In this issue we have a numerous papers and videos reporting the discussions, debates and policy proposals at Habitat III in Quito, Ecuador in October. They provide evidence of the challenges for and visions of life in today's and tommorrow's cities, including in relation to improvements in health for all in the city. We will keep an eye on these debates from Habitat III that affect urban health equity and invite you to send us your views for the next newsletter. What do you see as the major urban health challenges in our region? What success stories do we have? And how has Habitat III has contributed to meeting challenges for and nourishing success towards meeting the right to health in our cities?
When the Global Symposium on Health Systems Research (GSHR) gathers health systems researchers in November 2016 to explore ‘resilience’ in health systems in a context of inequality and economic, social, environmental and health challenges, what learning and insights will we bring to the table?
Between August and October this year we carried out two rounds of discussion drawing in diverse voices from amongst the over 300 people globally in our pra4equity list, hosted by the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The first was to discuss our experiences in learning from action in participatory action research (PAR) and the second on what that implies for how we understand the concept of resilience.
The PAR process involves gathering and systematising lived experience to collectively analyse and validate the underlying causes, set, take and reflect on actions on these causes and draw knowledge from it. In earlier meetings we realised that people are less confident of this phase of learning from action. There was a demand to discuss further the processes for building the understanding, power and self-confidence to produce and evaluate change.
In the discussions, people drew attention to various methods they used to facilitate learning from action, including through the ‘but why’ method, progress markers and wheel charts, and mapping or taking photographs of change from initial findings as a means to reflect on the change and what has enabled or blocked it. These processes and tools have not only been used to review how far we have achieved intended actions and outcomes, but also to reflect on the thinking and hypotheses on what produces change. The collaborative development of hypotheses for change by those involved in the PAR (as a form of critical theory or using PAR forecasts, like weather forecasts) was seen to be integral to learning from action. So too was helping people to document their ongoing learning.
In our learning network we’ve also used the reflections across countries on actions on the same problem area as a form of ‘meta-analysis’, to share insights on what facilitates the implementation of change, what blocks it and why, drawing learning also from what is similar and different across countries.
The steps of action and learning often take several PAR cycles to address deeper determinants and build meaningful change. This is especially relevant when people are engaging on deeply rooted power relations or determinants that are beyond local control, such as addressing gender in South Sudan or commercial sex work in Malawi. While not always the case, some noted that this can take more than a decade of work in both high and low income settings, calling for sustained processes.
This raises challenges in some settings. Tracking of change may stop too early, those working in communities may lack the time or resources to record and report the change and the resources and attention to do this may not last for the time needed. Researchers or facilitators may not always be included in or able to stay with change processes that take place over years. PAR processes may also differ from the institutional cultures or priorities of universities or of the trade unions, social movements and other organisations that represent or work with the social groups involved.
The power imbalances involved are often protected by strong interests. We reflected that before applying any method, including PAR, we need to be clearer on its strategic possibilities, given the contexts and social actors. While this may lead to choices within range of approaches and forms of activism, it was asserted that a self-determined understanding of the symbolic and material dimensions of inequalities remains a powerful starting point for any approach.
Notwithstanding the difficulties, numerous examples of positive experience were shared! In Monrovia, for example, PAR implemented after the Ebola epidemic led to a shared, more comprehensive understanding of maternal health amongst the health workers and community members involved, pointing to actions to strengthen the continuity and interaction of the different services and roles needed to improve maternal health care.
In our discussions it was also suggested that the action and change in PAR should not only be seen in terms of material changes in conditions, although this is important. It can in addition be seen in the change in the people involved. As one participant noted in the discussion, “we pay too much attention to the actions and not enough to the actors.” For those often excluded from formal planning and decision making, it is important to appreciate how far they themselves are transformed in the process, in terms of their consciousness and self- confidence to produce change. This can start early in the PAR process, even from the first step of recognising and listening to shared experience.
Given these reflections, we had a second, equally challenging discussion on the concept of resilience from a PAR lens. In part this was due to its adoption as a theme by the GSHSR and in part its increasing use in global discourse. Resilience has been used in environmental and physical sciences to describe the stability of a system against interference from external disturbances, but has migrated to the social sciences. The GSHR website says: “Resilience: absorbing shocks and sustaining gains…. Health systems must be resilient – able to absorb the shocks and sustain the gains already made….”
As was raised in June by Topp, Flores, Sriram and Scott, our network also challenged use of a term that implies ‘absorbing shocks’ and ‘stability’ when the system is an outcome of unjust and structural inequalities that undermine health. PAR has developed in many settings as a direct confrontation with these inequities, seeing their disruption as necessary for health. It would thus not comfortably be applied in the science of ‘absorbing shocks’, when these derive from such injustice.
At the same time some noted that there appears to be a second set of meanings to the term. Resilience has also been used in some contexts to refer to the capability to sustain a positive change or to resist negative change, to transform and move from a harmful equilibrium to new more positive one and the ability to self-organise into a healthier state. This appears to have greater resonance with the process in PAR, given that it draws in the learning from action on a system and intends to raise the direct power and capability of those directly affected.
Given how different these ‘meanings’ are, we noted that we need to understand explicitly and not assume how people are using the term resilience, including at GSHSR. It has often been applied in relation to shocks and emergencies, for example. However participants raised that ‘emergency’ responses commonly use command and control styles that do not strengthen the capacity of or build co-determination with the affected community. If resilience refers to the ability to move to a healthier state, then systems need to transform the conditions producing shocks to prevent them, and not merely to absorb them, and to do so in ways that are defined with and build the capabilities, voice and power of those directly affected.
Please send feedback or queries on the issues raised in this oped or interest in the pra4equity list to the EQUINET secretariat at email@example.com.
