Current Issue

EQUINET NEWSLETTER 206 : 01 May 2018

1. Editorial

Can essential benefit packages be a lever for universal health systems?
R Loewenson, M Mamdani, EQUINET


Current policy agendas raise an impetus for countries in east and southern Africa to be clearer with the public on what health care services they can expect to access. Commitments made to universal health coverage (UHC) and equity in health care point to a need to define the entitlements or service benefits that will be provided universally to respond equitably to population health needs. Constitutional provisions on the right to health care raise a demand to clarify what services people should be legally entitled to. Yet the gap between demand and resources suggest a need to clarify what can be funded and provided universally, taking costs into account. The diversity of funders and providers in most health systems in the region call for funders and providers to be aligned around these entitlements while social demand for public accountability calls for transparency on how resources and capacities are being used to deliver these entitlements.

As one response, many countries in east and southern Africa (ESA) have developed essential health benefit packages (EHBs) in order to define service benefits, to direct resources to priority, relevant and effective areas of health service delivery. EQUINET research in 2015-2017 through Ifakara Health Institute and Training and Research Support Centre working with ministries of health in Swaziland, Tanzania, Uganda and Zambia found that of the sixteen countries in the ESA region, thirteen had an EHB in place by 2016, albeit with different names and at different stages of design and implementation.

There was much in common in the way these EHBs were being developed and what they covered. The EHBs in the region cover similar services for communicable and non-communicable diseases, maternal and child health and public health. They generally combined an analysis of health burdens and cost-benefit or value-for-money to identify what services to include, taking on board policy goals and commitments. In some cases they took into account the priorities reported by stakeholders and external partners and, to a more limited extent, communities and parliamentarians. When countries used consultative, consensus-building design processes with wider stakeholders they widened awareness and debate on the choices to be made in what services to include, on the cost of care and on the entitlements included.

It would appear that the process for defining, costing and clarifying service benefits could be a key entry point for policy dialogue across stakeholders and an important basis to build an operational strategy for realising UHC in an equitable manner and for making clear the deficits to be met.

Indeed, ESA countries report a range of ways they are using their EHBs: They are being used as a tool for budgeting and planning at local government level; to guide priority setting and budgets; to purchase services from private, not-for-profit services and to monitor service performance. These areas of practice depend on quality system data, including from the from the private health sector, good population health information and data on the costs of services to both design, purchase and be accountable for delivery of the benefit.

While there are shortfalls in some of these areas of data, the funding gap has presented perhaps the greatest challenge in delivering on the EHB. ESA countries face clear challenges in reconciling the services they should provide to respond to population health need with the resources they have to do so. The estimates ESA countries calculated for what their EHBs would cost varied widely, from $4-$83/capita at primary care level to $22-$519/capita for referral services. In part this reflects differing assumptions and methods used for capital and recurrent costings. At the same time, in most ESA countries these figures point to a gap between the cost of a benefit package that responds to health needs, and the funds available for it, particularly in the public sector. Having these costs of the EHB raises a question for national and global levels of how, in the face of commitments to UHC, these costs will be met to turn the talk into action.

In the face of this funding gap, some countries have begun to explore new revenue sources from innovative financing, linking the EHB to policy dialogue on health financing. Resource constraints and vertical financing have, however, also motivated rationing of scarce resources, reducing the benefit to a smaller subset that can be funded from current budgets. This may focus resources on what is possible and avoid the frustration generated by the gap between aspiration and delivery. However, it also raises concerns on how to ensure fairness and public health effectiveness in the decisions on what services are covered and what is excluded. How should services treat people who present with a combination of conditions, one covered and one not? How to ensure the integration across services when some are funded and others not? How to avoid ‘minimum’ benefit packages becoming the ‘maximum’ provided? How to ensure that the poorest in the population get all their health needs addressed without costs that impoverish them?

In a regional dialogue within the countries involved the research, the EHB as a universal benefit was seen to be consistent with policy goals to build universal equitable health systems. It was seen to be a potentially useful measure to engage and build support from high-level political actors, funders, providers and communities on the different challenges that need to be addressed in implementing UHC, and to align public and private actors around national goals.
In facing the financing challenges given the desire to ensure universal provision of the benefit, it was felt that the EHB would be best funded through progressive tax financing and pooling of other social insurance, earmarked tax and private sector contributions to avoid segmentation and to ensure the universality of the benefit. At the same time it was felt that funding constraints not present a pressure to limit to curative services, and that the EHB include health promotion, public health and prevention measures, as both value for money, important for service integration and key for health sector engagement on inter-sectoral action for health.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the issue can be found in the regional meeting report at
http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Regional%20EHB%20Mtg%20Rep%20Nov2017.pdf , the country case study reports on the EQUINET website and synthesis paper at
http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Diss%20113%20EHB%20synthesis%202018.pdf

