EQUINET NEWSLETTER 203 : 01 February 2018

1. Editorial

Are we making progress in universal access to health workers? Reflections on the global health worker movement
Dr Francis Omaswa, ACHEST, Uganda

The 4th Global forum on Human Resources for Health (HRH) that took place in Dublin, Ireland in November 2017 provided a useful opportunity to reflect on how far we have progressed in the global movement on human resources for health. The achievement of Sustainable Development Goal (SDG) 3, including Universal Health Coverage will not be possible without universal access to skilled health workers. A global health workforce movement is thus critical to ensure this and that access to essential health services is not left to market forces alone, leaving many unable to access basic health services.

I coordinated the convening of the first Global HRH Forum in Kampala in 2008 as the Executive Director of the Global Health Workforce Alliance at the time and have attended all the subsequent forums in Thailand and Brazil. I was thrilled to witness in Dublin how the HRH movement remains alive and vibrant ten years after the first forum. It was attended by over 1000 delegates from over 70 countries representing government leaders, civil society, academia, employers, foundations, health care professional associations and unions, youth and the private sector.

Beyond the numbers, it was the outcomes of the Dublin Forum that represent potential advances in the health worker movement, globally, and in Africa.

I saw a renewal and rejuvenation of the global HRH movement, with many new champions committed to act on the Dublin call to provide a skilled, supported and motivated health worker for every person in every village everywhere, and the 2008 Kampala Forum call for “Health Workers for All and All for Health Workers.” A Global Health Workforce Network (GHWN) hosted in World Health Organization, Geneva now brings together a range of stakeholders in the movement to organise activities around these commitments, with hubs around various fields such as education and training, leadership and governance, labour markets and civil society. A new civil society coalition on HRH was launched in Dublin to drive advocacy and accountability.

There was strong participation of Africans from all parts of Africa at the Dublin Forum. The African Platform on HRH held a side event, adopted a business plan and elected a new governing board that was empowered to update the Constitution, to support the visibility of the movement in Africa and to convene the 6th Forum of the African HRH Platform.

We were informed that implementation had been initiated of the recommendations and five year action plan of the UN Secretary General’s High Level Commission of Health Employment and Economic Growth. This commission demonstrated that employment in health and the health sector itself should not be seen as a cost but as a significant contributor to economic growth and employment, especially of women. The economies of high income countries all enjoy significant contributions from the health sector.

A new international fund named “Working for Health Multi-Partner Trust Fund (MPTF)” was launched during the 2017 Dublin forum as a collaboration between the International Labour Organization, the Organization for Economic Co-operation and Development and the World Health Organization to support countries expand and transform their health workforce. The Government of Norway has made the first contribution and urged others to invest. The fund should enable development partners to pool contributions for use by ‘pathfinder’ countries to apply innovative approaches to building a ‘fit-for-purpose’ health workforce, especially those countries that are struggling to provide access to health care and facing the threat of emerging epidemics.

The Dublin Forum also saw the launch of the International Platform on Health Worker Mobility. This platform seeks to maximize mutual benefits and mitigate adverse effects from the increasing rate and complexity of the movement of health workers. It will strengthen evidence, analysis, knowledge exchange and policy action on health worker migration, including to support implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel. The forum also made commitments to improving the safety and security of health workers by upholding international humanitarian law. It strongly condemned violence, attacks and threats directed against health personnel and facilities, given their long term consequences for health workers, for the civilian population and for the healthcare systems of the countries concerned and their neighbours.

A special feature not seen in previous forums was the Youth Forum in Dublin that set its own ‘call for action’. Attracting and retaining young health workers is critical if we are to avert the shortfall of 18 million health workers, and transform the health and social workforce.

It was significant that the 2017 forum took place during a doctors’ strike in my own country, Uganda, and a similar nurses’ strike in Kenya. One of the most powerful take-away reflections for me was that while several speakers from high income countries reported how money is chasing and seeking to attract scarce health workers, in most of our African countries, it is health workers who are underfunded and chasing money. Unless we act to address the imbalance in the demand for health workers between high and low income countries, African countries will continue to be drained of health workers going to high income countries, even while African people continue to suffer the shortages of skilled health workers that undermine their access to health care and delivery on SDG3.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the Dublin Forum can be found at http://hrhforum2017.ie/

2. Latest Equinet Updates

Growing number of resources on the Participatory Action Research Portal
TARSC: EQUINET pra4equity network, 2017

