Current Issue

EQUINET NEWSLETTER 182 : 01 May 2016

1. Editorial

Implementing the International Health Regulations cannot just be about epidemic emergencies
Rangarirai Machemedze, SEATINI, Rene Loewenson, TARSC


Successive epidemics of international concern such as SARS, Ebola, Zika have raised the focus on responses to health emergencies, as ‘global health security’. It has also given new attention to the implementation of the International Health Regulations (IHR), including as an agenda item in the World Health Organisation’s 2016 World Health Assembly.

The IHR were adopted globally by member states in the WHO in 2005, including by all 46 countries in its Africa region. They seek to prevent, protect against, control and provide a public health response to the international spread of diseases “…in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” Countries were required by June 2012 to have developed core public health capacities for surveillance, reporting on and response to public health risks and emergencies, including at ports of entry. This includes capacities to provide specialized staff, multi-sectoral teams and laboratories and local investigations to prepare for, prevent and rapidly contain and control cross border public health risks that may be due to infectious diseases, food safety, and to chemical, radiation and zoonotic hazards. Countries unable to meet these core capacities by June 2012 could request for an extension to 2014 and in exceptional circumstances to June 2016. So we are now a month away from the time all countries were expected to have achieved these core capacities.

These capacities are not delinked from the core capacities needed to protect public health within countries, nor from comprehensive primary health care approaches that seek to engage all sectors to promote health and prevent ill health. Within countries, these capacities are not just a matter for the health sector. They call for society, state, private sector and non-state organizations to promote public health. For example, preventing communities living near mines from being poisoned by arsenic or mercury contamination of water, soil, and food calls for intervention from local authorities, planners, mine managers, state sectors responsible for infrastructure, mining, environment, health and labour, workers and communities. This includes workers and families who migrate from other countries to work on mines and who may otherwise return with long term lung, gastrointestinal, neurological or renal problems. While focusing on cross border risks, the presence of uncontrolled environmental risks, or of cholera, typhoid and other epidemics within African countries is not unimportant for the IHR, and certainly not for people in that country. These problems signal weaknesses in public health that may lead to risks spilling across borders. They may also arise from trade or economic determinants that are international in scope.

Hence, as we approach June 2016, while there has been progress in implementing the IHR, it is a matter of concern that there are still deficits in the core capacities. An October 2015 WHO report compiled feedback from 118 of 196 States Parties to the IHR on a self-assessment questionnaire on progress made in developing these core capacities. It showed that progress had been made globally in legislation and policy; coordination and collaboration with other sectors; improved detection, early warning, preparedness and emergency response capacities and in communication with the public and to stakeholders.

For the African region, reporting by March 2015 showed that African countries were also making progress on a number of core capacities. Not surprisingly given the responses and investments after the Ebola epidemic, the most notable improvements were in surveillance and laboratory capacities. Improvements in these areas are seen to be essential for early warning system for detection of any public health events for rapid response and control, to prevent them spilling over borders. There has been investment in surveillance and laboratory capacities in Africa through an Integrated Disease Surveillance Response, and international support for African and sub-regional communicable disease control centers for detection and early warning of infectious disease risks. There has, however, been less progress in preparedness, in capacities at ports of entry, and in capacities to deal with chemical and food safety risks. It suggests that while the region may be better prepared to deal with infectious disease epidemics, this may not be the case for other public health risks.

The progress suggests that the global health security agenda has given great focus to control of infectious diseases and ‘biosecurity’, not least as a response to the international spread of recent epidemics of Ebola virus and Zika virus. Significant new global resources are being mobilised for emergency responses. Assessment tools and reporting systems are being discussed in the WHO, with some proposals for new global mechanisms, global financing facilities and independent assessment by global actors.

However global health security cannot be reduced to emergency responses and infectious disease control, nor can the prevention of cross border disease be delinked from the measures taken from local to national level within countries and between countries in their regions to strengthen the primary health care and public health functioning of health systems. Uganda was able to respond to its 2000 Ebola epidemic within two weeks from first case to confirmation and controls being implemented. This speed of response was as much to do with the strength of systems within districts and the strength of communication between local and national levels of the health systems as the sophistication of its laboratory capacities. The spread of cholera and typhoid epidemics in Africa draws more from inadequate investment in safe water, sanitation and waste management systems and weak public health inspection than from gaps in emergency preparedness. New viral epidemics are emerging as poor communities and animal vectors are being squeezed into closer proximity by mono-cropping and mining activities; and new emergencies such as rising antimicrobial resistance are deeply embedded in how health systems function and interact with the public and with the pharmaceutical industry. Rising levels of chronic conditions in many African countries that foretell a future crisis of escalating unaffordable costs for countries and households are contributed to by cross border trade in harmful processes and products.

