A group of senior scientists—researchers, academics and intellectuals—from various parts of the world, with over 250 years’ combined experience of working to improve the oral health of communities, independent of any institution, government body or corporate entity, met in Colombia in March 2017 and prepared a statement on their analysis of the problem and recommendations about what should be done. This editorial presents paragraphs extracted from the statement. The full statement, referred to as La Cascada Declaration, together with associated papers, is available at https://lacascada.pressbooks.com/front-matter/introduction/.
We are concerned that the dental profession, worldwide, has lost its way.
Despite current knowledge of the causes of oral diseases, globally most people continue to experience significant levels of disease and disability. Although technological and scientific developments over the last 50 years have contributed to improvements in the quality of life for some, oral diseases continue to cause pain, infection, tooth-loss and misery for a vast number of people. While in many middle and high income countries, there have been marked overall improvements in oral health, oral health inequalities both between and within countries are now a major problem. The overall improvements in oral health have been the result of general improvements in living standards and conditions, changing social norms in society (improvements in personal hygiene and reduction in smoking) and the widespread use of fluoride toothpastes, rather than due to the clinical interventions of dentists.
Globally the profession has had little direct impact on the scale of the problem. Clinical interventions account for only a small proportion of improvements in the health of populations. This is as true of oral health as of general health.
The world has witnessed significant growth in social inequalities between the rich and the poor. …Austerity policies worldwide (commonly referred to as ‘structural adjustment programs’ in the global South) have diverted social and welfare spending away from the public to the private sector in the belief that ‘the market’ can meet social needs, despite evidence to the contrary. This has led to the creation of a two-tier health service—one for the rich, and the other, limited and often of poorer quality, for the majority.
Corporations and insurance companies are increasingly taking over the provision of health services, including dental services, in many countries. The treatment regimens that they promote are designed more to ensure adequate returns on investment for their shareholders than to improve the health status of the community, resulting in a tendency for the provision of excessive and sometimes inappropriate treatments.
Major food and beverage companies continue to promote the consumption of refined carbohydrates, free sugars in drinks, confectionary and in processed foods, even though these are major contributory factors for dental decay, not to mention obesity and diabetes. Advertisements of these products frequently and unjustifiably imply health benefits.
We believe that the dental profession, as presently constituted, is inappropriately educated for dealing adequately with oral health problems faced by the public. In many countries, there is an overproduction of dentists, most of whom provide services only in the main urban centers where private practice is more lucrative and services often fail to reach those in more remote areas of the country. In some cases, overproduction results in unemployment.
While there is no doubt that the intention of the profession is to improve health, commonly used treatment regimens for tooth decay (drillings and fillings) and gum diseases (scaling and polishing) do not by themselves arrest or control their progression. Furthermore, filling teeth inevitably leads to a cycle of replacements of increasing size, ultimately shortening the life of the dentition.
Dentistry is drifting, it seems, away from its task of prevention and control of the progression of disease and of maintaining health. The mouth has become dissociated from the body, just as oral health care has become separated from general medicine.
We believe dentistry is in crisis. Things must change.
Since clinical interventions account for only a small proportion of health improvements, the dental professions should be in the forefront of efforts that call for a reduction in income disparities and for a more just world in which everyone has access to resources and conditions for good health and well-being. Those industries whose products are harmful to health, especially producers of free sugars in foods, drinks, and producers of foods containing refined carbohydrates, should be required to label their products as harmful (just as has been done in many parts of the world in relation to tobacco and alcohol). The decline in government spending on the social sector cannot be justified in the light of excessive expenditures on war, the military, arms and other destructive initiatives. Corporations and industry should not be permitted to unduly influence research or clinical practice.
The dental profession is over-trained for what they do and under-trained for what they should be doing. Control of the most common oral diseases requires relatively little training and could and should be performed in most cases by community healthcare workers. Demonstration projects on the effectiveness of such approaches are needed.
Dentistry should become a specialism of medicine, just as ENT (ear, nose & throat), ophthalmology, dermatology, etc. are specialisms of medicine. As such, oral health physicians would be responsible for providing leadership of the oral health team, in the management of advanced disease and the provision of emergency care, relief and management of pain, infections and sepsis, management of trauma, diagnosis and management of soft-tissue pathologies and, where justifiable from the point of view of the maintenance of health, interventions to re-establish a functional dentition and orofacial reconstruction. Since the management and control of most common diseases could be undertaken by primary healthcare workers, a relatively small number of such oral health physicians would need to be trained. In addition, a relatively small number of public health dentists would be needed to coordinate oral health needs assessments, implement and evaluate community-based oral health improvement strategies and to act as oral health advocates to ensure the closer integration of oral health into wider policies.
The implications of the above recommendations are obvious: changing dentists into oral health physicians necessitates thorough revision of the education profiles of dental schools: an overhaul of the current curriculum for training of dentists; a reduction in the number of dentists trained; and an improvement in the quality of courses, especially ensuring that training is linked to the needs of the population.
The current state of dentistry worldwide is dire. It requires radical solutions. This short declaration has been produced to stimulate discussion about what needs to be done in the interest of the health of the majority of humankind. We recognise that the changes may take time to implement. Each country will need to assess how best to bring these about.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: firstname.lastname@example.org.
A group of senior scientists—researchers, academics and intellectuals—from various parts of the world, with over 250 years’ combined experience of working to improve the oral health of communities, independent of any institution, government body or corporate entity, met in Colombia in March 2017 and prepared a statement on their analysis of the problem and recommendations about what should be done. This editorial presents paragraphs extracted from the statement. The full statement, referred to as La Cascada Declaration, together with associated papers, is available at https://lacascada.pressbooks.com/front-matter/introduction/.
