EQUINET NEWSLETTER 197 : 01 August 2017

1. Editorial

The EQUINET newsletter as a health equity resource from the region
Editor, EQUINET Newsletter

The EQUINET newsletter intends to raise the visibility and accessibility of evidence about and from east and southern Africa on different aspects of equity in health. Now in its 197th issue, it has since its inception shared a total of nearly 12 000 papers, articles, resources and other information on and from the region on areas related to health equity.

Launched in May 2001 by EQUINET from within the region and appearing monthly for the sixteen years since then, it has included new knowledge and evidence on a range of areas, from values, policies and rights, financing, health worker issues, clinical and health service practices through to health determinants and governance that have a bearing on improved delivery on policy commitments to equity in health. Thank you to the many people generating evidence and debate on these areas and to those who have helped the newsletter to be a consistent vehicle for sharing this information.

While it appears monthly in members’ email boxes, what may be less well known is that the current database of 11 500 articles compiled over the years on the EQUINET website is a resource that can be searched by themes and by title, author or text key words, to support research and evidence for social and policy dialogue.

This database may itself be an interesting source of evidence for those reviewing policy trends in the region. While it provides an accessible source of specific information for people working on equity in health and its determinants, it may also provide an interesting insight into the rise and fall of attention to specific issues in the region, from HIV and the retention of health workers, to emergencies, chronic conditions and universal coverage. Some areas, such as gender equity, poverty and social participation in health, have also had persistent presence since the first newsletter in 2001, albeit with less visible focus and with different lenses and perspectives. For others, such as privatisation and the public-private mix of health services, there appears to have been a deficit in attention, with far less open access publication, despite their importance for health equity in the region.

The sixteen years of the newsletter also provide an insight into the changing nature of evidence. In 2001 there was a predominance of formal publications in journals, reports and print media. This continues, with a slow improvement in journal papers being led by authors from within the region. Today, however, there is a more diverse mix in the forms of evidence, adding an increasing presence of blogs, videos, talks, photojournalism and art forms. This has brought new voice to the evidence and analyses on health equity, although many still face barriers in access to digital media.

We’d like to hear your voice.

As we head towards the 200th issue, let us know where the newsletter has been useful to you and what improvements you would want to see.

For our 200th issue, we invite you to send us in August and September editorials written by you, and any links to videos, blogs, papers or other online resources you want to share on your perspective on the opportunities that we should be tapping in east and southern Africa for making immediate or longer term advances in equity in health (whether generally, or on a specific aspect), and how and by whom they could be taken forward.

Please send feedback or queries or editorial or url links to information to the EQUINET secretariat: admin@equinetafrica.org

2. Latest Equinet Updates

Are Health Centre Committees a Vehicle for Social Participation in Health? Report on a Regional HCC Review Meeting, June 2017

EQUINET through the Community Working Group on Health (CWGH) as the cluster lead for the work on social empowerment in health, in partnership with Training and Research Support Centre (TARSC), University of Cape Town (UCT) and Lusaka District Health Office (LDHO), with support from Open Society Initiative for Eastern Africa (OSIEA) have embarked on a regional programme, ‘HCCs as a vehicle for social participation in health systems in East and Southern Africa’ to address some of the outcomes mentioned above. This report documents the proceedings during the Regional HCC exchange visit held at Mwanza clinic, Goromonzi district on the 20th of June 2017 and the review meeting held in Harare on the 21st of June 2017. The meeting aimed to: discuss experiences with laws, policies, guidelines and constitutions on HCCs; share experiences in using Photovoice to enhance the role of HCCs; discuss current training materials and programmes for HCCs in the region and discuss strengthening of internal capacities of institutions working with HCCs through information exchange and skills inputs.

Center for Health, Human Rights and Development (CEHURD) Court case wins the Gender Justice Uncovered Awards 2017
Nanfuka G: CEHURD, June 2017

The Center for Health, Human Rights and Development (CEHURD), is an EQUINET cluster lead for the theme work on the right to health. CEHURD, Mubangizi Michael and Musimenta Jennifer Vs the Executive Director of Mulago National Referral Hospital and Attorney General of Uganda (Civil Suit No 212 of 2013), “Mulago case” and Justice Lydia Mugambe’s judgement won the Gender Justice Uncovered Awards in May 2017 hosted by Women’s Link Worldwide. In this landmark ruling Justice Lydia Mugambe noted that the disappearance of the couple's baby also resulted to psychological torture for the parents as well as putting the spotlight on the State's failure to fulfil its obligations under the right to health. The Court also pointed to the overburdened hospital staff which led to errors as another example of the failure of the State to comply with its obligations. The judgment won with 3,829 votes beating 17 other rulings that were nominated for the best judicial decision from all around the world in the Gender Justice Uncovered Awards under the People's Choice Gavel 2017 category. This award comes at a time when CEHURD is implementing the judgment through discussions and support to Mulago National Referral Hospital to develop and put in place mechanisms to ensure the safety of babies after delivery.

