Current Issue

EQUINET NEWSLETTER 184 : 01 July 2016

1. Editorial

Learning from regional work on health centre committees
I Rusike, T Nkrumah, C Chimhete, F Kowo and E Mutasa, Community Working Group on Health

Health Centre Committees (HCCs) are a mechanism through which community participation can be integrated into the health system to achieve a sustainable people-centered health system.

These community-based committees are increasingly becoming an established voice of the communities providing input into the health service delivery processes in the 16 East and Southern Africa (ESA) countries covered by EQUINET. In the Ngombe area of Lusaka, Zambia, for example, the Neighborhood Health Councils with local government have successfully addressed water and sanitation, garbage and housing concerns. In Kenya, Health Facility Committees manage funds from the Health Sector Services Fund for primary care, outreach and community based services. They link the facility with the community, to plan and oversee the performance of the services.

In a regional dialogue, delegates from ESA countries urged national authorities to better recognize and work with HCCs. Their recommendations, captured in EQUINET Policy Brief 37, included reforming public health laws to include provisions for participation and public information and to set laws that provide for the roles and duties of HCCs, backed by adequate information, training and resources for them to play these roles.

To advance these recommendations a consortium of organizations have come together in EQUINET to build and strengthen the capacity and effectiveness of HCCs, led by the Community Working Group on Health (CWGH) in partnership with the Training and Research Support Centre (TARSC) on photovoice and information sharing; University of Cape Town (UCT) School of Public Health on training programmes; and the Lusaka District Health Management Team (LDHMT) on legal provisions. With work in Kenya, Zambia, Malawi, South Africa, Uganda, and Zimbabwe and at ESA regional level, we are advocating for policy and legal recognition of HCCs, giving visibility to their roles as well as identifying and strengthening the different capacities that committees, communities and the health systems need for HCCs to implement these roles. This includes areas such as tracking and monitoring health system budgets and resources and their use and health system performance as well as the building social dialogue and accountability.

As part of the work, UCT in South Africa is building a database of information on the current training materials and training programmes for HCCs to enable us to share materials, skills and experiences on capacity building in the region, and to advocate for HCC training that addresses their roles comprehensively. and their coverage of the key areas of functioning. LDHMT in Zambia has initiated an in-country process to review the laws and regulations that provide for the establishment and functioning of HCCs, and to document the Zambia experience for wider regional exchange. In Zimbabwe, the CWGH has supported the HCCs to engage with government, so that HCC members can speak out about their concerns on the health system and on the support they need to successfully implement their roles. Training on community photography by TARSC means that the members have visual tools as well as words to raise evidence on their problems and progress.

Most ESA countries still do not have laws that explicitly or adequately recognise the functioning of the HCCs. We are thus advocating for their legal status and for them to have constitutions. This is important for their accountability to communities. It is also necessary if they are to directly receive, manage and account for public funds as was the case with Neighbourhood Health Committees in Zambia in the 1990s. The HCCs’ current vague mandates weaken their effectiveness, role and legitimacy, for communities and local actors and at national-level. We are thus sharing information on HCC constitutions, and on laws, statutes or guidelines on HCCs in the region and promoting their inclusion in law, including by showing their important positive role in the health system.

As a consortium, we are building a regional database of institutions and organizations working with HCCs in ESA countries so that we can better exchange and share information on the training materials, programmes underway with HCCs and the learning from them. We invite colleagues to send information to EQUINET if they are working in this area. We are building innovative ways of sharing and learning from our work, that build more direct voice, such as through photovoice where cameras are being put into the hands of communities and HCC members to identify and document community perspectives, experiences and actions related to their health conditions to be used in local HCC dialogue and wider reflection and learning.

Members of HCCs are carrying out exchange visits to allow for more direct learning and collective understanding of problems and achievements, creating inspiration to keep working and resulting in the launch of new initiatives.

We have seen evidence of the positive impact of HCCs in improved health outcomes. In Zimbabwe for example, since 2009, HCCs have played a role in in decision-making on the use of performance based funds at clinics, promoting improvements in facility-based deliveries, improving uptake of antenatal care and postnatal care visits and supporting demand by communities for these resources to be used to ensure delivery on patients’ rights at clinics. They have also mobilized resources to develop clinics such as by building waiting mothers’ homes, fencing clinics, supporting community health workers and raising advocacy on the needs of local services at higher levels.

We are seeing an increasing appreciation of the role of HCCs in community and primary care health interventions, with increasing attention and support from government, international and national partners. Our HCC in-country exchange visits are proving to be an effective way of sharing knowledge and good practice, inspiring others to see their own potential and act when they see the practical successes of other HCCs. “HCC exchange visits are rich in knowledge and should always be a key part of HCC activities carried out at local, district, provincial and national levels,” said Brighton Ngoteni, the HCC chairperson of Mudanda Clinic in Manicaland, Zimbabwe.

Our regional exchanges have also shown us that HCCs can only be as strong as the communities that support them. For this, we need to have recognition of the right to health, including on constitutions in the region, and comprehensive primary health care approaches that support health literacy and that inform communities, include communities and the views they bring in plans and services and give feedback to the communities for a people centred approach to universal health systems.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: and find further publications on the issue on the EQUINET website at

2. Latest Equinet Updates

EQUINET, June 2016

This brief introduces EQUINET, our organisation, work and the lessons we have learned in the struggle for equity and social justice in health. EQUINET is a consortium network of institutions registered in different countries in the region, with its secretariat at TARSC, a non-profit organization registered in Zimbabwe. The network constitution sets out its vision, principles, composition, structures, governance and procedures. The network is governed by a steering committee of institutions leading key areas of work from within and beyond east and southern Africa. The steering committee includes academic, government, civil society, parliament and non-profit institutions that co-ordinate different theme, process and country activities in the network and the secretariat. The five clusters of EQUINET work are: 1. Cross cutting equity analysis, integrating work in other clusters and the pra4equity network on PAR and the newsletter, together with theme work on the equity watch and district health systems. 2. Health rights and the law, integrating work of the learning network on heath rights, theme work on law and constitutional rights in health, and work in national networks. 3. Fairly resourcing health systems, integrating theme work on health financing and health workers. 4. Social empowerment for health, integrating theme work on health centre committees, and with parliamentarians and civil society. 5. Global engagement, including work on trade and health and health diplomacy.

