Current Issue

EQUINET NEWSLETTER 205 : 01 April 2018

1. Editorial

Making markets work for menstrual health: overcoming the ‘dignity deficit’
Nolwazi Ncube, Save the Girl Child Movement, Zimbabwe

Menstrual health is often mistakenly classified solely as a ‘women’s issue’. Yet with their link to reproduction and fertility, menstrual health and hygiene are not simply women’s issues, but matters of family and national concern. This is even more important in our region given the high share of adolescent females and women of child-bearing age in the population. In addition, the education, survival and health of girls and of women have an impact on the whole family. An appreciation of this impact underpins the global Sustainable Development Goal (SDG) 4 that seeks to ensure inclusive education for all, and SDG 5 that promotes gender equality.

So having just commemorated International Women’s day on 8 March 2018, and ahead of Menstrual hygiene day next month on 28 May, it seems fitting to discuss the issue of menstrual health.

In 2016, ahead of the 11 October global commemorations of the International Day of the Girl Child, UNICEF released a report entitled ‘Harnessing the Power of Data for Girls: taking stock and looking ahead to 2030’ ( The report presented a rather sombre picture of the state of gender equality in low-income countries, pointing to an unequal division of labour in homes that continues to burden the girl child and impede her educational outcomes.

Zimbabwe, like other countries in the region, has recognised the importance of educating girl children. The country has, over time, made strides with regard to gender parity in education, but still faces gaps in achieving it. To address some of these gaps, the 2005 five-year National Strategic Plan for the education of girls, orphans and other vulnerable children set out to accelerate progress towards universal primary education and to promote equity and empowerment through education. However, with the health, social and economic challenges in the country, the subsequent five-year plans launched in 2011 and 2016 gave more focus to orphaned and vulnerable children. It could have been easy to forget the day-to-day problems girls face with their changing reproductive health. But in a positive step in 2017, the Zimbabwe government introduced a duty rebate on the importation of raw materials (pulp, glue and virgin tissue) used in the manufacture of sanitary wear.

It is not the only country in the region to be taking up these pro-girl child measures.

Kenya has repealed sales tax on sanitary wear. Furthermore, since 2011 the Kenya government has allocated approximately 3 million US dollars to support the distribution of sanitary wear in schools in low-income communities. In 2016, Zambia’s Ministry of Health launched its ‘National guidelines for menstrual hygiene management’. In 2017, the Department of Women in South Africa drafted a ‘Sanitary dignity policy framework’.

In August 2017, I had the opportunity to engage the Deputy Director General of the Department of Women, Mr Prince Booi on this policy framework document. He highlighted that the policy aims to widen access to sanitary wear for extremely poor girls and women, where the provision of this service helps to restore their dignity. The name of this policy framework resonates with me, as it underscores the link between menstrual management and dignity. Girls and women without access to methods and materials for the hygienic management of their menstrual periods experience a cyclical threat to their dignity. Monthly, it can strip away their confidence and may even inhibit their mobility and capacity to carry out physical activities.

In the 1960s in America President Lyndon B Johnson declared ‘a national war on poverty’, using the term ‘dignity deficit’ to highlight the effect on men of unemployment and their inability to provide for their families as breadwinners within the home.

Women were far less in focus at the time. But women’s reproductive health is an even more powerful sign of the dignity deficit as described in 2017 by Arthur Brooks in an essay in ‘Foreign Affairs’ ( In it he paints the picture of a polarised America in which the rate of births for unmarried mothers is five times higher in women reaching up to high school education than that of college educated women. This is even more profound in girl children. In my own advocacy work in Zimbabwe I have seen how unintended pregnancies lead to dropping out from school and a social reproduction of vulnerability, unemployment and poverty.

Indeed, when Scottish Member of Parliament Monica Lennon began lobbying in 2017 for a bill to ensure free access to sanitary products in schools, colleges and universities it was profiled as a bid to end ‘period poverty’.

The measures taken by Zimbabwe, Kenya, Zambia and South Africa are thus important equity measures, particularly in overcoming market barriers to menstrual health and dignity. They are also ahead of those taken in many higher income settings. Whilst the City of New York legislated in 2016 for the roll out of free sanitary wear in public schools, homeless shelters and prisons, sanitary wear is still subject to sales tax in other districts in the state and other US states have not followed its example. At the same time, African countries can also look to other countries for further good practice. The 2013 documentary ‘Menstrual man’ and the 2018 movie ‘PadMan’ illuminate the work of Arunachalam Muruganantham in India for example. He confronted gender barriers in championing menstrual management and inventing a low-cost sanitary pad-manufacturing machine that is now used by rural women in India to locally manufacture sanitary pads.