3. Equity in Health

Early menarche: A systematic review of its effect on sexual and reproductive health in low- and middle-income countries
Ibitoye M; Choi C; Lee G; Sommer M: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178884, 2017

Adolescent girls aged 15–19 bear a disproportionate burden of negative sexual and reproductive health outcomes in low- and middle-income countries. The authors conducted this systematic review to better understand whether and how early menarche is associated with various negative sexual and reproductive health outcomes in low- and middle-income countries and the implications of such associations. They systematically searched eight health and social sciences databases for peer-reviewed literature on menarche and sexual and reproductive health in low- and middle-income countries. The authors’ review of the minimal existing literature (with 24 papers included) showed that early menarche is associated with early sexual initiation, early pregnancy and some sexually transmitted infections in low- and middle-income countries, as has been observed in high-income countries. Early menarche is also associated with early marriage–an association that may have particularly important implications for countries with high child marriage rates. Early age at menarche may be an important factor affecting the sexual and reproductive health of adolescent girls and young women in low- and middle-income countries. Given the association of early menarche with early marriage, the authors propose that ongoing efforts to reduce child marriage may benefit from targeting efforts to early maturing girls.

Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure prospective cohort study
Dokainish H; Teo K; Zhu J; et al.,INTER-CHF Investigators: The Lancet Global Health 5(7), e665-e672, 2017

Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions. Here, in the International Congestive Heart Failure (INTER-CHF) study, the authors aimed to measure mortality at 1 year in patients with heart failure in Africa, China, India, the Middle East, southeast Asia and South America and to explore demographic, clinical, and socioeconomic variables associated with mortality. The authors enrolled 5823 patients within 1 year with a 98% follow-up. Mortality was highest in Africa (34%) and India (23%), compared to an overall average of 16%. Regional differences persisted after multivariable adjustment. Independent predictors of mortality included cardiac variables and non-cardiac variables (body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease). 46% of mortality risk was explained by multivariable modelling with these variables; however, the remainder was unexplained. Marked regional differences in mortality in patients with heart failure persisted after multivariable adjustment for cardiac and non-cardiac factors. Therefore, variations in mortality between regions could be the result of health-care infrastructure, quality and access, or environmental and genetic factors. Further studies in large, global cohorts are suggested to be needed.

Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure
Buse K; Tanaka S; Hawkes S: Globalisation and Health 13(34), doi: 10.1186/s12992-017-0255-3, 2017

Non-communicable diseases (NCDs) represent a significant threat to human health and well-being, and carry significant implications for economic development and health care and other costs for governments and business, families and individuals. Risks for many of the major NCDs are associated with the production, marketing and consumption of commercially produced food and drink, particularly those containing sugar, salt and transfats (in ultra-processed products), alcohol and tobacco. The problems inherent in primary prevention of NCDs have received relatively little attention from international organisations, national governments and civil society, especially when compared to the attention paid to provision of medical treatment and long-term clinical management. Low political priority may be due in part to the complexity inherent in implementing feasible and acceptable interventions, such as increased taxation or regulation of access, particularly given the need to coordinate action beyond the health sector, and the fact that this brings public health into conflict with the interests of profit-driven food, beverage, alcohol and tobacco industries. The authors use a conceptual framework to review three models of governance of NCD risk: self-regulation by industry; hybrid models of public-private engagement; and public sector regulation. The authors analysed the challenges inherent in each model, and review what was known (or not) about their impact on NCD outcomes. While piecemeal efforts have been established, the authors argued that mechanisms to control the commercial determinants of NCDs are inadequate and efforts at remedial action too limited. The authors set out an agenda to strengthen each of the three governance models, with reforms that will be needed to the global health architecture to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress in reducing the global burden of NCDs.

4. Values, Policies and Rights

Reclaiming policies for the public
Third World Network (TWN): TWN Info, July 2017

A global coalition of civil society organisations and trade unions presented a report on 'Spotlight on Sustainable Development 2017'. The report provides a comprehensive independent assessment of the implementation of the 2030 Agenda and its Sustainable Development Goals (SDGs). In the 2030 Agenda governments committed to a revitalised Global Partnership between States and declared that public finance has to play a vital role in achieving the SDGs. But in recent decades, the combination of neoliberal ideology, corporate lobbying, business-friendly fiscal policies, tax avoidance and tax evasion has led to a massive weakening of the public sector and its ability to provide essential goods and services. The same corporate strategies and fiscal and regulatory policies that led to this weakening have enabled an unprecedented accumulation of individual wealth and increasing market concentration. The proponents of privatisation and public-private partnerships (PPPs) use these trends to present the private sector as the most efficient way to provide the necessary means for implementing the SDGs. But many studies and experiences by affected communities have shown that privatisation and PPPs involve disproportionate risks and costs for the public sector. PPPs can even exacerbate inequalities, decrease equitable access to essential services and jeopardise the fulfilment of human rights. Therefore, it is high time to counter these trends, reclaim public policy space and take bold measures to strengthen public finance, regulate or reject PPPs and weaken the grip of corporate power on people’s lives. These are indispensable prerequisites to achieve the SDGs and to turn the vision of the transformation of the world, as proclaimed in the title of the 2030 Agenda, into reality. The 160-page report is supported by a broad range of civil society organisations and trade unions, and based on experiences and reports by national and regional groups and coalitions from all parts of the world. Its 35 articles cover all sectors of the 2030 Agenda and the SDGs, and reflect the rich geographic and cultural diversity of their authors.

