Comrades, colleagues, citizens
As we prepare to host the UN Habitat 4 it is timely to reflect on the declarations made and the journey we've taken since the last conference in Quito, Ecuador in October 2016. (Is really it only the fourth conference - many of us weren't even born when the first was held in 1976!) We are fortunate here in Harare to be part of a regional movement, together with our strategic partner cities, towards more equitable and inclusive urban environments. Habitat 3 gave early voice to many of the changes that were nascent in our cities at the time: greater networking between cities, space for people to influence urban design in their cities, a consciousness of climate challenges and an awareness of the intertwined fortunes between urban and rural areas. Our cities today are not isolated. Whilst retaining their unique qualities and idiosyncrasies, they are part of highly globalised, networked ecosystems where our futures are deeply connected.
Our archives reveal that the atmosphere in Quito was aspirational. From the records excavated after the Great Data Crash of 2025, we reconstructed video footage of Habitat 3. The voice in it of the then Secretary-General of United Cities and Local Governments Africa, Jean Pierre Elong Mbassi still rings clear: “Local authorities are now on the map, what we want next is to be around the table…we hope that people will realise that without local authorities, there’s no way we can implement the global agendas adopted in 2015 and 2016”. This was echoed by the World Mayor’s Assembly who asserted two key demands: The first that city, metropolitan and regional governments be involved in UN negotiations, with powers to make decisions independent of national government; and the second that mayors have access to international finance and that instruments such as a Green Climate Fund also be allocated to and handled directly by cities.
In 2036, with collective, participatory urban budgeting now commonplace and seamless networks between cities, it is easy to forget that only a few decades ago cities were primarily considered national hubs, managed by nation states. We in East and Southern Africa have especially benefited from the Ore to Information Fund through which finance raised from the last mining operations was invested in open access technology infrastructure. This has allowed us to have the fastest data connectivity in the world, bringing huge benefits for technological innovation and education, access to health information, for the reach of health and economic services and capacities and new resources for community dialogue and action.
This month we celebrate 68 years since the principle of the ‘right to the city’ was first proposed by Henri Lefebvre. UN Habitat 3 was a critical marker for those campaigning for this right. We take it as commonplace today, but respect that those early struggles were not easily won.
Championed by Brazil and Ecuador, the ratification at Habitat3 of a New Urban Agenda (NUA) made this the first internationally negotiated document to reference the right to the city and encourage nation states to enshrine it in their laws. Under the slogan “Cities for people, not for profit!” civil society from various campaigns against gentrification, privatisation of public space and criminalisation of homeless and vulnerable citizens lobbied for the inclusion of the right. They called for governments to put citizens before private sector interests in the city, building on the 2004 World Charter on the Right to the City and the 2010 UN World “Right to the City” Urban Forum in Brazil.
At that time, Brazil and Ecuador were the only two countries to have this right enshrined in law. Still the Habitat3 negotiations saw large parts of the right to the city excluded from the final document. It did not mention the ‘social function of land’ or ‘participatory approaches at all stages of the urban policy and planning processes’. These clauses were struck off during the drafting. The NUA was also non-binding. As we look back in 2036, we owe a debt to the global Right to the City movement that brought together civil society, local government and other actors around the world, including from health, who picked up the baton after Quito, to implement the principles of equity and inclusivity in the 2016 NUA. Women in Informal Employment Globalizing and Organizing had already by 2016 publicised the economic, social and environmental contribution to cities of women informal sector workers and Colombia’s waste pickers had already won a court ruling to block a waste management contract that did not provide opportunities for informal recyclers. We have seen others follow suit, including those living in slums, health activists from communities affected by pollution and urban waste, increasingly bringing previously excluded groups to the policy making and planning table, affirming their rights to a city that ensures wellbeing for all. This has not been easy, especially given the legacies we inherited from the early years of the 21st century of unpredictable weather, rising sea levels, pollution and waste threatening the ecosystems of all in our cities, of massive socio-economic inequalities, of destructive wars and of big population movements across countries. However we now fully understand that inclusion and investment in wellbeing is not only as a matter of rights and justice, but is vital for our collective survival.
We were fascinated to find in our excavated websites an account by Barcelona's first female Mayor (to think - that city is now on its fifth female mayor!). Writing after Quito, Ms Colau said that Habitat 3 saw women coming to the forefront of political change. She noted that “the 21st Century is the century of cities - in part because this is a moment of great political uncertainty at many levels. But within that uncertainty, we see empowered citizens asking to be protagonists, and the city is the place to do this.”
We are looking forward to hosting Habitat 4 this year here in our region in real and virtual space. We welcome all joining us in our increasingly inclusive understanding of ‘the city’ with all the people and connected spaces that are critical to healthy urban life. As we gather to debate new challenges, we are fortunate to reflect on the debates, advances and still unresolved issues from Habitat 3 that we have found, to reflect on where we reached in 2030 with our sustainable development goals, and to bring in the voice of all to craft our Agenda for Habitat 4.
This oped was sent in response to our invitation for reflections post Habitat III. This issue provides a range of resources and publications related to urban health. Please send feedback or queries on the issues raised to the EQUINET secretariat: email@example.com.
Comrades, colleagues, citizens
The concept of global health security underpins the current framework for global preparedness and response to emerging infectious diseases. The Global Health Security Agenda –a collaboration between governments– was launched in 2014, aiming to make our interconnected world safe from infectious disease threats. The governments involved in the Global Health Security Agenda focus on strengthening their countries’ capacities for detection, response and prevention.
