From July 2019 the EQUINET newsletter will be coming out quarterly in March, June, September and December of every year. The next issue will thus be in September 2019. After discussion in the EQUINET steering committee we will try where feasible to have a stronger thematic focus on issues, while still keeping a wide range of coverage of resources, announcements and updates and publications. As a reminder we are keen to share information on and about the region and invite you to share news, information, papers, reports, briefs, announcements and resources of different types and are happy to receive editorials from or on the region. Please submit by visiting the newsletter on the EQUINET site and selecting "submit news" on the online menu. We are also keen to get your feedback on how to improve the newsletter as a resource for you so please do submit your feedback!
1. Editorial
Global meetings and processes can seem very distant from the realities at local level, despite the fact that the policies being made in global meetings have profound influence on these local realities. The People’s Health Movement (PHM) has for several years implemented a ‘WHO watch programme’ to follow and provide information, analysis and critical commentary for people on the global health debates taking place at the World Health Organisation (WHO).
In its Global Health Watch activities, PHM follows range of WHO meetings, including the World Health Assembly (WHA) and the WHO Executive Board (EB) and at regional level in the WHO Regional Committees, such as the one for the AFRO region. The analysis that PHM does explores how far these global processes and resolutions respond to local, regional and global contexts and priorities and how far states and other relevant stakeholders’ implement, comply with and are publicly accountable for the resolutions made.
The recently ended ‘WHA72’ that took place in end May 2019 was one such global meeting.
There were many debates at the WHA72, but two merit attention. One was on improving the transparency of markets for medicines, vaccines and other health-related products and technologies. A second was on the Ebola epidemic in the Democratic Republic of Congo (DRC) and the public health emergency response. Both were critical debates for African countries. Both issues need strong intervention from states, by galvanizing comprehensive workforces and capacities for both health systems and emergency responses, to address disease burdens and respond to disease outbreaks.
After the scrutiny and criticism of its response to the Ebola epidemic in West-Africa in 2014, WHO restructured its health emergencies program in 2016 to provide a more effective response. However, the virtual freeze in member state contributions has meant that the core funding for the program has not improved. The current Ebola outbreak in the DRC thus provided an opportunity to assess how successful the measures and resources are for such emergency responses. The DRC outbreak provided a tough test: it has been termed a complex emergency due to its occurrence in a highly volatile and extremely insecure conflict zone, politicizing the epidemic and raising the challenge of dealing with an outbreak in a war zone. At the recent WHA, WHO reported that its use of vaccination strategies enabled it to achieve unprecedented survival rates. It also pointed to other factors that enabled the response and improved survival, including significant investment in planning and capacities for epidemic preparedness, sustained testing for Ebola, improved screening, vaccination of frontline healthcare-workers and training of multidisciplinary teams for a rapid response mechanism.
While this work has been a significant contribution to addressing the Ebola emergency in DRC, there are still issues to address. PHM observe that WHO should mobilise member states and other relevant-stakeholders to find ethical and valid ways of more rapidly testing interventions to combat diseases like Ebola. A rapidly spreading emergency like Ebola calls for an urgent response, including quick advice on the most effective treatments to use. The concern is that the pace of development of new vaccines, drugs and diagnostics is not meeting the pace of rapid spread of health emergencies, such as that faced in the DRC. The time consuming nature and wide population enrolment of current medicine trials doesn’t match the urgency needed for responding to such rapidly spreading epidemics. This raises debate on what flexibilities can be introduced that do not compromise the quality and safety of trials.
At the same time, there is also a more general demand for improved access to medicines. Accessing medicines would have been critical for the approximately 1.6 million Africans who died of malaria, tuberculosis and HIV-related illnesses in 2015. While many of the diseases in Africa can be prevented or treated with timely access to appropriate and affordable medicines, vaccines and other health interventions, less than two percent of medicines consumed in Africa are produced on the continent. Many people cannot access locally produced drugs and many may not afford imported medicines.
The WHA discussed a draft roadmap on access to medicines, vaccines and other health products for 2019-2023. The roadmap proposes strategies to support quality, safety, efficacy and equitable access of health-products. The strategies include strengthening regulation, assessing the quality, safety and efficacy or performance of health products, including through market surveillance and investing in research and development (R&D) that meets public health needs. The strategies also include managing intellectual property so that it contributes to innovation and promotes public health, and ensuring evidence-based selection, fair and affordable pricing, procurement and supply chain management and appropriate prescribing, dispensing and rational use of health products.