2. Latest Equinet Updates
This brief discusses the strategies used for attracting and retaining skilled health workers in ESA countries, especially to address under-served rural and remote areas, primary care settings and in the public sector. It reviews practice to date and identifies strategic options, given both regional learning and the opportunity of the 2016 Global Strategy on Human Resources for Health. Whereas ESA countries have implemented various attraction and retention regimes, the results have not been well documented, with still limited evaluation and reporting of impact of these strategies. The evidence suggests a need for a comprehensive, multi-sectoral and co-ordinated approach to planning and implementation, to make the case for improved funding and with greater use of information and monitoring systems.
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’. As the places are limited if you will be in Vancouver on the 15th November morning and would like to participate in this skills session please can you notify on the email shown with your name, institution and a line or two on any prior PAR experience.
3. Equity in Health
Jean Pierre Elong Mbassi, Secretary-General of United Cities and Local Governments Africa, speaks about how cities help with implementing the Sustainable Development Goals (SDGs), Paris Agreement and more. He noted that it was a positive move to have had the second world assembly of local and regional governments in Quito in the framework of the UN Habitat 3 conference. This was an accomplishment from Habitat 2 when they were not included. This shows that local authorities are not part of the process, and the next step is to bring them around the table with higher level decision making authorities. He argued that without local authorities there is no way to implement global agendas and that if governments and regional bodies listen to cities, the SDGs, climate agendas, and related agreements will stand a significantly better chance of realisation.
Globally, 298,000 women die due to pregnancy related causes each year and half of these occur in Africa. In Uganda, maternal mortality has marginally reduced from 526/100,000 to 435/100,000 livebirths between 2001 and 2011. The presence of a skilled attendant during the entire continuum of care for maternal and new born care has great potential to reduce maternal and new born morbidities and mortality. In 2013, an intervention to mobilize communities in Masindi, Uganda for maternal and new born health was introduced and the results showed marked improvement in utilization of maternal health services such as antenatal care and health facility delivery. However, non-indigenous populations were found to use maternal health services less compared to the indigenous populations. The non-indigenous population are mainly from the West Nile region of Arua and Nebbi. These group of people provide a cheap source of labour for the sugar plantation and sugar factory in Kinyala. This study could not adequately explain why migrants were using maternal health services less. The aim of this study was to gain a deeper understanding of internal migrant’s low access and utilisation of maternal and new born care services in Masindi, Uganda. Key barriers to access were identified as lack of financial resources, social beliefs, neglect by health workers, lack of education and lack of male involvement. There are a number of barriers to access to maternity care among migrant women in Masindi, Uganda. These barriers can be addressed at two levels. At the household level, there should be deliberate efforts to engage with men to support their partners during pregnancy and childbirth for example, by saving money and preparing for transport to the health facility in case of antenatal care and delivery. At the district level, there is need for district local managers together with district health managers to create a dialogue platform in which communication barriers and the mistreatment of migrant women can be addressed in the health sector.
4. Values, Policies and Rights
Innovative and agile cities are better placed to solve major global challenges than national governments – in thrall to the momentum of the last century – but the fight must start now, argues Barcelona’s first female mayor. Colau argues that all the major global challenges – climate change, the economy, inequality, the very future of democracy – will be solved in cities. If nations want to succeed with their policies, cities must be counted as serious actors on the global stage. She argues that national governments are hostages to the momentum of the previous century – but that’s not the real world any more. We live in a world that functions by networking, by faster and more agile contact between cities. Colau notes that it is not possible to talk about a just, sustainable, equitable or inclusive city without speaking about the right to the city - a model of urban development that includes all citizens. She argues that the reference to it in the UN’s New Urban Agenda document ratified at Habitat III in Quito this week could be more ambitious. However it is necessary to recognise the problems overcome just to get this far. She comments that some global powers such as the United States and China resisted it completely; they didn’t want the right to the city in the declaration at all. Thanks to popular mobilisation in Latin America and in some European countries, this political movement has won its place on the agenda – and she notes it as a significant achievement. For the right to the city to become real, however, needs action to transform it into concrete policies and regulations. Colau notes that the most important tests will come after the summit finishes – when we find out whether all these statements can translate into commitments that create positive solutions for urban citizens.
Habitat III – the United Nation’s global conference on the future of cities – came to a close in late October. About 30,000 people gathered in Quito, Ecuador, to discuss the key issues facing cities today and sign off on the New Urban Agenda – the global strategy which will guide urban development over the next 20 years. The author describes the event: Efforts to make the conference inclusive – it was free and anyone could register – materialised in a big jamboree of all kinds of people interested in urban affairs (as well as complaints about long queues). The overall message of the conference emphasised the need to address social, economic and material inequalities in cities and urban areas. Yet - he notes- international experts often appeared oblivious to the enormous progress that the poorest urban communities have made to organise themselves and finance their futures. The main outcome of Habitat III was that UN nation states agreed on the New Urban Agenda (NUA): a non-binding document, which will guide policies over the next 20 years with the goal of making cities safer, resilient and sustainable and their amenities more inclusive. The NUA itself emerged from a consultative process, whereby UN-Habitat collected the inputs of a diverse community of urban scholars, leaders, planners and activists. Its key message was “leaving no one behind”. Its vision for the future of cities was one where aspirations of prosperity and sustainable development are linked to a desire for equality. Yet the document did not escape criticism: How far did it grassroots perspectives? How far did the consensual approach and redrafting exclude key issues? How will it be put into practice? Some proposed, for example, that 20% to 25% of global finance for development – in instruments such as the Green Climate Fund – should be allocated directly to cities. The author calls the consensus around the “right to the city” – an idea championed by Ecuador and Brazil – historical. The “right to the city” generally refers to the capacity of urban citizens to influence processes of urban development, and make a city they want to live in. Social movements promoted this right to denounce urban processes that generate injustices, such as gentrification, privatisation of public spaces, forced evictions and the mistreatment of urban refugees. But as it is not explicitly recognised as a universal human right, the NUA merely encourages governments to enshrine it in their laws.