2. Latest Equinet Updates
In the evaluation of the Reader on PAR in Health Systems Research (online on this site) one of the proposals made by many respondents was to have a website to share a range of PAR materials, and information on networks, trainers etc online. People indicated and we also noted that there are many existing resources on PAR but that we need to make it easier for people to find what is out there based on specific needs that they have. In response to this EQUINET is setting up in July/ August a PAR portal page called the “Participatory Action Research Portal”. The new portal will have a homepage and a series of ‘subpages’ for Training, resources - which will provide links to online training courses, whole training guides and reports of training activities; Methods, tools and ethics - which will provide links to online specific papers on PAR methods, to specific examples of tools, and to discussions/ guidelines on ethical issues; PAR work – which will provide links to stories, case studies, briefs, videos, text or photojournalism stories of PAR work, including facilitator reflections; Organisations and networks - which will provide the name, snippet of information, country and link to organisations and networks involved PAR; Publications - which will provide published journal papers and reports on PAR through links to the urls or on the EQUINET database and Other resources - which will provide ad hoc information that doesn’t fit anywhere else. The page is being worked on in July and August and will be launched in September 2017. A call has been made for institutions working with PAR to provide information on resources they would like the portal to make links to.
In 2017 EQUINET (through TARSC working with Maldaba a web design company) is developing a web platform for participatory action research (PAR) that would allow us to connect across countries on areas of local community level work and action on areas of health, health determinants and health systems that have wider regional and global relevance or relate to global policies being applied across our countries. In doing this we are building a new tool that will allow us to share, discuss, analyse and design actions across countries in the same way we have done so using PAR at local level, that we can use in future for many purposes. TARSC has opened a call for people with experience of PAR working in east and southern Africa who may be interested in being involved in this process. We will be taking forward the web platform for PAR between July 2017 and December 2019 working with eight sites and health workers and community members in a primary care facility in the site. We will be exploring how disease programme or funding targets such as for performance based financing are affecting health workers professionals roles and team work; health workers relationships with communities and the ability to deliver comprehensive primary health care. We invite people to apply to join the programme as country PAR facilitators. To participate in this programme we invite people who work in an organisation/ programme in a country in an east and southern African country; have had some exposure to PAR approaches; have access to internet; have ongoing work or interaction with at least one primary care centre and with the health workers and community members in it, such as through health centre committees, health literacy or other programmes; have primary care level services that are implementing some form of target driven funding or service delivery, such as in performance based financing or specific disease programmes, and are available for the activities, in the time frames and for the duration noted in the process above. If you are interested please email EQUINET at email@example.com by July 7th 2017 with your name, organisation, country and email address for communication, and: (1) list of any prior training received on PAR, with the course, institution providing the course and year; (2) A list of any PAR work you have implemented, with a line for each on what it was about and the year; (3) Confirmation that you have direct access to internet and what it costs you for a one hour session (if provided institutionally through your organisation please indicate this). (4) The name, location and urban/ rural location of a primary care centre that you regularly interact with, including with the health workers and community members, and whether the health workers and / or community members at this centre have access to the internet (not essential but useful). (5) The form of target driven funding or service delivery being implemented at the primary care service, (ie. performance based financing or specific disease programmes specify for what) and (6) Confirmation that you are available for the activities, in the time frames and for the duration noted in the process above. We will provide feedback to applicants who provide the full information above by last week of July.
Community Working Group on Health in partnership with Training and Research Support Centre, University of Cape Town School of Public Health, and
the Lusaka District Health Management Team under the auspices of EQUINET held a regional review meeting on Health Centre Committees as a vehicle for social participation in health systems in East and Southern Africa on 20-22 June in Harare. The meeting was held as part of a programme to
exchange experiences and information on the laws, roles, capacities, training and monitoring systems that are being applied to HCCs in the ESA region. The meeting discussed experiences with laws, policies, guidelines and constitutions on HCCs; shared experiences in using photo voice to enhance the role of HCCs; discussed current training materials and programmes for HCCs in the region and the strengthening of internal capacities of institutions working with HCCs through information exchange and skills inputs. The report will be made available on the EQUINET website.
3. Equity in Health
This study examined the change in equity of insecticide-treated net ownership among 19 malaria-endemic countries in sub-Saharan Africa before and after the launch of the Cover The Bed Net Gap initiative. To assess change in equity in ownership of at least one insecticide-treated net by households from different wealth quintiles, the authors used data from Demographic and Health Surveys and Malaria Indicator Surveys. The authors assigned surveys conducted before the launch (2003–2008) as baseline surveys and surveys conducted between 2009–2014 as endpoint surveys and did country-level and pooled multi-country analyses, dividing geographical zones into either low- and intermediate-risk or high-risk. To assess changes in equity, they calculated the Lorenz concentration curve and concentration index (C-index). Out of the 19 countries assessed, 13 countries showed improved equity between baseline and endpoint surveys and two countries showed no changes. Four countries displayed worsened equity, two favouring the poorer households and two favouring the richer. The multi-country pooled analysis showed an improvement in equity. Similar trends were seen in both low- and intermediate-risk and high-risk zones. They conclude that the mass insecticide-treated net distribution campaigns to increase coverage, linked to the launch of the Cover The Bed Net Gap initiative, have led to improvement in coverage of insecticide-treated net ownership across sub-Saharan Africa with significant reduction in inequity among wealth quintiles.