EQUINET Discussion paper 107: Literature Review: Essential health benefits in east and southern Africa
Todd G; Mamdani M; Loewenson R: IHI, Tanzania, TARSC, EQUINET, Harare, June 2016

An Essential Health Benefit (EHB) is a policy intervention designed to direct resources to priority areas of health service delivery to reduce disease burdens and ensure equity in health. Many east and southern Africa (ESA) countries have introduced or updated EHBs in the 2000s. Recognising this, EQUINET, through Ifakara Health Institute and Training and Research Support Centre is implementing research to understand the role of facilitators and the barriers to nationwide application of the EHB in resourcing, organising and in accountability on integrated health services. This literature review provides background evidence to inform the case study work and regional dialogue. It compiles evidence from published and public domain literature on EHBs in sixteen ESA countries, including information on the motivations for developing the EHBs; the methods used to develop, define and cost them; how they are being disseminated and communicated within countries; how they are being used in budgeting, resourcing and purchasing health services and in monitoring health system performance for accountability; and the facilitators and barriers to their development, uptake or use.

3. Equity in Health

Global Report on Diabetes
World Health Organization, Geneva, 2016

Diabetes prevalence is steadily increasing everywhere, most markedly in the world's middle-income countries. In many settings the environments and services do not enable the prevention and management of diabetes. As part of the 2030 Agenda for Sustainable Development, Member States have set an ambitious target to reduce premature mortality from non communicable diseases - including diabetes – by one third. This report presents trends in diabetes prevalence, in the contribution of high blood glucose (including diabetes) to premature mortality, and outlines actions governments are taking to prevent and control diabetes. From the analysis it is clear that stronger responses are needed not only from different sectors of government, but also from civil society and people with diabetes themselves, and also producers of food and manufacturers of medicines and medical technologies.

South African Health Review 2016
Padarath A; King J; Mackie E; Casciola J: Health Systems Trust, 2016

The 2016 South African Health Review presents evidence on the current legislative and policy framework guiding healthcare delivery, the challenges that underpin the performance of the health system, on water and food; and on personnel and programmes in the public health system. The report indicates that although tackling HIV targets will be daunting, they are likely to be affordable and cost-effective if implemented in a phased way and if annual increments to Government AIDS budgets are sustained. The report also discusses South Africa’s pharmaceutical pricing and transparency and the concept of and benefit from health research observatories. Finally the report provides a wide range of information on health trends, with a specific focus on the data needed to monitor non-communicable diseases.

Spatial modelling of perinatal mortality in Mchinji, Malawi
Banda M; Kazembe L; Lewycka S; King C; Phiri T; Masache G; Kazembe P; Mwasambo C: Spatial and spatio-temporal epidemiology16, 50-58, 2016

Annual global estimates of perinatal mortality show Malawi among sub-Saharan Africa with the highest rates. Targeted interventions are required to reduce this mortality. This study aimed to quantify small-scale geographical variations in perinatal mortality, and estimate risk factors associated with perinatal mortality in Mchinji district. Factors associated with reduced perinatal mortality were: previous pregnancy; early and consistent use of antenatal care; syphilis test; abdominal examination; pregnancy danger signs advice; skilled birth attendant; normal labour duration; gestation period of at least 9 months; and normal delivery. Perinatal babies whose mothers had a blood test were associated with high probability of dying. Perinatal babies from mothers between 16 and 40 years had reduced prevalence of dying while those aged less than 16 years and greater than 40 years were associated with higher prevalence of dying.

Trends and risk factors for childhood diarrhoea in Sub-Saharan countries (1990 - 2013): Assessing the neighbourhood inequalities.
Bado A; Susuman A; Nebie E: Global Health Action 9(30166), May 2016,

This paper assesses the risk factors of and neighborhood inequalities in diarrhoeal morbidity among under-5 year old children in selected countries in sub-Saharan Africa over the period 1990–2013, using DHS data from selected countries. The findings showed that the proportion of diarrhoeal morbidity among under-5 children varied considerably across the cohorts of birth from 10% to 35%, with increasing inequalities across DHS rounds. The main risk factors were the child’s age, size of the child at birth, the quality of the main floor material, mother’s education and her occupation, type of toilet, and place of residence.

4. Values, Policies and Rights

Almost Two Years Passed, No Member State Has Ratified SADC Employment and Labour Protocol
Southern Africa Coordination Council (SATUCC), 8 June 2016

Two years after it was signed in August 2014, SATUCC reports that no Member State has ratified the SADC Employment and Labour Protocol as of June 2016. The SADC Employment & Labour Protocol was developed to serve as legal framework for the cooperation of SADC Member States on matters concerning employment and labour in line with Article 22 of the SADC Treaty which provides as follows: “Member States shall conclude protocols as may be necessary in each area of cooperation, which shall spell out the objectives and scope of, and institutional mechanisms for cooperation and integration”. This Protocol was then finally endorsed by nine Member States during the SADC Heads of States Summit held in Victoria Falls, Zimbabwe in August of 2014. These are: DRC, Lesotho, Malawi, Mozambique, Namibia, Seychelles, South Africa, Zambia and Zimbabwe. However, for this Protocol to enter into force, it is required that at least 10 Member States representing two-thirds ratify it. Since then, no single Member State has ratified the Protocol. It is against this that the SADC Ministers of Labour and Social Partners during their meeting on 12th May 2016, directed the SADC Secretariat with support of the ILO to conduct a study to establish the problems and challenges underlying the non-ratification of the Protocol and further explore ways how to promote its ratification by Member States. SATUCC is conducting a regional campaign on the ratification and implementation of the SADC Employment and Labour Protocol.