In this paper, the authors assess the evolution of African Union policies related to women's and children's health, and analyse how these policies are prioritised and framed. It used a document review of all African Union policies developed from 1963 to 2010, focusing specifically on policies that explicitly mention health. The findings were discussed with key actors to identify policy implications. With over 220 policies in total, peace and security was the most common AU policy topic. Social affairs and other development issues became more prominent in the 1990s. The number of policies that mentioned health rose steadily over the years (with 1 policy mentioning health in 1963 to 7 in 2010). This change was catalysed by factors such as: a favourable shift in AU priorities and systems towards development issues, spurred by the transition from the Organisation of African Unity to the African Union; the mandate of the African Commission on Human and People's Rights; health-related advocacy initiatives, such as the Campaign for the Accelerated Reduction of Maternal Mortality in Africa (CARMMA); action and accountability requirements arising from international human rights treaties, the Millennium Development Goals (MDGs), and new health-funding mechanisms, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Prioritisation of women's and children's health issues in AU policies has been framed primarily by human rights, advocacy and accountability considerations, more that by frameworks looking at their economic impact. The authors suggest that more effective prioritisation of women's and children's health in African Union policies could be supported by widening the policy framework to integrate their economic benefit and strengthening the evidence base of policies and strengthening multi-stakeholder advocacy for them.
Amidst the many challenges facing the next WHO Director-General, the authors argue that the new WHO head should prioritise the right to health. They call for leadership on a Framework Convention on Global Health (FCGH), based in the right to health and aimed at national and global health equity. The treaty would, they argue, enhance accountability, transparency, and civil society participation and protect the right to health in trade, investment, climate change, and other international regimes, while catalysing governments to institutionalise the right to health at community through to national levels. With the Framework Convention on Tobacco Control having served as a proof of concept, the FCGH would be an innovative treaty finding solutions to overcome global health failings in accountability, equality, financing, and inter-sectoral coherence, with a national and global health financing framework. They raise options for reaching beyond the health sector with right to health assessments, public health participation in developing international agreements, and responsibility for all sectors for improving health outcomes. Finally they propose that the FCGH would reinvigorate WHO’s global health leadership, breathing new life into its founding principles and bringing badly-needed reforms to the institution, such as community participation, new priorities favouring social determinants of health, and a culture of transparency and accountability.
On 21 September 2016 the United Nations General Assembly (UNGA) adopted the political declaration on antimicrobial resistance. Its adoption provides recognition of the critical nature of antimicrobial resistance (AMR) at the highest political level. It recognises the World Health Organisation (WHO) Global Action Plan on AMR as the blue print of action. It also acknowledges that the lack of access to health services and antimicrobial medicines continues to affect more people than resistance, as a major challenge for developing countries. The document clearly states that research and development efforts should be guided by need and by the principles of affordability, effectiveness, efficiency and equity as well as be de-linked from the price and volume of sales. There are two calls for action in the text. The first one calls upon the WHO “together with Food and Agriculture Organisation (FAO) of the United Nations and the World Organisation for Animal Health (OIE), to finalise a global development and stewardship framework. ” Preliminary discussions on this framework have taken place in Geneva at the WHO Headquarters in early 2016 but this call for action gives an explicit mandate to continue the negotiations that will define and structure how this framework would look like. The second call for action requests the Secretary-General to establish an ad hoc interagency coordination group co-chaired by the Executive Office of the Secretary-General and the WHO. During the negotiations for the political declaration civil society groups that were following the process in New York told Third World Network that it was necessary that the UN, with all its agencies, participated in creating actions within their mandates to complement and support the WHO leadership in this issue due to the fact that AMR is interconnected with many other aspects beyond human health. According to several civil society organisations that attended the panel, while the declaration is a good step and recognition at the highest level of this critical issue the declaration had few commitments on the mobilisation of funds to support developing countries. It did not make specific commitments in the animal health sector. The declaration calls for a report back in 2018 at the UNGA and hopefully some of the commitments discussed in this meeting can be truly realised.
5. Health equity in economic and trade policies
The Congress of South African Trade Unions (COSATU) hosted the 3rd Africa Trilateral Summit in Johannesburg, South Africa in September 2016. Attended by the delegates from the unions affiliated to the three federations; Nigeria Labour Congress (NLC), Congress of South African Trade Unions (COSATU), and Trade Union Congress, Ghana (TUC); the Summit was held under the theme: Building a progressive workers movement for development alternatives for Arica: Decent work, industrialisation and Job Creation NOW. The Summit proposed formulating alternative growth and development path for both Africa’s industrialisation and a re-industrialisation approach to create jobs and fight poverty and to actively campaign against corruption, illicit financial flows and for tax justice, fair trade and inclusive development. The Summit proposed that unions work to build a democratic developmental state that serves the needs of its people and guarantees peace, justice and security, and to fight for a comprehensive social security system for all workers. The Africa Trilateral Cooperation is the historic relationship between COSATU (South Africa), NLC (Nigeria) and TUC (Ghana) on the African continent.
