Current Issue

EQUINET NEWSLETTER 198 : 01 September 2017

1. Editorial

Take health systems out of the market place to build their resilience
Mulumba, Moses, Center for Health Human Rights and development, Uganda


There is increasing global focus on building resilient and responsive health systems to improve population health. It raises questions: What constitutes a resilient health system? Is it one that is able to absorb shocks? Is it one that is able to anticipate shocks and engage with their political and economic determinants? To what extent has this language of resilience enabled an approach towards sustaining health systems in the most economically efficient manner feasible, with minimal public sector investments? And what does this mean for people’s rights to health?

A retrospective look at lessons from key moments in health policy, research and practice sheds light on some of these concerns. Key documents such the 1974 Lalonde Report, the 1978 Alma Ata Declaration on Primary Health and the 1986 Ottawa Charter from the first International Conference on Health Promotion focused policy attention on health systems built on prevention of health problems and promotion of good health. The Alma Ata Declaration emphasized investments in primary health care and highlighted that people have a right and duty to participate individually and collectively in the planning and implementation of their health care. The policy focus moved away from medicalized health systems to more inclusive ones, with community-engagement based on human rights principles.

There was however a shift in health policy from the last 1980’s. Primary health care approaches and health promotion strategies were criticized for being unmanageable, lacking clear measurable targets and being costly to sustain. Alternative, selective approaches were advanced, focused on specific diseases and measurable, cost effective interventions. Disease specific programs grew for key areas such as HIV and AIDS, tuberculosis, malaria and maternal health, with funding mainly targeting these programs. Funding and incentivizing disease specific intervention targets carries the risk of weakening wider primary health care measures, including for community participation in health decision making. A disease focus can ignore determinants of epidemics and other ‘neglected’ diseases, and set up parallel programming siphoning key health personnel from the wider health system to the better resourced diseases specific projects. These effects lead to health systems that have weak links to communities and wider health problems, that are neither resilient not responsive and that leave people exposed to outbreaks of epidemics, such as Ebola virus disease and cholera.

The mindset of efficiency over-riding other considerations in health systems was heavily reinforced in the late 1980s and early 1990’s, when the World Bank and the IMF introduced neoliberal structural adjustment programs as a condition for loans. The major budget cuts to the social sectors, including health, from these programmes are well documented. Economic models that imply that public expenditure on systems and social roles is wasteful or inefficient combined with a pressure of reduced public funding for health services, as reported in EQUINETs regional equity analyses in 2007 and 2012, reducing investment in comprehensive primary health care despite its pro-poor benefit and reinforcing the narrow disease focus. It also enabled the health sector to be judged by the same principles as other areas of the market, within development frameworks that heavily promoted the ‘free market’, despite the global market being anything but free. At national level, poverty reduction strategy papers that were seen as dealing with ‘transitional poverty’, segmenting it as an unfortunate by product of an essentially positive approach, metamorphosed into national development plans that conceptualised national health policies and strategies more from an economic than a public health perspective.

As raised in various reports, including by EQUINET, Oxfam and the Municipal Services Project, and by S Nishtar in her submission to the 2016 World Economic Forum, this mindset has opened the doorway in the current decade to the commodification of our public health systems in the market place, and in some settings to the sale of public assets or private sector roles that have commercialised the provision of health care and deepened inequities. The effect has been to slowly but surely weaken the role of the state in resilient and responsive health systems. It is therefore not surprising that the private sector role is growing in our health systems in the region, whether in terms of provisioning of services, or in the heavily promoted role of social health insurance and even voluntary and community health insurance (rather than mandatory insurance or taxes) as a vehicle for service funding, with the untested promise in the region of more resources and more efficient funding. As private actors have gained an increasing role in our health systems, they are also giving increasing voice to the private sector in health agenda setting at national and global level, most recently raised in the debates on the Framework for engagement of non-state actors in the World Health Organisation. It is thus not surprising to find that the current proposals on universal health coverage that we hear in the region are dominated by business models centred on health insurance rather than human rights principles.

These trends raise a challenge for us: To carry out research that critically interrogates that assumptions and paradigms introduced into our region and to explore how to defend and advance comprehensive primary health care and human rights based approaches in health systems. This implies more questioning from the region at global level of the assumptions that are driving this role of the market and the private sector in our health systems, and what implications it has for rights-holders and duty bearers. This has two evident implications: it implies that we cannot continue to allow a retreat of the state from the health sector, whether in terms of diminished funding, weakened regulatory power, public health services or participatory governance. It also implies that we bring communities, their rights and evidence, more centrally into the setting of policies, priorities and in shaping services, not simply as a means of taking on unfunded service burdens, but as the central resource for the state and public sector in building resilient and responsive health systems.

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

2. Latest Equinet Updates

EQUINET in the 13th annual Southern African Civil Society Forum
Johannesburg, August 14-16 2017

The 13th Southern African Civil Society Forum was held from 14-17 August 2017 at Birchwood Hotel and Conference Centre Johannesburg, organised by the Southern African Development Community (SADC) Council of Non government organisations (CNGO), Southern African Trade Union Co-ordinating Council (SATUCC) and Federation of Churches in Southern Africa (FOCISA). It involved about 300 delegates from different constituencies and civil society organisations across the SADC region. A commission session was convened by EQUINET and SATUCC within the 13th Southern African Civil Society Forum to share information on the findings and proposals for harmonised regional standards on health in the extractive sector. The session objectives were to discuss the key issues and formulate concrete strategies for responding to the regional context and priority challenges for protection of health in the extractive sector in the region and to make proposals for harmonised regional standards to protect health in the sector. Delegates recommended that health be included in the SADC harmonised standards for the mining sector, with a comprehensive focus on public health and environment, with details of what this means and actions proposed at national, regional and local level.

