When EQUINET was formed in 1998, all east and southern African countries had public policy commitments to improve health equity. This was a statement of values, and needed to be protected socially, as much as it demanded information on how to achieve it. As people from government, unions, civil society, parliament, academia from other institutions in the region, we saw that research could inform and reinforce this policy intention. We could expose the extent and forms of avoidable, unfair inequality and their determinants and propose ways of advancing equity in health. With inequalities a reflection of the power people have to direct resources towards their wellbeing, we saw research and knowledge as not neutral in these power relations.
This year we reflected on our experience from over two decades of EQUINET research on how, and how far our research practice had achieved these intentions.
Policies have been articulated and knowledge generated in our region by many, including ourselves on the inclusive economic policies, comprehensive public services and rights-based approaches to addressing social inequality. Yet our realities are increasingly driven by a global economy and a regional response that is generating instability, environmental and social costs; increasing extraction and export of natural resources; rising levels of precarious labour, social deficits and destruction of cultures. Our public institutions have become weaker and even basic forms of wellbeing commodified, disrupting cohesion, solidarity and collective agency. ESA countries are framed as ‘under-developed’ and ‘aid recipients’, with populations undergoing a ‘development pathway’, despite the economic insecurity, resource depletion and social deficits associated with this pathway. Responding to these trends, people in the network have done work to expose and show the harms and violations in people’s experience of these trends, and to point to opportunities for alternative policy and practice.
Research on these issues has involved relationships and dialogue with key constituencies, from the onset and throughout the process, and efforts to ensure rigour, quality, validity and ethical practice. We have shared results in a range of media and interactions. Implementation research, appreciative inquiry, realist review, benefit incidence analysis, policy analysis and other designs have, with the new lenses brought by diverse disciplines in the network, taken us outside biomedical paradigms and the ‘core curative care business’ that the health sector has retreated to, exploring the choices made in a range of sectors and what this means for the wellbeing of current and future generations.
However, the battle of ideas and struggle over wealth and power that lies at the heart of the trends generating inequalities in health in our region raise not just WHAT is investigated, but also WHO asks the questions, WHOSE assumptions are brought to bear and HOW the research is done. Research can explain and show alternatives to disempowering narratives of the inevitability of the status quo and generate knowledge in ways that empower those affected to affirm their reality, to reflect on the causes of their problems and to more directly articulate alternative explanations and build the self-confidence and organisation to produce change and to learn from actions taken.
Like others working on social justice, we are on a constant learning curve on how to do this. Participatory action research has, for example, provided a particularly powerful means for people to create counter-narratives to dominant characterizations that ignore or undermine them, transforming people from objects to subjects and strengthening strategic action and review. Yet we are still learning how to embed PAR within the democratic functioning of social organisations as well as testing, such as through online PAR, how to amplify the organisation, consciousness and voice from largely local PAR processes to engage global level drivers of inequity, without losing their authenticity. We’ve been excited by methods and capacities that allow for the complexity of the many overlapping stories in our lives and countries, including narrative research, ‘fiction’, theatre, photography, and social media, We’ve appreciated how technologies used in research are deeply connected to the processes and interests that use them.
Doing this work excites, reveals, generates energy and many collective ‘aha’ moments!. But it also exhausts, demands many hours of time and absorbs all those involved in social processes. Many talk about facing the double task of researching on inequities, while also challenging inequity in a global research system that undervalues the cross disciplinary, reflexive and participatory approaches and interactions that are features of equity related research. People in the region, particularly at local level, face travel, visa, cost, gender, class and racial barriers that exclude them from engaging in northern-based global processes.
In this context, being in a consortium network and the partnerships with the network have provided support, resources, exchanges and peer review for more self-determined work. The wide range of disciplines, lenses and constituencies in the network have provoked us to be more creative. Yet our region is changing, encountering new opportunities and challenges. We cannot afford to be over-comfortable in old relationships, methods and practice. So the question stays on the agenda: how can our research practice better promote equity and justice in health?
We welcome your feedback or queries on the issues raised in this oped – please send them to the EQUINET secretariat: admin@equinetafrica.org. Please visit http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Diss120%20Research%20for%20HE%202019%20lfs.pdf to read the discussions, ideas and examples in the full paper that the editorial draws from. Several papers included in this newsletter also provide interesting experiences and reflections on research for equity and equity in research systems.
1. Editorial
Six months after Cyclone Idai ravaged the eastern province of Manicaland in Zimbabwe, the devastating effects show that there is need for more work to do for the recovery. The survivors are still in dire straits, psychologically, emotionally and materially.
The traumatic events of 15 March 2019 remain etched on the minds of the survivors. Any rumbling sound, even light rain, sends them quaking, as a reminder of the tragic events of that ‘night of death’, when torrential rains and heavy winds claimed their loved ones and left them scarred.
Cyclone Idai resulted in a massive loss of life and injury, as well as destruction of critical infrastructure, including clinics, schools, roads, bridges, electricity base stations and houses. Manicaland province was the most affected, followed by Masvingo and Mashonaland East. The destruction also affected parts of neighbouring Mozambique and Malawi.
Government statistics indicate that 341 people died, 344 were missing, 183 were injured and 2213 people were displaced. Further, 230 dams burst and 20 000 livestock were lost. The loss of electricity compromised communication systems and hampered search and rescue efforts. The damage to communication networks means that many communities remain cut off from essential services. Despite government, with assistance from South Africa, having mobilized earth-moving equipment, some roads are still not passable.
