When leaders at the 2015 G7 summit called the 2014 Ebola epidemic ‘a wake-up call for all of us’ they acknowledged that the global response had been too slow, with inadequate health leadership, coordination and emergency funding. At the same time, as argued in the May 2016 editorial in the newsletter, emergency responses cannot be delinked from the strength and authority of health systems to prevent, detect and respond to emerging public health threats, nor to their power to engage sectors on their role in the economic, social, environmental, trade and other determinants of these threats. Shortfalls in public health capacities, including those set in the 2005 International Health Regulations (IHRs) are a warning sign of future outbreaks, often due to neglected diseases or public health risks that get inadequate attention or resources until they trigger large-scale and highly expensive outbreaks.
The two new global financing mechanisms introduced in 2015 to support health emergency responses are thus important additional resources. These are the World Health Organisation (WHO)’s Contingency Fund for Emergencies (CFE) and the World Bank’s Pandemic Emergency Facility (PEF).
The CFE emerged from discussions on the IHRs and was adopted at the 2015 World Health Assembly. It aims to fill the gap from the first 72 hours of a declared health emergency until resources from other financing mechanisms begin to flow. It covers all countries regardless of income to prevent events that have substantial public health consequences. As defined in the IHR, these may be due to infectious agents, chemicals, radiation, food safety or other hazards that can escalate into a public health emergency of international concern. The fund is triggered by national request and the level of funding is decided on a case-by-case basis from a $100m fund. It can support personnel; information technology and information systems; medical supplies; and field and local government support. To date, the CFE has disbursed $8.5 million for interventions related to the Zika virus in South America, on yellow fever in central Africa, and drought related food insecurity in Asia.
The 2015 G7, indicating reasons of accountability and effectiveness, located the PEF at the World Bank. It is currently being finalized for launch at the end of 2016, uniquely as an insurance mechanism rather than a grant fund, to support follow up measures in emergencies after initial funding, such as from CFE. It is only focused on infectious disease outbreaks that could become cross border epidemics. Unlike the CFE, only low income countries are eligible for PEF financing. Funds are provided through two delivery windows: an insurance mechanism for up to $500 million per outbreak, and a cash injection between $50 and $100 million. The disbursement criteria are yet to be clarified. The World Bank expresses its anticipation that an insurance model will bring ‘greater discipline and rigor to pandemic preparedness and incentivize better pandemic response planning’, including by building ‘better core public health capabilities for disease surveillance and health systems strengthening, toward universal health coverage’. However it is both ambiguous and problematic that the PEF is yet to state the specific measures for supporting and measuring these aims.
Although born from different governance processes, the two funds do have some links. For example, the CFE intends to be a first response and the PEF a subsequent deeper resource package. They make reference to one another, recognizing the need to interact for coherence of emergency responses.
However, only the CFE has a formal relationship with the IHRs and its core capacities, only the CFE is universal in coverage of all countries, comprehensive in addressing the full spectrum of cross border public health risks enumerated in the IHRs, including radiation, chemical and other risks, and only the CFE is managed under intergovernmental funding rules and institutional frameworks, with explicit support for system functions such as health information, planning and health worker mobilization.
It is not clear why the PEF seemingly circumnavigates the institutional and intergovernmental mechanisms of the IHRs. Two explanations stand out: Firstly, the PEF is a product of G7 processes, which similar to the establishment of the Global Fund in 2000, have supported funds that are independent of WHO governance processes. Secondly the PEF seeks to create an insurance market that will incentivize certain health system conditions to access the funds. The funding mechanism involves reinsurance and proceeds of ‘catastrophe bonds’ (capital-at-risk notes) issued by the International Bank for Reconstruction and Development purchased by insurance-linked securities and catastrophe bond investors, with development partners and international agencies covering the cost of the premiums and bond coupons. As a new financing mechanism drawing in development funds the trigger criteria for funding and reforms to be incentivized, as yet unstated, need to be carefully reviewed.
G7 countries are presently encouraging G20 countries to financially back the PEF and its insurance agenda this September in Hangzhou. But what of the CFE? It covers a wider spectrum of public health risks, fits most comfortably within the IHR framework and aligns more clearly with efforts to strengthen core IHR capacities and national response plans. How far will the PEF, despite its role to fund the ‘deeper’ response, strengthen the health systems to be more effective in detecting and responding to emergencies, and even more importantly in preventing them. How will the PEF explicitly strengthen capacities for the IHR, provide direct funding support for system capacities and align with existing national plans and intergovernmental frameworks? How far will both funds strengthen the community literacy, networks and capacities and the primary health care systems that are needed for effective prevention, preparedness and containment, or link with the rising mobilization of resources and personnel from within Africa, noting the significant role these played in the last major Ebola epidemic.
The addition of new global resources for managing public health are welcome. However, global measures need to reach beyond measures for surveillance and containment if they are to stretch beyond a remedial securitization of global health. Securing health calls for local, national and regional capacities for and global investment in systems that can identify, prepare for, prevent and manage significant public health risks, and for a re-invigorated public health authority and capability to mobilise attention to those communities and action on those key determinants of health that are often ignored, until the onset of such mass scale events.
Please see the full brief at http://tinyurl.com/jsgsgnh and send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: firstname.lastname@example.org.
2. Latest Equinet Updates
EQUINET is saddened by the news of the passing of Doctor TJ Ngulube, a long-time colleague in EQUINET, director of the Center For Health Science and Social Science Research in Zambia and significant contributor to EQUINETs early work on social participation in health, on parliamentary roles and equitable health systems. Colleagues in EQUINET have noted memories of TJ’s warmth, wisdom and friendship; his leadership and his consistent contribution to work in the region. We send sympathies to his family and colleagues and are the poorer for his passing.