SADC Ministers of Labour & Social Partners Approve Policy Frameworks on Youth Employment and Portability of Social Security Benefits
Southern Africa Coordination Council (SATUCC), 8 June 2016

In May 2016, the Southern African Development Community (SADC) Ministers of Labour and Social Partners at their meeting in Gaborone, Botswana, considered and approved two regional policy frameworks pertaining to employment and labour as part of the milestones for the SADC Regional Decent Work Programme (2013-2019). These are: SADC Youth Employment Promotion Policy Framework and the Cross boarder Portability of Accrued Social Security Benefits Policy Framework. The SADC Youth Employment Promotion Policy Framework guides SADC Member States on a harmonised, integrated and coherent approach to realising decent, secure and sustainable employment and entrepreneurship for the youth in the SADC region. The SADC Cross boarder Portability of Accrued Social Security Benefits Policy Framework responds to the fact that non-citizens are quite often discriminated against when it comes to access to social security. Portability of social security benefits is limited because SADC countries do not have a common regional policy framework on the matter despite that a few countries had already concluded bilateral labour and social security agreements. The main aim of the SADC Cross boarder Portability of Accrued Social Security Benefits Policy Framework is thus to provide mechanisms to enable workers moving within the SADC region to keep the social security benefits which they might have acquired under the legislation of one Member State or to enjoy corresponding rights under the legislation of the other Member State.

The role of the law in reducing tuberculosis transmission in Botswana, South Africa and Zambia
Verani A; Emerson C; Lederer P; Like G; Kapata N; Lanje S; Peters A; Zulu I; Marston B; Miller B: Bulletin of the World Health Organization, 94(6), 405-480, 2016

This study determined whether laws and regulations in Botswana, South Africa and Zambia – three countries with a high tuberculosis and HIV infection burden – address elements of the World Health Organisation (WHO) policy on tuberculosis infection control. An online desk review of laws and regulations that address six selected elements of the WHO policy on tuberculosis infection control in the three countries was conducted in November 2015 using publicly available domestic legal databases. The six elements covered: (i) national policy and legal framework; (ii) health facility design, construction and use; (iii) tuberculosis disease surveillance among health workers; (iv) patients’ and health workers’ rights; (v) monitoring of infection control measures; and (vi) relevant research. The six elements were found to be adequately addressed in the three countries’ laws and regulations. In all three, tuberculosis case-reporting is required, as is tuberculosis surveillance among health workers. Each country’s legal and regulatory framework also addresses the need to respect individuals’ rights and privacy while safeguarding public health. These laws and regulations create a strong foundation for tuberculosis infection control. Although the legal and regulatory frameworks thoroughly address tuberculosis infection control, their dissemination, implementation and enforcement were not assessed, nor was their impact on public health. The authors argue that future research should assess the implementation and public health impact of these laws and regulations.

Universal Health Coverage’s evolving location in the post-2015 development agenda: Key informant perspectives within multilateral and related agencies during the first phase of post-2015 negotiations
Brolan C; Hill P: Health Policy and Planning 31(4) 514-526, 2015

This study examines health’s evolving location in the first-phase of the next iteration of global development goal negotiation for the post-2015 era, through the synchronous perspectives of representatives of key multilateral and related organizations. As part of the Go4Health Project, in-depth interviews were conducted in mid-2013 with 57 professionals working on health and the post-2015 agenda within multilaterals and related agencies. Using discourse analysis, this article reports the results and analysis of a Universal Health Coverage (UHC) theme: contextualizing UHC’s positioning within the post-2015 agenda-setting process immediately after the Global Thematic Consultation on Health and High-Level Panel of Eminent Persons on the Post-2015 Development Agenda (High-Level Panel) released their post-2015 health and development goal aspirations in April and May 2013, respectively. Although more participants support the High-Level Panel’s May 2013 report’s proposal—‘Ensure Healthy Lives’—as the next umbrella health goal, they nevertheless still emphasize the need for UHC to achieve this and thus be incorporated as part of its trajectory. The final post-2015 SDG framework for UN General Assembly endorsement in September 2015 confirmed UHC’s continued distillation in negotiations, as UHC ultimately became one of a litany of targets within the proposed global health goal.

5. Health equity in economic and trade policies

Africa's Blue Economy: A policy handbook
United Nations Economic Commission for Africa, March 2016

Africa’s 'Blue world' is made of vast lakes and rivers and an extensive ocean resource base. The Blue Economy can play a major role in Africa’s structural transformation, sustainable economic progress, and social development. The largest sectors of the current African aquatic and ocean based economy are fisheries, aquaculture, tourism, transport, ports, coastal mining, and energy. This Policy Handbook, offers a step by step guide to help African member States to better mainstream the Blue Economy into their national development plans, strategies, policies and laws. The Blue Economy approach is premised in the sustainable use, management and conservation of aquatic and marine ecosystems and associated resources.