This situation presented a public health threat of water and vector borne diseases, such as cholera, typhoid and malaria. Malaria deaths have spiked in Manicaland following the Cyclone. The trauma and loss has certainly led to mental health problems. The damage to infrastructure has impeded access to health services, raising the risk that people cannot access or default on treatment and care. In addition, local health services are understaffed and lack adequate medicines.
The magnitude of the disaster was greater than government alone could cope with. The international community, United Nations agencies, civil society organisations and individuals all contributed. For example, the Community Working Group on Health (CWGH) with Medico International provided relief and aid to 171 households in holding camps in April to June 2019. This interaction also led to input to recommendations to the Civil Protection Unit and other inter-ministerial committees responsible for preventing disease outbreaks and ensuring provision of safe and clean water in the holding camps. Yet the high death toll from Cyclone Idai indicated the lack of disaster preparedness and planned mitigation by government, considering the earlier heavy loss from Cyclone Eline in 2000. Many lives could have been saved had the warnings for Cyclone Idai been widely disseminated in the local media to warn households and a response mobilized to evacuate people from the affected areas.
The situation continues to be precarious up to today. Manicaland Provincial Affairs Minister Dr Ellen Gwaradzimba noted that the situation in that province is now worsened by drought, affecting about 1.7 million people, in a situation where food reserves and fields were destroyed. Even while the response moves from an emergency to a recovery phase, the need to both learn from the experience and to sustain intervention is clear, including to respond to continuing vulnerability and to resettle internally-displaced people.
At a Provincial All-stakeholder Dialogue Meeting on Cyclone Idai in June concern was raised over the weak execution of the disaster emergency plans for evacuation and rescue and the absence of community-based emergency plans. For example, the reluctance of people to leave their ancestral land, even after being alerted of the disaster, was one factor that impeded evaluation. The dialogue meeting recommended that a government emergency response fund be set up; that communities be educated on first aid and disaster risk management in schools and in the community; and that campaigns be undertaken on disaster preparedness and mitigation.
While much effort has already been made in improving access to public and social services, resources are needed to restore roads, bridges, houses and sanitary facilities. Survivors need counseling and psychosocial support services. Displaced people and affected communities need new land for more rapid permanent resettlement and investments in their livelihoods and social services.
In all these inputs the planning, preparations, decisions and responses need to be people-centered. Putting people at the centre of the next steps, including in the planning for any future emergencies, is central to the response.
2. Latest Equinet Updates
This paper reflects on experience from over two decades of EQUINET research practice to promote health equity in east and southern Africa. The paper was written by members of the EQUINET steering committee and the newsletter team. It draws examples and research features from EQUINET publications available online, a search of publications in the 221 issues of the EQUINET newsletter, and papers, reports, blogs, articles and editorials obtained from key word searches in Google. Despite policy commitments and gains in selected aspects of health, conditions in the region are increasingly driven by a global economy and a regional response that is generating instability, environmental and social costs; intense extraction of natural resources; rising levels of precarious labour, social deficits and weakened public institutions, disrupting social cohesion, solidarity and collective agency. These conditions call for certain features and forms of research. The paper describes diverse research on the costs to health equity of social deficits, inequitable resource outflows and the commodification of public services, as well as research on alternatives and policies on food security, health services, environment and rights that confront these trends. The paper describes specific features of research that respond more directly to the understanding that power relations are central to inequities in health. These research processes explain and show alternatives to disempowering narratives of the inevitability of the status quo and generate knowledge in ways that intend to empower those affected. They pay attention to who defines the research questions, who designs, implements and uses the research. This implies designs and methods that involve people in affirming and validating their realities, generating reflection on causes and building analysis, self-confidence and organisation to act and to learn from action. It presents specific examples of research approaches and the role of a consortium network in advancing them, while noting the ways in which many researchers face the double task of investigating inequities, while also challenging inequity in a global research system.
Primary Health Care (PHC) has inspired and galvanized action on health. PHC affirms that health is a state of complete physical, mental and social wellbeing and not merely the absence of disease and that health is a fundamental human right. In the past decade, global institutions have promoted and channeled external funds through performance-based financing (PBF), as a strategy to improve service delivery and access. While there have been studies on whether these particular services targeted under PBF have improved, there has been little systematic evaluation of its system-wide effects, nor of its impacts on comprehensive PHC. In EQUINET, we thus saw it to be important to ask: How is the use of targets in PBF affecting health workers’ professional roles, work and interaction with communities and their ability to deliver comprehensive PHC? In 2018-2019 the PAR involved 21 online participants from seven sites in five ESA countries, including health workers from primary health cent res, community members in HCCs and country site facilitators from seven national health civil society organisations in the region, referred to in this brief collectively as the ‘online participants’. We also included offline local discussions with an average of 19 community members and 15 health workers per site. Four major areas of action and ten proposals were made within them for PBF to enable and not detract from PHC. These are 4 briefs each of which present the general findings and proposals from the work with separate final points in the first brief for local level; in the second for district and national level; in the third brief for regional level agencies and in the fourth brief for international agencies. The link is to one of the briefs but all four are on the website.
