Current Issue

EQUINET NEWSLETTER 201 : 01 December 2017

1. Editorial

Accountability for Health Equity: Reflections for Southern Africa
Cynthia Ngwalo Lungu, Johannesburg, South Africa


In July 2017, I attended a conference by the Institute of Development Studies (IDS) themed ‘Unpicking Power and politics for transformative change: Towards Accountability for health equity’. The conference examined the practices and politics shaping accountability in health systems from local to global levels. As a southern African, these are my reflections on this from the conference discussions.

Accountability for health equity is essentially about citizens being able to hold governments to account to deliver health for all. It is about inclusivity and ensuring better health for the less privileged, marginalised and vulnerable people.

It is commonly known that within Southern Africa public sector financing for health is meagre and below the 15% committed to in the Abuja declaration. People in need struggle to access health care. In some countries people walk up to 30 km to get to the nearest health centre, only to find that it doesn’t have the basic resources to function. In countries where the health system has largely been privatised it can be virtually impossible for poor people to afford health care. This situation is worsened when there is abuse of resources, a lack of transparency in health management, a lack of public information on health budgets and expenditures, when budget and policy processes are centralised in a top down approach that allows for little or no citizen participation in decision-making.

In response, the region has seen a rapid development of social accountability initiatives that trigger active citizenship, where communities actively participate in health decision making and hold governments to account on how resources are mobilised and used. The Centre for civil society capacity building, a Mozambican organisation, recounted in conference how social accountability initiatives in that country have improved transparency in resources for health and but influenced the development of formal national mechanisms for health accountability using scorecards for citizens to input to decisions and provide feedback on services.

While these efforts have achieved varying positive outcomes, they often tackle ‘low hanging fruit’, addressing local challenges like health worker attitudes or cleanliness within the vicinity of health facilities, thereby bringing about change in local practice. While these changes are commendable, they are often tied to project timelines, are localised and often do not trigger national level changes. Community level initiatives have struggled to address more systemic challenges, such as access to information, budget setting or expenditure tracking and bottlenecks in procuring and supplying medicines. The IDS meeting argued that this is because social accountability efforts have failed to respond to higher level constraints affecting the ability of local service providers to respond to community feedback. Much more broadly social accountability initiatives have in some cases failed to recognise the complex power dynamics that are typical of health systems. Social accountability efforts ought to engage with power if they are to bring about equity and social justice, otherwise, there is the risk that initiatives will simply replicate existing social hierarchies.

Another factor affecting these social accountability initiatives is sustainability and ability to outlive short-term project timelines. There is a need to cultivate an active citizenship that raises voice to point out accountability concerns without relying on external drivers. Given the weaknesses in general environments to support this, we need to recognise and explore the role of formal structures for accountability in health, notwithstanding their pitfalls. This implies critically considering the extent to which the community voice can be integrated with local level formal accountability structures without being compromised or ‘swallowed’ by them. In the Northern part of Malawi, for example, the Catholic Commission for Justice and Peace has cultivated an active citizenship that engages within the formal mechanisms in health, as a form of structured and sustainable citizen engagement with the health system.

From the convening it was very clear that social accountability initiatives should respond to particular contexts. For example, in the case of politically charged states within Southern Africa, communities and civil society pushing for health rights and social justice are often tackling a wide range of issues that may confront power and carry unintended political connotations. Traditional social accountability tools and approaches which work in accommodative participatory environments may not be useful in politically charged contexts as Social accountability proponents become human rights defenders who need a unique set of skills to pursue issues without risking their own lives and security. The operating environment calls for unique capacities, language, strategies and mechanisms to achieve results without exacerbating conflict.

While many of these social accountability initiatives appear to focus on public sector services, there are other non-state and private for profit actors involved in the delivery of health care. Across the region health has attracted markets and business operators resulting in a range of providers, in some cases in public -private -partnerships. How do we ensure that in the face of a growing private sector, public interests continue to take centre stage as a means to achieving equity in health? What mechanisms can be used to hold these private actors to account on social goals and health needs, when their preoccupation is with profit margins and ‘fair returns’? Lessons from the negative effects of pluralistic health markets in other countries, such as Mongolia, can be used by the region to inform the development and implementation of sound regulation of the ‘business of health’ and to ensure that PPP’s and health financing schemes including health insurance are developed in an accountable manner and in line with equity goals.