Gender Equality and Equity in Health Will Anchor Drive Towards a Sustainable National Development
Chatterjee S; Kariuki S: Inter Press Service, April 2016

The Government of Kenya (GoK) in partnership with United Nations Population Fund (UNFPA) at the sidelines of the 60th Session of the UN Commission of Women in New York launched the report on the ‘Assessment of the UNFPA Campaign to End Preventable Maternal and New-born Mortality in support of the Campaign for Accelerated Reduction of Maternal Mortality in Africa’ The report captures the important strides the country has made to significantly address disparities in advancing maternal and new-born health at all levels, as part GoK's commitment to address inequalities, as a key principle of Agenda 2030, to ensure that no one is left behind. This video records the event.

Joint Statement - First Plenary Meeting of the Africa Global Partnership Platform
African Union: New Partnership for Africa's Development, Dakar, October 2015

The first plenary meeting of the Africa Global Partnership Platform (AGPP/the Platform) was held in Dakar, Senegal on 22 October 2015. The meeting re-affirmed the strong commitment of African countries and partners to achieving food security for the continent, through agricultural growth and transformation to create agricultural commodity value chains for smallholder farmers, create job opportunities for the youth in food and agricultural value chains, and support entry and participation of women and youth in agricultural and agri-food SMEs, in line with SDG 8. This was also seen as the most viable entry point for sustainable industrialization on the continent. The meeting also underlined the need to promote further regional integration, particularly through the development of intra-African trade of food and agricultural commodities. The signing of the COMESA-EAC-SADC Tripartite Free Trade Agreement and the fast-tracking of negotiations for the Continental Free Trade Area was seen as important to contribute to more stable food and agricultural markets at regional and country levels in Africa. The meeting highlighted the gaps in implementation of the CAADP goal of allocating at least 10% of public expenditure to the agricultural sector.

6. Poverty and health

Millions of Malawians hungry as food crisis deepens
Henderson P: Pambuzuka News, 16 June 2016

The author reports that Almost four million Malawians are battling severe famine due to poor or no harvests because of the effect of El Nino, which last year affected most of the country’s southern and northern regions, and that this could double by the end of the year. The number of hungry people is expected to rise to eight million by December 2016 and this is exactly half of the population. Torrential rains in the north aggravated the already dramatic situations, and in February a state of emergency was declared. In the meantime food prices continue to rise as Malawi’s Kwacha continues to lose value, forcing the poorest families to further reduce their already precarious daily meals, or to sell goods in order to make ends meet. According to a report by World Food Program (WFP) of May, 2016, in most parts in Southern Africa harvesting was underway, temporarily alleviating some market pressure and allowing for food price improvements in pockets of the region as people consume their own production. The report, however, states that, crop expectations remain poor following one of the driest seasons in 35 years with seasonal rainfall deficits experienced throughout the region, particularly in central and southern Malawi.

7. Equitable health services

Assessment of universal health coverage for adults aged 50 years or older with chronic illness in six middle-income countries
Goeppel C; Frenz P; Grdabenhenrich L; Keil T; Tinnemann P: Bulletin of the World Health Organization, 94(4), 276-285C, 2016

This study assesses universal health coverage for adults aged 50 years or older with chronic illness in China, Ghana, India, Mexico, the Russian Federation and South Africa. The authors obtained data on 16 631 participants aged 50 years or older who had at least one diagnosed chronic condition from the World Health Organization Study on Global Ageing and Adult Health. Access to basic chronic care and financial hardship were assessed and the influence of health insurance and rural or urban residence was determined by logistic regression analysis. The weighted proportion of participants with access to basic chronic care ranged from 21% in Mexico to 48% in South Africa. Access rates were unequally distributed and disadvantaged poor people, except in South Africa where primary health care is free to all. Rural residence did not affect access. The proportion with catastrophic out-of-pocket expenditure for the last outpatient visit ranged from 15% in China to 55% in Ghana. Financial hardship was more common among poor people in most countries but affected all income groups. Health insurance generally increased access to care but gave insufficient protection against financial hardship. No country provided access to basic chronic care for more than half of the participants with chronic illness. Poor people were less likely to receive care and more likely to face financial hardship in most countries. However, inequity of access was not fully determined by the level of economic development or insurance coverage. The authors argue that future health reforms should aim to improve service quality and increase democratic oversight of health care.

Critiquing the response to the Ebola epidemic through a Primary Health Care Approach
Scott V; Crawford-Browne S; Sanders D: BMC Public Health16(410), 2016,

The 2014/2015 West Africa Ebola epidemic has caused the global public health community to engage in difficult self-reflection. First, it must consider the part it played in relation to an important public health question: why did this epidemic take hold and spread in this unprecedented manner? Second, it must use the lessons learnt to answer the subsequent question: what can be done now to prevent further such outbreaks in the future? The authors contribute to the current self-reflection by presenting an analysis using a Primary Health Care (PHC) approach. This approach is appropriate as African countries in the region affected by EVD have recommitted themselves to PHC as a framework for organising health systems and the delivery of health services. The approach suggests that, in an epidemic made complex by weak pre-existing health systems, lack of trust in authorities and mobile populations, a broader approach is required to engage affected communities. In the medium-term health system development with attention to primary level services and community-based programmes to address the major disease burden of malaria, diarrhoeal disease, meningitis, tuberculosis and malnutrition is needed. This requires the development of local management and an investment in human resources for health. Crucially this has to be developed ahead of, and not in parallel with, future outbreaks. In the longer-term a commitment is required to address the underlying social determinants which make these countries so vulnerable, and limit their capacity to respond effectively to, epidemics such as EVD.

