Current Issue

EQUINET NEWSLETTER 192 : 01 March 2017

1. Editorial

The World Health Organisation should counter the privatization of health governance, but does it?
Claudio Schuftan, Peoples Health Movement, Ho Chi Minh City

While economics is not World Health Organisation (WHO)’s core expertise, the impact of poverty and income maldistribution on population health clearly justifies the organisation working with other agencies within or outside the UN system to focus much more attention on questions of disparity. Things being the way they are right now, it is thus difficult to make sense of the shrinking scope of WHO’s role in global health governance.

One factor could be the wide and ambiguous use of slogans about ‘stakeholders’ and the fait-accompli of ‘multi-stakeholder platforms’ and ‘public-private partnerships’. The term ‘stakeholders’, bundling together public interest civil society organizations with international NGOs, private sector enterprises and philanthropies under the term ‘non-state actors’, appears to endow all of these private ‘stakeholders’ with the right to a ‘seat at the table’, with only the tobacco and arms industries declared off limits. Such ‘sitting rights’ jeopardize people’s human rights as enshrined in various instruments, including the right to health.

‘Donor’ countries (the US in particular) continue to push the WHO towards working with industry through such ‘multi‐stakeholder partnerships’, rather than giving it the chance to implement regulatory and fiscal strategies that could make a real difference. Bilateral funders and big philanthropies demand that WHO provide data according to their particular interests, beyond the compilation of country-reported statistics. They focus on providing technical interventions, and introduce a bias away from interventions on the right to health or social determinants.

This treatment of WHO is part of a wider onslaught on the UN system generally. The whole UN system is held hostage to short-term, unpredictable, funding. The freezing and periodic withholding of countries’ assessed contributions and tightly earmarked voluntary contributions creates dependence on private philanthropy. It applies a sustained pressure to adopt the multi‐stakeholder partnership model of program design and implementation that gives global corporations an undeserved ‘seat at the table’.

If the WHO reform is to realise the vision of its Constitution, it will require a global mobilization around the democratization of global health governance, within the wider global mobilization for human rights and equity in global economic and political governance. Globalization has created new collective health needs that cross old spatial, temporal and political boundaries. In response, we need global health governance institutions that represent the many, not the few; and that are sufficiently agile to act effectively in a fast-paced world and capable of bringing together the best ideas and boundary-shattering knowledge available.

Yet the WHO seems strangely detached from the broader political turmoil and changes unfolding around the world. WHO may point to its 193 member states and claim to be universally representative, but it is far from politically inclusive. Like the alienation felt by millions around the world, many members of the global health community have turned elsewhere to move issues forward and get things done. We thus see a steady decline of WHO, clinging to obsolete political institutions and bureaucratic models, yet kept alive by member states as an essential public institution. This decline is not because WHO is not needed, but because it has not adapted to and is not publicly financed for a changing world. It is not the WHO that we need today.

Political innovation must thus become a fundamental part of the process of WHO reform. We need to think: How might virtual and interactive town halls improve communication between global health policy-makers and the constituencies they serve? How might the closed world of global policy-making be opened up and strengthened through virtual public consultations, feedback and monitoring systems? How might the concept of global citizenship become institutionalized within our global health institutions, especially WHO?

We also need to challenge the re-legitimation of the ‘free trade agenda’ in health that has strengthened intellectual property (patent) protection regimes despite their well-known negative consequences for public health. We need to question the mantra of the ‘realistic costing of outputs’ that prescribe programme implementation models where programmes comprise a set of planned outputs from prescribed activities with known costs. This approach leaves little, if any, room for flexibly managing complexity in planning and implementing systems. It makes health actors, including WHO, wary of the longer term implementation processes needed in health systems, partly because they disrupt ‘production schedules’ demanded by funders.

These models also contradict our understanding that health care is just one of the factors influencing health and can only be considered part of the solution. As the 2008 WHO Commission on the Social Determinants of Health stated, “Social injustice is killing people on a grand scale and constitutes a greater threat to public health than a lack of doctors, medicines or health care services”. The conditions under which people live and work, their socioeconomic development, education, housing and other conditions have a major impact on health behaviours and outcomes. A robust analysis of the root causes of the preventable global disease burden is thus essential to understand which ‘stakeholders’, or duty bearers, are part of the problem and which are part of the solution. Consistent with human rights principles and the findings of the 2008 Commission report, such analysis enables us to identify which can be trusted to have a seat at the policy table.

This influence of social injustice on health and the analysis of root causes of preventable disease appears most obscured in the influence of external funders over health ministries in the global south. It keeps them focused slogans such as ‘development assistance’ and ‘public-private partnerships’ that in their design serve the agenda of the richest 1%. In so doing it sustains a world view of the beneficence of private enterprise and that accepts as natural and unchanging conditions of global inequality and environmental degradation.