The global health security agenda cannot thus be narrowed to one of emergency responses to infectious disease. Instead, global health security also needs to identify and act on the determinants to prevent such emergencies. The IHR as an overarching umbrella for international public health obligations recognises this. So too, in their intent, do the Sustainable Development Goals. While many determinants of global health security lie outside the health sector, and while resources are indeed needed to deal with emergencies and their economic and social impacts, a health sector response to preventing and controlling emergencies needs to link with and support longer term health systems strengthening. This starts locally, within countries and particularly with the comprehensive primary health care and public health approaches that are needed to identify, prevent and manage risk before it grows into an emergency.

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

2. Latest Equinet Updates

EQUINET PRA paper: Reflections on actions and learning from participatory work on health in Cassa Banana, Zimbabwe.
Kaim B: TARSC, ZADHR, Cassa Banana Community Health Committee, EQUINET, Harare, 2016

Over the last two years (2014-2015), the Training and Research Support Centre in cooperation with the Zimbabwe Association of Doctors for Human Rights has been building a programme that aims to foster local and national dialogue to build active citizenship and public and private accountability on water and sanitation, as a key element of primary health care. The work draws on experiences and learning arising from the Health Literacy programme and pra4equity network within EQUINET. This paper explores the Cassa Banana residents’ response to their health situation over the last two years, with a particular focus on the role of the Community Health Committee (CHC) in meeting community health needs and in trying to strengthen relations with the Harare City Council and other key stakeholders. In doing so, the paper reflects on the successes and challenges faced by the CHC, and looks at issues of leadership, social cohesion and power within the community as key components to the successful mobilisation of a diverse and fractured community in trying to get its needs met. It ends by recommending possible actions to deal with the problems identified and comments on the extent to which the challenges faced in Cassa Banana can be generalised to other communities in Zimbabwe.

3. Equity in Health

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in the United Republic of Tanzania
Kanté A; Nathan R; Jackson E; Levira F; Helleringer S; Masanja H; Phillips J: Bulletin of the World Health Organisation 94(4), 233-308

This study explored trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011. The authors used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. They estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models. The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births in 2000 to 66.2 in 2011 and in Rufiji from 118.4 deaths per 1000 live births in 2000 to 76.2 in 2011. Combining both sites, in 2000–2001, the risk of dying for children of uneducated mothers was 1.44 times higher than for children of mothers who had received education beyond primary school and in 2010–2011, the HR was 1.18. In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 in 2000–2001 to 1.48 in 2010–2011, while in Ifakara, disparities narrowed from 1.30 to 1.15 in the same period. While childhood survival has improved, mortality disparities still persist. The authors thus argue for policies and programmes that both reduce child mortality and address socioeconomic disparities.

4. Values, Policies and Rights

African Union model law on medical products regulation
African Union Heads of State: African Union, Addis Ababa, 2015

Member States of the African Union endorsed in 2015 the milestones for the establishment of a single medicines regulatory agency in Africa within the context of the African Medicines Regulatory Harmonization programme. Concerned that the proliferation of Substandard/Spurious/Falsified/Falsely- labelled/Counterfeit medical products on the continent poses a major public health threat and noting that regulatory systems of many African countries remain inadequate the states called for legislation relating to medical products through Regional Economic Communities and the African Union to ensure access to medical products that are safe, efficacious, and of assured quality to the African population. They called for the adoption and domestication of a model law on medical products regulation in Africa for the creation of a harmonized regulatory environment on the continent; and adopted the African Union Model Law on Medical Products Regulation.

AU Policy Framework and Plan of Action on Ageing
African Union, HelpAge International Africa Regional Development Centre; Addis Ababa, 2002

The population of older people throughout the world is increasing rapidly, with Africa projected to have about 210 million older people by 2050. In addition to the usual physical, mental and physiological changes associated with ageing, old people in Africa are argued to be particularly disadvantaged due to lack of social security for everyday social and economic needs. This policy framework binds all AU member countries to develop policies on ageing and is being used as a guide in the formulation of national policies to improve the lives of the continent’s older people. The authors argue that advocacy efforts need improve the adaptation and domestication of the policy and encourage appropriate consultations with older people in these processes, including to ensure the allocation of resources for the implementation of commitments. Notably, the International Plan of Action on Ageing agreed upon in Madrid during the Second World Assembly on Ageing in April 2002, borrowed significantly from the AU Policy Framework.