2. Latest Equinet Updates

Mining and Public Health in Zambia Meeting report, 10 April 2018, Lusaka, Zambia
Ministry of Health Zambia; EQUINET

The Southern African Development Community (SADC) framework for harmonising mining policies, standards and laws, approved by the SADC Mining Ministers in 2006, specifies that member states develop, adopt and enforce appropriate and uniform health, safety and environmental guidelines for the sector and seeks to harmonized standardization in health as an immediate milestone area. The Ministry of Health in Zambia is in the process of improving public health in the mining sector in the country as part of its Universal Health Coverage policy, as well as to address the social determinants of health. A meeting was thus held to dialogue with key national level representatives of health and related sectors on evidence and actions related to public health in mining. The meeting aimed to 1. Share and dialogue with key national level representatives of health and related sectors on: evidence from Zambia on mining and health with a focus on population/public health issues and the current responses to health promotion, prevention and management, and on evidence from regional level on public health issues and health standards in mining, and their implications for regional responses. 2. To discuss follow up actions in relation to key areas of health and cross sectoral collaboration on mining and public health in Zambia and for regional co-operation and exchange on setting and implementing harmonised standards on mining and health.

3. Equity in Health

A fuzzy set qualitative comparative analysis of 131 countries: which configuration of the structural conditions can explain health better?
Paykani T; Rafiey H; Sajjadi H: International Journal for Equity in Health 17(10) doi: https://doi.org/10.1186/s12939-018-0724-1, 2018.

In this study, following the World Health Organization Commission On Social Determinants of Health (CSDH) approach the authors aimed to unravel complexity and answer the kinds of questions that are outside the scope of conventional variable-oriented approach. A fuzzy-set qualitative comparative analysis of 131 countries was conducted to examine the configurational effects of five macro-level structural conditions on life expectancy at birth. The potential causal conditions were level of country wealth, income inequality, quality of governance, education, and health system. The data collected from different international data sources were recorded during 2004–2015. The analysis indicated a configuration of conditions including high level of governance, education, wealth, and affluent health system to be consistently sufficient for high life expectancy. The configurations linked to high life expectancy were not the opposite of those associated with low life expectancy and the authors identified areas for further research.

The Inverse Equity Hypothesis: Analyses of Institutional Deliveries in 286 National Surveys
Victora C; Joseph G; Silva I; et al: American Journal of Public Health 108(4) 464-471, 2018

This study tested the inverse equity hypothesis, which postulates that new health interventions are initially adopted by the wealthy and thus increase inequalities—as population coverage increases, only the poorest will lag behind all other groups. The authors analysed the proportion of births occurring in a health facility by wealth quintile in 286 surveys from 89 low- and middle-income countries (1993–2015) and developed an inequality pattern index. Positive values indicate that inequality is driven by early adoption by the wealthy (top inequality), whereas negative values signal bottom inequality. Absolute inequalities were widest when national coverage was around 50%. At low national coverage levels, top inequality was evident with coverage in the wealthiest quintile taking off rapidly; at 60% or higher national coverage, bottom inequality became the predominant pattern, with the poorest quintile lagging behind. The authors argue that policies need to be tailored to inequality patterns. When top inequalities are present, barriers that limit uptake by most of the population must be identified and addressed. When bottom inequalities exist, interventions must be targeted at specific subgroups that are left behind.

UN aims to eliminate yellow fever epidemics in Africa by 2026
Times LIVE, Reuters, April 2018

Nearly 1 billion people in Africa will be vaccinated against yellow fever by 2026 in an ambitious United Nations campaign to eliminate epidemics of the deadly disease on the continent. The mosquito-borne viral disease is a major killer in Africa, where it can spread fast in highly populated areas with devastating consequences. "With one injection we can protect a person for life against this dangerous pathogen," said Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) at the programme's launch in Nigeria, a priority target country. A major vaccination campaign in Angola and Congo in 2016 brought one of the worst outbreaks of the disease in decades under control after more than 400 people died. The vaccination programme is a joint venture by the WHO, UNICEF, the GAVI global vaccine alliance and more than 50 health partners.

4. Values, Policies and Rights

Militarized Humanitarianism in Africa
Rock J: Foreign Policy in Focus, May 2014

The U.S. Africa Command (AFRICOM) has rapidly expanded its presence on the African continent since its establishment. Emphasizing a “3D” approach of “defense, diplomacy, and development,” AFRICOM’s charge is described as coordinating “low-cost, small-footprint operations” throughout the African continent. Writing in the New York Times, Eric Schmitt marveled at AFRICOM’s Operation Flintlock, a multinational and multiagency training operation in Niger. He wrote glowingly about fighting terrorism with mosquito nets: “Instead of launching American airstrikes or commando raids on militants,” he wrote, “the latest joint mission between the nations involves something else entirely: American boxes of donated vitamins, prenatal medicines, and mosquito netting to combat malaria.” The author asks however if AFRICOM’s humanitarian undertakings should be approached as gestures of goodwill or conflict-deterrence, or rather as signs of a militarized U.S. approach to foreign policy in Africa.