Understanding how domestic health policy is integrated into foreign policy in South Africa: a case for accelerating access to antiretroviral medicines
Modisenyane M; Hendricks S; Fineberg H: Global Health Action 10(1), doi: http://dx.doi.org/10.1080/16549716.2017.1339533, 2017

South Africa, as an emerging middle-income country, is becoming increasingly influential in global health diplomacy. However, little empirical research has been conducted to inform arguments for the integration of domestic health into foreign policy by state and non-state actors. This study aimed to address this knowledge gap, as an empirical case study analysing how South Africa integrates domestic health into its foreign policy, using the lens of access to antiretroviral (ARV) medicines. It explored state and non-state actors’ perceptions regarding how domestic health policy is integrated into foreign policy to achieve better insights into health and foreign policy processes at the national level. Employing qualitative approaches, the authors examined changes in the South African and global AIDS policy environment. Purposive sampling was used to select key informants, a sample of state and non-state actors who participated in in-depth interviews. Secondary data were collected through a systematic literature review of documents retrieved from five electronic databases, including review of key policy documents. Qualitative data were analysed for content. The findings showed the interplay among social, political, economic and institutional conditions in determining the success of this integration process. A series of national and external developments, stakeholders, and advocacy efforts and collaboration created these integrative processes. South Africa’s domestic HIV/AIDS constituencies, in partnership with the global advocacy movement, catalysed the mobilisation of support for universal access to ARV treatment nationally and globally, and the promotion of access to healthcare as a human right. The report concludes that transnational networks may influence government’s decision making by providing information and moving issues up the agenda.

5. Health equity in economic and trade policies

Listen to Civil Society: Medicines for People, Not Profit
Quigley F: Health and Human Rights Journal Blog, May 2017

In her final address to the World Health Assembly (WHA) as WHO Director-General, Dr. Margaret Chan identified access to medicines as the most contentious issue of her decade-long tenure. That struggle was engaged, she said, “especially when intellectual property and the patent system were perceived as barriers to both affordable prices and the development of new products for diseases of the poor.” Dr. Chan also had advice for the delegates gathered before her at the Palais de Nations in Geneva: “Listen to civil society. Civil society are society’s conscience.” Just a few hours after Dr. Chan yielded the podium, a spirited demonstration was held outside the grounds of the Palais de Nation. Organised by the student-led advocacy group Universities Allied for Essential Medicines, the demonstrators called for the WHA delegates and the new director-general to listen to the WHA’s member states from Southeast Asia, Africa, and Latin America. Those nations have long called for WHO to prioritise the medicines issue. The term “de-linkage” was repeated by many panellists at an antimicrobial resistance discussion which happened at a side event. It describes a drug development model that is an alternative to the current intellectual property paradigm, where government-granted patent monopolies allow drug prices to be hiked to levels that are sometimes hundreds of times above the price of production. The justification for the high prices is that the price charged for medicines needs to fund research and development. Deliberately “de-linking” the R&D costs from the price of medicines bypasses those calculations, and instead undercuts the very foundation of the monopoly pricing argument. It calls for taking advantage of the already-significant government and philanthropic commitment to research and using it to fund non-profit R&D to a sufficient level that the price of medicines does not need to be connected to research costs. This would allow medicines to be far more affordable

Open letter to WHO on industrial animal farming and public health
Weathers S; Hermanns S; and 270 expert signatories: Open Letter Animal Farming, 2017

Over 200 scientists, policy experts and others concerned persons are urging the new World Health Organisation (WHO) Director-General to recognise and address factory farming as a growing public health challenge. Just as the WHO has bravely confronted companies that harm human health by peddling tobacco and sugar-sweetened beverages, they argue that it must not waver in advocating for the regulation of industrial animal farming. Total consumption of antibiotics in animal food production is projected to grow by almost 70% between 2010 and 2030. According to the WHO, two of the three most commonly used classes of antibiotics in U.S. animal farming—penicillins and tetracyclines—are of critical importance to humans. Practices such as the constant low dosing of antibiotics and environmental pollution through animal waste make industrial animal farms the perfect breeding ground for antibiotic resistance by allowing transmission into the environment and nearby community. The authors raise other risks of industrial animal farming and call on WHO to strengthen WHO’s Global Action Plan on Antimicrobial Resistance to encourage member states of the WHO to ban the use of growth-promoting antibiotics in animal farming, as well as low-dose “disease prevention” antibiotics. Member states should be encouraged to articulate specific, verifiable standards for what constitutes legal antibiotic use in animal farms. Amongst other recommendations they argue that WHO should encourage member states to adopt nutrition standards and implement health education campaigns to inform citizens of the health risks of meat consumption and work closely with ministers of health and agriculture to formulate policies that advocate for a greater proportion of plant-based foods in the diets of member states. Lastly, they recommend that the WHO should consider funding the scientific development of plant-based and other meat alternatives, which have the potential to eliminate or reduce the harms of factory farming.

6. Poverty and health

Determining baselines for human-elephant conflict: A matter of time
Pozo R; Coulson T; McCulloch G; Stronza A; Songhurst A: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178840, 2017

Northern Botswana holds the largest population of African elephants in the world, and in the eastern Okavango Panhandle, 16,000 people share and compete for resources with more than 11,000 elephants. Hence, it is not surprising this area represents a human-elephant conflict (HEC) ‘hotspot’ in the region. Crop-raiding impacts lead to negative perceptions of elephants by local communities, which can strongly undermine conservation efforts. The authors investigated the trend in the number of reported raiding incidents as one of the indicators of the level of HEC, and assessed its relationship to trends in human and elephant population size, as well as land-use in the study area from the 1970s to 2015. They found that the level of reported crop raiding by elephants in the eastern Panhandle appears to have decreased since 2008, which seems to be related more to the reduction in agricultural land allocated to people in recent years, more than the human and elephant population size. Although the study represents a first step in developing a HEC baseline in the eastern Panhandle, it highlights the need for additional multi-scale analyses that consider progress in conservation conflict to better understand and predict drivers of HEC in the region.