These market measures and initiatives signal a potential shift in the recognition of the importance menstrual health in countries – taking it from a position of being hidden to one that is profiled and addressed in the public sphere, and more importantly an issue that has implications for equity and dignity.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat:

2. Latest Equinet Updates

Advancing public health rights, claims and standards in mining, Report of a Side Session at the Alternative Mining Indaba, 6 February 2018, Cape Town South Africa
EQUINET; TARSC; SATUCC; Benchmarks Foundation; SADC CNGO, EQUINET, Harare, 2018

The Alternative Mining Indaba has been held annually since 2010 at the same time as the Mining Indaba to provide a platform for communities affected by mining to voice their concerns and be capacitated to fight for their rights. The theme for the 2018 AMI was: “Making Natural Resources Work for the People: Towards Just Legal, Policy and Institutional Reform”. This report presents information on a side session at the Indaba that aimed to raise and discuss the key public health challenges facing workers and communities in the extractive sector / mining in east and southern Africa, the strategies for responding to them, including proposals for harmonised regional health standards, and the proposals made by civil society to advance them.

EQUINET discussion paper 113: The role of an essential health benefit in health systems in east and southern Africa: Learning from regional research
Loewenson R; Mamdani M; Todd G; Kadowa I; Nswilla A; Kisanga O; Luwabelwa M; Banda P; Palale M; Magagula S: TARSC and IHI, EQUINET, Harare, 2018

An Essential Health Benefit (EHB) is a policy intervention defining the service benefits (or benefit package) in order to direct resources to priority areas of health service delivery to reduce disease burdens and ensure health equity. Many east and southern African (ESA) countries have introduced or updated EHBs in the 2000s. Recognising this in 2015-2017, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), through Ifakara Health Institute (IHI) and Training and Research Support Centre (TARSC), with ministries of health in Swaziland, Tanzania, Uganda and Zambia, implemented desk reviews and country case studies, and held a regional meeting to gather and share evidence and learning on the role of EHBs in resourcing, organising and in accountability on integrated, equitable universal health systems. This report synthesises the learning across the full programme of work. It presents the methods used, the context and policy motivations for developing EHBs; how they are being defined, costed, disseminated and used in health systems, including for service provision and quality, resourcing and purchasing services and monitoring and accountability on service delivery and performance, and for learning, useful practice and challenges faced. This research pointed to the evidence within the region for policy dialogue on universal health systems. It raised the usefulness of designing, costing, implementing and monitoring an EHB as a key entry point and operational strategy for realising universal health coverage and systems and for making clear the deficits to be met.

3. Equity in Health

District Health Barometer 2016/2017, South Africa
Massyn N; Padarath A; Peer N; et al: Health Systems Trust, South Africa, 2017

This 12th edition of the District Health Barometer (DHB) covers 52 districts and includes a total of 47 financial and health indicators, 11 of which are new. This annual publication provides an overview of the performance of public health services in South Africa and has become an important planning and management resource for health service providers, managers, researchers and policy makers in the country. The DHB plays an important role in providing information for district mangers to benchmark their districts against the others in the country and in strengthening the use of data for priority setting and decision making. The Barometer is used as the basis for workshops with district managers which provides an opportunity to engage with the data and collaborate with technical experts on how best to use this information for planning. This edition paints a mixed picture, showing significant gains in some areas while highlighting areas that need further attention. Mortality rates in South Africa increased between 1997 and 2006 and declined thereafter until 2015, mainly due to the HIV epidemic and the roll-out of ARTs. Despite this, HIV and AIDS and associated conditions still stand out as being a leading cause of morbidity, together with cerebrovascular diseases, ischaemic heart disease, diabetes mellitus, road injuries, interpersonal violence and hypertensive heart disease.

Next wave of interventions to reduce under-five mortality in Rwanda: a crosssectional analysis of demographic and health survey data
Amoroso C; Nisingizwe M; Rouleau D; et al: BMC Pediatrics 18(27) doi: 10.1186/s12887-018-0997-y, 2018

This paper reports on a cross-sectional study of 9002 births to 6328 women age 15–49 in the 2010 Rwanda Demographic and Health Survey to identify correlates of under-five mortality in all children under-five, 0–11 months, and 12–59 months. The results indicated that of 14 covariates associated with under-five mortality in bivariate analysis, the following remained associated with under-five mortality in multivariate analysis: household being among the poorest of the poor, child being a twin, mother having 3–4 births in the past 5 years compared to 1–2 births, mother being HIV positive, and mother not using contraceptives compared to using a modern method. Mother experiencing physical or sexual violence in the last 12 months was associated with under-five mortality in children ages 1–4 years. Under five survival was associated with a preceding birth interval 25–50 months compared to 9–24 months, and having a mosquito net. It was concluded that in the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. The results of the study suggest that Rwanda’s next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence.

4. Values, Policies and Rights

Extractive Laws in Africa: What is the state of these laws? Why are our laws a problem? Why and on what should we call for reforms?
Graham Y: Alternative Mining Indaba, February 2018

The overarching legal framework for minerals across Africa is public ownership. Citizens should be the collective beneficial owners of the mineral resources that are managed on their behalf by the state as a trustee. Graham asserts, however, that the reality in Africa is different. The collective ownership of minerals and the trustee role of the state has been compromised. Mining activists have tended to focus on accountability and transparency in relation to the regimes of mineral exploitation that governments have adopted. Graham asserts that there is a more fundamental accountability question in how the choices being made advance the inter- generational interests of citizens. Graham identifies that the citizen should at the very least not be made worse off by the development of assets of which he/she is part owner. He argues that there should be a stronger accountability framework where a minerals and development policy provides for inter-generational benefit, with linkages to development. There is a need to retreat from a 'first come first served' approach to awarding mining contracts, to collect more geological information to inform award of concessions and reform revenue law to be sensitive to mining price cycles so revenue collection can be optimised.

