Current Issue

EQUINET NEWSLETTER 200 : 01 November 2017

1. Editorial

What do Harare youth think needs to happen in our cities to improve our wellbeing?
Busisiwe Shumba, Sithembile Zimbeva, Piason Mareya, Simon Kapombe, Bridget Kajawu, Shingirai Denhere, Arthur Nyandwe and Ishmael Makaya, Harare


In September this year the civic centre of Harare was buzzing with the sound of music and discussions, markets, installations, workshops and multiple activities. It was Shoko Festival time, and the museum, library and other civic buildings transformed into a magnet for young people to get away from the stresses of our shrinking economy and nourish our creativity.

Shoko festival is one of Zimbabwe’s fastest-growing international festivals and over seven years has grown into a major cultural event. The festival this year was held at a time when many are struggling with the socio-economic problems brought about by the myriad of problems in the economy. We wondered – is art a luxury at such a time? What can it contribute to improving our wellbeing in a harsh climate?

Our experience at the festival indicates that it is anything but a luxury!

This year’s festival was held with the theme ‘YOUtopia’, as a vibrant creative space in which people could explore and imagine the qualities they seek for themselves and their community or society. So we took advantage of the space and theme to take a discussion that we have been having as young people on what kind of city will improve our wellbeing to a wider audience.

In the past year as a group of young people in the Civic Forum on Human Development from diverse settings and suburbs in Harare we have been working with the Training and Research Support Centre in EQUINET to understand what is driving the inequalities in health in our urban areas, at least for ourselves as young people. With our health services often focused on treating diseases, we took a wider lens to build a more holistic understanding of what will promote our health today and in the future. In our own discussions we identified issues that go well beyond the scope of health services, including the way our cities provide spaces for us to create jobs, the green spaces and access to internet that we need to meet, connect and exchange ideas, and the access to urban land we need to have to grow food and build decent housing. We looked at how these issues are being addressed in other parts of the world and found a lot to inspire us on how we could do things differently here in Harare.

So we decided to participate in the Shoko festival with a stand on “picturing our urban futures” to hear and see what other young people thought. Over two days we explored what kind of city people, especially young people coming to Shoko festival wanted to live in? How did they imagine things could be different in ways that promote their wellbeing? We had an art table, where people drew in one half of the page features of areas they live, work or meet in in the city as they are now, and in the other half how they would like them to be. We had postits where people wrote short text on what they thought was affecting their wellbeing or what changes they wanted to see in for our cities to promote our wellbeing. We discussed what people saw as the different aspects of their wellbeing.

We had no rules and gave a free space and materials for young people to draw or write or say what they thought. Many youth preferred drawing their views than writing or talking.

By the end of the two days there were pink, yellow and green postits all over the glass wall on one side of the stand and artwork of all colours filling the wall on the other side and young people talking in between. We were surrounded by the analysis and the possible, in a space youth culture that radiated positive activism and ideas. Shoko is about celebrating positive youth culture that is trending and relevant in the cities that has been associated with hip-hop, dancehall to spoken word and comedy as well as graffiti and cutting edge ideas on how to use new media and technology.

The drawings were clear and the statements were short but full of meaning: “litter free and free wifi!” “a violence free city”, “ a safe city”. The tensions were economic, but also environmental and many were social or linked to mental stress.

The art work and postits highlighted how young people vision a different urban future to overcome the significant differences in opportunities for wellbeing that currently exist and to ensure that our cities work and promote health for all. Many showed how much mental stress is caused by bad conditions like public transport systems where touts push people into overcrowded combis, and how much people want to live in communities free of violence and of rising piles of waste and litter.

The art and postits showed the desire to move from roads with potholes, traffic congestion and chaos, environments with rubbish and poorly maintained parks to one where public spaces, roads and transport are safe and clean. Rather than have cities where the best buildings are for private finance and vendors compete for space with pedestrians, they visioned cities where the best buildings are for community processes and economic activities. They indicated that cities need to enable people to work and create jobs, including by giving access to free wifi, and people should have community spaces to gather and exchange views.

Are these visions of the future utopic? We don’t think so. They are a feasible, practical vision of what we should be demanding, contributing to and achieving for all in our cities and would do more for our health and wellbeing than all the medicines we consume.

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

2. Latest Equinet Updates

EQUINET discussion paper 111: A case study of the role of an Essential Health Benefit in the delivery of integrated health services in Zambia
Luwabelwa M; Banda P; Palale M; Chama-Chiliba C: EQUINET Discussion paper 111, Zambia Ministry of Health, EQUINET: Lusaka

This case study report compiles evidence on the experience of the Essential Health Benefit (EHB) in Zambia. The paper aims to contribute to national and regional policy dialogue regarding the role the EHB plays in budgeting, resourcing and purchasing of health services as well as monitoring health system performance for accountability. It outlines the motivations for developing the EHBs in Zambia, the barriers encountered in the process, the methods used to develop EHBs, and issues related to dissemination and communication of its content. The paper was done under the auspices of an EQUINET research programme through Ifakara Health Institute (IHI) and Training and Research Support Centre (TARSC), in association with the ECSA Health Community, supported by IDRC (Canada), and with the permission of the Ministry of Health of Zambia.