The 2016 Dar Es Salaam Call to Action on Diabetes and Other non-communicable diseases (NCDs) advocates national multi-sectoral NCD strategies and action plans based on available data and information from countries of sub-Saharan Africa and beyond. The authors estimated trends from 1980 to 2014 in age-standardised mean body mass index (BMI) and diabetes prevalence in these countries, in order to assess the co-progression and assist policy formulation. They pooled data from African and worldwide population-based studies which measured height, weight and biomarkers to assess diabetes status in adults aged ≥ 18 years. African data came from 245 population-based surveys (1.2 million participants) for BMI and 76 surveys (182 000 participants) for diabetes prevalence estimates. The age-standardised mean BMI increased from 21.0 kg/m2 to 23.0 kg/m2 in men, and from 21.9 kg/m2 to 24.9 kg/m2 in women. The age-standardised prevalence of diabetes increased from 3.4% to 8.5% in men, and from 4.1% to 8.9% in women. Estimates in northern and southern regions were mostly higher than the global average; those in central, eastern and western regions were lower than global averages. A positive association was observed between mean BMI and diabetes prevalence in both sexes in 1980 and 2014. These estimates, based on limited data sources, confirm the rapidly increasing burden of diabetes in Africa. This rise is being driven, at least in part, by increasing adiposity, with regional variations in observed trends. African countries’ efforts to prevent and control diabetes and obesity should integrate the setting up of reliable monitoring systems, consistent with the World Health Organisation’s Global Monitoring System Framework.
4. Values, Policies and Rights
Dr. Tedros Adhanom Ghebreyesus, newly elected Director-General of the World Health Organisation (WHO) for the next five years, believes WHO must evolve and adapt to urgent global health challenges, and “put the right to health at the core of its functions, and be the global vanguard to champion them.” Universal health coverage will be his topmost priority. “The growing momentum around universal health coverage—combined with the global commitment to sustainable development and its motto of “leaving no one behind”—offers unique opportunities to advance equity in health.” In a Q&A with Health and Human Rights Dr Tedros discussed the “hundreds of millions of people missing out on essential health care or falling into poverty trying to pay for it. That is a violation of the human right to health that demands our full attention and urgent action.” He acknowledged that implementation of policies to achieve universal health cover is difficult and requires collaboration and partnership across stakeholders. He explained this collaborative approach guided Ethiopia’s pursuit of equitable health access when he was minister of health. Dr Tedros told Health and Human Rights that he is committed to transforming the way that WHO operates with the core principles of health as a human right and universal health coverage for the most vulnerable are at the forefront of all our work. Too often, Dr Tedros noted, human rights and gender equity are secondary considerations when UN organisations develop programming. He stressed that this is outdated and must change.
Recently, there has been a growing push for countries to achieve universal health coverage (UHC) in order to strengthen health systems and improve health equity and access to health services. Importantly, not all potential paths to a universal health system are consistent with human rights requirements. Simply expanding health coverage, especially if it continues to exclude poor and vulnerable communities, is not sufficient from a human rights perspective. The author in this paper presents the requirements that a human rights approach to UHC imposes. These include locating UHC within the context of a national effort to provide equitable access to the social determinants of health; making access to essential health services and public health protections a legal entitlement, with redress for failures to provide these benefits; paying explicit attention to equity in the design of the universal health system, including in health financing. There should be opportunities for consultation with and the participation of the population in the design of the path to UHC and the determination of benefits packages. The process for pursuing the progressive realisation of UHC should first expand coverage for high-priority services to everyone, with special efforts to ensure that disadvantaged groups are reached. The author notes that the goal of achieving UHC can generally be realised only in stages, through a long process of gradual realisation, given limitations in resource availability and administrative capacity, and that this imposes difficult trade-offs along the way.
5. Health equity in economic and trade policies
States should control corporations across national borders to protect communities from the negative impacts of their activities, UN human rights experts have said in an authoritative new guidance * on the Obligations of States parties to the International Covenant on Economic, Social and Cultural Rights (CESCR) in the context of business activities. “States should regulate corporations that are domiciled in their territory and/or jurisdiction. This refers to corporations which have their statutory seat, central administration or principal place of business on their national territory,” the experts of the UN Committee on Economic, Social and Cultural rights say in the guidance*, officially termed the General Comment, published today. In practice, the Committee expects home States of transnational corporations to establish appropriate remedies, guaranteeing effective access to justice for victims of business-related human rights abuses when more than one country is involved. In light of the practices revealed by the Panama Papers and the Bahamas Leaks, the General Comment emphasizes that States should ensure corporate strategies do not undermine their efforts to fully realize the rights set out in the Covenant. The new General Comment sets out what States can and must do in order to ensure that companies do not violate rights such as the right to food, housing, health or work, which the States themselves are bound to respect: “Businesses cannot ignore that the expectations of society are changing. The first ones to change shall be rewarded by consumers, whose purchasing choices are increasingly driven by immaterial aspects — the reputation of the company, and the ethical and sustainability dimensions associated with its products.” The issue of business and human rights has been addressed recently in different forums, including the Human Rights Council and the International Labour Conference, and through a combination of tools — regulations, self-imposed codes of conduct, economic incentives and action plans. Zdzislaw Kedzia, the Vice-Chair of the UN Committee on Economic, Social and Cultural rights noted that “It may be tempting for States to seek refuge behind the initiatives taken by the corporate sector, rather than adopting the appropriate regulatory and policy initiatives that they must adopt. Our General Comment seeks to recall their obligations under the Covenant and define the role they must assume in regulating corporate conduct.”
Today, the ways and means of technology access and usage are suggested by the author to be driven by power dynamics centering on the needs of specific demographics and experiences, channeling a colonialist exercise of control, establishing who gets to use a tool or service, and to which extent. A growing number of researchers, scholars, artists and advocates has been looking into how a colonialist approach sits at the core of how a great deal of digital technology is developed, distributed, and capitalised. This has progressively contributed to a new lens through which to analyse the subject matter, which can be referred to as the concept of decolonizing technology. With the objective to build a resource to inspire new learning and reflections on the concept of decolonizing technology, this post includes a reading list on the topic. This list represents a snapshot of some the work done to date on the concept of decolonizing technology. It aims to inspire further research and discoveries of any other possible resource and initiative delving deeper into this subject, from many more and different perspectives.