3. Equity in Health

Lifestyle and income-related inequality in health in South Africa
Mukong A; Van Walbeek C; Ross H: International Journal for Equity in Health 16(103), doi: 10.1186/s12939-017-0598-7, 2017

Many low - and middle-income countries are experiencing an epidemiological transition from communicable to non-communicable diseases, imposing both economic and health burdens on their societies. While the prevalence of such diseases varies with socioeconomic status, the inequalities can be exacerbated by lifestyles. This paper explored the contribution of smoking and alcohol consumption to health inequalities, incorporating measures of health directly associated with these lifestyle practices from National Income Dynamic Study panel data for South Africa. The authors found significant smoking-related and income-related inequalities in both self-reported and lifestyle-related ill-health. The results suggest that smoking and alcohol use contribute positively to income-related inequality in health. Smoking participation accounts for up to 7.35% of all measured inequality in health and 3.11% of the inequality in self-reported health. The estimates are generally higher for all measured inequality in health (up to 14.67%) when smoking duration is considered. Alcohol consumption accounts for 27.83% of all measured inequality in health and 3.63% of the inequality in self-reported health. This study provides evidence that inequalities in both self-reported and lifestyle-related ill-health are highly prevalent within smokers and poor people. The authors suggest that policies aimed at reducing tobacco consumption and harmful alcohol will improve health and reduce health inequalities.

Measurement and decomposition of socioeconomic inequality in single and multimorbidity in older adults in China and Ghana: results from the WHO study on global AGEing and adult health
Kunna R; Sebastian M; Williams J: International Journal for Equity in Health 16(79), doi: 10.1186/s12939-017-0578-y, 2017

There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana, using data from the World Health Organisation Study on Global AGEing and Adult Health 2007–2010. In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China. In Ghana inequalities were significant and more highly concentrated among the rich. In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multi morbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multi- morbidity. The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions.

Mortality among twins and singletons in sub-Saharan Africa between 1995 and 2014: a pooled analysis of data from 90 Demographic and Health Surveys in 30 countries
Monden C; Smits J: The Lancet Global Health 5(7), e673-e679, 2017

Sub-Saharan Africa has the world's highest under-5 and neonatal mortality rates as well as the highest naturally occurring twin rates. Twin pregnancies carry high risk for children and mothers. Under-5 mortality has declined in sub-Saharan Africa over the last decades. It is unknown whether twins have shared in this reduction. The authors pooled data from 90 Demographic and Health Surveys for 30 sub-Saharan Africa countries on births reported between 1995 and 2014 to address this question. Under-5 mortality among twins declined from 327 per 1000 live births in 1995–2001 to 213 in 2009–14. This decline of 35% was less steep than the 51% reduction among singletons. Twins account for an increasing share of under-5 deaths in sub-Saharan Africa: currently 11% of under-5 mortality and 15% of neonatal mortality. Excess twin mortality cannot be explained by common risk factors for under-5 mortality, including birth-weight. The difference with singletons was especially stark for neonatal mortality and 52% of women pregnant with twins reported receiving medical assistance at birth. The authors note that an alarming one-fifth of twins in the region dies before age 5 years, three times the mortality rate among singletons. Twins account for a substantial and growing share of under-5 and neonatal mortality, but they are largely neglected in the literature. They argue that co-ordinated action is required to improve the situation of this extremely vulnerable group.

The State of the World’s Children 2016: A fair chance for every child
United Nations Children's Fund: UNICEF, New York, 2016

Based on current trends, 69 million children under five will die from mostly preventable causes, 167 million children will live in poverty, and 750 million women will have been married as children by 2030, the target date for the Sustainable Development Goals – unless the world focuses more on the plight of its most disadvantaged children, according to a UNICEF report released today. The State of the World’s Children, UNICEF’s annual flagship report, paints a stark picture of what is in store for the world’s poorest children if governments, funders, businesses and international organisations do not accelerate efforts to address their needs. The publication argues that progress for the most disadvantaged children is not only a moral, but also a strategic imperative. Stakeholders must have an obvious choice to make: invest in accelerated progress for the children being left behind, or face the consequences of a far more divided world by 2030. At the start of a new development agenda, the report concludes with a set of recommendations to help chart the course towards a more equitable world.

4. Values, Policies and Rights

Charter of the North African Network for Food Sovereignty
North African Network for Food Sovereignty: Pambazuka News, July 2017

Activists from organisations in North Africa met in Tunis in July 2017 to set up the North African Network for Food Sovereignty. The network’s charter states that food sovereignty is the human right of peoples as individuals and communities to define their own food systems. Food sovereignty is tied to the right of people to self-determination at the political, economic, social, cultural and environmental levels. It means, working with nature and protecting resources to produce sufficient, healthy and culturally appropriate food by giving priority to local production and staple food, putting in place popular agrarian reforms, guaranteeing free access to seeds, protecting national produce and by involving people in elaborating agricultural policies. The charter identifies that this is undermined by extractivist policies implemented in the name of development and by neoliberal adjustment policies. In order to address this the North African Food Sovereignty Network was formed to achieve food sovereignty, climate and environmental justice, through critical studies; campaigns, workshops, direct actions as well as networking, coordination and solidarity with movements that share objectives.

How access to knowledge can help universal health coverage become a reality
Bruijns S: The Conversation, 29 June 2017

The WHO Director General Dr Ghebreyesus has set universal health coverage (UHC) as one of the main priorities for his term. His goal is a challenging one, especially for low and middle income countries which make up around 84% of the world’s population. They only have access to half the physicians and a quarter of the nurses that high income countries have access to. Similarly low and middle income countries only spend around US $266 per capita on health care. In contrast, high income countries spend US $5 251 per capita. This means that attaining universal health coverage in poorer settings is challenging. Large cuts to foreign aid investment from a number of high income economies only compound this challenge. Low and middle income countries also invest around a third of what high income countries invest in research to generate the knowledge needed for UHC. They also have access to around a fifth of the researchers high income countries have access to. Much of the knowledge required to establish the universal health coverage already exists but poor access presents a major barrier to achieving the goal. To unlock this knowledge for everyone’s benefit, the author proposes that policymakers and publishers consider more innovative ways to provide access to available knowledge.