This participatory skills session convened under the umbrella of the pra4equity network is being held at the Heath System Global Conference. In the session we will discusses methods and tools to build learning from action as a key element of participatory action research, directly engaging affected communities to build responsive health systems. The session draws on approaches and experience from Africa, Latin America and participants globally to discuss the methods/tools, their application and their integration in health systems. From prior global symposia, methods for learning from action were identified as weak in PAR practice. This session seeks to address this gap. It is targeted at researchers and practitioners. It uses methods resources and group discussions of case studies from health managers, policy actors, civil society and researchers in low and middle income countries to discuss the participatory processes and methods for learning from action at different levels, and the issues in applying and institutionalising these methods. We will also review what these participatory efforts to transform and build knowledge on health systems implies for the understanding of ‘resilience’.
3. Equity in Health
In 2010, the UN’s Population Division predicted that the African continent, the population of which is now 1·2 billion, will have 3·5 billion people by the year 2100. By 2015, the projection for the year 2100 had risen to 4·4 billion. In many ways this is good news for Africa—the population increase reflects impressive progress in reducing mortality, especially child mortality, and improving life expectancy. But the response to the news in developed countries has been of concern, often turning into panic. John Bongaarts, vice president of the Population Council, warned that “Most of these people are going to end up in slums. That’s not good news.” Mertule Mariam said: “Alarmingly, population growth in Africa is not slowing as quickly as demographers had expected...the number of Africans seeking a better life in Europe and other richer places is likely to increase several times over”. These reactions have revived discussions in developed countries on what should be done to alleviate the apparent crisis. Policy prescriptions in developed countries focus on family planning services and education of girls. The author argues that these recommendations might be sensible, but if Africans do not take the lead in framing the population discourse, their motivations and needs could be overlooked. New policies must consider African development. An African-led response to population change might begin with efforts to establish the size of the population Africa wants, in the context of broader developmental ambitions. Rather than being dictated by fears in developed countries of mass emigration, conflict, and environmental destruction, such a strategy would be based on the needs of African people. As well as national objectives, a continent-wide perspective on population goals led by the African Union, might be useful. Just as many of the drivers of population change are pan-national (eg, armed conflict, environmental damage, or economic pressures), so are some of its results. In consultation with their people, African Governments will no doubt propose further population policies that are closely tailored to the needs of their societies. What is important, the author poses, is that these objectives and policies are established by Africans.
The global health situation is facing many critical challenges, and multiple actions must be taken urgently to prevent crises from boiling over. This paper reflects on the 2016 World Health Assembly (WHA) as the world’s prime public health event, attended by 3,500 delegates, including Health Ministers from most of the 194 countries.World Health Organisation director-general Dr Margaret Chan gave an overview of what went right and what is missing in global health. 19,000 fewer children dying every day, a 44% drop in maternal mortality, the 85% cure rate for tuberculosis, and 15 million people living with HIV now receiving therapy, up from just 690,000 in 2000. Chan also described how health has become a globalised problem, with air pollution becoming a transboundary health hazard, and drug-resistant pathogens being spread through travel and food trade. The recent Ebola and Zika outbreaks showed how global health emergencies can quickly develop. The world is not prepared to cope with the dramatic resurgence of emerging and re-emerging infectious diseases. Chan said the global health landscape is being shaped by three slow-motion disasters: climate change, antimicrobial resistance and the rise of chronic non-communicable diseases. The assembly agreed that the WHO set up a new Health Emergencies Programme to enable it to give rapid support to countries and communities to prepare for, face or recover from emergencies caused by health hazards including disease outbreaks, disasters and conflicts. On anti-microbial resistance, many developing countries stressed the importance of funds and technology to help them develop national action plans by 2017. The WHA called on the WHO to develop an implementation plan and urged governments to develop national policies on marketing unhealthy foods to children. Two environment-related health issues were discussed. Air pollution accounts for eight million deaths worldwide annually – 4.3 million due to indoor and 3.7 million to outdoor air pollution. The assembly welcomed a new WHO road map for actions in 2016-19 to tackle the health effects of air pollution. A controversial issue is how the WHO should relate to “non-state actors”. After two years of negotiations, the WHA adopted the Framework of Engagement with Non-State Actors (FENSA), which provides the WHO with policies and procedures on engaging with non-governmental organisations, private sector entities, philanthropic foundations and academic institutions.
Vision impairment is a leading cause of disability, and a barriers to access education and employment, which may force people into poverty. This study determined the prevalence of self-reported vision difficulties as an indicator of vision impairment in economically disadvantaged regions in South Africa, and to examine the relationship between self-reported vision difficulties and socio-economic markers of poverty, namely, income, education and health service needs. A cross-sectional study was conducted in 27 economically disadvantaged districts (74901 respondents) to collect data from households on poverty and health, including vision difficulty. As visual acuity measurements were not conducted, the researchers used the term vision difficulty as an indicator of vision impairment. The prevalence of self-reported vision difficulty was 11.2%. More women (12.7%) compared to men (9.5%) self-reported vision difficulty (p < 0.01). Self-reported vision difficulty was higher (14.2%) for respondents that do not spend any money. A statistically significant relationship was found between the highest level of education and self-reporting of vision difficulty; as completed highest level of education increased, self-reporting of vision difficulty became lower (p < 0.01). A significantly higher prevalence of self-reported vision difficulty was found in respondents who are employed (p < 0.01). The evidence from this study suggests associations between socio-economic factors and vision difficulties that have a two-fold relationship (some factors such as education, and access to eye health services are associated with vision difficulty whilst vision difficulty may trap people in their current poverty or deepen their poverty status).