The authors argue that an insular, authoritarian wave has been on the rise that is playing on people's fears and insecurities, undermining democratic institutions that are vital to maintaining the ties of accountability between the elected and the public: and multilateral infrastructures. Global health is argued to rely on an outward-looking, internationalist stance, since the threats that are faced know no borders. So how can global health advance in an era of retreat? Politics drive policies and the public drives the political. All sectors must thus, it is argued, be politically active in order to affect the development and implementation of public policies, including academia and the knowledge it brings. To successfully advance financial and political capital investments in global health, arguments must be framed by how they improve the security and prosperity of citizens and the nation. Investing in global health and multinational actions is a path to address these threats that know no borders.
This document discusses guidance on ethical procurement for health and for protecting labour rights in medical supply chains. It is an update to an earlier document in response to evidence of abuse of worker rights at several factories manufacturing health-care products destined for global markets. Poor labour conditions should concern all those in health care. Work is inextricably correlated to physical and mental well-being: unsafe working conditions risk bodily injury; inadequate remuneration links to malnutrition, poor housing and lack of opportunity. Long or irregular working hours and a lack of respect at work contribute to stress, anxiety and depression. Working conditions found in the manufacture of some health-care products have been among the worse encountered anywhere. The document reports on the measures taken by other countries and that comply with the International Labour Organisation Declaration on fundamental principles and rights at work, as well as with local employment and health and safety legislation. For example for high-risk products, suppliers are contractually required to allow independent audit of manufacturing sites to identify problems and to oblige remedial action, a measure that has led to demonstrable improvements in working conditions for the people making products for the health-care system. The paper also notes that there are still limited measures for protection of health and safety in the growing global market for health-care products, estimated to soon be worth over US$ 500 billion annually.
6. Poverty and health
In Namibia, a generations-long tradition of tapping the sap of palm trees runs counter to recent environmental protection efforts. Is this an essential cultural practice or merely destructive? These striking portraits investigate. The images in this series portray the Himba men who select, prepare and maintain Makalani palms during the sap tapping process. The Himba people from this area have utilised this plant family for generations, passing down the knowledge and technique needed to carry out the process of obtaining the liquid. Although the Makalani palm is a protected tree in Namibia and the tapping of palms a banned practice, the Himba firmly believe that it is their right to continue the tradition. They argue against Western law and instead follow ancient cultural traditions that respect these palms through their utilisation. In turn, they promote their conservation on a local, cultural level.
Tobacco use among people living with HIV results in excess morbidity and mortality. However, very little is known about the extent of tobacco use among people living with HIV in low-income and middle-income countries (LMICs). The authors assessed the prevalence of tobacco use among people living with HIV in LMICs. The authors used Demographic and Health Survey data collected between 2003 and 2014 from 28 LMICs where both tobacco use and HIV test data were made publicly available. They estimated the country-specific, regional, and overall prevalence of current tobacco use (smoked, smokeless, and any tobacco use) among 6729 HIV-positive men from 27 LMICs (aged 15–59 years) and 11 495 HIV-positive women from 28 LMICs (aged 15–49 years), and compared them with those in 193 763 HIV-negative men and 222 808 HIV-negative women, respectively. The authors estimated prevalence separately for males and females as a proportion, and the analysis accounted for sampling weights, clustering, and stratification in the sampling design. They computed pooled regional and overall prevalence estimates through meta-analysis with the application of a random-effects model. They computed country, regional, and overall relative prevalence ratios for tobacco smoking, smokeless tobacco use, and any tobacco use separately for males and females to study differences in prevalence rates between HIV-positive and HIV-negative individuals. The overall prevalence among HIV-positive men was 24·4% for tobacco smoking, 3·4% for smokeless tobacco use, and 27·1% for any tobacco use. The authors found a higher prevalence in HIV-positive men of any tobacco use (risk ratio [RR] 1·41 and tobacco smoking than in HIV-negative men (both p<0·0001). The difference in smokeless tobacco use prevalence between HIV-positive and HIV-negative men was not significant. The overall prevalence among HIV-positive women was 1·3% for tobacco smoking, 2·1% for smokeless tobacco use, and 3·6% for any tobacco use. The authors found a higher prevalence in HIV-positive women of any tobacco use, tobacco smoking and smokeless tobacco use than in HIV-negative women. The high prevalence of tobacco use in people living with HIV in LMICs mandates targeted policy, practice, and research action to promote tobacco cessation and to improve the health outcomes in this population.
Born 1994, Tshepo Jamillah Moyo (TJ) is an unapologetic black Pan African Inter-sectional Feminist performance artist. Her work centres on the exploration of black African womanhood. In this conversation, she discusses her provocation at a recent march in Botswana on the 3rd of June where human rights and gender activists, and fellow women marched in the RIGHT TO WEAR WHAT I WANT walk, which aimed to highlight that no one has the right to violate another human being based on what they are wearing. Moyo argues that there is a need for an intersectional feminism that thinks about every single woman, and all the intersections of her life where oppression derives from.
The role of gender in prevention of mother-to-child transmission (PMTCT) participation under Option B+ has not been adequately studied, but it is critical for reducing losses to follow-up. This study used qualitative methods to examine the interplay of gender and individual, interpersonal, health system, and community factors that contribute to PMTCT participation in Malawi and Uganda. The authors conducted in-depth interviews with women in PMTCT, women lost to follow-up, government health workers, and stakeholders at organisations supporting PMTCT as well as focus group discussions with men. They analysed the data using thematic content analysis. The authors found many similarities in key themes across respondent groups and between the two countries. The main facilitators of PMTCT participation were knowledge of the health benefits of ART, social support, and self-efficacy. The main barriers were fear of HIV disclosure and stigma and lack of social support, male involvement, self-efficacy, and agency. Under Option B+, women learn about their HIV status and start lifelong ART on the same day, before they have a chance to talk to their husbands or families. Respondents explained that very few husbands accompanied their wives to the clinic, because they felt it was a female space and were worried that others would think their wives were controlling them. Many respondents said women fear disclosing, because they fear HIV stigma as well as the risk of divorce and loss of economic support. If women do not disclose, it is difficult for them to participate in PMTCT in secret. If they do disclose, they must abide by their husbands’ decisions about their PMTCT participation, and some husbands are unsupportive or actively discouraging. To improve PMTCT participation, the authors propose that Ministries of Health use evidence-based strategies to address HIV stigma, challenges related to disclosure, insufficient social support and male involvement, and underlying gender inequality.