The role of women's leadership and gender equity in leadership and health system strengthening
Dhatt R; Theobald S; Buzuzi S; et al.: Global Health, Epidemiology and Genomics 2(e8), doi: https://doi.org/10.1017/gheg.2016.22, 2017

This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women's leadership within global health is an opportunity to further health system resilience and system responsiveness. The authors conclude with an agenda and tangible next steps of action for promoting women's leadership in health as a means to promote the global goals of achieving gender equity. This includes leadership that is gender responsive and institutionalised; development of enabling environments for women's leadership; increasing thought leadership events related to women's role in global health; supporting leadership development, including management training and soft skills and building capacity, including formal training in technical skills, research and mentorship. The authors also call for improved policy and practice in terms of the health and safety risks women face in carrying out their health-related roles.

5. Health equity in economic and trade policies

A paradigm shift for socioeconomic justice and health: from focusing on inequalities to aiming at sustainable equity
Garay J; Chiriboga D: Public Health 149, doi: http://dx.doi.org/10.1016/j.puhe.2017.04.015, 2017

This study measured the ‘best possible health for all’, incorporating sustainability, to establish the magnitude of global health inequity. The authors identified countries with three criteria: firstly, a healthy population—life expectancy above world average; secondly, living conditions feasible to replicate worldwide—per-capita gross domestic product (GDP-pc) below the world average; and thirdly, sustainability—per-capita carbon dioxide emissions lower than the planetary pollution boundary. Using these healthy, feasible, and sustainable (HFS) countries as the gold standard, the authors estimated the burden of global health inequity (BGHiE) in terms of excess deaths, analysing time-trends (1950–2012) by age, sex, and geographic location. Finally, the authors defined a global income ‘equity zone’ and quantified the economic gap needed to achieve global sustainable health equity. A total of 14 countries worldwide met the HFS criteria. Since 1970, there has been a BGHiE of about 17 million avoidable deaths per year (about 40% of all deaths), with 36 life-years-lost per excess death. Young children and women bore a higher BGHiE, and, in recent years, the highest proportion of avoidable deaths occurred in Africa, India, and the Russian Federation. By 2012, the most efficient HFS countries had a GDP-per capita/ year of US$2165, which the authors proposed as the lower equity zone threshold. The estimated US$2.58 trillion economic gap represents 3.6% of the world's GDP—twenty times larger than current total global foreign aid. Sustainable health equity metrics provide a benchmark tool to guide efforts toward transforming overall living conditions, as a means to achieve the ‘best possible health for all.’

Magufuli: Barrick ready to pay what it owes Tanzania
Mtulya A: The Citizens, 14 June 2017

President of the United Republic of Tanzania, John Magufuli has met with Prof John Thornton, Chairman of Barrick Gold Canada, parent company of Acacia Mining to discuss the issue of mineral sand exportation in Tanzania. The new development came after Dr Magufuli received two reports on the exportation of mineral concentrates abroad for smelting. The first committee probed at the technical aspects of the concentrate and the second committee examined the economic and legal frameworks around the export. Both reports damned Acacia for foul play and suggested that Tanzania lost over Sh100 trillion since it started exporting concentrates in the late 1990s. Dr Magufuli who was accompanied by the Minister for Legal and Constitutional Affairs Prof Palamagamba Kabuki said the meeting was successful and Barrick have “repented” for what has happened and they are ready to compensate Tanzania for the loss that has been incurred over the years. Dr Magufuli announced on a video clip tweeted on the official government spokesperson account that Barrick have “repented” and are ready to compensate Tanzania for the loss incurred over the years. Garrick Gold Canada is the largest shareholder of the Acacia Mining Company. On March 2017, the export of mineral concentrates by Barrick from Tanzania was stopped by Presidential directive.

Open letter to WHO on industrial animal farming
Weathers S; Hermanns S; and 270 expert signatories: Open Letter Animal Farming, 2017

In this letter over 200 scientists, policy experts and others concerned persons are urging the new World Health Organisation Director-General to recognise and address factory farming as a growing public health challenge. The authors suggest that WHO negotiate country-level standards for antibiotic use in animal husbandry, in coordination with the Food and Agricultural Organisation. Member states should be encouraged to articulate specific, verifiable standards for what constitutes legal antibiotic use in animal farms. Further, meat producers should dispose of antibiotics and waste residue properly to prevent environmental contamination and excess greenhouse gas emissions and work with all relevant ministries, including those outside of health, to reduce the size and number of factory farms to better balance dietary need and ecological capacity. WHO should discourage member states from subsidising factory farming and its inputs, which can cause significant harm to the public and consider the application of relevant fiscal policies in member states that would help to reduce meat demand and consumption, especially where consumption exceeds health recommendations. WHO should encourage member states to adopt nutrition standards and implement health education campaigns which inform citizens of the health risks of meat consumption and work closely with ministers of health and agriculture to formulate policies that advocate for a greater proportion of plant-based foods in the diets of member states. Lastly, they recommend that the WHO should consider funding the scientific development of plant-based and other meat alternatives, which have the potential to eliminate or reduce the harms of factory farming.

The future of cities according to women : Interview with Thozama Mputa, Michelle Mlati and Counterspace
Interview with Thozama Mputa, Michelle Mlati and Counterspace: Future Cape Town, 9 August 2017

In April and May 2017, the Constructing Future Cities project supported by the British Council engaged with 5 women artists on the topic of future cities. Mputa identified the fact that women do not feel safe and are not safe in cities as something that needs to be addressed. Sputa noted that one would experience a space differently if one had an opportunity to contribute and to be informed during the design process. One would take pride in the space, be able to use the space effectively and educate others on spaces in the city. Her vision of a future city; a city that acknowledges its past, celebrates the present and plans for change, an inclusive city designed by its inhabitants and explored by its visitors. Her artwork makes use of hatching to illustrate and merge faces, landscapes and cityscapes. Creating rhythm and pattern emphasised by the use of colour. Mlati identified a need to expand thinking about energy sources, moving beyond solar panels as infrastructure towards thinking of an intersection of art, architecture and energy. Mlati notes that those whose experiences of the city have flourished despite alienation hold clues from future urban practice.