Guidelines for responsible short-term global health activities: developing common principles
Lasker J; Aldrink M; Balasubramaniam R; et al: Globalization and Health 14(18) doi:, 2018

Growing concerns about the value and effectiveness of short-term volunteer trips intending to improve health in underserved Global South communities has driven the development of guidelines by multiple organizations and individuals. These are intended to mitigate potential harms and maximize benefits associated with such efforts. This paper analyzes 27 guidelines derived from a scoping review of the literature available in early 2017, describing their authorship, intended audiences, the aspects of short term medical missions (STMMs) they address, and their attention to guideline implementation. It further considers how these guidelines relate to the desires of host communities, as seen in studies of host country staff who work with volunteers. There is broad consensus on key principles for responsible, effective, and ethical programs--need for host partners, proper preparation and supervision of visitors, needs assessment and evaluation, sustainability, and adherence to pertinent legal and ethical standards. Host country staff studies suggest agreement with the main elements of this guideline consensus, but they add the importance of mutual learning and respect for hosts. Guidelines must be informed by research and policy directives from host countries that is now mostly absent. Also, a comprehensive strategy to support adherence to best practice guidelines is argued to be needed, given limited regulation and enforcement capacity in host country contexts and strong incentives for involved stakeholders to undertake or host STMMs that do not respect key principles.

Political Priority for Abortion Law Reform in Malawi: Transnational and National Influences
Daire J; Kloster M; Storeng K: Health and Human Rights Journal, March 2018

In July 2015, Malawi’s Special Law Commission on the Review of the Law on Abortion released a draft Termination of Pregnancy bill. If approved by Parliament, it will liberalize Malawi’s strict abortion law, expanding the grounds for safe abortion and representing an important step toward safer abortion in Malawi. Drawing on prospective policy analysis (2013–2017), the authors identify factors that helped generate political will to address unsafe abortion. Notably, the authors show that transnational influences and domestic advocacy converged to make unsafe abortion a political issue in Malawi and to make abortion law reform a possibility. Since the 1980s, international actors have promoted global norms and provided financial and technical resources to advance ideas about women’s reproductive health and rights and to support research on unsafe abortion. Meanwhile, domestic coalitions of actors and policy champions have mobilized new national evidence on the magnitude, costs, and public health impacts of unsafe abortion, framing action on unsafe abortion as part of a broader imperative to address Malawi’s high level of maternal mortality. Although these efforts have generated substantial support for abortion law reform, an ongoing backlash from the international anti-choice movement has gained momentum by appealing to religious and nationalist values. Passage of the bill confronts, for example, the current United States’ government position prohibiting the funding of safe abortion.

5. Health equity in economic and trade policies

African leaders sign continental free-trade agreement
Al Jazeera News: 21 March 2018

African leaders have signed an agreement to set up a massive free-trade area to improve regional integration and boost economic growth across the continent. The deal to create the African Continental Free Trade Area (AfCFTA) was signed at an extraordinary summit in Kigali, Rwanda by representatives of 44 of the 55 African Union (AU) member states. The agreement commits countries to removing tariffs on 90 percent of goods, with 10 percent of "sensitive items" to be phased in later. It will also liberalise trade in services and might in the future include free movement of people and a single currency. AfCFTA will now have to be ratified by individual countries. Nigeria pulled out of the signing ceremony. The Nigeria Labour Congress (NLC) had warned government against signing the agreement, calling it a "renewed, extremely dangerous and radioactive neo-liberal policy initiative". A further protocol, the Protocol on Free Movement of People has to date been signed by 27 countries.

Listeriosis: One of many food horrors of South Africa’s profit-driven, corporate-controlled food system
COPAC, SAFC: South Africa, March 2018

The South African Food Sovereignty Campaign (SAFSC) and Co-operative and Policy Alternative Centre issued as press statement calling the outbreak of listeriosis in South Africa as a food horror of a profit-driven corporate food system, with limited state regulation. They blame the current corporate controlled food system for compromised health standards in South Africa, which has led to food horrors of not only listeriosis, but also obesity, hunger, malnutrition, child stunting and diabetes. The private sector with profit as its main motive, claims that it has solutions to end food crises, but these organisations say that it is perpetuating the very crises that the poor and vulnerable face on a daily basis, and that the listeriosis outbreak, as well as ongoing hunger, hiking obesity and diabetes rates and contamination of soils with pesticides, tell a story of the failure of the corporate food system to ensure adequate nutrition for all citizens, and the destruction of natural environments. The South African Food Sovereignty Campaign (SAFSC) calls for greater state regulation based on the People’s Food Sovereignty Act. This Act calls for the democratic planning of the food system, increased state regulation on destructive practices of the corporate controlled food system, prioritising local food supply over trade, a ban on advertising of all junk food, and greater reliance on small-scale food producers to feed citizens culturally appropriate and nutritious food.