7. Equitable health services
Heart failure is a major cause of disease burden in sub-Saharan Africa. The authors aim to provide a better understanding of the capacity to diagnose and treat heart failure in Kenya and Uganda to inform policy planning and interventions. They analysed data from a nationally representative survey of health facilities in Kenya and Uganda (197 health facilities in Uganda and 143 in Kenya) and report on the availability of cardiac diagnostic technologies and select medications for heart failure. Facility-level data were analysed by country and platform type (hospital vs ambulatory facilities). Functional and staffed radiography, ultrasound and ECG were available in less than half of hospitals in Kenya and Uganda combined. Of the hospitals surveyed, 49% of Kenyan and 77% of Ugandan hospitals reported availability of the heart failure medication package. ACE inhibitors were only available in 51% of Kenyan and 79% of Ugandan hospitals. Almost one-third of the hospitals in each country had a stock-out of at least one of the medication classes in the prior quarter. Few facilities in Kenya and Uganda were prepared to diagnose and manage heart failure. Medication shortages and stock-outs were common. The authors’ findings call for increased investment in cardiac care to reduce the growing burden of heart failure.
Evaluation of influenza surveillance systems is poor, especially in Africa. In 2007, the Institut Pasteur de Madagascar and the Malagasy Ministry of Public Health implemented a countrywide system for the prospective syndromic and virological surveillance of influenza-like illnesses. In assessing this system’s performance, the authors identified gaps and ways to promote the best use of resources. The authors investigated acceptability, data quality, flexibility, representativeness, simplicity, stability, timeliness and usefulness and developed qualitative and/or quantitative indicators for each of these attributes. Until 2007, the influenza surveillance system in Madagascar was only operational in Antananarivo and the observations made could not be extrapolated to the entire country. By 2014, the system covered 34 sentinel sites across the country. At 12 sites, nasopharyngeal and/or oropharyngeal samples were collected and tested for influenza virus. Between 2009 and 2014, 177 718 fever cases were detected, 25 809 (14.5%) of these fever cases were classified as cases of influenza-like illness. Of the 9192 samples from patients with influenza-like illness that were tested for influenza viruses, 3573 (38.9%) tested positive. Data quality for all evaluated indicators was categorised as above 90% and the system also appeared to be strong in terms of its acceptability, simplicity and stability. However, sample collection needed improvement. The influenza surveillance system in Madagascar performed well and provided reliable and timely data for public health interventions. Given its flexibility and overall moderate cost, the authors argue that this system may become a useful platform for syndromic and laboratory-based surveillance in other low-resource settings.
Three African countries have been chosen to test the world’s first malaria vaccine, the World Health Organisation announced in April 2017. Ghana, Kenya, and Malawi will begin piloting the injectable vaccine next year with hundreds of thousands of young children, who have been at highest risk of death. The vaccine, which has partial effectiveness, has the potential to save tens of thousands of lives if used with existing measures, the WHO regional director for Africa, Dr. Matshidiso Moeti, said in a statement. The challenge is whether impoverished countries can deliver the required four doses of the vaccine for each child. Malaria remains one of the world’s most stubborn health challenges, infecting more than 200 million people every year and killing about half a million, most of them children in Africa. Bed netting and insecticides are the chief protection. A global effort to counter malaria has led to a 62 percent cut in deaths between 2000 and 2015, WHO said. But the U.N. agency has said in the past that such estimates are based mostly on modelling and that data is so bad for 31 countries in Africa — including those believed to have the worst outbreaks — that it couldn’t tell if cases have been rising or falling in the last 15 years. The vaccine will be tested on children five to 17 months old to see whether its protective effects shown so far in clinical trials can hold up under real-life conditions. At least 120,000 children in each of the three countries will receive the vaccine, which has taken decades of work and hundreds of millions of dollars to develop. Kenya, Ghana and Malawi were chosen for the vaccine pilot because all have strong prevention and vaccination programs but continue to have high numbers of malaria cases, WHO said. The countries will deliver the vaccine through their existing vaccination programs. WHO is hoping to wipe out malaria by 2040 despite increasing resistance problems to both drugs and insecticides used to kill mosquitoes. The malaria vaccine has been developed by pharmaceutical company GlaxoSmithKline, and the $49 million for the first phase of the pilot is being funded by the global vaccine alliance GAVI, UNITAID and Global Fund to Fight AIDS, Tuberculosis and Malaria.
8. Human Resources
Community Health Workers feel unrecognised and undervalued by community leaders and health professionals. This was the central message from a major thematic discussion held on the HIFA forums and sponsored by The Lancet, Reachout Project/Liverpool School of Tropical Medicine, World Vision International and USAID Assist Project. More than 60 HIFA members contributed their experience and expertise to the discussion, including CHW programme managers, researchers and policymakers, as well as a large number of CHWs and ASHAs from India and Uganda. Countries represented included Burundi, Cameroon, Canada, Ethiopia, France, Ghana, India, Iran, Japan, Kenya, Malaysia, Netherlands, New Zealand, Nigeria, Pakistan, Rwanda, Switzerland, Tanzania, Uganda, UK, and USA. Other major concerns were lack of training and supervision; access to healthcare information; remuneration; equipment, medicines, and need for mobile phones/computers. CHWs said they are asked to carry out a wide range and ever increasing number of tasks, but often without the appropriate facilities to enable this. CHWs feel unrecognised and undervalued by official health care providers which not only reduces morale but also creates a disjoint between perceived influence by community, and their actual influence, reducing their respect from the community. Furthermore, this lack of respect is reflected in their lack of training and supervision, and results in a paucity of avenues for them to voice their needs and concerns.