Most countries in east and southern Africa have rich deposits of a range of mineral reserves that are highly sought after in global trade. Extractive industries (EIs), largely multinationals from all regions of the world, extract these minerals, oil and gas from the earth through mining, dredging and quarrying. Countries in east and southern Africa thus face a challenge to make and implement policy choices that link these natural resources to improved social and economic development, and to ensure that extraction processes do not harm health or environments. EQUINET is working with trade union partners in the Southern Africa Coordination Council (SATUCC), Ex mineworkers in the Southern Africa Miners Association (SAMA) and civil society through Benchmarks SA on health in the mining sector in east and southern African (ESA) countries. EQUINET are holding a regional meeting on February 1 and 2 2020 in Cape Town South before the Alternative Mining Indaba to share health literacy information on mining and health, distribute the health literacy module on mining and health, and share other materials and experiences in EQUINET’s ongoing programmes and advocacy on mining and health in the region. The workshop is aimed at trade union, ex mineworker and civil society health organisers. There are very limited sponsored places and self-sponsored places left so those interested, and those attending the AMI who wish to join the meeting, are asked to apply soonest by email.
3. Equity in Health
This study assessed the outcomes of children diagnosed with hearing impairment 3 years earlier in terms of referral uptake, treatment received and satisfaction with this treatment and social participation. A population-based longitudinal analysis of children with a hearing impairment was conducted in two rural districts of Malawi. Key informants within the community identified the cohort in 2013. Informants clinically screened children at baseline and by questionnaires at baseline and follow-up in 2016. 752 children were diagnosed in 2013 as having a hearing impairment and 307 traced for follow-up in 2016. Referral uptake was low, more likely among older children and less likely for those with an illiterate caregiver. Few of the children who attended hospital received any treatment and 63.6% of caregivers reported satisfaction with treatment. Difficulty making friends and communicating needs was reported for 10.0% and 35.6% of the children, respectively. Lack of school enrolment was observed for 29.5% of children, and was more likely for older children, girls and those with an illiterate caregiver. The authors propose that more widespread and holistic services are required to improve the outcomes of children with a hearing impairment in Malawi.
The Health and Aging Study in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) is led by an interdisciplinary team of collaborators from Harvard School of Public Health, University of Witwatersrand, Johannesburg, and the INDEPTH Network, a global network of health and demographic surveillance systems based in Ghana. By integrating the HAALSI data with cause of death data from the INDEPTH Health and Demographic Surveillance System (HDSS) data at the MRC/Wits Agincourt research site, the authors explored the interrelationships between physical and cognitive functioning, lifestyle risk factors, household income and expenditure, depression and mental health, social networks and family composition, HIV infection and cardio-metabolic disease. In South Africa, the research found that people who were participating in the national HIV treatment programme were more likely to receive care for high blood pressure and achieve control of both blood pressure and blood sugar. This finding suggests that strong primary care systems are an important part of the answer to the disease trends of older adults and that South Africa’s national HIV treatment programme may offer a great platform for expanding primary care for all South Africans. Good health habits formed in childhood and in young adulthood – including avoiding smoking and alcohol overuse, engaging in physical activity and eating a nutritious diet are identified as being crucial to healthy ageing of the society of a whole.
4. Values, Policies and Rights
With young women increasingly exposed to sexualized messages, they are argued to need clear, trustful and open communication on sexuality more than ever. However, in Mozambique, communication about sexuality is hampered by strict social norms. This paper evaluates an intervention aimed at reducing the generational barrier in talking about sexuality to contribute to better communication within the family context. The intervention consisted of three weekly one-hour coached sessions in which female adults and young people interacted about sexuality. Realist evaluation was used as a framework to assess context, mechanisms and outcomes of the intervention. Interviews were conducted among 13 participants of the sessions. The interaction sessions were positively appreciated by the participants and contributed to a change in norms and attitudes towards communication on sexuality within families. Recognition of similarities and awareness of differences were key in the mechanisms leading to these outcomes. This was reinforced by the use of visual materials and the atmosphere of respect and freedom of speech that characterized the interactions. Limiting factors were related to the long-standing taboo on sexuality and existing misconceptions on sexuality education and talks about sex. By elucidating mechanisms and contextual factors, the study adds knowledge on strategies to improve transgenerational communication about sexuality.
Primary health care (PHC), codified at the historic 1978 Alma Ata Conference, was advocated as the means to achieve health for all by the year 2000. The principles of PHC included universal access and equitable coverage; comprehensive care emphasising disease prevention and health promotion; community and individual participation in health policy, planning, and provision; intersectoral action on health determinants; and appropriate technology and cost-effective use of available resources. These principles were to inform health-care provision at all levels of the health system and the programmatic elements of PHC that focused primarily on maternal and child health, communicable diseases, and local social and environmental issues. PHC emphasised community participation through a network of workers at all levels who would be trained both “socially and technically”. UHC is concerned with improved access to quality health services and protection from financial risks associated with health care. However, UHC, unlike PHC, is silent on social determinants of health and community participation.
This paper explores how major global abortion discourses manifest themselves in Tanzania and indicates potential implications of a hybrid abortion regime. The study combined a review of legal and policy documents on abortion, publications on abortion in Tanzanian newspapers between 2000 and 2015 and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health. Tanzania’s abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, reflecting the major global discourses. The paper demonstrates that a hybrid discursive regime relating to abortion is found even in the legally restrictive abortion context of Tanzania. The authors argue that a complex discourse cuts across the restrictive - liberal divide and opens avenues for enhanced access to abortion related knowledge and services.