This editorial draws on points raised in the work of PHM and other colleagues, including K Detavernier, M Kok, K Lee, D Legge and E Pisani. For further information visit the PHM website at . Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat:

2. Latest Equinet Updates

10th ECSA Best Practices Forum and 26th Directors Joint Consultative Committee Meeting
ECSA HC: 10 to 12 April 2017, Arusha, Tanzania; Submission of Abstracts deadline: March 17, 2017

The East, Central and Southern Africa Health Community (ECSA-HC) will host the
10th Best Practices Forum and 26th Directors Joint Consultative Committee from 10 to 12 April 2017 in Arusha, Tanzania. The theme is Promoting Multi-Sectoral Collaboration for Health through Sustainable Development Goals. The Conference will address its Theme through the following sub-themes:
1. Good Governance and Leadership Practices in the Health sector
2. Mitigating the Impact of emerging and re-emerging diseases.
3. Multi-Sectoral responses to Non-communicable Diseases.
4. Accountability for Women’s, Children’s and Adolescent Health post-2015
The ECSA-HC is inviting abstracts of best practices and scientific papers that are relevant to the conference sub themes. The scientific papers and best practices should consist of case studies and evidence based programme experiences that are innovative, unique or have added value and new thinking in health. The abstracts and scientific papers will form the basis for the recommendations that will be presented to the Health Ministers for further deliberation and adoption as resolutions. Further information is available on the website. EQUINET has a formal association with ECSA HC and will be represented at the meeting.

3. Equity in Health

Patterns and determinants of malaria risk in urban and peri-urban areas of Blantyre, Malawi
Mathanga D; Tembo A; Mzilahowa T; Bauleni A; Mtimaukenena K; Taylor T; Valim C; Walker E; Wilson M: Malaria Journal 15(590), 2016

Although malaria disease in urban and peri-urban areas of sub-Saharan Africa is a growing concern, the patterns and drivers of transmission in these settings remain poorly understood. Factors associated with variation in malaria risk in urban and peri-urban areas were evaluated in this study. A health facility-based, age and location-matched, case–control study of children 6–59 months of age was conducted in four urban and two peri-urban health facilities (HF) of Blantyre city, Malawi. Children with fever who sought care from the same HF were tested for malaria parasites by microscopy and PCR. Those testing positive or negative on both were defined as malaria cases or controls, respectively. A total of 187 cases and 286 controls were studied. In univariate analyses, higher level of education, possession of TV, and electricity in the house were negatively associated with malaria illness; these associations were similar in urban and peri-urban zones. Having travelled in the month before testing was strongly associated with clinical malaria, but only for participants living in the urban zones. Use of long-lasting insecticide nets the previous night was not associated with protection from malaria disease in any setting. In multivariate analyses, electricity in the house, travel within the previous month, and a higher level of education were all associated with decreased odds of malaria disease. Only a limited number of Anopheles mosquitoes were found by aspiration inside the households in the peri-urban areas, and none was collected from the urban households. Travel was the main factor influencing the incidence of malaria illness among residents of urban Blantyre compared with peri-urban areas. Identification and understanding of key mobile demographic groups, their behaviours, and the pattern of parasite dispersal is argued to be critical to the design of more targeted interventions for the urban setting.

Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level
Lu C; Black M; Richter L: The Lancet 4 (12) e916–e922, 2016

In this paper the authors used 2010 estimates to assess how many children aged younger than 5 years were exposed to stunting or extreme poverty. The authors used country-level prevalence of stunting in children younger than 5 years based on the 2006 Growth Standards proposed by WHO and poverty ratios from the World Bank to estimate children who were either stunted or lived in extreme poverty for 141 low-income and middle-income countries in 2004 and 2010. To avoid counting the same children twice, the authors excluded children jointly exposed to stunting and extreme poverty from children living in extreme poverty. To examine the robustness of estimates, the authors also used moderate poverty measures. The estimated number of children exposed to the two risk factors in low-income and middle-income countries decreased from 279 million in 2004 to 249 million in 2010; and the prevalence of children at risk fell from 51% to 43% globally. Sub-Saharan Africa had the highest prevalence in both years, however.

4. Values, Policies and Rights

Monitoring the implementation of the right to health under the constitution of Kenya: A training manual
Kenya Legal & Ethical Issues Network (KELIN): Nairobi 2016

This training manual is intended to enhance the role of civil society in promoting and protecting of the right to health under the Constitution. It will play an integral part in ensuring that civil society organisations have the knowledge and skills to hold duty bearers accountable to effective and efficient health service delivery. Schedule Four of the Kenya Constitution creates two levels of governance with distinct functions. The national government is mandated to formulate health policy and manage national referral health facilities while the county government is responsible for delivery of health services at the local level. The civil society groups that are working on health issues must therefore understands the roles and responsibilities of the different actors at both levels if they are to meaningfully engage in national and county processes. The manual is presented in four modules. The first module outlines the constitutional provisions on the right to health and what these provisions mean to the implementation of health as a right. The second module addresses the substance of the right to health including the international standards developed for the implementation of this right. The third module outlines the systems and structures of the devolved government and the role of the different state organs and agencies at national and county level in health service delivery. The fourth module then focuses on the role of the civil society in monitoring the implementation of the right to health. It also highlights the key issues concerning the right to health and outlines the specific responsibilities of civil society in holding each level of government to account for their mandates to deliver on the right to health.

Psychosocial risk and protective factors associated with perpetration of gender-based violence in a community sample of men in rural KwaZulu-Natal, South Africa
Mngoma N; Fergus S; Jeeves A; Jolly R: The South African Medical Journal 106(12), 2016

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; to determine whether there are differences in anxiety, depression, social support and self-esteem between perpetrators and non-perpetrators. A cross-sectional study using quasi-probability cluster sampling was done in 13 wards in Harry Gwala District, KZN. Participants were then randomly chosen from each ward proportionate to size. The participants were relatively young (median age 22 years); over half were schoolgoers, and 91.3% had never married. Over 43% of the sample reported clinical levels of anxiety and depressive symptoms on the Brief Symptom Inventory. Rates of GBV perpetration were 60.9%, 23.6% and 10.0% 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. The authors propose that interventions to address GBV need to take modifiable individual-level factors into account.