In the context of public health emergencies, the Agenda has received financial and political support from international organizations and almost 50 countries. However, there is tension between the aims of global health security and governments’ mandate to ensure national security. The 1994 United Nations Development Programme’s Human Development Report first introduced the concept of human security, referring to security of citizens as individuals rather than that of the states in which they live. We posit that the use of the term global health security can have a negative unintended effect on the ultimate goal of improving health for all. There are three reasons why this term potentially privileges the security of the state rather than the security of individuals.
First, global health security, in its current use, is largely focused on protecting high-income countries against public health threats coming from low- and middle-income countries. Ebola virus, Marburg, Zika virus, dengue, chikungunya, Rift Valley and Lassa fevers, originated in low- and middle-income countries. If the Agenda is used to prioritize global health risk depending on the origin of infections, resource allocation may become even more skewed towards high-income settings. To ensure that a health security agenda is an integral part of national and foreign policy of each country, political attention and coordination between national ministries is needed as well as support from the national security budget.
Second, global health security tends to emphasize disease containment to protect national security rather than the prevention of future local outbreaks. Disease containment is common practice in the control of emerging infectious diseases. A national security perspective often results in unilateral, neo-colonial and/or short-term solutions designed to protect national borders. For example, many countries and airline companies imposed travel restrictions during the 2013–2016 Ebola virus disease outbreak in western Africa, contrary to World Health Organization recommendations.
Third, we argue that respect for human rights and values such as equity and solidarity should underlie each national security agenda. Such values are consistent with the motives of many people who provide health services in public health emergencies. Health security agendas should aim to build resilience to future outbreaks of infectious diseases, and require a long-term systems approach based on surveillance and national health system strengthening.
Protecting the world from infectious disease threats requires that national governments share the responsibility of serving those most in need, wherever they live. We believe that the concept of global health security should be expanded to include solidarity and sustainability. In this way, we will be able to develop a long-term approach and overcome the limitations of current responses to global health emergencies.
This editorial appeared first as an open access editorial in the WHO Bulletin in December 2016 at n/volumes/94/12/16-171488/en/.
2. Latest Equinet Updates
This three hour participatory skills session discussed methods/ tools to build learning from action as a key element of participatory action research (PAR) and briefly the implications for what this means for an understanding of ‘resilience’ in health systems. It was held as a satellite session at the 2016 Global Symposium on Health Systems Research. The session drew on approaches and experience from Africa, Latin America and participants globally to discuss the methods/tools, their application and their integration in health systems. It integrated input from two rounds of moderated discussion on these questions held on the pra4equity list prior to the Global Symposium. The EQUINET,TARSC, AHPSR, WHO, IDRC Methods Reader on PAR was also distributed. The session was attended by 62 delegates from all regions of the world.
3. Equity in Health
For the Third United Nations Conference on Housing and Sustainable Urban Development, Habitat III agenda for the next 20 years of urban development to succeed, the health of the nearly four billion people who dwell in cities today must be a central concern. Decisions related to urban planning and governance can create or exacerbate major health risks – or they can foster healthier environments and lifestyles, that in turn reduce the risks of both communicable and noncommunicable diseases. The New Urban Agenda adopted at Habitat III, clarifies that health is not only about the provision of health care services, recognising that the shape and form of urban development influences the health of city residents. Those who design, plan, build and govern cities exercise great influence over the basic ingredients of a healthy life, including access to decent housing, clean air and water, nutritious food, safe transport and mobility, opportunities for physical activity, and protection from injury risks and toxic pollutants. Cities that offer these fundamentals can dramatically reduce the incidence and associated costs of a wide range of diseases – from heart disease and stroke, to vector-borne diseases and childhood illnesses – while improving health equity for those most often exposed to such risks, such as children, older people, women, people with disabilities, and the poor. Cities that offer health-enabling environments and coordinated support for healthy lifestyles can ensure that their citizenry are not only healthier and happier, but more economically productive, with far lower costs to both families and societies due to work-related illnesses and injuries. This paper clarifies these and other critically important connections between health and urban policies. It also provides a detailed vision for integrating health into urban planning and governance, and offers practical guidance on health-promoting approaches for those tasked with implementing the New Urban Agenda in the years to come.
The Innov8 approach is a resource that supports the operationalisation of the Sustainable Development Goal (SDGs) commitment to “leave no one behind”. Innov8 is an 8-step analytic process undertaken by a multidisciplinary review team. It results in recommendations to improve programme performance through concrete action to address health inequities, support gender equality and the progressive realisation of universal health coverage and the right to health, and address critical social determinants of health. The Innov8 Technical Handbook is a user-friendly resource that includes background readings, country examples and analytical activities to support a programmatic review process. The Technical Handbook will be complemented by the release of a wider set of materials currently under development by WHO as part of the Innov8 resource package.
It is not clear whether between-country health inequity in Sub-Saharan Africa has been reduced over time due to economic development and increased foreign investments. The authors used the World Health Organization’s data about 46 nations in Sub-Saharan Africa to test if under-5 mortality rate (U5MR) and life expectancy (LE) converged or diverged from 1990 to 2011. The authors explored whether the standard deviation of selected health indicators decreased over time (i.e., sigma convergence), and whether the less developed countries moved toward the average level in the group (i.e., beta convergence). The variation of U5MR between countries became smaller from 1990 to 2001. Yet this trend did not continue after 2002. Life expectancy in Africa from 1990–2011 demonstrated a consistent convergence trend, even after controlling for initial differences of country-level factors. The lack of consistent convergence in U5MR partially resulted from the fact that countries with higher U5MR in 1990 eventually performed better than those countries with lower U5MRs in 1990, constituting a reversal in between-country health inequity.