4. Values, Policies and Rights
This new report by the Center for Health, Human Rights and Development (CEHURD). “Facing Uganda’s Law on Abortion: Experiences from Women and Service Providers” raises that an unclear abortion law in Uganda means that women and adolescents seek unsafe abortions and are vilified by their families and communities, with doctors and health workers who provide legal post-abortion care being arrested. This report highlights experiences and perspectives of individuals who have been affected by or have dealt with abortion. It includes interviews with women and girls who ended pregnancies, as well as doctors, nurses, health worker, lawyers, police and community members. Abortion in Uganda is legal in limited circumstances, yet approximately 85,000 women each year receive treatment for complications from unsafe abortion and an additional 65,000 women experience complications but do not seek medical treatment. The CEHURD report also draws on a research report by the Center for Reproductive Rights in 2012 on Uganda’s laws and policies on termination of pregnancy that found that the laws and policies are more expansive than most believe, and that Uganda has ample opportunity to increase access to safe abortion services.
The right to health has been enshrined in a number of core international and regional human rights treaties, to which WHO African Region Member States are signatories. This therefore imposes an obligation on them to make every possible effort using available resources to respect, protect, fulfil and promote the right to health of their citizens. This study analysed key issues and challenges affecting the realisation of the right to health in African countries. A survey questionnaire was sent by email to the then 46 Member States in the African Region through the WHO Country Representatives, and explored legal, policy and institutional aspects that affect the realisation of the right to health and the main health related human rights issues, and challenges in implementing the right to health. Twenty-five (54%) countries responded. The main findings were that all countries were signatories to at least one human rights treaty that recognises the right to health; all countries had national legislation touching on aspects of the right to health but only 12 countries (48%) had policies or strategies for mainstreaming human rights in healthcare. On issues affecting the realisation of the right to health: 88% identified access to health care services, medical products, and technologies; 52% identified inadequate financing for health; 28% cited marginalisation, stigma and discrimination of some groups and communities; and 24% cited gender-related inequities and violations. Lack of awareness of the right by the general population and health workers was cited by 52% of the respondents. A lot remains to be done towards the realisation of the right to health in the African Region. Member States are encouraged to review their legislation and policies to assess their consistency with human rights standards, and put in place institutional mechanisms and adequate resources that will ensure their implementation, enforcement and monitoring.
Established under Section 25 of the HIV Prevention and Control Act of 2006, the HIV and AIDS Tribunal of Kenya is the only HIV-specific statutory body in the world with the mandate to adjudicate cases relating to violations of HIV-related human rights. Yet, very limited research has been done on this tribunal. Based on findings from a desk research and semi-structured interviews of key informants conducted in Kenya, this article analyses the composition, mandate, procedures, practice, and cases of the tribunal with the aim to appreciate its contribution to the advancement of human rights in the context of HIV. It concludes that, after a sluggish start, the HIV and AIDS Tribunal of Kenya is now keeping its promise to advance the human rights of people living with and affected by HIV in Kenya, notably through addressing barriers to access to justice, swift ruling, and purposeful application of the law. The article, however, highlights various challenges still affecting the tribunal and its effectiveness, and cautions about the replication of this model in other jurisdictions without a full appraisal.
5. Health equity in economic and trade policies
A detailed new database provides information on Chinese loans to African governments and state-owned enterprises (SOEs). Started in 2007 the database details a total of $86.9 billion of Chinese loans from 2000 to 2014, with the loans verified on the ground or with relevant stakeholders and cross-checked the data in multiple languages. This paper reports five initial lessons that emerge from the endeavour. Media perceptions of Africa-China relations tend to emphasise high sums of money going from China to Africa – such as reports that $1 trillion in Chinese financing destined for Africa by 2025 – but the reality appears far more modest. According to the database, China loaned $86.9 billion to African governments and SOEs from 2000 to 2014. Although the average value of Chinese loans to Africa from 2000-14 may be just $6.2 billion/year, this number has been growing in recent years. While China is sometimes portrayed as only being interested in Africa’s natural riches, the data paints a more complex picture. 28% of Chinese financing goes to transport; 20% to energy; and 8% communication. When China’s engagement in Africa is talked about in the international media, “aid”, “loans”, “investment”, and “development finance” are often mixed up or used interchangeably. That means that whenever China offers any money to an African country, it is typically interpreted as a combination of aid and development assistance. The database avoids these conceptual confusions by focusing on loans without trying to define these as either aid or not. It tracks both concessional and commercial lines of credit extended by government, policy, and commercial banks and their corresponding suppliers/contractors. The project shows that using clearly defined categories such as loans can be a much more meaningful and unambiguous approach to understanding the impacts of Chinese money in African countries than many previous methods.
In May 2010, 192 Member States endorsed Resolution WHA63.14 to restrict the marketing of food and non-alcoholic beverage products high in saturated fats, trans fatty acids, free sugars and/or salt to children and adolescents globally. The authors examined the actions taken between 2010 and early 2016 – by civil society groups, the World Health Organization (WHO) and its regional offices, other United Nations (UN) organisations, philanthropic institutions and transnational industries – to help decrease the prevalence of obesity and diet-related non-communicable diseases among young people. By providing relevant technical and policy guidance and tools to Member States, WHO and other UN organisations have helped protect young people from the marketing of branded food and beverage products that are high in fat, sugar and/or salt. The progress achieved by the other actors the authors investigated appears variable and generally less robust. The authors suggest that the progress being made towards the full implementation of Resolution WHA63.14 would be accelerated by further restrictions on the marketing of unhealthy food and beverage products and by investing in the promotion of nutrient-dense products. This should help young people meet government-recommended dietary targets. Any effective strategies and actions should align with the goal of WHO to reduce premature mortality from non-communicable diseases by 25% by 2025 and the aim of the UN to ensure healthy lives for all by 2030.