5. Health equity in economic and trade policies
Human rights lawyers are reported to be preparing to bring a landmark case against British American Tobacco on behalf of hundreds of children and their families forced by poverty wages to work in conditions of gruelling hard labour in the fields of Malawi. Leigh Day’s lawyers are seeking compensation for more than 350 child labourers and their parents in the high court in London, arguing that the British company is guilty of “unjust enrichment”. Leigh Day says it anticipates the number of child labourer claimants to rise as high as 15 000. While BAT claims it has told farmers not to use their children as unpaid labour, the lawyers say the families cannot afford to work their fields, because they receive so little money for their crop. Many of the families are from Phalombe, one of the poorest regions in the south of the country. Children as young as three are involved in tobacco farming, the letter of claim says, often during harvest when the work can be especially hazardous. Children are particularly vulnerable to the effects of toxic pesticides, fertiliser and green tobacco sickness, from nicotine absorption while handling the leaves. Symptoms include breathing difficulties, cramps and vomiting. BAT is one of the most profitable companies in the world, making an operating profit last year of £9.3bn on sales of £24.5bn. Like other big tobacco companies, it has distanced itself from the farmers by commissioning a separate company to buy a stipulated amount of tobacco leaf each year.
Sugar sweetened beverages (SSB) are a major source of sugar in the diet. Although trends in consumption vary across regions, in many countries, particularly LMICs, their consumption continues to increase. In response, a growing number of governments have introduced a tax on SSBs. SSB manufacturers have opposed such taxes, disputing the role that SSBs play in diet-related diseases and the effectiveness of SSB taxation, and alleging major economic impacts. Given the importance of evidence to effective regulation of products harmful to human health, the authors scrutinised industry submissions to the South African government’s consultation on a proposed SSB tax and examined their use of evidence. The findings not only highlight the value of improving the transparency and scrutiny of regulatory impact assessments and consultations in health policy-making, but also other modes of industry political activity. The authors argue that. efforts need to be made to enhance appraisal of industry use of evidence. Ideally, there should be a presumption in favour of in-depth critical appraisal, organised and financially supported by national governments. Beyond this, there is a strong case for closer transnational collaboration between civil society actors and academics that centres on producing real-time appraisals of companies’ use of evidence in both public consultations and other contexts in which they provide information to policy actors and the public.
A conference organised by the Brenthurst Foundation, a Johannesburg-based think-tank and lobby group gave Huawei a slot to pitch its vision for the future of African cities. It is a vision that revolves around surveillance, artificial intelligence and 5G communication networks, creating a world where your every movement is tracked, recorded and searchable. Human Rights Watch describes this technology, however, as “algorithms of repression”, given a potential for abuse of people’s rights.
Nearly all African countries have endorsed the continental free trade agreement. Trading is scheduled to commence in 2020 after key negotiations are concluded. Implementation of the agreement is likely to impact health in at least five areas: human capital investments, health innovations, trade for social impact, health security and universal health coverage. The author reccommends that health and development stakeholders take proactive measures to ensure health is protected in policies, programs and negotiations. While the five proposed areas are not exhaustive, they are argued to represent a basic foundation for rigorous research and informed engagement by health and development leaders in AfCFTA and trade-related processes. Other issues such as research and development, biopharmaceutical innovation and intellectual property rights also need to be considered.
6. Poverty and health
Structural adjustment programmes of international financial institutions have typically set the fiscal parameters within which health policies operate in developing countries. Yet, a systematic understanding of the ways in which these programmes impact upon child and maternal health is currently lacking. This article systematically reviews observational and quasi-experimental articles published from 2000 onward in online databases and grey literature from websites of IMF, World Bank and African Development Bank. Studies were considered eligible if they empirically assessed the aggregate effect of structural adjustment programmes on child or maternal health in developing countries. Of 1961 items yielded through database searches, reference lists and organisations’ websites, 13 met the inclusion criteria. The authors found that structural adjustment programmes had a detrimental impact on child and maternal health. In particular, these programmes undermined access to quality and affordable healthcare and adversely impacted upon social determinants of health, such as income and food availability. According to the authors, the evidence suggests that a fundamental rethink is required by international financial institutions if low income countries are to achieve the Sustainable Development Goals on child and maternal health.
7. Equitable health services
Little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. Data from a household survey of 2002 women living in rural Tanzania was used to describe the extent of disrespectful care during outpatient visits, who receives disrespectful care and the association with patient satisfaction, rating of quality and recommendation of the facility to others. Women were asked about their most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. The most common reasons for seeking care were fever or malaria, vaccination and non-emergent check-up. Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic. While there is currently a lot of attention on disrespectful maternity care, the authors suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.
This study investigated health system constraints affecting treatment and care by women with cervical cancer in Harare, Zimbabwe. A sequential explanatory mixed methods design was used. Phase 1 comprised of two surveys namely: patient and health worker surveys with sample sizes of 134 and 78 participants respectively. In phase 2, 16 in-depth interviews, 20 key informant interviews and 6 focus groups were conducted to explain survey results. Health system constraints identified were: limited or lack of training for health workers, weakness of surveillance system for cervical cancer, limited access to treatment and care, inadequate health workers, reliance of patients on out-of-pocket funding for treatment services and lack of back-up for major equipment. The qualitative inquiry found barriers to be: high costs of treatment and care, lack of knowledge about cervical cancer and bad attitudes of health workers, few screening and treating centres located mostly in urban areas, lack of clear referral system resulting in bureaucratic processes and limited screening and treating capacities in health facilities due to lack of resources. The study showed that the health system and its organization present barriers to access of cervical cancer treatment and care among women.