National policies on the management of latent tuberculosis infection: review of 98 countries
Jagger A; Reiter-karam S; Hamadab Y; et al: Bulletin of the World Health Organisation 96(3) 173–184, 2018

This paper is a review of policies on management of latent tuberculosis infection in countries with low and high burdens of tuberculosis. The authors divided countries reporting data to the World Health Organization Global Tuberculosis Programme into low and high tuberculosis burden, based on World Health Organization criteria. National policy documents on management of latent tuberculosis were identified through online searches, government websites, World Health Organization country offices and personal communication with programme managers. A descriptive analysis was done with a focus on policy gaps and deviations from World Health Organization policy recommendations. Documents were obtained from 68 of 113 low-burden countries and 30 of 35 countries with the highest burdens of tuberculosis or human immunodeficiency virus (HIV)-associated tuberculosis. Screening for children aged < 5 years with household tuberculosis contact was the policy of 25 (83.3%) high- and 28 (41.2%) low-burden countries. In most high-burden countries the recommendation was symptom screening alone before treatment, whereas in all low-burden countries it was testing before treatment. Some low-burden countries’ policies did not comply with WHO recommendations: nine (13.2%) recommended tuberculosis preventive treatment for travellers to high-burden countries and 10 (14.7%) for patients undergoing abdominal surgery. The authors raise that lack of solid evidence on certain aspects of management of latent tuberculosis infection results in national policies which vary considerably and highlight a need to advance research and develop clear, implementable and evidence-based WHO policies.

5. Health equity in economic and trade policies

Africa is not poor, we are stealing its wealth
Dearden N: Al Jazeera, May 2017

"Africa is rich, but we steal its wealth". That's the essence of a report from several campaign groups released in May 2017. Based on a set of new figures, it finds that sub-Saharan Africa is a net creditor to the rest of the world to the tune of more than $41bn. It reports that there is money going in to sub-Saharan Africa the tune of around $161bn a year in the form of loans, remittances from those working outside Africa and sending money back home, and from development aid. There's also $203bn leaving the continent. Some of this is direct, such as $68bn from taxes foregone, such as when multinational corporations legally organise flows to indicate that they are generating their wealth in tax havens. These flows are asserted by the author to amount to around 6% percent of the continent's entire gross domestic product and three times what Africa receives in aid. The report estimates that $29bn a year is being lost from Africa through illegal logging, fishing and trade in wildlife. Given these and other sources of loss the author asserts that if African countries are to benefit from foreign investment, they must be allowed to - even helped to - legally regulate that investment and the corporations that often bring it.

Flexibilities provided by the Agreement on Trade-Related Aspects of Intellectual Property Rights
Correa C: Bulletin of the World Health Organisation 96(3) 148, 2018

To minimize the problems caused by the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), academics, governments of low-income countries, many nongovernmental organizations, the World Health Organization (WHO) and other United Nations organizations pay special attention to the Agreement’s so-called flexibilities. The extent to which such flexibilities have already been incorporated into national laws and practice shows substantial variation. Several compulsory licenses – allowing a company to produce a patented product or process without the consent of the patent owner – have been issued for medicines, mainly to treat infections with human immunodeficiency virus. Most of these licenses have led to substantial reductions in the costs of treatment. The use of such licenses is not limited to low- and middle-income countries. Another important flexibility is provided by the definition of the standards of patentability, and the rigour with which they are applied in determining whether a claimed invention is patentable. Weaknesses or gaps in such standards can allow ever-greening by the pharmaceutical industry. Research has shown that the TRIPS flexibilities are poorly exploited and that much more could be done to align intellectual property protection with public health policies. To support the more extensive exploitation of the flexibilities provided by the Agreement on TRIPS, the author argues that a continuous effort from academics, governments, international and nongovernmental organizations is needed, observing that the health of a large part of the world’s population depends on timely and effective action.