Strategising national health in the 21st century: a handbook
World Health Organisation, 2016

This handbook is designed as a resource for providing up-to-date and practical guidance on national health planning and strategising for health. It establishes a set of best practices to support strategic plans for health and represents the wealth of experience accumulated by WHO on national health policies, strategies and plans (NHPSPs). WHO has been one of the leading organisations to support countries in the development of NHPSPs. The focus on improving plans has grown in recent years, in recognition of the benefits of anchoring a strong national health sector in a written vision based on participation, analysis, and evidence.

5. Health equity in economic and trade policies

Antibiotic Resistance in the Food Chain: A Developing Country-Perspective
Founou L; Founou R; Essack S: Frontiers in Microbiology, 2016

Food animals are considered as key reservoirs of antibiotic-resistant bacteria with the use of antibiotics in the food production industry having contributed to the actual global challenge of antibiotic resistance (ABR). There are no geographic boundaries to impede the worldwide spread of ABR. If preventive and containment measures are not applied locally, nationally and regionally, the limited interventions in one country, continent and for instance, in the developing world, could compromise the efficacy and endanger ABR containment policies implemented in other parts of the world, the best-managed high-resource countries included. Multifaceted, comprehensive, and integrated measures complying with the One Health approach are thus 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. The World Health Organisation, World Organisation for Animal Health, and the Food and Agriculture Organisation recommend implementing 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.

South Centre Statement on the Amendment to the WTO TRIPS Agreement to Ease Access to Affordable Medicine
South Centre: Geneva, January 2017

An amendment to the TRIPS Agreement that aims to facilitate the access to affordable medicines has entered into force upon approval by two thirds of the WTO members. The amendment reflects the recognition by WTO Members of the need for the continued enhancement of global intellectual property rules to allow Members to systematically take measures to protect public health. The United Nations Secretary General’s High Level Panel on Access to Medicines has highlighted the importance of designing legislation that allows for quick, fair, predictable and implementable compulsory licenses for legitimate public health needs, and recommended WTO Members to revise the paragraph 6 system in order to find a solution that enables a swift and expedient export of pharmaceutical products produced under compulsory license. The South Centre stresses the continued importance for Least-Developed Countries (LDCs) to make full use of the special status they enjoy in not being required to adopt rules on patent protection and most other rules of the TRIPS Agreement, in order to build their technological capabilities and reduce obstacles to affordable access to medicines. The LDCs would not need, in this case, to make use of the system. Close attention will need to be paid to the design of national implementing legislations and the feedback from potential user entities of the system on any hurdles they may face that diminish interest in its use. The evaluation of the system must continue in the TRIPS Council. The South Centre offers to provide assistance to countries in examining national implementing legislations, and providing information to potential interested parties. Templates for facilitated implementation and meeting of conditions required under the system may be provided.

TRIPS amendment on access to cheaper drugs comes into force
Third World Network: SUNS #8387 January 2017

A protocol amending the WTO TRIPS Agreement that would enable developing countries with insufficient or no manufacturing capacities in the pharmaceutical sector to import cheaper generic medicines produced under compulsory licencing came into force on Monday, 23 January. The annex to the protocol amending the TRIPS Agreement contains a new Article which contains five paragraphs on the obligations of exporting Members in relation to compulsory licences, AND the modification of obligations to the extent necessary to enable a pharmaceutical product produced or imported under a compulsory licence to other countries within a regional trade agreement. "This is an extremely important amendment. It gives legal certainty that generic medicines can be exported at reasonable prices to satisfy the needs of countries with no pharmaceutical production capacity, or those with limited capacity," said WTO Director-General Roberto Azevedo. Ambassador Modest Mero of Tanzania, Chair of the TRIPS Council, underlined the importance of the entry into force of the first-ever amendment of the multilateral agreements administered by the WTO but also a concrete response by trade ministers to address the concerns in the area of public health.

Walter Rodney and the racial underpinnings of global inequality
Paschal T: Pambazuka News, January 2017

While inequality has become a topic of increased popularity and politicization in recent years, most of the attention has focused on how 1% own an increasingly large share of the world’s wealth, rather than on inequalities between nations. In a global context in which national borders and citizenship pose few barriers to the mobility of capital, the reality is also a story of the world’s richest nations continuing to reap a disproportionate amount of the globe’s profits. Contemporary analyses of global inequality, capitalism, and development would benefit from the lessons of earlier works concerned with similar questions decades before. One example is the classic work written by Walter Rodney, How Europe Underdeveloped Africa. While some contemporary accounts recognise that the problems of African countries do not lie exclusively in Africa, they do not go far enough. Piketty’s discussion of the extraction of wealth from the African continent, for example, is largely independent from his analysis of the accumulation of wealth in other parts of the globe. For Rodney, it was impossible to explain development and the accumulation of wealth in one region without deeply understanding its relations to other regions of underdevelopment and the extraction of wealth. This relation, he argued was not accidental; it was endemic to capitalism itself.