Universal Health Coverage (UHC) is normally understood as ‘people being able to access curative, preventive and palliative health services without incurring financial hardship’. Yet this interpretation is only one part of the overall picture of health. To mitigate and prepare for such environmental and societal changes and the subsequent impact on health the authors suggest that there are at least three major ways in which health systems need to radically transform. Firstly, health systems across the world continue to be predominantly ‘sick care’ systems. Despite the success of immunization campaigns, the availability of contraceptive services and other preventive interventions, most investment is in healthcare facilities that provide primarily personal, curative health services. The World Health Organization estimates that low- and middle-income countries direct only 11-12 per cent of their total health spending towards preventive services. Secondly, animal and wildlife information systems vary enormously across countries in their objectives and structure but rarely interact with systems for tracking human health. This means that opportunities to identify dangerous viruses and diseases in the animal population before they crossover into humans are frequently missed. Thirdly, at the UN General Assembly (UNGA) the community of academics and activists concerned with non-communicable diseases were vocal, and rightly so. Such diseases now account for 41 out of the world’s 57 million deaths each year. The authors suggest that there is a need to move away from a narrow view of ‘sick care’ to one that prepares for and acknowledges present day complexities and challenges to achieve UHC.
screening programme for preschool children in the Western Cape, South Africa, supported by mobile health technology and delivered by community health workers. The authors trained four community health workers to provide dual sensory screening in preschool centres of Khayelitsha and Mitchells Plain during September 2017–December 2018. Community health workers screened children aged 4–7 years using mobile health technology software applications on smart-phones. Community health workers screened 94.4% of eligible children at 271 centres at a cost of US$5.63 per child. The number of children who failed an initial hearing and visual test was 435 and 170, respectively. Of the total screened, 111 children were diagnosed with a hearing and/or visual impairment. Mobile health technology supported community health worker delivered hearing and vision screening in preschool centres provided a low-cost, acceptable and accessible service, contributing to lower referral numbers to resource-constrained public health institutions.
8. Human Resources
unity health workers (CHWs) possess multiple, overlapping roles and identities, which makes them effective primary health care providers when properly supported with adequate resources. This also limits their ability to implement interventions that only target certain members of their community and prevents them from performing certain duties when it comes to sensitive topics such as family planning. To understand the multiple identities of CHWs qualitative and ethnographic methods involved participant observation, open-ended and semi-structured interviews and focus group discussions with CHWs, their supervisors, and their clients between October 2013 and June 2014 in Rufiji, Ulanga and Kilombero Districts in Tanzania. The findings suggest that it is difficult to distinguish between personal and professional identities among CHWs in rural areas. Important aspects of CHW services such as personalization, access, and equity of health services were influenced by CHWs’ position as local agents. However, the study also found that their personal identity sometimes inhibited CHWs in speaking about issues related to family planning and sexual health. Being local, CHWs were viewed according to the social norms of the area that consider the gender and age of each worker, which tended to constrain their work in family planning and other areas. Furthermore, the communities welcomed and valued CHWs when they had curative medicines; however, when medical stocks were delayed, the community viewed the CHWs with suspicion and disinterest. Community members who received curative services from CHWs also tended to become more receptive to their preventative health care work. Although CHWs’ multiple roles constrained certain aspects of their work in line with prevalent social norms, overall, the multiple roles they fulfilled had a positive effect by keeping CHWs embedded in their community and earned them trust from community members, which enhanced their ability to provide personalized, equitable and relevant services. However, CHWs needed a support system that included functional supply chains, supervision, and community support to help them retain their role as health care providers and enabled them to provide curative, preventative, and referral services.
9. Public-Private Mix
The authors report that there is consensus that local pharmaceutical production in sub-Saharan Africa in close proximity to where medicines are needed can reduce dependence and improve health outcomes for the population. Many African governments, regional economic communities and the African Union have recognized the need for active support to the development of the sector if these benefits are to be realized. However, concrete action on the ground is reported to have remained hesitant and piecemeal to date. This document contains advice for government policy makers, the private sector especially pharmaceutical manufacturers in sub-Saharan African countries, development partners and finance institutions on how to promote pharmaceutical production. The guide focuses on the key areas of competitiveness, market access, technology and access to finance. It further proposes a path of how governments could embark on and steer a policy development process as well as giving guidance on policy interventions. The document especially emphasizes the interconnectedness of key intervention areas and recommends that promotional measures from key areas should be combined to increase impact.
10. Resource allocation and health financing
Increasing fiscal space is argued to be important for health sector public financing. One strategy is to mobilize additional government revenues through new taxes or increased tax rates on goods and services. The authors illustrate how countries can assess the feasibility and quantitative potential of different revenue-raising mechanisms. The processes and results from country assessments in Benin, Mali, Mozambique and Togo are reviewed and synthesized. The studies analysed new taxes or increased taxes on airplane tickets, phone calls, alcoholic drinks, tourism services, financial transactions, lottery tickets, vehicles and the extractive industries. Study teams in each country assessed the feasibility of new revenue-raising mechanisms using six qualitative criteria. The quantitative potential of these mechanisms was estimated by defining different scenarios and setting assumptions. Consultations with stakeholders at the start of the process served to select the revenue-raising mechanisms to study and later to discuss findings and options. Exploring feasibility was essential, as this helped rule out options that appeared promising from the quantitative assessment. Stakeholders rated stability and sustainability positive for most mechanisms, but political feasibility was a key issue throughout. The estimated additional revenues through new revenue-raising mechanisms ranged from 0.47–1.62% as a share of general government expenditure in the four countries. Overall, the revenue raised through these mechanisms was small. The authors advise countries to consider multiple strategies to expand fiscal space for health.