These are significant challenges, but there are also opportunities to strengthen accountability through innovation. Despite low internet penetration and high telecommunication charges in some parts of the region, information technology is spreading. Throughout the region, technology is fast becoming a powerful tool in pushing for social economic rights- with the click of a button communities can voice public health concerns or access critical health sector information. With these tools, the means to accountability for transformative change may indeed lie in people’s hands!

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the IDS meeting can be found at http://www.ids.ac.uk/opinion/naming-the-moment

2. Latest Equinet Updates

Resource curse or fair benefit: Protecting health in the extractive sector in east and southern Africa
EQUINET, TARSC, SATUCC, SADC CNGO: Harare, 2017

The extractive (or mining) sector is a major economic actor in east and southern Africa. The mineral resources extracted are sought after globally, and how the sector operates affects the lives of millions of people. This brief aimed mainly civil society discusses the health impacts of the sector, how far these risks are recognised in policy and controlled in practice, and what civil society can do to ensure that health is protected in EI activity. It presents the proposals made at the 13th Southern Africa Civil society Forum in 2017 to advocate for regional health standards for EIs and a bottom up local to regional campaign for civil society to advocate for these harmonised standards for health in the mining (extractive) sector in SADC.

3. Equity in Health

The Lancet Countdown: Tracking Progress on Health and Climate Change
Watts, Nick et al.: The Lancet , 389 (10074 ), 1151 - 1164, 2017

The Lancet Countdown: tracking progress on health and climate change is an international, multidisciplinary research collaboration between academic institutions and practitioners across the world that aims to track the health impacts of climate hazards; health resilience and adaptation; health co-benefits of climate change mitigation; economics and finance; and political and broader engagement. The Lancet Countdown aims to report annually on a series of indicators across these five areas in tandem with existing monitoring processes, such as the UN Sustainable Development Goals and WHO's climate and health country profiles. The indicators will also evolve over time through ongoing collaboration with experts and a range of stakeholders, and be dependent on the emergence of new evidence and knowledge.

4. Values, Policies and Rights

Social Protection or Humanitarian Assistance: Contested Input Subsidies and Climate Adaptation in Malawi
Haug R; Wold B: IDS Bulletin 48(4), doi: http://dx.doi.org/10.19088/1968-2017.155, 2016

This article assesses factors that contributed to the success of the farm input support programme in Malawi in 2005–15, and the lessons from this experience in relation to climate change adaptation. Important factors were the ability to balance external and internal drivers that affected policy formulation, national ownership and prestige that influenced and motivated implementation capability, creation of conducive conditions its demand-driven nature. However, the flooding in 2015 and the drought in 2016 revealed that Malawi needs more effective measures to reduce long-term vulnerability to future adverse impacts of climate change. The authors argue that the lessons learned from this social protection programme can prove useful in relation to efforts to achieve sustainable responses to climate change that could reduce the need for humanitarian assistance.

Teaching videos on human rights
Yamin A: Global Health Education and Learning Incubator, Georgetown, 2017

These short videos provide an overview of the history of human rights; health and human rights; and health, human rights and development. They were developed to make human rights more accessible to non-lawyers and non-academics. The videos are accompanied by tools for further learning, including an annotated bibliography, glossary of terms, timeline of key events, and fact sheet on universal health coverage. The first video provides an explanation on what human rights are and why they are important. The second video offers a brief history of health and human rights since World War II. The third video gives a description of how health-related human rights developed during the era of the Millennium Development Goals (2000-2015) and the Sustainable Development Goals (2016-2030). The series concludes by considering the vital role that human rights plays in diverse political environments.