EQUINET Discussion paper 112: A case study of the Essential Health Care Package in Swaziland
Magagula SV: Ministry of Health Swaziland, with IHI, TARSC, EQUINET, Harare

The Essential Health Benefit (EHB) is known as Essential Health Care Package (EHCP) in Swaziland. This desk review provides evidence on the experience of EHCPs in Swaziland and includes available policy documents and research reports. It was implemented in an EQUINET research programme through Ifakara Health Institute (IHI) and Training and Research Support Centre (TARSC), in association with the ECSA Health Community, supported by IDRC (Canada). The desk review presents the motivations for and methods used to develop, define and cost EHCP. It includes key informant input from a multi-disciplinary national task team through a workshop of key stakeholders with technical support from the World Health Organisation (WHO). It outlines how the EHCP has been disseminated and used in the budgeting and purchasing of health services and in monitoring health system performance for accountability. The paper also reports on the facilitators and barriers to development, uptake and use of the EHCP. In guiding the provision of services for all, the EHCP was envisaged to contribute towards the alleviation of poverty and as a tool for universal health coverage. Its implementation calls for a health service Infrastructure that is in good condition, competent health personnel, readiness to undergo training in new medical technology, supporting laws and capacity in the health financing unit. The EHCP in Swaziland was intended to guide the provision of health services. However, its costs were beyond the national resources to fund it. The adoption of a more restricted health service package currently being assessed in ten clinics in all four regions of the country suggests that a phased approach to delivery of an EHB may be more affordable financially for the country.

3. Equity in Health

Noncommunicable Diseases Progress Monitor 2017
World Health Organization: WHO, Geneva, 2017

In May 2015 the World Health Organization published a Technical Note on its 2017 reporting to the United Nations General Assembly on the progress achieved in the implementation of national commitments included in the 2011 UN Political Declaration and the 2014 UN Outcome Document on NCDs. The Technical Note was updated in September 2017 to ensure alignment with the updated set of WHO ‘best-buys’ and other recommended interventions for the prevention and control of non communicable diseases that was endorsed by the World Health Assembly in May 2017. The Progress Monitor provides data on the 19 indicators on progress in NCDs and their control and management for all of WHO’s 194 Member States. The indicators include setting time-bound targets to reduce NCD deaths; developing all-of-government policies to address NCDs; implementing key tobacco demand reduction measures, measures to reduce harmful use of alcohol and unhealthy diets and promote physical activity; and strengthening health systems through primary health care and universal health coverage.

What 115 years of data tells us about Africa’s battle with malaria past and present
Snow B: The conversation, October 2017

The author reports on efforts in the last 21 years tracking down malaria survey reports done across Africa. The greatest challenge was that they were mostly hidden in old government archives or curated by the World Health Organisation. Their final report covers over 50,000 surveys dating back 115 years. This is the largest repository containing information on over 7.8 million blood tests for malaria. They analysed malaria infection prevalence for each of 520 administrative units across countries south of the Sahara and Madagascar for 16 time periods. The study suggests that the prevalence of malaria infection in sub-Saharan Africa today is at the lowest point since 1900. The biggest historical reduction in malaria coincided with the introduction of new tools to fight malaria. After the Second World War, the discovery of DDT for indoor spraying and chloroquine drugs made a difference in treating malaria. In 2005 the rolling out of insecticide treated bed nets and new antimalarial drugs, led to a further drop of malaria cases. The lowest periods of malaria prevalence were evident when the international community abandoned specific malaria control investment in Africa, during the late 1960s, through the 1970s and early 1980s. The gains made after 2005 are also reported to have stalled since 2010. Declining malaria funding, insecticide and drug resistance are the obvious threats to the elimination of malaria in Africa. The authors observe from the evidence that the malaria map in Africa might shrink a bit at the margins but that middle belt isn’t going anywhere in our lifetimes with what we have at our disposal now – bed nets and drugs. When insecticide and drug resistance becomes established, they argue that unless we have new classes of both drugs and insecticides or a natural period of drought, malaria will revert in large parts of Africa to what it was in the 1990s, another perfect storm.

4. Values, Policies and Rights

A revolutionary power to heal
Pashad V: Pambazuka News, October 2017

In a letter to his five children written en route to Bolivia, Ernesto Che Guevara said: “Always be able to feel deep within your being all the injustices committed against anyone, anywhere in the world. This is the most beautiful quality a revolutionary can have.” This article about Che Guevara, 50 years after his execution, explores Che’s story and legacy. His tutelage in revolutionary thought came from his experiences among the leprosy patients of Venezuela and the tin miners of Bolivia, among the revolutionaries of Argentina and the 1954 coup in Guatemala. Reality radicalised him. Mario Terán Salazar, the soldier who shot Che, went into hiding. Many years later, in 2006, the Cuban government operated on Che’s killer to remove a cataract from his eye without charge. The author points to this to highlight that Che’s legacy was not revenge, but doctor’s love for humanity.