‘These are not luxuries, it is essential for access to life’: Disability related out-of-pocket costs as a driver of economic vulnerability in South Africa
Hanass-Hancock J; Nene S; Deghaye N; Pillay S: African Journal of Disability 6(0), a280, 2017

Middle-income countries are home to a growing number of persons with disabilities but with limited evidence on the factors increasing economic vulnerability in people with disabilities in these countries. This article presents data related to elements of this vulnerability in one middle-income country, South Africa. Focusing on out-of-pocket costs, it uses focus group discussions with 73 persons with disabilities and conventional content analysis to describe these costs. A complex and nuanced picture of disability-driven costs evolved on three different areas: care and support for survival and safety, accessibility of services and participation in community. Costs varied depending on care and support needs, accessibility (physical and financial), availability, and knowledge of services and assistive devices. The development of poverty alleviation and social protection mechanisms in middle-income countries like South Africa should, the authors argue, better consider diverse disability-related care and support needs not only to improve access to services such as education and health but also to increase the effect of disability-specific benefits and employment equity policies

7. Equitable health services

Non-communicable diseases and HIV care and treatment: models of integrated service delivery
Duffy M; Ojikutu B; Andrian S; Sohng E; Minior T; Hirschhorn L: Tropical Medicine and International Health 00(00), doi:10.1111/tmi.12901, 2017

Non-communicable diseases (NCD) are a growing cause of morbidity in low-income countries including in people living with human immunodeficiency virus (HIV). Integration of NCD and HIV services can build upon experience with chronic care models from HIV programmes. The authors described the models of NCD and HIV integration, challenges and lessons learned. A literature review of published articles on integrated NCD and HIV programs in low-income countries and key informant interviews were conducted with leaders of identified integrated NCD and HIV programs. Information was synthesised to identify models of NCD and HIV service delivery integration. Three models of integration were identified as follows: NCD services integrated into centres originally providing HIV care; HIV care integrated into primary health care (PHC) already offering NCD services; and simultaneous introduction of integrated HIV and NCD services. Major challenges identified included NCD supply chain, human resources, referral systems, patient education, stigma, patient records and monitoring and evaluation. The range of HIV and NCD services varied widely within and across models. conclusions Regardless of model of integration, leveraging experience from HIV care models and adapting existing systems and tools is a feasible method to provide efficient care and treatment for the growing numbers of patients with NCDs. The authors argue that operational research should be conducted to further study how successful models of HIV and NCD integration can be expanded in scope and scaled-up by managers and policymakers seeking to address all the chronic care needs of their patients.

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania
Kruk M; Chukwuma A; Mbaruku G; Leslie H: Bulletin of the World Health Organisation 95(6), 389-480, 2017

This study analysed factors affecting variations in the quality of antenatal and sick-child care in primary-care facilities in seven African countries, using service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania in 2006–2014. Based on World Health Organization protocols, they created indices of process quality for antenatal care (first visits) and for sick-child visits and assessed national, facility, provider and patient factors that might explain variations in quality of care. Overall, health-care providers performed a mean of 62% of eight recommended antenatal care actions and 55% of nine sick-child care actions at observed visits. The quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The authors conclude that the quality of two essential primary-care services for women and children was weak and varied across and within the countries. They observe that analysis of reasons for variations in quality could identify strategies for improving care.

8. Human Resources

A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: a cluster randomised controlled trial in South Africa
Horwood C; Butler L; Barker P; et al.: Human Resources for Health 15(39), doi: 10.1186/s12960-017-0210-7, 2017

Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs. This cluster randomised controlled trial investigated the effectiveness of a continuous quality improvement intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Intervention CHWs received a 2-week training in WHO Community Case Management followed by mentoring for 12 months. Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs. At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy and the postnatal period. Intervention mothers had higher maternal and child health knowledge scores and reported higher exclusive breastfeeding rates to 6 weeks. HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW. Uptake of facility-based interventions was not significantly different. Improved training and mentoring of CHWs can, it is thus argued, improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.

Capacity-building for a strong public health nutrition workforce in low-resource countries
Delisle H; Shrimpton R; Blaney S; Du Plessis L; Atwood S; Sanders D; Margetts B: Bulletin of the World Health Organisation 95(5) 385-388, 2017

This paper highlights current issues and challenges in public health nutrition in low- and middle-income countries and shares recommendations for the development of this workforce. Several factors are argued to contribute to a scarcity of nutrition professionals in low- and middle-income countries, including: a lack of understanding of the role of public health nutrition in the prevention and management of the various forms of malnutrition; a low-income country priority for doctors and nurses (and sometimes also frontline workers) within meagre health workforce expenditures; a higher priority for undernutrition interventions than for those for nutrition-related chronic diseases, despite their escalation in these countries. Both food system changes, at the level of production, processing and distribution, and behaviour change communication are argued to be needed to reorient the nutrition transition, and nutritionists have a major role to play in this regard. Although it requires sustained efforts, training can be regarded as the easy part of nutrition workforce development in low- and middle-income countries. More challenging steps are recognition of the nutrition profession and its regulation, opening up government jobs for nutrition graduates and financing local training programmes and nutritionists’ salaries in the public sector. The underlying causes of malnutrition, and hence sustained solutions to the problem, lie to a large extent in the non-health sectors. The authors argue that nutrition has to be addressed not only by other health professionals, but also by agriculture and education professionals and field workers, who need to integrate relevant nutrition tasks into their professional activities (such as orienting food production towards meeting the population’s nutrition requirements or teaching healthy eating to schoolchildren).