Young women in Malawi face many challenges in accessing family planning, including distance to the health facility and partner disapproval. The author’s primary objective was to assess if training Health Surveillance Assistants in couples counselling would increase modern family planning uptake among young women. In this cluster randomised controlled trial, 30 Health Surveillance Assistants from Lilongwe, Malawi received training in family planning. The Health Surveillance Assistants were then randomised 1:1 to receive or not receive additional training in couples counselling. All Health Surveillance Assistants were asked to provide family planning counselling to women in their communities and record their contraceptive uptake over 6 months. Sexually-active women <30 years of age who had never used a modern family planning method were included in this analysis. Generalised estimating equations with an exchangeable correlation matrix to account for clustering by Health Surveillance Assistants were used to estimate risk differences and 95% confidence intervals. 430 (53%) young women were counselled by the 15 Health Surveillance Assistants who received couples counselling training, and 378 (47%) were counselled by the 15 Health Surveillance Assistants who did not. 115 (26%) from the couples counselling group had male partners present during their first visit, compared to only 6 (2%) from the other group. Nearly all (99.5%) initiated a modern family planning method, with no difference between groups. Women in the couples counselling group were 8% more likely to receive male condoms and 8% more likely to receive dual methods. Training Health Surveillance Assistants in family planning led to high modern family planning uptake among young women who had never used family planning. Couples counselling training increased male involvement with a trend towards higher male condom uptake.
Social accountability is defined as the responsibility of institutions to respond to the health priorities of a community. There is an international movement towards the education of health professionals who are accountable to communities. There is little evidence of how communities experience or articulate this accountability. In this grounded theory study eight community based focus group discussions were conducted in rural and urban South Africa to explore community members’ perceptions of the social accountability of doctors. The discussions were conducted across one urban and two rural provinces. Group discussions were recorded and transcribed verbatim. Initial coding was done and three main themes emerged following data analysis: the consultation as a place of respect (participants have an expectation of care yet are often engaged with disregard); relationships of people and systems (participants reflect on their health priorities and the links with the social determinants of health) and Ubuntu as engagement of the community (reflected in their expectation of Ubuntu based relationships as well as part of the education system). These themes were related through a framework which integrates three levels of relationship: a central community of reciprocal relationships with the doctor-patient relationship as core, a level in which the systems of health and education interact and together with social determinants of health mediate the insertion of communities into a broader discourse. The paper outlines an ubuntu framing in which the tensions between vulnerability and power interact and reflect rights and responsibility as important for social accountability. Communities are argued to bring a richer dimension to social accountability through their understanding of being human and caring.
9. Public-Private Mix
The author points out that no single non-governmental institution or individual wields more influence, and no one’s support is more powerful in global health, than the Gates Foundation and its namesake founders, Bill and Melinda Gates. The foundation has $39.6 billion in assets and spent $2.9 billion on developmental assistance for global health in 2015 alone ― more than every country in the world except the U.S. and the U.K. The author argues that WHO has frequently fallen short of its goal to protect and promote health of all people, leading some to propose returning to a more philanthropy-focused model. That means private charities such as the Gates Foundation might play an even larger role in protecting public health, which calls for scrutiny of the role that philanthropy has played in recent years. When the Gates Foundation takes aim at a disease, it can elicit billions of dollars from governments and reshape the world’s agenda for scientific research, to the cost of other diseases. WHO reliance on voluntary contributions from countries and private donors, including the Gates Foundation, for around 80 percent of its budget is argued to make the organisation vulnerable to outside pressure and funder 'pet programs', which skews global health priorities. The author documents trends post 2014 and argues that the world remains grossly underprepared for outbreaks of infectious disease, which are likely to become more frequent in the coming decades, according to a meta-analysis of post-Ebola studies published in January 2017. The author indicates that public and state funding remains critical for international health efforts and cannot be left to private players to fill the void.
10. Resource allocation and health financing
The World Health Organisation African region, covering the majority of Sub-Saharan Africa, faces the highest rates of maternal and neonatal mortality in the world. This study uses data from the State of the World's Midwifery 2014 survey to cast a spotlight on the World Health Organisation African region, highlight the specific characteristics of its sexual, reproductive, maternal and newborn health (SRMNH) workforce and describe and compare countries' different trajectories in terms of meeting the population need for services. Using data from 41 African countries, this study used a mathematical model to estimate potential met need for SRMNH services, defined as "the percentage of a universal SRMNH package that could potentially be obtained by women and newborns given the composition, competencies and available working time of the SRMNH workforce." The model defined the 46 key interventions included in this universal SRMNH package and allocated them to the available health worker time and skill set in each country to estimate the potential met need. Based on the current and projected potential met need in the future, the countries were grouped into three categories: (1) 'making or maintaining progress' (expected to meet more, or the same level, of the need in the future than currently): 14 countries including Ghana, Senegal and South Africa, (2) 'at risk' (currently performing relatively well but expected to deteriorate due to the health workforce not keeping pace with population growth): 6 countries including Gabon, Rwanda and Zambia, and (3) 'low performing' (not performing well and not expected to improve): 21 countries including Burkina Faso, Eritrea and Sierra Leone. The three groups face different challenges, and the authors argue that policy solutions to increasing met need should be tailored to the specific context of the country and that national health workforce accounts be strengthened so that workforce planning can be evidence-informed.