The resolution on transparency of markets for medicines, vaccines, and other health-related products and technologies adopted at this year’s WHA is a substantial stride towards improving the affordability of and access to medicines and other technologies. For example, there is currently an information gap on what different countries pay for medicines and on the actual cost of R&D and manufacture of medicines. The lack of transparency on this gives pharmaceutical corporations a significant advantage and allows them to charge extortionate prices, maximizing profit over human life.
Despite the obvious benefit of improved transparency in these issues, the resolution received mixed reactions. Germany, Hungary and the United Kingdom dissociated themselves from the resolution, using a range of procedural reasons. They claimed that the roadmap was “rushed through” and breached procedure, with inadequate consultation with all experts. The dissociation raised governance concerns. However the resolution was approved by a majority of states and will support the space for governments in Africa to negotiate medicine prices. Given the current crisis of unaffordable pricing of many medical technologies, the resolution, if implemented, will support greater public disclosure of prices of medicines and other health-related products. This information should help to reduce the prices of these products, now needed also for rising levels of chronic conditions such as cancers, hepatitis and diabetes, many of which are too costly for universal access in low and middle income countries.
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The resolution was thus welcomed by African countries. It needs to be further monitored for its implementation to assess if it achieves its purpose and goal in relation to universal health coverage (UHC). At the same time, as raised by PHM during a debate at the WHA on UHC, accessing medicines also depends on investing in comprehensive primary health care. Further, as was the original intention of Alma Ata, we need to apply human rights-based and comprehensive approaches not just to treating disease, but also to ensuring health. As we address issues of transparency and of responsiveness to emergencies, that also depends on a deeper redistribution of power and wealth.
You can read more about PHM ‘watch’ activities and findings in the Global Health Watch at https://www.ghwatch.org/wha72 . Commentaries, statements and policy briefs can be found on the WHO Tracker at https://who-track.phmovement.org/.
2. Latest Equinet Updates
EQUINET commissioned this desk review paper. It aims to contribute to a regional understanding of the positive and negative implications of the different domestic health financing options being explored, advocated and implemented in the East and Southern African (ESA) region. It presents issues to be addressed in the implementation of these financing options from the perspective of equitable progression towards universal health coverage (UHC), to inform policy dialogue and decisions on domestic health financing in ESA countries. The paper considers only one aspect of health financing reform, namely, revenue collection. It distinguishes between policy instruments, i.e., the sources of finance, and policy strategies, i.e., how these instruments are deployed to achieve various objectives or to address contextual features. Non-contributory sources (essentially tax-financed) and contributory (employment-based) options are explored. The paper presents: a. A typology of domestic revenue instruments and strategies; b. Domestic financing trends and options in place, or under consideration, in ESA countries; c. A review of low- and middle-income country experiences of domestic financing options; and d. Conclusions on the findings and lessons for ESA countries.
This brief aims to present the positive and negative implications of the different domestic revenue sources being explored, advocated and implemented in the East and Southern African (ESA) region. It presents issues to be considered in choosing between, and implementing, the different non-contributory and contributory options for revenue collection, given the policy commitments in the region to equity and universal health coverage (UHC). The brief draws information from experiences of other low and middle income countries globally, including on the fiscal, revenue, progressiveness and acceptability implications of different options. The brief highlights that revenue collection measures need to be accompanied by measures to strengthen strategic purchasing and access to equitable, effective, quality care. The full report the brief is drawn from is also being made available on the EQUINET website.
3. Equity in Health
This paper seeks to determine the prevalence of chronic respiratory diseases in urban and rural Uganda and to identify risk factors for these diseases. The population-based, cross-sectional study included adults aged 35 years or older. All participants were evaluated by spirometry according to standard guidelines and completed questionnaires on respiratory symptoms, functional status and demographic characteristics. The presence of four chronic respiratory conditions was monitored: chronic obstructive pulmonary disease, asthma, chronic bronchitis and a restrictive spirometry pattern. The age-adjusted prevalence of any chronic respiratory condition was 20.2%; the age-adjusted prevalence of chronic obstructive pulmonary disease was significantly greater in rural than urban participants, whereas asthma was significantly more prevalent in urban participants: 9.7% versus 4.4% in rural participants. The age-adjusted prevalence of chronic bronchitis was similar in rural and urban participants, as was that of a restrictive spirometry pattern. For chronic obstructive pulmonary disease, the population attributable risk was 51.5% for rural residence, 19.5% for tobacco smoking, 16.0% for a body mass index over 18.5 kg and 13.0% for a history of treatment for pulmonary tuberculosis. The prevalence of chronic respiratory disease was high in both rural and urban Uganda.