Capacity and Consent: Empowering Adolescents to Exercise their Reproductive Rights
Centre for Reproductive Rights: Center for Reproductive Rights NY 2017

With adolescents and youth constituting a quarter of the global population – for a total of 1.8 billion people – it has never been more critical that their human rights be fully recognised and realised within global arenas and at the regional, national, and community level. This publication sets forth the barriers adolescents face in realising their sexual and reproductive health and rights, discusses recent critical developments in the human rights framework underpinning these rights, and proposes a way forward for guaranteeing all adolescents the full exercise of their sexual and reproductive health and rights.

Realizing Universal Health Coverage in East Africa: the relevance of human rights
Yamin A; Maleche A: Biological Medicine Central International Health Human Rights 17(1) doi: 10.1186/s12914-017-0128-0, 2017.

The authors argue that applying a robust human rights framework would change thinking and decision-making in efforts to achieve Universal Health Coverage (UHC), and advance efforts to promote women's, children's, and adolescents' health in East Africa, a priority under the Sustainable Development Goals. They point to a gap between global rhetoric of human rights and ongoing health reform efforts,. and seeks to fill part of that gap by setting out principles of human rights-based approaches, and then applying those principles to questions that countries undertaking efforts toward UHC and promoting women's, children's and adolescents' health, will need to face. The paper focuses in particular on ensuring enabling legal and policy frameworks, establishing fair financing; priority-setting processes, and meaningful oversight and accountability mechanisms. In a region where democratic institutions are argued to be weak, the authors argue that the explicit application of a meaningful human rights framework could enhance equity, participation and accountability, and in turn the democratic legitimacy of health reform initiatives being undertaken in the region.

5. Health equity in economic and trade policies

World running out of antibiotics, says WHO in new reports
Third World Network: TWN Info Service on Health Issues, Oct17/02, 2017

On 19 September, the World Health Organization released a new report that reaffirms the world is running out of antibiotics to fight key and deadly infections due to the fast pace of resistance by bacteria and the lack of new antibiotics to replace or supplement the existing antibiotics. Most new drugs in the pipeline are only modifications of existing classes of antibiotics and are short term solutions, says the WHO. And there are very few potential treatment options for antibiotic resistant infections causing the greatest health threats including resistant TB. This article by TWN explore the issue and the level of (under)investment in new treatments. It argues further for improved infection prevention and control and for fostering appropriate use of existing and future antibiotics.

6. Poverty and health

Tuberculosis, human rights and ethics considerations along the route of a highly vulnerable migrant from sub-Saharan Africa to Europe
Wild V; Jaff D; Shah NS; et al.: International Union Against Tuberculosis and Lung Disease 21(10)1075-1085, 2017

Migrant health is a critical public health issue, and in many countries attention to this topic has focused on the link between migration and communicable diseases, including tuberculosis (TB). This paper traces a commonly used migration route from sub-Saharan Africa to Europe, identifying situations at each stage in which human rights and ethical values might be affected in relation to TB care. The authors highlight three strands of discussion in the ethics and justice literature in an effort to develop more comprehensive ethics of migrant health. These strands include theories of global justice and global health ethics, the creation of ‘firewalls' to separate enforcement of immigration law from protection of human rights, and the importance of non-stigmatization to health justice.

7. Equitable health services

Diabetes in sub-Saharan Africa: from clinical care to health policy
Atun R; Davies J; Gale E; et al: The Lancet Diabetes & Endocrinology Commission 5(8), doi: http://dx.doi.org/10.1016/S2213-8587(17)30181-X, 2017

This study analysed factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. The authors pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006-2014). Based on World Health Organisation protocols, the authors created indices of process quality for antenatal care (first visits) and for sick-child visits. The authors assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service. Data were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% of eight recommended antenatal care actions and 54.5% of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.

Health systems in low income countries - four new overviews
Cochrane: Cochrane EPOC, October 2017

Four new Cochrane EPOC overviews of reviews show reliable evidence on the effects of different ways of organising, financing, and governing health systems in low-income countries and identify important evidence gaps. Strengthening health systems in low-income countries is key to achieving universal health coverage and achieving the health-related Sustainable Development Goals. Achieving these goals requires informed decisions about health systems. A team of Cochrane researchers from Argentina, Chile, Norway, and South Africa prepared four overviews of the available evidence from up-to-date systematic reviews about the effects of health system arrangements in low-income countries. They included 124 systematic reviews in the four overviews. For each review, a user-friendly summary of key findings was produced (see http://supportsummaries.org/), enabling users to explore the overview findings in more depth. The summaries include over 480 key messages about the effects of health system arrangements in low-income countries.

Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda.
Niyitegeka J; Nshimirimana G; Silverstein A; et al.: Biological Medicine Central Pregnancy Childbirth 17(1), doi: 10.1186/s12884-017-1426-1, 2017

In low-resource settings, access to emergency caesarean section is associated with various delays leading to poor neonatal outcomes. In this study, the authors described the delays a mother faces when needing emergency caesarean delivery and assessed the effect of these delays on neonatal outcomes in Rwanda. It included 441 neonates and their mothers who underwent emergency cesarean section in 2015 at three district hospitals in Rwanda. Four delays were measured: duration of labour prior to hospital admission, travel time from health centre to district hospital, time from admission to surgical incision, and time from decision for emergency caesarean section to surgical incision. Neonatal outcomes were categorised as unfavourable and favourable. The authors assessed the relationship between each type of delay and neonatal outcomes using multivariate logistic regression. In their study, 9.1% of neonates had an unfavourable outcome, 38.7% of neonates' mothers laboured for 12-24 h before hospital admission, and 44.7% of mothers were transferred from health centres that required 30-60 min of travel time to reach the district hospital. Furthermore, 48.1% of caesarean sections started within 5 h after hospital admission and 85.2% started more than 30 min after the decision for caesarean section was made. Neonatal outcomes were significantly worse among mothers with more than 90 min of travel time from the health centre to the district hospital compared to mothers referred from health centres located on the same compound as the hospital. Neonates with caesarean deliveries starting more than 30 min after decision for caesarean section had better outcomes than those starting immediately. Longer travel time between health centre and district hospital was associated with poor neonatal outcomes, highlighting a need to decrease barriers to accessing emergency maternal services. However, longer decision to incision interval posed less risk for adverse neonatal outcome. While this could indicate thorough pre-operative interventions including triage and resuscitation, this relationship should be studied prospectively in the future.

8. Human Resources

Pilot study of quality of care training and knowledge in Sub-Saharan African medical schools
Bowser D; Abbas Y; Odunleye T; et al.: International Journal of Medical Education 8, 24 doi: 10.5116/ijme.595b.b38c, 2017

This study identified the level of knowledge and competencies related to quality of care during medical education in sub-Saharan African medical schools. A cross-sectional study design was utilised to examine the capacity of medical schools in sub-Saharan African countries to teach about the concepts of quality of care and the inclusion of these concepts in their curriculum. A purposeful convenience sampling technique was used to select participants from 25 medical schools in 5 sub-Saharan African countries. Respondents included medical school deans or senior academic personnel. While 45% of the schools surveyed are teaching on at least one of the six domains of the Institute of Medicine’s definition of quality of care, there are some schools who report not teaching about quality at all, or that they “do not know”. Despite these low numbers, when asked about topics related to quality of care, many schools are teaching applied management related topics and almost all schools teach about equity and patient-centred care. The results have implications for incorporating quality of care in medical education and for practitioners. The tool developed for this study could be used in future qualitative and quantitative studies to further understanding of how to improve the teaching and learning about quality of care in medical schools.

‘I am treated well if I adhere to my HIV medication’: putting patient–provider interactions in context through insights from qualitative research in five sub-Saharan African countries
Ondenge K; Renju J; Bonnington O; et al.: Jo Sexually Transmitted Infections 93 (Issue Supplement 3), doi: http://dx.doi.org/10.1136/sextrans-2016-052973, 2017

The nature of patient–provider interactions and communication is widely documented to significantly impact on patient experiences, treatment adherence and health outcomes. Yet little is known about the broader contextual factors and dynamics that shape patient–provider interactions in high HIV prevalence and limited-resource settings. Drawing on qualitative research from five sub-Saharan African countries, the authors seek to unpack local dynamics that serve to hinder or facilitate productive patient–provider interactions. This qualitative study, conducted in Kisumu (Kenya), Kisesa (Tanzania), Manicaland (Zimbabwe), Karonga (Malawi) and uMkhanyakude (South Africa), draws upon 278 in-depth interviews with purposively sampled people living with HIV with different diagnosis and treatment histories, 29 family members of people who died due to HIV and 38 HIV healthcare workers. Data were collected using topic guides that explored patient testing and antiretroviral therapy treatment journeys. The authors analysis revealed an array of inter-related contextual factors and power dynamics shaping patient–provider interactions. These included participants’ perceptions of roles and identities of ‘self’ and ‘other’; conformity or resistance to the ‘rules of HIV service engagement’ and a ‘patient-persona’; the influence of significant others’ views on service provision; and resources in health services. They observed that these four factors/dynamics were located in the wider context of conceptualisations of power, autonomy and structure. They argue that patient–provider interaction is complex, multidimensional and deeply embedded in wider social dynamics, and that interventions to improve patient experiences and treatment adherence through enhanced interactions need to go beyond the existing focus on patient–provider communication strategies.

9. Public-Private Mix

Commercial determinants of health - the role of governments remains crucial
The Graduate Institute: GI, Geneva, 2017

A multi stakeholder panel on “Governing Non-Communicable Diseases - Addressing the Commercial Determinants of Health” was held as a side-event during the 70th session of the World Health Assembly. It explored the commercial determinants of health, their links to the political determinants of health and how to navigate the narrow space to create both health and wealth, not just the latter at the expense of the first. The panel identified that government has a central role in taking the lead in policy formulation and in creating a political space for this. Rocco Renaldi from the International Food and Beverage Alliance highlighted the need for governments to create a regulated space and to encourage systemic change within the private sector which will allow them to adjust their strategies to meet the challenge. of chronic conditions. NCD Alliance Executive Director Katie Dain raised in contrast that the private sector has no role in policy development as this remains the responsibility of governments. The event made a case for enhanced engagement between different sectors of government to build systems of accountability, monitoring and implementation to manage the private sector in health.