Payment for Performance (P4P) aims to improve provider motivation to perform better, but little is known about the effects of P4P on accountability mechanisms. The authors examined the effect of P4P in Tanzania on internal and external accountability mechanisms. The authors carried out 93 individual in-depth interviews, 9 group interviews and 19 Focus Group Discussions in five intervention districts in three rounds of data collection between 2011 and 2013. The authors carried out surveys in 150 health facilities across Pwani region and four control districts, and interviewed 200 health workers, before the scheme was introduced and 13 months later. The authors examined the effects of P4P on internal accountability mechanisms including management changes, supervision, and priority setting, and external accountability mechanisms including provider responsiveness to patients, and engagement with Health Facility Governing Committees. P4P had some positive effects on internal accountability, with increased timeliness of supervision and the provision of feedback during supervision, but a lack of effect on supervision intensity. P4P reduced the interruption of service delivery due to broken equipment as well as drug stock-outs due to increased financial autonomy and responsiveness from managers. Management practices became less hierarchical, with less emphasis on bureaucratic procedures. Effects on external accountability were mixed, health workers treated pregnant women more kindly, but outreach activities did not increase. Facilities were more likely to have committees but their role was largely limited. P4P resulted in improvements in internal accountability measures through improved relations and communication between stakeholders that were incentivised at different levels of the system and enhanced provider autonomy over funds. P4P had more limited effects on external accountability, though attitudes towards patients appeared to improve, community engagement through health facility governing committees remained limited. Implementers should examine the lines of accountability when setting incentives and deciding who to incentivise in P4P schemes.
Despite decades of interventions, malaria is still one of the biggest killer diseases in Africa continent. In 2015 alone, an estimated 429 000 people died of malaria according to the World Health Organisation, 90% of them in Africa. Beyond the lives lost, how much economic damage does malaria really do to sub-Saharan economies? That’s a question CGTN's Ramah Nyang explored in conversation with the CEO of the African Medical & Research Foundation.The drug RTSS prevents more than forty strains of malaria in toddlers. It is being rolled out to more than 300 000 children in Kenya, Ghana and Malawi in trials and more vaccines are being tested. It is unlikely that one vaccines will eradicate all malaria, but testing vaccines can significantly reduce the impact of malaria. Malaria was eradicated in Europe and America in the 1930s and many are asking why this cannot be done again in Africa.
11. Equity and HIV/AIDS
Scarce data are available on the epidemiology of hypertension among HIV patients in rural sub-Saharan Africa. The authors explored the prevalence, incidence and risk factors for incident hypertension among patients who were enrolled in a rural HIV cohort in Tanzania. A prospective longitudinal study including HIV patients enrolled in the Kilombero and Ulanga Antiretroviral Cohort was carried out between 2013 and 2015. Non-ART subjects at baseline and pregnant women during follow-up were excluded from the analysis. Incident hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg on two consecutive visits. Cox proportional hazards models were used to assess the association of baseline characteristics and incident hypertension. Among 955 ART-naïve, eligible subjects, 111 (11.6%) were hypertensive at recruitment. Ten women were excluded due to pregnancy. Of the remaining individuals, 9.6% developed hypertension during a median follow-up of 144 days from time of enrolment into the cohort. ART was started in 75.5% of patients, with a median follow-up on ART of 7 months. Cox regression models identified age, body mass index and estimated glomerular filtration rate as independent risk factors for hypertension development. Traditional cardiovascular risk factors predicted incident hypertension, but no association was observed with immunological or ART status. These data support the implementation of routine hypertension screening and integrated management into HIV programmes in rural sub-Saharan Africa.
12. Governance and participation in health
This paper seeks to advance the authors’ understanding of health policy agenda setting and formulation processes in a lower middle income country, Ghana, by exploring how and why maternal health policies and programmes appeared and evolved on the health sector programme of work agenda between 2002 and 2012. The authors theorised that the appearance of a policy or programme on the agenda and its fate within the programme of work is predominately influenced by how national level decision makers use their sources of power to define maternal health problems and frame their policy narratives. National level decision makers used their power sources as negotiation tools to frame maternal health issues and design maternal health policies and programmes within the framework of the national health sector programme of work. The power sources identified included legal and structural authority; access to authority by way of political influence; control over and access to resources (mainly financial); access to evidence in the form of health sector performance reviews and demographic health surveys; and knowledge of national plans such as Ghana Poverty Reduction Strategy. The authors argue that understanding of power sources and their use as negotiation tools in policy development should not be ignored in the pursuit of transformative change and sustained improvement in health systems in low- and middle income countries.
13. Monitoring equity and research policy
An evaluation exercise was carried out to assess the performance of Community Animal Health Workers (CAHWs) in the delivery of animal health care services in Karamoja region, identify capacity gaps and recommend remedial measures. Participatory methods were used to design data collection tools. Questionnaires were administered to 204 CAHWs, 215 farmers and 7 District Veterinary Officers (DVOs) to collect quantitative data. Seven DVOs and 1 Non Government Organisation (NGO) representative were interviewed as key informants and one focus group discussion was conducted with a farmer group in Nakapiripirit to collect qualitative data. Key messages from interviews and the focus group discussion were recorded in a notebook and reported verbatim. 70% of the farmers revealed that CAHWs are the most readily available animal health care service providers in their respective villages. CAHWs were instrumental in treatment of sick animals, disease surveillance, control of external parasites, animal production, vaccination, reporting, animal identification, and performing minor surgeries. Regarding their overall performance 88.8% of the farmers said they were impressed. The main challenges faced by the CAHWs were inadequate facilitation, lack of tools and equipment, unwillingness of government to integrate them into the formal extension system, poor information flow, limited technical capacity to diagnose diseases, unwillingness of farmers to pay for services and sustainability issues. CAHWs remain the main source of animal health care services in Karamoja region and their services are largely satisfactory. The technical deficits identified are argued to require continuous capacity building programs, close supervision and technical backstopping and strategic deployment of paraprofessionals that are formally recognised by the traditional civil service.
The maternal mortality ratio (MMR) has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, ‘guilty until proven innocent’. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. The authors show, however, that measurement experts’ work has also been driven by the need to secure political priority for safe motherhood and by donors’ need to justify and monitor the results of investment flows. They explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. the authors analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented funders who have introduced new forms of administrative oversight and accountability that depend on indicators.