The institutional context of tobacco production in Zambia
Labonté R; Lencucha R; Drope J: Globalisation and Health 14(5) doi:, 2018

Tobacco production is said to be an important contributor to Zambia’s economy in terms of labour and revenue generation. In light of Zambia’s obligations under the WHO Framework Convention of Tobacco Control (FCTC) the authors examined the institutional actors in Zambia’s tobacco sector to better understand their roles and determine the institutional context that supports tobacco production in Zambia. Findings from 26 qualitative, semi-structured individual or small-group interviews with key informants from governmental, intergovernmental and non-governmental organisations were analysed, along with data and information from published literature. Although Zambia is obligated under the FCTC to take steps to reduce tobacco production, the country’s weak economy and strong tobacco interests make it difficult to achieve this goal. Respondents uniformly acknowledged that growing the country’s economy and ensuring employment for its citizens are the government’s top priorities. Lacklustre coordination and collaboration between the institutional actors, both within and outside government, contributes to an environment that helps sustain tobacco production in the country. A Tobacco Products Control Bill has been under review for a number of years, but with no supply measures included, and with no indication of when or whether it will be passed. As with other low-income countries involved in tobacco production, there is inconsistency between Zambia’s economic policy to strengthen the country’s economy and its FCTC commitment to regulate and control tobacco production. The absence of a whole-of-government approach towards tobacco control has created an institutional context of duelling objectives, with some government ministries working at cross-purposes and tobacco interests left unchecked. With no ultimate coordinating authority, this industry risks being run according to the desire and demands of multinational tobacco companies, with few, if any, checks against them.

The Political Economy of Renewable Energy Investment in Kenya
Osiolo H; Pueyo A; Gachanja J: IDS Bulletin 48(5-6), doi:, 2017

Kenya has been hailed as a successful sub-Saharan African country in attracting private investment for renewable energy. However, this paper observes that energy poverty remains very high, with connectivity rates lower than the average for sub-Saharan Africa and poor quality of supply for those connected. Several constraints persist to achieve universal access to clean and affordable electricity: high system costs, including a deficient transmission and distribution infrastructure; low rural demand and inadequate planning to meet it; and local opposition to large renewable infrastructure. This article considers the political economy of these constraints, explaining how they arose, which policies can address them and which actors back or oppose these policies. The overarching message is that a prominent state role is required to fund the network components of the electricity system and to reach the less profitable segments of society, namely the rural poor. However, the authors find that this clashes with a dominant private sector-led narrative in the international development community.

6. Poverty and health

Factors associated with household food insecurity and depression in pregnant South African women from a low socio-economic setting: a cross-sectional study
Abrahams Z; Lund C; Field S; et al: Social Psychiatry and Psychiatric Epidemiology, doi:, 2018

This study aimed to assess factors associated with food insecurity and depression in a sample of pregnant South African women in a low-income suburb in Cape Town. Pregnant women attending a local clinic for their first antenatal visit were invited to participate. The shortened form of the US Household Food Security Survey Module was used to measure food insecurity. The Expanded Mini-International Neuropsychiatric Interview was used to diagnose depression, anxiety, alcohol and drug dependence, and assess for suicidal ideation and behaviour. Logistic regression modelling was conducted to explore factors associated with food insecurity and depression in separate models. The authors found that 42% of households were food insecure and that 21% of participants were depressed. The odds of being food insecure were increased in women with suicidal behaviour, with depression and in those with three or more children. The odds of depression was greater in women who were food insecure, substance dependent or diagnosed with an anxiety disorder. Food insecurity and depression are strongly associated in pregnant women. The relationship between food insecurity and depression is complex and requires further investigation. Interventions that improve both food security and mental health during the perinatal period are likely to benefit the physical and mental well-being of mothers and children.

7. Equitable health services

Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries
Rwabukwisi F; Bawah A; Gimbel S; Phillips J et al: BMC Health Services Research 17(Suppl3) doi:, 2017

In this study, the authors captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. Four major overarching lessons were highlighted. Variety and inclusiveness of concerned key players are necessary to address complex health system issues at all levels. A learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the Population Health Implementation and Training partnership projects.

How to assess and prepare health systems in low- and middle-income countries for integration of services—a systematic review
Topp S; Abimbola S; Joshi R: Health Policy and Planning 33(2) March 2018, doi:, 2017

Despite growing support for integration of frontline services, a lack of information about the pre-conditions necessary to integrate such services hampers the ability of policy makers and implementers to assess how feasible or worthwhile integration may be, especially in low- and middle-income countries (LMICs). The authors adopted a modified systematic review with aspects of realist review of quantitative and qualitative studies that incorporated assessment of health system preparedness for and capacity to implement integrated services. From an initial list of 10 550 articles, 206 were selected for full-text review by two reviewers who independently reviewed articles and inductively extracted and synthesized themes related to health system preparedness. Five ‘context’ related categories and four health system ‘capability’ themes were searched. The contextual enabling and constraining factors for frontline service integration were: the organizational framework of frontline services, health care worker preparedness, community and client preparedness, upstream logistics and policy and governance issues. The intersecting health system capabilities identified were the need for: sufficiently functional frontline health services, sufficiently trained and motivated health care workers, availability of technical tools and equipment suitable to facilitate integrated frontline services and appropriately devolved authority and decision-making processes to enable frontline managers and staff to adapt integration to local circumstances. This review demonstrates that synthesis is possible. It presents a common set of contextual factors and health system capabilities necessary for successful service integration which may be considered indicators of preparedness and could form the basis for an ‘integration preparedness tool’.