10. Resource allocation and health financing

A Political Economy Analysis of Domestic Resource Mobilization in Uganda
Kjær A; Ulriksen M; Kangave J; Katusiimeh M: United Nations Research Institute for Social Development WP 2017-8, Geneva, 2017

This synthesis paper brings together the research findings from four papers prepared by the Uganda team in the UNRISD Politics of Domestic Resource Mobilisation for Social Development project. It addresses three broad themes: bargaining and contestation, key relations, and institution building with regard to mobilising resources for social development. The authors analyse how political economy factors affect revenue raising and social spending priorities in Uganda. It applies a political settlement theory, exploring revenue bargaining or political negotiations that shape revenue mobilisation, revenue composition and policy priorities guiding revenue allocation. The authors focus on three instances of revenue bargains: legislative tax reform, institutional performance of the revenue agencies, and policy making. The first two instances relate to the actual mobilisation of resources, whereas the third example focuses on bargains over spending priorities within a given revenue base. The findings indicate that in Uganda, a low-income country with competing political factions, there are specific challenges to mobilising resources for social development. The need to maintain political power is argued by the authors to have led to reduced tax intakes as taxes levied on rural voters are abolished and tax exemptions introduced for powerful supporters. On the spending side, social development concerns are argued to compete with other public policy areas as well as the pressure to allocate resources for political purposes.

Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries
Stenberg K; Hanssen O; Edejer T; et al.: The Lancet Global Health 5(9), e875-e887, 2017

No estimates of the additional resources needed to strengthen comprehensive health service delivery towards the attainment of SDG 3 and universal health coverage in low-income and middle-income countries have been published. The authors developed a framework for health systems strengthening, within which population-level and individual-level health service coverage is gradually scaled up over time. They developed projections for 67 low-income and middle-income countries from 2016 to 2030, representing 95% of the total population in low-income and middle-income countries. The authors considered four service delivery platforms, and modeled two scenarios with differing levels of ambition: a progress scenario, in which countries' advancement towards global targets is constrained by their health system's assumed absorptive capacity, and an ambitious scenario, in which most countries attain the global targets. They estimated the associated costs and health effects, including reduced prevalence of illness, lives saved, and increases in life expectancy. They projected available funding by country and year, taking into account economic growth and anticipated allocation towards the health sector, to allow for an analysis of affordability and financial sustainability. The authors estimate that an additional $274 billion spending on health is needed per year by 2030 to make progress towards the SDG 3 targets (progress scenario), whereas US$371 billion would be needed to reach health system targets in the ambitious scenario—the equivalent of an additional $41 or $58 per person, respectively, by the final years of scale-up. In the ambitious scenario, total health-care spending would increase to a population-weighted mean of $271 per person across country contexts, and the share of gross domestic product spent on health would increase to a mean of 7.5%. Around 75% of costs are for health systems, with health workforce and infrastructure (including medical equipment) as the main cost drivers. Despite projected increases in health spending, a financing gap of $20–54 billion per year is projected. Should funds be made available and used as planned, the ambitious scenario would save 97 million lives and significantly increase life expectancy by 3.1–8.4 years, depending on the country profile. All countries will need to strengthen investments in health systems to expand service provision in order to reach SDG 3 health targets, but even the poorest can reach some level of universality. In view of anticipated resource constraints, each country will need to prioritise equitably, plan strategically, and cost realistically its own path towards SDG 3 and universal health coverage.

Zimbabwe Parliament To Boycott 2018 Budget Unless It Meets Abuja Target
: Pembere K: Health Times, 11 October 2017

The Zimbabwe Parliamentary Portfolio committee on Health says it will not entertain a flimsy allocation of funds to the health sector in the forthcoming 2018 budget presentation unless the 15% Abuja target is met. Zimbabwe is a signatory to the Abuja Declaration of 2001 in which African Union countries pledged to allocate at least 15 percent of their annual budgets to improving the health sector. Since then, the country is yet to meet the target. In the 2017 budget, the health sector only got 7 percent of total government spending. Non state organisations expect the treasury to meet the Abuja declaration which states that 15 percent of the National budget should be dedicated to health to show commitment to ensuring a healthy and productive nation. Presenting the 2017 national budget, the then Finance and Economic Development Minister Patrick Chinamasa announced that $281,9 million will be channeled towards the sector inclusive of remuneration for the public health care personnel ($223 million), operations and maintenance ($29,6 million), as well as capital expenditure that has been pegged at $29,5 million. Binga North MP Prince Dubeko Sibanda sharing his experience in Uganda learnt that if a budget ignores the plight of the marginalized it doesn’t get Parliamentary approval to be passed. “One thing I took in Uganda, they have got a law which says unless the budget meets certain criteria or takes care of people that are generally marginalized that budget should not be passed. Its part and parcel of their law. Its never passed,” the parliamentarian said.