Despite the global consensus on the importance of shifting to a model of sustainable development, identifying pathways that can simultaneously and equally fulfil social, economic and environmental goals remains extremely difficult. After briefly tracing the evolution of the concept of sustainable development to its central place in current international development debates, the paper explains what is understood by eco-social policies. This paper analyses opportunities for and barriers to the effective adoption of eco-social policies in national programmes by undertaking a comparative analysis of three case studies: Payment for Ecosystem Services in Costa Rica, the Ishpingo-Tambococha-Tiputin (ITT) proposal for Yasuní National Park in Ecuador and the Virunga Alliance in the Democratic Republic of Congo. The three programmes had varying degrees of success. The Virunga Alliance is a development project that aims to foster peace and prosperity through the responsible economic development of natural resources for 4 million people who live within a day’s walk of the park’s borders. The project identified poverty and the lack of a sustainable business sector as the root causes of Virunga’s problems, forcing the park’s inhabitants to over-exploit natural resources for their daily fuel and food needs. While the Payment for Ecosystem Services was a successful national programme that led to unprecedented forest recovery in Costa Rica, the ITT proposal was a governmental policy initiative that failed due to various national and international issues. The Virunga Alliance operated with an eco-social logic by involving job creation and clean energy provision. While the outputs were successfully achieved, the outcomes were at risk in part due to regional insecurity and a fragile national economy. The author looks at the different approaches taken in each country, analysing the benefits and trade-offs as well as the factors that led to their adoption or defeat. After briefly tracing the evolution of the concept of sustainable development to its central place in current international development debates, the paper explains what is understood by eco-social policies.
6. Poverty and health
Informal employment makes up more than half of non-agricultural employment in most developing regions, according to Women in Informal Employment Globalising and Organising (WIEGO). In three major regions (South Asia, sub-Saharan Africa, Latin America and the Caribbean) plus urban China, informal employment is a greater source of non-agricultural employment for women than for men. Elsewhere in East and Southeast Asia, these shares are roughly the same. WEIGO advocates made this case at Habitat III, urging national and local governments to support the urban informal economy. The group released a paper listing the sector-specific needs of urban informal workers from local and national governments, noting that despite their contributions, informal workers’ lives and livelihoods continue to be vulnerable in many cities. Many myths persist about the informal economy in the minds of policymakers and the general public, such as the conflation of the informal economy with illegal activities. Sally Roever, urban policies programme director for WIEGO, pointed to ‘micro-innovations’, which can make a huge difference....Like a municipality issuing identity cards to waste pickers. Residents view a waste picker with an ID card as legitimate entity and are more likely to be cooperative. This enhances the productivity of waste pickers.” She gave the example of Bogota, where recyclers are formally recognised stakeholders in the city's waste-management system. WIEGOs efforts also have prompted the creation of two labour groups — the Association of Recyclers of Bogotá organisation that represents the city’s 3,000 informal recyclers, while the National Association of Recyclers in Colombia represents 12,000 members. These are argued to serve as precedent and inspiration for other informal workers globally.
This report from Building Resources Across Communities’s (BRAC) Youth Watch team in Uganda. It shares lessons from the Research and Evaluation Unit's mixed-methods research, including a nationally representative survey of youth, focus groups, and in-depth case studies. Chapter 1 introduces the conceptual framework used in this report and describes the research methodology. Chapter 2 presents the asset portfolio of Ugandan youth. Chapter 3 outlines the position of youth in the family, community and political participation. Chapter 4 discusses the perceived opportunities of Ugandan youth, versus their aspirations. Chapters 5 to 7 outline the health outcomes for Ugandan youth, focusing on risky sexual behaviour, examples of success stories among youth and policy recommendations. The report points out the need for a comprehensive approach that emphasises employment and institutional support to avoid conditions that lead to early pregnancy in young women and sexually transmitted infections and HIV. "Improved support from communities and local governments along with increased access to financial services and vocational training are key to facilitate healthy transition of youth into adulthood.....The combination of the multiple barriers facing youth - including limited assets and support, difficult economic, political and social environments, and limited perceived opportunities for the future - negatively influences the self-esteem, motivations, and aspirations of youth."
The author reports that food is becoming scarce in large parts of rural Zimbabwe with United Nations agencies and government warning more than one in three Zimbabweans may need food assistance by next March. The government has appealed for $1.5 billion in emergence support to cover the food and nutrition, agriculture, water, education, and health sectors. Mbire is a traditionally rain starved area, which lies in the Zambezi escarpment, near the border with Zambia. In Mbire, George Nyarugwe, the Acting District Administrator, said at the local clinics there was growing anecdotal evidence of forced child marriages with many of the young mothers telling nurses they were forced to marry because of the drought. Similar reports have been made in Mt Darwin in the country’s northeast and in Seke, near Harare, according to the Zimbabwe Vulnerability Assessment Committee report released in January. Between last December and April, UNICEF says 3,042 new child protection cases were reported in 65 districts in Zimbabwe, with child neglect showing the highest incidence at 568, followed by sexual abuse at 306 and physical abuse at 218. There are plans to train government, non-government organisation and community social workers to better protect children in drought afflicted areas.
7. Equitable health services
Director General of the World Health Organisation, Dr Margaret Chan, addressed the Tokyo International Conference of Africa's Development (TICAD) held in Nairobi, Kenya, in August 2016. She raised the issue of Ebola as an example of the consequences of failing to invest in the community and resilient health systems. Dr Chan noted that well-functioning health systems that cover entire populations are now regarded as the first line of defence against the threat from emerging and re-emerging diseases. Apart from strengthened health security, Africa has much to gain from its commitment to universal health coverage (UHC). For decades, the biggest barriers to better health in Africa have been weak health systems and inadequate human and financial resources. A commitment to UHC means a commitment to address these barriers. UHC also addresses a third barrier to progress of dire poverty, including poverty caused by catastrophic spending on health care. A commitment to UHC, backed by country-specific plans for implementation gives African countries a huge opportunity to leap ahead. Dr Chan offered three pieces of advice. First, to understand that UHC is a direction for a journey, not a destination. Second, use the power of robust data to shape equitable policies in line with national contexts. For example, Kenya used the results from a survey of public expenditure to launch its innovative Health Sector Services Fund that provides direct cash transfers to primary health care facilities. Third, if UHC is to work as both a poverty-reduction strategy and a boost to health security, countries need to ensure that reforms reach health systems at the district level that support impoverished communities, and are best placed to engage them in health promotion, prevention, and the delivery of services that match perceived needs.