6. Poverty and health

Food security and coping strategies of an urban community in Durban
Mtolo A: Durban University of Technology Thesis, 2016

This study determined the food security status, coping strategies, food intake and the nutritional status of the Kenneth Gardens community, in urban KwaZulu-Natal. Residents are low income bracket earners and many rely on state disability and pension grants for survival. The research tools included; a food security questionnaire, anthropometric measurements, a socio-demographic questionnaire, a food frequency questionnaire, and 24-hour recall questionnaires conducted in triplicate. The most commonly used coping strategy during periods of food scarcity was “Rely on less expensive and preferred food”. The second used coping strategy was “Reduce the number of meals eaten in a day” , followed by “Contribute to a food stokvel in order to ensure food over a scarce period" and “Restrict consumption by adults in order for small children to eat”. Utilisation of these food coping strategies indicate a degree of food insecurity. Low income and high unemployment increased the prevalence of food insecurity, leading to the coping strategies reported.

From Corn to Popcorn? Urbanisation and food consumption in Sub-Sahara Africa: Evidence from rural-urban migrants in Tanzania
Cockx L; De Weerdt J: 2016 AAAE Fifth International Conference Paper Number 249270, 2016

Sub-Saharan Africa is currently in the midst of an unprecedented wave of urbanisation that is expected to have wide-ranging implications for food and nutrition security. Though this spatial transformation of the population is increasingly put forward as one of the main drivers of changes in food consumption patterns, empirical evidence remains scarce and the comparative descriptive design of existing research is prone to selection bias as urban residence is far from random. Based upon longitudinal data from the Tanzania National Panel Survey and the Kagera Health and Development Survey, this study is the first to assess the impact of urbanisation on food consumption through comparing individuals’ food consumption patterns before and after they have migrated from rural to urban areas. The authors find that even after controlling for individual fixed heterogeneity, baseline observable characteristics and initial household fixed effects, urbanisation is significantly associated with important changes in dietary patterns, including a shift away from traditional staples towards more processed and ready-to-eat foods. While there is some evidence of changes that can be deemed beneficial from a nutritional point of view - including increased consumption of vegetables and animal source foods - the results also largely confirm concerns about the association between urbanisation and heightened consumption of sugar and fats. In addition, the authors find no support for the hypothesis that urbanisation is associated with more diverse diets. Finally, the results indicate that rural-urban migration significantly contributes to reducing volatility in food consumption.

Participatory Slum Upgrading Programme
Okello M; Oenga I; Chege P: Practical Action, 2017

Launched in 2008, the Participatory Slum Upgrading Programme (PSUP) is a joint effort of the African, Caribbean and Pacific (ACP) Group of States, the European Commission (EC) and UN-Habitat. To date, the programme has reached out to 35 countries, 160 cities, and 2 million slum dwellers. The approach is grounded in integrating slum dwellers into the broader urban fabric using city-wide participatory planning methods. In practical terms, PSUP puts slums on the ‘urban’ maps and facilitates dialogue at local, national and regional levels that is necessary for a ‘mind-set change’, key for inclusive urbanisation. PSUP provides tools and practical experience of inclusive integrated slum upgrading through which all stakeholders learn key lessons. It builds confidence in participatory planning; institutionalises partnerships and improved governance arrangements, equips government with key financing mechanisms for slum upgrading including mechanisms to engage and empower slum dwellers themselves to advance delivery of relevant, community led improved infrastructure in slums.

7. Equitable health services

Health systems context(s) for integrating mental health into primary health care in six Emerald countries: a situation analysis
Mugisha J; Abdulmalik J; Hanlon C; Petersen I; Lund C; Upadhaya N; Ahuja S; Shidhaye R; Mntambo N; Alem A; Gureje O; Kigozi F: International Journal of Mental Health Systems 11(7), 2017

Mental, neurological and substance use disorders contribute to a significant proportion of the world’s disease burden, including in low and middle income countries. In this study, the authors focused on the health systems required to support integration of mental health into primary health care (PHC) in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. A checklist guided by the World Health Organisation Assessment Instrument for Mental Health Systems was developed and was used for data collection in each of the six countries participating in the Emerging mental health systems in low and middle-income countries (Emerald) research consortium. The documents reviewed were from the following domains: mental health legislation, health policies/plans and relevant country health programs. Data were analysed using thematic content analysis. Three of the study countries (Ethiopia, Nepal, Nigeria, and Uganda) were working towards developing mental health legislation. South Africa and India were ahead of other countries, having enacted recent Mental Health Care Act in 2004 and 2016, respectively. Among all the 6 study countries, only Nepal, Nigeria and South Africa had a standalone mental health policy. However, other countries had related health policies where mental health was mentioned. The lack of fully fledged policies is likely to limit opportunities for resource mobilisation for the mental health sector and efforts to integrate mental health into PHC. Most countries were found to be allocating inadequate budgets from the health budget for mental health, with South Africa (5%) and Nepal (0.17%) were the countries with the highest and lowest proportions of health budgets spent on mental health, respectively. Other vital resources that support integration such as human resources and health facilities for mental health services were found to be inadequate in all the study countries. Monitoring and evaluation systems to support the integration of mental health into PHC in all the study countries were also inadequate. Integration of mental health into PHC will require addressing the resource limitations that have been identified in this study. There is a need for up to date mental health legislation and policies to engender commitment in allocating resources to mental health services.