Making the SDGs Transformational: UNRISD and the 2030 Agenda for Sustainable Development
Ladd P: United Nations Research Institute for Social Development (UNRISD), 2015

UNRISD director Paul Ladd shares his reflections on the Sustainable Development Goals (SDGs). He argues that social development means keeping people at the centre, and recognising the contributions that can be made by all people, regardless of gender, age, race, ethnicity, physical ability, sexuality or any other characteristic. Enhancing well-being means that processes, relationships and institutions need to be transformed into ones that are based on equity and justice. This is critically shaped by how governments are run, how technology is used, how people adapt to demographic change, and how economies are structured, all of which depends on the political agenda. He argues that the 17 SDGs have many welcome innovations, including the aspiration to not tackle issues in silos, to leave no one behind and the recognition that all countries have problems. This presents a more political agenda than the Millennium Development Goals (MDGs) that preceded them, with solutions largely found in policy change and doing things differently, rather than solely spending more money on technocratic 'solutions' that, while well-meaning, ignored the power dynamics that determine who benefits from them and who is left by the wayside. Finally he observes that UNRISD’s three research programmes—social policy, gender and development, and the social dimensions of sustainable development—intend to make a critical contribution to debates on which policies and institutions, in which contexts, will make the most progress towards achieving the SDGs.

5. Health equity in economic and trade policies

Activists lead fight for the right to cheaper drugs
Health Systems Trust, 12 April 2016

Southern African states are being alerted to the concessions on intellectual property rights that they can take advantage of within the agreement on Trade-Related Aspects on Intellectual Property Rights (TRIPS) by the Southern African Regional Programme of Access to Medicines and Diagnostics (SARPAM). SARPAM is communicating the flexibilities within the TRIPS to protect public health, including compulsory licensing and parallel importation, as they note that many of these concessions are not yet being used by African countries to access essential medicines. They article reports ways that states and activists have advanced use of these flexibilities. For example in 2002, Zimbabwe used of one of them after declaring a period of emergency to override anti-retroviral medicine patents to import generic medicines for HIV. The article notes that the issue still demands activism. In March 2016, for example, activists marched to the Johannesburg offices of the multinational pharmaceutical company Roche to put pressure on the company to lower the extremely high cost of a life-saving cancer drug.

Collected readings on post extractivism
Various authors: Yes to Life, No to Mining, 2016

This collection of writings draws together the thoughts of scholars, activists, historians and social commentators on post-extractivism in different contexts. As a system of thought and action, post-extractivism offers a new and radical approach to the problems caused by mining and extractivism in general. Founded in philosophies of Buen Vivir (Good Living) it proposes radical alternatives to current models of ‘development’ thinking that support an oppressively extractive, non-reciprocal relationship with Earth and each other, and suggests fields of action and transition to change the current status-quo.

Increasing Access to High-Quality, Safe Health Technologies Across Africa: African Union Model Law on Medical Products Regulation
PATH, NEPAD, March 2016

The regulation of health technologies is a critical component of every country’s public health system and ensures that high-quality, safe health technologies reach the people who need them most. To harness momentum for regulatory harmonization, the Pan-African Parliament, New Partnership for African Development, and African Union Commission spearheaded the development of the African Union Model Law on Medical Products Regulation, which guides member states and regional economic communities in harmonizing regulatory systems and providing an enabling environment for the development and scale-up of health technologies. This paper outlines the measures for implementation of the law.

The China Africa Project
Olander E; vanStaden C: China Africa Project, 2016

The China Africa Project is a multimedia resource dedicated to exploring various aspects of China’s growing engagement with Africa. Through a combination of original content and curation of third-party material from across the Internet, the CAP’s objective is purely informational. The site states that none of the blog’s authors or producers have any vested interest in any Chinese or African position.

Wellbeing Economics and Buen Vivir: Development Alternatives for Inclusive Human Security
Ruttenberg T: Wellbeing Economics and Buen Vivir, XXVIII, 2013

As international development strategies struggle to address issues of human insecurity and socioeconomic inequality, inspiring alternatives are taking shape outside the traditional development discourse. The author argues that locating development strategies within the current neoliberal capitalist framework limits the possibility of success of development goals and strategies, largely designed by 'the North' and argued to be rarely successful in 'the South'. The author argues that these have potential to transform development policy in the South. This article discusses well-being economics, questioning the notion that high income and consumption constitutes genuine wealth, noting that income contributes up to the point of satisfying basic needs, after which human well-being is argued to rest on supporting the development of human potentialities through meaningful livelihoods, strengthening social relations and promoting ways of life in harmony with nature. She argues that this is being applied in the political philosophy of “buen vivir” (living well) in selected Latin American social movements and states to guide a development policy that is more inclusive of human security and their environments. The paper explores the manner in which the concept puts improvement of the quality of life, capacities and potential of the population and its harmonious coexistence with nature at the centre of the economic system, within constitutions, policies in selected countries and in relation to their impact.