In Tanzania, the prevention of mother to child transmission of HIV (PMTCT) is a health sector priority, but there is very little information on how well gender mainstreamed in relation to national PMTCT guidelines. In this paper the authors research assessed the gender content of key policy documents in order to better understand how this area could be strengthened, using a WHO Gender Responsive Assessment Scale (GRAS). The GRAS divides gender responsiveness into 5 levels. Level 1, gender unequal, contains content which perpetuates gender inequality by reinforcing unbalanced norms, roles and relations. Level 2, gender blind, contains content which ignores gender norms, roles and relations and differences in opportunities and resource allocation for women and men. Level 3, gender sensitive, contains content which indicates awareness of the impact of gender norms, roles, and relations, but no remedial actions are developed. Level 4, gender specific, contains content which goes beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. Level 5, gender transformative, contains content which includes ways to transform harmful gender norms, roles and relations. The findings showed that gender-related issues are mentioned in all of the guidelines, indicating some degree of gender responsiveness. The level of gender responsiveness of PMTCT policy documents, however, varies, with some graded at GRAS level 3 (gender sensitive), and others at GRAS level 4 (gender specific). None of the reviewed policy documents could be graded as gender transformative. While the policy documents indicate recognition of gender inequality in decision-making and access to resources as a barrier to accessing PMTCT services by women, no attempt is made to transform harmful gender norms, roles, or relations. Overall, gender was not mainstreamed into any of the documents in the sense that gender was not considered in all key sections. Overall, the study revealed limited integration of gender concerns (less or lack of attention on the disadvantageous position of women in terms of inequality in ownership of resources, power imbalance in decision making, asymmetrical division of roles, and masculine norms that distance men from maternal and child care) in PMTCT guidelines. The authors suggest that revision of guidelines to mainstream gender is greatly needed if PMTCT services are to effectively contribute towards a reduction of child and maternal morbidity and mortality in Tanzania
8. Human Resources
Management and supervision of community health workers (CHWs) is important for the success of CHW programmes. This study explored factors influencing motivations of supervisors in CHW programmes. The authors conducted qualitative interviews with 26 programme staff providing supervision to CHWs in eight community-based organisations in marginalised communities in the greater Durban area of South Africa from July 2010 to September 2011. Findings show that all the supervisors had previous experience working in the health or social services sectors and most started out as unpaid CHWs. Most of the participants were poor women from marginalised communities. Supervisors’ activities include the management and supply of material resources, mentoring and training of CHWs, record keeping and report writing. Supervisors were motivated by intrinsic factors like making a difference and community appreciation and non-monetary incentives such as promotion to supervisory positions; acquisition of management skills; participation in capacity building and the development of programmes; and support for educational advancement like salary, bonuses and medical benefits. Hygiene factors that serve to prevent dissatisfaction are salaries and financial, medical and educational benefits attached to the supervisory position. Demotivating factors identified are patients’ non-adherence to health advice and alienation from decision-making. Dis-satisfiers include working in crime-prevalent communities, remuneration for CHWs, problems with material and logistical resources, job insecurity, work-related stressors and navigating the interface between CHWs and management. While participants were dissatisfied with their low remuneration, they were not demotivated but continued to be motivated by intrinsic factors. The authors findings suggest that CHWs’ quest for remuneration and a career path continues even after they assume supervisory positions. Supervisors continue to be motivated to work in mid-level positions within the health and social services sectors. Global efforts to develop and increase the sustainability of CHW programmes will benefit immensely from insights gained from an exploration of supervisors’ perspectives. Further, they suggest that national CHW programmes be conceptualised with the dual purpose of building the capacity of CHWs to strengthen health systems and reducing unemployment especially in marginalised communities.
The health worker shortage in rural areas is a problems in many African countries, in part due to fewer incentives and support systems available to attract and retain health workers in these areas. This study explored the willingness of community health officers (CHOs) to accept and hold rural and community job postings in Ghana. A discrete choice experiment was used to estimate the motivation and incentive preferences of CHOs in Ghana. All CHOs working in three Health and Demographic Surveillance System sites in Ghana, 200 in total, were interviewed between December 2012 and January 2013. Respondents were asked to choose from choice sets of job preferences. Mixed logit analyses of the data found a shorter projected time frame before study leave as the most important motivation for most CHOs, while an education allowance for children, a salary increase and housing provision also played a role. While male CHOs had a high affinity for an early opportunity to go on study leave, CHOs who had worked at the same place for a long time valued more a salary increase. To reduce health worker shortage in rural settings, policymakers could provide “needs-specific” motivational packages.
9. Public-Private Mix
The South African Competition Commission’s healthcare market enquiry on Tuesday convened a special session in Pretoria, at which stakeholders were due to give oral presentations in response to a report by the World Health Organisation (WHO). The report, contested by the private actors, concluded that the cost of hospital care in SA was high when measured against GDP per capita and that the driving forces were in-house hospital and specialist fees. The Organisation for Economic Co-operation and Development (OECD) collected the data and conducted the study, which compared the prices of South African private hospitals to those of 20 OECD countries. The health market inquiry was established to determine why medical inflation has historically risen faster than consumer price inflation, and whether there are barriers to effective competition in the private healthcare sector. The public hearings aim to explore the relationships among different players.
10. Resource allocation and health financing
Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20–64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005–2010) for RMNH expenditures (2005–2010) and 165 % for CH expenditures (2005–2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals.