Immunisation drive hailed as watershed for Africa as leaders target public health
Kodal H: The Guardian, February 2017

In a double move hailed as a milestone for public health, African leaders have launched an agency to tackle global threats such as Ebola and pledged to make immunisation available throughout the continent by 2020. Under the twin commitments, African heads of state will establish regional health centres around the continent, increase funding for immunisation, improve supply chains and delivery, and prioritise vaccines as part of broader efforts to strengthen health systems. At the heart of the new health push will be the Africa Centres for Disease Control and Prevention, which will help countries across the continent to deal with major health emergencies by establishing systems for early warning and response surveillance. Based in Addis Ababa, the new organisation will liaise with regional centres in Zambia, Gabon, Kenya, Nigeria and Egypt. Dr Matshidiso Moeti, the World Health Organization’s (WHO) regional director for Africa, said the announcements, made on Tuesday at the African Union summit in Addis Ababa, demonstrated a strong commitment by African leaders to “save lives across the continent”. “This is a very important milestone,” said Moeti. “We are extremely excited to have got here with the immunisation declaration. It’s something we worked on for quite a few months with a range of partners, and it includes commitments with heads of state and partners in mobilising finances for the vaccines.
“It shows leaders reiterating their commitments to saving the lives of children across the continent, and contributing their own funding, as they transition into middle-income states.”

Socioeconomic and modifiable predictors of blood pressure control for hypertension in primary care attenders in the Western Cape, South Africa
Folb N; Bachmann M; Bateman E; Steyn K; Levitt N; Timmerman V; Lombard C; Gaziano T; Fairall L: The South African Medical Journal 106(12), 2016

There are few reports of the effect of socioeconomic and potentially modifiable factors on the control of hypertension in South Africa (SA). This study investigated associations between patients’ socioeconomic status and characteristics of primary healthcare facilities, and control and treatment of blood pressure in hypertensive patients. 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 antihypertension medications were recorded at baseline and follow-up. Blood pressure was uncontrolled in 60% of patients at baseline, less likely in patients with a higher level of education or in English compared with Afrikaans respondents. Treatment was intensified in 48% of patients with uncontrolled blood pressure at baseline, 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.

The link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review
Shoman H; Karafillakis E; Rawaf S: Globalization and Health 13(1), 2017

This study determined the effects of health systems’ organisation and performance on the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and lessons learned. The WHO health system building blocks were used to evaluate the performance of the health systems in these countries. A systematic review of articles published from inception until July 2015 was conducted following the PRISMA guidelines. Electronic databases including Medline, Embase, Global Health, and the Cochrane library were searched for relevant literature. Grey literature was also searched through Google Scholar and Scopus. Articles were exported and selected based on a set of inclusion and exclusion criteria. Data was then extracted into a spreadsheet and a descriptive analysis was performed. Each study was critically appraised using the Crowe Critical Appraisal Tool. The review was supplemented with expert interviews where participants were identified from reference lists and using the snowball method. Thirteen articles were included in the study and six experts from different organisations were interviewed. A shortage of health workers had an important effect on the control of Ebola but also suffered the most from the outbreak. This was followed by information and research, medical products and technologies, health financing and leadership and governance. Poor surveillance and lack of proper communication also contributed to the outbreak. Lack of available funds jeopardised payments and purchase of essential resources and medicines. Leadership and governance had least findings but an overarching consensus that they would have helped prompt response, adequate coordination and management of resources. Ensuring an adequate and efficient health workforce is thus judged to be of high importance to ensure a strong health system and a quick response to new outbreaks. Adequate service delivery results from a collective success of the other blocks. Health financing and its management is crucial to ensure availability of medical products, fund payments to staff and purchase necessary equipment. The authors also note that leadership and governance needs to be explored for their role in controlling outbreaks.

8. Human Resources

Limits and opportunities to community health worker empowerment: A multi-country comparative study.
Kane S; Kok M; Ormel H; Otiso L; et al.: Social Science & Medicine 164, 2016, doi:

In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'empowerment of communities'. To be able to empower the communities they serve, the authors argue, it is essential that CHWs themselves be, and feel, empowered. The authors present here a critique of how diverse national CHW programs affect CHW's empowerment experience. They present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used. CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact. While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need, it is argued, to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.

‘Why do an MPH?’ Motivations and intentions of physicians undertaking postgraduate public health training at the University of Cape Town
Zweigenthal VE, Marquez E; London L: Global Health Action, 9(1), 2017

Public health (PH) approaches underpin the management and transformation of health systems in low- and middle-income countries. Despite the Master of Public Health (MPH) rarely being a prerequisite for health service employment in South Africa, many physicians pursue MPH. This study identified their motivations and career intentions and explored MPH programme strengths and gaps in under- and post-graduate PH training. A cross-sectional study using an online questionnaire was completed by physicians graduating with an MPH between 2000 and 2009 and those enrolled in the programme in 2010 at the University of Cape Town. Nearly a quarter of MPH students were physicians. Of the 65 contactable physicians, 48% responded. They were mid-career physicians who wished to obtain research training (55%), who wished to gain broader perspectives on health (32%), and who used the MPH to advance careers (90%) as researchers, policy-makers, or managers. The MPH widened professional opportunities, with 62% changing jobs. They believed that inadequate undergraduate exposure should be remedied by applying PH approaches to clinical problems in community settings, which would increase the attractiveness of postgraduate PH training. The MPH was found to allow physicians to transition from pure clinical to research, policy and/or management work, preparing them to innovate changes for effective health systems, responsive to the health needs of populations.

