EQUINET NEWSLETTER 219 : 01 June 2019

1. Editorial

Health must not remain a privilege of the powerful alone
Professor Asha George, Chair, Health System Global Board and University Western Cape

Forty years on from the Alma Ata declaration, those who are the most vulnerable are still the least likely to access quality healthcare and to live healthy lives. Research is critical for understanding and addressing the systems of power that undermine health and health equity. Leaders must invest in more inclusive, introspective and innovative research partnerships to strengthen robust, resilient and responsive health systems to achieve ‘health for all’.

At the 2018 Fifth Global Symposium for Health Systems Research in Liverpool, UK, delegates made a strong plea for action to address the ‘power and privilege’ that continues to undermine global health. In supporting health systems as a key foundation for ensuring the health and wellbeing of citizens and communities world over, this call was repeated to those participating in the 2018Global Conference for Primary Healthcare in Astana, Kazakhstan. The call for Astana to renew and build upon a promise made forty years ago in Alma Ata, Kazakhstan to achieve ‘health for all’ was a reminder for us to reflect on how far we have come, but also how far we have to go.

While the ambition remains as noble and important as it was in 1978, we are living in a completely different world with unprecedented challenges, with pollution, militarisation, unregulated commercial interests, polarising ideologies, pandemics and ageing populations, to name a few. These challenges are marked by increasing and intersecting inequalities, within countries and between them. We know that the impact of these political threats and social inequities affect those at the bottom of the ladder, if they are on the ladder at all.

At the same time, social voice and leverage, including social media initiatives like #MeToo, #TimesUp, and #PeriodPoverty, independent journalism, progressive legislative action and everyday activism by citizens and communities do hold those in positions of power to account. Citizen voice and community participation, a hallmark of Alma Ata, merits further consideration, scrutiny and support. They remain essential for mobilising the broader awareness, engagement and political commitment needed for domestic policies to materialize universal principles and goals, including human rights, gender equality, global solidarity, universal health coverage and the sustainable development goals.

We have had many recent historical markers raising the profile of health equity, including the birth of the UK National Health Service (NHS), the Alma Ata declaration for primary health care and the Commission for Social Determinants of Health. But, what does that mean in real terms if we do not learn, or change the power structures that continue to undermine health and equity?

As raised at the 2018 Global Symposium on Health Systems Research, the causes of bad (and good) health are multiple, and go beyond the health sector, so must we. Just as people’s lives and needs cannot be neatly divided into categories to match government structures or professional disciplines, our research, policy and practice needs to transcend these boundaries. Supporting effective multi-sectoral action for health needs not just greater technical understanding, but also research on how best to facilitate, monitor and govern multi-sectoral action inclusive of actors for whom health is not a shared starting point.

Engaging communities in policy, practice and research is essential. While recognizing the importance of community health worker programs, further understanding of the diverse actors that make up community ecosystems and who broker social change is needed through context specific, nationally embedded research. Greater understanding of the multiple social networks and power relations within and outside of communities is needed to ensure equitable partnerships to sustain the social changes that underpin effective health interventions.

Advances in commercial products, services, technologies, and business models have generated diverse forms of service provision, expanding the influence of the private sector. These advances have created novel opportunities to expand the reach of the health system, as well as challenges due to the misalignment with commercial interests. We need to invest more in learning how to strengthen various government capacities to effectively steer these opportunities and ensure that vigilance and a healthy critique about private sector engagement remains.

While some benefit from improvements in quality, affordable healthcare, healthy environments, and economic opportunities, others remain marginalized without adequate access or voice. We must continue to include and reach the most marginalized, move beyond polarising social identities, to build social solidarity that address systems and structures of power, otherwise we will be having this same conversation in another forty years. Research must not only continue to identify who is left behind and why, but also support understanding of how best to change that.

We often talk about power and privilege in terms of ‘the other’ or ‘them’ over there in another space. But in all senses we must look inward and reflect on our own position if we are to truly address the pervasive inequities that continue to shape our society and health. This is no truer than in the field of health policy and systems research. Health policy and systems research is more inclusive of marginalized voices than ever, but certain vulnerable populations, geo-political configurations and planetary concerns remain under-represented. The assessment of power, privilege and positionality remains central to our work in health policy and systems research, and so it be must elsewhere if we are to realize health for all.