Health workforce and governance: the crisis in Nigeria
Adeloye D; David R; Olaogun A; Auta A; Adesokan A; Gadanya M; Opele J; Owagbemi O; Iseolorunkanmi A: Human Resources for Health 15(32), doi: 10.1186/s12960-017-0205-4, 2017

In Nigeria, several challenges have been reported within the health sector, especially in training, funding, employment, and deployment of the health workforce. The authors reviewed the recent health workforce crises in the Nigerian health sector to identify key underlying causes and provide recommendations toward preventing and/or managing potential future crises in Nigeria. The authors observe that the Nigerian health system is relatively weak, and there is yet a coordinated response across the country. A number of health workforce crises have been reported in recent times due to several months’ salaries owed, poor welfare, lack of appropriate health facilities and emerging factions among health workers. Poor administration and response across different levels of government were found to have played contributory roles to further internal crises among health workers, with different factions engaged in protracted supremacy challenge. These crises have consequently prevented optimal healthcare delivery to the Nigerian population. The authors argue for various measures, including an inclusive stakeholders’ forum in the health sector; and a solid administrative policy foundation that allows coordination of priorities and partnerships in the health workforce and among various stakeholders.

9. Public-Private Mix

The medical device development landscape in South Africa: Institutions, sectors and collaboration
De Jager K; Chimhundu C; Saidi T; Douglas TS: South African Journal of Science 13(5/6), 2017

A characterisation of the medical device development landscape in South Africa would be beneficial for future policy developments that encourage locally developed devices to address local healthcare needs. The landscape was explored through a bibliometric analysis (2000–2013) of relevant scientific papers using co-authorship as an indicator of collaboration. Collaborating institutions found were divided into four sectors: academia (A); healthcare (H); industry (I); and science and support (S). A collaboration network was drawn to show the links between the institutions and analysed using network analysis metrics. The academic sector collaborated the most extensively both within and between sectors; local collaborations were more prevalent than international collaborations. Translational collaborations (AHI, HIS or AHIS) are considered to be pivotal in fostering medical device innovation that is both relevant and likely to be commercialised. Few such collaborations were found, suggesting room for increased collaboration of these types in South Africa. These results could inform the development of strategies and policies to promote certain types of medical device development. Further studies could identify drivers and barriers to successful medical device development in South Africa.

10. Resource allocation and health financing

Sub-national assessment of aid effectiveness: A case study of post-conflict districts in Uganda
Ssengooba F; Namakula J; Kawooya V; Fustukian S: Globalisation and Health 13(32), doi: 10.1186/s12992-017-0251-7, 2017

In post-conflict settings, many state and non-state actors interact at the sub-national levels in rebuilding health systems by providing funds, delivering vital interventions and building capacity of local governments to shoulder their roles. Aid relationships among actors at sub-national level represent a vital lever for health system development. This study was undertaken to assess the aid-effectiveness in post-conflict districts of northern Uganda. This was a three district cross sectional study conducted from January to April 2013. Managers of organisations involved in service delivery were interviewed and asked to list the external organisations that contribute to three key services. For each inter-organisational relationship a custom-made tool designed to reflect the aid-effectiveness in the Paris Declaration was used. Three hundred eighty four relational ties between the organisations were generated from a total of 85 organisations interviewed. Satisfaction with aid relationships was mostly determined firstly by the extent managers were able to negotiate own priorities, by their awareness of expected results, and thirdly on the provision of feedback about their performance. Provider satisfaction was mostly determined by awareness of expected results and feedback on performance. These findings illustrate the focus on “results” domain and less on “ownership” and “resourcing” domains. The capacity and space for sub-national level authorities to negotiate local priorities requires more attention especially for health system development in post-conflict settings.

11. Equity and HIV/AIDS

Sex in the shadow of HIV: A systematic review of prevalence, risk factors, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa
Toska E; Pantelic M; Meinck F; Keck K; Haghighat R; Cluver L: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178106, 2017

This systematic review synthesises the extant research on prevalence, factors associated with, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. Studies were located through electronic databases, grey literature, reference harvesting, and contact with researchers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies that reported on HIV-positive participants (10–24 year olds), included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy), and were conducted in sub-Saharan Africa were included. Forty-two records reported one or multiple sexual practices for 13,536 HIV-positive adolescents/youth from 13 sub-Saharan African countries. Seventeen cross-sectional studies reported on individual, relationship, family, structural, and HIV-related factors associated with sexual risk-taking. However, the majority of the findings were inconsistent across studies, and most studies scored <50% in the quality checklist. Living with a partner, living alone, gender-based violence, food insecurity, and employment were correlated with increased sexual risk-taking, while knowledge of own HIV-positive status and accessing HIV support groups were associated with reduced sexual risk-taking. Of the four intervention studies (three RCTs), three were effective at reducing sexual risk-taking, with one reporting no difference between the intervention and control groups. Sexual risk-taking among HIV-positive adolescents and youth is high, with inconclusive evidence on potential determinants and the authors argue for ffective and feasible low-cost interventions to reduce risk for this group.