11. Equity and HIV/AIDS
n Zimbabwe, research was conducted to assess the acceptability and accuracy of human immunodeficiency virus (HIV) self-testing. During implementation, the authors evaluated sex workers’ preferences for and feasibility of distribution of test kits before the programme was scaled-up. In Malawi, the authors conducted a rapid ethnographic assessment to explore the context and needs of female sex workers and resources available, leading to a workshop to define the distribution approach for test kits. Once distribution was implemented, the authors conducted a process evaluation and established a system for monitoring social harm. In Zimbabwe, female sex workers were able to accurately self-test. The preference study helped to refine systems for national scale-up through existing services for female sex workers. The qualitative data helped to identify additional distribution strategies and mediate potential social harm to women. In Malawi, peer distribution of test kits was the preferred strategy. The authors identified some incidents of social harm among peer distributors and female sex workers, as well as supply-side barriers to implementation which hindered uptake of testing. Involving female sex workers in planning and ongoing implementation of human immunodeficiency virus self-testing is essential, along with strategies to mitigate potential harm. Optimal strategies for distribution and post-test support are argued to be context-specific and to need to consider existing support for female sex workers and levels of trust and cohesion within their communities.
The paper assessed preference and uptake for the enabling environment created to deliver the different community-based HIV testing services to female sex workers along the Malaba-Kampala highway. Malaba – Kampala high way is one of the major high ways with many different hot spots where the actual buying and selling of sex takes place. The authors defined female sex workers as any female, who undertakes sexual activity after consenting with a man for money or other items/benefits as an occupation or as a primary source of livelihood irrespective of site of operation within the past six months. The authors assessed the preference and uptake of different community-based HIV testing services delivery model among female sex workers based on the proportion of female sex workers who had an HIV counseling and testing in the last 12 months and the proportion of female sex workers who were positive and linked to care. Overall, 86% of the female sex workers had taken an HIV test in the last 12 months. Of the 390 Female Sex workers, 72% had used static facilities, 25% had used outreaches, and 3.3% used peer to peer mechanisms to have an HIV test. Overall, 35% of the female sex workers who had taken an HIV test were HIV positive. Of the 159, 83% were successfully linked into care. Ninety one percent reported to have been linked into care by static facilities. Challenges experienced included; lack of trust in the results given during outreaches, failure to offer other testing services including hepatitis B and syphilis during outreaches, inconsistent supply of testing kits, condoms, STI drugs, and unfriendly health services due to the infrastructure and non-trained health workers delivering KP HIV testing services. Most of the Female Sex workers had HIV counseling and testing services and were linked to care through static facilities. Community-based HIV testing service delivery models are challenged with inconsistent supply of HIV testing commodities and unfriendly services. The authors recommended strengthening of all HIV testing community-based HIV testing service delivery models by ensuring constant supply of HIV testing/AIDS care commodities offering Female Sex workers friendly services, and provision of comprehensive HIV/AIDS health care package.
12. Governance and participation in health
Over 200 women farm workers from across the Western Cape marched to Parliament on Wednesday demanding that the Department of Agriculture, Forestry & Fisheries (DAFF) and the Department of Labour work together to ban 67 pesticides to protect the health of farm workers. They also want farmers to be held accountable if they disobey labour practices. Research done by the 'Women on Farms' project showed that 73% of women seasonal workers interviewed did not receive protective clothing and 69% came into contact with pesticides within an hour after it had been sprayed. For safety, different pesticides have their own “re-entry period” that has to be adhered to. The WFP campaign to ban pesticides is also being supported by Oxfam South African and Oxfam Germany. With the memorandum, members from Oxfam Germany handed over a placard with 29,302 signatures on it from German consumers supporting the ban.
In January the All Party Parliamentary Group (APPG) for Africa working in coalition with the APPG for Diaspora, Development and Migration and the APPG for Malawi hosted a meeting in parliament to hear oral evidence on UK visa refusals for African visitors. Participating organisations and individuals gave numerous accounts of conferences, festivals, collaborations and business and trade partnerships that had been undermined due to legitimate African participants being denied visas. Statistics show that UK visa refusals are issued at twice the rate for African visitors than for those from any other part of the world. Evidence strongly demonstrates that the UKVI system lacks consistency, intelligence and any accountability. The immediate cost, needing to access the internet and to pay in a foreign currency all present initial barriers. Other than the practical barriers faced by the applicants, the huge distances between the place of application and where the decisions are made means they are usually made away from local expertise, context and insight that would have previously be held at the High Commissions. The last report on visa services, from the Independent Chief Inspector in 2014 found that over 40% of refusal notices were “not balanced, and failed to show that consideration had been given to both positive and negative evidence”. The panel heard that applicants are often refused based on a lack of proof or information that was not required or even mentioned under the guidelines for the application. The meeting concluded that the current system was not designed but has organically grown into something that is not fit for purpose.
Following the High-Level Meeting on Universal Health Coverage (UHC) UN member states are expected to show more financial and political commitment to accelerate progress towards UHC.. Different approaches have been taken by different countries in Africa for this. Rwanda has used affordable health finance and insurance mechanisms - financed by both the national government and individuals - as a crucial driver for UHC. In 2018, Kenya also unveiled a plan for reaching UHC by 2022 by piloting UHC in four counties. The prioritization of such policy options and the ways to implement them are seen to require a. context-dependent balancing act that should be grounded in the correct application of evidence in decision-making processes. This is obserbed to demand measures to build individual and institutional capabilities to generate and use evidence to support value-based design and implementation of relevant system-level policy reforms for UHC.