5. Health equity in economic and trade policies

Access to medicines and hepatitis C in Africa: can tiered pricing and voluntary licencing assure universal access, health equity and fairness?
Assefa Y; Hill PS; Ulikpan A; et al,: Globalization and Health 13(73)1-11, 2017

This paper analyses the implications of a tiered pricing and voluntary licensing strategy for access to Direct Acting Antivirals (DAAs) for treating Hepatitis C Virus (HCV). Seven countries in Africa were examined (Egypt, Ethiopia, Nigeria, Democratic Republic of Congo, Cameroon, Rwanda and South Africa) to assess their financial capacity to provide DAAs for treating HCV under present voluntary licensing and tiered-pricing arrangements. The cost of 12-weeks of generic DAA varied from $684 per patient treated in Egypt to $750 per patient treated in other countries. The current prices of DAAs are much higher than the median annual income per capita and the annual health budget of most of these countries. If governments alone were to bear the costs of universal treatment coverage, then the required additional health expenditure from present rates would range from a 4% increase in South Africa to a staggering 403% in Cameroon. The current arrangements for increasing access to DAAs, to eliminate HCV would require increases in expenditure that are too burdensome for governments, individuals and families. The authors argue that countries need to implement the flexibilities in the Doha Declaration on Trade Related Intellectual Property Rights agreement, including compulsory licensing and patent opposition to address this, and this requires political commitment, financial will, global solidarity and civil society activism.

Disentangling regional trade agreements, trade flows and tobacco affordability in sub-Saharan Africa
Appau A; Drope J; Labonté R; et al: Globalisation and Health 13(81) doi: https://doi.org/10.1186/s12992-017-0305-x, 2017

In principle, trade and investment agreements are meant to boost economic growth. However, the removal of trade barriers and the provision of investment incentives to attract foreign direct investments may facilitate increased trade in and/or more efficient production of commodities considered harmful to health such as tobacco. The authors analyze existing evidence on trade and investment liberalization and its relationship to tobacco trade in Sub-Saharan African countries. Comparisons are made between tobacco trading patterns and foreign direct investments made by tobacco companies. The authors estimate and compare changes in the Konjunkturforschungsstelle (KOF) Economic Globalization measure, relative price measure and cigarette prices. Preferential regional trade agreements appear to have encouraged the consolidation of cigarette production, which has shaped trading patterns of tobacco leaf. Since 2002, British American Tobacco has invested in tobacco manufacturing facilities in Nigeria, Kenya and South Africa strategically located to serve different regions in Africa. Following this, British America Tobacco closed factories in Ghana, Rwanda, Uganda, Mauritius and Angola. At the same time, Malawi and Tanzania exported a large percentage of tobacco leaf to European countries. After 2010, there was an increase in tobacco exports from Malawi and Zambia to China, which may be a result of preferential trade agreements the EU and China have with these countries. Economic liberalization has been accompanied by greater cigarette affordability for the countries included in the analysis. Only excise taxes and income are reported by the authors to have an effect on cigarette prices within the region. The results suggest that the changing economic structures of international trade and investment are likely heightening the efficiency and effectiveness of the tobacco industry. As tobacco control advocates consider supply-side tobacco control interventions, the authors suggest that they consider carefully the effects of these economic agreements and whether there are ways to mitigate them.

6. Poverty and health

Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services
Mutebi A; Kananura R; Ekirapa-Kiracho; et al.: Global Health Action 10(S4)82-91, 2017

Data on the characteristics of community-based savings groups were collected from 247 community-based savings group leaders in the districts of Kamuli, Kibukuand Pallisa using a self-administered open-ended questionnaire, and in-depth interviews with seven community-based savings group leaders. Ninety-three percent of the community-based savings groups said they elected their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent used metallic boxes to keep their money, while 10% kept their money in mobile money and banks. The community-based savings groups were formed mainly to increase household income, to develop the community and to save for emergencies. The community-based savings groups faced challenges of high illiteracy among the leaders, irregular attendance of meetings, and lack of training on management and leadership. Saving groups in Uganda are reported to have the basic required structures, but with challenges in relation to training and management of the groups and their assets, calling for technical support in these areas.