What is it going to take to move youth-related HIV programme policies into practice in Africa?
Mark D; Taing L; Cluver L; Collins C; Iorpenda K; Andrade A; Hatane L: Journal of the International AIDS Society 20(Suppl 3)21491, 2017

HIV has been reported to be the leading cause of mortality amongst adolescents in Africa. This has brought attention to the changes in service provision and health management that many adolescents living with HIV experience when transferring from specialised paediatric- or adolescent-focused services to adult care. When transition is enacted poorly, adherence may be affected and the continuum of care disrupted. The authors present the case that considerable gaps remain in moving policy to practice on this at global, national, and local levels and that standard operating procedures or tools to support this transition are lacking. Guidance often overlooks the specific needs and rights of adolescents, in particular for those living with HIV. In some cases, prohibitive laws can impede adolescent access by applying age of consent restriction to HIV testing, counselling and treatment, as well as SRH services. Where adolescent-focused policies do exist, they have been slow to emerge as tangible operating procedures at health facility level. A key barrier is the nature of existing transition guidance, which tends to recommend an individualised, client-centred approach, driven by clinicians. In low- and middle-income settings, flexible responses are resource intensive and time consuming, and therefore challenging to implement amidst staff shortages and administrative challenges. They propose that national governments adopt transition-specific policies to ensure that adolescents seamlessly receive appropriate and supportive care, as part of a broader adolescent-centred policy landscape and adolescent-friendly orientation and approach at health system level. Youth involvement and community mobilisation are seen to be essential for this. .

12. Governance and participation in health

The WHO’s new African leader could be a shot in the arm for poorer countries
Sanders D: The Conversation, May 2017

Dr Tedros Ghebreyesus is the first African to be elected as the Director-General of the World Health Organisation (WHO) in its 70 year history. The massive margin for Tedros – 133 votes vs 50 for the UK candidate – suggests that the entire Global South voted for him. Professor David Sanders in this interview suggests that the vote almost certainly represents a vote against big power domination and machinations in the WHO which often appears to ignore the main challenges and aspirations of low and middle income countries. Professor Sanders notes that Dr Ghebreyesus needs to use his strong mandate – notably from the Global South – to truly reform the WHO and its operations in favour of the world’s poor majority. To do this, he needs to push strongly for member states to honour their commitments to the WHO and to rapidly and significantly increase their financial contributions. He also needs to ensure that the influence of the food, beverage, alcohol and tobacco industries to control non communicable diseases is resisted. This will be difficult given that a framework has been passed that allows non-state actors to participate in WHO policy-making processes. Further he argues that Dr Ghebreyesus must ensure that the health systems of low and middle income countries are strengthened so that health emergencies such as infectious disease outbreaks can be contained. This will ensure that agenda for health security isn’t focused on securing the health of rich country populations against contagion from the poor but on protecting all, particularly the most vulnerable. Hi raises that what will be interesting to watch over the next five years is whether the evident solidarity between low and middle income counties in voting in Dr Ghebreyesus as their candidate is maintained during the debates and decisions about world health.

Uganda’s Achievement in Family Planning and Reproductive Health: Advocacy pays off
Partners in Population and Development: PPD, Uganda, 2017

Uganda has released the result of Demographic Health Survey (UDHS 2016) highlighting the success in family planning and reproductive health. Uganda’s population is the second youngest in the world, with half of the country younger than 15.7 years old (just older than Niger’s median age of 15.5 years). As of January 2017, the population of Uganda was estimated to be 40 million, the age structure defines 49.9% in the below 15 years, 48.1% in 15-64 year of age group and the rest 2.1% are 64+ n the past 10 years, showing increasing growth rate (3.24 in 2016 est.), the country has added more than 10 million, from 24 to 35 million. DHS 2016 showed noteworthy success in maternal health care. Nearly three-quarters (74%) of live births were delivered by a skilled provider and almost the same proportion (73%) were delivered in a health facility which was almost half in 15 years back. Throughout the course of their lifetimes, Ugandan women have a 1-in-35 chance of dying due to pregnancy-related causes; every day, 16 women die in childbirth. However, the overall trend indicates a decline of pregnancy-related mortality over the time. Infant and child mortality rates are basic indicators of a country’s socioeconomic situation and quality of life. The country’s infant mortality rate was one of the highest in the world, but 2016 DHS showed steep declining trend. The Contraceptive Prevalence Rate (CPR) has risen steadily from a low starting point and moved upward sharply in most years in Uganda, on the other hand the unmet need of contraceptive is showing gradual decreasing trend. As the country’s population continues to grow, the majority of that growth is taking place in rural areas, where access to health services is extremely limited. PPD argues that with the call for universal access to reproductive health and family planning, the country is moving rapidly towards this goal. Such progress will help the country move closer to the targeted demographic that are linked with the larger development goals. Significant effort is argued to still be required to mitigate rural-urban disparity. Political commitment beyond the health sector, partner collaboration, community provision to increase community engagement is reported to lie behind the trends in the DHS key indicators report.

13. Monitoring equity and research policy

Quality of care: measuring a neglected driver of improved health
Akachi Y; Kruk M: Bulletin of the World Health Organisation 95(6), 389-480, 2017

The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is argued to be inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. The authors propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalise civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.

South Africa’s vital statistics are currently not suitable for monitoring progress towards injury and violence Sustainable Development Goals
Prinsloo M; Bradshaw D; Joubert J; Matzopoulos R; Groenewald P: South African Medical Journal 107(6), 470-471, 2017