IMF conditionality: still undermining healthcare?
Brunswijck G; Griffiths J: Global Health Check, April 2018

An IMF blog in March 2017 claimed that: “A number of studies have found that IMF support for countries’ reforms, on average, either preserve or increase public health spending.” However, the evidence provided was weak. Of the six studies referenced, one, by Oxford and Cambridge university researchers flatly contradicts this claim. Two were not related to health expenditure: one looked at revenue, not expenditure, and the second had a broader remit and contained no new evidence on the IMF and health. One was over a decade old and did not directly support the claim; while another was a link to an IMF page on the Ebola crisis. In fact the only referenced study that supported the claim was written by the staff who authored the blog. The IMF’s concern not to be seen to be impacting negatively on health expenditure in the poorest countries can be viewed as an improvement. However, the authors suggest that it is clear that IMF conditionality can constrain expenditure on health and other related services, at odds with the SDG commitment to achieve universal health coverage. The next scheduled review of IMF funding to low-income countries is planned for 2018. The authors argue that it is time for a much broader reform of IMF conditionality. Citing Eurodad’s detailed study, in 2014, that found that IMF conditions are often highly controversial and intrusive on key economic policy issues, they suggest that these policies should be the crux of democratic debate in country, not mandated from Washington.

6. Poverty and health

Attitudes towards help-seeking for sexual and gender-based violence in humanitarian settings: the case of Rwamwanja refugee settlement scheme in Uganda
Odwe G; Undie C; Obare F: BMC International Health and Human Rights 18(1) doi: https://doi.org/10.1186/s12914-018-0154-6, 2018

This paper examined the association between attitudes towards seeking care and knowledge and perceptions about sexual and gender-based violence (SGBV) among men and women in a humanitarian setting in Uganda. A cross-sectional survey was conducted from May to June 2015 among 601 heads of refugee households in Rwamwanja Refugees Settlement Scheme, South West Uganda. Results showed increased odds of having a favorable attitude toward seeking help for SGBV among women with progressive attitudes towards SGBV; who felt that SBGV was not tolerated in the community; those who had not experienced violence; and those who were aware of the timing for post-exposure prophylaxis. In contrast, results for the male sample showed lack of variations in attitude toward seeking help for SGBV for all independent variables except timing for post exposure prophylaxis. Among individuals who had experienced SGBV, the odds of seeking help was more likely among those with favorable attitude towards seeking help than among those with unfavorable help-seeking attitudes. The findings of the paper suggest that targeted interventions aimed at promoting awareness and progressive attitudes towards SGBV are likely to encourage positive help-seeking attitudes and behaviours in humanitarian contexts.

7. Equitable health services

Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia
Banks K; Karim A; Ratcliffe H; et al: Health Policy and Planning 33(3) 317–327, 2017

The study explored the frequency and associated factors of disrespect and abuse in four rural health centres in Ethiopia. The experiences of women who delivered in these facilities were captured by direct observation of client-provider interaction and exit interview at time of discharge. Incidence of disrespect and abuse were observed in each facility, with failure to ask woman for preferred birth position most commonly observed. During exit interviews, 21% of respondents reported at least one occurrence of disrespect and abuse. Bivariate models using client characteristics and index birth experience showed that women’s reporting of disrespect and abuse was significantly associated with childbirth complications, weekend delivery and no previous delivery at the facility. Facility-level fixed-effect models found that experience of complications and weekend delivery remained significantly and most strongly associated with self-reported disrespect and abuse. The results suggest that addressing disrespect and abuse in health centres in Ethiopia will require a sustained effort to improve infrastructure, support the health workforce in rural settings, enforce professional standards and target interventions to improve women’s experiences as part of quality of care initiatives.

Scoping literature review on the basic health benefit package and its determinant criteria
Hayati R; Bastani P; Kabir M; et al: Globalization and Health 14(26), https://doi.org/10.1186/s12992-018-0345-x, 2018

This study aimed to extract criteria used in health systems for defining the benefit package in different countries around the world using scoping review method. A systematic search was carried out in online libraries and databases between January and April 2016. After studying the articles’ titles, abstracts, and full texts, 9 articles and 14 reports were selected for final analysis. In the final analysis, 19 criteria were extracted. Due to diversity of criteria in terms of number and nature, they were divided into three categories. The categories included intervention-related criteria, disease-related criteria, and community-related criteria. The largest number of criteria belonged to the first category. Indeed, the most widely applied criteria included cost-effectiveness, effectiveness, budget impact, equity, and burden of disease. According to the results, different criteria were identified in terms of number and nature in developing benefit package in world health systems. The authors conclude that it seems that certain criteria, such as cost-effectiveness, effectiveness, budget impact, burden of disease, equity, and necessity, that were most widely utilized in countries under study could be for designing benefit package with regard to social, cultural, and economic considerations.