The Participatory Action Research Portal for resources on Participatory Action Research (PAR) on the EQUINET website has a growing number of resources on PAR related to training courses, training guides and reports of training activities; methods, tools and ethics; PAR work and journal publications on PAR. The portal is a resource for all those working with PAR and includes resources in any language. There is a form for people to send videos, photojournalism, organisations, journal papers, training guides and other resources for the portal. The url link shown here is in English but there is also a Spanish version at http://www.equinetafrica.org/content/portal-de-recursos-para-la-investigaci%C3%B3n-acci%C3%B3n-participativa-iap

3. Equity in Health

Children Count
Children’s Institute, University of Cape Town, 2017

The Children Count website hosts information about children in South Africa: their living conditions, care arrangements, health status, and access to schools and other services. These child-centred statistics are based on the best available national data. The website includes downloadable fact sheets on 40 indicators, as well as an interactive tool that enables you to view tables and graphs for different years and provinces. Children Count / Abantwana Bablulekile is an ongoing data and advocacy project of the Children’s Institute.

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa
Agyepong I; Sewankambo N; Binagwaho A; et al. Kassebaum: The Lancet 390(10114)p2803–2859, 2017

This Commission was prompted by sub-Saharan Africa's potential to improve health on its own terms, and largely with its own resources. It promotes evidence-based optimism, with caution. Sub-Saharan countries are noted to face difficult development agendas in the decades to come, but also immense opportunities to be acted upon. A key message of this commission is that the opportunities ahead cannot be unlocked with 'more of the same' approaches and by keeping to the current pace. The commission advocates an approach based on people-centred health systems and inspired by progress, which can be adapted in line with each country's specific needs. A comprehensive approach and system-wide changes are required. Broad partnerships beyond the medical and health community are argued to be essential to move the health agenda forward. Without a serious shift in mindsets across all levels of society, all sectors of government, and all institutions it is seen to be difficult to have meaningful and sustainable change. Young people in Africa are observed to be key to bringing about the transformative changes needed to rapidly accelerate efforts to improve health and health equity across sub-Saharan Africa.

4. Values, Policies and Rights

The importance of gender analysis in research for health systems strengthening
Theobald S; Morgan R; Hawkins K; et al.: Health Policy and Planning 32(Suppl 5)v1-v3, 2017

This editorial discusses a collection of papers examining gender across a range of health policy and systems contexts, from access to services, governance, health financing, and human resources for health. The papers interrogate differing health issues and core health systems functions using a gender lens. Together they produce new knowledge on the multiple impacts of gender on health experiences and demonstrate the importance of gender analyses and gender sensitive interventions for promoting well-being and health systems strengthening. The findings from these papers collectively show how gender intersects with other axes of inequity within specific contexts to shape experiences of health and health seeking within households, communities and health systems; illustrate how gender power relations affect access to important resources; and demonstrate that gender norms, poverty and patriarchy interplay to limit women’s choices and chances both within household interactions and within the health sector. The authors note that health systems researchers have a responsibility to promote the incorporation of gender analyses into their studies in order to inform more strategic, effective and equitable health systems interventions, programmes, and policies. Responding to gender inequitable systems, institutions, and services in this sector requires an ‘all hands-on deck’ approach. They note that it is not possible to claim to take a ‘people-centred approach’ to health systems if the status quo continues.

5. Health equity in economic and trade policies

Honest Accounts 2017: How the world profits from Africa’s wealth
Curtis M; Jones T: Curtis Research, Jubilee Debt Campaign and others, 2017

This report presents the movement of all the main financial resources into and out of Africa, mainly using 2012 figures. It found that $134 billion entered the continent in 2017, mainly in the form of loans, foreign investment and aid. However, some $192 billion was taken out, mainly in profits made by foreign companies, tax dodging and the costs of adapting to climate change. Africa was found to suffer a net deficit of $58 billion a year. This is reported to have has led to reductions in government holdings of international reserves and lower (but still significant) multinational company profits taken out of the continent. They report that there are now more loans to African governments, another in inflow, although this comes at the cost of future debt payments and possibly debt crises.