4. Values, Policies and Rights
Recent legislative developments in Africa have focused international attention on the legal status of lesbian, gay, bisexual and transgender (LGBT) people in the continent. Attempts by various African governments to revise or introduce new legislation on same-sex sexual conduct and marriage, and the response of the international community, has sparked extensive coverage of the associated political, social and cultural controversies. Away from the headlines are several African countries that have never criminalised same- sex sexual conduct and that are outliers to the apparent ‘trend’ of discriminatory legislation in the continent. One of these is Rwanda. Compared with the situation in neighbouring countries, state-sponsored homophobia appears negligible in Rwanda, and violent attacks are minimal. In the international arena, Rwanda has emerged as an unlikely champion for LGBT rights, and domestically has designated sexual orientation as a ‘private matter’. This study explores Rwanda’s relatively progressive position on LGBT-related issues and its implications for Rwandan civil society. It examines the strategies employed by national as well as international actors to advance LGBT rights and to address social and economic marginalisation. The study questions assumptions about the uniformity of the ‘African experience’ and seeks to enhance understanding of the nuance and diversity that exists both within and between countries on the continent.
The author claims that the battle for global sustainability will be won or lost in cities. Yet the UN’s Habitat III conference was argued in a 10-point manifesto that resulted from a convening of the Second World Assembly of Local and Regional Governments to miss the voices of the individuals and groups who actually run those cities. Mayors and other leaders from more than 500 cities formed a collective voice calling for “A Seat at the Global Table.” Their manifesto lays out why local governments need to be integrated into international talks traditionally reserved for national policymakers. With support from key figures such as UN Secretary General Ban Ki-moon, the assembly pushed for a “paradigm shift in global governance” that would give local leaders more say in what strategies to implement and how. sign and adopt it. The UCLG named Parks Tau, the former mayor of Johannesburg, as their new head.
The Zimbabwean study on safe and inclusive cities seeks to research on manifestations of urban violence, poverty exclusion and inequalities informed by the following underlying research questions: Can the State in terms of both its direct and indirect actions, be implicated in promoting urban violence when its role in addressing issues of urban poverty, inequality and exclusion is examined? Has the state embraced laws and policies founded on continuities of inequalities, rather than a focus on structural change in framing state urban policy in townships, in a manner which does not address those factors that link poverty, inequality and exclusion to urban violence? At municipal level, have laws and policies consolidated rather than shifted gender inequalities in urban townships, thereby continuing to contribute to women’s vulnerability to urban poverty, inequality, exclusion and urban violence? Have communities participated in addressing these problems? The research into context and lived realities took place in Kadoma, Zimbabwe, drawing on the services of 38 masters in women’s law research students who worked in six groups in four broad thematic areas: poverty families and employment, urban environmental health issues, security challenges in Kadoma especially for women girls and access to courts and access to justice. The Women’s law approach assessed the gap between what laws such as Legal Aid Act; Maintenance Act, Administration of Estates Act and Domestic Violence Act against women’s lived experiences and impact of such laws on issues of equality, exclusion and poverty related issues. The human rights approach sought to understand the role of the state in practice against human rights standards as provided in selected human rights instruments on matters such as social and economic rights particularly relating to matters such as the right to housing, the right to work; the right to health; the right to food and equality before the law and fair representation.
5. Health equity in economic and trade policies
Food animals are considered as key reservoirs of antibiotic-resistant (ABR) bacteria with the use of antibiotics in the food production industry having contributed to the global challenge. There are no geographic boundaries to impede the worldwide spread of ABR, and limitations in the interventions in one country could compromise the efficacy and endanger containment policies implemented in other parts of the world. Multifaceted, comprehensive, and integrated measures complying with the One Health approach are argued to be imperative to ensure food safety and security, effectively combat infectious diseases, curb the emergence and spread of ABR, and preserve the efficacy of antibiotics for future generations. Countries are urged to follow the World Health Organisation, World Organisation for Animal Health, and the Food and Agriculture Organisation of the United Nations recommendations to implement national action plans encompassing human, (food) animal, and environmental sectors to improve policies, interventions and activities that address the prevention and containment of ABR from farm-to-fork. This review covers (i) the origin of antibiotic resistance, (ii) pathways by which bacteria spread to humans from farm-to-fork, (iii) differences in levels of antibiotic resistance between developed and developing countries, and (iv) prevention and containment measures of antibiotic resistance in the food chain.
This report provides updated information on the status of implementing the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions (“the Code”) in and by countries. It presents the legal status of the Code, including - where such information is available - to what extent Code provisions have been incorporated in national legal measures. The report also provides information on the efforts made by countries to monitor and enforce the Code through the establishment of formal mechanisms. Its findings and subsequent recommendations aim to improve the understanding of how countries are implementing the Code, what challenges they face in doing so, and where the focus must be on further efforts to assist them in more effective Code implementation.
6. Poverty and health
What would a city free from poverty really look like for urban youth in Tanzania? Dr Nicola Banks, ESRC Future Research Leader, in this video presented information from local research on young people’s vision for a poverty-free city in Tanzania. The video reports evidence from participatory discussion with youth. Urban youth make up a huge proportion of city populations- and the video highlights the economic and social opportunities Tanzanian youth raised in their discussions.