If you miss them, then you’re missing out
Riria J: Daily Nation, 7 November 2017

The author reports an estimated 65 per cent of women-led small and medium-sized enterprises (SMEs) in the developing economies that are either unserved or underserved financially. SMEs provide 80 per cent of Kenya’s employment and contribute 20 per cent of our GDP, according to latest reports from African Economic Outlook. Data on registered firms shows that women hold ownership roles in 48 per cent of Kenyan SMEs. The World Bank says that only 51 per cent of Kenyan women have access to a simple bank account, much less a business loan or insurance to protect them financially. The author notes that microfinance can address this deficit through loans designed specifically for women-led SMEs that need access to working capital to expand their businesses, that have flexible monthly repayment amounts, security and collateral requirements, and longer repayment periods.

7. Equitable health services

Antimicrobial resistance among children in sub-Saharan Africa
Williams P; Isaacs D; Berkley J: The Lancet Infectious Diseases, doi: http://dx.doi.org/10.1016/S1473-3099(17)30467-X, 2017

Antimicrobial resistance is an important threat to international health. Therapeutic guidelines for empirical treatment of common life-threatening infections depend on available information regarding microbial aetiology and antimicrobial susceptibility, but sub-Saharan Africa lacks diagnostic capacity and antimicrobial resistance surveillance. The authors systematically reviewed studies of antimicrobial resistance among children in sub-Saharan Africa since 2005. Among neonates, gram-positive bacteria were responsible for a high proportion of infections among children beyond the neonatal period, with high reported prevalence of non-susceptibility to treatment advocated by the WHO therapeutic guidelines. There are few up-to-date or representative studies given the magnitude of the problem of antimicrobial resistance, especially regarding community-acquired infections. Research should focus on differentiating resistance in community-acquired versus hospital-acquired infections, implementation of standardised reporting systems, and pragmatic clinical trials to assess the efficacy of alternative treatment regimens.

Development of a Hypertension Health Literacy Assessment Tool for use in primary healthcare clinics in South Africa, Gauteng
Mafutha N; Mogotlane S; De Swardt H: African Journal of Primary Health Care and Family Medicine 9(1)1-8, 2017

This study investigated the development of a hypertension heath literacy assessment tool to establish patients’ comprehension of the health education they receive in primary healthcare clinics in Tshwane, Gauteng, South Africa. The design was quantitative, descriptive and contextual. The study population comprised health promoters who were experts in the field of health, documents containing hypertension health education content and individuals with hypertension. The tool was administered to 195 participants concurrently with a learning ability battery. The health literacy assessment tool was found to be a valid tool that can be used in busy primary healthcare clinics as it takes less than two minutes to administer. This tool can inform the healthcare worker on the depth of hypertension health education to be given to the patient, empowering the patient and saving time in primary healthcare facilities.

8. Human Resources

Improving the performance of community health workers in Swaziland: findings from a qualitative study
Geldsetzer P; De Neve JW; Boudreaux C; et al.: Human Resources for Health 15(68)1-9, 2017

This qualitative formative research study aimed to inform the design of interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, the authors aimed to determine what leads to improved performance of CHWs. The CHW cadres studied were the rural health motivators, mothers-to-mothers mentors, HIV expert clients, and a community outreach team for HIV. Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: increased monetary compensation of CHWs, a more reliable supply of equipment and consumables, additional training, and an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as key factors.

Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania
Helga N; Mujinja P; Kilewo C; et al.: Human Resources for Health 15(61)1-12, 2017

From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and prevention of mother-to-child transmission services in Dar es Salaam, Tanzania. Slightly over half of the providers were dissatisfied with their current job, and 35% intended to leave it. Most providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The following factors were associated with providers’ intention to leave their current job: dissatisfaction at not being recognized by one’s superior, and poor feedback on the overall unit performance. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback are argued to be key to retaining satisfied health workers for prevention of mother-to-child transmission providers.