14. Useful Resources
In 2016, more refugees arrived in Uganda–including nearly half a million people from South Sudan alone–than crossed the Mediterranean Sea to Europe. While the numbers in Africa are increasing, the situation isn’t new: As the world continues to focus on the European refugee crisis, an equally large crisis has been unfolding in Africa. A new visualization shows the flow of refugees around the world from 2000 to 2015, and makes the lesser-known story in Africa–and in places like Sri Lanka in 2006 or Colombia in 2007–as obvious as what has been happening more recently in Syria. Each yellow dot represents 17 refugees leaving a country, and each red dot represents refugees arriving somewhere else.
15. Jobs and Announcements
The East African Community (EAC) in collaboration with leading national, regional and international Partners is organising the first ever “1st EAC Heads of State Summit on Investment in Health and Joint International Health Sector Investors and Donors Round-table Meeting and International Trade Exhibition” as part of proceedings of the 19th Ordinary Summit of the EAC Heads of State, from 27th to 30th November 2017 at the Commonwealth Speke Resort Hotel & Conference Centre, Munyonyo, Kampala, Uganda. The Theme of the Summit and Round-table Meeting and Trade Exhibition is "Investing in Health Systems, Infrastructure, Health Services and Research for accelerated attainment of Universal Health Coverage (UHC) and health-related Sustainable Development Goals (SDGs) in the EAC by the year 2030". The event will incorporate an International Trade Fair and Open Air Exhibitions and it will provide an opportunity for high level discussions among Partner States, national, regional and international Partners, local investors and other stakeholders aimed at focusing attention on the urgent need for major investments in the health sector.
The Council for the Development of Social Science Research in Africa (CODESRIA) announces a call for submission of proposals from academics and researchers in African universities and Research Centers for the 2017 session of its annual Democratic Governance Institute. The institute will be held in the Council’s headquarters in Dakar, Senegal from 4 – 15 September 2017 on the theme “Economic Governance and Africa’s Economic Transformation’. The Democratic Governance Institute, launched in 1992 by CODESRIA, is an annual interdisciplinary forum which brings together about fifteen researchers from various parts of the continent and the Diaspora, as well as some non-African scholars engaged in innovative research on topics related to the general theme of governance. An area where Africa’s play a critical role in the global economy is the resource extraction sector. After the resource boom of the 2000-2010 decade and the confidence attending to the ‘Africa rising’ narratives, a number of countries are experiencing deeper economic regression. Creative ways to support the extraction of resources have not kept pace with demands of Africans for an interrogation of the place of Africa in the global value chain. Fast and fleeting forms of extraction are now being implemented because appetite for Africa’s resources from external markets remains high and continues to grow. While useful provisions to counter the appetite for African resources exist, many intellectuals have not publicized the African Mining Vision of the African Union to reiterate demands for changing the structures of mining and African economies.The theme of “Economic Governance and Africa’s Economic Transformation’ has been selected with the hope that laureates will have time to reflect in some depth on the contemporary economic trends in the continent and the kind of governance architecture required to insulate African economies from dangerous global economic networks. Applicants who wish to be considered as laureates should be PhD candidates or scholars in their early career with a proven capacity to conduct research on the theme of the Institute. Intellectuals active in the policy process and/or social movements and civil society organizations are also encouraged to apply. The number of places offered by CODESRIA at each session is limited to fifteen (15). Young African academics from the Diaspora and Non-African scholars who are able to fund their participation may also apply for a limited number of places. All applications or requests for additional information should be sent electronically to the email below.
The objective of this course is to help sharpen the facilitation techniques of people who use participatory methods for their projects, and who work with groups. This course will deepen their understanding of group processes, and provides a space for facilitators to learn from each other by sharing knowledge and experiences. The training course will be run in a workshop style with a high degree of participant involvement using adult learning methods. Group work and role plays will be interspersed with input sessions combining theory and practice. The trainers are expert facilitators, and will also demonstrate the skills that they share. The course is also designed to include a range of different method that can be used to facilitate group processes. The training course covers essential skills for facilitation, the roles of a facilitator and interpersonal communication and conversation styles in facilitation. Further, the course will introduce participants to skills on how to manage group dynamics & understanding group decision-making processes, how to design a facilitation process and facilitation tools and techniques and how to use them.
The Alan J. Flisher Centre for Public Mental Health (CPMH), a joint initiative of the Psychology Department at Stellenbosch University and the Department of Psychiatry and Mental Health at the University of Cape Town, is an independent inter-disciplinary academic research and teaching centre for public mental health promotion and service development in Africa. The CPMH is proud to invite applications from across the African continent for the MPhil in Public Mental Health in 2018. A key gap in current mental health professional training in South Africa and elsewhere in Africa is an orientation to public mental health. This means an orientation to the mental health needs of populations, and the policies, laws and services that are required to meet those needs. The training offered by the Centre provides clinicians, health service managers, policy makers and NGO workers with crucial skills to enable them to plan and evaluate the services that they deliver and manage; lobby effectively for mental health; take on leadership roles in the strengthening of mental health systems; and conduct research in various aspects of public mental health in Africa. The MPhil in Public Mental Health is a part-time research degree that aims to develop advanced research skills, enabling participants to undertake their own research projects (such as evaluating services, policies and interventions) as well as interpret research findings for mental health policy and practice. The programme is designed to be accessible to practitioners who work full-time, and who are from a range of backgrounds: social work, psychology, psychiatry, medicine, occupational therapy, nursing, health economics, public mental health, public health, health service management, policy making and non-governmental organisations (NGOs). The training aims to build the professional capacity and leadership of the participants in their work, while contributing to knowledge generation in Africa. The degree requires the completion of a 3-week residential training module in research methodology for public mental health in Cape Town and the preparation of a dissertation of a minimum of 20 000 words, in either monograph or publication ready format.
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