13. Monitoring equity and research policy
Health facility data are a critical source of local and continuous health statistics. Countries have introduced web-based information systems that facilitate data management, analysis, use and visualisation of health facility data. Working with teams of Ministry of Health and country public health institutions analysts from 14 countries in Eastern and Southern Africa, the authors explored data quality using national-level and subnational-level (mostly district) data for the period 2013–2017. The focus was on endline analysis where reported health facility and other data are compiled, assessed and adjusted for data quality, primarily to inform planning and assessments of progress and performance. The analyses showed that although completeness of reporting was generally high, there were persistent data quality issues that were common across the 14 countries, especially at the subnational level. These included the presence of extreme outliers, lack of consistency of the reported data over time and between indicators (such as vaccination and antenatal care), and challenges related to projected target populations, which are used as denominators in the computation of coverage statistics. The authors propose continuous efforts to improve recording and reporting of events by health facilities, systematic examination and reporting of data quality issues, feedback and communication mechanisms between programme managers, care providers and data officers, and transparent corrections and adjustments will be critical. to improve the quality of health statistics generated from health facility data.
his study aimed to estimate the 2015 national and subnational universal health coverage service coverage (UHC) status for Ethiopia. The UHC service coverage index was constructed from indicators of four major categories using survey data and administrative data. The overall Ethiopian UHC service coverage for 2015 was 34.3%, ranging from 52.2% in Addis Ababa city to 10% in the Afar region. The coverage for non-communicable diseases, reproductive, maternal, neonatal and child health and infectious diseases were 35%, 37.5% and 52.8%, respectively. The national UHC service capacity and access coverage was only 20% with large variations across regions, ranging from 3.7% in the Somali region to 41.1% in the Harari region. The 2015 overall UHC service coverage for Ethiopia was low compared with most of the other countries in the region. There was a substantial variation among regions. The authors argue that Ethiopia should rapidly scale up promotive, preventive and curative health services through increasing investment in primary healthcare if it aims to reach the UHC service coverage goals, and to narrow the gap across regions, such as through redistribution of the health workforce, increasing resources allocated to health and providing focused technical and financial support to low-performing regions.
Sub-Saharan Africa accounts for 13.5% of the global population but less than 1% of global research output. In 2008, Africa produced 27 000 published papers—the same number as The Netherlands. Informed by a nuanced understanding of the causes of the current scenario, the authors propose action that should be taken by African universities, governments, and development partners to foster the development of research-active universities on the continent. Sub-Saharan Africa depends greatly on international collaboration and visiting academics for its research output. Many researchers whose publications are associated with sub-Saharan Africa are described as non-local and transitory; they spend less than 2 years at sub-Saharan African institutions. Meanwhile, intra-Africa collaboration remains severely restricted. The authors note that research-intensive universities across sub-Saharan Africa need to be identified, recognised, strengthened, and invested in. These research-intensive universities should focus their resources on graduate training and research. Creating and maintaining research-intensive universities will require consistent investment in human capital, research equipment, and relevant administrative support, at far higher levels than is available under current conditions. New funding mechanisms need to be created to support research-intensive Africa universities. At a minimum, research-intensive universities should commit their own resources to research. African Governments must increase their support for research in general and provide targeted funding for research-intensive universities. They suggest that this will only succeed and be sustained if there is accountability, transparency, and efficiency in the use of funds at research-intensive universities.
Over the past two decades, Africa has returned to academic agendas outside of the continent. At the same time, the field of African Studies has come under increasing criticism for its marginalisation of African voices, interests, and agendas. This article explores how the complex transformations of the academy have contributed to a growing division of labour. Increasingly, African scholarship is associated with the production of empirical fact and socio-economic impact rather than theory, with ostensibly local rather than international publication, and with other forms of disadvantage that undermine respectful exchange and engagement. This discourages engagement with Africa as a place of intellectual production in its own right. By arguing that scholars can and should make a difference to their field, both individually and collectively, the author suggests ways of understanding and engaging with these inequalities.
In 2018, Ifakara Health Institute disseminated results emerging from the formative study for Children In the Mining (CIM) seeking to improve access to social- economic and health services for children living in the mining areas in Bukombe, Songwe and Chunya districts of Tanzania. Using an action-based approach, members of the Kerezia community involved reflected on the findings and developed a plan of action to address the social-economic problems that face children living in the mining areas. The villagers prioritized water, roads and schooling. A while later the villagers reported to the IHI researchers: "We are happy to tell you that one of our priorities has been implemented and through the efforts of community members, we have constructed a foundation for the primary school here in our village [........] I was really wondering how I could see you and inform you about this progress." The Kerezia story is argued to highlight how scientists need to go beyond the traditional methods of sharing research findings and apply action-based dissemination where possible to influence change at the grass roots.
Countries in the Global South continue to struggle to train and retain good researchers and practitioners to address local, regional and global health challenges. As a result, there is an ongoing reliance on the Global North for solutions to local problems and an inability to develop alternative approaches to problem solving that take local (non-northern) contexts into account. Current paradigms of scientific advancement provide no long-term models to challenge the status quo or privilege knowledge that is generated primarily in the Global South. This has major impacts on access to funding which perpetuates the problem. The authors argue that there needs to be a concerted and demonstrable shift to value and promote the development of research and scientific traditions that are borne out of the reality of local contexts that complement knowledge and evidence generated in the Global North.