9. Public-Private Mix

Can the private sector help achieve universal health coverage?
Nishtar S: World Economic Forum, 2016

When the world committed to ending poverty, protecting the planet and ensuring prosperity for all with the 17 Sustainable Development goals, we knew no single entity would be able to achieve such lofty goals – it would take collaboration. “A successful sustainable development agenda requires partnerships between governments, the private sector and civil society,” Goal 17 stated. The author argues that in few areas is that more obvious than in the fight to achieve universal health coverage, which falls under Goal 3 of Good Health and Wellbeing. If universal health coverage in all countries is to be achieved, even those where privately-financed market delivery is predominant, this will depend on the ability of governments to harness their potential. In such contexts, she observes, it is critical to build the stewardship capacity of public agencies so that they can frame and implement rules that define the environment and the incentives that guide the behaviours of health system players. Rather than focusing on privatisation, marketisation or the scaling up of private provision, the idea would be to get private actors involved in the pursuit of universal health coverage and financial protection goals. Although the private sector often has a dominant role in the provision of healthcare, too often governments do not know enough about how these providers operate, and there is little, if any, regulation in place. She recommends that countries examine if service delivery models incorporating tools such as franchising and social marketing and utilising economies of scale, standardisation, and/or market incentives can enable universal health coverage within their respective health systems. In recent years, public ownership and not-for-profit service provision and autonomous governance arrangements have been promoted over publicly financed, owned and operated models. However, gains due to hospital autonomy should go beyond revenues for hospitals and incentives for staff and must also enhance quality and equity. New frameworks of participatory governance and appropriate channels of accountability and regulation need to be established. She notes however that the commercial presence of a foreign service provider could create a dual market structure, with high-quality services being provided to affluent consumers to the detriment of the healthcare needs of poorer people. Additionally, the movement of healthcare providers and brain drain – both internal and external – can lead to a loss of trained healthcare providers in the home country. Policy safeguards will be needed to prevent this type of situation.

10. Resource allocation and health financing

Assessing fiscal space for health expansion in low- and middle-income countries: a review of the evidence
Barroy H; Sparkes S; Dale E: Working Paper, World Health Organisation, WHO/HIS/HGF/HF Working Paper/16.3, 2016

Despite the proliferation of the term ‘fiscal space for health’ in recent years, there has been no comprehensive review of how the concept can be applied to assess and support the expansion of resources for the health sector. There is also a certain amount of confusion regarding the conceptual underpinnings and application of fiscal space for health analysis, notably regarding the way in which such analysis can help countries realise potential fiscal space for health expansion. In this paper, a qualitative review of 35 studies was undertaken in four stages to identify all fiscal space for health studies and to systematically assess their findings and methods. These four stages involved a literature search, crowd-sourcing techniques, data extraction, and comprehensive qualitative analysis. The study shows that economic growth, budget re-prioritisation and efficiency improving measures are the main drivers of fiscal space for health expansion. There is scarce evidence regarding the prospective role of earmarked funds, and development assistance for health in expanding fiscal space for the sector. The lack of standardised methods and metrics to systematically assess fiscal space for health results in variations in the analytical approaches used, and limits study relevance and applicability for policy reform. The paper concludes that a more contextualised approach to fiscal space analysis is required, which focuses on key sources of fiscal space for health expansion and includes efficiency enhancements. Fiscal space analysis should be systematically embedded in domestic budgeting processes and explicitly consider both technical and political feasibility of assessed options. Adopting this approach could offer considerable potential for optimising government budget and expenditure decisions and more effectively support progress toward UHC.

Sugar tax could make SA a world leader in obesity prevention – WHO
Medical Brief: African Medical Digest February 2017.

South Africa could prevent almost half-a-million deaths over 40 years by introducing its proposed tax on sugary drinks, according to the World Health Organisation (WHO). “No country in the world has hit obesity with a 20% tax, so South Africa could be a world leader and reduce childhood obesity,” said the WHO’s Dr Temo Waqanivalu. He was speaking at the recent public hearing on the proposed tax on sugary drinks, convened by parliament’s committees of finance and health. “A child eating burger and chips, washed down with sugary drink and followed by crisps and chocolate bar, would have to run a half-marathon to get rid of the effects. You cannot out-exercise a bad diet,” said Waqanivalu. The report says at the packed meeting, all parties agreed that South Africa had a significant problem with obesity but while academics praised the tax, industry players pleaded for other measures. Treasury has proposed a tax of 2.29c per gram of sugar on soft drinks, which would work out to be about a 20% tax on a Coca Cola.

The influence of power and actor relations on priority setting and resource allocation practices at the hospital level in Kenya: a case study
Barasa E; Cleary S; Molyneux S; English M: BMC Health Services Research, 2016, doi: 10.1186/s12913-016-1796-5