MamaYe Factsheet on Malawi’s Blood Services
MamaYe – Evidence for Action, Dar es Salaam, 2016

MamaYe is a campaign initiated by Evidence for Action, a multi-year programme which aims to improve maternal and newborn survival in sub-Saharan Africa. It is led by African experts in the six countries, Nigeria, Ghana, Sierra Leone, Ethiopia, Malawi and Tanzania and supported by experts in academic and other institutions specialising in maternal and newborn health. MamaYe has produced a factsheet to summarise the evidence on Malawi’s blood services, including how much blood is collected and how much is needed. Just over one third of blood needed in Malawi is being collected. The factsheet covers the importance of blood for preventing maternal deaths, the 4 key components of World Health Organization’s strategy for safe and effective use of blood and achievements in Malawi in blood donation and availability. The factsheet also reviews continued challenges for availability of blood in Malawi and an overview of Malawi’s blood transfusion services, including: the organisation of the blood transfusion services; blood supply; donor population; blood use towards maternal, newborn and child health; and blood safety and screening.

New health sector strategies on HIV, viral hepatitis and sexually transmitted infections
World Health Organisation: Geneva, June 2016

Three global health sector strategies on HIV, viral hepatitis and sexually transmitted infections (STIs) for 2016-2021 were adopted by the 2016 World Health Assembly, outlining key actions to be undertaken by countries and WHO, along five strategic directions, over the course of the next six years. The HIV strategy aims to achieve "fast-track" targets by 2020 towards ending AIDS by 2030. The hepatitis strategy – the first of its kind - introduces the first-ever global targets, including the target to eliminate viral hepatitis as a public health threat by 2030. For the HIV strategy, a central element for success will be country efforts to implement "Treat All" recommendations.

No health security without health systems
Kamal-Yanni M: Global Health Check, May 2016

The Ebola outbreak shocked the world of global health. Even while Ebola lingers in West Africa the future of health security and the organisation of health systems are being debated. There have been many conferences held and reports published to provide “lessons learned from the Ebola crisis. A thread running through all of these events has been an agreement on the need to build resilient health systems. Yet building such a system requires planning, investment and serious long term commitment. Short term investment does not produce the necessary workforce needed for a functioning health system. Dhillon and Yates identified 5 key areas that require immediate attention in order to rebuild health systems: community based systems; access to generic medicines; restoring preventive measures; integrating surveillance into health systems and strengthening management. The author identifies 6 critical foundations for resilient health systems: An adequate number of trained health workers, including non-clinical staff and Community Health Workers (CHWs), available medical supplies, including medicines, diagnostics and vaccines, robust health information systems, including surveillance, an adequate number of well-equipped health facilities including access to clean water and sanitation, adequate financing and a strong public sector to deliver equitable, quality services. The author argues that building resilient systems that protect people’s health and deal with outbreaks has to address all the six elements of the system simultaneously and systematically and that a long term global commitment for building health systems must start now.

8. Human Resources

Close-to-community providers of health care: increasing evidence of how to bridge community and health systems
Theobald S; Hawkins K; Kok M; Rashid S; Datiko D; Taegtmeyer M:Human Resources for Health 14(32), June 2016

The recent thematic series on close-to-community providers published in this journal brings together 14 papers from a variety of contexts and that use a range of research methods. The series clearly illustrates the renewed emphasis and excitement about the potential of close-to-community (CTC) providers in realising universal health coverage and supporting the sustainable development goals. This editorial discusses key themes that have emerged from this rich and varied set of papers and reflect on the implications for evidence-based programming. The authors argue that it is a critical stage in the development of CTC programming and policy which requires the creation and communication of new knowledge to ensure the safety, sustainability, quality and accessibility of services, and their links with both the broader health system and the communities that CTCs serve.

Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?
Courtright P; Mathenge W; Kello A; Cook C; Kalua K; Lewallen S: Human Resources for Health14(1)11, 2016

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.

9. Public-Private Mix

Medical savings accounts: assessing their impact on efficiency, equity and financial protection in health care
Wouters O; Cylus J; Yang W; Thomson S; McKee M: Health Economics, Policy and Law, 1(3)321-35, 2016

Medical savings accounts (MSAs) allow enrolees to withdraw money from earmarked funds to pay for health care. The accounts are usually accompanied by out-of-pocket payments and a high-deductible insurance plan. This article reviews the association of MSAs with efficiency, equity, and financial protection. The authors draw on evidence from four countries where MSAs play a significant role in the financing of health care: China, Singapore, South Africa, and the United States of America. The available evidence suggests that MSA schemes have generally been inefficient and inequitable and have not provided adequate financial protection. The impact of these schemes on long-term health-care costs is unclear. Policymakers and others proposing the expansion of MSAs should make explicit what they seek to achieve given the shortcomings of the accounts.

The world's health sector is expanding. Can it heal our economies?
Tulenko K: World Economic Forum, May 2016

The author writes that the health sector is predicted to be the largest source of job creation for the next decade globally. Its growth is being driven by increasing numbers of older people and by the expansion of the global middle class. As these two groups grow, the higher levels of healthcare they demand will cause seismic shifts in the amount of money being spent in the health sector, driving employment. Even without these trends, the world would need millions more health workers. Despite increased training, it is not meeting population demand. The world no longer dominated by infectious diseases requiring episodic treatment, and is instead becoming dominated by non-communicable, chronic diseases such as heart disease, diabetes, cancer, and mental-health conditions, which require continuous treatment. Unlike traditional employment sectors such as agriculture and manufacturing, which shed jobs as technology advances, healthcare tends to add jobs with increasing technology. The author argues that the health sector will be an economic engine that not only creates new jobs and business but, by making workers in other sectors healthier and more productive, will enable those sectors to grow faster creating tens of millions of new jobs.