6. Poverty and health

World's poor to suffer most unless developed countries act fast on climate change
Khan A: Pambuzuka News, December 2017

Storms and hurricanes are becoming more severe due to warmer sea temperatures. Low lying island nations, like the Maldives, now experience annual flooding with the seawater contaminating groundwater supplies. Whether flooding, drought or other climate-related catastrophic events, the author observes that low income countries nations and their populations suffer most, given their lack of resources, infrastructure, emergency services and preparedness. They also point to a further consequence relating to the quality of food. Rising CO2 levels speed up plant growth increasing carbohydrates through plant sugars and diluting nutrition due to reduced minerals and protein. The nutrient quality of our food is expected to fall as CO2 levels rise this century. The effect will be worst felt by the world's poorer populations relying on a plant diet. Extreme weather events affect production, distribution, spoilage and contamination. The author notes that those most affected will be people in Africa, Asia and the Americas.

“If it's issues to do with nutrition…I can decide…”: gendered decision-making in joining community-based child nutrition interventions within rural coastal Kenya
Muraya K; Jones C; Berkley ; et al.: Health Policy and Planning 32 (Suppl 5) ppv31–v39 2017

This qualitative study undertaken in rural Coastal Kenya aimed to explore the interaction between household gender relations and a community-based child nutrition programme. It focused on household decision-making dynamics related to joining the intervention. Fifteen households whose children were enrolled in the programme were followed up over a period of 12 months. Over 60 household visits, group and individual in-depth interviews were conducted with a range of respondents, supplemented by non-participant observations. Data were analysed using a framework analysis approach. Engagement with the intervention was highly gendered with women being the primary decision-makers and engagers. Women were responsible for managing child feeding and minor child illnesses in households. As such, involvement in community-based nutrition interventions and particularly one that targeted a condition perceived as non-serious, fell within women’s domain. Despite this, the nutrition programme of interest could be categorized as gender-blind. Gender was not explicitly considered in the design and implementation of the intervention, and the gender roles and norms in the community with regards to child nutrition were not critically examined or challenged. In fact, the authors argue that the intervention might have inadvertently reinforced existing gender divisions and practices in relation to child nutrition, by excluding men from the nutrition discussions and activities and thereby supporting the notion of child feeding and nutrition as “women’s business”. To improve outcomes, community based nutrition interventions are argued to need to understand and take into account gendered household dynamics, and incorporate strategies that promote behaviour change and attitude shifts in relation to gendered norms and child nutrition.

7. Equitable health services

Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries
Rwabukwisi F; Bawah A; Gimbel S; et al.: BMC Health Services Research 17 (Suppl 3), doi: 10.1186/s12913-017-2662-9, 2017

This paper captures common implementation experiences and lessons learned to understand core elements of successful health systems interventions. Qualitative data was used rom key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through African Health Initiative in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. Four major overarching lessons were highlighted. First, a variety and inclusiveness of concerned key players are necessary to address complex health system issues at all levels, with a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Also identified was inclusion of strong implementation science tools and strategies that allowed informed and measured learning processes and efficient dissemination of best practices. Five to seven years was seen to be the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects. The authors conclude that the African Health Initiative experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.

Healthy Lives for Vulnerable Women and Children: Applying Health Systems Research
Godt S; Agyepong I; Flores W; et al: in_focus, IDRC, October 2017

Tremendous challenges remain for the most vulnerable populations, including women, children, and adolescents, to enjoy the healthy lives and well-being. Much of their poor health is caused by poverty, gender, lack of education, and social marginalization as well as inaccessible healthcare services. Strong, equitable, and well-governed health systems can contribute to sustainably improving their lives. But building strong health systems is challenging. This book draws on 15 years of IDRC-funded health systems research undertaken by researchers working closely with communities and decision-makers. They have generated contextually relevant evidence at local, national, regional, and global levels to tackle these entrenched health systems challenges. Six lessons have been distilled to inform and inspire a new generation of health leaders and researchers while some critical reflections on the remaining challenges are shared with others in the global health community, including funding organizations.

Integrating family planning services into HIV care: use of a point-of-care electronic medical record system in Lilongwe, Malawi
Tweya H; Feldacker C; Haddad L; et al: Global Health Action 10(1), doi: http://dx.doi.org/10.1080/16549716.2017.1383724, 2017

Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers’ ability to counsel women about pregnancy risks and contraceptive options. This study assessed trends in the use of contraceptive methods after implementing an electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15–49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi. The authors conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. Between February 2012 and December 2016, in HIV clinics, the proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016. Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence and never thought about it. Incorporating the FP EMR module into HIV clinical care was found to prompt healthcare workers to encourage the use of contraceptives.

Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda
Wanyenze R; Bwanika J; Beyeza-Kashesya J; et al: Global Health Action 10(1), doi: http://dx.doi.org/10.1080/16549716.2017.1380361, 2017

This study assessed uptake and correlates of cervical screening among HIV-infected women in care in Uganda. A nationally representative cross-sectional survey of HIV-infected women in care was conducted from August to November 2016. Structured interviews were conducted with 5198 women aged 15–49 years, from 245 HIV clinics. Knowledge and uptake of cervical screening and human papillomavirus (HPV) vaccination were determined. Overall, 94% had ever heard of cervical screening and 66% knew a screening site. However, 47% did not know the schedule for screening and 50% did not know the symptoms of cervical cancer. One-third rated their risk of cervical cancer as low. Uptake of screening was 30%. Women who had never been screened cited lack of information and no time as the main reasons. Increased likelihood of screening was associated with receipt of HIV care at a level II health center and private facilities, knowledge of cervical screening, where to go for screening, and low perception of risk. HPV vaccination was 2%. Cervical screening and HPV vaccination uptake were very low among HIV-infected women in care in Uganda. Improved knowledge of cervical screening schedules and sites, and addressing fears and risk perception are thus seen to potentially increase uptake of cervical screening in this vulnerable population.

8. Human Resources

How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia
Witter S; Wurie H; Chandiwana P; et al.: Health Policy and Planning 32(Suppl 3) iii3–iii13, 2017

This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied—Uganda, Sierra Leone, Zimbabwe and Cambodia—which were at different distances from conflict and crisis, as well as having unique conflict stories. The authors captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. The authors examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. They find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts—particularly in relation to physical threats and psychosocial threats—while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but important gaps were found which point to ways in which they should be better protected and supported in the future.

Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts
Jolley E; Mafwiri M; Hunter J; et al: BMC Health Services Research 17(1), doi:10.1186/s12913-017-2787-x, 2017

This study seeks to understand how eye health services are delivered by primary health workers who have received training and what constraints remain to effective service provision. A qualitative investigation into the experiences of 20 primary health workers trained in primary eye care and eight key informants working within specialist eye health services or regional and district health management positions in two districts in Tanzania. Despite feeling confident in their own eye care skills, most primary health workers felt constrained in the services they could provide to their communities by insufficient resources needed for diagnosis and treatment, and by lack of systematic supportive supervision to their work. Specialist ophthalmic staff were aware of this issue, although for the most part they felt it was not within their capacity to remedy and that it fell within the remit of general health managers. Many participants discussed the low support to eye health from the national government, evidenced through the lack of dedicated funding to the area and traditional reliance on outside funds including international charities. The authors noted that although training of primary health workers is useful, it is not sufficient to address the burden of eye health disease present in rural communities in Tanzania. It is likely that broader engagement with the general health system, and most likely with the private sector, will be necessary to improve the coverage of eye health care to remote and poor communities such as those in Morogoro.

Women on the move: migration, care work and health
World Health Organisation: WHO, Geneva, 2017

Care workers - who are largely migrant women, often working in informal home settings - make a considerable contribution to public health in many countries but are themselves exposed to health risks, face barriers to accessing care, and enjoy few labour and social protections. This WHO report, and its reflection on potential next steps, aims to foster debate about approaches to ensure that the global community meets its obligations in relation to these care workers. The report focuses on paid home-based care workers who attend to the varied needs of children, older people, people with disabilities and the disabled and ill people.It notes that a significant knowledge gap exists when it comes to how migrant care workers’ health is influenced – both positively and negatively – by the labour they perform and the contexts in which they undertake this work. The report highlights three key steps for all countries and regions to consider to improve the health and well-being of migrant care workers and their families:1. To generate evidence on the nature of migrant care work, the contributions to global health care and the terms and conditions of their employment. 2. To improve access to health services through specific measures to address non-discrimination, promote inclusion and participation of migrant care workers. 3. Promote and recognize care as a global public good that contributes to global health and well-being. The authors advocate for holistic, universal and person-centred health and social care systems.