6. Poverty and health

World poverty could be cut in half if all adults completed secondary education
United Nations Educational, Scientific and Cultural Organisation: UNESCO Policy Paper 32, Fact sheet 44, New York, 2017

This UNESCO policy paper reports that the global poverty rate could be more than halved if all adults completed secondary school. Yet, new data from the UNESCO Institute for Statistics (UIS) show persistently high out-of-school rates in many countries, making it likely that completion levels in education will remain well below that target for generations to come. The paper demonstrates the importance of recognising education as a core lever for ending poverty in all its forms, everywhere. The analysis of education’s impact on poverty shows that nearly 60 million people could escape poverty if all adults had just two more years of schooling. Despite education’s potential, new UIS data show that there has been virtually no progress in reducing out-of-school rates in recent years. Globally, 9% of all children of primary school age are still denied their right to education, with rates reaching 16% and 37% for youth of lower and upper secondary ages, respectively. In total, 264 million children, adolescents and youth were out of school in 2015. UNESCO argues that education must reach the poorest households to maximise its benefits and reduce income inequality.

7. Equitable health services

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania.
Kruk M; Chukwuma A; Mbaruku G; Leslie H: Bulletin World Health Organisation 95(6), 408-418, 2017

This study analysed factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. The authors pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006-2014). Based on World Health Organisation protocols, the authors created indices of process quality for antenatal care (first visits) and for sick-child visits. The authors assessed national, facility, provider and patient factors that might explain variations in quality of care. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The quality of two essential primary-care services for women and children was weak and varied across and within the countries. The authors propose that analysis of reasons for these variations in quality could identify strategies for improving care.

World Health Organisation: What is people-centred care?
World Health Organisation: WHO, Geneva, 2017

This video from WHO introduces the concept of people-centred care. Globally, one in 20 people still lack access to essential health services that could be delivered at a local clinic instead of a hospital. And where services are accessible, they are often fragmented and of poor quality. WHO is supporting countries to progress towards universal health coverage by designing health systems around the needs of people instead of diseases and health institutions, so that everyone gets the right care, at the right time, in the right place.

“I cry every day and night, I have my son tied in chains”: physical restraint of people with schizophrenia in community settings in Ethiopia
Asher L; Fekadu A; Teferra S; De Silva M; Pathare S; Hanlon C: Globalisation and Health 13(47), doi: 10.1186/s12992-017-0273-1, 2017

A primary rationale for scaling up mental health services in low and middle-income countries is to address human rights violations, including physical restraint in community settings. The voices of those with intimate experiences of restraint, in particular people with mensystetal illness and their families, are rarely heard. This study aimed to understand the experiences of, and reasons for, restraint of people with schizophrenia in community settings in rural Ethiopia in order to develop constructive and scalable interventions. A qualitative study was conducted, involving 15 in-depth interviews and 5 focus group discussions with a purposive sample of people with schizophrenia, their caregivers, community leaders and primary and community health workers in rural Ethiopia. Most of the participants with schizophrenia and their caregivers had personal experience of the practice of restraint. The main explanations given for restraint were to protect the individual or the community, and to facilitate transportation to health facilities. These reasons were underpinned by a lack of care options, and the consequent heavy family burden and a sense of powerlessness amongst caregivers. Whilst there was pervasive stigma towards people with schizophrenia, lack of awareness about mental illness was not a primary reason for restraint. All types of participants cited increasing access to treatment as the most effective way to reduce the incidence of restraint. Restraint in community settings in rural Ethiopia entails the violation of various human rights, but the underlying human rights issue is one of lack of access to treatment, calling for the scale up of accessible and affordable mental health care.

8. Human Resources

Harmonising community-based health worker programs for HIV: a narrative review and analytic framework
De Neve JW; Boudreaux C; Gill R; Geldsetzer P; Vaikath M; Bärnighausen T; Bossert T: Human Resources for Health 15 (45), doi:10.1186/s12960-017-0219-y, 2017

Many countries have created community-based health worker (CHW) programs for HIV, often through national and non-governmental initiatives, raising questions of how well these different approaches co-ordinate. The authors conducted a literature review on the harmonisation of CHW programs, defining harmonisation, and identifying and describing the major issues and relationships surrounding the harmonisation of CHW programs, including key characteristics, facilitators, and barriers for each of the priority areas of harmonisation. The authors found a large number and immense diversity of CHW programs for HIV. This includes integration of HIV components into countries’ existing national programs along with the development of multiple, stand-alone CHW programs. While harmonisation is likely a complex political process, with in many cases incremental steps toward improvement, a wide range of facilitators are available to decision-makers. They can be categorised into those involved in the intervention itself, in relation to stakeholders, health systems, and the broad context.

Measuring three aspects of motivation among health workers at primary level health facilities in rural Tanzania
Sato M; Maufi D; Mwingira U; Leshabari M; Ohnishi M; Honda S: PLoS ONE 12(5): e0176973, doi: https://doi.org/10.1371/journal.pone.0176973 , 2017

Tanzania faces a critical shortage of skilled health workers. While training, deployment, and retention are important, motivation is also necessary for all health workers, particularly those who serve in rural areas. This study measured the motivation of health workers who were posted at government-run rural primary health facilities. The authors sought to measure three aspects of motivation—management, performance, and individual aspects—among health workers deployed in rural primary level government health facilities. In addition, they also sought to identify the job-related attributes associated with each of these three aspects. Two regions in Tanzania were selected for the research. In each region, the authors further selected two rural districts in each in which they carried out their investigation. Motivation was associated with marital status, having a job description and number of years in the current profession for management aspects; having a job description for performance aspects; and salary scale for individual aspects. The authors conclude that having a clear job description motivates health workers, and that the existing Open Performance Review and Appraisal System, of which job descriptions are the foundation, needs to be institutionalised in order to effectively manage the health workforce in resource-limited settings.