This oped is updated from a blog that first appeared on the Health System Global site in October 2018 at https://tinyurl.com/y4aoz54g. and builds on discussions held at the Global Symposium on Health Systems Research in October 2018. Asha George is supported by the South African Research Chair's Initiative of the Department of Science and Technology and National Research Foundation of South Africa (Grant No 82769). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author and the NRF does not accept any liability in this regard.

2. Latest Equinet Updates

Health Literacy training and processes in the Mining Sector
EQUINET: Regional meeting, Harare and follow up work, March 2019

From 2016, co-ordinated by Training and Research Support Centre (TARSC), EQUINET has implemented research and policy engagement on extractive industries / mining and health in east and southern Africa (ESA), working with regional partners in East Central and Southern Africa Health Community, the Southern African Trade Union Co-ordinating Council, SADC Council of NGOs, the Alternative Mining Indaba ad others. The work and knowledge shared contributed to the development of a Mining and Health Literacy Module, to provide information and support discussion on advancing public health and implementing the right to health in the mining sector in the ESA region. In March 2019, against this background, TARSC in EQUINET organised a regional meeting on health literacy in the mining sector in Harare, Zimbabwe from 28-29 March 2019 for organisations that had been actively involved in planning and leading work on health in mining to date. The meeting involved delegates from Botswana Federation of Trade Unions, Benchmarks Foundation, Swaziland Migrant Mineworkers Association, Southern African Trade Union co-ordinating conference, Botswana Labour Migrants Association, Zimbabwe Congress of Trade Unions, National Mineworkers Union of Zimbabwe, Southern and East African Trade Information and negotiations Institute and TARSC. The meeting discussed health literacy outreach for workers, communities and ex mineworkers in the mining sector; shared information on the scope of and groups covered in current mining and health capacity building programmes and reviewed the methods for and use of the EQUINET health literacy module on Mining and health. Delegates planned collectively subsequent follow up training activities on mining and health, and discussed co-operation on upcoming regional processes on health in mining. The group agreed to continue to work together as a ‘Mining and Health’ Working group to take follow up work forward, with each contributing inputs related to their work. A health literacy training of trainers workshop on mining and health will be held in follow and those interested should please contact EQUINET using the feedback form at the website shown.

3. Equity in Health

Building a tuberculosis-free world: The Lancet Commission on tuberculosis
Reid M; Arinaminpathy N; Bloom A; Bloom B; et al: The Lancet Commissions 393(1017b, p1331-1384, 2019

Tuberculosis can be treated, prevented, and cured. Rapid, sustained declines in tuberculosis deaths in many countries during the past 50 years provide compelling evidence that ending the pandemic is feasible. Yet this disease—which has plagued humanity since before recorded history and has killed hundreds of millions of people over the past two centuries—remains a relentless scourge. In 2017, 1.6 million people died from tuberculosis, including 300 000 people with HIV, representing more deaths than any other infectious disease. Moreover, in many parts of the world, drug-resistant forms of tuberculosis threaten struggling control efforts. The world can no longer ignore the enormous pall cast by the tuberculosis epidemic. Going forward, the global tuberculosis response must be an inclusive, comprehensive response within the broader sustainable development agenda. No one-size-fits-all approach can succeed.

Ebola situation worsening while support lags
World Health Organisation: Statement from High-Level Mission to Butembo, DRC, WHO, 2019

WHO Director-General Dr Tedros Adhanom Ghebreyesus and WHO Regional Director for Africa, Dr Matshidiso Moeti, visited Butembo, in the Democratic Republic of the Congo. It was in Butembo on 19 April that WHO epidemiologist Dr Richard Mouzoko was killed by armed men while he and colleagues were working on the Ebola response. Dr Tedros and Dr Moeti traveled to Butembo to express their gratitude and show support to WHO and partner organization staff, while also assessing the next steps needed to strengthen both security and the Ebola response effort. They also met with local political, business and religious leaders, and called on them to accelerate their efforts to stabilize the surrounding environment. They urged the international community to step up support to contain the Ebola outbreak, including filling the funding gap that threatens to stymie the Ebola response. Most Ebola response activities, including community engagement, vaccination, and case investigation, have been re-launched following a slowdown in the wake of the attack that left Dr. Mouzoko dead and two people injured. However, they expressed deep concern that a rise in reported cases in recent weeks is straining resources even further. Only half of the currently requested funds have been received, which could lead to WHO and partners rolling back some activities precisely when they are most needed.