10. Resource allocation and health financing

Africa Health Budget Network & International Budget Partnership - Transparency and Participation Scorecard
Africa Health Budget Network & International Budget Partnership, 2016

This scorecard can help one see at a glance how a country is doing on the areas of budget transparency and participation most relevant for the health sector. All the information in the scorecard comes from the Open Budget Survey 2015. The information collected by the Open Budget Survey is not health specific, but the authors have selected the indicators most relevant to the health sector. Budget documents in different countries display how much will be spent on what priorities in different ways, with more or less detail. For citizens and civil society to understand what is being spent on their health, a high level of detail is required: one doesn’t just need to see the amount as classified by Ministry (e.g. what is allocated to the Ministry of Health) but also by function (e.g. primary healthcare), by economic classification (e.g. how much is spent on health workers’ salaries) or by programme (e.g. how much is spent on free healthcare for pregnant women). There is also an indicator which measures whether budget documents explicitly make the link between money spent, intended health outcomes, and actual results. Information is not enough for accountability. Civil society and citizens also need entry points to influence decisions during the budget process: this is what participation in budgeting provides. There are many ways to facilitate this, from releasing the budget timetable so that Civil Society organisations can get ready for important meetings or information release, to holding formal hearings at different stages in the budget process for the public to feed in their priorities. The scorecard is available in English and French.

How can health ministries present persuasive investment plans for women’s, children’s and adolescents’ health?
Anderson I; Maliqi B; Axelson H; Ostergren M: Bulletin of the World Health Organisation 94(6) 468-474, 2016

Most low- and middle-income countries face financing pressures if they are to adequately address the recommendations of the Global Strategy for Women’s, Children’s and Adolescent’s Health. Negotiations between government ministries of health and finance are a key determinant of the level and effectiveness of public expenditure in the health sector. Yet ministries of health in low- and middle-income countries do not always have a good record in obtaining additional resources from key decision-making institutions. This is despite the strong evidence about the affordability and cost–effectiveness of many public health interventions and of the economic returns of investing in health. This article sets out 10 attributes of effective budget requests that can address the analytical needs and perspectives of ministries of finance and other financial decision-makers. The authors developed the list based on accepted economic principles, a literature review and a workshop in June 2015 involving government officials and other key stakeholders from low- and middle-income countries. The aim is to support ministries of health to present a more strategic and compelling plan for investments in the health of women, children and adolescents.

11. Equity and HIV/AIDS

Pain in amaXhosa Women Living With HIV/AIDS: Translation and Validation of the Brief Pain Inventory–Xhosa
Parker R; Jelsma J; Stein D: Journal of Pain and Symptom Management 51(1)126-132, 2016

Pain has been reported as the second most commonly reported symptom in people living with HIV. In South Africa, there are more than five million people living with HIV. Approximately, two million belong to the Xhosa cultural group. A culturally appropriate, valid, and reliable instrument is required to measure pain and its impact in this population. This article documents the process of translation of the Brief Pain Inventory (BPI) into the BPI-Xhosa and presents the results of the validity and reliability testing of the instrument. The translated BPI-Xhosa, a demographic questionnaire and the European Quality of Life-5 Dimensions Xhosa version (EQ-5D-Xhosa) health-related quality of life instrument were administered to 229 amaXhosa women living with HIV in a resource-poor urban settlement in South Africa. A 74% prevalence of pain was recorded. The BPI-Xhosa had good concurrent validity when compared with the previously validated EQ-5D-Xhosa. The BPI-Xhosa was found to be a valid instrument to measure pain prevalence, severity, and interference in amaXhosa women living with HIV.

The History of the HIV/AIDS Epidemic in Africa
Kagaayi J; Serwadda D: Current HIV/AIDS Reports, doi 10.1007/s11904-016-0318-8 May 2016

HIV testing of African immigrants in Belgium showed that HIV existed among Africans by 1983. However, the epidemic was recognized much later in most parts of sub-Saharan Africa due to stigma and perceived fear of possible negative consequences to the countries’ economies. This delay had devastating mortality, morbidity, and social consequences. In countries where earlier recognition occurred, political leadership was vital in mounting a response. The response involved establishment of AIDS control programs and research on the HIV epidemiology and candidate preventive interventions. Over time, the number of effective interventions has grown. Triple antiretroviral therapy (ART) has led to a rapid decline in HIV-related morbidity and mortality in addition to prevention of onward HIV transmission. Other effective interventions include safe male circumcision, and pre- and post-exposure prophylaxis. However, since none of these is sufficient by itself, the authors argue for a combination package of these interventions in the public health response.

12. Governance and participation in health

Meet BRCK, Internet access built for Africa
Juliana Rotich: TED Talk, June 2013

Tech communities are booming all over Africa, says Nairobi-based Juliana Rotich, cofounder of the open-source software Ushahidi. But it remains challenging to get and stay connected in a region with frequent blackouts and spotty Internet hookups. So Rotich and friends developed BRCK, offering resilient connectivity for the developing world. Juliana Rotich is co-founder and executive director of Ushahidi, a nonprofit tech company, born in Africa, that develops free and open-source software for information collection, interactive mapping and data curation. Ushahidi builds tools for democratizing information, increasing transparency and lowering the barriers for individuals to share their stories. Through, and accompanying mobile applications, Ushahidi is making crowdsourcing tools available and useful. Their latest product is BRCK, a tool for resilient connectivity -- anywhere.