9. Public-Private Mix

Private Sector Participation and Health System Performance in Sub-Saharan Africa
Yoong J; Burger N; Spreng C; et al: PLoS ONE 5(10), doi: https://doi.org/10.1371/journal.pone.0013243, 2017

The role of the private health sector in developing countries remains a much-debated and contentious issue. Critics argue that the high prices charged in the private sector limits the use of health care among the poorest, consequently reducing access and equity in the use of health care. Supporters argue that increased private sector participation might improve access and equity by bringing in much needed resources for health care and by allowing governments to increase focus on underserved populations. However, little empirical exists for or against either side of this debate. The authors examined the association between private sector participation and self-reported measures of utilization and equity in deliveries and treatment of childhood respiratory disease using regression analysis, across a sample of nationally-representative Demographic and Health Surveys from 34 SSA economies. To measure private sector participation, we computed the percentage of live births that took place in a private (for-profit or non-profit/mission) health facility and the percentage of children with ARI symptoms who were treated at a private health facility. Private sector participation was positively associated with greater overall access and reduced disparities between rich and poor as well as urban and rural populations, including after controlling for confounders including per capita income and maternal education. However, higher private sector participation may be affected by other variables that also affect access and equity. In addition to an increased level of overall service utilization, countries with a relatively large share of private sector participation tend to also have significantly higher levels of maternal education and also higher levels of GDP per capita, so the relationships may be confounded by differences in socioeconomic development (particularly maternal education, a well-established key determinant of health service utilization and child health outcomes). The authors controlled for maternal education and per capita income but report that other confounders such as better functioning transportation infrastructure may also influence both private sector participation and access. They further notes that the appropriate role of the private sector might depend on the capacity of governments to provide effective stewardship and regulation, the health care financing environment, and the organization of the public health sector.

10. Resource allocation and health financing

Free maternity services in Kenya: How can the policy be improved going forward?
RESYST, London School of Hygiene & Tropical Medicine, 2017

In order to increase access to and use of maternal health services, in June 2013, the President of Kenya announced a policy offering free care for all women giving birth in a public health facility. This policy brief highlights both the positive and negative effects of the Free Maternity Services Policy based on research conducted in health facilities in three counties in Kenya. It outlines the challenges to implementing the policy and suggests how the Ministry of Health can make improvements going forward. The policy appears to have increased use of maternity services and provided additional funding for some facilities; however, its hurried implementation led to confusion about what services were included, and some clients were still required to pay for services. The policy was not accompanied by any supportive interventions to increase the capacity of health facilities. As a result, increased demand for services put a strain on health workers and compromised quality of care. The implementation of the Free Maternity Services Policy highlights the need for whole system change as opposed to isolated policy interventions. Going forward, the authors argue that the national Ministry of Health must provide clear guidelines as to what the policy covers and communicate these effectively to health facilities and providers. The county governments should strengthen the capacity of health facilities to cope with additional demand.

From blockchain technology to global health equity: can cryptocurrencies finance universal health coverage?
Till B; Peters A; Afshar S; Meara J: BMJ Global Health 2(4), doi: https://doi.org/10.1136/bmjgh-2017-000570,, 2017

Blockchain technology and cryptocurrencies could remake global health financing and usher in an era global health equity and universal health coverage. The authors outline and provide examples for at least four important ways in which this potential disruption of traditional global health funding mechanisms could occur: universal access to financing through direct transactions without third parties; novel new multilateral financing mechanisms; increased security and reduced fraud and corruption; and the opportunity for open markets for healthcare data that drive discovery and innovation. The authors present these issues as a paramount to the delivery of healthcare worldwide and relevant for payers and providers of healthcare at state, national and global levels; for government and non-governmental organisations; and for global aid and intergovernmental organisations.

11. Equity and HIV/AIDS

Prevention of mother to child transmission of HIV in Tanzania: assessing gender mainstreaming on paper and in practice
Nyamhanga T; Frumence G; Simba D: Health Policy and Planning 32 (Suppl 5)ppv22-v30, 2017

Despite recognition of gender in Tanzania’s political arena and prioritization of prevention of mother to child transmission (PMTCT) by the health sector, there is very little information on how well gender has been mainstreamed into National PMTCT guidelines and organizational practices at service delivery level. Using a case study methodology, the authors combined document review with key informant interviews to assess gender mainstreaming in PMTCT on paper and in practice in Tanzania. The authors reviewed PMTCT policy/strategy documents using the World Health Organisation’s Gender Responsive Assessment Scale. The scale differentiates between level 1 to 5. Key informant interviews were conducted with 26 leaders purposively sampled from three government health facilities in Mwanza city to understand their practices. The gender responsiveness of PMTCT policy/strategy documents varies. Those which are gender sensitive indicate gender awareness, but with no remedial action developed; while those which are gender specific go beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. The interviews suggested that there has been little attention to the holistic integration of gender in the delivery of PMTCT services.