4. Values, Policies and Rights

A cross-sectional mixed-methods study of sexual and reproductive health knowledge, experiences and access to services among refugee adolescent girls in the Nakivale refugee settlement, Uganda
Ivanova O; Rai M; Mlahagwa W; Tumuhairwe J; et al: Reproductive Health 16 (35) 1-11, 2019

Humanitarian crises and migration make girls and women more vulnerable to poor sexual and reproductive health (SRH) outcomes. This mixed-methods study assessed SRH experiences, knowledge and access to services of 260 refugee girls 13-19 years old in the Nakivale settlement, Uganda between March and May 2018. The majority of girls were born in DR Congo and Burundi. the findings showed weak knowledge of SRH and methods for preventing HIV and pregnancy, school days missed due to menstruation and that 30 of the 260 girls were sexually active, of which 11 had experienced forced sexual intercourse. The latter occurred during conflict, in transit or within the camp. The preferred sources for SRH information was parents or guardians, although participants expressed that they were afraid or shy to discuss other sexuality topics apart from menstruation with parents. Only 30% of the female adolescents had ever visited a SRH service centre, mostly to test for HIV and to seek medical aid for menstrual problems. The authors found that adolescent refugee girls lack adequate SRH information, experience poor SRH outcomes including school absence due to menstruation, sexual violence and FGM and recommend comprehensive SRH services including sexuality education, barrier-free access to SRH services and parental involvement for refugee communities.

How can we achieve UHC in Africa by 2030?: Reflection on Africa Health Agenda International Conference (AHAIC) 2019
Saha S; Kavattur P; Goheer A: Health Systems Global blog, April 2019

Health should not be like playing the lottery - but that is what it has become in Africa. If you’re born rich you win, if you are born poor, you lose.’ This statement was made by Dr Githinji Gitahi, Group CEO of Amref Health Africa at the opening ceremony of the Africa Health Agenda International Conference (AHAIC) which took place in Kigali, Rwanda in March 2019. The conference was focused on Multi-Sectoral Action to achieve Universal Health Coverage (UHC) in Africa by 2030. The conference delegates observed that technology and data are needed to achieve UHC but that most of the technology available is focused on secondary and tertiary sectors and on curative care, rather than at community level. There is also need for regulation of new generation actors that are technology-focused. The authors propose that cross-regional dialogue and knowledge sharing is needed where countries can learn from each other, avoiding traditional silos and engaging multi-stakeholder and multi-sectoral partnerships and shifting the paradigm from a view of health as an investment rather than an expenditure.

5. Health equity in economic and trade policies

Climate costs South Africa 10% of its GDP
Kings S: Mail and Guardian, South Africa, April 2019

Research suggests that poor countries in the south would have 24% larger economies if it wasn’t for global warming. This is because the world is 1°C hotter than it was a century ago. That warming means crops fail, economic productivity goes down and people get sick or die because of the heat. South Africa is argued to be between 10% and 20% poorer than it would have been without that warming in the last six decades. Nigeria is 29% poorer and India is 30% poorer. The research, titled “Global warming has increased global inequality' reports that rich countries have benefited from this warming. By calculating temperature and economic growth between 1961 and 2010, the researchers found that already rich countries, mostly in colder climates, have growth spurts during an unusually hot year. This is because hotter weather moves them closer to what is known as the “empirical optimum” — the closer a country’s average temperature is to 13°C, the more its economy thrives. South Africa’s average is around 17°C and is only increasing with global warming. The researchers concluded that global warming has meant countries are also more unequal. Richer people can insulate themselves from extreme events — by buying food when the price goes up or by being able to claim from insurance — and keep functioning. Those with few resources to start with do not have such a buffer. This local and global inequality in the impact of global warming is the topic of fierce international negotiation. While China and India are massively growing their emissions, the authors note that they still represent a fraction of total emissions in the last two centuries, with China has emitted half of what the United States has and India a seventh.