Zimbabwe's public sector health spending one of the lowest in SADC
Langa V: NewsDay October 2017

Zimbabwe government spending towards health this year averaged US$21 per person, lower than 2016 levels, the Community Working Group on Health (CWGH), in Zimbabwe, said in its contribution to the 2018 National Budget consultations. CWGH said the per capita allocation towards health is one of the lowest in the Southern African Development Community (SADC) region whose average spending on health per person is $146. CWGH raised concerns about the total budget allocation to health, which has remained lower than the 15% of the total budget committed to in the Abuja Declaration. The CWGH said Zimbabwe has made significant gains in the area of HIV prevalence, child and maternal mortality, but noted an over-dependence on external funding, poor infrastructure and ill-equipped hospitals, as well as a worrying ratio of patients to health personnel. The CWGH observed that Zimbabwe relies heavily on imports for drugs, equipment and other hospital consumables, and called for government to broaden the tax base to fund health.

“If donors woke up tomorrow and said we can't fund you, what would we do?” A health system dynamics analysis of implementation of PMTCT option B+ in Uganda
Doherty T; Besada D; Goga A; Daviaud E; Rohde S; Raphaely N: Globalisation and Health 13(51) 2017

In October 2012 Uganda extended its prevention of mother to child HIV transmission (PMTCT) policy to Option B+, providing lifelong antiretroviral treatment for HIV positive pregnant and breastfeeding women. The rapid changes in and adoption of new PMTCT policies are argued by the authors to have not been accompanied by research to explore health system preparedness to implement such programmes. The implementation of Option B+ provides many lessons which can inform the shift to ‘Universal Test and Treat’, a policy which many sub-Saharan African countries are preparing to adopt, despite fragile health systems. This qualitative study of PMTCT Option B+ implementation in Uganda three years following the policy adoption, uses the health system dynamics framework to explore the impacts of this programme on ten elements of the health system. Qualitative data were gathered through rapid appraisal during in-country field work. Key informant interviews and focus group discussions (FGDs) were undertaken with the Ministry of Health, implementing partners, multilateral agencies, district management teams, facility-based health workers and community cadres. The authors conducted a simple manifest analysis, using the ten elements of a health system for grouping data into categories and themes. Of the ten elements in the health system dynamics framework, context and resources (finances, infrastructure and supplies, and human resources) were the most influential in the implementation of Option B+ in Uganda. Support from international actors and implementing partners attempted to strengthen resources at district level, but had unintended consequences of creating dependence and uncertainty regarding sustainability. The health system dynamics framework is argued to offer a novel approach to analysis of the effects of implementation of a new policy on critical elements of the health system. Its emphasis on relationships between system elements, population and context is helpful in unpacking impacts of and reactions to pressures on the system, which adds value beyond some previous frameworks.

11. Equity and HIV/AIDS

Socioeconomic differences in mortality in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: a population surveillance analysis
Kabudula C; Houle B; Collinson M; et al.: The Lancet Global Health 5(9) doi: https://doi.org/10.1016/S2214-109X(17)30297-8, 2017

The authors assessed socioeconomic disparities in mortality indicators in a rural South African population over the period 2001–13 using data from 21 villages of the Agincourt Health and socio-Demographic Surveillance System (HDSS). They calculated the probabilities of death from birth to age 5 years and from age 15 to 60 years, life expectancy at birth, and cause-specific and age-specific mortality by sex (not in children <5 years), time period, and socioeconomic status (household wealth) quintile for HIV/AIDS and tuberculosis, other communicable diseases (excluding HIV/AIDS and tuberculosis) and maternal, perinatal, and nutritional causes, non-communicable diseases, and injury. They quantified differences with relative risk ratios and relative and slope indices of inequality. The authors found significant socioeconomic status gradients for mortality and life expectancy at birth, with outcomes improving with increasing socioeconomic status. An inverse relation was seen for HIV/AIDS and tuberculosis mortality and socioeconomic status that persisted from 2001 to 2013. Deaths from non-communicable diseases increased over time in both sexes, and injury was an important cause of death in men and boys. Neither of these causes of death, however, showed consistent significant associations with household socioeconomic status. The poorest people in the population continue to bear a high burden of HIV/AIDS and tuberculosis mortality, despite free antiretroviral therapy being made available from public health facilities. They argue that integrated strategies are needed to improve access to and uptake of HIV testing, care, and treatment, and management of non-communicable diseases in the poorest populations.

Understanding the relationship between couple dynamics and engagement with HIV care services: insights from a qualitative study in Eastern and Southern Africa
Wamoyi J; Renju J; Moshabela M, et al.: Sexually Transmitted Infections, 93(Issue Supplement 3), doi: http://dx.doi.org/10.1136/sextrans-2016-052976, 2017

This paper explores the interplay between couple dynamics and the engagement of people living with HIV (PLHIV) with HIV care and treatment services in three health and demographic surveillance sites in Tanzania, Malawi and South Africa. A qualitative study was conducted involving 107 in-depth interviews with PLHIV with a range of HIV care and treatment histories, including current users of HIV clinics, and people not enrolled in HIV care. Interviews explored experiences of living with HIV and how and why they chose to engage or not with HIV services. The authors found an interplay between couple dynamics and HIV care and treatment-seeking behaviour in the three countries. Being in a relationship impacted on the level and type of engagement with HIV services in multiple ways. In some instances, couples living with HIV supported each other which improved their engagement with care and strengthened their relationships. The desire to fulfil societal expectations and attract a new partner, or have a baby with a new partner, or to receive emotional or financial support, strengthened on-going engagement with HIV care and treatment. However, fear of blame, abandonment or abuse resulted in unwillingness to disclose and often led to disputes or discord between couples. There was little evidence of intra-couple understanding of each other’s lived experiences with HIV, and the authors found that couples rarely interacted with the formal health system together. Couple dynamics influenced engagement with HIV testing, care and treatment for both partners through a myriad of pathways. The authors propose that couple-friendly approaches to HIV care and treatment move beyond individualised care and which recognise partner roles in HIV care engagement.