8. Human Resources

Nursing education challenges and solutions in Sub Saharan Africa: an integrative review
Bvumbwe T; Mtshali N: BMC Nursing, 17:3, https://doi.org/10.1186/s12912-018-0272-4, 2018

This integrative review examined literature on nursing education challenges and solutions in Sub Saharan Africa to inform development of a model for improving the quality, quantity and relevance of nursing education at local level through a search of online libraries. Twenty articles and five grey sources were included. The findings of the review generally support World Health Organisation framework for transformative and scale up of health professions education. Six themes emerged; curriculum reforms, profession regulation, transformative teaching strategies, collaboration and partnership, capacity building and infrastructure and resources. Challenges and solutions in nursing education are common within countries. The review shows that massive investment by development partners is resulting in positive development of nursing education in Sub Saharan Africa. However, strategic leadership, networking and partnership to share expertise and best practices are argued from the evidence to be critical. The authors propose that Sub Saharan Africa needs more reforms to increase capacity of educators and mentors, responsiveness of curricula, strongly regulatory frameworks, and availability of infrastructure and resources.

Practitioner Expertise to Optimize Community Health Systems: Harnessing Operational Insight
Ballard M; Schwarz R; Johnson A; et al: Community Health Worker Impact, USA, 2017

To harness the potential of community health workers (CHWs) to extend health services to poor and marginalized populations the authors argue that there is a need to better understand how CHW programs can be optimized. This paper presents the experience of and insights from application by selected organizations that have developed high-impact CHW programs with governments and communities in different countries globally. They present a series of design principles that, in their experience, drive programmatic quality and are debated or not commonly found in programs across the globe: CHWs must meet minimum standards before working; point of care fees should be avoided when possible; CHWs should go door to door and provide training on when to seek help; continuing training should be a requirement; CHWs should benefit from a dedicated supervisor and be paid and should be part of a strong local health system and data feedback loops.

9. Public-Private Mix

From Kenya’s postelection violence, an online community forms to give aid
Habib J: The Christian Science Monitor, March 2018

Kenya’s post election violence has led to the founding of RescueBnB – a community with the mission to map the locations of those in need of shelter and connect them with volunteer hosts. With a core team of volunteers, a web developer set up the pro bono website, and Kenyans have spread the word on social media. Within 48 hours of this, they had assembled more than 100 volunteers across the country and had arranged multiple home stays with vetted hosts. To date, RescueBnB has supported 800 people across Kenya, and team members say that’s just the start. RescueBnB has since begun crowdfunding to provide care packages as well as to cover medical expenses. Its partnerships with community organizations and religious groups helped it reach more individuals, and companies stepped in to assist. A supermarket chain welcomed shoppers to drop off donations, and a boda boda (motorbike) delivery company volunteered to get the donations into the hands of people who needed them.

Health-industry linkages for local health: reframing policies for African health system strengthening
Mackintosh M; Mugwagwa J; Banda G; et al: Health Policy and Planning 33(4), doi: https://doi.org/10.1093/heapol/czy022, 2018

Low-income African populations continue to suffer poor access to a broad range of medicines, despite major international funding efforts. A current wave of pharmaceutical industry investment in SSA is associated with active African government promotion of pharmaceuticals as a key sector in industrialisation strategies. The authors present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. Key policies are identified that can ensure that local health systems benefit from the investments. The authors argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. This local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions.

10. Resource allocation and health financing

A more progressive tax regime is a viable and better alternative to addressing revenue shortfalls, civil society organisations tell Parliament
NGOpulse: SANGONeT, South Africa, March 2018

In February, a broad cross-section of South African civil society organisations (CSOs) called on Parliament to halt the proposed increase in value-added tax (VAT), demonstrating that such a move for general revenue collection would make the tax regime more regressive, potentially violate the equality clause in the Constitution, and worsen already unacceptably high levels of poverty and inequality. They illustrated that more progressive alternatives exist. The organisations argued that a reconsideration of the tax regime was not to be taken lightly and therefore not something National Treasury could unilaterally decide on, without proper public consultation. The CSOs highlighted that tax can and must play a redistributive role in the economy, while ensuring sufficient revenue collection for pressing social needs. Yet the proposed 2018 budget not only increases the fuel levy and VAT, the least progressive tax instruments, but also opts to cut down on social spending in areas such as basic education, health care, housing, municipal infrastructure, informal settlement upgrading and transport. They argue that the VAT increase for general revenue (and not specifically for health), will have negative consequences for service delivery and affect poor and working class communities the most.