The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania
Naburi H; Ekström A; Mujinja P; et al.: Human Resources for Health 15(35), doi: 10.1186/s12960-017-0207-2, 2017

This time and motion study in Dar es Salaam, Tanzania estimated the potential of task-shifting in services for prevention of mother to child transmission (PMTCT) to reduce nurses’ workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to community health workers in the Tanzanian public-sector health system. A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 min, followed by the first PNC visit which took 29 minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 and 13 minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses’ time could be shifted to community health workers, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on community health workers salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to community health workers, giving them more time for specialised PMTCT tasks and reducing the average cost per PMTCT patient.

9. Public-Private Mix

Improving primary health care facility performance in Ghana: efficiency analysis and fiscal space implications
Novignon J; Nonvignon J: Biological Medical Central Health Services Research 17(1) 399, doi: 10.1186/s12913-017-2347-4, 2017

This study estimated efficiency among primary health facilities (health centres), examined the potential fiscal space from improved efficiency and investigated the efficiency disparities in public and private facilities. Data was from the 2015 Access Bottlenecks, Cost and Equity project conducted by the Institute for Health Metrics and Evaluation. The Stochastic Frontier Analysis was used to estimate efficiency of health facilities. Efficiency scores were then used to compute potential savings from improved efficiency. Outpatient visits was used as output while number of personnel, hospital beds, expenditure on other capital items and administration were used as inputs. Disparities in efficiency between public and private facilities were estimated using the Nopo matching decomposition procedure. The average efficiency score across all health centres included in the sample was estimated to be 0.51, about 0.65 and 0.50 for private and public facilities, respectively. Significant disparities in efficiency were identified across the various administrative regions. With regards to potential fiscal space, the authors found that, on average, facilities could save about US$7634 if efficiency was improved. The authors also found that fiscal space from efficiency gains varies across rural/urban as well as private/public facilities, if best practices are followed. They argue for primary health facility managers to improve productivity via effective and efficient resource use, through training of health workers and improving the facility environment alongside effective monitoring and evaluation exercises.

10. Resource allocation and health financing

Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries
Stenberg L; Hanssen O; Edejer T; et al.: The Lancet Global Health, Doi: http://dx.doi.org/10.1016/ S2214-109X(17)30263-2, 2017

The ambitious development agenda of the Sustainable Development Goals (SDGs) requires substantial investments across several sectors, including for SDG 3 (healthy lives and wellbeing). No estimates of the additional resources needed to strengthen comprehensive health service delivery towards the attainment of SDG 3 and universal health coverage in low-income and middle-income countries have been published. The authors developed a framework for health systems strengthening, within which population-level and individual-level health service coverage is gradually scaled up over time and calculated projections for 67 low-income and middle-income countries from 2016 to 2030. The authors estimated that an additional $274 billion spending on health is needed per year by 2030 to make progress towards the SDG 3 targets (progress scenario), whereas US$371 billion would be needed to reach health system targets in the ambitious scenario—the equivalent of an additional $41 or $58 per person, respectively, by the final years of scale-up. In the ambitious scenario, total health-care spending would increase to a population-weighted mean of $271 per person across country contexts, and the share of gross domestic product spent on health would increase to a mean of 7.5%. Around 75% of costs are for health systems, with health workforce and infrastructure (including medical equipment) as the main cost drivers. Despite projected increases in health spending, a financing gap of $20–54 billion per year is projected. Should funds be made available and used as planned, the ambitious scenario would save 97 million lives and significantly increase life expectancy by 3·1–8·4 years, depending on the country profile. All countries will need to strengthen investments in health systems to expand service provision in order to reach SDG 3 health targets, but even the poorest can reach some level of universality. In view of anticipated resource constraints, each country will need to prioritise equitably, plan strategically, and cost realistically its own path towards SDG 3 and universal health coverage.

Implementation research to improve quality of maternal and newborn health care, Malawi
Brenner S; Wilhelm D; Lohmann J; Kambala C; Chinkhumba J; Muula A; Allegri M: Bulletin of World Health Organisation 95(7), 491–502, 2017

This study evaluated the impact of a performance-based financing scheme on maternal and neonatal health service quality in Malawi. The authors conducted a non-randomised controlled before and after study to evaluate the effects of district- and facility-level performance incentives for health workers and management teams. The authors assessed changes in the facilities’ essential drug stocks, equipment maintenance and clinical obstetric care processes. The authors observed 33 health facilities, 23 intervention facilities and 10 control facilities and 401 pregnant women across four districts. The scheme improved the availability of both functional equipment and essential drug stocks in the intervention facilities. The authors observed positive effects in respect to drug procurement and clinical care activities at non-intervention facilities, likely in response to improved district management performance. Birth assistants’ adherence to clinical protocols improved across all studied facilities as district health managers supervised and coached clinical staff more actively. Despite nation-wide stock-outs and extreme health worker shortages, facilities in the study districts managed to improve maternal and neonatal health service quality by overcoming bottlenecks related to supply procurement, equipment maintenance and clinical performance. To strengthen and reform health management structures, performance-based financing may be a promising approach to sustainable improvements in quality of health care.

11. Equity and HIV/AIDS

Effect of eliminating CD4-count thresholds on HIV treatment initiation in South Africa: An empirical modelling study
Bor J; Ahmed S; Fox M; Rosen S; Meyer-Rath G; Katz I; Tanser F; Pillay D; Bärnighausen T: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178249, 2017