12. Governance and participation in health

“We are toothless and hanging, but optimistic”: sub county managers’ experiences of rapid devolution in coastal Kenya
Nyikuri M; Tsofa B, Okoth P; et al.: International Journal for Equity in Health 16(113)1-11, 2017

This study presents qualitative research to examine the early experiences of devolution in the health sector in Kenya in March 2013. The authors observed a diverse range of management meetings, support supervision visits and outreach activities involving sub-county managers between May 2013 and June 2015, and conducted interviews with purposively selected sub-county managers from three sub-counties. The authors found that sub county managers as with many other health system actors were anxious about and ill-prepared for the unexpectedly rapid devolution of health functions to the newly created county government. They experienced loss of autonomy and resources and confused lines of accountability within the health system. The study illustrates the importance in accelerated devolution contexts for: mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system; clear lines of communication during reforms to these actors and anticipating and managing the effect of change on intangible software issues such as trust and motivation. More broadly, the authors show the value of examining organisational change from the perspective of key actors within the system, and highlight the importance in times of rapid change of drawing upon and working with those already in the system. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained capacity building within the health system.

13. Monitoring equity and research policy

Research priority setting for integrated early child development and violence prevention (ECD+) in low and middle income countries: An expert opinion exercise
Tomlinson M; Jordans M; MacMillan H; et al.: Jo Child Abuse Negligence 72,131-139, 2017

Reducing children's exposure to harmful events and violence is essential for early childhood development. The authors used the Child Health and Nutrition Initiative method for the setting of research priorities in integrated early childhood development and violence prevention programs. An expert group was identified and invited to systematically list and score research questions. A total of 186 stakeholders were asked to contribute five research questions each, and contributions were received from 81 respondents. These were subsequently evaluated using a set of five criteria: answerability; effectiveness; feasibility and/or affordability; applicability and impact; and equity. Of the 400 questions generated, a composite group of 50 were scored by 55 respondents. The highest scoring research questions related to the training of community health workers to deliver early childhood development and violence prevention programs interventions effectively and whether these interventions could be integrated within existing delivery platforms such as HIV, nutrition or mental health platforms. The findings from this research priority setting exercise is argued to potentially help guide funders and others towards funding priorities for important future research related to early childhood development and violence prevention.

The SWPER index for women’s empowerment in Africa: development and validation of an index based on survey data
Ewerling F; Lynch J; Victora C; van Eerdewijk A; Tyszler M; Barros A: Lancet Global Health 5(9) e916-e923, 2017

The Sustainable Development Goals strongly focus on equity. Goal 5 explicitly aims to empower all women and girls, reinforcing the need to have a reliable indicator to track progress. This study developed a novel women’s empowerment indicator from widely available data sources, broadening opportunities for monitoring and research on women’s empowerment. The authors used Demographic and Health Survey data from 34 African countries, targeting currently partnered women. They identified items related to women’s empowerment present in most surveys, and used principal component analysis to extract the components. The authors carried out a convergent validation process using coverage of three health interventions as outcomes; and an external validation process by analysing correlations with the Gender Development Index. Findings 15 items related to women’s empowerment were selected. They retained three components (50% of total variation) which, after rotation, were identified as three dimensions of empowerment: attitude to violence, social independence, and decision making. All dimensions had moderate to high correlation with the Gender Development Index. Social independence was associated with higher coverage of maternal and child interventions; attitude to violence and decision making were more consistently associated with the use of modern contraception. Interpretation The index, named Survey-based Women’s emPowERment index, is argued to have the potential to widen the research on women’s empowerment and to give a better estimate of its effect on health interventions and outcomes. It allows within-country and between-country comparison, as well as time trend analysis, which no other survey based index provides.

14. Useful Resources

Africa Region webinar on “how to submit a successful organised session abstract”
Thursday 9 November 2017, 10:00 - 11:30 UTC

The Health Systems Global Africa Region webinar on “how to submit a successful organised session abstract” will be to offer 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). The webinar will give 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. Perspectives from the Programme Working Group on the symposium theme and what the Scientific Committee will be looking for in strong abstracts will be shared, as will the experiences of those who have successfully had their organised session abstracts accepted at previous global symposia.

15. Jobs and Announcements

9th Alternative Mining Indaba
5th to 7th February 2018, Double Tree by Hilton Upper East Side Hotel Cape Town.