Evaluation of results-based financing in the Republic of the Congo: a comparison group pre–post study
Zeng W; Shepard D; de Dieu Rusatira J; et al: Health Policy and Planning 33(3) 392–400, 2018

In this study on a pilot results based financing (RBF) in the Republic of the Congo from 2012 to 2014, the authors conducted pre- and post-household surveys and gathered health facility services data from both intervention and comparison groups. Using a difference-in-differences approach, the study evaluated the impact of RBF on maternal and child health services. The household survey found statistically significant improvements in quality of services regarding the availability of medicines, perceived quality of care, hygiene of health facilities and being respected at the reception desk. The health facility survey showed no adverse effects and significantly favourable impacts on: curative visits, patient referral, children receiving vitamin A, HIV testing of pregnant women and assisted deliveries. These improvements, in relative terms, ranged from 42% to 155%. However, the household survey found no statistically significant impacts on the five indicators measuring the use of maternal health services, including the percentage of pregnant women using prenatal care, 3+ prenatal care, postnatal care, assisted delivery, and family planning. Surprisingly, RBF was found to be associated with a reduction of coverage of the third diphtheria, pertussis, and tetanus immunization among children in the household survey. From the health facility survey, no association was found between RBF and full immunization among children.

11. Equity and HIV/AIDS

The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe
Busza J; Dauya E; Bandason T; et al: Health Policy and Planning 33(3) 328–334, 2018

For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, the authors based their intervention on an existing evidence-based framework for successful community health worker (CHW) programmes. To assess CHWs’ experiences delivering the intervention, they conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study explored community health workers’ perceptions of how the intervention’s structure and management affected their performance, and considers implications for the programme’s future scale-up and adoption in other settings. Community health workers expressed strong motivation, commitment and job satisfaction. Intensive supervision and mentoring emerged as critical to ensuring community health workers long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and community health workers. Concerns raised by community health workers included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful community health workers programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies.

12. Governance and participation in health

How Ugandans are mapping their neighbourhoods to Solve Energy and Health-Related Risks
Urban Action Lab, Makerere University Uganda, 2016

The Urban Action Lab of Makerere University Uganda, is a lead partner of Co-designing Energy Communities (CO-DEC), a collaborative research project in Kampala and Nairobi, which is fostering cross-sector learning amongst university students and local community members to scale up local energy solutions, such as briquette-making, and create highly accurate maps of risk-prone businesses, infrastructure and residential dwellings, in regards to the use of traditional and modern energy sources. The community co-researchers collaborated with academics from Makerere University to map their own neigbourhood of Kasubi-Kawaala, in order to address in-and outdoor air pollution associated with poor management of wastes, leaky toilet seals and sewer pits, the use of biomass and fossil fuels from the informal urban economy. The maps were boundary objects for community-led learning and action that linked participating organisations and individual co-researchers to local sustainability-oriented experiments around regenerative use of wastes for energy briquettes; planting of indigenous trees with leafy canopies that reduce air pollutants in homesteads and around business premises; while building consensus on the policy options for enabling actors from Kampala Capital City Authority to own and energetically pursue an agenda for scaling up alternative energy solutions that bring about co-benefits in the health and housing sector.

Knowledge integration in One Health policy formulation, implementation and evaluation
Hitziger M; Esposito R; Canali M; et al: Bulletin World Health Organisation 96(3) 211–218, 2018

The One Health concept covers the interrelationship between human, animal and environmental health and requires multi-stakeholder collaboration across many cultural, disciplinary, institutional and sectoral boundaries. Yet, the implementation of the One Health approach appears hampered by shortcomings in the global framework for health governance. Knowledge integration approaches, at all stages of policy development, could help to address these shortcomings. The identification of key objectives, the resolving of trade-offs and the creation of a common vision and a common direction can be supported by multi-criteria analyses. Evidence-based decision-making and transformation of observations into narratives detailing how situations emerge and might unfold in the future can be achieved by systems thinking. Finally, transdisciplinary approaches can be used both to improve the effectiveness of existing systems and to develop novel networks for collective action. To strengthen One Health governance, the authors propose that knowledge integration becomes a key feature of all stages in the development of related policies and suggest several ways in which such integration could be promoted.

Lessons learnt from implementation of the International Health Regulations: a systematic review
Amitabh S; Allen L; Cifuentes S: Bulletin of the World Health Organisation 96(2)110-121E, 2017

While bi- and multilateral communication and collaboration are the foundation for global control of infectious disease epidemics, they are strengthened by the International Health Regulations (IHR). Although IHR (2005) describes what must be achieved by countries, there is limited knowledge on how countries should proceed in achieving the core capacities. To fill this gap and accelerate implementation of IHR (2005), the World Health Assembly in 2015 identified a need to evaluate and share the lessons learnt from countries that have implemented IHR (2005). This systematic review was conducted in accordance with Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines, using a predefined protocol. The authors identified five global lessons learnt that related to multiple IHR (2005) core capacities. Some major cross-cutting themes included the need for mobilizing and sustaining political commitment; for adapting global requirements based on the local socio-cultural, epidemiological, health system and economic contexts; and for conducting baseline and follow-up assessments to monitor IHR (2005) status. The authors argue that despite considerable progress, countries that are yet to implement IHR (2005) core capacities may have insufficient human and financial resources to meet their obligations in the near future.