8. Human Resources

Exploring the care provided to mothers and children by community health workers in South Africa: missed opportunities to provide comprehensive care
Wilford A; Phakathi S; Haskins L; et al: BMC Public Health 18(171), doi:, 2018

In this study the authors explored the performance of by community health workers (CHWs) providing maternal and child health services at household level and the quality of the CHW-mother interaction using observations and in-depth interviews. Fifteen CHWs and 30 mothers/pregnant women were purposively selected in three rural districts of KwaZulu-Natal, South Africa. CHWs provided appropriate and correct health information but there were important gaps in the content provided. Mothers expressed satisfaction with CHW visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household, and requested training and support from supervisors during household visits. The authors assert that key building blocks for a successful CHW programme are in place to provide services for mothers and children in households but further training and supervision is required if the gaps in CHW knowledge and skills are to be filled.

How to do (or not to do)… Measuring health worker motivation in surveys in low- and middle-income countries
Borghi J; Lohmann J; Dale E; et al: Health Policy and Planning 33(2) doi:, 2018

A health system’s ability to deliver quality health care depends on the availability of motivated health workers, which are insufficient in many low income settings. Increasing policy and researcher attention is directed towards understanding what drives health worker motivation and how different policy interventions affect motivation, as motivation is key to performance and quality of care outcomes. As a result, there is growing interest among researchers in measuring motivation within health worker surveys. However, there is currently limited guidance on how to conceptualize and approach measurement and how to validate or analyse motivation data collected from health worker surveys, resulting in inconsistent and sometimes poor quality measures. This paper begins by discussing how motivation can be conceptualized, then sets out the steps in developing questions to measure motivation within health worker surveys and in ensuring data quality through validity and reliability tests. The paper also discusses analysis of the resulting motivation measure/s.

9. Public-Private Mix

Fiscal policy to improve diets and prevent non-communicable diseases: from recommendations to action
Thow A; Downs S; Mayes C; et al: Bulletin of the World Health Organisatio 96(3) 201–210, 2018

The World Health Organization has recommended that Member States consider taxing energy-dense beverages and foods and/or subsidizing nutrient-rich foods to improve diets and prevent noncommunicable diseases. Numerous countries have either implemented taxes on energy-dense beverages and foods or are considering the implementation of such taxes. However, several major challenges to the implementation of fiscal policies to improve diets and prevent noncommunicable diseases remain. Some of these challenges relate to the cross-sectoral nature of the relevant interventions. For example, as health and economic policy-makers have different administrative concerns, performance indicators and priorities, they often consider different forms of evidence in their decision-making. In this paper, the evidence base for diet-related interventions based on fiscal policies are described and the key questions that need to be asked by both health and economic policy-makers are considered. From the health sector’s perspective, there is most evidence for the impact of taxes and subsidies on diets, with less evidence on their impacts on body weight or health. The authors highlight the importance of scope, the role of industry, the use of revenue and regressive taxes in informing policy decisions.

10. Resource allocation and health financing

Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy
Okungu V; Chuma J; Mulupi S; et al: BMC Health Services Research 18(37), doi:, 2018

This study documented the views of informal sector workers regarding different prepayment mechanisms, to inform the design and policy implications of financing Universal health coverage in Kenya. This was part of larger study which involved a mixed-methods approach. Data was collected from informal sector workers: focus group discussions, individual in-depth and a questionnaire survey. The findings showed that informal sector workers in rural and urban areas prefer different prepayment systems for financing Universal health coverage. Preference for a non-contributory system of financing Universal health coverage was particularly strong in the urban study site. Over 70% in the rural area preferred a contributory mechanism in financing Universal health coverage. The main concern for informal sector workers regardless of the overall design of the financing approach to Universal health coverage included a poor governance culture, especially one that does not punish corruption. Other reasons especially with regard to the contributory financing approach included high premium costs and inability to enforce contributions from informal sector. On average 47% of all study participants, the largest single majority, are in favour of a non-contributory financing mechanism. Strong evidence from existing literature indicates difficulties in implementing social contributions as the primary financing mechanism for Universal health coverage in contexts with large informal sector populations. The authors argue that non-contributory financing should be strongly recommended to policymakers to be the primary financing mechanism, supplemented by social contributions.

The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique
Warren A; Cordon R; Told M; et al: Globalisation and Health 13(89) doi:, 2017

The Global Fund is one of the largest actors in global health, disbursing in 2015 close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients’ misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. The authors conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing. Analysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund’s structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. While decision-makers in Geneva recognize in-country coordination as vital to successful implementation, to date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique’s in-country coordination groups. In-country partners provide much needed support for Global Fund recipients, but the authors argue that roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership.