Two of the most important targets to achieving the United Nation’s Sustainable Development Goals (SDGs) for reducing violence and other injuries are Target 3.6: to ‘halve the number of global deaths and injuries from road traffic accidents’ by 2020; and Target 16.1: the significant reduction of ‘all forms of violence and related death rates everywhere’. Police statistics on homicide, and transport deaths from the Road Traffic Management Corporation, are considered to be under-reported and are not a reliable source for monitoring SDGs. In South Africa (SA), vital statistics data are the only routine source that captures unnatural and natural deaths through death registration. Since the early 1990s, focused initiatives have identified and addressed deficiencies in the completeness of death registration and recent estimates indicate that completeness for persons aged ≥2 years is >90%. However, there are still concerns about the quality of data relating to the cause of death, i.e. under- reporting of HIV/AIDS deaths owing to misclassification to other causes, a large proportion of deaths with ill-defined causes, and the validity of single-cause data. The misclassification of injury deaths is another major limitation. The Inquest Act of 1959 precludes forensic pathologists from reporting the manner of death, i.e. whether it is due to homicide, suicide, transport or other unintentional injuries, on the basis that it may prejudice the findings of the inquest. Homicides are therefore grossly under-represented in official vital statistics. The misclassification of injury deaths was clearly demonstrated in a nationally representative study of injury deaths presenting to state forensic mortuaries in 2009. The absence of information on the manner of injury death in the official statistics needs to be addressed urgently. A review and possible amendment of the Inquest Act would possibly take years. The authors recommend that the death notification form be amended in line with the updated World Health Organisation’s recommendation, to include a stand-alone field for information about the manner of injury death for unnatural causes. Forensic pathologists when uncertain can include a proviso stating that such information is for statistical purposes only. This matter is currently being discussed with relevant stakeholders.

14. Useful Resources

AND THEN SHE SAID - 5 Novels, 5 Women, 5 Stories
Jallow M: Positively African, October 2016

Experience African literature in a totally new way through an intimate re-imagining of five acclaimed novels, performed for the stage. Reimagined and retold by five women the stories grapple with questions of race, sexuality, patriarchy, friendship, love, loneliness and much more. Drawing from the historical novel ‘The Orchard of Lost Souls’ by the young award-winning Somali-British writer Nadia Mohamed, Raya Wambui bears witness to the painful experience of three Somali women. Patricia Kihoro’s presents a performance of Zukiswa Wanner’s painfully funny and profoundly perceptive ‘Maid in SA: 30 ways to leave your madam’.

New BMC and HSG webinar series: Understanding the peer review and publication process
Logan H: BMC Health Services Research and BioMed Central journals, 2017

Publishing is an important part of sharing the outcomes of research, but the publication process and requirements may sometimes feel like a closed book. HSG and BioMed Central, publisher of BMC Health Services Research which is affiliated with HSG, have partnered to deliver a series of five webinars to open up the peer review and publication processes. Aimed at researchers at a variety of career stages, the series covered: how to prepare an article and choose the right journal, what happens during peer review, publishing models and open access, research and publication ethics and how to be a peer reviewer. This series is now finished, but information on the full series of webinars is provided, including the recordings and slides of all of the webinars.

15. Jobs and Announcements

Adolescent and Youth Health Policy Short Course
Deadline for applications: 25 August 2017

This short-course in Cape Town, South Africa, has been developed to support staff of governmental and non-governmental organisations working at national, provincial and district levels, in the implementation of the new Adolescent & Youth Health Policy 2017 and allied policies. It aims to build the capacity of those with management responsibilities for the implementation of policies through improved knowledge about adolescence, key health problems affecting young people and priority evidence-based interventions to address them and strengthen programming skills. This course is provided by the Desmond Tutu HIV Foundation, housed within the Desmond Tutu HIV Centre (DTHC) at the University of Cape Town.

Council for the Development of Social Science Research in Africa (CODESRIA) Humanities Call: Meaning-making Research Initiatives (MRI)
Deadline for applications: 15 September 2017

Within the framework of its 2017-2021 Strategic Plan, CODESRIA introduces Meaning-Making Research Initiative (MRI) as the principal tool for supporting research. Like previous tools, MRI will focus on supporting research that contributes to agendas for imagining, planning and creating African futures. The Council is issuing this special call for proposals because of the peculiar challenges that teaching and research in the Humanities are encountering in African universities today. It is also motivated by the important contributions that scholarship in the Humanities can make to an understanding of Africa and efforts to construct African futures. CODESRIA seeks projects that broach new and interesting questions and employs innovative methods to address these issues. Projects that address important social challenges on the continent and that are rooted in conversations between the Humanities and other fields of knowledge like the social and natural sciences are strongly encouraged. Work that examines on the status and importance of the Humanities in society and reflects on how to develop humanities teaching and research in universities are also encouraged. Group initiatives: MRIs under this special call should be groups of researchers from one country or multiple countries. Each group should have between 3 and 5 members and should take into account CODESRIA’s core principles of gender, linguistic, intergenerational, interdisciplinary diversity. All applications must engage with CODESRIA’s 2017-2021 thematic priorities and cross-cutting issues: democratic processes, governance, citizenship and security in Africa; ecologies, economies and societies in Africa; higher education dynamics in a changing Africa.

Fifth Global Symposium on Health Systems Research (HSR2018)
8 – 12 October 2018, Liverpool, UK

The Global Symposium on Health Systems Research is organised every two years by Health Systems Global to bring together the full range of players involved in health systems and policy research and practice. The Alma Ata vision of ‘Health for All’ remains as compelling today as it was in 1978, as reflected in goal 3 of the Sustainable Development Goals (SDGs). But the world has changed in forty years. Despite improved health outcomes, there remain extraordinary challenges for health equity and social inclusion, such as demographic and disease transitions, conflicts and their subsequent migrations, pluralistic health systems and markets, and climate change. Political systems still marginalise those most in need. Yet there are new opportunities for health systems to achieve universal coverage. The Fifth Global Symposium will advance conversations and collaborations on new ways of financing health; delivering services; and engaging the health workforce, new social and political alliances, and new applications of technologies to promote health for all.