14. Useful Resources
Crowdsourcing tools, such as challenge contests, are increasingly used to improve public health. Crowdsourcing is the process of having a large group, including experts and non-experts, solve a problem and then share the solution with the public. This guide provides practical advice on designing, implementing and evaluating crowdsourcing activities for health and health research – with descriptions and examples of contests collected through a challenge contest The guide includes: descriptions of and methods for challenge contests for health and health research; how to organize and evaluate contests; practical resources, such as a challenge contest checklist; case studies; and a table of commended challenge contests for health submitted through the report’s challenge contest in 2017. The report was developed by the Social Entrepreneurship to Spur Health (SESH) and the TDR-supported Social Innovation in Health Initiative (SIHI).
In this TED talk, Chimamanda Ngozie Adichie warns of ‘the danger of the single story’. She describes how impressionable and vulnerable people are in the face of a story, particularly as children. She notes that stories matter, but also that many stories matter and no single story can portray a reality. Stories have been used to dispossess and to malign, but stories can also be used to empower and to humanize. Stories can break the dignity of a people, but stories can also repair that broken dignity.
15. Jobs and Announcements
The theme for the 7th International Conference on the History of Occupational and Environmental Health is ‘Occupational and Environmental Health: At the Crossroads of Migrations, Empires and Social Movements’. The scientific programme will focus on the migration of workers in various time periods, the interconnections of empires, public health in post-colonial periods, and the role of trade unions and other social movements in occupational and environmental health. The evolution of occupational and environmental health especially in Africa, as well as globally, will be addressed. The conference is intended to promote interconnections among historians, social scientists and occupational and environmental practitioners/researchers. Leading historians in occupational and environmental health have been invited to give keynote lectures. In addition, there will be an open call for abstracts for oral and poster presentations and a pre-conference methods training workshop. Please visit the conference website for instructions on submission of your abstract: You may now register for the Conference at https://icohhistory2020.ukzn.ac.za/registration-information/. Early bird registration will close on 15 January 2020. Early and mid-level academics from African countries are encouraged to apply for the fee waiver.
The Sixth Global Symposium on Health Systems Research (HSR2020) is now accepting individual abstracts (including oral presentations and posters), multimedia abstracts and skills-building sessions. You can find out more about key dates and how to submit on the HSR2020 abstracts webpage.
The CADFP is a scholar exchange program for African higher education institutions to host a diaspora scholar for 14-90 days for projects in curriculum co-development, research collaboration and graduate student teaching and mentoring. Accredited universities in Ghana, Kenya, Nigeria, South Africa, Tanzania and Uganda and member institutions of the African Research Universities Alliance (ARUA) can submit a project request to host a scholar. Scholars born in Africa, who live in the United States or Canada and work in an accredited college or university in either of those two countries, can apply online to be placed on a roster of candidates for a fellowship. Scholars must hold a terminal degree in their field and may hold any academic rank. Links and information about the African host institution project request application, scholar roster application, and review guidelines are posted on the CADFP website.
The International Conference on Thinking (ICOT2020) will showcase African thinking and its contribution to shaping the progress of societies around the world. ICOT2020 will take place in Ekurhuleni, Johannesburg, South Africa, with the theme of thinking to transform societies. The core focus is education, with environment, business, health, sport and society as the other strands. Sub-themes engage with teaching for better thinking engagement, impact and innovation, fostering an entrepreneurial mindset, breaking from poverty creating, imagining, innovating, promoting an ethic of care towards a sustainable future and exploring African ways of thinking.
The International Health Economics Association (iHEA) is pleased to invite nominations for the Annual Student Paper Prize in Health Economics. Nominations should include a brief letter of nomination (250 words max) and a copy of the paper (preferably pdf). A student is defined as someone currently studying (full or part time) at a higher education institution, at either Masters or Doctoral level. In addition, students who have completed their studies in the year previous to the announcement qualify as long as the paper was written while registered as a student. Papers can be published or unpublished, but must be in comparable format to a published paper in Journal of Health Economics or Health Economics, of maximum length 8,000 words. Self nomination is acceptable. Papers should be in English. If a submitted paper has more than one author, the student contribution must be at least 75% overall and an accompanying letter must be signed by co-authors to support this, stating the nature of their contribution (conceptualization, analysis, writing etc.). A joint student paper with 50-50 contributions is acceptable. The Prize will be subsidized travel and attendance at the 2021 iHEA Congress in Cape Town to present the paper in a Student Prize Special Organised Session chaired by the iHEA President, or Chair of the Prize Committee; the equivalent of US$1,000; and the offer (if the author wishes, and the paper is unpublished) of potential fast track publication in Health Economics, subject to Editorial approval. The papers in 2nd and 3rd place will receive the equivalent of US$250 each and free registration (but not travel) at the 2021 Cape Town iHEA Congress. They will be invited to give brief presentations at the iHEA Congress Student Prize Special Organized Session. Applications and inquiries to the email address below.
The Africa Multiple Cluster of Excellence at the University of Bayreuth is establishing four Junior Research Groups commencing on July 1, 2020 and is seeking to appoint Four Junior Research Group Leaders for a funding period of four years. The doctoral students will pursue their degrees within the Bayreuth International Graduate School of African Studies. African women and women of colour are strongly encouraged to apply and applicants with children are highly welcome.
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