The unfunded priorities: an evaluation of priority setting for noncommunicable disease control in Uganda
Essue B; Kapiriri L: Globalization and Health 14(22), doi:, 2018

This paper examined the influence of national, sub-national and global factors on priority setting for noncommunicable disease control in Uganda. A mixed methods design that used the Kapiriri Martin framework for evaluating priority setting in low income countries and the evaluation period was 2005–2015. Priority setting for noncommunicable diseases was not entirely fair nor successful. While there were explicit processes that incorporated relevant criteria, evidence and wide stakeholder involvement, these criteria were not used systematically or consistently in the contemplation of noncommunicable diseases. There were insufficient resources for noncommunicable diseases, despite being a priority area. There were weaknesses in the priority setting institutions, and insufficient mechanisms to ensure accountability for decision-making. Priority setting was influenced by the priorities of major stakeholders, such as development assistance partners, which were not always aligned with national priorities. There were major delays in the implementation of noncommunicable disease-related priorities and in many cases, a failure to implement. This evaluation revealed the challenges that low income countries are grappling with in prioritizing noncommunicable diseases in the context of a double disease burden with limited resources. The authors propose that strengthening local capacity for priority setting would help to support the development of sustainable and implementable noncommunicable disease-related priorities and that global support to low income countries for noncommunicable diseases must catch up to align with NCDs as a global health priority.

11. Equity and HIV/AIDS

Determinants of facility readiness for integration of family planning with HIV testing and counseling services: evidence from the Tanzania service provision assessment survey, 2014–2015
Bintabara D; Nakamura K; Seino K: BMC Health Services Research 17(844), doi:, 2017

This study examined determinants of facility readiness for integration of family planning with HIV testing and counseling services in Tanzania using data from the 2014–2015 Tanzania Service Provision Assessment Survey. A total of 1188 facilities were assessed and considered ready for integration of family planning with HIV testing and counseling services if they scored ≥ 50% on both family planning and HIV testing and counseling service readiness indices as identified by the World Health Organization. Of all the health facilities, 915 reported offering both family planning and HIV testing and counseling services, while only 536 were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned, having routine management meetings, availability of guidelines, in-service training of staff, and availability of laboratories for HIV testing. The authors judge the proportion of facility readiness for the integration of family planning with HIV testing and counseling in Tanzania to be unsatisfactory and suggest that the Ministry of Health distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and refresher training to health providers, as determinants of facility readiness.

12. Governance and participation in health

Factors influencing the capacity of women to voice their concerns about maternal health services in the Muanda and Bolenge Health Zones, Democratic Republic of the Congo: a multi-method study.
Mafuta E; De Cock Buning T; Lolobi D; et al: BMC Health Services Research, Biology 18(37), doi:, 2018

This paper aims to identify factors that influence the capacity of women to voice their concerns regarding maternal health services at the local level. A secondary analysis was conducted of the data from three studies carried out between 2013 and 2015 in the context of a WOTRO initiative to improve maternal health services through social accountability mechanisms in the Democratic Republic of the Congo. Data from 21 interviews and 12 focus group discussions were analysed using an inductive content analysis. The women living in the rural setting were mostly farmers/fisher-women or worked at odd jobs. They had not completed secondary school. Around one-fifth was younger than 20 years old. The majority of women could describe the health service they received but were not able to describe what they should receive as care. They had insufficient knowledge of the health services before their first visit. They were not able to explain the mandate of the health providers. The information they received concerned the types of healthcare they could receive but not the real content of those services, nor their rights and entitlements. They believed that they were laypersons and therefore unable to judge health providers, but when provided with some tools such as a checklist, they reported some abusive and disrespectful treatments. Factors influencing the capacity of women to voice their concerns in Democratic Republic of the Congo rural settings were found to be mainly associated with insufficient knowledge and a socio-cultural context. These findings suggest that initiatives to implement social accountability have to address community capacity-building, health providers’ responsiveness and the socio-cultural norms .

From Kisiizi to Baltimore: cultivating knowledge brokers to support global innovation for community engagement in healthcare
Ibe C; Basu L; Gooden R; et al: Globalization and Health 14(19), doi:, 2018

Reverse Innovation has been endorsed as a vehicle for promoting bidirectional learning and information flow between low- and middle-income countries and high-income countries, with the aim of tackling common unmet needs. One such need, which traverses international boundaries, is the development of strategies to initiate and sustain community engagement in health care delivery systems. In this commentary, the authors discuss the Baltimore “Community-based Organizations Neighborhood Network: Enhancing Capacity Together” Study. This randomized controlled trial evaluated whether or not a community engagement strategy, developed to address patient safety in low- and middle-income countries throughout sub-Saharan Africa, could be successfully applied to create and implement strategies that would link community-based organizations to a local health care system in Baltimore, a city in the United States. Specifically, the authors explore the trial’s activation of community knowledge brokers as the conduit through which community engagement, and innovation production, was achieved. Cultivating community knowledge brokers holds promise as a vehicle for advancing global innovation in the context of health care delivery systems. As such, further efforts to discern the ways in which they may promote the development and dissemination of innovations in health care systems is warranted.