Sharing Histories—a transformative learning/teaching method to empower community health workers to support health behaviour change of mothers
Altobelli L: Human Resources for Health 15(54)1-9, 2017

One way of improving health globally is promoting mothers’ adoption of healthy home practices for improved nutrition and illness prevention in the first 1000 days of life from conception. The challenge is how to promote learning and behaviour change of mothers more effectively in low-resource settings where access to health information is poor, educational levels are low, and traditional beliefs are strong. In addressing that challenge, a new learning/teaching method called “Sharing Histories” is in development to improve the performance of female community health workers in promoting mothers’ behaviours for maternal, neonatal and child health. This method builds self-confidence and empowerment of community health workers in learning sessions that are built on guided sharing of their own memories of childbearing and child care. Community Health Workers can later share histories with the mother, building her trust and empowerment to change. For professional primary health care staff who are not educators, Sharing Histories is simple to learn and use so that the method can be easily incorporated into government health systems and ongoing community health workers programs. The author presents the Sharing Histories method, describes how it differs from other social and behaviour change methods, and discusses selected literature from psychology, communications, and neuroscience that helps to explain how and why this method works as a transformative tool to engage, teach, transform, and empower Community Health Workers to be more effective change agents with other mothers in their communities.

Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda
Namazzi G; Okuga M; Tetui M; et al.: Global Health Action 10(S4)72-81, 2017

This paper explores knowledge levels of community health workers (CHWs), describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy in eastern Uganda. The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The visits aimed to promote birth preparedness and utilization of maternal and newborn health (MNH) services. CHWs’ knowledge of MNH improved after training. However, knowledge of new born danger signs declined after a year. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57% and CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and maintained low dropout rates at 3.6%. Their challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of a means of transport, such as bicycles.

9. Public-Private Mix

Mental health leadership and patient access to care: a public–private initiative in South Africa
Szabo C; Fine J; Mayers P; et al.: International Journal of Mental Health Systems 11(52)1-8, 2017

Despite the significant adverse social and economic costs of mental illness, psychiatric and related services receive a low level of priority within the health care system. A public–private mental health leadership initiative, emanating from a patient access to care programme, was developed to build leadership capacity within the South African public mental health sector. The projects were varied in nature but all involved identification of and a plan for addressing an aspect of the participants’ daily professional work which negatively impacted on patient care due to unmet needs. Six such projects were included with personnel from psychiatry, psychology, occupational therapy and nursing. Each project group was formally mentored as part of the initiative, with mentors being senior professionals with expertise in psychiatry, public health and nursing. Participants acquired both skills and the confidence to sustain the changes that they themselves had initiated in their institutions. The initiative gave impetus to the inclusion of public mental health as part of the curriculum for specialist training.

10. Resource allocation and health financing

Financing A National Health Insurance for South Africa
The Davis Tax Committee: Ministry of Finance, South Africa, 2017

The Davis Tax Committee was established in 2013 by the Minister of Finance to inquire into the role of the tax system in promoting inclusive economic growth, employment creation, development and fiscal sustainability. This report concentrates on identifying long term financing principles – the specific operationalisation which will be informed by more detailed implementation and costing plans in order to manage the transition from the status quo to the financing regime envisaged in the National Health Insurance (NHI) in South Africa. This report examines the definition, rationale and design of the proposed NHI. It explores international experience in financing universal health coverage, with a focus on middle income developing countries and existing sources of health financing in South Africa are analysed. Cost estimates and potential macroeconomic impacts are discussed and the report concludes with an evaluation of options for NHI financing. The authors identify a number of factors in the design of NHI, as well as its implementation, all of which have an impact on its financing trajectory. These include parameters on risk pooling, on health care purchasing and on provision. Risk pooling decisions include whether there would be a single or multiple purchaser, the level of consolidation of risk pools and their coverage and composition as well as the nature of the resources allocation formula (evidence and needs based, risk equalisation etc.). The structure of purchasing encompasses, inter alia, the scope and pricing of the benefit package (which had not yet been defined in the White Paper), contractual arrangements with health care providers such as GPs and hospitals, quality management systems, payment and information systems.

11. Equity and HIV/AIDS

Community burden of undiagnosed HIV infection among adolescents in Zimbabwe following primary healthcare-based provider-initiated HIV testing and counselling: A cross-sectional survey
Simms V; Dauya E; Dakshina S, et al.: Public Library of Science Medicine (PLOSMed) 14(7) doi: https://doi.org/10.1371/journal.pmed.1002360, 2017

The authors investigated the change in the community burden of undiagnosed HIV infection among older children and adolescents following implementation of provider-initiated testing and counselling (PITC) in Harare, Zimbabwe. Over the course of 2 years (2013–2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6–15 years. In 2015, the authors conducted a representative cross-sectional survey of 8–17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out. Of 7,146 children in 4,251 eligible households, 76.8% agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% and over a third of participants with HIV were undiagnosed. Based on extrapolation from the survey sample to the community, the authors estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures none of which are perfect. Facility-based approaches are argued to be inadequate in achieving universal coverage of HIV testing among older children and adolescents, and community-based approaches are identified as necessary in this age group.