An internal IMF report admitting the destructive nature of neoliberalism may have come too late for many African countries. The neoliberal structural adjustment programs have led to economic hardships, political instability and conflicts in most African countries where they have been implemented. The report makes three devastating conclusions: One, that the neoliberal reform program has not delivered increased economic growth. Secondly, neoliberal reforms have increased inequality. And thirdly, the increased inequality caused by neoliberal reforms has in turn undermined the level and sustainability of economic growth. The report states that the removal of barriers to capital flows, or financial openness, has often resulted in short-term speculative, so-called “hot” inflows, in developing countries. However, such speculative capital inflows to African countries are often quickly withdrawn by industrial country investors as they seek better returns elsewhere, destabilising African economies which were initial recipients of such “hot” inflows. Such speculative inflows neither boost growth nor allow the African country to share the costs of such destabilisation with the industrial countries from which speculators originate. The authors conclude that there was an increased “acceptance of controls to limit short-term debt flows that are viewed as likely to lead to – or compound – a financial crisis”. They argue that while exchange rates and financial policies could help to alleviate risks of increased financial instability, “capital controls are a viable, and sometimes the only, option when the source of an unsustainable credit boom is direct borrowing from abroad”. The report says that although high public debt is detrimental to growth and welfare, it would be better for African and developing countries to pay off their public debt over a longer time, rather than cut current productive spending needs. To lower public debt, proponents of neoliberal reforms have proposed that taxes should be raised or public spending cut, or both. If African countries do not come up with quality policies, or if they have them, but the policies are captured by corrupt elements, or half-heartedly implemented, or not implemented at all, they won’t be able to take advantage of the seeming retreat of the four-decade long globally dominant “neoliberalism”.
Conditionalities attached to loans from the World Bank and IMF were among the key negative influences on health and its social determinants between 1980 and 2000 in many of the more than 75 low- and middle-income countries in which they were applied. Best available evidence suggests that this 'neoliberal epidemics' era is not over. In the future, neoliberalism is likely to reflect the erosion of territorial divisions between core and periphery, or the global North and the global South, in the world economy. The authors write that the success of efforts to fight neoliberal epidemics and reduce health inequalities will depend on blurring boundaries: between the global and local frames of reference, and between public health practice and the politics of health. This last blurring means a return to the wisdom of Rudolf Virchow, to the effect that ‘medicine is a social science, and politics is nothing else but medicine on a large scale’. As Martin McKee and colleagues wrote in a 2012 commentary on the failure of austerity policies, ‘Virchow’s words are as relevant today as they ever were’. Understanding how to translate that insight into political action will require the development of a comparative political science of health inequalities – a critically important project that remains in its infancy.
6. Poverty and health
The Training and Research Support Centre and Zimbabwe Association of Doctors for Human Rights reported on how Participatory Action Research (PAR) was used in the Cassa Banana community to explore, analyse and take action on priority health problems faced by the community. PAR activities led to the formation of a Community Health Committee (CHC) and the development of a community action plan that prioritised lack of clean water and poor sanitation as the key health problem in the area. The work in Cassa Banana is building a body of knowledge on strategies to support community efforts to take action and on how to hold duty bearers accountable. As part of this process, in October 2015, nine community members were trained as community photographers using a PAR tool called Photovoice. The photographers took hundreds of photographs reflecting the lives and struggles in their community. They then self-edited the photographs to be included it in a 12-page advocacy booklet that described their community. It showcases challenges in the community and the community’s response to it. Some of the questions included are: Has the process of taking and using the photos deepened understanding of underlying conditions at community level? Has it changed relations and/or levels of organizing between community members (both photographers and non-photographers)? And what impact has use of the booklet had in facilitating changes in interactions with duty bearers? Cassa Banana and partners will be reflecting on these questions in the coming months.
In reflections on her fieldwork in South Africa, Asanda Benya writes about the difficulties and insights she gained while researching underground female mine-workers. Through immersive anthropological research she examined how women make sense of themselves against the masculine underground and mining culture. Some women often remarked that they were “men at work, and women at home”. They admitted to changing how they behaved in the multiple spaces they navigated. It is these shifts in women’s gender performances and identities that the study explored. To get at these gender performances and gendered identities she spent almost a year working underground as a winch operator, and a general labourer, pulling blasted rock from the stope face to the tip.
Indications of significant food supply shortages are likely to impact on the next marketing season. The rains experienced in late March and early April provided some relief to livestock farmers, but arrived too late for both staple foods and cash crops. These adverse weather conditions are likely to reduce crop production in southern Angola, Namibia, Botswana, Zimbabwe, Lesotho, Malawi, Madagascar and South Africa. The negative impact of flooding will also affect food security in Malawi, Madagascar and Mozambique. Nearly 29 million people are currently food insecure in southern Africa region mainly due to the carry-over effects of the past poor harvest season combined with other structural factors. Unless a two-track approach is quickly taken to address the current food insecurity and to establish measures to mitigate against the El Niño effects, the existing food insecurity will deepen and increase in scope with its effects will last till 2017. In July, Southern African Development Community (SADC) launched the Regional Appeal seeking US$2.7 billion.