This research explored health financing policies for universal health coverage to identify issues that need to be addressed and approaches that can fruitfully be pursued in future policy design. The authors systematically searched the following databases: PubMed, SCOPUS, and COCHRANE up to January 2016 and included health financing policy assessment toward universal health coverage followed by a thematic and descriptive synthesis of data. Twenty three papers were included. The authors categorised dimensions that were important in health financing assessment to achieve UHC into nine groups as follows: stewardship, raising revenues and contribution methods, risk pooling and financial protection, resource allocation purchasing, human resources, policy stakeholders, policy content, policy context, and policy process. As countries commit to expand universal health coverage, the authors argue that these dimensions identified from the literature can help policy makers to prioritise competing demands, make rational choices, and adapt their approaches.
11. Equity and HIV/AIDS
When Rose Matuulane was pregnant five years ago, she had to wait for a nurse to visit her small village, Otse in Botswana, to provide antenatal check-ups. When the nurse could not make it, Ms. Matuulane had to travel 84 km to the nearest clinic, in Shoghong, arriving the day before so that she could rise early and queue for hours. If she or any other woman additionally needed a family planning consultation, cervical cancer screening, HIV testing and counselling, or HIV treatment, they would have to come back another day, waiting again for hours. Ms. Matuulane, 24, is now a mother of two. The experience she had with her second pregnancy was worlds apart from the first. In 2011, shortly after she had her first baby, UNFPA helped to introduce integrated reproductive health care services at the Otse Health Post. It meant Ms. Matuulane no longer had to travel all the way to Shoshong. The new approach – called a “one-stop shop model” – also meant women no longer had to return time and again for different sexual and reproductive health services. The one-stop shop model is helping to increase women’s access to life-saving maternal health care and family planning. It is also a critical tactic in the fight against Botswana’s devastating HIV epidemic. The country has an HIV prevalence of 22 per cent among 15-to-49 year olds, according to 2015 UNAIDS estimates. A staggering 18 per cent of maternal deaths in the country are due to HIV-related causes. By integrating a full suite of reproductive health care together with a full range of HIV services – including prevention, testing and antiretroviral treatment – health workers have more opportunities to provide both kinds of care. The project – a partnership between the Ministry of Health, UNFPA and UNAIDS, with funding from the European Union, and the Swedish and Norwegian development agencies – is being piloted in seven countries in the East and Southern Africa Region. Botswana is the first of the pilot countries to implement the approach nationwide. Since the programme’s launch, the number of women visiting clinics for post-natal care, who are then able to simultaneously receive HIV and family planning services, has increased by 63 per cent, according to a recent report. The number of women seeking family planning, who are now able to access HIV services at the same time, has increased by 89 per cent.
12. Governance and participation in health
Maternal and child health issues have gained global political attention and resources in the past 10 years, due in part to their prominence on the Millennium Development Goal agenda and the use of evidence-based advocacy by policy networks. This paper identifies key factors for this achievement, and raises questions about prospective challenges for sustaining attention in the transition to the post-2015 Sustainable Development Goals, far broader in scope than the Millennium Development Goals. The paper uses participant observation methods and document analysis to develop a case study of the behaviours of global maternal and child health advocacy networks during 2005–2015. The development of coordinated networks of heterogeneous actors facilitated the rise in attention to maternal and child health during the past 10 years. The strategic use of epidemiological and economic evidence by these networks enabled policy attention and promoted network cohesion. The time-bound opportunity of reaching the 2015 Millennium Development Goals created a window of opportunity for joint action. As the new post-2015 goals emerge, networks seek to sustain attention by repositioning their framing of issues, network structures, and external alliances, including with networks that lay both inside and outside of the health domain. Issues rise on global policy agendas because of how ideas are constructed, portrayed and positioned by actors within given contexts. Policy networks play a critical role by uniting stakeholders to promote persuasive ideas about policy problems and solutions. The author argues that the behaviours of networks in issue-framing, member-alignment, and strategic outreach can force open windows of opportunity for political attention -- or prevent them from closing.
In a penetrating analysis of events in South Africa, Jonathan Grossman writes a linked analysis of the student mobilisations and of the workers at Marikana. The author that an old legacy of struggle is being rediscovered and rescued, reflecting a solidarity between workers and students taking action. Grossman argues that the struggle for free education and against outsourcing in the public sector at the universities now needs to become the struggle for free education at all levels and free basic services, against outsourcing and for a living wage across the whole of the public sector. He argues that this is necessary for the renewal of the workers movement to tap into the vitality of a student-worker alliance that enriches both struggles in South Africa with a more holistic vision.
Progress in analysing the instrumental view of governance as an engine for growth, poverty reduction, and inclusive development has been held back by the difficulty in framing governance. This essay seeks to address this problem by 1) reframing urban governance 2) evaluating its aims, processes, and outcomes, and 3) explaining those outcomes on the basis of which some lessons are teased out. Using examples from Africa and an institutional political economy approach the author argues that, overall, while urban economies are growing; both urban poverty and inequality levels have risen substantially. Urban governance has paved the way for new forms of urban development that only benefit the few, including in how differences in how urban services and resources are experienced, accessed, and controlled. The author argues that the underlying reasons for this disjuncture between “urban governance” in theory and “actually existing urban governance” are 1) difficulties in implementing urban governance theory consistently in practice, 2) problems arising because urban governance theory has been implemented in practice, 3) tensions that would entangle most policies which do not address historical and structural economic issues, 4) restrictive assumptions, and 5) incoherence among the different dimensions of urban governance. To resolve these contradictions, the author puts the case for major structural and institutional change involving: 1) the re-ordering of the roles of the state, market, and society as institutions of change; 2) re-working the relationships that bind together land, labour, capital, and the state, and 3) re-organising the channels for keeping the attainment of the ends of urban governance in check.