Priority setting and resource allocation in healthcare organisations often involves the balancing of competing interests and values in the context of hierarchical and politically complex settings with multiple interacting actor relationships. Despite this, few studies have examined the influence of actor and power dynamics on priority setting practices in healthcare organisations. This paper examines the influence of power relations among different actors on the implementation of priority setting and resource allocation processes in public hospitals in Kenya. The authors used a qualitative case study approach to examine priority setting and resource allocation practices in two public hospitals in coastal Kenya. They collected data by a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations in case study hospitals over a period of 7 months. The authors applied a combination of two frameworks, Norman Long’s actor interface analysis and VeneKlasen and Miller’s expressions of power framework to examine and interpret findings. The interactions of actors in the case study hospitals resulted in socially constructed interfaces between: 1) senior managers and middle level managers 2) non-clinical managers and clinicians, and 3) hospital managers and the community. Power imbalances resulted in the exclusion of middle level managers (in one of the hospitals) and clinicians and the community (in both hospitals) from decision making processes. This resulted in, amongst others, perceptions of unfairness, and reduced motivation in hospital staff. It also puts to question the legitimacy of priority setting processes in these hospitals. The authors suggest that designing hospital decision making structures to strengthen participation and inclusion of relevant stakeholders could improve priority setting practices. This should however, be accompanied by measures to empower stakeholders to contribute to decision making. They also suggest that strengthening soft leadership skills of hospital managers could also contribute to managing the power dynamics among actors in hospital priority setting processes.

11. Equity and HIV/AIDS

Sub-Saharan Africa’s ‘exceptional’ progress against HIV – surveys
African Medical Media Digest: Medical Brief, December 2016

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 unique, 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. The data demonstrate that the 90-90-90 global targets set forth by UNAIDS in 2014 are attainable, (that is for 90% of people with HIV to be diagnosed, 90% of those diagnosed to receive HIV treatment, and 90% of those on treatment to be effectively treated and achieve suppression of their infection). This would translate to 73% of all HIV-positive people being virally suppressed. 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. Preliminary data analyses show that, as of 2016: 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 are argued to 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.

Transactional sex and risk for HIV infection in sub-Saharan Africa: a systematic review and meta-analysis
Wamoyi J; Stoebenau K; Bobrova N; Abramsky T; Watts C: Journal of the International Aids Society 19(20992) 2016

Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women’s heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesised. The authors set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarise the findings through a meta-analysis. Nineteen papers from 16 studies met the inclusion criteria. Of these 16 studies, 14 provided data on women and 10 on men. The authors found a significant, positive, unadjusted or adjusted association between transactional sex and HIV in 10 of 14 studies for women, one of which used a longitudinal design. Out of 10 studies involving men, only two indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. The meta-analysis confirmed general findings from the systematic review. Transactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the causal pathways between transactional sex and HIV.

12. Governance and participation in health

Using Minecraft for Youth Participation in Urban Design and Governance
Banks N: Global Development Institute, 2015

UN-Habitat believes that ICT can be a catalyst to improve governance in towns and cities and help increase levels of participation, efficiency and accountability in public urban policies, provided that the tools are appropriately used, accessible, inclusive and affordable. Research shows that ICT use by youth can have a direct impact on increasing civic engagement, giving them new avenues through which to become informed, shape opinions, get organised, collaborate and take action. Youth are at the centre of the ICT revolution, both as drivers and consumers of technological innovation. They are almost twice as networked as the global population as a whole, with the ICT age gap more pronounced in least developed countries where young people are up to three times more likely to be online than the general population. This video shows UN-Habitat’s approach to using Minecraft to encourage youth participation in urban design and governance, to design and present their vision for public spaces in the city, as an input to planning. UN-Habitat’s experiences of using the video game Minecraft as a community participation tool for public space design is reported to show that providing youth with ICT tools can promote improved civic engagement.

13. Monitoring equity and research policy

Health system learning sites: understanding health systems through research collaboration and engagement
Resilient and Responsive Health Systems (RESYST), 2016

Health policy and systems research is centrally concerned with people, their relationships and the actions that they take towards strengthening health systems. To understand complex health systems, researchers must actively engage with system actors, ranging from health managers to service users, learning from their tacit knowledge and about their experience. In Kenya and South Africa, researchers have established learning sites specifically to support a wide range of research focused on health systems governance issues at the district level. Both countries have devolved government structures and county (Kenya) and provincial and district (South Africa) managers now play a pivotal role in the development, management and delivery of health services. Learning sites provide unusual opportunities to learn about the daily processes of decision-making that comprise health system governance, and to support managers in taking action to strengthen them. This brief covers: What is a learning site? How did learning sites emerge? What happens in a learning site? What is the value of learning sites for researchers and health managers? and what small-scale steps are being taken to strengthen the health system?

New WHO data portal to help track progress towards universal health coverage
WHO: Geneva, December 2016

The World Health Organisation (WHO) has launched a new data portal to track progress towards universal health coverage (UHC) around the world. The portal shows where countries need to improve access to services, and where they need to improve information. The portal features the latest data on access to health services globally and in each of WHO’s 194 Member States, along with information about equity of access. In 2017 WHO will add data on the impact that paying for health services has on household finances. The portal shows that less than half of children with suspected pneumonia in low income countries are taken to an appropriate health provider. Of the estimated 10.4 million new cases of tuberculosis in 2015, 6.1 million were detected and officially notified in 2015, leaving a gap of 4.3 million. High blood pressure affects 1.13 billion people. Over half of the world's adults with high blood pressure in 2015 lived in Asia. Around 24% of men and 21% of women had uncontrolled blood pressure in 2015. About 44% of WHO’s member states report having less than 1 physician per 1000 population. The African Region suffers almost 25% of the global burden of disease but has only 3% of the world’s health workers.