Voluntary Medical Male Circumcision for HIV Prevention in 14 Priority Countries in Eastern and Southern Africa
World Health Organisation: WHO, Geneva, 2017

This progress brief outlines key highlights of the VMMC (Voluntary Medical Male Circumcision) intervention in Eastern and Southern Africa. Nearly 15 million VMMCs have been performed for HIV prevention in 14 countries of eastern and southern Africa. These circumcisions are reported to potentially avert over half a million new HIV infections through to 2030. In 2016, 2.8 million VMMCs were performed and all countries in the region, except Uganda and Rwanda, increased the number of VMMCs performed in the year. The majority of clients were aged 15 years or older.

12. Governance and participation in health

Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers’ use of information in decision-making: experience from Cape Town, South Africa
Scott V and Gilson L: International Journal for Equity in Health 16(159)1-15, 2017

This paper reports on work to explore how primary healthcare facility managers’ use of information for decision-making is influenced by governance across levels of the health system in Cape Town, South Africa. Central governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based health information system which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the sub-district level had influence over what information was valued, generated and used locally. Strengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.

How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya.
Tsofa B; Goodman C; Gilson L; et al.: International Journal for Equity Health 16(1)151-163, 2017

In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous devolved county governments, with a substantial transfer of responsibility for healthcare from the central government to these counties. This study analysed the effects of this decentralization on health sector planning, budgeting and financial management at county level in Kilifi County. The authors found that the implementation of devolution created an opportunity for local level prioritisation and community involvement in health sector planning and budgeting, increasing opportunities for equity in local level resource allocation. However, this opportunity was not harnessed due to accelerated transfer of functions to counties before county level capacity had been established to undertake the decentralised functions. The authors also observed some indication of re-centralisation of financial management from health facility to county level. They conclude that to enhance the benefits of decentralised health systems, resource allocation, priority setting and financial management functions between central and decentralised units need to be guided by considerations around decision space, organisational structure and capacity and accountability.

Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals
Erasmus E; Gilson L; Govender V; et al: International Journal of Equity in Health 16(1)164-177, 2017

This paper uses the concepts of organizational culture and organizational trust to explore the implementation of equity-oriented policies - the Uniform Patient Fee Schedule and Patients' Rights Charter - in two South African district hospitals. The hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, that granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the Uniform Patient Fee Schedule. The hospitals' Patients' Rights Charter paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the Patients' Rights Charter, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, as key aspects of the organisational context that can profoundly influence policies. In addition to putting in place necessary staff and resources, tasks such as relationship management, the negotiation of values and paying careful attention to how policies are practically framed and translated into practice are seen to be necessary to ensure equity aspects are not neglected.

Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity
Accountability for Health Equity Programme: Institute of Development Studies, Sussex, 2017

While “accountability” has become an increasingly popular buzzword in health systems debates and health service delivery, it has multiple – and contested – meanings. In July 2017, IDS brought together 80 activists, researchers, public health practitioners and policy makers to examine the forces that shape accountability in health systems, from local to global levels. This workshop report records the presentations and discussions on accountability for health equity that are emerging in different country contexts, exploring how accountability relationships develop and change over time.