6. Poverty and health

Factors influencing men’s involvement in antenatal care services: a cross-sectional study in a low resource setting, Central Tanzania
Gibore N; Bali T; Kibusi S: Reproductive Health 16(52)1-10, 2019

In this paper the authors sought to determine the level of men’s involvement in antenatal care and the factors influencing their involvement in these services. A cross sectional study of 966 randomly selected men aged 18 years or older was conducted in Dodoma Region, from June 2014 to November 2015. Face to face interviews were conducted using a pretested structured questionnaire. The level of men’s involvement in antenatal care was high and 89% of respondents made joint decisions on seeking antenatal care. More than half of respondents accompanied their partners to the antenatal clinic at least once. Less than a quarter of men were able to discuss issues related to pregnancy with their partner’s health care providers, although 77% of respondents provided physical support to their partners during the antenatal period. Factors influencing men’s involvement in antenatal care were occupation, ethnicity, religion, waiting time, information regarding men’s involvement in antenatal care and men’s perception about the attitude of health care providers. Overall, more than half of respondents reported high involvement in antenatal care services. Access to information on men’s involvement, religion, occupation, ethnicity, waiting time and men’s perception about the attitude of care providers were significant factors influencing men’s involvement in antenatal care services in this study. The authors observe that health promotion is needed to empower men with essential information for meaningful involvement in antenatal care services.

7. Equitable health services

Are foreigners stealing your jobs and healthcare? Find out
Heleta S: NGO pulse, Sangonet, April 2019

Clinic and hospitals in the public sector in South Africa are stretched, but the author argues that this is not because of immigrants as is being proposed in some quarters, but because of understaffing, poor planning and other problems. A 2018 World Bank study showed that between 1996 and 2011, every immigrant worker generated two jobs for South Africans, mostly because their diverse skill sets led to productivity gains and multiplier effects. Immigrants also contribute to the national fiscus through payment of VAT and purchase goods and services, such as rent, from South Africans. The author calls for xenophobic blaming of foreigners to be resisted and for South Africans to see this for what it is: scapegoating of immigrants to hide domestic failures

Knowledge, attitudes and practices of cervical cancer prevention among Zambian women and men
Nyambe A; Kampen J; Baboo S; Van Hal G: BMC Public Health 19(508)1-15, 2019

This paper addresses the relationship between knowledge about cervical cancer, attitudes, self-reported behavior, and immediate support system, towards screening and vaccination of cervical cancer of Zambian women and men, as a basis for improving and adjusting existing prevention programs. A cross-sectional mixed methods study was conducted with women and men residing in Chilenje and Kanyama, Zambia. Less than half of the respondents had heard of cervical cancer, 20.7% of women had attended screening and 6.7% of the total sample had vaccinated their daughter. Knowledge of causes and prevention was very low. There was a strong association between having awareness of cervical cancer and practicing screening and vaccination. Social interactions were also found to greatly influence screening and vaccination behaviors. The low level of knowledge of causes and prevention of cervical cancer suggests a need to increase knowledge and awareness among both women and men. The authors note that interpersonal interactions have great impact on practicing prevention behaviors.

Maternal overweight and obesity and the risk of caesarean birth in Malawi
Nkoka O; Ntenda P; Senghore T; Bass P: Reproductive Health 16(40) 1-10, 2019

This paper investigated the association between maternal overweight and obesity and caesarean births in Malawi. The authors utilised cross-sectional population-based Demographic Health Surveys data collected from mothers aged 18–49 years in 2004/05, 2010, and 2015/16 in Malawi. The results showed that maternal overweight in 2015/16 and from 2004 to 2015 were risk factors for caesarean births in Malawi. Women who had one parity, and lived in the northern region were significantly more likely to have undergone caesarean birth. In order to reduce non-elective caesarean birth in Malawi, the authors propose that public health programs focus on reducing overweight and obesity among women of reproductive age.