12. Governance and participation in health

Citizen Voices, Community Solutions: Designing Better Transparency and Accountability Approaches to Improve Health
Transparency for Development: Harvard Kennedy School, USA, 2017

This study was designed to address the question of whether a community-led transparency and accountability program can improve health outcomes and community empowerment, and, if so, how and in what contexts. To answer this question, researchers and civil society organization partners co-designed a program that would activate community participation in improving maternal and newborn health outcomes. This report presents the design of the work that was implemented in 200 villages in Tanzania and Indonesia and studied using a mixed methods impact evaluation. The team faced challenges including how to best foster community participation, how to structure the information gathering and sharing component, how to facilitate social action in communities, and how to ensure communities review their successes and failures in implementing social actions.

Decision space for health workforce management in decentralized settings: a case study in Uganda
Alonso-Garbayo A; Raven J; Theobald S: Health Policy and Planning 32(Suppl 3) iii59–iii66, 2017

This paper aimed to improve understanding about how district health managers perceive and use their decision space for human resource management (HRM) and how this compares with national policies and regulatory frameworks governing HRM. To assess the decision space that managers have in six areas of HRM (e.g. policy, planning, remuneration and incentives, performance management, education and information) the study compares the roles allocated by Uganda’s policy and regulatory frameworks with the actual room for decision-making that district health managers perceive that they have. Results show that in some areas District Health Management Team (DHMT) members make decisions beyond their conferred authority while in others they do not use all the space allocated by policy. DHMT members operate close to the boundaries defined by public policy in planning, remuneration and incentives, policy and performance management. However, they make decisions beyond their conferred authority in the area of information and do not use all the space allocated by policy in the area of education. DHMTs’ decision-making capacity to manage their workforce is influenced by their own perceived authority and sometimes it is constrained by decisions made at higher levels. The authors conclude that decentralization, to improve workforce performance, needs to devolve power further down from district authorities onto district health managers. DHMTs need not only more power and authority to make decisions about their workforce but also more control over resources to be able to implement these decisions.

Malaria control in rural Malawi: implementing peer health education for behaviour change
Malenga T; Kabaghe A; Manda-Taylor L; et al: Globalization and Health 13(84), doi: https://doi.org/10.1186/s12992-017-0309-6, 2017

This descriptive study reports on the feasibility, acceptability and appropriateness of health animator-led community workshops for malaria control. Quantitative data were collected from self-reporting and researcher evaluation forms. Qualitative assessments were done with health animators, using three focus groups in 2015 and seven in-depth interviews (October 2016–February 2017). Seventy seven health animators were trained from 62 villages. A total of 2704 workshops were conducted, with consistent attendance from January 2015 to June 2017, representing 10–17% of the population. Attendance was affected by social responsibilities and activities, relationship of the village leaders and their community and involvement of community health workers. Active discussion and participation were reported as main strengths of the workshops. Health animators personally benefited from the mind-set change and were proactive peer influencers in the community. Although the information was comprehended and accepted, availability of adequate health services was a challenge for maintenance of behaviour change. the authors argue that community workshops on malaria are a potential tool for influencing a positive change in behaviour towards malaria, and applicable for other health problems in rural African communities. Social structures of influence and power dynamics affect community response. they suggest that there is need for systematic monitoring of community workshops to ensure implementation and sustain health behaviour change.

The role of NGOs in Africa: are they a force for good?
Sangonet Pulse, December 2017

Non-governmental organisations (NGOs) have become key actors in responding to poverty and related suffering. In Africa, NGOs play a leading role in providing health care and education. But NGOs also have their detractors who argue that they are receiving growing amounts of external aid, but aren’t the most suitable actors for really improving people’s lives. Some critics insist that the neoliberal policies advanced by international actors have limited the influence of the state and that NGOs have benefited as a result. NGOs are criticised for their focus on technical solutions to poverty instead of the underlying issues, and for being more dependent and accountable to their funders than those they serve. Instead of empowering local populations to organise themselves, the authors argue that there is a risk that NGOs empower people to attain licensed, rather than emancipatory, freedoms; these are freedoms achieved “within the system” which improve lives, but don’t dramatically change power dynamics.