7. Equitable health services
Cardiovascular diseases are the leading cause of death globally, killing 17.5 million people per year and 80% of deaths from these diseases occur in low- and middle-income countries. Evidence suggests that the main drivers of the global cardiovascular disease epidemic are urbanisation and industrialisation, which lead to an increase in sedentary lifestyles, unhealthy dietary patterns, tobacco consumption and increased alcohol consumption. Hypertension is a leading risk factor for cardiovascular diseases, and its prevalence is increasing worldwide – from 25% in 2000 to a projected 40% in 2025. The rising burden of hypertension in low- and middle-income countries is amplified by the public’s low levels of awareness, treatment and control of this condition, particularly among slum residents, who typically constitute a large portion of neglected urban populations in such settings. Studies in slum populations suggest that when people are made aware of having hypertension they do tend to seek care. However, the level of adherence to treatment for hypertension remains low for several reasons, including, but not limited to, the high costs of treatment and to patients’ perceptions of a low risk of cardiovascular diseases and belief in a one-time cure for disease rather than to lifelong preventive treatment and monitoring. In response to the rising burden of cardiovascular disease risk factors in slum populations in Kenya, a community-based intervention was developed and implemented in the capital city, Nairobi. This intervention, known as SCALE UP (the sustainable model for cardiovascular health by adjusting lifestyle and treatment with economic perspective in settings of urban poverty), has been described in detail elsewhere. The intervention had multiple components with the overall aim of reducing cardiovascular diseases risk through awareness campaigns, improvements in access to screening and standardised clinical management of hypertension. This paper shares experiences of implementing a comprehensive intervention for primary prevention of hypertension in a slum setting and to examine the processes, outcomes and costs of the intervention. It raises lessons for policy-makers and other stakeholders looking to implement similar interventions in highly resource-constrained settings.
Sub-Saharan Africa (SSA) communities suffer a disease burden that is aggravated by shortage of medical personnel and medical supplies such as medical devices. This paper outlines how for a long time, observation and practical experiences meant that people learned to use different plant species that led to the emergence of traditional medicine (TM) systems. The ancient Pharaonic Egyptian TM system is for example, said to be one of the oldest documented forms of TM practice in Africa and a pioneer of world’s medical science. These medical practices diffused to other continents and were accelerated by advancement of technologies while leaving Africa lagging behind in the integration of the practice in formal health-care system. The author raises issues that drag back integration, such as the lack of development of education curricula for training TM experts as the way of disseminating the traditional medical knowledge and practices. A few African countries such as Ghana have managed to integrate TM products in the National Essential Medicine List while South Africa, Sierra Leone, and Tanzania have TM products being sold over the counters due to the availability of education training programs. This paper analyses the contribution of TM practice and products in modern medicine and gives recommendations that Africa should take in the integration process to safeguard the SSA population from disease burdens.
8. Human Resources
The 2013–2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security. Chronically fragile and under-resourced health systems enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11 310 deaths (as of 5 May 2016) in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating. Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public’s lack of access to health services. Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilisation of communities when an outbreak has been identified. In this paper the authors make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems.
This study aimed to determine the knowledge, opinions and practices of healthcare workers in maternity wards in a regional hospital in Bloemfontein, Free State Province, South Africa, regarding infant feeding in the context of HIV. For this descriptive cross-sectional study, all the healthcare workers in the maternity wards of Pelonomi Regional Hospital who voluntarily gave their consent during the scheduled meetings (n = 64), were enrolled and given self-administered questionnaires. Only 14% of the respondents considered themselves to be experts in HIV and infant feeding. Approximately 97% felt that breastfeeding was an excellent feeding choice provided proper guidelines were followed. However, 10% indicated that formula feeding is the safest feeding option. 45% stated that heat-treated breast milk is a good infant feeding option; however, 29% considered it a good infant feeding option but it requires too much work. Only 6% could comprehensively explain the term “exclusive breastfeeding” as per World Health Organisation (WHO) definition. Confusion existed regarding the period for which an infant could be breastfed according to the newest WHO guidelines, with only 26% providing the correct answer. Twenty per cent reported that no risk exists for HIV transmission via breastfeeding if all the necessary guidelines are followed. Healthcare workers' knowledge did not conform favourably with the current WHO guidelines, even though these healthcare workers were actively involved in the care of patients in the maternity wards where HIV-infected mothers regularly seek counselling on infant feeding matters.
9. Public-Private Mix
This report explores evidence on the private sector in delivery of health care services for public health goals particularly in the areas of MNCH and SRH. It finds that there is a considerable body of evidence on the private provision of healthcare in low- and middle-income countries, often focusing on SSA, but that the evidence base is not robust. The arguments in favour of private healthcare suggest it is more responsive and efficient, while arguments in favour of public services suggest they are more equitable and better equipped than the market to respond to health needs. Some studies find that the private sector is unregulated, has financial incentives for inappropriate healthcare, and is expensive. There is very little evidence on the comparative cost-effectiveness of the private sector. This varies considerably across country contexts and types of services. There is no conclusive evidence that the private sector is more cost-effective or more efficient than the public sector. The literature warns that increased use of private services may crowd out or decrease the funding available to the public sector. The major criticism of private sector services is that their higher user fees create inequality of access, limiting their use by the poor. The literature is quite clear that private for-profit health services create inequality. Private non-profit, or services run by NGOs, appear to mitigate some of the inequality effects. In practice, boundaries can be blurred between public and private; both formal and informal cost recovery schemes operate at public facilities. NGOs providing healthcare are generally seen as private, although they may not charge for their services. The difference between free-at-the-point-of-use NGOs and out-of-pocket-expenditure on private doctors can be enormous, and it is important to differentiate between the types of providers when reviewing the evidence on private services.