Sociodemographic inequities in cervical cancer screening, treatment and care amongst women aged at least 25 years: evidence from surveys in Harare, Zimbabwe
Tapera O; Kadzatsa W; Nyakabau A; Mavhu W; et al: BMC Public Health 19(428)1-12, 2019

This paper investigated socio-demographic inequities in cervical cancer screening and utilization of treatment among women in Harare, Zimbabwe. Two cross sectional surveys were conducted in Harare with a total sample of 277 women aged at least 25 years from high, medium, low density suburbs and rural areas. Only 29% of women reported ever screening for cervical cancer. Cervical cancer screening was less likely in women affiliated to major religions and those who never visited health facilities or doctors or visited once in previous 6 months. Ninety-two of selected patients were on treatment. Women with cervical cancer affiliated to protestant churches were 68 times more likely to utilize treatment and care services compared to those in other religions. Province of residence, education, occupation, marital status, income, wealth, medical aid status, having a regular doctor, frequency of visiting health facilities, sources of cervical cancer information and knowledge of treatability of cervical cancer were not associated with cervical cancer screening and treatment respectively. The authors recommend strengthening health education in communities, including in churches, to improve uptake of screening and treatment of cervical cancer.

8. Human Resources

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa
Orgill M; Gilson L; Chitha W; Michel J; et al: International Journal for Equity in Health 18(53) 1-15, 2019

The research paper explored, from a bottom up perspective, how efforts by the South African government to disseminate and diffuse innovations were experienced by district level senior managers and why some efforts were more enabling than others. Managers valued the national Minister of Health’s role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on the benefits of new innovations, total funding they will receive, their specific role in implementation and the range of stakeholders involved. The authors proposed that those driving reform processes from the top remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts should be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the frontline and national policies, managing long chains of dissemination and natural diffusion.

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; Wilso I; et al: Journal of the International Association of Providers of AIDS Care 18, 1-10, 2019

This study examined the experiences of HIV care providers in a high patient volume HIV treatment and care program in Western Kenya 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 study revealed that health system strengthening must include efforts to improve the working environment for providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.

9. Public-Private Mix

Investing in health R&D: where we are, what limits us, and how to make progress in Africa
Simpkin V; Namubiru-Mwaura E; Clarke L; et al: BMJ Global Health 4(2), doi: http://dx.doi.org/10.1136/bmjgh-2018-001047, 2019

Global research and development (R&D) pipelines for diseases that disproportionately affect African countries appear to be inadequate, with governments struggling to prioritise investment in R&D. This article provides insights into the sources of investment in health science research, available research capacity and level of research output in Africa. Africa has 15% of the world’s population, yet only accounted for 1.1% of global investments in R&D in 2016. There were substantial disparities within the continent, with Egypt, Nigeria and South Africa contributing 65.7% of the total R&D spending. In most countries of the Organisation for Economic Co-operation and Development, the largest source of R&D funding is the private sector. R&D in Africa is mainly funded by the public sector, with significant proportions of financing in many countries coming from international funding. Challenges that limit private sector investment include unstable political environments and poor governance practices. Evidence suggests various research output and research capacity limitations in Africa in terms of university rankings, number of researchers, number of publications, clinical trials networks and pharmaceutical manufacturing capacity and substantial regional disparities within the continent. The authors propose that incentivising investment is crucial to foster current and future research output and research capacity. This paper outlines some of the initiatives under way for this, including through innovative and collaborative financing mechanisms that stimulate further investment.

10. Resource allocation and health financing

Hundreds march in Cape Town for National Health Insurance
Gonstana M-A: GroundUp, April 2019

Hundreds of people marched through Cape Town to Parliament in April to demand that government implement the National Health Insurance (NHI) system, including members of Sonke Gender Justice; Movement for Change and Social Justice (MCSJ) and the People’s Health Movement South Africa. They sang and danced holding banners and placards. MCSJ founder Mandla Majola, described the NHI as the “first step to better our public healthcare system”. He said the NHI was a fund that would ensure the implementation of proper healthcare for all and would bridge the gap between private and public sectors. Before the march, the MCSJ identified ten private hospitals and sent a small group of people to each hospital to picket outside to try and get help for one member in each group who was struggling to get help at a public clinic. In a memorandum, addressed to Minister of Health Aaron Motsoaledi, the MCSJ highlights structural problems in public clinics and hospitals, such as overcrowding and bed shortages; understaffing and maladministration, such as the disappearance of patient folders and staff shortages; the rural and urban divide, such as the long commutes to and from facilities; and the disparities between private and public sectors, such as drug shortages and long queues. The marchers demanded that NHI be implemented rapidly and adequately; that national government widen the awareness of NHI through initiatives like road shows and campaigns and that there be transparency in the NHI process.