13. Monitoring equity and research policy

A comparable yardstick: adjusting for education bias in South African health system responsiveness ratings
Rossouw L; Smith A: Health Policy and Planning 32(Suppl3) iii67–iii74, 2017

Health-system responsiveness (HSR) measures the experience of health-system users in terms of the non-clinical aspects of the health system. The authors explore the association between education levels and reporting behaviour in terms of HSR in South Africa using data from the World Health Organization Study on Global Ageing and Adult Health for South Africa (WHO SAGE) conducted in 2007 and 2008. The authors consider the reporting behaviour of 1499 adults aged 50 and older in terms of the reported HSR for their most recent outpatient provider visit during the preceding 12 months. More specifically, they explore whether there are systematic biases in reporting behaviour by education levels and other socio-economic covariates through the use of data from anchoring vignettes. Large differences were found in HSR ratings between the lowest and highest education groups after adjusting for reporting bias using the anchoring vignettes. This finding holds across all seven HSR domains captured in the WHO SAGE dataset. In the most extreme case, individuals with no education are likely to underreport poor HSR by between 2.6 and 9.4% percentage points compared with individuals with secondary schooling or higher. It is proposed that policy-makers take cognizance of potential reporting biases in HSR ratings and make the necessary adjustments to obtain data that are as true and accurate as possible. The need for this is seen to be especially acute in a country such as South Africa with large socio-economic inequalities and disparities in access to healthcare.

Assessing the health workforce implications of health policy and programming: how a review of grey literature informed the development of a new impact assessment tool
Nove A; Cometto G; Campbell J: Human Resources for Health 15(79), doi: https://doi.org/10.1186/s12960-017-0252-x, 2017

In their adoption of WHA resolution 69.19, World Health Organization Member States requested all bilateral and multilateral initiatives to conduct impact assessments of their human resources for health funding. No standard tools exist for assessing the impact of global health initiatives on the health workforce, but tools exist from other fields. This paper describes how a review of grey literature informed the development of a draft health workforce impact assessment tool and how to introduce the tool. A search of grey literature yielded 72 examples of impact assessment tools and guidance from a wide variety of fields including gender, health and human rights. These examples were reviewed, and information relevant to the development of a health workforce impact assessment was extracted from them using an inductive process. A number of good practice principles were identified from the review. These informed the development of a draft health workforce impact assessment tool, based on an established health labour market framework. The tool consists of a relatively short and focused screening module to be applied to all relevant initiatives, followed by a more in-depth assessment to be applied only to initiatives for which the screening module indicates that significant implications for HRH are anticipated. It thus aims to strike a balance between maximizing rigour and minimising administrative burden. The authors propose that the new tool will help to ensure that health workforce implications are incorporated into global health decision-making processes from the outset and to enhance positive human resources for health impacts and avoid, minimise or offset negative impacts.

The change-makers of West Africa
Godt S; Mhatre S; Schryer-Roy AM: Health Research Policy and Systems 15 (52), doi: https://doi.org/10.1186/s12961-017-0208-6, 2017

This journal supplement is a contribution to changing practice by putting the perspectives, experiences and knowledge of West Africans on the table. It presents findings from a series of research and capacity development projects in West Africa funded by the International Development Research Centre's Maternal and Child Health programme. The evidence presented centres around two key themes. First, the theme that context matters. The evidence shows how context can change the shape of externally imposed interventions or policies resulting in unintended outcomes. At the same time, it highlights evidence showing how innovative local actors are developing their own approaches, usually low-cost and embedded in the context, to bring about change. The collection of articles discusses the critical need to overcome the existing fragmentation of expertise, knowledge and actors, and to build strong working relationships amongst all actors so they can effectively work together to identify priority issues that can realistically be addressed given the available windows of opportunity. Vibrant West African-led collaborations amongst researchers, decision-makers and civil society, which are effectively supported by national, regional and global funding, need to foster, strengthen and use locally-generated evidence to ensure that efforts to strengthen health systems and improve regional health outcomes are successful. The authors argue that the solutions are not to be found in the ‘travelling models’ of standardised interventions.

14. Useful Resources

Health Systems Governance Collaborative new interactive web platform
Health Systems Governance Collaborative: Geneva, 2017

The Health Systems Governance Collaborative is a group of practitioners, policy makers, academics, civil society representatives, agencies, decision-makers and other committed citizens seeking to connect and engage about important health systems governance issues. The Collaborative fosters creative and safe spaces to address health systems governance challenges and promote real impact on the ground. It offers a place to connect with the great variety of stakeholders in health systems governance worldwide, confront ideas, disseminate knowledge and share experiences. The Collaborative encourages people to engage through this online interactive platform, where they can participate in consultations and discussions.