The World Health Organisation recommends initiating antiretroviral therapy (ART) regardless of CD4 count. The authors assessed the effect of ART eligibility on treatment uptake and simulated the impact of WHO’s recommendations in South Africa, through an empirical analysis of cohort data using a regression discontinuity design, used for policy simulation. They enrolled all patients (n = 19,279) diagnosed with HIV between August 2011 and December 2013 in the Hlabisa HIV Treatment and Care Programme in rural South Africa. Patients were ART-eligible with CD4<350 cells/mm3 or Stage III/IV illness. The authors estimated: (1) distribution of first CD4 counts in 2013; (2) probability of initiating ART ≤6 months of HIV diagnosis under existing criteria at each CD4 count; (3) probability of initiating ART by CD4 count if thresholds were eliminated; and (4) number of expected new initiators if South Africa eliminates thresholds. In 2013, 39% of patients diagnosed had a CD4 count ≥500. 8% of these patients initiated even without eligible CD4 counts. If CD4 criteria were eliminated, the authors project that an additional 19% of patients with CD4 ≥500 would initiate ART; and 73% would not initiate ART despite being eligible. Eliminating CD4 criteria would increase the number starting ART by 27%. If these numbers hold nationally, this would represent an additional 164,000 initiators per year, a 5% increase in patients receiving ART and 5% increase in programme costs. Removing CD4 criteria alone will modestly increase timely uptake of ART. However, the authors results suggest the majority of newly-eligible patients will not initiate. Improved testing, linkage, and initiation procedures are needed to achieve 90-90-90 targets.

The importance of sexual and reproductive health and rights to prevent HIV in adolescent girls and young women in eastern and southern Africa
World Health Organisation: WHO Evidence Brief, WHO/RHR/17.05, Geneva, 2017

Over the last several years, countries in the eastern and southern Africa (ESA) region have made significant and commendable progress in preventing mother-to-child transmission (PMTCT) of HIV and in scaling up HIV treatment efforts. However, despite these gains, there have been no significant reductions in new HIV infections and the region continues to be the hardest hit by the epidemic, highlighting the need to place stronger emphasis on HIV prevention. The risk of HIV infection among adolescent girls and young women (AGYW) in the ESA region is of particular concern. The 2016 UNAIDS World AIDS Day report, Get on the Fast-Track – The life-cycle approach to HIV, stated that efforts to reduce new HIV infections among young people and adults have stalled, threatening to undermine progress towards ending AIDS as a global public health threat by 2030. This evidence brief reviews the background and makes recommendations for steps to develop a comprehensive approach to HIV prevention for AGYW in the context of sexual and reproductive health and rights. Firstly, it calls for measures to build on current commitments and national priorities and in a comprehensive approach. Further steps include reviewing evidence-based interventions for AGYW, operationalising and evaluating multisectoral approaches through reviewing different country strategies and identifying funding opportunities. Several next steps were proposed, including exploring and developing a few case studies of specific programme experience or coordination processes and mechanisms to illustrate possible best practices and address outstanding questions and monitoring, evaluating and documenting the scale-up of integrated HIV-prevention and SRHR interventions for AGYW in the context of different initiatives, to identify optimal approaches to scaling up the delivery of successful interventions.

12. Governance and participation in health

African peasants highlight their struggles at Via Campesina global conference
Monjane B: Pambuzuka News, July 2017

Peasants across Africa are intensifying their struggles against land grabs and other harmful policies that promote industrial agriculture. At a recent international conference organised by the world’s largest peasants movement, Via Campesina, African peasants had opportunities to share their experiences of struggle and to learn. This conference happens at a time when Africa is undergoing a harsh moment, as indicated by Ibrahima Coulibaly from the National Coordination of Peasant Organizations (CNOP) in Mali. They note that land, mineral resources, seeds and water are increasingly being privatised due to the myriad of investment agreements and policies driven by new institutional approaches, imposed on the continent by western powers and Bretton Woods institutions. Elizabeth Mpofu, from the Zimbabwe Smallholder Farmers Forum, is a small-scale farmer who had access to land after she took part in the radical land occupation that resulted in the fast-track land reform in the early 2000s. According to her, building alternatives is to take direct action. Domingos Buramo, from the Mozambique Peasants Union (UNAC), brought to the conference the experience of the Mozambican peasants and other civil society organisations against land grabbing and large-scale investment projects in Mozambique. He mentioned that the resistance to ProSavana, a large-scale agricultural project proposed for Mozambique, is an example of how transformative articulated struggles could be. “Now the government is changing its vision as a result of our work. We can change our societies”, he said. Africa - including the Maghreb region - was the last continent to be part of Via Campesina. Since 2004 the number of African peasant movements joining La Via Campesina has been increasing. African movements consider their membership to the peasant movement as a strategic process of amplifying their struggles and reinforcing internationalism.

Engaging Parliament to clarify the legal and policy frame work of Abortion in Uganda
Juuko D: Center for Health, Human Rights and Development (CEHURD), Uganda, June 2017

CEHURD within the Coalition to Stop Maternal Mortality Due to Unsafe Abortion (CSMMUA) held a meeting in June 2017 with Uganda Women’s Parliamentary Association (UWOPA) to clarify on the legal and policy framework on sexual and reproductive health and to discuss evidence based approaches to address unsafe abortion even where the law is restrictive. In Uganda, unsafe abortion is one of the leading causes of maternal morbidity and mortality, contributing to approximately 26% of the estimated 6,000 maternal deaths every year and an estimated 40% of admissions for emergency obstetric care. The meeting was motivated by a conviction that as policy makers, Members of Parliament (MPs) have a role to play in law reform on sexual and reproductive health issues and to interact with communities in their various constituencies. The meeting paved a way for an open discussion on unsafe abortions as a public health issue and the different stakeholders’ and policy makers' roles in reducing abortion related deaths in Uganda.

The Cholera Epidemic in Zimbabwe, 2008–2009: A Review and Critique of the Evidence
Cuneo N; Sollom R; Beyrer C: Health and Human Rights Journal, Papers in Press Blog, July 2017

The 2008–2009 Zimbabwe cholera epidemic resulted in 98,585 reported cases and caused more than 4,000 deaths. In this study, the authors used a mixed-methods approach that combined primary qualitative data from a 2008 Physicians for Human Rights-led investigation with a systematic review and content analysis of the scientific literature. Their initial investigation included semi-structured interviews of 92 key informants, which the authors supplemented with reviews of the social science and human rights literature, as well as international news reports. The authors investigation revealed that the 2008–2009 Zimbabwean cholera epidemic was exacerbated by a series of rights abuses, including the politicisation of water, health care, aid, and information. The authors argue that the failure of the scientific community to directly address the political determinants of the epidemic exposes the challenges to maintaining scientific integrity in the setting of humanitarian responses to complex health and human rights crises. While the period of the cholera epidemic is now a decade in the past, the findings remain relevant for contexts where health and rights interact and in contexts where governance concerns affect improvements in health.