Rates of gender-based violence (GBV) in South Africa (SA) are among the highest in the world. In societies where social ideals of masculinity encourage male dominance and control over women, gender power imbalances contribute to male perpetration and women’s vulnerability. The drivers that cause men to perpetrate GBV and those that lead to HIV overlap and interact in multiple and complex ways. Multiple risk and protective factors for GBV perpetration by males operate interdependently at a number of levels; at the individual level, these include chronic anxiety and depression, which have been shown to lead to risky sexual behaviours. This study examined psychosocial risk factors (symptoms of anxiety and depression) as well as protective factors (social support and self-esteem) as self-reported by a cohort of males in rural KwaZulu-Natal (KZN) Province, SA; and to determine whether there are differences in anxiety, depression, social support and self-esteem between perpetrators and non-perpetrators. The participants were relatively young (median age 22 years); over half were school goers, and 91% had never married. Over 43% of the sample reported clinical levels of anxiety and depressive symptoms. Rates of GBV perpetration were 61%, 24% and 10% for psychological abuse, non-sexual physical violence and sexual violence, respectively. GBV perpetration was associated with higher depression, higher anxiety, lower self-esteem and lower social support. Interventions to address GBV need to take modifiable individual-level factors into account.
The Human City Project is a community-driven media, architecture, urban planning and human rights movement in Port Harcourt, Nigeria. It is a collaboration between local and international community organisers, filmmakers, broadcasters, urban planners, architects, designers, university researchers and ordinary people from across Port Harcourt’s informal settlements. Those involved share skills and technologies for communities to record their experiences, tell their stories and change their lives. They are moved by the conviction that democratic design principles can make cities more creative and just. Based on community mapping of needs and priorities, a community radio station was started – Chicoco Radio – formally owned by Chicoco Community Media Initiative, an incorporated board of trustees drawn from communities across the city. With a campaign of 'the people live here' communities in the informal settlements in Port Harcourt have resisted eviction, and are carrying out activities to map and make visible their conditions and needs, develop their voice and capacity to participate meaningfully in the shaping of their city, including to change the way the city is imagined and inhabited on principles of social justice and equity. With the means to tell their stories on film, on air and in court, charting their reality on maps and describing their visions in urban action plans, these communities are changing their lives and shaping their city.
Slum dweller federations, like many other social movements, cater for the youth in their constituencies. This is critical to their relevance as agents of change and contributes to the sustainability of the movements. This story is a case study of the youth federation that is aligned to Kenya’s slum dwellers federation. At the slum level, the youth had organized themselves into junior councils that discussed various issues, like how to gain access to football pitches in neighbouring schools. When the annual Youth Council elections came around that year, for the first time slum youth showed up in great numbers and elected their own for all the posts, including junior mayor. From its beginnings in a couple of slums, the movement spread to slums in four of the city’s eight divisions, and the youth called it “Mwamko wa Vijana” (“Youth Awakening”). Three years after it was initiated, a range of activities are underway: a football team, acrobatic and dance troupes, a study group, and a waste collection business. They note: “We share issues in common that we can federate around – education, recreation, income generation and mentoring.” The prospect of renewing the youth federation every year is a daunting task but each year new youth come in that are charged up and compelling in their aspirations, so that there is little choice but to do it again.
7. Equitable health services
This study investigated associations between patients’ socioeconomic status and characteristics of primary healthcare facilities, and control and treatment of blood pressure in hypertensive patients in South Africa. The authors enrolled hypertensive patients attending 38 public sector primary care clinics in the Western Cape, SA, in 2011, and followed them up 14 months later as part of a randomised controlled trial. Blood pressure was measured and prescriptions for anti-hypertension medications were recorded at baseline and follow-up. Logistic regression models assessed associations between patients’ socioeconomic status, characteristics of primary healthcare facilities, and control and treatment of blood pressure. Blood pressure was uncontrolled in 60% of patients at baseline, which was less likely in patients with a higher level of education and in English compared with Afrikaans respondents. Treatment was intensified in 48% of patients with uncontrolled blood pressure at baseline, which was more likely in patients with higher blood pressure at baseline, concurrent diabetes, more education, and those who attended clinics offering off-site drug supply, with a doctor every day, or with more nurses. Patient and clinic factors influence blood pressure control and treatment in primary care clinics in SA. Potential modifiable factors include ensuring effective communication of health messages, providing convenient access to medications, and addressing staff shortages in primary care clinics.
8. Human Resources
Primary health care (PHC) plays a vital role in maintaining population health, preventing suffering and providing coverage of essential services. In Kenya, primary health centres and dispensaries are often managed by the most senior clinical staff member at the facility who is responsible for performing both clinical and managerial duties. PHC managers, also known as in-charges, play a key role in the functioning of health services on a day-to-day basis. KEMRI-Wellcome Trust has conducted research in one of the 47 counties in Kenya to better understand the role and responsibilities of PHC managers and their coping strategies within the context of devolution and uncertainty. The key findings from the research are set out in this brief, as well as recommendations to support PHC managers. The research found that PHC managers carry out a variety of tasks to ensure facilities can function effectively. These include: developing annual work plans, ensuring coverage and delivery of services, providing leadership and management to frontline staff. Despite the challenges faced by PHC managers in the period since devolution, facilities remained open and functioning. A key support system for in-charges was the sub-county managers, some of whom had played the role of line managers to in- charges for decades.