4. Values, Policies and Rights
This proposed strategy provides a vision and way forward on how the world and its health community need to respond to environmental health risks and challenges until 2030, and to ensure safe, enabling and equitable environments for health by transforming ways of living, working, producing, consuming and governing. The Health Assembly noted the report, and requested the Director-General to report back on progress at the 74th World Health Assembly in 2022. The WHO draft global strategy envisions a world in which sustainable development has eliminated the almost one quarter of the disease burden caused by unhealthy environments, through health protection and promotion, good public health standards, preventive action in relevant sectors and healthy life choices, and which manages environmental risks to health. The strategy sets six strategic objectives. Strategic objective 1 aims towards primary prevention: to scale up action on health determinants for health protection and improvement in the 2030 Agenda for Sustainable Development. Strategic objective 2 calls for cross-sectoral action to act on determinants of health in all policies and in all sectors. Strategic objective 3 concerns a strengthening health sector leadership, governance and coordination roles. Strategic objective 4 aims towards building mechanisms for governance, and political and social support. Strategic objective 5 calls for generating the evidence base on risks and solutions, and to efficiently communicate that information to guide choices and investments. Lastly, strategic objective 6 aims to guide actions by monitoring progress towards the Sustainable Development Goals.
In his address to the 72nd session of the World Health Assembly, Dr Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organisation (WHO) said that strong primary health care is the front-line in defending the right to health, including sexual and reproductive rights. According to WHO, the “triple billion” targets that are at the heart of its strategic plan for the next five years are: one billion more people benefiting from universal health coverage (UHC); one billion more people better protected from health emergencies; and one billion more people enjoying better health and well-being. Dr Tedros cited various initiatives in countries that demonstrate progress and new normative products developed by WHO that are being used globally to protect and promote health. He highlighted three priorities that must guide discussions to make advances in primary health care: health is about political leadership; health is about partnership; and health is about people.
Community participation, the central principle of the primary health care approach, is widely accepted in the governance of health systems. Health Committees (HCs) are community-based structures that can enable communities to participate in the governance of primary health care. Previous research done in the Cape Town Metropole, South Africa, reports that HCs' potential can, however, be limited by a lack of local health providers' (HPs) understanding of HC roles and functions as well as lack of engagement with HCs. This study was the first to evaluate HPs' responsiveness towards HCs following participation in an interactive rights-based training. Thirty-four HPs, from all Cape Metropole health sub-districts, participated in this qualitative training evaluation. Two training groups were observed and participants completed pre- and post-training questionnaires. Semi-structured interviews were held with 10 participants 3–4 months after training. Following training, HPs understood HCs to play an important role in the communication between the local community and HPs. HPs also perceived HCs as able to assist with and improve the quality and accessibility of PHC, as well as the answerability of services to local community needs. HPs expressed intentions to actively engage with the facility's HC and stressed the importance of setting clear roles and responsibilities for all HC members. This training evaluation reveals HPs' willingness to engage with HCs and their desire for skills to achieve this. Moreover, it confirms that HPs are crucial players for the effective functioning of HCs. This evaluation indicates that HPs' increased responsiveness to HCs following training can contribute to tackling the disconnect between service delivery and community needs. Therefore, the training of HPs on HCs potentially promotes the development of needs-responsive PHC and a people-centred health system.
More than 75% of emerging infectious diseases are zoonotic in origin and a transdisciplinary, multi-sectoral One Health approach is a key strategy for their effective prevention and control. In 2004, US Centers for Disease Control and Prevention office in Kenya established the Global Disease Detection Division of which one core component was to support, with other partners, the One Health approach to public health science. A Zoonotic Disease Unit has provided Kenya with an institutional framework to highlight the public health importance of endemic and epidemic zoonoses including Rift Valley Fever, rabies, brucellosis, Middle East Respiratory Syndrome Coronavirus, anthrax and other emerging issues such as anti-microbial resistance. The programme is implementing capacity building programs, surveillance, workforce development, research, coordinated investigation and outbreak response. This has led to an improved outbreak response and generated data that has informed disease control programs to reduce the burden of and enhance preparedness for endemic and epidemic zoonotic diseases, enhancing global health security. Since 2014, the Global Health Security Agenda implemented through Centers for Disease Control and Prevention office in Kenya and other partners in the country has provided additional impetus to maintain this effort and Kenya’s achievement now serves as a model for other countries in the region. Significant gaps remain in implementation of the One Health approach at subnational administrative levels. however, with sustainability concerns, competing priorities and funding deficiencies.