6. Poverty and health

Cardiovascular disease and impoverishment averted due to a salt reduction policy in South Africa: an extended cost-effectiveness analysis
Watkins D; Olson Z; Verguet S; Nugent R; Jamison D: Health policy and planning 31(1) 75-82, 2015

The South African Government recently set targets to reduce cardiovascular disease (CVD) by lowering salt consumption. The authors conducted an extended cost-effectiveness analysis to model the potential health and economic impacts of this salt policy. They used surveys and epidemiologic studies to estimate reductions in CVD resulting from lower salt intake; the reduction in out-of-pocket (OOP) expenditures and government subsidies due to the policy and the financial risk protection (FRP) from the policy. The authors found that the salt policy could reduce CVD deaths by 11%, with similar health gains across income quintiles. It could save households US$ 4.06 million (2012) in OOP expenditures (US$ 0.29 per capita) and save the government US$ 51.25 million in healthcare subsidies (US$ 2.52 per capita) each year. The cost to the government would be only US$ 0.01 per capita, so the policy would be cost saving. If the private sector food reformulation costs were passed on to consumers, food expenditures would increase by <0.2% across all income quintiles. Preventing CVD could avert 2000 cases of poverty yearly. The authors concluded that, in addition to health gains, population salt reduction can have positive economic impacts—substantially reducing OOP expenditures and providing financial protection, particularly for the middle class. The policy could also provide large government savings on health care.

White Paper: National Sanitation Policy
South African National Department of Health: Pretoria, 2016

The sanitation sector in South Africa is currently regulated by three policy documents, namely the White Paper on Water Supply and Sanitation (1994); the White Paper on a National Water Policy of South Africa (1997) and the White Paper on Basic Household Sanitation (2001). These documents provide procedures, rules and allocation mechanisms for sanitation, implemented through laws, regulations; economic measures; information and education programmes; and assignment of rights and responsibilities for providing services. After several years of implementation, a number of challenges and unintended consequences were identified. The regulatory responsibilities were unclear, shifting between departments. Devolving responsibility for implementation to local government resulted in significant changes in the sector. Increased urbanisation is noted to increase stress on urban sanitation systems, but so too is changing human settlement in rural areas placing increased strain on small and limited sanitation systems. The department thus argues for policy review to address these challenges to deliver sanitation.

7. Equitable health services

Rural Health Care Access and Policy in Developing Countries
Strasser R; Kam S; Regalado S: Annual Review of Public Health 37, 395-412, 2016

Compared to their urban counterparts, rural and remote inhabitants experience lower life expectancy and poorer health status, and a shortage of health professionals. This article explores rural areas of Sub-Saharan Africa (SSA). Using the conceptual framework of access to primary health care, sustainable rural health service models, rural health workforce supply, and policy implications, this article presents a review of the academic and gray literature as the basis for recommendations designed to achieve greater health equity. An alternative international standard for health professional education is recommended. Decision makers should draw upon the expertise of communities to identify community-specific health priorities and should build capacity to enable the recruitment and training of local students from under-serviced areas to deliver quality health care in rural community settings.

Effects of Response to 2014–2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa
Parpia A; Ndeffo-Mbah M; Wenzel N; Galvani A: Emerging infectious diseases 22(3) 433-41, 2016

Response to the 2014–2015 Ebola outbreak in West Africa overwhelmed the healthcare systems of Guinea, Liberia, and Sierra Leone, reducing access to health services for diagnosis and treatment for the major diseases that are endemic to the region: malaria, HIV/AIDS, and tuberculosis. To estimate the repercussions of the Ebola outbreak on the populations at risk for these diseases, the authors developed computational models for disease transmission and infection progression. They estimated that a 50% reduction in access to healthcare services during the Ebola outbreak exacerbated malaria, HIV/AIDS, and tuberculosis mortality rates by additional death counts of 6,269 (2,564–12,407) in Guinea; 1,535 (522–2,8780) in Liberia; and 2,819 (844–4,844) in Sierra Leone. The authors report that the 2014–2015 Ebola outbreak was catastrophic in these countries, and its indirect impact of increasing the mortality rates of other diseases was also substantial.

Equity and achievement in access to contraceptives in East Africa between 2000 and 2010
Shah C; Griffith A; Ciera J; Zulu E; Palermo T: International Journal of Gynaecology and Obstetrics 133(1), 53-58, 2016

This paper presents trends in equity in contraceptive use and contraceptive-prevalence rates in six East African countries. In this repeated cross-sectional study, Demographic and Health Survey data from women aged 15–49 years in Ethiopia, Kenya, Malawi, Rwanda, Tanzania, and Uganda between 2000 and 2010 were analysed. Individuals were ranked according to wealth quintile, urban/rural populations stratified, and a concentration index calculated. Equity and contraceptive-prevalence rates increased in most country regions over the study period. In rural Rwanda, contraceptive-prevalence rates increased from 3.9 to 44.0. Urban Kenya showed highest equity with a concentration index of 0.02. The Pearson correlation coefficient between improvements in concentration index and contraceptive-prevalence rates was significant. The results indicate that countries seeking to increase contraceptive use should also prioritize equity in access.