13. Monitoring equity and research policy

Equity in international health research collaborations in Africa: Perceptions and expectations of African researchers
Munung N; Mayosi B; de Vries J: PLOS One 12(10), doi: https://doi.org/10.1371/journal.pone.0186237, 2017

In this paper, the authors report on a qualitative interviewing study in which they involved 17 genomics researchers in Africa. The authors describe their perceptions and expectations of international genomics research and biobanking initiatives in Africa. All interviewees were of the view that externally funded genomics research and biobanking initiatives have played a critical role in building capacity for genomics research and biobanking in Africa and in providing an opportunity for researchers in Africa to collaborate and network with other researchers. Whilst the opportunity to collaborate was seen as a benefit, some interviewees stressed the need for these collaborations to have mutual benefits for all partners, including their collaborators in high income countries. They voiced two major concerns of being part of these collaborative initiatives: the possibility of exploitation of African researchers and the non-sustainability of research capacity building efforts. They thus recommended genuine efforts to create transparent and equitable international health research partnerships through,: having rules of engagement, enabling African researchers to contribute to the design and conduct of international health projects in Africa, and mutual and respectful exchange of experience and capacity between research collaborators. These were identified as hallmarks to equitable international health research collaborations in Africa.

Where does research fit in a post-truth world?
Guth J: Special Programme for Research and Training in Tropical Diseases (TDR), UNICEF, UNDP, World Bank, WHO, November 2017

A large study in 3 west African countries examined how to increase the numbers of pregnant women receiving malaria preventive treatment, and getting diagnosed and treated. There were many health systems issues that were identified that created barriers, such as lack of transportation or well-trained healthcare providers at the regional health facilities. Video interviews were conducted with people involved in the project and shared with policy-makers, healthcare providers and community members. The use of video helped to provide local context – of settings and people. It strengthened the understanding and credibility of the associated research results and showed strong collaboration between the research team and community, a proven facilitator in research uptake. The video was reported to have had a profound when it was shared and led to strong statements of commitments to make changes based on this study. The author suggests that it is necessary to use every tool possible to show the utility of science and how it improves people’s lives in ways that they can see and feel.

14. Useful Resources

Africa Region webinar: How to submit a successful organised session abstract
Health Systems Global: HSG, November 2017

Health Systems Global Africa Region hosted a webinar on “how to submit a successful organised session abstract”, the recording of which is now available to watch online. The webinar offered tips on how participants can increase their chances of having their abstracts successfully accepted for an organised session at the Fifth Global Symposium on Health Systems Research in Liverpool, October 2018 (HSR2018). It gives an overview of the importance of raising the profile of African health policy and systems research at HSR2018, and how organised sessions can be a powerful way of achieving this. It presents a brief overview, a series of short presentations, and a question and answer session with participants.

The Role of Parliamentarians in Ending Child Marriage
Girls not Brides: The Global Partnership to End Child Marriage, 2016

Developed by Girls Not Brides to promote collaboration between civil society organisations and parliamentarians, this toolkit provides an overview of what child marriage is, and existing international legal instruments that prohibit the practice. It lists concrete examples and recommendations on how parliamentarians can take action, not only in Parliament but in their constituencies and internationally. Parliamentarians are encouraged to take action through means such as parliamentary meetings, establishing forums and meeting with civil society organisations. The toolkit will be particularly useful to hold governments accountable for their commitment to ending child marriage in target 5.3 of the Sustainable Development Goals (SDGs).

15. Jobs and Announcements

ICASA 2017: 19th International Conference on AIDS and STDs in Africa
4-9 December 2017, Abidjan, Côte d'Ivoire

The 2017 ICASA conference theme “Africa: Ending AIDS-delivering differently” engages the continent and its stakeholders in the post SDG framework, where sustainability of the response in reaching 90, 90, 90 of UNAIDS will not be possible unless human rights are made a key priority with the application of science based evidence, particularly as commitments are threatened as a result of the global economic downturn. The organisers are anticipating 7 000 -10 000 of the world’s leading scientists, policy makers, activists, PLHIV, government leaders and heads of state and civil society representatives as an opportunity to promote inter-sectoral achievements in the AIDS response and to strengthen the partnership among governments, civil society, and development partners.

Call for abstracts: Health Systems Trust 2018 Conference
9 – 11 May 2018, Birchwood Conference Centre, Johannesburg, South Africa.

The HST 2018 Conference is organised under the theme “Reimagining health systems towards achieving the SDGs” and follows the inaugural 2016 gathering of health systems stakeholders from around South Africa and the rest of the continent. The call for abstracts is now open. In the spirit of leaving no one behind, submissions are invited that discuss challenges faced and solutions adopted at various levels in the health system towards achieving the transformative Sustainable Development Goals agenda.