5. Health equity in economic and trade policies
The 72nd World Health Assembly (WHA) of health ministers in May 2019 adopted the resolution on “Improving the transparency of markets for medicines, vaccines, and other health products” in what is considered as a first step to improve the transparency on medicine pricing and other factors impacting prices such as clinical trial costs. The resolution urges the WHO Member States in accordance with their national and regional legal frameworks and contexts to take appropriate measures to publicly share information on the net prices of health products. Further, the resolution urges Member States to take measures to disclose the net price i.e. the price received by the manufacturer instead of the price paid by the government or customers. The resolution requires that costs from human subject clinical trials, regardless of outcomes, be made publicly available or be voluntarily provided. Further, the resolution provides a clear mandate to the WHO Secretariat to “analyse the availability of data on inputs throughout the value chain, including on clinical trial data and price information”. Unlike the initial draft, first proposed by Italy and then supported by a group of countries, the resolution does not create any responsibility on the part of Member States to ensure transparency on R&D cost and clinical trial cost. TWN report that the debate on the resolution brought out out the division within Europe between the countries with pharmaceutical industry such as Germany, France, the United Kingdom, Switzerland, Sweden and Denmark on the one hand, and countries that do not have strong pharmaceutical industry such as Spain, Portugal, the Netherlands, Austria and Norway. The USA supported the resolution, stating the commitment of the Trump Administration’s initiative to legislate to ensure competition in the pharmaceutical market through transparency in pricing. Though the resolution was adopted by consensus i.e. without any objection from the Member States, Germany, Hungary and the UK stated their disassociation from the resolution at the WHA plenary.
A World Health Assembly resolution this year proposed that drug prices could be reduced if countries forced pharmaceutical companies to be open about what it really costs to produce medicines. The plan is to give governments a way to enforce changes in the way medicine prices are set. In South Africa, cancer patients pay exorbitant prices to stay alive. Blood cancer patients are paying over R 800 000 for a year’s worth of one chemotherapy medicine, according to a report by the Cancer Alliance. Loopholes in South African patent laws are said to be one reason medicine prices are this high. Currently, companies that bring new drugs onto the market are awarded market monopolies through being awarded long-term patents that prevent anyone else from manufacturing a similar drug for many years. For example, the company that brought the blood cancer drug in question onto the market has had protection from competitors for 40 years, according to a briefing paper by the Initiative for Medicines, Access and Knowledge. In an overhauled system, it is proposed that market monopolies be capped at 15 years with small rewards offered when new, good drugs enter the market.
E-cigarettes allow users to inhale solutions that usually contain nicotine in a colourless liquid such as propylene glycol – an additive typically found in food and cosmetics. This solution is heated in hand-held devices and produces a vapour, which is why smoking e-cigarettes is often called “vaping”. South Africa’s new tobacco control Bill, which was published in July last year, proposes the same harsh regulations for e-cigarettes as their traditional cigarette counterparts. These include advertising restrictions, plain packaging and the banning of smoking areas in restaurants and public buildings. After the Bill’s publication, the Vapour Products Association (VPA), which represents e-cigarette manufacturers and retailers, publicly asserted that e-cigarettes are 95% safer than conventional cigarettes and may even help traditional smokers to quit, quoting an expert review by Public Health England in 2015. The UK study has however been widely criticised with some scientists taking issue with its methodology, arguing the research was based on the opinions of experts, instead of clinical trials. Anthony Westwood, a pulmonologist at the School of Child and Adolescent Health at the University of Cape Town, explains: “Our children cannot afford to find out in 20 years that they’ve got cancer because of e-cigarettes. “We have a chance to defuse this ticking time bomb.”
Natural resource governance activists have called on African leaders and corporates to stop the systematic looting of resources because it deprives the states of meaningful revenue needed for development. The call was made at a regional conference on the political economy of resource looting in the SADC region organized by Centre for Natural Resource Governance (CNRG) Southern Africa Political Economy Series (SAPES Trust) and regional watchdog Southern African Resource Watch (SARW) in Harare in May 2019. Southern Africa is said to be losing tens of billions of American dollars in potential natural resources revenue through systematic looting which includes trade mispricing, tax avoidance, corruption and transnational organized crime involving ruling elites and foreign actors, regional natural resource experts have said. SADC delegates present at the conference suggested that there is need to harmonise the laws in the region and adopt mineral resource governance and stronger contract negotiations to curb the leakages.