13. Monitoring equity and research policy
Building Capacity to Use Research Evidence (BCURE) is a programme of work funded by the UK Department for International Development (DFID) which aims to build the skills, knowledge and systems that will allow policy makers and practitioners in low income countries to access, appraise and use rigorous evidence. BCURE works through a consortium of organisations, focusing on building capacity to make evidence informed decisions. Examples of some of the different interventions are incorporating processes to improve evidence use by Cabinet Ministers, using innovative online training methods to improve the skills of individuals to make evidence informed decisions, establishing open policy dialogues between government officials, civil society and the research sector to promote the use of evidence in decision making and developing the African Evidence Network – where policy makers and practitioners can discuss and share lessons on evidence use. Each project has a primary provider, who oversees the management of that work. BCURE is being delivered with a specific focus on building the capacity of locally based partner organisations in the countries where projects are operating, as essential for the sustainability of the programme.
The International Panel on Social Progress (IPSP) is a global initiative that brings together a large group of scholars brought together to compile evidence across disciplines to rethink ideas of a just society. They recognised the interconnected forces of: weakening traditional nation states; technological change; profound and unequal transformations in health and education outcomes; and contestations between the religious and secular. IPSP have produced this report aimed at social actors, movements, organisations, politicians and decision-makers, to provide them with the best evidence on questions that bear on social change. The report has 22 chapters covering a comprehensive range of areas that have an important bearing on society now and into the future. It is the first comprehensive synthesis of social sciences knowledge about key issues facing humankind today. This first draft is available for public consultation and comment and IPSP invite comments from all concerned citizens and organisations. There is a web based platform for comments and inputs.
Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasised the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualising a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005–2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. The challenges faced by LMICs include rapid urbanisation, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs).
14. Useful Resources
The Media Action radio programme Hiigsiga Nolosha (meaning desire or aspirations for life) is designed for Somali youth as a discussion platform to prompt "dialogue and interaction across divides, create... understanding and acceptance between youth from different parts of the country, improve... how youth are viewed (by themselves and adults), give... young people hope and motivation for the future and help... them to believe they can positively contribute to their country." The project was created to improve capacity of local Somali partner radio stations to deliver audience-driven, and particularly youth-focused, media programming. Hiigsiga Nolosha "has been broadcast via the BBC Somali Service and three partner community radio stations and included both a drama Maalmo Dhaama Maanta (A Better Life than Today) and discussion segments produced by each partner radio station." Phase I formative research showed a need for programming in which youth could exchange "ideas and experiences and come up with solutions to the challenges they face. The impact evaluation at the end of Phase I found that the programme had given Somali youth an opportunity to interact and express their ideas, had helped to highlighted commonalities of young people, had positively shifted how young Somalis viewed themselves and contributed to youth empowerment."
Democracy in Africa, a site promoting writing from African authors, have assembled a reading list on African Politics. This reading list is collated in solidarity with those who are currently attempting to decolonise the university across Africa, and beyond. It includes readings on themes such as Citizenship and Statehood, Social Movements and Civil Society, the Politics of Gender and Youth, the Politics of International Development amongst others. The hosts welcome your recommendations of outstanding scholarship to add to it. Currently, the list focuses on English translations and texts but the site hosts are in the midst of developing lists in other languages and would welcome suggestions.
This open access book presents findings of and separately authored case study examples of work in a global study titled ‘Building the Next Generation of Community-Based Researchers’ (a.k.a. the Next Gen project), funded by the Social Science and Human Research Council of Canada. The Next Gen project aimed to increase access to high quality training in Community-Based Research (CBR) within higher education institutions (HEIs) and civil society organisations (CSOs). The book presents a state-of-the art in pedagogies and strategies for building CBR capacities, to strengthen the existing training for fieldwork and theoretical and curricular content on participatory research within and outside academia. It outlines a number of important trends, approaches and challenges in the field of training the next generation of researchers in CBR; through a comparative analysis of 21 institutional case studies of CBR training providers from around the world and includes the results of a global survey of training CBR in HEIs & CSOs. With over 40 contributing authors from all around the world, Knowledge and Engagement is the first book of its kind, which represents a collective effort to bring many note-worthy aspects within one umbrella (i.e., ‘Community Based Research’), analyse the current scenario and training opportunities, and provide recommendations with regard to what can be done in the best possible manner. It includes two case studies from East and Southern Africa, namely Training And Research Support Centre Zimbabwe and Umphilo waManzi South Africa.
The Inequality Question is a unique project to debate global inequality issues. On the last Thursday of each month – #ThoughtfulThursday – children formerly or currently living on the streets of Uganda choose one inequality question to discuss and lead a live conversation online, with participants worldwide. These conversations give participants and facilitators the opportunity to discuss their thoughts, experiences and aspirations on how to make the world a more equal place. Individuals, classes, groups and organisations are joining into the conversation, not only to have direct discussions with children experiencing many inequalities, but also to spark ideas that lead them to undertake an “Inequality Challenge”, so that they can become a catalyst for change. Samuel Woria undertook one of the Inequality Challenges that focused on gender. For one week, six women dictated all of Samuel’s decisions. Samuel chose to take part in this challenge because he believes that men in Uganda do not treat women fairly and equally. His experiment not only facilitated challenging conversations, but also made an impact in his community. Many men have contacted Samuel to say they are trying to alter their behaviour towards women, and women have expressed their happiness to be shown such public support in their struggle for equality.