Yellow fever vaccine supply: a possible solution
Monath T; Woodall J; Gubler D; Yuill T; Mackenzie J;Martins R; Reiter P; Heymann D: The Lancet 387;10028; 1599–1600, 2016

The authors note the emerging epidemic of yellow fever in Angola and spread of similar Aedes aegypti mosquito-borne viruses including dengue, chikungunya, and now Zika, albeit with differences noted. Yellow fever was first identified as a viral infection in 1900, has been reported from more than 57 countries and yellow fever outbreaks have case fatality rates as high as 75% in hospitalised cases. There has been an effective yellow fever vaccine since the late 1930s, but with outbreaks in unvaccinated populations in 1987 in urban Nigeria, despite a mass vaccination campaign. According to WHO, the current yellow fever outbreak is in more than six of Angola's 18 provinces, and there has been movement of unvaccinated travellers from Angola to neighbouring Democratic Republic of the Congo, but also to further states, including Mauritania, and China. Southeast Asian countries are now considered at risk because the Aedes vector is present and the population is unvaccinated. However should yellow fever outbreaks occur elsewhere in Africa, in Latin America, or in Asia, the authors note that the current global supplies of yellow fever vaccine may be inadequate.

8. Human Resources

Explaining retention of healthcare workers in Tanzania: moving on, coming to ‘look, see and go’, or stay?
Shemdoe A; Mbaruku G; Dillip A; Bradley S; William J; Wason D; Hildon Z: Human Resources for Health14(1)2, 2016

In Tanzania staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore this the authors explored which cadres are most problematic to recruit and keep in post, for what reasons and why do some stay and cope? Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials. Mid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post. The Human Resources for Health system in Tanzania was reported to lack transparency. The authors suggest that centralised monitoring could help to avoid early departures, misallocation of training, and to enable other incentives. It should match workers' profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, they argue that priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and in measures to involve the community in reforming the culture and practices in services.

9. Public-Private Mix

Expensive private healthcare highlighted at inquiry
Mashego P: BDLive, February 2016

The high cost of private health care in South Africa was profiled in a February 2016 health market inquiry amid revelations that South Africans pay six times the international average for hospital stays. A World Health Organisation study on price levels for private hospitals found that 42% of the funds spent on private voluntary health insurance in South Africa were equivalent to 4% of the country’s gross domestic product. This is six times the average in the Organisation for Economic Cooperation and Development (OECD) countries, despite the expenditure in SA only covering 17% of the population. The report found that South Africans stayed in hospitals for an average of 3.9 days compared to 5.1 days in OECD countries and paid an estimated R20bn in out-of-pocket payments for healthcare. Speaking on the sidelines of the inquiry, Health Minister Aaron Motsoaledi said that healthcare prices were "exorbitant" and that needed to change.

Out-of-pocket expenditure and its determinants in the context of private healthcare sector expansion in sub-Saharan Africa urban cities: evidence from household survey in Ouagadougou, Burkina Faso
Beogo I; Huang N; Gagnon MP; Amendah D: BMC Research Notes 9(1)34, 2016

This study investigated the level and determinants of out-of-pocket (OOP) spending among individuals reporting illness or injury in Ouagadougou, Burkina Faso and who either self-treated or received healthcare in either a private or public facility. A cross-sectional study was conducted with a representative sample of 1017 households in 2011. Among the surveyed sample, 29.6% persons reported a sickness or injury. Public providers were the single most important providers of care, whereas private and informal providers accounted for 29.8 and 34.0%, respectively. Almost universally (96%), households paid directly for care, with an average expenditure per episode of illness of 17.4USD. The total expenditure was higher for those receiving care in private facilities compared to public ones and the insured patients’ bill almost tripled uninsured. Medication was the most expensive component of expenditure in both public and private facilities. OOP was the principal payment mechanism of households. Considering the importance of private healthcare in Burkina Faso, the authors argue that regulatory oversight is necessary and an extensive protection policy to shield households from catastrophic health expenditure is required.