A network of journalists report that electronics companies, including Canon, Apple and Nokia, are re-evaluating their supply chains following reports they may be using gold extracted from a London listed Tanzanian gold mine that has been criticised for environmental failures. More recently, the Tanzanian government has imposed penalties on the mine and ordered the operators to build an alternative to its tailings reservoir, which is used to store potentially hazardous by-products of mining. Under Tanzanian law, no mine should operate within 200 metres of a home or 100 metres of a farm, but the mining company reported that it had not been able to meet this requirement. The company has built a wall in some areas, improved security training and introduced a grievance mechanism, which have led to a marked reduction in conflict over the past two years, but locals claimed there were still accidents and violence as a result of incursions, and toxic wastewater continued to seep from the mine into residential areas and waterways nearby. While there is scrutiny of the supply chain there is concern that this focuses on small-scale miners rather than multinationals, that there is not enough attention to environmental standards and local laws, and that responsibility gets diluted along the supply chain.
6. Poverty and health
At the International Labour Conference, IMF Managing Director Christine Lagarde unveiled an institutional view on social spending that will guide Fund staff on social protection, health and education. This responds to an IMF Internal Evaluation Office report noting that the institution was increasingly out-of-step with “the rights-based approach to social protection espoused by UN agencies including the ILO.” The IMF view is primarily focused on social assistance. These benefits, generally targeted to the poorest, are often advocated by the IMF as a measure to mitigate its conditionality and policy advice including austerity and the expansion of regressive taxation such as Value-Added Taxes. The institutional view argues that regressive taxes can be offset by more progressive social transfers. The Fund’s approach to social assistance and reducing spending has led to the promotion of narrow targeting through proxy means testing in many developing countries that erroneously excludes large numbers of recipients. The difficulties of narrow targeting are acknowledged but do not result in a clear change in policy. The International Labour Conference discussion of the General Survey concerning the Social Protection Floors Recommendation No. 202 highlighted how pressures from the IMF to cut social spending and the wage bill in public sector workers and to reduce the coverage of social protection have impeded the ability of states to deliver on their commitment to deliver adequate, comprehensive social protection systems consistent with ILO standards. In the past, the IMF has been more open to social protection floors, working jointly with the ILO after 2010 to support financing of national floors. Throughout the creation of the institutional view, the ITUC advocated for the IMF to support countries in financing comprehensive social protection systems and close coordination with the ILO.
7. Equitable health services
This paper applied Tanahashi’s equity model to identify the perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. The authors carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Their findings revealed that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. The authors observe that achieving universal health coverage means that all aspects of equity need to be addressed, including quality, and that community health services can play a crucial role in this.
The author questions whether Uganda national referral hospitals are performing their function. The author asks why a section of persons should be given special treatment by government in the names of being ‘Very Important Persons’ to access the best medical services in referral facilities for first line care or in ‘uptown’ private medical facilities and abroad. The author proposes that government perform its core minimum obligation and ensure that its public health care facilities function effectively.
8. Human Resources
The authors examined whether non-monetary employment incentives were cost-effective in attracting and retaining public sector health workers in rural areas of Zambia. The study consisted of two key phases: Firstly, in qualitative interviews with 25 health workers and focus group discussions with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment. A questionnaire, consisting of hypothetical job “choice sets,” was presented to 474 practicing health workers and students. Using administrative data, the authors estimated the cost of implementing potential attraction and retention strategies per health worker year worked. Although health workers preferred urban jobs to rural jobs, employment incentives influenced health workers’ decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job. Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake. The authors note that non-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages.
In this paper, the authors examine how deployment policies and practices were adapted during the conflict and post-conflict periods with the aim of drawing lessons for future responses to similar conflicts. Qualitative data was collected in a cross-sectional survey to investigate deployment policy and practice during the conflict and post-conflict period in Amuru, Gulu and Kitgum districts in Northern Uganda in 2013. Two large health employers from Acholi were selected, the district local government and Lacor hospital, a private provider. Twenty-three key informants’ interviews were conducted at the national and district level, and in-depth interviews with 10 district managers and 25 health workers. There was no evidence of change in deployment policy due to conflict, but decentralisation from 1997 had a major effect for the local government employer. Health managers in government and those working for Lacor hospital both implemented deployment policies pragmatically, especially because of the danger to staff in remote facilities. Lacor hospital introduced bonding agreements to recruit and staff their facilities. While managers in both organisations implemented the deployment policies as best as they could, some deployment-related decisions were noted as possibly leading to longer-term problems. While it may not be possible to change deployment policies during or after conflict, the authors observe that if given sufficient autonomy, local managers can adapt deployment policies appropriately to need, but that they should also be supported with the necessary management skills to enable this.