The Habitat process was launched by the UN in 1976, when governments began to recognise the risks of rapid urbanisation: in particular, rising inequality, falling quality of life and unsustainable development. More than half of the world’s population now lives in urban areas, and this figure is predicted to rise to almost 70% by 2050. As a result, cities have become focal points for addressing many of humanity’s greatest challenges. Economic inequalities have dramatically increased, and are heavily concentrated in urban areas: almost one third of city-dwellers live in informal settlements, such as slums. Habitat is a state-led process, so many world leaders and UN representatives will be at the conference. The UN also established a General Assembly of Partners to encourage the participation of local authorities, grassroots and indigenous organisations, women’s and youth groups, as well as the private and charitable sectors. The main topic of discussion was the Zero Draft of the New Urban Agenda (NUA): a 24-page document, which outlines the nation states’ shared vision for a sustainable urban future. The NUA has undergone three rounds of revisions between May and September 2016, to iron out conflicts and reach a consensus between the UN nation states. The “right to the city” is also enshrined in the document, calling on governments to create “cities for people, not for profit”, ensuring an inclusive, gender and age sensitive approach to city planning, as well as continuing efforts to reduce urban poverty. Unlike the Paris climate agreement or the SDGs, the NUA is non-binding – it merely provides guidelines for those involved in urban development. It does not give practical advice about how the NUA should be carried out, and who is in charge of implementing it. It does recognise the need for producing evidence to inform the implementation of the NUA, but does not indicate how progress should be measured and assessed.
15. Jobs and Announcements
The International Baby Food Action Network (IBFAN) and the Department of Health - Republic of South Africa are co-hosting the 2nd World Breastfeeding Conference in collaboration with WHO, UNICEF, WABA and gBICS partners in Johannesburg South Africa from 11th to 14th December 2016. The Conference will provide an opportunity to review the global investment promises for maternal, infant and young child nutrition in light of resolutions from the 65th WHA of 2012, and to generate ideas for further resource mobilisation and/or strengthening of interventions. In addition, the conference will provide an opportunity to broaden understanding barriers to breastfeeding including promotion of artificial feeding by manufacturers, unsupportive health facility practices, more working mothers, inadequate traditional support, among others and address breastfeeding in a human rights framework. Furthermore, the conference will raise awareness on progress so far made in improving breastfeeding rates, which has occurred at different speeds in many countries and raise awareness on a number of challenges to the promotion, protection and support of breastfeeding and other IYCF interventions due to the funding, structural, policy and political environment.
59th International Conference on Multidisciplinary Research & Practice(ICMRP) is to bring together innovative academics and industrial experts in the field of Science Technology and Management to a common forum. All the registered papers will be published by the World Research Library and will be submitted for review for indexing by Google Scholar etc. All submissions to the conference will be reviewed by at least two independent peers for technical merit and content. It is anticipated that a broad range of research and applied topics will be covered during the conference.
Makerere University College of Health Sciences, School of Public Health, Uganda in partnership with Nottingham Trent University, UK and Ministry of Health, Uganda invites submissions of abstracts for the symposium on Community Health Workers (CHWs) and their contribution towards the Sustainable Development Goals (SDGs). Sub themes include CHWs programmes (past, present and future), CHWs and health systems and the role of CHWs in the SDGs era. For further details on the symposium themes, the abstract format, dates for registration and the conference details see the website.
The Health Systems Cluster in Sierra Leone is recruiting a P3 Technical Officer to work on District Strengthening. This is an extremely exciting position and opportunity to become part of our small, but dynamic health systems strengthening cluster within the WHO Sierra Leone office. The deadline for applications is 10 November, and more information is available in the website. The WHO Country Office is also supporting Sierra Leone’s College of Medicine and Allied Health Sciences (COMAHS) by helping to recruit a number of short-term faculty as found in other folders on the other current vacancies on the website.
Do you know of excellent health policy and systems research publications on human resources for health (HRH)? Health Systems Global at the University of Western Cape are looking for submissions for a reader that provides guidance on and examples of excellent HRH research within the broader rubric of people-centred health policy and systems research. Please see the blog post for more detail and submit your suggestions using the google sheet. Submit publication suggestions here: https://docs.google.com/spreadsheets/d/18B7QW5Xv-RLyiz0i-oxLigvtecJObhbyaW3lEffUXvI/edit#gid=0
Pambazuka News is preparing a special issue on the labour movement and the struggles for Africa's liberation today. Pambazuka News wishes to dedicate a Special Issue to the labour movement and the struggles for Africa's liberation today. Labour has a mission that goes beyond agitation for worker rights towards the bigger project of concrete self-determination of the African people through ownership of their resources and means of production, etc. Shaun Whittaker of the Marxist Study Group of Namibia and former member of the Workers' Organisation for Socialist Action (South Africa) is guest editor for the special issue. Authors are urged to write on their own countries and not generalize about the entire continent. They should try to only focus on one of the sub-themes or a related sub-theme. Articles should be up to 3, 000 words.
Previously known as the African Institute for Agrarian Studies(AIAS), and renamed to SMAIAS in 2016 in honour of its late Founder and Executive Director, Professor Sam Moyo, the SMAIAS in Harare has been in operation for over thirteen years. The SMAIAS aims to enhance Africa’s agrarian transformation by promoting informed participation towards effective land and agrarian policies and reform, by means of Pan- African and South-South partnerships, interdisciplinary research initiatives, policy dialogues, training, and information dissemination. It interacts with various organisations and countries to assist them in developing capacity for policy formulation and research. It also facilitates policy dialogue among governments, academics, civil society and others on land and agrarian developments, especially on the land rights of marginalised social groups. Under the overall authority of the Board of Trustees and the direct supervision of the Chairperson of the Board of Trustees, the Executive Director will be expected to provide intellectual, administrative and strategic leadership to the secretariat of the SMAIAS. Only African citizens will be considered for this post.
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