10. Resource allocation and health financing

Modelling the impact of raising tobacco taxes on public health and finance
Goodchild M; Perucic AM; Nargis N: Bulletin of the World Health Organisation 94(4), 233-308

This study investigated the potential for tobacco taxes to contribute to the 2030 agenda for sustainable development by reducing tobacco use, saving lives and generating tax revenues. A model of the global cigarette market in 2014 – developed using data for 181 countries – was used to quantify the impact of raising cigarette excise in each country by one international dollar (I$) per 20-cigarette pack. All currencies were converted into I$ using purchasing power parity exchange rates. The results were summarized by income group and region. According to the study model, the tax increase would lead the mean retail price of cigarettes to increase by 42% – from 3.20 to 4.55 I$ per 20-cigarette pack. The prevalence of daily smoking would fall by 9% – from 14.1% to 12.9% of adults – resulting in 66 million fewer smokers and 15 million fewer smoking-attributable deaths among the adults who were alive in 2014. Cigarette excise revenue would increase by 47% – from 402 billion to 593 billion I$ – giving an extra 190 billion I$s in revenue. This, in turn, could help create the fiscal space required to finance development priorities. For example, if the extra revenue was allocated to health budgets, public expenditure on health could increase by 4% globally. The authors argue that tobacco taxation can prevent millions of smoking-attributable deaths and create the fiscal space needed to finance development, particularly in low- and middle-income countries.

11. Equity and HIV/AIDS

Agenda for zero discrimination in health care
UNAIDS, Geneva, 2016

People around the world face barriers to accessing quality health care and enjoying the highest attainable standard of health. Why this occurs varies between countries and communities, but some barriers are present everywhere. These include the various forms of discrimination faced by people who are marginalized, stigmatized, criminalized and otherwise mistreated because of their gender, nationality, age, disability, ethnic origin, sexual orientation, religion, language, socio-economic status, or HIV or other health status, or because of selling sex, using drugs and/or living in prison. One in eight people living with HIV report having been denied health care. Examples of HIV-related stigma and discrimination go beyond denial of care or lower quality care, and include forced sterilization, stigmatizing treatment, negative attitudes and discriminatory behaviour from providers, lack of privacy and/or confidentiality and mandatory testing or treatment without informed consent. UNAIDS argue that such discriminatory practices undermine people’s access to HIV prevention, treatment and care services and the quality of health-care delivery, as well as adherence to HIV treatment.

12. Governance and participation in health

Developed countries turning against non-State actor WHO engagement framework
Gopakumar K: Third World Network (TWN) Info Service on Health Issues 5, 21 April16

Developed countries are reported to be turning against the World Health Organization’s framework of engagement with non-State actors (FENSA), by putting conditions for its adoption as negotiations on it enter into the last stage. Member States from Europe are reported to be raising three issues to block the adoption of FENSA. First, that the adoption of FENSA is possible only when there is a clear understanding on the implications of its implementation, especially financial and human resource implications. Secondly, that the Secretariat be given flexibility to suspend FENSA norms while engaging with non-State actors to respond to emergencies, and thirdly that the implementation of FENSA be at all three levels of WHO viz. headquarters, regional and national.

Exploring perceptions of community health policy in Kenya and identifying implications for policy change
Mccollum R; Otiso L; Mireku M; Theobald S; de Koning K; Hussein S; Taegtmeyer M: Health Policy and Planning 31(1),10, 2016

Kenya is currently revising its community health strategy (CHS) alongside political devolution, revisioning responsibility for local services. This explores drivers of policy change from key informant perspectives and perceptions of current community health services from community and sub-county levels, including perceptions of what is and what is not working well. It highlights implications for managing policy change. The authors conducted 40 in-depth interviews and 10 focus group discussions with a range of participants to capture plural perspectives from policymakers, sub-county health management teams, facility managers, community health extension worker (CHEW), community health workers (CHWs), clients and community members in two purposively selected counties: Nairobi and Kitui. There was widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload were seen as main drivers for strategy change. Areas that informants felt should change included: lack of clear supervisory structure and adequate travel resources, uneven coverage and inequity in community health services, limited community knowledge about the strategy and home-based HIV testing and counselling. The recommendations point towards a more people-centred health system for improved equity and effectiveness, if the policy is to be effectively implemented.

Partnerships, Power and the SDGs
Faul M: UNRISD seminar, Geneva, March 2016

Partnerships, and their accompanying networks, are now presented as an essential ingredient for fair SDG implementation. But what happens in practice? Network analysis reveals how development ‘partners’ may in fact informally depart from established rules and relationships, with the end result that networks may amplify the very disparities of power they were intended to reduce. In this seminar, Moira Faul argues that with a better understanding of how partnership works, network members could rewire relationships for more inclusion, and ultimately better policy and practice solutions.