Working with Parliamentary Committees of Health to Tackle Health Issues in Africa
African Institute for Development Policy (AFIDEP), Network of African Parliamentary Committees of Health (NEAPACOH): Kenya, 2017

The Network of African Parliamentary Committees of Health (NEAPACOH), previously known as the Southern and Eastern Africa Parliamentary Alliance of Committees on Health (SEAPACOH)) is one of the active networks engaging members of parliament in Africa to strengthen the delivery of their functions of oversight, legislation and representation, in tackling health challenges in the region. This study sought to understand NEAPACOH’s contributions in strengthening parliamentary committees in Africa to tackle health and population challenges, and identify ways in which the network can become more effective in the delivery of its mandate. Given the integral role of information or evidence in the delivery of the parliamentary functions, the study had a special interest in understanding how the network promotes evidence-informed discharge of the health committee, to generate learning needed to strengthen NEAPACOH as well as inform future efforts aimed at strengthening the delivery of parliamentary functions in Africa.

13. Monitoring equity and research policy

Research gaps and emerging priorities in sexual and reproductive health in Africa and the eastern Mediterranean regions
Ali M; Farron M; Ouedraogo L; et al: Reproductive Health 15(39) doi:, 2018

This paper presented the results of a priority setting exercise that brought together researchers and program managers from the World Health Organization Africa and Eastern Mediterranean regions to identify key sexual reproductive health issues. In June 2015, researchers and program managers from the World Health Organization Africa and Eastern Mediterranean regions met for a three-day meeting to discuss strategies to strengthen research capacity in the regions. A prioritization exercise was carried out to identify key priority areas for research in sexual reproductive health. The process included five criteria which are answerability, effectiveness, deliverability and acceptability, potential impact of the intervention/program to improve reproductive, maternal and newborn health substantially, and equity. The six main priorities were identified as creation and investment in multipurpose prevention technologies, addressing adolescent violence and early pregnancy, improved maternal and newborn emergency care, increased evaluation and improvement of adolescent health interventions including contraception, further focus on family planning uptake and barriers, and improving care for mothers and children during childbirth. They indicate that setting priorities is the first step in a dynamic process to identify where research funding should be focused to maximize health benefits. A focus on priority setting suggests a need to identify who is thus involved in this process.

14. Useful Resources

Local Government Community of Practice
Gender Links for Equality and Justice: website, 2018

The Local government Community of Practice is a ‘virtual’ community that seeks to enable interaction on various gender and governance issues. Ideal for local government practitioners and academia this platform invokes participants to learn and share best practices, resources and critical thinking on gender and service delivery across the SADC region to bring ‘the local government we want’. Members are encouraged to make use of the Local Government Gender Score Card tool that measures the Centres of Excellence (COE) progress in gender mainstreaming and sensitive service delivery. Aligned is a newly developed Local Government Citizen’s Score Card that provides an opportunity for community members served by COE councils to assess and measure council’s progress towards achieving gender sensitive and responsive service delivery. The results from these tools aim to assist in strengthened policies and development projects that are implemented to achieve the Sustainable Development Goals and SADC Gender Protocol Agenda 2030.

Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: A manual for health managers
World Health Organization, WHO, Geneva, 2017

This manual is intended for health managers at all levels of the health systems. It is based on World Health Organization (WHO) 2013 guidelines for responding to intimate partner violence and sexual violence against women. The manual primarily addresses public sector health services, but is also relevant for health services in the private sector, including services provided by nongovernmental organizations. It is intended for policy-makers, health services managers at hospital or health facility level who have responsibility for facility level planning as well as day-to-day coordination and management of services, and offers easy steps, practical tips and job aids to help plan and manage services.

15. Jobs and Announcements

15th International Conference on Urban Health: Managing Urbanisation for Health, 26-30 November 2018, Kampala, Uganda
Deadline for abstracts: 14 May 2018

The 15th International Conference on Urban Health will bring together interdisciplinary researchers, practitioners, policy-makers, health and urban stakeholders and community leaders to exchange ideas and advance research and practice across sectors on how best to manage the rapid urbanisation occurring in all regions of the world. Abstracts are invited for oral and poster presentations, pre-formed panels, workshops and special tracks on the following conference themes: The Governance of Complex Systems, Culture and Inclusivity, Disasters, Epidemics, and the Unexpected, Cities as Economic Engines, Monitoring and Evaluation of Urban Health Indicators, Safety, Security, and Justice, Spiritual Health in the City.

Africa Innovation Summit 2019
6-8 June 2018, Kigali, Rwanda

The 2018 Summit will be a multifaceted event that will bring together stakeholders from various sectors, including decision makers to seek innovative and disruptive solutions for the challenges facing African countries. The focus of AIS 2018 will include energy access, water, health, food security and climate change. AIS II will be a three-day event and the program will include five plenary sessions to introduce major thematic issues followed by a series of facilitated workshops, which will take place in focused workgroups to deepen the dialogue and to seek solutions to address the key challenges facing African countries. Each workshop will focus on a specific theme with three to four panelists and will be led by a facilitator. The aims of the discussions are to seek solutions, develop an agenda and mobilize the people and stakeholders for collective action going forward. The AIS 2018 will include activities before, during and after the Summit.