The private sector has a large and growing role in health systems in low-income and middle-income countries. The goal of universal health coverage provides a renewed focus on taking a system perspective in designing policies to manage the private sector. This perspective requires choosing policies that will contribute to the performance of the system as a whole, rather than of any sector individually. This paper draws and extrapolates main messages from the papers in the Lancet series and additional sources to inform policy and research agendas in the context of global and country level efforts to secure universal health coverage in low-income and middle-income countries. Recognising that private providers are highly heterogeneous in terms of their size, objectives, and quality, the authors explore the types of policy that might respond appropriately to the challenges and opportunities created by four stylised private provider types: the low-quality, underqualified sector that serves poor people in many countries; not-for-profit providers that operate on a range of scales; formally registered small-to-medium private practices; and the corporate commercial hospital sector, which is growing rapidly and about which little is known.
Although the private sector is an important health-care provider in many low-income and middle-income countries, its role in progress towards universal health coverage varies. Studies of the performance of the private sector have focused on three main dimensions: quality, equity of access, and efficiency. The characteristics of patients, the structures of both the public and private sectors, and the regulation of the sector influence the types of health services delivered, and outcomes. Combined with characteristics of private providers—including their size, objectives, and technical competence—the interaction of these factors affects how the sector performs in different contexts. Changing the performance of the private sector will require interventions that target the sector as a whole, rather than individual providers alone. In particular, the performance of the private sector seems to be intrinsically linked to the structure and performance of the public sector, which suggests that deriving population benefit from the private health-care sector requires a regulatory response focused on the health-care sector as a whole.
10. Resource allocation and health financing
The author argues that the key to sustainable, adequate and predictable financing of Africa’s development no longer lies in the delivery of aid from traditional donors but largely in unlocking the domestic resource potential, so that the continent can harness more of its own revenue for development. Africa’s much celebrated growth over the last two decades has benefited in large part from public revenues derived from the sale of natural resources. While the tax base remains narrow, and tax compliance levels low on the continent, revenues from tax collection continue to increase, rising from USD 259.3 billion in 2005 to USD 527.3 billion in 2012. A 2013 study by NEPAD and UNECA shows that the fundamentals and resource potential exist for the continent to raise more financial resources domestically to implement its development programmes and finance its own institutions. At the same time, South-South Cooperation in Africa is increasing, with more public finances being channelled from emerging economies to Africa via various bilateral and multi-lateral arrangements. In contrast, there is clear evidence that Official Development Assistance (ODA) from traditional donors is dwindling – falling from 38% as a proportion of all external financial flows to Africa in 2000 to 27% in 2014. Africa’s reliance on aid and the sale of natural resources, as opposed to broad-based tax collection, for example, is argued to have distorted accountability over public expenditure, with governments incentivised to meet the needs of the extractive and commodity private sector corporations and the priorities of external funders, as opposed to those of their citizens. The author suggests that aid will achieve its best outcomes when it is used in ways that complement and bolster domestic financing, support other financing mechanisms and help African countries to better manage revenues for their citizens’ development.
Governments are being overwhelmed by the rapid growth of Africa’s cities. Strategic planning has been insufficient and the provision of basic services is worsening. Since the 1990s, widespread devolution has substantially shifted responsibility for coping with urbanisation to local authorities, yet municipal governments across Africa receive a paltry share of national income with which to discharge their responsibilities. Responsible city authorities are examining how to improve revenue generation and diversify their sources of finance. Following the creation of a sustainable development goal for cities (SDG 11), and ahead of the Habitat III summit in October 2016, this Africa Research Institute event examined some of the financing options and the urgent need for a proactive approach on the part of national and municipal governments. The speakers in the podcast include, Professor Susan Parnell Department of Environmental and Geographical Sciences, Jeremy Gorelick, Lead technical adviser, Dakar Municipal Finance Program and Dr Beacon Mbiba, Senior Lecturer, Urban Policy and International Development.
11. Equity and HIV/AIDS
The successes of HIV treatment scale-up and the availability of new prevention tools have raised hopes that the epidemic can finally be controlled and ended. Reduction in HIV incidence and control of the epidemic requires high testing rates at population levels, followed by linkage to treatment or prevention. As effective linkage strategies are identified, it becomes important to understand how these strategies work. The authors use qualitative data from The Linkages Study, a recent community intervention trial of community-based testing with linkage interventions in sub-Saharan Africa, to show how lay counselor home HIV testing and counselling (home HTC) with follow-up support leads to linkage to clinic-based HIV treatment and medical male circumcision services. They conducted 99 semi-structured individual interviews with study participants and three focus groups with 16 lay counselors in Kabwohe, Sheema District, Uganda. The participant sample included both HIV+ men and women (N=47) and HIV-uncircumcised men (N=52). Interview and focus group audio-recordings were translated and transcribed. The transcripts were analysed to identify emergent themes. Trial participants expressed interest in linking to clinic-based services at testing, but faced obstacles that eroded their initial enthusiasm. Follow-up support by lay counselors intervened to restore interest and inspire action. Together, home HTC and follow-up support improved morale, created a desire to reciprocate, and provided reassurance that services were trustworthy. In different ways, these functions built links to the health service system. They worked to strengthen individuals’ general sense of capability, while making the idea of accessing services more manageable and familiar, thus reducing linkage barriers. Home HTC with follow-up support leads to linkage by building “social bridges,”, viz: interpersonal connections established and developed through repeated face-to-face contact between counselors and prospective users of HIV treatment and male circumcision services. Social bridges are found to link communities to the service system, inspiring individuals to overcome obstacles and access care.