Youth Voices at the 13th Southern African Civil Society Forum
Mahlangu S; Dick S; Chizungu R; Mwanza E: Youth@SAIIA, August 2017

Each year, the Southern African Development Community (SADC) holds a special Southern Africa Civil Society Forum. The 13th annual Forum took place in mid August in Johannesburg. Members of the SAIIA Youth Policy Committee and alumni of the SAIIA Young Leaders Conference were there, to provide an eye-witness account of the proceedings. Civil society is defined as a ‘community of citizens linked by common interests and collective activity.’ This was evident at the 13th SADC Civil Society Forum from day one.
The Forum serves as a platform for civil society organisations from all over the region to meet and consolidate their stance, which is then presented as a declaration to the SADC secretariat. The theme for this year’s forum was ‘Building People’s Organisations, Securing Our Common Future, Consolidating Our Gains and Confronting Our Challenges’. These four blogs present the voice and reflections of young people attending various sessions at the Forum.

13. Monitoring equity and research policy

World health statistics 2017: monitoring health for the SDGs, Sustainable Development Goals
World Health Organization: WHO, Geneva, 2017

The World Health Statistics series is World Health Organisation’s annual compilation of health statistics for its 194 Member States. World Health Statistics 2017 focuses on the health and health-related Sustainable Development Goals (SDGs) and associated targets by bringing together data on a wide range of relevant SDG indicators. World Health Statistics 2017 is organised into three parts. In Part 1, six lines of action are described which WHO is now promoting to help build better systems for health and to achieve the health and health-related SDGs. In Part 2, the status of selected health-related SDG indicators is summarised, at both global and regional level, based on data available as of early 2017. Part 3 then presents a selection of stories that highlight recent successful efforts by countries to improve and protect the health of their populations through one or more of the six lines of action. Annexes A and B present country level estimates for selected health-related SDG indicators. As in previous years, World Health Statistics 2017 has been compiled primarily using publications and databases produced and maintained by WHO or United Nations groups of which WHO is a member, such as the United Nations Inter-agency Group for Child Mortality Estimation.

14. Useful Resources

A global database of abortion laws, policies, health standards and guidelines
Johnson B; Mishra V; Lavelanet A; Khosla R; Ganatra B: World Health Organisation, doi: http://dx.doi.org/10.2471/BLT.17.197442, 2017

In June 2017 the United Nations Development Programme in collaboration with other United Nations agencies launched a new, open-access Global Abortion Policies Database. The online database contains comprehensive information on the abortion laws, policies, health standards and guidelines for WHO and United Nations (UN) Member States. It is intended for use by policy-makers, human rights bodies, nongovernmental organisations, public health researchers and civil society. The database is designed to further strengthen global and national efforts to eliminate unsafe abortion by facilitating comparative and country-specific analyses of abortion laws and policies, placing them in the context of information and recommendations from WHO technical and policy guidance on safe abortion. The main objectives of the database are to promote greater transparency of abortion laws and policies and state accountability for the protection of women and girls’ health and human rights.

The Land of No Men: Inside Kenya’s Women-Only Village
Tadic E: Broadly, 2015

Titled “The Land of No Men: Inside Kenya’s Women-Only Village” the 30-minute documentary report takes audiences to northern Kenya, “where the foothills of Mount Kenya merge into the desert,” home to the people of Samburu, which is also where Rebecca Lolosoli founded Umoja village as a safe haven for women from a society long-maintained as a strict patriarchy for over 500 years. “Umoja, which means “unity” in Swahili, is quite literally a no man’s land, and the matriarchal refuge is now home to the Samburu women who no longer want to suffer abuses, like genital mutilation and forced marriages, at the hands of men. Throughout the years, it has also empowered other women in the districts surrounding Samburu to start their own men-excluding villages. Broadly visited Umoja and the villages it inspired to meet with the women who were fed up with living in a violent patriarchy.”

Tunatazama
A Network of Southern African Communities Living Near Mines

This website is a space for community activists living near mines in southern Africa to share information, resources and experiences.
The countries currently participating in this project are: Lesotho, South Africa, Zimbabwe, Zambia, the Democratic Republic of Congo (DRC), Mozambique and Tanzania. Activists in each country document problems they experience and events they participate in and share this on a WhatsApp group. These posts are then shared on this site in the respective country blogs. Each country, in addition, maintains their own country blog. Additionally, Activists can view the posts on a mobile app called “Action Voices” which can be downloaded on an Android phone from the Google Play store. This website and the activities are a joint project of several organisations in southern Africa. These include:The Bench Marks Foundation – South Africa; Southern Africa Resource Watch (SARW) – Southern Africa; Zimbabwe Environmental Law Association (ZELA) – Zimbabwe; Centre for Environment Justice (CEJ) – Zambia; Associação de Apoio e Assistência Jurídica às Comunidades (AAAJC) – Mozambique; Norwegian Church Aid (NCA), Tanzania and Maluti Community Development Forum – Lesotho.

15. Jobs and Announcements

2017 CODESRIA Social Policy in Africa Conference
20 - 22 November 2017, Tshwane, South Africa

The DST/NRF SARChI Chair in Social Policy and its partners invite abstracts of papers to be presented at the 2017 Social Policy in Africa Conference. The conference will take place from 20-22 November 2017 at the University of South Africa (Pretoria, South Africa). The organisers invite abstracts and papers that offer critical reflections on (a) Africa’s experience with social policy since Africa’s decade of independence in the 1960s, (b) contemporary experiences of social policy, and (c) prospective inquiries into social policy for addressing Africa’s diverse challenges of developmental and human wellbeing. The conference seeks to theorise Africa’s social policy experiences (formal and non-formal) in rethinking social policy to return to a wider vision of social policy and a more holistic development that reinforces the complementarity of economic and social policies. the conference calls for reflections on how the multiple tasks of social policy can be activated to enhance the quality of lives for the rural population. How can land and agrarian reforms be understood from a social policy perspective?