13. Monitoring equity and research policy

Implementation of Urban Health Equity Assessment and Response Tool: a Case of Matsapha, Swaziland.
Makadzange K; Radebe Z; Maseko N; et al: Journal of Urban Health, doi: 10.1007/s11524-018-0241-y, 2018

This paper illustrates a case of applying the Urban Health Equity Assessment and Response Tool in Matsapha, Swaziland. A descriptive single-case study design using qualitative research methods was adopted to collect data from purposively selected respondents. The study revealed that residents of the Matsapha peri-urban informal settlements faced challenges with conditions of daily living which impacted negatively on their health. There were health equity gaps. The application of the tools was facilitated by the formation of an all-inclusive team, intersectoral collaboration and incorporating strategies for improving urban health equity into existing programmes and projects.

Mobilization initiative on gender equity in health research launched
TDR: World Health Organisation, Geneva, February 2018

TDR Global has launched a 3-month mobilization initiative on gender equity in health research. The aim is to enhance women’s position in health research and to address the impact of gender on infectious diseases of poverty through research. The initiative will share experience and thoughts on gender equity in health research. Challenge-solving workshops are being planned to identify local challenges, create local teams and offer training. TDR Global talks are opportunities to share best practices and experiences on enhancing gender equity in health research. Working groups on specific issues are options for organizing webinars, training and sharing ideas.

14. Useful Resources

Engaging Men and Boys in Family Planning: A Strategic Planning Guide
Family Planning High Impact Practices, USA, 2018

This document aims to lead program managers, planners, and decision-makers through a strategic process to identify effective investments for engaging men in efforts to improve sexual and reproductive health. In this guide, male engagement refers to the involvement of men and boys in family planning programs across life stages, including addressing gender norms and gender equality. The guide follows four steps; defining the behavioural aim of the initiative, assessing men’s and boys’ knowledge and attitudes related to reproduction and contraception, assessing how gender norms affect male engagement in family planning, and identifying programming approaches that engage men and boys.

15. Jobs and Announcements

International Fellowship funded by the Urban Studies Foundation
Deadline for Applications: 15 May 2018

The ACADEMY project is designed to provide resources and opportunities for student and staff mobility from four regions of Africa, offering support for Masters, Doctoral and short research, teaching and administrative visits between the consortium partners. Applications are particularly invited from female candidates and disadvantaged groups. Applicants should be nationals and residents of eligible African countries, have sufficient knowledge of the language of instruction of courses in the host country and fulfil the criteria of one of the target groups. Target Group 1 is for those students who are registered in one of partner universities and staff must be working in one of the five partner universities. Target Group 2, students must be registered in any African Higher Education Institution and those who have graduated from any African Higher Education Institution. Students having previously benefitted from a scholarship under the Intra-ACP or the Intra-Africa Academic Mobility Schemes are not eligible.

15th International Conference on Urban Health: Managing Urbanisation for Health, 26-30 November 2018, Kampala, Uganda
Deadline for abstracts: 14 May 2018

The 15th International Conference on Urban Health will bring together interdisciplinary researchers, practitioners, policy-makers, health and urban stakeholders and community leaders to exchange ideas and advance research and practice across sectors on how best to manage the rapid urbanisation occurring in all regions of the world. Abstracts are invited for oral and poster presentations, pre-formed panels, workshops and special tracks on the following conference themes: The Governance of Complex Systems, Culture and Inclusivity, Disasters, Epidemics, and the Unexpected, Cities as Economic Engines, Monitoring and Evaluation of Urban Health Indicators, Safety, Security, and Justice, Spiritual Health in the City.

22nd International AIDS Conference (AIDS 2018) 23-27 July 2018, Amsterdam, the Netherlands
Registration deadline: 17 May 2018

The International AIDS Conference is the largest conference on any global health issue in the world. First convened during the peak of the AIDS epidemic in 1985, it continues to provide a unique forum for the intersection of science, advocacy, and human rights. Each conference is an opportunity to strengthen policies and programmes that ensure an evidence-based response to the epidemic. The theme of AIDS 2018 is “Breaking Barriers, Building Bridges”, drawing attention to the need of rights-based approaches to more effectively reach key populations, including in Eastern Europe and Central Asia and the North-African/Middle Eastern regions where epidemics are growing.