13. Monitoring equity and research policy

SDGs indicators: more about politics than statistics
Vandemoortele J: Deliver 2030, February 2016

In his book Damned Lies and Statistics (2001), Best points out that ‘people who bring statistics to our attention have reasons for doing so’. Some statistics are manufactured and manipulated as ammunition for political struggles, although their purpose is hidden behind assertions of objectivity and accuracy. The author argues that numbers often get amplified in the echo chamber of mainstream media and that one should never accept on face value that statistics always reveal truths. He argues that they are often used to manage perceptions more than to help analysis and understanding of complex realities. He thus urges people to be involved in reviewing and commenting on the work of and proposals from the UN Statistical Commission as they develop indicators for the SDGs.

The West African Health Organization’s experience in improving the health research environment in the ECOWAS region
Aidam J; Sombié I: Health Research Policy and Systems14(30), 20 April 2016

The West African Health Organization (WAHO) implemented a research development program in West Africa during 2009–2013 with components of stewardship, financing, sustainable resourcing and research utilization. This paper describes how programme and lessons learnt, triangulating activity reports, an independent evaluation and the authors’ experiences with stakeholders. WAHO and major stakeholders validated these findings during a regional meeting. All 15 ECOWAS countries benefited from this regional research development programme. WAHO provided technical and financial support to eight countries to develop their policies, priorities and plans for research development to improve their research governance and organised capacity-strengthening training in health systems research methodology, resource mobilization, ethical oversight and on HRWeb, a research information management platform. WAHO helped launch a regional network of health research institutions to improve collaboration between regional participating institutions and mobilised funding for the programme. It supported 24 health research projects. High staff turnover, weak institutional capacities and ineffective collaboration were some of the challenges encountered during implementation. The regional collaborative approach to health research was found to be effective given the challenges in the region, and with research partnerships and funding helped strengthen local health research environments.

14. Useful Resources

Bhekisisa Centre for Health Journalism Website
Bhekisisa, Mail and Guardian, 2016.

The South African-based Mail & Guardian newspaper has launched an Africa wide health journalism centre, Bhekisisa. Bhekisisa means "to scrutinise" in Zulu. It has its own website. is mentoring reporters in African countries to file solutions-based health features for the website and is working with health policymakers, activists and researchers to write opinion pieces for the website.

Participatory Governance Toolkit
Christian C: All Africa, 2016

This toolkit contains tools and resources relating to different categories of participatory governance practices, including for (1) public information, for citizens to access relevant information about government policies, decisions and actions; (2) education and deliberation; (3) public dialogue for communication between citizens and state; (4) design and implementation of public policies and plans that respond effectively to citizens’ priorities and needs; (5) public budgets and expenditures to help citizens understand and influence decisions about the allocation of public resources, monitor public spending and hold government actors accountable for their management of public financial resources (6) monitoring and evaluating the accessibility, quality and efficiency of public services and (7) monitoring and overseeing public action and seeking retribution for injustices or misdeeds.

Video: Health care in Cuba and the Philippines: what are the differences?
Third World Health Aid, April 2016

April 7 was World Health Day and the European Day of Action against commercialisation of Health Care. For this occasion, Third World Health Aid launched its new video that compares the health system of Cuba with the privatized system in the Philippines and its impact on the population. It spreads a strong message of the necessity of free and accessible health care, and community involvement. In this video, Third World Health Aid compare the situation in two developing countries. Cuba is famous for its excellent health care, which is free of charge for its citizens. In the Philippines, access to health care is not so evident. Third World Health Aid see a big inequality. What explains this big difference.? The video shows a walk together with local health workers in the neighbourhoods of Havana and Manilla, the capitals of these two countries. It shows the different experiences of the broad range of factors affecting health, including health care.

15. Jobs and Announcements

Call for Applicants: South African Field Epidemiology Training Programme
Closing date: 30 June 2016

The South African Field Epidemiology Training Programme (SAFETP) is requesting applications for the incoming 2017 class from qualified health professionals with an interest in public health and commitment to public service. The programme is a combination of didactic and practical training in which the resident is grounded in the academic basics of public health and is assigned to field sites where s/he learns by doing while being mentored by supervisors in projects that address key public health priorities. This residency programme is a two year, full time training, from which residents graduate with a Masters in Public Health (MPH) from the University of Pretoria. The 2017 cohort will begin in January 2017 and end in December 2018. The training focuses on investigations of public health outbreaks (an acute health event or other epidemiological activity) and using epidemiology and biostatistics to conduct descriptive and analytical studies. Bursaries/stipends may be available for select South African applicants fulfilling predefined criteria. For applicants applying from other African countries - the eligibility requirements still apply and the international applicant must have the required visa and permissions to study in South Africa. The applicants must ensure that all the costs related to participation in SAFETP are fully covered for the 2 years of training – salaries/stipends, university registration and tuition fees, accommodation, travel and accommodation to investigate outbreaks. Further information available on the website.