9. Public-Private Mix
Non-state actors, including humanitarian agencies, play a prominent role in providing health care in low- and middle-income countries. Between 2007 and 2009, Musina, a South African municipality bordering Zimbabwe, became the site of several interventions by non-state organisations as an unprecedented number of Zimbabweans crossed the border, putting strain on already burdened local systems. After the initial need for humanitarian relief dissipated, organisations started to implement projects that were more developmental in nature. For example, Médecins sans Frontières developed a mobile clinic programme to improve health care access for migrant farm workers, a programme that was subsequently integrated into the Department of Health. Since the handover of the programme, it has faced multiple challenges. Using qualitative methodology and a case study approach, this paper traces the development of the programme, exploring the changing relationship between MSF and the state during this time. This research raises questions about the implications of short-term ‘innovative’ interventions targeting the access that migrants have to care, within a context in which policy and programmatic responses to health are not 'migration aware'. The authors highlight the ways in which the energies and resources of local health department employees were redirected by MSF's involvement in the area.
Many governments in sub-Saharan Africa are seeking to establish public–private partnerships (PPPs) to finance and operate new healthcare facilities and services. While there is a large empirical literature on PPPs in high-income countries, much less is known about their operation in low-income and middle-income countries. This paper seeks to inform debates about the use of PPPs in sub-Saharan Africa by describing the planning and operation of a high-profile case in Maseru, Lesotho. The paper highlights several beneficial impacts of the transaction, including the achievement of high clinical standards, alongside a range of key challenges—in particular, the higher-than-anticipated costs to the Ministry of Health. Governments may use budget-related incentives to promote the use of PPPs which may threaten financial sustainability in the long term. The authors suggest that future proposals for PPPs need to be exposed to more effective scrutiny and challenge, taking into account state capacity to proficiently manage and pay for contracted services.
The African Commission on Human and People’s Rights calls on States Parties to the African Charter to take appropriate policy, institutional and legislative measures to ensure respect, protection, promotion and realization of economic, social and cultural rights, in particular the right to health and education and to fulfil their obligations on this. The Commission calls on States Parties to adopt legislative and policy frameworks regulating private actors in social service delivery and ensure that their involvement is in conformity with regional and international human rights standards. States Parties are invited to ensure that the involvement of private actors in the provision of social services is a result of a participatory policy formulation process and continues to be subject to democratic scrutiny and to the human rights principles of transparency and participation. The Commission considers carefully the risks for the realization of economic, social and cultural rights of public-private partnerships and ensure that any potential arrangements for public-private partnerships are in accordance with their substantive, procedural and operational human rights obligations, and do not violate the norms and principles of the rights contained in the African Charter; and to ensure through regular impact assessments that the involvement of private actors in the provision of health services and education does not create systemic adverse impacts on human rights. Further States Parties are to ensure access to an effective remedy for violations of the right to health and education or other human rights violations by private actors involved in the provision of health and education services. The Commission reminds private actors of their responsibility to respect economic and social rights, particularly the right to health and education and to refrain from infringing on human rights as they engage in the provision of these services.
10. Resource allocation and health financing
This report summaries the methods for analyzing health equity available to policymakers regarding the allocation of health sector resources. The authors provide an overview of the major tools that have been developed to measure, evaluate and promote health equity, along with the data required to operationalise them. These are organized into four key policy questions facing decision-makers: What is the current level of inequity in health? Does government health expenditure benefit the worst-off? Can government health expenditure more effectively promote equity? and which interventions provide the best value for money in reducing inequity? Benefit incidence analysis is identified as the principal tool for estimating the distribution of current public health sector expenditure, with geographical resource allocation formulae and health system reform being the main government policy levers for improving equity. Techniques from the economic evaluation literature, such as extended and distributional cost-effectiveness analysis can be used to identify ‘best buy’ interventions from a health equity perspective. A range of inequality metrics, from gap measures and slope indices to concentration indices and regression analysis, can be applied to these approaches to evaluate changes in equity. Methods from the economics literature can be used to generate novel evidence on the health equity impacts of resource allocation decisions. They provide policymakers with a toolkit for addressing multiple aspects of health equity, from health outcomes to financial protection, and can be adapted to accommodate data commonly available in either high income or low and middle income settings. However, the quality and reliability of the data are crucial to the validity of all methods.
The authors estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance for health (DAH) from 1990 to 2018. Future scenarios of health spending using an ensemble of linear mixed-effects models were estimated, with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. Between 1995 and 2016, health spending grew at a rate of 4% annually, although it grew slower in per capita terms and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries, mainly due to growth in government health spending, and in lower-middle-income countries, mainly from DAH. The decomposition analysis identified governments’ increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending.