Questioning Photovoice Research: Whose Voice?
Evans-Agnew R; Rosemberg MA: Qualitative Health Research 26(8) 1019-1030, 2016

Photovoice is an important participatory research tool for advancing health equity. This paper critically reviews how participant voice is promoted through the photovoice process of taking and discussing photos and adding text/captions. PubMed, Scopus, PsycINFO, and Web of Science databases were searched from the years 2008 to 2014 and reviewed for how participant voice was (a) analysed, (b) exhibited in community forums, and (c) disseminated through published manuscripts. Of 21 studies, 13 described participant voice in the data analysis, 14 described participants’ control over exhibiting photo-texts, seven manuscripts included a comprehensive set of photo-texts, and none described participant input on choice of manuscript photo-texts. The findings indicate that photovoice designs vary in the advancement of participant voice, with the least advancement occurring in manuscript publication. The authors indicate that future photovoice researchers should expand approaches to advancing participant voice.

Simon Njami on the restitution of African art and artists’ huge potential for subversion
Cessou S: _TRUEAfrica, April 2016

This is an interview with Simon Njami, a curator responsible for many exhibitions of contemporary African art gathering artists from 20 different African countries. On African photography he notes ‘Photography is necessarily contextual. First, it’s about the gaze and who is taking the picture. In Africa, it’s also a matter of re-appropriating one’s own image. The South African photographer Santu Mofokeng questions the role of humanity in his work. Africa is only 50 years old. It has done a lot to rebuild the past, live the present and look towards the future.’ On art and politics on the continent he argues ‘Egyptian artists were at the forefront of the protest before the Revolution. Senegalese young rappers launched the movement Y’en a Marre (‘Enough is enough’) in 2011...Art has a dual function....It’s a space of relative freedom’ . He raises the huge social potential of art, but also says 'Having said that, one has to tickle an elephant for a while before it starts laughing. In practice, change takes a while, even if it seems inevitable'.

13. Monitoring equity and research policy

Adapting HIV patient and program monitoring tools for chronic non-communicable diseases in Ethiopia
Letebo M; Shiferaw F: Globalization and Health 12(26), June 2016

Chronic non-communicable diseases (NCDs) have become a huge public health concern in developing countries. Many resource-poor countries facing this growing epidemic, however, lack systems for an organised and comprehensive response to NCDs. Successfully responding to the problem requires a number of actions by the countries, including developing context-appropriate chronic care models and programs and standardisation of patient and program monitoring tools. In this cross-sectional qualitative study the authors assessed existing monitoring and evaluation tools used for NCD services in Ethiopia. Since HIV care and treatment program is the only large-scale chronic care program in the country, they explored the tools being used in the program and analysed how they might be adapted to support NCD services in the country. Document review and in-depth interviews were the main data collection methods used. The interviews were held with health workers and staff involved in data management purposively selected from four health facilities with high HIV and NCD patient load. Thematic analysis was employed to make sense of the data. The authors findings indicate the apparent lack of information systems for NCD services, including the absence of standardised patient and program monitoring tools to support the services. They identified several HIV care and treatment patient and program monitoring tools currently being used to facilitate intake process, enrolment, follow up, cohort monitoring, appointment keeping, analysis and reporting. Analysis of how each tool being used for HIV patient and program monitoring can be adapted for supporting NCD services is presented. Given the similarity between HIV care and treatment and NCD services and the huge investment already made to implement standardised tools for HIV care and treatment program, adaptation and use of HIV patient and program monitoring tools for NCD services can improve NCD response in Ethiopia through structuring services, standardising patient care and treatment, supporting evidence-based planning and providing information on effectiveness of interventions.

Metrics in Urban Health: Current Developments and Future Prospects
Prasad A; Gray C; Ross A; Kano M: Annual Review of Public Health 37, 113-133, 2016

The research community has shown increasing interest in developing and using metrics to determine the relationships between urban living and health. In particular, the authors have seen a recent exponential increase in efforts aiming to investigate and apply metrics for urban health, especially the health impacts of the social and built environments as well as air pollution. A greater recognition of the need to investigate the impacts and trends of health inequities is also evident through more recent literature. Data availability and accuracy have improved through new affordable technologies for mapping, geographic information systems and remote sensing. However, less research has been conducted in low- and middle-income countries where quality data are not always available, and capacity for analysing available data may be limited. For this increased interest in research and development of metrics to be meaningful, the best available evidence must be accessible to decision makers to improve health impacts through urban policies.

14. Useful Resources

A Free Course on Medicines in Health Systems working towards UHC
World Bank Open Learning Campus, 2016

Many countries are reforming their health systems working toward universal health coverage (UHC). These reforms can be harnessed to increase equity in medicines access, affordability, and appropriate use of medicines. However, they also have the potential to decrease the effectiveness of prescribing and dispensing, increase unnecessary use of medicines, and derail systems from a path toward sustainable universal coverage. The goal of the Medicines in Health Systems course is to strengthen the capacity of practitioners working toward universal health coverage in low- and middle-income country health systems to design, implement, and monitor evidence-informed pharmaceutical policy and management strategies. Specifically, after completing the course, participants will be able to explain the different roles medicines play in health systems, and the roles and responsibilities of different system actors with respect to medicines in systems. They will be able to illustrate the competing objectives that system stakeholders face when striving toward greater availability of and more equitable access to high quality medicines, at affordable costs for households and the system, and with appropriate use to achieve target health outcomes. Participants will learn to assess the potential of different medicines policy and management approaches to balance these competing objectives, and identify the facilitators of and barriers to success of specific strategies, in a given context. Lastly, participants will learn to lay out strategies for monitoring desired and potential unintended outcomes of specific medicines policy and management strategies in a given setting. It provides step-by-step guidelines for clinicians, ranging from diagnoses to correct medicine dosages, and how to administer the medicine.