This study was conducted to gain an understanding of nurses’ and midwives’ intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa. A total of 190 nurses and midwives completed a cross-sectional survey. The survey included components on demographics, knowledge of maternal and child healthcare (MCH) and family planning (FP) services, attitude towards family planning services, subjective norms regarding maternal and child healthcare and family planning services, self-efficacy with maternal and child healthcare and family planning services, and intentions to provide maternal and child healthcare and family planning services to adolescents. Self-efficacy to conduct MCH and FP services and years of experience as a nurse- midwife were associated with stronger intentions to provide the services. Self-efficacy had a strong and positive association with the intentions to provide both MCH and FP services, while there is a moderate association with attitude and norms. The authors argue that there is a need to improve and strengthen nurses’ and midwives’ self-efficacy in conducting both MCH and FP services in order to improve the quality and utilisation of the services by adolescents in South Africa.
9. Public-Private Mix
Kenya faces severe health workforce shortages, especially at the primary health care level. Currently, the density of nurses per 100,000 of the population is 103.4, far below the World Health Organisation minimum target threshold of 500 nurses per 100,000 required to provide sufficient coverage for essential interventions. RESYST research has shown that private and faith-based training institutions currently make up 30% of admissions for nursing courses in Kenya, and are increasingly being considered an important way of increasing nurse production. Students from private nursing institutions are much more likely to graduate than public sector students; of which up to 40% do not successfully complete their training. The curriculum of private institutions, however, is more limited with less focus on public health issues such as health equity and the social determinants of health. Whilst Kenya has increased capacity to train nurses in recent years, severe blockages remain in the system, including in nurses’ employment prospects upon graduation. This video is based on research carried out as part of the RESYST health workforce theme, which looks at the role of the private sector in addressing human resource constraints in Kenya.
10. Resource allocation and health financing
This paper examines the potential to expand public HIV financing, and the extent to which governments have been utilising these options. First, with data from the 14 most HIV-affected countries in sub-Saharan Africa, the authors estimate the potential increase in public HIV financing from economic growth, increased general revenue generation, greater health and HIV prioritisation, as well as from more unconventional and innovative sources, including borrowing, health-earmarked resources, efficiency gains, and complementary non-HIV investments. The authors then adopt a novel empirical approach to explore which options are most likely to translate into tangible public financing, based on cross-sectional econometric analyses of 92 low and middle-income country governments' most recent HIV expenditure between 2008 and 2012. If all fiscal sources were simultaneously leveraged in the next five years, public HIV spending in these 14 countries could, it is estimated, increase from US$3.04 to US$10.84 billion per year. This could cover resource requirements in South Africa, Botswana, Namibia, Kenya, Nigeria, Ethiopia, and Swaziland, but not even half the requirements in the remaining countries. The empirical results suggest that, in reality, even less fiscal space could be created (a reduction by over half) and only from more conventional sources. International financing may also crowd in public financing. The authors observe that most HIV-affected lower-income countries in sub-Saharan Africa will not be able to generate sufficient public resources for HIV in the medium-term, even if they take very bold measures. Considerable international financing will be required for years to come. HIV funders will need to engage with broader health and development financing to improve government revenue-raising and efficiencies
KEMRI-Wellcome Trust has conducted research to understand how county hospitals in Coastal Kenya set priorities and allocate resources between services. Data was collected in 2012 and 2013. This brief presents the key findings from the research, showing how hospital managers set priorities and the reasons behind their decisions. Even though the study was conducted pre-devolution, findings remain relevant post-devolution, especially in counties where hospitals still enjoy financial autonomy and as they plan ways to structure hospital financing and priority setting. The brief provides recommendations for county departments of health to improve hospital financing and budgeting, and for hospital managers to improve priority setting and ensure a fair allocation of resources between services. Key messages from the report included that hospitals lack explicit processes for setting healthcare priorities; this provides room for the use of inappropriate priority setting criteria such as lobbying and favouritism. Evidence is not used in decision- making. Hospitals are severely under-resourced and depend on user fee revenues. This has turned hospitals into revenue-maximisers whereby managers prioritise services that generate revenue through user-fees and overlook services with limited moneymaking potential, including those for young children and disabled people. Many key stakeholders including middle level managers, clinicians and community members, are not included in priority setting processes. It is important for hospital managers to institute clearly defined procedures and ensure that priority setting is inclusive. Hospital managers are often clinicians with limited training and skills in management and leadership. Many did not choose to become leaders. Educational institutions and county departments of health both have a role to play in strengthening management and leadership capacity, as well as incentivising hospital managers.
This paper describes and evaluates the budgeting and planning processes in public hospitals in Kenya. The authors used a qualitative case study approach to examine these processes in two hospitals in Kenya and collected data by in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), by a review of documents, and non-participant observations within the hospitals over a 7 month period. The budgeting and planning process in the case study hospitals was characterized by lack of alignment, inadequate role clarity and the use of informal priority-setting criteria. The hospitals incorporated economic criteria by considering the affordability of alternatives, but rarely considered the equity of allocative decisions. In the first hospital, stakeholders were aware of - and somewhat satisfied with - the budgeting and planning process, while in the second hospital they were not. Decision making in both hospitals did not result in reallocation of resources. With regard to procedures, the budgeting and planning process in the first hospital was more inclusive and transparent, with the stakeholders more empowered compared to the second hospital. In both hospitals, decisions were not based on evidence, implementation of decisions was poor and the community was not included. There were no mechanisms for appeals or to ensure that the procedures were met in both hospitals. Public hospitals in Kenya could improve their budgeting and planning processes by harmonising these processes, improving role clarity, using explicit priority-setting criteria, and by incorporating both consequences (efficiency, equity, stakeholder satisfaction and understanding, shifted priorities, implementation of decisions), and procedures (stakeholder engagement and empowerment, transparency, use of evidence, revisions, enforcement, and incorporating community values).