The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis
Cambiano V; Johnson C; Hatzold K; Terris-Prestholt F; et al: Journal of the International AIDS Society 22(51), doi: https://doi.org/10.1002/jia2.25243, 2019

This study assessed the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa, using a synthesis model. In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision. However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to women having transactional sex was the most cost-effective. To maximize population health within a fixed budget, the authors argue that CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality.

11. Equity and HIV/AIDS

Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study
Sanga E; Mukumbang F; Mushi A; Lerebo W; et al: Biological Medical Central Public Health 19(383), 1-15, 2019

This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform the design of interventions to improve linkages to HIV care. The authors conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region Tanzania between August 2014 and July 2015. The authors identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual’s level. At providers’ level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centres were important contextual factors influencing linkage to care. The authors argue that interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care.

12. Governance and participation in health

G20-Africa engagement: Finding a roadmap to shared development
van Staden C; Sidiropoulos E: South African Institute of International Affairs (SAIIA) Occasional Paper No 294, 2019

The G20 plays an important role in global rule-making. Africa is significantly under-represented in this body, with only South Africa a permanent member. This makes Africa a rule-taker. At the same time the G20 has started to pay more attention to Africa and the continent’s future development now occupies a somewhat more central position on the grouping’s agenda. The G20 Initiative on Supporting Industrialization in Africa and Least Developed Countries, launched under China’s G20 presidency of 2016, and the 2017 German presidency’s Compact with Africa offered unprecedented moments of engagement. However, the question remains how Africa can use these initiatives to deepen its engagement with the G20 and boost its own development. This paper draws on extensive interviews with key stakeholders to analyse G20–Africa engagement by focusing on three presidencies: China in 2016, Germany in 2017, and Argentina in 2018. It shows how China’s Industrialisation Initiative was crucially informed by its pre-existing African engagement, while Germany’s Compact with Africa both gained and suffered from a more narrowly focused commercial engagement. It then shows how Argentina, despite lacking a similar African initiative, managed to continue G20–Africa engagement through person-to-person diplomacy. The paper points out both the benefits and the limits of these engagements and suggests a series of further initiatives that could allow Africa a more significant say in the G20.

The C-Word: Tackling the enduring legacy of colonialism in global health
Saha S; Kavattur P; Goheer A: Health Systems Global blog, April 2019

The authors write that definitions of “global health” are generally depoliticized and invoke trans-national health issues and collaboration. Yet they argue that global health is only the newest iteration of what was formerly “international health”, “tropical medicine” and “colonial medicine”, with historical roots lie in colonial endeavours and imperial interests. They report a widespread frustration with how global health is taught in universities in ways that create and perpetuate neo-colonial relations; and a desire for alternative conceptualizations of the “global” that fundamentally tackle structures of power. The authors observe in the paper the various issues that need to be tackled if there is an intent to 'decolonise' global health, commenting that it is not a one-day event or a checkbox. It is a process that leads to futures that are unknown, but that one should dare to imagine.

13. Monitoring equity and research policy

Setting the global research agenda for community health systems: literature and consultative review
Agarwal S; Kirk K; Sripad P; Bellows B; et al: Human Resources for Health 17(22), doi: https://doi.org/10.1186/s12960-019-0362-8, 2019

Globally, there is renewed interest in and momentum for strengthening community health systems. Recent reviews have identified factors critical to successful community health worker (CHW) programs but pointed to significant evidence gaps. This systematic review identifies areas for a global research agenda to strengthen CHW programs. Research gap areas that were identified in the literature and validated through expert consultation include selection and training of CHWs and community embeddedness, institutionalisation of CHW programs (referrals, supervision, and supply chain), CHW needs including incentives and remuneration, governance and sustainability of CHW programs, performance and quality of care, and cost-effectiveness of CHW programs. Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time. As international interest and investment in CHW programs and community health systems continue to grow, the authors propose that it becomes critical not only to analyse the evidence that exists, but also to clearly define research questions and collect additional evidence to ensure that CHW programs are effective, efficient, equity promoting, and evidence based.