12. Governance and participation in health
Sustainable Development Goal Three is rightly ambitious, but achieving it will require doing global health differently. Among other things, the authors argue that progressive civil society organisations will need to be recognised and supported as vital partners in achieving the necessary transformations. The authors argue, using illustrative examples, that a robust civil society can fulfil eight essential global health functions. These include producing compelling moral arguments for action, building coalitions beyond the health sector, introducing novel policy alternatives, enhancing the legitimacy of global health initiatives and institutions, strengthening systems for health, enhancing accountability systems, mitigating the commercial determinants of health and ensuring rights-based approaches. Given that civil society activism has catalysed tremendous progress in global health, there is a need to invest in and support it as a global public good to ensure that the 2030 Agenda for Sustainable Development can be realised. Given that civil society activism has catalysed tremendous progress in global health, the authors consider civic engagement as vital to the transformation promised by the SDGs. The authors recognise the need for further research on role of CSOs in health governance at national and global levels. Many of the leading civil society organisations in global health, as well as those providing direct services, are struggling for survival, due to decreased resources. The authors suggest that this trend will have to be reversed if SDG3 is to be achieved. The historic commitment to finance civil society, made in the 2016 UN Political Declaration on Ending AIDS, recognises both the essential functions CSOs fulfil and the need to support them in doing so.
Closing space for African sexual and gender minority groups is argued by this author to affect access to critical services that no one else provides. In Kenya, for example, the Muslims of Human Rights (MUHURI) provide safe injection sites to prevent the sharing of needles among drug users, as studies show that needle sharing facilitates the spread of HIV. As a result, when the state froze the group's bank accounts, the crackdown also threatened the safety and wellbeing of people who need HIV treatment and care. To fight on their own, many GSM groups have been using the courts to help win victories. Whether it has been appealing the repressive Ugandan anti-gay law, or ordering the un-freezing of bank accounts in Kenya, or ruling against the denial of registration of LEGABIBO (an LGBT rights group in Botswana), most of these court victories are based on constitutionally guaranteed rights and freedoms of most open and democratic countries, and held under the International Declaration of Human Rights. Fostering partnerships with international organizations such as UNAIDS and the UN Human Rights Council has been very helpful for GSM organizations to facilitate their role in service access.
The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. Its potential use in health technology assessments (HTAs) has recently been identified another justification for AFR-based process guidance, but it has also raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions, the authors argue that increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. They suggest that legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and differences in evidence to arrive at a decision.
13. Monitoring equity and research policy
This research determined the quantity and quality of publications in biomedical research in top-producing countries in West Africa during 2005–14 as well as characteristics of journals and collaborative evidence in the area. Data was drawn from MEDLINE/PubMed and Google Scholar while the impact factors of the journals were retrieved from the SCImago Journal and Country Rank portal. Quantity of publications was measured by counting the number of publications attributable to a country while h-index was extracted to measure quality. Productivity was analysed by sorting the data according to their first named authors, journals and publication dates, and analysed using MS Excel and LOTKA®. Nigeria, Ghana, Senegal, Burkina Faso and Mali had the highest number of publications. In respect of productivity, apart from Côte d’Ivoire that had an α value less than 2 indicating a higher level of productivity, all other countries had an α value greater than 2. West African Journal of Medicine is the only journal of West African origin in the list of top ten journals where the authors from the sub-region published their papers, and it ranked tenth. Nigeria and Ghana published more of their research in local journals in comparison with other countries, but these journals have very low mean impact factors. This study reinforces the need for improved research production and collaboration between the big and small countries.
A functional national health research system (NHRS) is crucial in strengthening a country’s health system to promote, restore and maintain the health status of its population. Progress towards the goal of universal health coverage in the post-2015 sustainable development agenda will be difficult for African countries without strengthening of their NHRS to yield the required evidence for decision-making. This study developed a barometer to facilitate monitoring of the development and performance of NHRSs in WHOs African Region. The African national health research systems barometer algorithm was developed in response to a recommendation of the African Advisory Committee for Health Research and Development of WHO. Survey data collected from all the 47 Member States in the WHO African Region using a questionnaire were entered into an Excel spreadsheet and analysed. The barometer scores for each country were calculated and the performance interpreted according to a set of values ranging from 0% to 100%. The overall NHRS barometer score for the African Region was 42%, which is below the average of 50%. Among the 47 countries, the average NHRS performance was less than 20% in 10 countries, 20–40% in 11 countries, 41–60% in 16 countries, 61–80% in nine countries, and over 80% in one country. The performance of NHRSs in 30 (64%) countries was below 50%. An African NHRS barometer with four functions and 17 sub-functions was developed to identify the gaps in and facilitate monitoring of NHRS development and performance. The NHRS scores for the individual sub-functions can guide policymakers to locate sources of poor performance and to design interventions to address them.
14. Useful Resources
Businesses are often implicated in human rights violations. Yet the patterns behind claims of corporate human rights abuses and the pursuit of justice and remedy associated with those claims remain unstudied and thus unknown. Who makes claims about corporate human rights abuse? How do companies respond? And, what explains why some claims are addressed and others are not? To address some of these gaps, the CHRD team is currently creating a database of claims of corporate human rights abuses from 2000 through today. The database intends to inform practitioners, policymakers, and academics alike and the data will be made readily available.