11. Equity and HIV/AIDS
High rates of attrition are weakening Mozambique’s national HIV Program’s efforts to achieve 80% treatment coverage. In response, Mozambique implemented a national pilot of Community Adherence and Support Groups (CASG). CASG is a model in which antiretroviral therapy (ART) patients form groups of up to six patients. On a rotating basis one CASG group member collects ART medications at the health facility for all group members, and distributes those medications to the other members in the community. Patients also visit their health facility bi-annually to receive clinical services. A matched retrospective cohort study was implemented using routinely collected patient-level data in 68 health facilities with electronic data systems and CASG programs. A total of 129,938 adult ART patients were registered in those facilities. Of the 129,938 patients on ART, 6,760 were CASG members. A propensity score matched analysis was performed to assess differences in mortality and loss to follow-up (LTFU) between matched CASG and non-CASG members. Non-CASG participants had higher LTFU rates than matched CASG participants; however, there were no significant mortality differences between CASG and non-CASG participants. Compared with the full cohort of non-CASG members, CASG members were more likely to be female, tended to have a lower median CD4 counts at ART initiation and be less likely to have a secondary school education. ART patients enrolled in CASG were significantly less likely to be LTFU compared to matched patients who did not join CASG. CASG appears to be an effective strategy to decrease LTFU in Mozambique’s national ART program.
In an effort to support countries, programme managers, health workers and other stakeholders seeking to achieve national and international HIV goals, this 2016 update of the WHO guidelines issues new recommendations and additional guidance on HIV self-testing (HIVST) and assisted HIV partner notification services. The guidelines support the routine offer of voluntary assisted HIV partner notification services as part of a public health approach and provide guidance on how HIVST and assisted HIV partner notification services could be integrated into both community-based and facility-based approaches and be tailored to specific population groups. The guidelines support the introduction of HIVST as a formal intervention using quality-assured products that are approved by WHO and official local and international bodies.
National surveys in Zimbabwe, Malawi, and Zambia reveal exceptional progress against HIV, with decreasing rates of new infection, stable numbers of people living with HIV, and more than half of all those living with HIV showing viral suppression through use of antiretroviral medication. For those on antiretroviral medication, viral suppression is close to 90%. These data are the first to emerge from the Population HIV Impact Assessment (PHIA) Project, a multi-country initiative funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The project deploys household surveys, which measure the reach and impact of HIV prevention, care and treatment programs in select countries. Importantly, the data positively demonstrate that the 90-90-90 global targets set forth by UNAIDS in 2014 are attainable, even in some of the poorest countries in the world. The data show that once diagnosed, individuals are accessing treatment, staying on treatment, and their viral load levels are suppressed to levels that maintain their health and dramatically decrease transmission to others. In Zimbabwe, among adults ages 15 to 64, HIV incidence is 0.45%; HIV prevalence is 14.6% (16.7% among females and 12.4% among males); 60.4% of all HIV-positive people are virally suppressed, and 86% of those on treatment are virally suppressed. In Malawi, among adults ages 15 to 64, HIV incidence is 0.37%; HIV prevalence is 10.6% (12.8% among females and 8.2% among males); 67.6% of all HIV-positive people are virally suppressed, and 91% of those on treatment are virally suppressed. In Zambia, among adults ages 15 to 59 years, HIV incidence is 0.66%; HIV prevalence is 12.3% (14.9% among females and 9.5% among males); 59.8% of all HIV-positive people are virally suppressed, and 89% of those on treatment are virally suppressed. The results from the first three PHIA surveys compel the global community to strengthen its efforts to reach those who have yet to receive an HIV test and to engage, support, and enable those who test HIV-positive to start and stay on effective treatment in order to achieve long-term viral suppression.
12. Governance and participation in health
This study aims to identify key context features and underlying mechanisms through which community health committees build community capacity within the field of maternal and child health. Since such groups typically operate within or as components of complex health interventions, they require a systems thinking approach and design, and thus so too does their evaluation. Using a mixed methods realist evaluation with intraprogramme case studies, this protocol details a proposed study on community health committees in rural Tanzania and Uganda to better understand underlying mechanisms through which these groups work (or do not) to build community capacity for maternal and child health. It follows the realist evaluation methodology of eliciting initial programme theories to inform the field study design.
The concept of social cohesion is increasingly being used in local and international policy discourse and scholarship. The idea of collective efficacy, defined as ‘social cohesion among neighbours combined with their willingness to intervene on behalf of the common good’, has been posited as having an important protective effect against violence. This article investigates the relevance of international framings of social cohesion and collective efficacy, - largely conceptualised and tested in the global North - to the conditions of social life and violence prevention in a city in the global South. These circumstances are interrogated through an ethnographic study conducted in Khayelitsha township in the Western Cape, where a major internationally funded and conceptualised violence prevention intervention, Violence Prevention through Urban Upgrading (VPUU), has been implemented. The ethnographic material contests some of the key assumptions in international discourses on social cohesion and the manner in which social cohesion has been interpreted and effected in the violence prevention initiatives of the VPUU. Khayelitsha communitarian world views support forms of mutual sociality that are underpinned by a philosophy of ubuntu in which personhood is achieved through social relations rather than through individual empowerment. However, these communitarian networks and ‘ways of life’ are argued to be under social and structural strain and can be conduits not only for reciprocity, but also for violence.