The feasibility of measuring and monitoring social determinants of health and the relevance for policy and programme – a qualitative assessment of four countries
Blas E; Ataguba J; Huda TM; Bao GK; Rasella D; Gerecke MR: Global Health Action 9 (1), 2017

ince the publication of the reports by the Commission on Social Determinants of Health (CSDH), many research papers have documented inequities, explaining causal pathways in order to inform policy and programmatic decision-making. At the international level, the sustainable development goals (SDGs) reflect an attempt to bring together these themes and the complexities involved in defining a comprehensive development framework. However, to date, much less has been done to address the monitoring challenges, that is, how data generation, analysis and use are to become routine tasks. In an attempt to explore these monitoring challenges, indicators covering a wide range of social determinants were tested in four country case studies (Bangladesh, Brazil, South Africa, and Vietnam) for their technical feasibility, reliability, and validity, and their communicability and usefulness to policy-makers. Twelve thematic domains with 20 core indicators covering different aspects of equity, human rights, gender, and SDH were tested through a review of data sources, descriptive analyses, key informant interviews, and focus group discussions. To test the communicability and usefulness of the domains, domain narratives that explained the causal pathways were presented to policy-makers, managers, the media, and civil society leaders. For most countries, monitoring is possible, as some data were available for most of the core indicators. However, a qualitative assessment showed that technical feasibility, reliability, and validity varied across indicators and countries. Producing understandable and useful information proved challenging, and particularly so in translating indicator definitions and data into meaningful lay and managerial narratives, and effectively communicating links to health and ways in which the information could improve decision-making. This exercise revealed that for monitoring to produce reliable data collection, analysis, and discourse, it will need to be adapted to each national context and institutionalised into national systems. This will require that capacities and resources for this and subsequent communication of results are increased across countries for both national and international monitoring, including the successful implementation of the SDGs.

14. Useful Resources

Atlas of health and climate
Department of Public Health and Environment: World Health Organisation, Geneva

Human health is profoundly affected by weather and climate. Extreme weather events kill tens of thousands of people every year and undermine the physical and psychological health of millions. Droughts directly affect nutrition and the incidence of diseases associated with malnutrition. Floods and cyclones can trigger outbreaks of infectious diseases and damage hospitals and other health infrastructure, overwhelming health services just when they are needed most. The Atlas of health and climate is a product of a unique collaboration between the meteorological and public health communities. It provides sound scientific information on the connections between weather and climate and major health challenges. It outlines the consequences for a range from diseases of poverty to emergencies arising from extreme weather events and disease outbreaks.

Change a life with just one swipe!
Matroos J: Design Indaba, 2016

The Radi-Aid Awards celebrates creativity in fundraising campaigns worldwide. Specifically, it challenges the perception of the global south as helpless victims who are dependent on donations from the West. The initiative is best known for its videos that debunk and poke fun at the stereotypes perpetuated by aid campaigns. This recent video, “The Radi-Aid App: Change A Life With Just One Swipe” flips the script on the usual aid campaign. In it Africans are asked to donate to the cold citizens of Norway, challenging the notion that the material circumstances of others are easily fixed by single interventions and raising that perpetuating stereotypes can do more harm than good.

15. Jobs and Announcements

Addressing Health Inequities Conference
Century City Conference Venue, Cape Town, South Africa. 10-12 February 2017

This conference is a Joint initiative of the South African Medical Association (SAMA), World Medical Association (WMA) and the School of Public Health at the University of Witwatersrand. The keynote speaker is Sir Michael Marmot, ex-Chair of the WHO Commission on Social Determinants of Health.

Building Children's Nursing for Africa Conference
28 - 30 March 2017, Cape Town, South Africa

The theme for the 2017 conference is ‘Pillars of Practice’ in paediatric and children’s nursing and will showcase recent research, clinical practice projects, education and leadership initiatives. The organisers are excited about showcasing good clinical nursing. More and more research confirms the parents vital role in improving outcomes for children, so workshops and conversations about collaboration and innovative strategies of enrolling people are anticipated. The conference themes cover what nurses measure - how and why - and how this is turned into data, clinical leadership, establishing families into the care hub, clinically relevant teaching and sustainable innovation in paediatrics.

Call for Papers: Law and the New Urban Agenda, 4th Annual International & Comparative Urban Law Conference
Deadline for proposal submissions: March 6, 2017

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 and 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.

Civil Society Scholar Awards 2017 -2018
Open Society Scholarship Programs, Deadline 31 March 2017

The Civil Society Scholar Awards (CSSA) support international academic mobility to enable doctoral students and university faculty to access resources that enrich socially-engaged research and critical scholarship in their home country or region. Civil Society Scholars are selected on the basis of their outstanding contributions to research or other engagement with local communities, to furthering debates on challenging societal questions, and to strengthening critical scholarship and academic networks within their fields. The Awards are open to the following academic populations:
• Doctoral students of eligible fields studying at accredited universities inside or outside of their home country; or
• Full-time faculty members (must have a minimum of a master’s degree) teaching at universities in their home country;
Who are citizens of: Afghanistan, Albania, Angola, Azerbaijan, Belarus, Bosnia and Herzegovina, Cambodia, Democratic Republic of Congo, Republic of Congo, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Guinea, Haiti, Kosovo, Laos, Libya, Macedonia, Moldova, Mongolia, Myanmar/Burma, Nepal, Palestine, Papua New Guinea, Serbia, Sudan, South Sudan, Syria, Swaziland, Tajikistan, Tunisia, Turkmenistan, Uzbekistan, or Yemen. See more information on the website.


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