African Capital Cities Sustainability Forum 2018
5-7 June 2018, City of Tshwane, South Africa

The African Capital Cities Sustainability Forum (ACCSF) functions as a network for the mayors of capital cities across the continent to achieve the sustainable development goals that are common to all and, in the words of Solly Msimanga, executive mayor of Tshwane, “to establish commonalities and challenges faced by major cities in Africa while showcasing and sharing successful initiatives towards the emergence of truly African, original and appropriate answers in addressing the sustainability imperative at the urban scale.”

Cochrane South Africa invites applications for the Aubrey Sheiham Evidence-based Health Care in Africa Leadership Award 2018
Applications close: 31 July 2018

Since 2001 through the generosity of the late Professor Aubrey Sheiham 16 Cochrane researchers from low- and middle-income countries have been funded and supported to complete Cochrane Reviews on topics relevant to their region, and to cascade knowledge about Cochrane and evidence-based health care (EBHC) to their local networks. In 2014, the scholarship evolved into a new award focusing on leadership in EBHC - the Aubrey Sheiham EBHC in Africa Leadership Award, administered by Cochrane South Africa. With an updated and more concentrated focus, the fellowship is awarded annually to an individual based in Africa, and supports the conduct and dissemination of a high-impact Cochrane Review on a topic relevant to resource-constrained settings. The Cochrane Review should be registered with a Cochrane Review Group at the time of application. An update of an existing review is allowed if it will have high impact. The applicant should provide proof that relevant evidence is available for inclusion in the review. In addition to completing their chosen Cochrane Review and disseminating its findings, the award recipient will support capacity development by mentoring a novice author based in Africa through the review process. This continues the scholarship’s tradition of building knowledge and research networks, which will be actively supported by Cochrane South Africa.

Scholarships available for the Applied Conflict Transformation Studies [ACTS] programme for Africa, 2018 - 2020
Deadline for applications: 29th April 2018

The ACTS programme takes place under the joint auspices of the International Centre of Nonviolence at Durban University of Technology (DUT) and Grace to Heal, an NGO based in Bulawayo. It is taught by a highly skilled and experienced team, with both local and international staff. This practical programme is offered part-time over 2-2.5 years. Stage one involves three coursework modules, each of which requires up to 10 days residence in Bulawayo, plus guided study at home. Subject to satisfactory progress, students may proceed to stage two, a thesis based on action research. This involves two further residential sessions after formal registration at Durban University of Technology. The final qualification is a Master’s Degree in Management Sciences (MManSc). The programme is closely associated with the ACTS programme for Asia, based at the Centre for Peace and Conflict Studies in Siem Reap, Cambodia. The procedure is for people to make a formal application for the course by filling in the forms, and attach a request for scholarship support. Information can be obtained at the email address below.

Seventy-first World Health Assembly
21-26 May 2018, WHO, Geneva, Switzerland

The World Health Assembly is the decision-making body of WHO. It is attended by delegations from all WHO Member States and focuses on a specific health agenda prepared by the Executive Board. The main functions of the World Health Assembly are to determine the policies of the Organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget. The provisional agenda includes: Addressing the global shortage of, and access to, medicines; the global strategy and plan of action on public health, innovation and intellectual property; preparation for a high-level meeting of the General Assembly on ending tuberculosis; physical activity for health; maternal, infant and young child nutrition; safeguarding against possible conflicts of interest in nutrition programmes; and poliomyelitis – containment of polioviruses.

The Council for the Development of Social Science Research in Africa 15th General Assembly: Africa and the Crisis of Globalisation 17 – 21 December 2018, Dakar, Senegal
Deadline for abstracts or panel proposals: 15 April 2018

The Council for the Development of Social Science Research in Africa (CODESRIA) announces its 15th General Assembly in Dakar, Senegal from 17-21 December 2018. The theme chosen for the General Assembly is ‘Africa and the Crisis of Globalization'. Scholars wishing to be considered for participation in the 15th Assembly as paper presenters or convenors of panels are invited to send abstracts or panel proposals for consideration by the CODESRIA Scientific Committee by 15th April 2018. Successful applicants will be expected to submit full papers for a second round of review by 1st July 2018. The selected participants in the GA will be informed in August 2018. Abstracts for paper presentation should not exceed 600 words while panel proposals should not exceed 1,200 words. Each should clearly indicate the sub-theme in which the paper or panel is located. The Council has created a portal on the website through which all abstracts and panel proposals will be submitted.


Contact EQUINET at and visit our website at

SUBMITTING NEWS: Please send materials for inclusion in the EQUINET NEWS to Please forward this to others.

SUBSCRIBE: The Newsletter comes out monthly and is delivered to subscribers by e-mail. Subscription is free. To subscribe, visit or send an email to

This newsletter is produced under the principles of 'fair use'. We strive to attribute sources by providing direct links to authors and websites. When full text is submitted to us and no website is provided, we make the text available as provided. The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET or the institutions in its steering committee. While we make every effort to ensure that all facts and figures quoted by authors are accurate, EQUINET and its steering committee institutions cannot be held responsible for any inaccuracies contained in any articles. Please contact immediately regarding any issues arising.