For the past 10 years voluntary medical male circumcision has been recommended as a way of reducing female-to-male transmission of HIV. Estimates show that it could reduce infections by 60%. Several sub-Saharan African countries with high rates of HIV prevalence but low rates of male circumcision have rolled out the procedure as part of their HIV prevention initiatives. Since 2007 more than 9 million circumcisions have been performed in eastern and southern Africa. But to cover more than 80% of men on the continent by 2025, about 20 million more men need to be circumcised. If this happens about 3.4 million new HIV infections could be averted, reducing the number of people who would need HIV treatment and care. While circumcision has been encouraged there are many places where it has faced challenges. This is linked to misconceptions about the purpose of circumcision as well as religious and cultural concerns which prevent men from getting circumcised. Uganda is argued in this article to be a case in point. By the end of 2015 the country’s health ministry aimed to circumcise 80% – or 4.2 million – men aged between 15 and 49. But between 2008 to 2013 the country only managed to circumcise 50% of this population. Most of these were young boys. This research found that religious and cultural beliefs compete with the messages about the purpose of circumcision. The authors found that this got in the way of men deciding whether or not to be circumcised medically and also affected the way they behaved afterwards. When medical circumcision is introduced in settings where there are high rates of HIV, the authors argue that it must take into account local beliefs about circumcision and local religious and social group leaders and women must be involved in the roll-out.
Many Voices Make a City is a series of mini-dramas written, performed and produced by Chicoco Radio trainees, each explores an aspect of participatory urban design. This episode features a starchitect, a celebrity engineer and feisty market woman who knows what she wants. For those who need a little help with Pidgin English, this version is subtitled.
The study reported in this video sought to understand the role of strong social cohesion in the cities of Cape Town and Rio de Janeiro, both of which suffer from high levels of inequality, poverty, and violence. In response, local governments and non-governmental organisations in both cities have tried to counteract these phenomena through a variety of strategies, programs, and projects. This work explored the role played by social cohesion in the cycle of inequality, poverty, and violence, noting that social cohesion can act as one of a number of violence-prevention factors. The project provides theoretical, methodological, and practical insights, which contribute to better public policies in the domain of poverty and violence reduction, replicable in other regions.
Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. The authors frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. The authors sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs). The authors searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” They identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability. When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed. Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality.
This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. Saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women’s access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.
13. Monitoring equity and research policy
Health systems research is increasingly being conducted in low and middle-income countries (LMICs). Such research should aim to reduce health disparities between and within countries as a matter of global justice. For such research to do so, ethical guidance that is consistent with egalitarian theories of social justice proposes it ought to (amongst other things) focus on worst-off countries and research populations. Yet who constitutes the worst-off is not well-defined. By applying existing work on disadvantage from political philosophy, the paper demonstrates that (at least) two options exist for how to define the worst-off upon whom equity-oriented health systems research should focus: those who are worst-off in terms of health or those who are systematically disadvantaged. The paper describes in detail how both concepts can be understood and what metrics can be relied upon to identify worst-off countries and research populations at the sub-national level (groups, communities), considering real-world cases of health systems research in Uganda and India in 2011. It is recommended that health researchers (or other actors) should use the concept that best reflects their moral commitments—namely, to perform research focused on reducing health inequalities or systematic disadvantage more broadly. If addressing the latter, it is recommended that they rely on the multidimensional poverty approach rather than the income approach to identify worst-off populations.
Faraz Khalid, a 2016 Emerging Voice for Global Health, a PhD candidate at Tulane School of Public Health and Tropical Medicine, USA, and a health financing consultant with the Prime Minister National Health Insurance Program, Pakistan, shares quotes from senior researchers gathered at meetings and conferences attended throughout the year, including the Emerging Voices in Global Health 2016 training program preceding the Global Symposium on Health Systems Research 2016 in Vancouver. These include Gorik Ooms, Professor at London School of Hygiene and Tropical Medicine (LSHTM) who notes “If one accepts that health is a human right, one can only assess the present situation of global health (and its enormous inequalities) as a massive and continued human rights violation. Young (and older) health systems researchers must find a middle ground between assuming that states will continue to behave more or less as they currently are (which leaves little room for improvement), or assuming that states will live up to their domestic and international responsibilities (which seems unlikely to happen). In this uncomfortable position, it is important to be aware that whatever solutions we recommend, they will shape the future, one way or the other.”
The strategic importance of monitoring social determinants of health (SDH) and health equity and inequity has been a central focus in global discussions. This study aims to define a framework for monitoring SDH and health equity. This review provides a global summary and analysis of the domains and indicators that have been used in recent studies covering the SDH. It describes the range of international and national studies and the types of indicators most frequently used; reports how they are used in causal explanation of the SDH; and identifies key priorities and challenges reported in current research for national monitoring of the SDH. The authors conducted a scoping review of published SDH studies in PubMed 2004-2014 to obtain evidence of socio-economic indicators. The final sample consisted of 96 articles. SDH monitoring is well reported in the scientific literature independent of the economic level of the country and magnitude of deprivation in population groups. The research methods were mostly quantitative and many papers used multilevel and multivariable statistical analyses and indexes to measure health inequalities and SDH. In addition to the usual economic indicators, a high number of socio-economic indicators were used. The indicators covered a broad range of social dimensions, which were given consideration within and across different social groups. The authors identified a need to make indicators more wide-ranging in order to include a broader range of social conditions, and for WHO to provide intersectoral and interdisciplinary means of building a more comprehensive standardised approach to monitoring the SDH and improving equity in health.