11. Equity and HIV/AIDS
This paper looks at the increasing burden of hypertension across sub-Saharan Africa where HIV prevalence is the highest in the world, but current care models are inadequate to address the dual epidemics. Little data exist on the effectiveness of integrated HIV and chronic disease care delivery systems on blood pressure control over time. Population screening for HIV and hypertension, among other diseases, was conducted in ten communities in rural Uganda as part of the SEARCH study. Individuals with either HIV, hypertension, or both were referred to an integrated chronic disease clinic. Based on Uganda treatment guidelines, follow-up visits were scheduled every 4 weeks when blood pressure was uncontrolled, and either every 3 months, or in the case of drug stock-outs more frequently, when blood pressure was controlled. The authors described demographic and clinical variables among all patients and used multilevel mixed-effects logistic regression to evaluate predictors of hypertension control. Following population screening of 34,704 adults age ≥ 18 years, 4554 individuals with hypertension alone or both HIV and hypertension were referred to an integrated chronic disease clinic. Within 1 year 2038 participants with hypertension linked to care and contributed 15,653 follow-up visits over 3 years. Hypertension was controlled at 15% of baseline visits and at 46% of post-baseline follow-up visits. Hypertension control at follow-up visits was higher among HIV-infected patients than uninfected patients and improved hypertension control was achieved in an integrated HIV and chronic care model.
12. Governance and participation in health
BoLAMA report in a press statement that it has without much success made all efforts to engage and collaborate with the Government of Botswana on miners’ right to health, specifically for those suffering from TB and other occupational diseases. BoLAMA assert that TB rates in Botswana remain high and a multi-sectoral accountability framework is required. This framework which is aligned with the End TB Strategy and UN Political Declaration on TB requires key populations and civil society to work in collaboration with Governments. The regional TB/Silicosis class action is seen as an opportunity to reduce the economic hardships of ex-miners who due to contracting occupational lung diseases have been rendered redundant and not in gainful employment. The court case, to which BoLAMA has been party, is slated to be finalized in 2019. BoLAMA called on the Government of Botswana to; i) remember her commitments under the WHO EndTB Strategy from which the TB National Strategic Plan is aligned; ii) implement the UN Political Declaration on the fight against TB; iii) ensure an inter-ministerial committee including BoLAMA deal with ex-miners issues; and iv) provide support in the TB/Silicosis regional class suit.
This study explores how health facility committees monitor the quality of health services and how they demand accountability of health workers for their performance in Malawi. Documentary analysis and key informant interviews were complemented by interviews with purposefully selected health facility committees members and health workers regarding their experiences with health facility committees. The informal and constructive approach that most health facility committees use is shaped both by formal definition and expectations of their role and resource constraints. The primary social accountability role of health facility committees appeared to be co-managing the social relations around the health facility and promoting access to and quality of services. The results suggest that health facility committees can address poor health worker performance and the authors suggest that social accountability approaches with health facility committees be integrated in existing quality of care programs and that accountability arrangements and linkages with upward accountability approaches be clarified.
13. Monitoring equity and research policy
This study sought to investigate the facilitators, best practices and barriers of integrating family planning data into the district and national Health management information systems in Uganda. The authors conducted a qualitative study in Kampala, Jinja, and Hoima Districts of Uganda, based on 16 key informant interviews and a multi-stakeholder dialogue workshop with 11 participants. The technical facilitators of integrating family planning data from public and private facilities in the national and district Health management information systems were user-friendly software; web-based and integrated reporting; and availability of resources, including computers. Organizational facilitators included prioritizing family planning data; training staff; supportive supervision; and quarterly performance review meetings. Key behavioural facilitators were motivation and competence of staff. Collaborative networks with implementing partners were also found to be essential for improving performance and sustainability. Significant technical barriers included limited supply of computers in lower level health facilities, complex forms, double and therefore tedious entry of data, and web-reporting challenges. Organizational barriers included limited human resources; high levels of staff attrition in private facilities; inadequate training in data collection and use; poor culture of information use; and frequent stock outs of paper-based forms. Behavioural barriers were low use of family planning data for planning purposes by district and health facility staff. Family planning data collection and reporting are integrated in Uganda’s district and national health management information systems. Best practices included integrated reporting and performance review, among others. Limited priority and attention is given to family planning data collection at the facility and national levels. Data are not used by the health facilities that collect them. The authors recommend reviewing and tailoring data collection forms and ensuring their availability at health facilities. All staff involved in data reporting should be trained and regularly supervised.