Toolkit for Integrating Gender in the Monitoring and Evaluation of Health Programs
MEASURE Evaluation, December 2017

This toolkit aims to help international health programs integrate a gender perspective in their monitoring and evaluation (M&E) activities, measures, and reporting. It is designed for use by health program staff working in various health sectors (such as HIV; malaria; reproductive, maternal, newborn, and child health; and tuberculosis), and for various health agencies and initiatives. The toolkit will support health program staff to integrate gender in their programs, projects, and M&E activities. Its objectives are to provide processes and tools for integrating gender in a health program’s M&E activities, guidance on facilitating communication with primary stakeholders on the importance of gender and M&E, and additional resources on gender-integrated programming and M&E.

15. Jobs and Announcements

Call for Emerging Voices for Global Health 2018 (EV4GH 2018)
Deadline for submission: 5 March 2018

Emerging Voices for Global Health (EV4GH) is an innovative multi-partner training program for young, promising and emerging health policy & systems researchers, decision makers and other health system actors with an interest to become influential global health voices and/or local change makers. EV4GH coaches “Emerging Voices” to participate actively in international conferences where global health issues are addressed and to raise their voice in scientific and policy debates. The EV4GH programme is managed by an internationally representative governance committee consisting of EV alumni elected by previous EV4GH participants and a few invited members from academia. There are two tracks for which participants can apply to be an EV 2018. While one track is reserved for researchers involved in health policy and systems research, the other track seeks to attract health professionals, activists, decision or policy-makers and/or other health systems actors.

CODESRIA 2017 Gender Institute: Feminist Scholarship, Universities and Social Transformation in Africa
Deadline for Applications: 15 March 2018

CODESRIA invites applications from academics and researchers from African universities and research centres to participate in the 2017 session of the Gender Institute, in Dakar, Senegal May 14-25, 2018. The 2017 session of the institute seeks to provide an opportunity for participants to reflect on gains made and persisting challenges, especially in respect of the ways in which the engagements have made universities in Africa better institutions to spearhead social transformation. Candidates submitting proposals for consideration should be PhD students or early career academics in the social sciences and humanities and those working in the broad field of gender and women studies. Scholars outside universities but actively engaged in the area of policy process and/or social movements and civil society organizations are also encouraged to apply. Twenty places are available.

Director: Comprehensive HIV & AIDS Care Management and Treatment
Deadline for Applications: 19 February 2018

Applications are open for the above post in South Africa to manage the coordination of programme activities related to the implementation of the Comprehensive Care Management and Treatment plan and National Strategic Plan 2017-2022 for persons living with HIV and AIDS. Oversee the implementation of the Comprehensive HIV, TB, and Branch clinical guidelines and reviews thereof. The candidate will oversee the capacity building of clinicians (basic and advanced), quality improvement implementation for HIV plans. The candidate will liaise with all stakeholders such as NHLS, District Support Partners, MRC, Universities for guideline reviews. The post-holder will be expected to develop effective mechanisms to monitor progress of programme implementation and regular reviews of programme performance, writing reports as per statutory requirements.

International Children’s Peace Prize Nomination
KidsRights: The deadline for entries is March 1st 2018

The nomination process for the International Children’s Peace Prize 2018 has started. KidsRights calls upon individuals and organizations across the globe to nominate eligible children, regardless of race, place of birth or social standing, who have demonstrated the skill and determination necessary to personally improve the rights of children. The child should not be older than 17 years by the time of the nomination deadline, from anywhere in the world, and have a clear history of standing up and fighting for his/her own rights and/or the rights of other children, which has led to a concrete result. The child should agree to being nominated for the prize. The messages of all the nominees will be posted on the Kidrights website. The nomination form and the full list of criteria can be found on the website.

Workshop: Comparing the Copperbelt: Political culture and knowledge production in Central Africa, 23-24 July 2018 (Kitwe, Zambia)
Deadline for Applications: 15 February 2018

'Comparing the Copperbelt' is an ERC-funded research project, running at the University of Oxford from 2016-2020. The project aims to examine the Copperbelt (in both Zambia and the DR Congo) as a single region divided by a (post-)colonial border, across which flowed minerals, people and ideas. This workshop aims to bring together researchers on and in the Copperbelt region to share ideas on social, environmental and cultural history. Research papers from a variety of disciplinary backgrounds (history, anthropology, economics, etc.), approaches and regional focuses (both old and new mining regions) are welcomed. The workshop seeks to bring together academics, trade union leaders and environmental activists to foster discussions about the history and current condition of the Copperbelt region.


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