14. Useful Resources
Know Your City is a global campaign of Slum Dwellers International (SDI) and UCLG-A. Around the world, slum dwellers collect city-wide data and information on informal settlements. This work creates alternative systems of knowledge that are owned by the communities and have become the basis of a unique social and political argument that supports an informed and united voice of the urban poor. SDI’s databases are becoming the largest repositories of informal settlement data in the world and the first port of call for researchers, policy makers, local governments and national governments.
Whilst the peoples’ right to participate in making decisions that affect them, many governments and development agencies still apply top- down development paradigms. This toolkit's strength is the fact that it has been developed based on empirical project work undertaken in Kitale, a secondary town in Kenya. It is targeted at social workers, planners, development workers, community groups and development agencies operating at the micro-level through existing government structures, in this case the local authority. As a tool, it is intended to mobilise and create synergy with local residents, local development institutions and development agency workers; and demonstrate how locally available resources and experiences may be harnessed in order to improve access to basic infrastructure and services for improved urban livelihoods. The toolkit has been divided into three parts; the first part looks at the philosophical foundation, origin, development and strengths of participatory planning methodologies globally, regionally and locally; the second part looks at the processes that are mandatory in any given participatory planning exercise; while the third gives an empirical and step wise account of the Kitale projects implementation processes; key milestones, challenges faced, innovations and/or best practices, and lessons learnt.
Jockin Arputham from the Indian slums came up with an idea to organise marginalised communities in slums to improve conditions for themselves, in the form of a Slum Dwellers union. This organisation now exists in over 30 countries: This video describes how it works in Kenya.
15. Jobs and Announcements
The theme for the 2017 Building Children's Nursing for Africa Conference is ‘Pillars of Practice’ in paediatric and children’s nursing and will showcase recent research, clinical practice projects, education and leadership initiatives. The Child Nurse Practice Development Initiative is an established and strategically significant nurse-led programme which is now the main training hub for children’s nursing on the African continent. The conference themes include establishing families as the care hub, clinically relevant teaching: breaking the mould of parrot-style learning, sustainable innovation in paediatrics, thinking nurses who collaborate across disciplines, and examining what nurses measure - how and why?
The Fordham Urban Law Center, in conjunction with the University of Cape Town (UCT), is pleased to announce a call for participation in the 4th Annual International and Comparative Urban Law Conference, to be held on Monday July 17th and Tuesday July 18th, 2017. The Conference will be held at UCT in Cape Town, South Africa. The Conference will provide a dynamic forum for legal and other scholars to engage and generate diverse international, comparative, and interdisciplinary perspectives in the burgeoning field of urban law. The Conference will explore overlapping themes, tensions, and opportunities for deeper scholarly investigation and practice with a comparative perspective. The Conference is open to urban law topics across a broad spectrum, such as: Structure and workings of local authority and autonomy;Urban and metropolitan governance and finance; Economic and community development; Housing and the built environment; Unique challenges facing cities in developing nations and the Global South; Urban public health; Migration and citizenship; Urban equity and inclusion; Sustainability and resilience. While the Conference will foster a broad dialogue about cities and legal systems in comparative and international perspective, we specifically invite submissions to focus on the role of law in New Urban Agenda adopted this past October by the United Nations at the Habitat III Conference in Quito, Ecuador. In keeping with this framework, the conference seeks to investigate the role of laws in promoting the New Urban Agenda in a manner that is democratic, sustainable and equitable.
The Global Health Watch is an alternative World Health Report that incorporates the voices of marginalised people and civil society into discussions around social justice and global health. The Global Health Watch aims to monitor the activities of global institutions, shift the health policy agenda to recognise the political, social and economic determinants of health, provide a forum for global civil society to question and challenge the influence of neoliberalism on health and global health policy and make recommendations for change and highlight alternatives. Global Health Watch (GHW) have identified broad areas to be covered in the 5th issue of the Watch, which is officially scheduled for release in the end of 2017. GHW are now seeking your assistance in sourcing case studies that can add value to each of these important topics. These case studies and testimonies will form part of the electronic accompaniment to the development of the Watch and in some cases may also appear in the electronic or print edition of the Watch. The case studies will amplify and give a more personal voice to the contents of the Watch. They will also make the issues more accessible and meaningful to readers who may be able to see their own experiences reflected in the experiences of others.
The South African Health Review’s Emerging Public Health Practitioner Award (EPHPA) is open to young public health practitioners or student researchers in the fields health sciences, medicine or public health who are currently studying for their Masters or Honours degree, or are in the final year of their Bachelor’s degree. Individuals seeking to publish a paper dealing with public health policy development or implementation in a respected and widely read South African peer-reviewed journal are encouraged to apply. The South African Health Review’s Emerging Public Health Practitioner Award is offered to South African citizens or permanent residents who are under the age of 35 on 28 February 2017. The applicant must be first author on the paper. Any other authors may only be cited in a supervisory capacity. To apply, submit a complete chapter along with a copy of your ID and EPHPA Entry form.
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