ACADEMY Project: African Trans-Regional Cooperation through Academic Mobility Intra-Africa
Deadline for Applications: 15 May 2018

The ACADEMY project is designed to provide resources and opportunities for student and staff mobility from four regions of Africa, offering support for Masters, Doctoral and short research, teaching and administrative visits between the consortium partners. Applications are particularly invited from female candidates and disadvantaged groups. Applicants should be nationals and residents of eligible African countries, have sufficient knowledge of the language of instruction of courses in the host country and fulfil the criteria of one of the target groups. Target Group 1 is for those students who are registered in one of partner universities and staff must be working in one of the five partner universities. Target Group 2, students must be registered in any African Higher Education Institution and those who have graduated from any African Higher Education Institution. Students having previously benefitted from a scholarship under the Intra-ACP or the Intra-Africa Academic Mobility Schemes are not eligible.

African Doctoral Dissertation Research Fellowship Program (ADDRF) – Call for Applications
Deadline for Applications: 15 May 2018

The African Population and Health Research Center (APHRC) in partnership with Ipas, Guttmacher Institute, Gynuity Health Projects and Ibis Reproductive Health is pleased to announce a call for applications to support up-to four African doctoral candidates undertaking dissertation research on the topic of abortion. These organisations have been involved in efforts to eliminate deaths and injuries from unsafe abortion, as well as increasing women's ability to exercise their sexual and reproductive health and rights globally. The dissertation grant is designed to bridge strategic gaps in research capacity and knowledge management to help researchers, health professionals and policymakers to increase their contribution in addressing issues related to abortion. The ADDRF Program will award up to four (4) fellowships in 2018 to doctoral students. These fellowships will be awarded to doctoral students who are within two years of completing their thesis.

Council for the Development of Social Science Research in Africa (CODESRIA) Meaning-making Research Initiatives: Special call for female researchers
Deadline for applications: 31 May 2018

In 2017 CODESRIA introduced the Meaning-making Research Initiative (MRI) as its principal tool for supporting research. Projects funded under this initiative should propose research on important aspects of African social realities that fall under CODESRIA’s priority themes as outlined in the CODESRIA Strategic Plan. Projects should be guided by clear questions that explore puzzling aspects of the social realities of Africa and its position in the world while at the same time reflecting an interest in questions of diversity including the gendered one, should engage constructively and rigorously with African futures and be theoretically ambitious with a clear goal of providing new and innovative ways of understanding and making sense of African social realities. Applications should indicate the ways in which the following cross-cutting themes are integrated in their proposals: gender, generations, inequality, rurality and urbanity, memory and history, as well as futures and alternatives. Increasing the participation of female scholars in the work and governance of CODESRIA has been a long-term goal of the Council. All projects should: 1) be headed by female scholars; and 2) have only women as members.

Heterogeneous Infrastructures in African Cities
Deadline for Applications: 30 May 2018

As part of broader efforts to develop regional learning across the continent, the Situated Urban Political Ecology collective and Urban Action Lab at Makerere University will be hosting a workshop on urban infrastructures in Africa from November 12-15, 2018. Scholars and practitioners are increasingly grappling with alternative modes of infrastructural provision. This is motivated by scholarly interest in everyday infrastructural practices and politics as well as concerns about the economic, environmental, social and political viability of universal, uniform infrastructure networks. In theory and practice, this is resulting in challenges to existing urban theorization, political agendas and infrastructure provision. This workshop will seek to develop new research questions, outputs and networks with the aim of thinking through the heterogeneity of infrastructure provisioning in cities across sub-Saharan Africa, thinking beyond individual artefacts towards understanding dynamic configurations of people and technology.

IDRC Doctoral Research Awards 2018
Deadline for Applications: 30 May 2018

IDRC is now accepting applications for this year’s IDRC Doctoral Research Awards (IDRA). This call is open to Canadians, permanent residents of Canada, and citizens of developing countries pursuing doctoral studies at a Canadian university. These awards are intended for field research in developing countries to improve the lives of people in the developing world.

The African Postdoctoral Training Initiative - a partnership of the African Academy of Sciences, the Bill and Melinda Gates Foundation, and the U.S. National Institutes of Health
Deadline for Applications: 11 May 2018

The African Academy of Sciences (AAS), the U.S. National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation are partnering under the auspices of the Coalition of African Research & Innovation (CARI) to establish a post-doctoral training fellowship program, the African Postdoctoral Training Initiative (APTI) at the intramural laboratories of NIH. APTI fellows will train in a global health research area of priority for their home institutions and countries. While at the NIH, the fellows must be on leave or sabbatical from their home institution under the NIH Intramural Visiting Fellow Program. The research priority areas are in infectious diseases, nutrition, and reproductive, maternal, and child health and developing skills for clinical and translational research. Candidates must be citizens of and currently employed in an academic, research, or government position in an African country. Candidates must have less than 5 years of relevant research experience by their entry on duty date at NIH.

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