ICASA 2017: 19th International Conference on AIDS and STDs in Africa
4-9 December 2017, Abidjan, Côte d'Ivoire

The conference theme “Africa: Ending AIDS-delivering differently” engages the whole continent and all stakeholders in the post SDG framework. The 19th ICASA is an opportunity to renew this global commitment by drawing the world’s attention to the fact that the legacy is now under threat as a result of the global economic downturn. This year’s ICASA is an opportunity for the international community, and all Africans, to join efforts in committing to achieving an AIDS-free Africa. Given the urgency of the issue the organisers are anticipating 7 000 -10 000 of the world’s leading scientists, policy makers, activists, PLHIV, government leaders – as well as a number of heads of state and civil society representatives – will be joining the debate on how to achieve this vision. The conference will be chaired by Dr Ihab AbdelRhaman Ahmed, an epidemiologist and President of the Society for AIDS in Africa (SAA). It will be co-chaired by Dr. Raymonde Coffie Goudou, Ministry of Health representing the Government of Côte d’Ivoire. The conference will be an opportunity to promote inter-sectoral achievements in the AIDS response and to strengthen the partnership among governments, civil society, and development partners. The objectives of ICASA include promoting innovation, partnerships to increase domestic investments to achieve 90/90/90 targets, integrating approaches for sustainable Responses towards ending AIDS, TB, Hepatitis and associated diseases and translating science into action to maximise programme impact. Further objectives include providing a platform to Maintain and Sustain Investment for CSO and FBO’s, providing a platform to promote rights-based models to overcome structural and policy barriers towards universal access.

Lawyers for Human Rights: National Director, South Africa
Application closing date: 1 October 2017

With six offices spread around the country, Lawyers for Human Rights (LHR) has a national footprint and offers specialist public interest legal services in key programme areas such as refugee and migrant rights, land reform, housing, environmental justice, penal reform, gender equality, worker rights and strategic litigation. LHR is seeking to appoint a National Director to lead the organisation with various human rights programmes and law clinics around the country. The candidate will be required to provide strategic thinking, positioning and management of LHR and manage the organisations programmes and law clinics effectively. The candidate will represent the organisation and advocate with government, multilateral organisation, the United Nations and other relevant institutions, and coordinate closely with programs managers on fundraising. The candidate will need to identify and build strategic partnerships and networks and foster meaningful relationships and have a close and interactive relationship with the LHR Board on developmental issues and be accountable to the Board.

Rural Health Conference 2017
22-25 September 2017, North West Province, South Africa

The Rural Health Conference is an vibrant event bringing together doctors, therapists, nurses, clinical associates, health students and NGOs, always in a rural location. Attendees will meet up and share ideas and friendship with colleagues from around South Africa and Africa. The themes for the conference include Recognising Rural Health Challenges, Working together – Better and Smarter, Use of innovations in Communication Technology and Healthcare, Using Trans-disciplinary Teamwork to find innovative solutions and Working together to Advocate for better Rural Health.

Smile Train: Programme Manager
Application closing date: 8 September 2017

Smile Train is an international children’s charity that provides 100%-free cleft repair surgery and comprehensive cleft care to children in 85+ developing countries. Their sustainable model empowers local doctors to provide cleft care in their own communities. The overall purpose of the role is to devise, plan and implement local strategies to achieve the mission and goals of Smile Train in terms of high-quality and safe cleft lip and palate care through effective management of programmes and partnerships in Southern Africa. Key responsibilities for the position include instituting suitable business processes and necessary control mechanisms for the continual monitoring of financial, programmatic, and medical targets in the region and receiving, reviewing, and analysing all grant requests from local stakeholders. The candidate will need to ensure all operations are legally and financially transparent and in compliance with all local laws and laws of the U.S. that apply to local business practices and lead efforts to share Smile Train’s global messaging locally and help to build the brand and awareness of Smile Train programs in Southern Africa. The candidate will be responsible for capturing and sharing stories, images, and videos that help to tell Smile Train’s story and that could be used across the organisation to further Smile Train’s mission. Lastly the candidate will be required to build and nurture the ‘Smile Train’ brand, developing an image of a focused, committed, ethical and caring organisation upholding and furthering ‘best practices’ in cleft care.

UFS: Master in Development Studies
Application closing date: 29 September 2017

The Centre for Development Support within the Faculty of Economic and Management Sciences at the University of the Free State is presenting a two-year part-time, interdisciplinary degree - Master of Development Studies. This programme combines distance-based learning with five one-week contact sessions held at the University f the Free State. The programme is a qualification aimed at those in NGOs, government, parastatals or private sector. Candidates with an Honours degree or postgraduate diploma or candidates with a degree and extensive development related work experience are invited to apply. The compulsory first year modules include studies in development, underdevelopment and poverty, governance and development, development and the environment, applied development research and project management. Students select two elective modules with a mini-dissertation in the second year.

World Trade Organisation Public Forum 2017 — “Trade: Behind the Headlines”
Registration closing date: 12 September 2017

At a time when the debate on trade has rarely been as prominent or controversial, the WTO's 2017 Public Forum, "Trade: Behind the Headlines", offers an opportunity to go beyond the rhetoric and examine in detail the realities of trade – the opportunities it offers and the challenges it can bring. The Forum will provide a platform for discussions among policy makers, civil society representatives, business people and researchers as they consider how to make trade work for more people and ensure that the trading system is as inclusive as it can be. The opportunities that trade generates for greater growth and development and its ability to create jobs, raise incomes and reduce prices is, for some, only part of the story. There is a growing feeling that now is the time to consider the broader picture. While trade has indeed pulled millions out of poverty, the reality is that for some the experience has been different. The Public Forum is the WTO’s largest annual outreach event.

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