The 9th Alternative Mining Indaba will be held under the theme Making Natural Resources Work for the People: Towards Just Legal, Policy and Institutional Reforms. Attracting several hundred SADC and wider community representatives, civil society organizations, and multi-lateral organizations and other stakeholders it provides a forum to actively participate in discussing and providing viable recommendations for the future of natural resource extraction in Africa. Registration will be opening soon.

Call for abstracts - Fifth Global Symposium on Health Systems Research
Deadline for organised session abstracts 15 January 2018

The call for abstracts for the Fifth Global Symposium on Health Systems Research is now open. The Fifth Global Symposium on Health Systems Research will take place in Liverpool, UK, on 8-12 October 2018. The Fifth Global Symposium will advance conversations and collaborations on new ways of financing health, delivering services and engaging the health workforce, new social and political alliances, and new applications of technologies to promote health for all. Within the overarching Symposium theme, we welcome abstracts linked to the following four sub-themes: 1. The SDGs as a stimulus for renewed multisectoral action; 2. Polemic and pragmatism: engaging the private sector in moving towards universal health coverage; 3. Leaving no one behind: health systems that deliver for all and 4. Community health systems – where community needs are located, but often the invisible level of health systems. The deadline for organized session proposals is the 15 January, 2018 and the deadline for individual abstracts is 5 March, 2018.

Commons:Wiki Loves Africa 2017/en
Wikimedia Commons: Wikimedia, October 2017

Wiki Loves Africa is an annual contest where anyone across Africa can contribute media that relates to that year's theme to Wikimedia Commons for use on Wikipedia and other project websites of the Wikimedia Foundation. Wiki Loves Africa encourages participants to contribute media (photographs, video and audio) that illustrate the specific theme for that year. Each year the theme changes and is chosen by the community from universal, visually-rich and culturally-specific topics (for example, markets, rites of passage, festivals, public art, cuisine, natural history, urbanity, daily life, notable persons, etc). This year's photo contest is being held under the theme ... People at Work. It invites photographs that document all manner of occupations that are undertaken across the African continent - formal and informal, contemporary or ancient, business-oriented or creative. There are two special prizes for photo essays that capture Women Working or Rare, Fading or Threatened Traditional Crafts, Styles or Way of Working. The competition starts on 1st October 2017 and closes on 30th November 2017. Winners will be announced around February 2018.

Mistra Urban Futures Annual International Conference 2017
13 – 15 November, Imperial Hotel Kisumu, Kisumu, Kenya

Mistra Urban Futures Annual International Conference is taking place from 13 to 15 November 2017 in Kisumu, Kenya under the banner "Realising Just Cities - Learning Through Comparison". The rapidly growing number of people moving into cities all over the world also present a challenge of unprecedented size. It is crucial to find ways to make urbanisation a source for wealth, health and sustainability – which is shared. Mistra Urban Futures arranges yearly a conference about Realising Just Cities. This year’s conference focuses on learning through comparison covering themes such as transportation, urban food, waste management, migration, participatory cities, neighbourhood transformation and cultural heritage.

Paradigm Shift: South Africa Regional Partnerships Coordinator
Closing date: 11 November, 2017

The Paradigm Shift Programme is a holistic, economic development outreach tool that connects business men and women within the church to micro entrepreneurs in poor communities. Paradigm Shift seeks to appoint a Regional Partnerships Coordinator to be based in South Africa. This position is part-time, and can be fulfilled working remotely but with frequent teleconferencing and face-to-face meetings built in. The responsibilities include managing communication between volunteer teams and Paradigm Shift, ensuring the training and coaching of Point Persons, creating and executing strategic plans for national expansion, new partnership development and communications. The post requires a minimum of a Bachelor’s Degree, demonstrated expertise in key areas mentioned in job description, interpersonal, written and verbal communication skills and experience of working with people working their way out of poverty.

Tanzania Country Director and Clinical Training Project Manager
SolidarMed: Closing date: Thursday, 30 November, 2017

SolidarMed is a leading non-profit organization working to improve the health of people in rural Sub Saharan Africa. This position comprises both the management of the project “Support to Edgar Maranta School of Nursing” and the coordination of the country program. It is a fixed term appointment based in Ifakara, Tanzania to start as soon as possible, with a certain flexibility. The key responsibilities include coordination, monitoring, budgeting, reporting and annual planning of the country program and providing strategic and public health guidance and leadership to the program. An advanced degree in health and a Master in Public Health, good understanding and clinical experience of issues related to maternal and child health, and infectious diseases such as HIV, TB and malaria are required. Experience in a public health context in Sub-Saharan Africa, ideally at district level, sound knowledge and experience of management and administration and good writing and reporting skills (in English) and basic Kiswahili are required.

The Demographic and Health Surveys Fellows Program
Deadline for Submissions: 10 November, 2017

The Demographic and Health Surveys (DHS) Fellows Program aims to increase capacity of university faculty from DHS countries and to build long-term institutional sustainability for universities to train students and faculty to further analyze DHS data. The Program provides intensive mentorship to teams of three university faculty members that are selected on a competitive basis from four to six universities every year. The fellowship includes two separate workshops and preparation of publication-quality research papers with mentoring from DHS Program researchers. In addition to original research projects, fellows are also required to design and implement a range of internal capacity strengthening activities at their home universities.

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