Amitav Ghosh - The Great Derangement: Climate Change and the Unthinkable
Schmidt J: The Anthropo.scene, June 2016

Are we deranged? The acclaimed Indian novelist Amitav Ghosh argues that future generations may well think so. How else to explain our imaginative failure in the face of global warming? Ghosh examines in a series of video lectures our inability—at the level of literature, history, and politics—to grasp the scale and violence of climate change. The extreme nature of today’s climate events, Ghosh asserts, make them peculiarly resistant to contemporary modes of thinking and imagining. This is particularly true of serious literary fiction: hundred-year storms and freakish tornadoes simply feel too improbable for the novel; they are automatically consigned to other genres. In the writing of history, too, the climate crisis has sometimes led to gross simplifications; Ghosh shows that the history of the carbon economy is a tangled global story with many contradictory and counterintuitive elements, and suggests that global crises like the climate crisis challenge our thinking and ask us to imagine other forms of human existence—a task that fiction can support.

Black Girl
Mohdin A: Quartz, June 2016

The writer and director, Ousmane Sembène, uses a then newly independent Senegal, hungry for political and social alternatives, as the backdrop for this widely acclaimed film. Through the film’s main character, Diouana Sembène makes a powerful argument about Senegal’s independence and the impact of colonialism in Africa. It was one of the first African films to receive international acclaim. The short one-hour film, released in 1966, is a simple yet powerful story of a Senegalese nanny, who hopes and dreams of a better future, but is tied down by the French couple who hire her. Sembene presents a powerful critique of black aspiration to be in a France, or more broadly, in a colonizer’s country. Though people are now free in Senegal, they will in many ways still be seen as colonial objects. At a time where issues of race and class are resonating more than ever, and countries are struggling to come to terms with their colonial legacies, Black Girl remains a powerful story about personal and political freedom—one that stills hits just as hard.

The People Versus The Rainbow Nation
Alyssa Klein: OkayAfrica, 19 May 2016

“Is South Africa’s rainbow nation a myth? What is race in 2016?” These are the questions explored in a powerful new documentary film from South Africa. The People versus the Rainbow Nation investigates what drove the country’s students towards mass action in 2015, between the successful #RhodesMustFall campaign to the nationwide #FeesMustFall protests. Filmmaker Lebogang Rasethaba (Future Sound of Mzansi) and producer Allison Swank follow the lives of students across four South African universities as they explore the notion that more than two decades since South Africa’s first democratic elections, the struggle is far from over. “I think it’s about to get really intense in South Africa,” says one student. “I don’t believe in the Rainbow Nation. The Rainbow Nation is a fallacy,” says another.

15. Jobs and Announcements

5th Annual Outbreak Control and Prevention Africa Conference
23 - 24 August 2016, Johannesburg, South Africa

The Intelligence Transfer Centre is hosting the 5th Annual Outbreak Control and Prevention Africa Conference. The two day conference will enable participants to network with key role players in the industry, and to analyse disaster risk management and preparedness plans, and look surveillance and clinical treatment of infectious diseases in hospitals and confined spaces. Speakers will also examine the role of medical and health innovation to prevent and treat deadly infectious diseases.

Amnesty International Refugee and Migrant Rights MOOC 2016
Course launches: November 2016

In November 2016 Amnesty International will launch a Massive Open Online Course (MOOC) on the subject of refugee and migrant rights to educate and empower audiences in the 25 to 35 age range to take action on the human rights issues associated with Amnesty’s Global Campaign on People on the Move. The 3-4 week course requiring 2-3 hours of participants’ time per week, will be launched in November in Spanish, French and English. The introductory course will remain open for people to complete the course anytime over a six month period. The three overall objectives of the MOOC are to provide knowledge and empower people to take action for refugee and migrant rights and to do so on a large scale, contributing to the campaign and growth.

Health Systems Global seeks views on its next five years
Health Systems Global: June 2016

HSG is asking its members and other interested parties to share their views to inform HSG’s priorities over the next five years. HSG’s 2016-2020 Draft Strategic Plan sets out the membership network’s strategic objectives and what actions should be taken in pursuit of these. Please also see the slideshow outlining the 2016-2020 Draft Strategic Plan. The HSG Strategic Plan 2016-2020 consultation process will run from 17 June until the end of 22 July 2016. HSG particularly welcomes ideas and suggestions in response to the following questions: How can HSG be an attractive home and effective voice for a diverse membership of policy-makers, researchers, NGOs, media and funders? And what can HSG do to bring these different groups together? What are the key Health Policy and Systems Research (HPSR) issues that HSG should be actively advocating on and should HSG be a more conspicuous campaigner for its members and the wider health systems community? If so, how? How can HSG grow its membership in geographic regions and stakeholder communities (policy-makers, researchers, NGOs, media and funders) where its membership base is currently smaller? HSG members and other stakeholders can participate in this consultation process in a number of different ways, including two face-to-face consultation meetings, an online consultation and feedback submission via email.

International AIDS Conference
17th-22nd July 2016, Durban, South Africa

The International AIDS Conference is a gathering for those working in the field of HIV, as well as policy makers, persons living with HIV and other individuals committed to ending the pandemic. It is a chance to assess state of affairs, evaluate recent scientific developments and lessons learnt, and collectively chart a course forward. The AIDS 2016 programme will present new scientific knowledge and offer many opportunities for structured dialogue on the major issues facing the global response to HIV. A variety of session types – from abstract-driven presentations to symposia, bridging and plenary sessions – will meet the needs of various participants. Other related activities, including the Global Village, satellite meetings, exhibitions and affiliated independent events, will contribute to an exceptional opportunity for professional development and networking.


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