Fourth Global Symposium on Health Systems Research
14-18 November 2016, Vancouver, Canada

The Canadian Society for International Health (CSIH) is organizing the Fourth Global Symposium on Health Systems Research in Vancouver at the Vancouver Convention Centre on behalf of Health Systems Global (HSG). The theme for 2016 is “Resilient and responsive health systems for a changing world”. The Global Symposium on Health Systems Research is hosted every two years by HSG to bring together its members with the full range of players involved in health systems and policy research. The Symposium aims to share new state-of-the-art evidence; review the progress and challenges towards implementation of the global agenda of priority research; identify and discuss the approaches to strengthen the scientific rigour of health systems research including concepts, frameworks, measures and methods; and facilitate greater research collaboration and learning communities across disciplines, sectors, initiatives and countries.

Global Health Action (GHA) Call for Papers: ‘Gender and health inequalities: intersections with other relevant axes of oppression’
Deadline: End of August 2016

This call for papers entitled ‘Gender and health inequalities: intersections with other relevant axes of oppression’ aims to generate knowledge about how gender inequalities in health/disease/mortality/and access to health care systems interact with other important axes of oppression (race/ethnicity, social class, religion, and/or migratory status, among others) through different levels of power (from the global to the local) at different lifetime stages for a population. It also aims to contribute to a better understanding of the relationship between gender (in)equalities and health (inequalities). The editors welcome different types of contributions: empirical research, theoretical papers, methodological papers, and reviews. Studies aiming to contribute to developing gender and social theories building on intersectional, ecosocial, relational, or biosocial approaches are welcome. Also of interest are methodological papers using qualitative, quantitative, or mixed methods, and are particularly studies that explore means of better addressing the complexity of analysing health inequalities according to this multidimensional or multiple approach. The editors also welcome papers that address not only issues of dominance and/or suffering but also those about resistance, agency, resilience, and/or empowerment. They encourage submissions from researchers working in low-, middle-, and high-income countries.

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.

Public Health Association of South Africa 2016 Conference
19th - 22th September 2016, East London Convention Centre, South Africa

The Public Health Association of South Africa 2016 Conference builds on the 2015 Conference theme of “Health and Sustainable Development: The Future”. The 2016 Conference will focus on how public health education as well as practice will need to transform to achieve the Sustainable Development Goals (SDGs). The 2016 Conference will feature workshops, satellite sessions, panel discussions, oral and poster presentations and site visits. The panel debate format of 2015 will be retained with National Health Insurance a potential topic. The 2016 Conference forms part of the University of Fort Hare’s centenary and this very special occasion will be marked during the opening of the conference.

UNU-WIDER PhD Internships
Applications open 1 March and 1 September of each year

The UNU-WIDER PhD Internship Programme gives registered doctoral students an opportunity to utilize the resources and facilities at UNU-WIDER for their PhD dissertation or thesis research, and to work with UNU-WIDER researchers in areas of mutual interest. PhD interns typically spend 3 consecutive months at UNU-WIDER and return to their home institution afterwards. They prepare one or more research papers and present a seminar on their research findings. PhD interns may also have the opportunity to publish their research in UNU-WIDER’s working paper series. Applicants must be enrolled in a PhD programme and have shown ability to conduct research on developing economies. Candidates working in other social sciences may apply but should keep in mind that UNU-WIDER is an economics-focused institute. Candidates should be fluent in oral and written English and possess good quantitative and/or qualitative analytical skills. Preference is given to applicants who are living or working in developing countries and who are at later stages of the PhD. For further information see the website.

World Nutrition Congress 2016
30th Aug - 2nd Sept 2016, Cape Town, South Africa

This congress is taking place at a time of unprecedented challenges in population nutrition. Global and national food systems are increasingly concentrated and globalised, with small scale food production being rapidly marginalised in countries where such activity previously predominated. In many countries people are mobilising to defend their rights and taking action to recover and preserve indigenous and environmentally sustainable food systems. Several African countries are experiencing a ‘nutrition transition’ but are not yet as advanced along this trajectory as is South Africa, your host country. Together with ‘Big Food’ – large corporations in the food system – South African food companies (manufacturers and retailers) are expanding into Sub-Saharan Africa, influencing many countries’ food environments and nutritional indicators. Hence, South Africa’s experience and policies can inform improved understanding and policy making on the continent and can also provide a platform for all concerned with the impact of the food system on the health of humanity and our planet. The holding of the WPHNA Congress in South Africa has the potential to inform key policy makers and researchers and significantly shape the food and nutrition policy landscape in South Africa, Africa and beyond.

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