Grand Challenges Canada Funding Opportunities
Deadline for applications: 3 August 2017

Through the Stars in Reproductive, Maternal, Newborn and Child Health Request for Proposals, Grand Challenges Canada seeks bold ideas for products, services and implementation models that could transform how persistent challenges in reproductive, maternal, newborn and child health are addressed in low- and middle-income countries. Of particular interest to Grand Challenges Canada are innovations to improve reproductive, maternal, newborn and child health in humanitarian contexts, notably among internally displaced and refugee populations, as well as innovations that improve the sexual and reproductive health and rights of women and girls, so that they are empowered and have greater influence over their lives and futures.

MPhil in Public Mental Health: Call for Applications
Deadline for Applications 1 September 2017

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.

PHASA Conference 2017 (The Public Health Association of South Africa)
4-7 September 2017, Johannesburg, South Africa

The Public Health Association of South Africa invites the local, regional and international public health community to Johannesburg, South Africa for their 13th annual conference. The theme of the 2017 conference is “A Global Charter for the Public’s Health”: Implications for Public Health Practice in South Africa. Last year, the conference considered public health practices in the context of the Sustainable Development Goals. This year the conference will critically reflect on the WFPHA/WHO collaboration “A Global Charter for the Public’s Health” and its implications for public health in South Africa. The conference will examine the four enabling functions of the Charter, viz. governance, capacity, information and advocacy. There will be conversations on how these four enabling functions can be strengthened in South Africa and discussions on critical current issues like globalisation and decolonisation in relation to public health.

PhD Bursaries for Researching Obesogenic Food Environments in South Africa
Applications considered monthly. Final closing date 31st October 2017.

The Postgraduate Diploma in Poverty, Land and Agrarian Studies is a unique programme offered by PLAAS at the University of the Western Cape. It is the only programme in the land and agrarian studies field at a South African university. Two PhD bursaries are available as part of the IDRC-funded project “Researching Obesogenic Food Environments”, which is led by Profs David Sanders and Rina Swart at the UWC School of Public Health in partnership with the Institute for Poverty, Land and Agrarian Studies (PLAAS) and with Kwame Nkrumah University of Science and Technology (KNUST) in Ghana. PLAAS is an excellent platform for academic teaching and learning in land and agrarian reform, poverty and natural resources management. Established PLAAS researchers, involved in socially relevant and innovative research, are also course coordinators. The application of teaching and learning takes place through contact time with coordinators, self-learning through extensive reading and analysis, together with writing assignments. Applicants with extensive work experience (at least ten years) in land and agrarian issues, and with good writing abilities, without an undergraduate degree, may apply to be considered on the basis of recognition of prior learning (RPL).

Scholarship for Research on Demilitarisation in Lesotho
Deadline for applications: 31 August 2017

For many countries, there are arguments against military expenditure, including its opportunity costs and the availability of cost effective alternative ways of providing security. A number of countries exist without a military, including Costa Rica, Iceland, Panama and Mauritius. The Peacebuilding Programme at Durban University of Technology is offering a scholarship at master’s or doctoral level to extend this work. In particular, the student might work in the following areas: Examine the findings of the Lesotho foresight and scenarios project, titled ‘The Lesotho we want: imagining the future, shaping it today’; and ideas towards a demilitarisation initiative which fit with and build on the attitudes and priorities of the population. The student would, in conjunction with others, plan a campaign to build acceptance of the idea of demilitarisation and then implement the plan. Demilitarisation would be a political decision so the idea has to find acceptance in the minds of politicians. In conjunction with others, the student would plan and implement ways to bring this about.

SFH: HIV Self-Testing Programme Manager
Deadline for applications: 20 August 2017

The Society for Family Health (SFH) is a South African affiliate of Population Services International (PSI), an international NGO network operational in over 70 countries. SFH in South Africa concentrates on issues of HIV/ AIDS. As part of their HIV/AIDS control efforts, SFH is using social marketing to motivate behaviour change with respect to consistent condom use, HIV testing and other safer behaviours. The duties and responsibilities include project management, monitoring and evaluation, supervision, coordination and relationship management, managing budgets and reporting. The successful candidate will be a creative, innovative and strategic thinker, and will have: excellent communication, analytical, organisational, interpersonal and cross-cultural skills; a strong interest in private sector approaches to development; and a proven ability to produce results and meet objectives under difficult circumstances.

World Health Organisation (WHO) Call for Research Findings on Digital Health Interventions
Deadline for submissions: 15 September 2017

In response to a global need for evidence-based global recommendations on the use of digital health interventions available via mobile device, the WHO Department of Reproductive Health and Research in collaboration with other WHO departments has commenced the process of developing WHO Guidelines. As part of this process, over the coming months, a series of systematic reviews of research evidence have been commissioned on specific digital health topics. WHO is requesting from the global community any and all relevant primary studies that should be considered for inclusion in the systematic reviews. This is an opportunity to contribute to the literature that will be included in the systematic reviews that will be informing WHO Guidelines on Digital Health Interventions. The Guidelines will systematically consolidate evidence of effectiveness related to these digital health interventions, as well as review associated feasibility, costs, and risks, in order to formulate concrete recommendations to inform evidence-based investments and prioritisation. Studies can focus on issues related to effectiveness, equity, resource use acceptability, feasibility, or resource use/cost-effectiveness, and can be from any setting, can be both published or unpublished, can include both randomised and non-randomised studies and qualitative studies. The systematic review team will review all submitted papers and determine if they fulfil the inclusion criteria.


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