15. Jobs and Announcements
The Council for the Development of Social Science Research in Africa (CODESRIA) invites applications from suitably qualified senior African scholars for the position of Executive Secretary in its pan-African Secretariat located in Dakar, Senegal. This position, which will fall vacant in 2017, is the most senior management post in the Executive Secretariat and the successful candidate will be expected to function as the leader of the institution and a diverse team of staff under the overall supervision of the Executive Committee of the Council. Established in 1973 as a pioneering, independent, pan-African and not-for-profit organisation for the development of social research in Africa, CODESRIA is today widely recognised as the premier institution on the continent for the generation and dissemination of multidisciplinary research knowledge in the social sciences and humanities. The position of Executive Secretary is a key one both in the development of the programme mandate of the Council and the realisation of the strategic institutional objectives set by the triennial General Assembly of its members.
WHO's new e-learning course on health financing policy for UHC has now been launched. This e-learning course comprises six modules which cover the core functions of health financial policy as conceptualised by WHO. Each module is divided into a number of sub-topics. This is a foundational course which targets participants of various levels of experience and expertise. The course is designed to be used in a variety of ways: as preparation for those who will attend a WHO face-to-face course, for those who are for various reasons unable to attend a face-to-face course, and for those who have already attended courses and wish to refresh their knowledge. Individual modules can also be used as part of a programme of blended capacity building. The course is also designed to work seamlessly on a range of devices, operating systems, and browser in a responsive fashion, in order to maximise ease of use. Module 1 provides an overview of the goals of universal health coverage, health financing and what UHC brings to health financing policy. The following modules cover revenue raising, pooling revenues, purchasing and benefit package design.
The Fourth Global Symposium on Health Systems Research will be held in Vancouver at the Vancouver Convention Centre. The theme for 2016 is “Resilient and responsive health systems for a changing world”. The Global Symposium on Health Systems Research is hosted every two years by HSG to bring together its members with the full range of players involved in health systems and policy research. There is currently no other international gathering that serves the needs of this community. The Symposium aims to share new state-of-the-art evidence; review the progress and challenges towards implementation of the global agenda of priority research; identify and discuss the approaches to strengthen the scientific rigour of health systems research including concepts, frameworks, measures and methods; and facilitate greater research collaboration and learning communities across disciplines, sectors, initiatives and countries. Participants will include researchers, policy-makers, funders, implementers, civil society and other stakeholders from relevant national and regional associations and professional organisations. The program will include plenary addresses from world experts, as many as 12-15 concurrent sessions made up from abstracts and other proposals, an estimated 600 poster presentations, a vibrant marketplace and many other networking opportunities.
This free online course will explore the intersection of medicine, medical anthropology and the creative arts. Through each of its six weeks, participants visit a new aspect of human life and consider it from the perspectives of people working in health sciences, social sciences and the arts. The course will introduce participants to the emerging field of medical humanities and the concept of whole person care, via these six themes: The Heart of the Matter: A Matter of the Heart, Children’s Voices and Healing, Mind, Art and Play, Reproduction and Innovation, Tracing Origins, Death and the Corpse. Participants will question the propensity to separate the body from the mind in healthcare, consider what defines humanity, and share points of connection and difference between art and medicine. Contributors to the course will include a psychologist, heart surgeon, pathologist, oncologist, geneticist, sociologist, poet and visual artist. They will pose critical questions about how we deal with health, healing and being human. Each has been filmed on location in Cape Town, including at the Red Cross War Memorial Children’s Hospital, the Heart of Cape Town Museum, and the Pathology Learning Centre.
High rates of maternal death and teen pregnancy persist in West and Central Africa. Research and programming efforts are not sustainably reducing these rates. The challenge is how to link the evidence on useful health interventions with evidence on how to effectively deliver the interventions within the health systems of West and Central Africa. This project aims to build the foundation for delivering better maternal, new born, child and adolescent health care by addressing this gap and enhancing the capacity of researchers and leaders. As part of the South-South collaborative approach the program is partnering with consortiums led from the University of Cape Town and the University of the Western Cape in South Africa and is offering PhD fellowships within the programme, including using mixed qualitative and quantitative methods for building explanations for what mechanisms underpinned the outcomes observed as a result of the program through the doctoral level training of young researchers from Anglophone and Francophone countries and institutions in the sub-region. The PhD fellows /researchers in Maternal, New born, Child and Adolescent health and Health Policy and Systems research will develop their thesis projects as sub-projects of the larger monitoring and evaluation. Participation in the project is a full time commitment for four years. The successful fellow will be based in the project office, which is currently located in the Dodowa Health Research Centre of the Ghana Health Service.
This post graduate diploma in Public Health aims to strengthen the ability of middle managers to manage various programs and strengthen the health system as a whole as a bridge into the Master of Public Health. It aims to equip graduates with the critical knowledge skills to be able to engage in reflection on public health practices for eg. Health system, health service management, service delivery and critically analyse existing data sources to be able to engage in operational research, plan, implement, monitor and evaluate programs. Graduates will be provided with the skill and expertise to manage the health system and health programmes at district, provincial and national levels. The following learning outcomes are expected of the student: to have gained an understanding of the key components of public health and its application to the relevant context and apply the necessary principles within the local context; to be able to measure at a descriptive level health and management indicators such that they may be analyse the relevant program outputs; to have an insight on the organisation of services and programs to be able to optimise and better manage the relevant programs; to be able to identify challenges within the health system and programs so that they may be able to generate workable solutions to local; to be able to plan, implement, monitor and evaluate public service interventions that results in action planning and optimal use of resources.
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