When ethics and politics collide in donor-funded global health research
Storeng K; Palmer J: The Lancet, doi: https://doi.org/10.1016/S0140-6736(19)30429-5, 2019

In this paper, the authors share their experience of censorship in evaluation research for global health. Their experience shows a broader trend of external funders and implementing partners who deliberately use ethical and methodological arguments to undermine essential research. In a context of chronic underfunding of universities and their growing dependence on externally-driven research grants, the authors propose several structural and cultural changes to prevent manipulation of research governance systems and to safeguard the independence of research. While they acknowledge censorship to be a strong word, they justify its use in situations found where researchers in commissioned research-based evaluations are asked by funders to omit important results from their final report. The authors note that universities' provide methodological and subject area expertise and strong systems of research ethics and governance, but also observe that current systems are ill equipped to deal with these challenges.

14. Useful Resources

WHO Watch
Peoples Health Movement, 2019

PHM follows closely the work of WHO, both through the World Health Assembly and the Executive Board. A team of PHM volunteers attends WHO bodies’ meetings – following the debate, talking with delegates and making statements to the EB. The PHM’s commentaries covers most of the agenda items of the WHO bodies’ meetings and includes a note on the key issues in focus at the meeting, a brief background and critical commentary. Reports on key issues are also prepared. PHM is part of a wider network of organizations committed to democratizing global health governance and working through the WHO-Watch project. Information from PHM on the proceedings of the May 2019 World Health Assembly can be found at the website provided.

World Health Organisation (WHO) Guideline Recommendations on digital interventions for health system strengthening
World Health Organisation: WHO, Geneva, 2019

Digital health, or the use of digital technologies for health, has become a salient field of practice for employing routine and innovative forms of information and communications technology (ICT) to address health needs. The World Health Assembly Resolution on Digital Health unanimously approved by WHO Member States in May 2018 demonstrated a collective recognition of the value of digital technologies to contribute to advancing universal health coverage (UHC) and other health aims of the Sustainable Development Goals (SDGs). This guideline presents recommendations on emerging digital health interventions that are contributing to health system improvements, based on an assessment of the benefits, harms, acceptability, feasibility, resource use and equity considerations. This guideline urges readers to recognize that digital health interventions are not a substitute for functioning health systems, and that there are significant limitations to what digital health is able to address. It presents a subset of prioritized digital health interventions accessible via mobile devices, and will gradually include a broader set of emerging digital health interventions in subsequent versions. It includes the following topics: birth notification via mobile devices; death notification via mobile devices; stock notification and commodity management via mobile devices; client1-to-provider telemedicine; provider-to-provider telemedicine; targeted client communication via mobile devices; digital tracking of patients’/clients’ health status and services via mobile devices; health worker decision support via mobile devices; provision of training and educational content to health workers via mobile devices (mobile learning-mLearning).

15. Jobs and Announcements

72nd session of the World Health Assembly
20-28 May 2019, Geneva

The World Health Assembly is the decision-making body of WHO. It is attended by delegations from all WHO Member States and focuses on a specific health agenda prepared by the Executive Board. Background reports, daily information can be found at the website shown.

Accelerating universal health coverage: a call for papers
Deadline for submissions: 15 June 2019

In 2020, the world will still have a decade to harness global momentum and advance progress towards UHC by 2030. A special issue of the Bulletin of the World Health Organization will focus on the theme of accelerating progress towards UHC to encourage learning and information sharing on this dimension of the Sustainable Development Goals (SDGs). The issue will explore policy options and country experiences on how to expand population coverage, service coverage and financial protection. Manuscripts that capture knowledge and experience in addressing bottlenecks and root causes of stagnation that hamper successful UHC advancement are welcomed. Analysis of breakthroughs in health systems that have been conducive to rapid expansion of coverage are also encouraged. Papers should focus on, for example, implementation science in health systems, innovative health financing, strategic purchasing, UHC and primary health care, the role of the private sector, policy coherence across government levels (particularly in decentralized health systems), the role of innovative technology and the design and use of health information. Best practices in good governance for health, based on transparency and accountability, would also be useful to learn how vested interests that hamper progress towards UHC are countered in different socioeconomic and political contexts. Comparative cross-country analyses are encouraged.

