitioner Award
Deadline for Applications: 31 July 2019

This call invites practitioners to submit a completed manuscript to the South African Health Review (SAHR) to apply for the 2019 Emerging Public Health Practitioner Award. The successful candidate will have their paper published in the 2019 edition of the SAHR. The winner will also receive a cash prize and access to wider networks of practising public health practitioners and researchers in the field. Preference will be given to papers that take cognisance of the World Health Organisation’s six building blocks for an effective, efficient and equitable health system. The SAHR aims 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. To be eligible for the award, the applicant must be a South African citizen or permanent resident, with a valid South African ID number, currently registered for a Master’s degree in health sciences/medicine or public health at a South African tertiary institution. The applicant must be the sole author of the paper. Any other contributions may only be recognised as acknowledgements. Entries will be assessed by a panel of public health experts. The official prize-giving ceremony will take place at the launch of the 22nd edition of the SAHR.

The Mandela Institute for Development Studies: Diamond Empowerment Fund Scholarship
Deadline for applications: Friday, 31 May, 2019

The Mandela Institute for Development Studies has partnered with the Diamond Empowerment Fund to establish the first in a series of Diamond Empowerment Fund Scholarships. The Fund was inspired by Nelson Mandela who encouraged Diamond Empowerment Fund’s co-founders to tell the world the positive impact Africa’s diamonds were having in building healthy and educated communities on the continent. The Mandela Institute for Development Studies, Diamond Empowerment Fund Scholarship will be earmarked for students from a diamond producing country whose chosen post-graduate study will be in a field that meets the needs for improving the quality of life for Africans. Preference will be given to students who want to gain critical skills in short supply on the continent. Applications are invited from qualifying students in eligible countries, namely Angola, Botswana, Central African Republic, Democratic Republic of Congo, Lesotho, Liberia, Namibia, Sierra Leone, South Africa, Tanzania and Zimbabwe.


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