14. Useful Resources
This resource provides a range of films which are useful training materials and resources. Films include reflections on community actions towards improving health, such as Community Working Group on Health (CWGH) documentary on “Strengthening Community Feedback Mechanisms for Improved Health Service Delivery” and a documentary film on “How South Africans are taking food security into their own hands” by a student featuring individuals from Klapmuts, Belhar, and Gugulethu in the Western Cape who are initiating food gardens and other programmes to empower their communities and strengthen food security and sovereignty. A short documentary tells the story of the Network of Community Defenders for the Right to Health, users of healthcare services that have organized themselves to identify problems, engage with authorities for resolutions and demand accountability. Also featured is a training video which explores the role of Health Committees from different perspectives – from that of a facility manager, a health care provider, health committee members and patients. Two further films from the Community Systems Strengthening (CSS) project reflect on the social determinants of health and the importance of responding to community health issues in a more holistic manner.
15. Jobs and Announcements
The Association of Schools of Public Health in Africa (ASPHA) welcomes abstract submissions for oral and poster presentations for the 2019 ASPHA Conference and Annual Meeting. The main theme of the conference is ‘Universal Health Coverage in Africa: The Role of Public Health Workforce.’ The sub-themes of the conference are ‘Developing Public Health Workforce to expand Universal Health Coverage’, ‘Innovations to improve Maternal, Newborn, Child and Adolescent Health Care in Africa’, ‘Current and Emerging Public Health Issues (Non-communicable and Communicable diseases)’, ‘Evidence to Policy: Financing Healthcare for Universal Health Coverage’ and ‘Public Health Education’. Consider including the following information in the abstract, when relevant: objective, problem under investigation, hypothesis, or research goal, the description of research methods, summary of findings and statement of how the research advances public health. See the website for further information.
The 2019 2nd Social Policy in Africa International Conference invites abstracts and papers that address the dynamics of social policymaking in Africa, identify the drivers of policies and their policy preferences, and address the issue of the nature of politics and the constitution of the public sphere necessary for enhanced economic transformation, human flourishing, and new forms of social compact in inclusive development. Presenters are invited to engage with these issues and explore the different national and regional experiences of modes of governance of the African social policy space, the drivers of public policy, and explore the modes of governance and politics necessary for enhanced human wellbeing and development. The conference also invites papers in the broad areas of social policy not directly concerned with the theme of the 2019 conference.
This conference will tackle robotics, electronic health records, delivering personalised healthcare, artificial intelligence, IoT in healthcare, driving down the cost of care with technology, security, legal impact of eHealth, healthcare policy, telemedicine advances, future of healthcare and much, much more. The summit will look at the role technology plays in patient empowerment, disease diagnosis and enhancing operational efficiency in medical facilities. HISA 2019 presents the latest healthcare technologies and showcasing their practical application and integration into existing healthcare infrastructure.
The United Nations Research Institute for Social Development (UNRISD) is seeking potential case studies for its project Cities in Transition—Urban Struggles for Just Transition(s), run by the Just Transition Research Collaborative (JTRC). This project analyses urban approaches to just transition, exploring the role of cities in implementing progressive and transformative just transition strategies and plans. Building on the theoretical framework and assessment carried out by the Just Transition Research Collaborative and published in the report Just Transition(s) to a Low-Carbon World (2018), the project collects new empirical evidence and stories from several cities, and fosters exchange of experience and mutual learning on the role of cities in just transition. The research contributes a better understanding of the potential of city-level just transition policies and frameworks to influence higher level policy change and climate justice. The case studies will be a major part of a research report which will be presented to decision makers and activists at the United Nations Climate Change Conference COP 25 in Santiago de Chile in December 2019.
The Museums Association of Namibia is inviting musicians and members of the public to assist by identifying musical instruments, recordings, photographs or stories that might be included in the museum. They are calling on submissions to the development of the museum by Namibian artists and the general public alike, to contribute ideas about what the museum should contain. The museum will be a museum of Namibian music that will endeavour to showcase all forms of Namibian music across all genres, cultures, instruments, uses and time.
The theme of the 2019 SAMA conference is “Leadership and Quality in Healthcare – Let’s close the Gap” and will cover the future direction of healthcare and various initiatives of the National Health Insurance (NHI). It also resonates with the discussions emanating from the private sector in South Africa. The conference will feature a parallel research track and undergraduate and postgraduate students, as well as colleagues involved in research are invited to attend and participate.
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