International Studies Association International Conference 2019: Exploring the agency of the Global South in International Studies (Practices)
1-3 August 2019, Legion Center for International Affairs & Diplomacy, University of Ghana, Accra

Representing over 100 countries, the International Studies Association (ISA) has more than 6,500 members worldwide and is the most respected and widely known scholarly association in this field. Endeavouring to create communities of scholars dedicated to international studies, the ISA is divided into 7 geographic subdivisions of ISA (Regions), 29 thematic groups (Sections) and 4 Caucuses which provide opportunities to exchange ideas and research with local colleagues and within specific subject areas. This year’s conference explores the theme of the agency of the Global South in International Studies (Practices).

PhD position in social sciences or humanities or related fields
Deadline for applications: 12 June 2019

The position is being offered in the context of the Swiss National Science Foundation (SNSF) and the French Agence Nationale de la Recherche's (ANR) co-funded project, “Self-Accomplishment and Local Moralities in East Africa” (SALMEA). The selected candidate will serve as a full member of the project and will be fully integrated into the team's activities. Possible research topics are therefore varied and may cover a wide range of issues related to violence, kinship (including family formation and identity), religion, and wealth (including land ownership) in Eastern Africa. The PhD candidate will be attached to IMAF (Institut des Mondes Africains) in Aix en Provence. Based in Paris and Aix en Provence, the institute brings together scholars with an interest in Africa who are affiliated with the CNRS, IRD, EHESS, EPHE, the University of Paris 1, and Aix Marseille University. The successful candidate will be allowed to write his/her doctoral dissertation either in French or English. He/she will be enrolled at the Aix Marseille University Doctoral School. The candidate must have obtained, or be close to obtaining, an MA or an equivalent degree in a relevant field (demography, history, geography, anthropology, political science etc.). The candidate is expected to demonstrate sufficient skills in both French and English so as to adapt quickly to the working and research environment in Aix and in East Africa. Selection will involve a two-stage process, starting with the consideration of submitted application, and followed by interviews with selected candidates on July 1st 2019.

Postgraduate training support
The Special Programme for Research and Training in Tropical Diseases, World Health Organisation

The Special Programme for Research and Training in Tropical Diseases (TDR) postgraduate training scheme provides a full academic scholarship in collaboration with universities in LMICs to train MSc students. The training is specifically focused on subjects or disciplines relevant to implementation research. Items covered by the scholarship include full time tuition and board, cost of dissertation research / field work, return air travel from home country to institution and contribution towards the purchase of essential textbooks / learning materials. Candidates must apply to institutions in their respective regions (Africa, Asia, Latin America or Middle East) to be eligible for consideration. Prospective candidates are advised to contact the institution directly for details on eligibility and academic requirements for admission. They should also familiarise themselves with the field of implementation research / implementation science which is the focus of this scheme. The participating universities are: James P Grant School of Public Health, BRAC University, Bangladesh, Universidad de Antioquia, National School of Public Health, Colombia, University of Ghana, School of Public Health, Ghana, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia, American University of Beirut, Faculty of Health Sciences, Lebanon, University of the Witwatersrand, School of Public Health, South Africa, and University of Zambia, Department of Public Health, Zambia.

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 Special Programme for Research and Training in Tropical Diseases (TDR) Global launches crowdfunding challenge to help researchers fund their own research future
Deadline for submissions: 30 June 2019

TDR Global is partnering with SESH to build capacity for crowdfunding among a group of low- and middle-income country researchers focused on infectious diseases. Crowdfunding for infectious diseases research is both a science and an art – one must have both a compelling research question and also a clear way to effectively communicate this with the public. The team will identify selected individuals and build their capacity to use crowdfunding related to infectious diseases in low- and middle-income countries(LMICs). Submissions should be less than 1200 words of text in English that describe the: scientific question and hypothesis; significance of the project; relevance to the public; personal motivation for research and personal connection to the disease and geographic location; areas for mentorship. The project has three stages. The first is an open challenge contest to solicit infectious diseases research ideas in LMICs, followed by a capacity building workshop to help individuals gain skills and hone their message. Lastly there will be a crowdfunding pilot to seek a limited amount of money (10,000 USD – 50,000 USD) for local research projects.


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