Call For Papers: African Street Literatures
Deadline for abstracts: 15 December 2017

This is an open call for papers for a special issue of English Studies in Africa that will focus on African street literature. This refers to literature that emerges and is shaped by the specific factors determining everyday life in sub-Saharan Africa’s megacities, where new and emergent forms of literary expression dominate cultural circuits and flows. The intensification of social, political, economic, health and environmental precariousness, alongside uneven spurts of economic growth, rapid urbanisation, unprecedented access to technology and global connectivity, and a correlated surge in cultural and aesthetic expression, make African cities concentrated locations of vulnerable modernity. The call thus seeks to give a space for writing that reflects these features of the African city.

Call for participation VII World Social Forum on Health and Social Security, Brazil
Salvador de Bahia Brazil, 10-12 March 2018

The VII World Social Forum on Health and Social Security will be held in Salvador de Bahia Brazil from 10th to 13th of march 2018, immediately before the 11th World Social Forum that will happen from the 13th to the 17h of March. The organisers are inviting suggestions for the definition of contents and methodology of the WSFHSS. Contact armandodenegri@yahoo.com or through the website from the 25th of November 2017. Please look at the invitation video: https://youtu.be/DU_ODDLLaYQ

The 6th Quadriennial General Meeting and the 13th Scientific Conference of the East, Central and Southern Africa College of Nursing (ECSACON)
ECSACON: Safari Park Hotel, Nairobi, Kenya, 3 – 7 September 2018

The 2018 ECSACON conference follows the theme ‘Nurses and Midwives responding to global agenda on sustainable development goals and universal health coverage’. The conference will focus on quality and affordability of Maternal, Newborn and Child Health Services and increasing access to health care including GBV services and SRHR among the youth, nursing and midwifery workforce development to achieve HRH2030 Agenda. The conference will showcase innovations in preparing competent, skilled and motivated nurses and midwives, Nursing and midwifery workforce preparedness to respond to global calls, challenges and/or disasters. The conference will prioritize communicable and NCDs including mental health and nutrition. The call is open to ECSACON Members, Non ECSACON Members from the ECSA region and Non ECSACON Members from outside the region

The United Nations Trust Fund to End Violence against Women
Deadline for applications: 5 December 2017

The UN Trust Fund to End Violence against Women (UN Trust Fund) awards grants to initiatives that demonstrate that violence against women and girls can be systematically addressed, reduced and, with persistence, eliminated. Civil society organizations are invited to submit grant proposals for a minimum of US$50,000 up to a maximum of US$1 million for a period of three years. Proposals are invited under the following three programmatic areas: (1) Improving access for women and girls to essential, safe and adequate multi-sectoral services to end violence against women and girls; (2) Increasing effectiveness of legislation, policies, national action plans and accountability systems to prevent and end violence against women and girls; and (3) Improving prevention of violence against women and girls through changes in knowledge, attitudes and practices. This year, the UN Trust Fund is also seeking applications that specifically focus on addressing violence against women and girls in the context of the current forced displacement and refugee crisis; or addressing violence against women and girls with disabilities. Applications from women’s rights, women-led, and small women’s organizations are prioritized, in recognition of them being the driving force of the ending violence against women agenda, as well as being at the forefront of reaching women and girls survivors at the grassroots level.

UN Environment Assembly
4-6 December 2017, Nairobi, Kenya

The UN Environment Assembly meeting in 2017 aims to produce a political declaration on pollution, linked to the Sustainable Development Goals, to signal that humanity can work together to eliminate the threat of pollution and the destruction of our planet. There will be resolutions and decisions adopted by Member States to address specific dimensions of pollution and voluntary commitments by Governments, private sector entities and civil society organizations to clean up the planet. The Assembly will also include The #BeatPollution Pledge, a collection of individual commitments to clean up the planet. This year's Assembly will also launch the interactive Leadership Dialogues, which will provide participants with an opportunity for high-level engagement and discussion on how to achieve a pollution-free planet.

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