EQUINET NEWSLETTER 204 : 01 March 2018

1. Editorial

We have a right to demand better! Rights based activism in Africa as a determinant of health
Kristi Heather Kenyon, Global College, University of Winnipeg, Canada

HIV represents an unprecedented pandemic, and one that is forcing civil society to innovate to meet the challenges. Civil society engaging on HIV has carried out one of the most vocal, widespread and innovative advocacy campaigns in health, drawing on language and approaches from other sectors and regions. HIV activists have in the process brought human rights into health advocacy, even in settings where rights are perceived to be foreign and confrontational. Why do civil society advocacy groups working on HIV choose to express their claims in the language of human rights? How do they understand this choice? What impact do they see it having? What impact does it have?

I explored these questions in sub-Saharan Africa, a region hard hit by the pandemic.

The answers might surprise: the decision to use rights was fueled by individual belief not pressure from external funders. It was also the individual empowerment effects of ‘rights-talk’, rather than their legal effect, that activists felt to be most important.

I explored the experience of nine local civil society organizations selected from four countries (Ghana, Uganda, South Africa, Botswana), located respectively in three sub-regions of sub-Saharan Africa (West , East and Southern Africa). Choosing from the three regions provided insight into civil societies operating in different contexts and at different levels - local, national, regional. To allow for a systematic comparison, I chose organizations that vary in the extent to which they use human rights in advocacy. The case studies drew on 145 semi-structured interviews conducted with these organizations, as well as with others in the HIV sector. I also reviewed relevant events, documents and press accounts.

Over the past twenty years many funders have embraced the human rights framework. While I am not suggesting that international funders are not important, I found that their preferences were not particularly influential in whether organizations used rights-based advocacy. Groups using this framework didn’t lose interest when it became less popular with external funders, nor did their interest rise or fall with changes in funding. Many of the civil society groups have at least a dozen funders who usually support particular projects rather than the organization as a whole. Because organizations have so many funders, any single funder rarely influences the framework an organization chooses for its advocacy.

The organizations instead chose human rights primarily due to a mix of principles and structural factors. Organizations with a leader with a strong human rights orientation and regular interaction with other employees were more likely to choose a rights-based approach. In settings where human rights are not a common discourse, groups manage to thrive- even in isolation - when they had powerful “rights champions” as leaders. Such leaders have been able to incubate a rights-oriented organizational culture, attracting personnel who have, or will acquire a similar orientation.

People who worked for organizations that gave strong attention to human rights in advocacy often held strong personal belief in the framework. Respondents often explained this passionately, describing human rights as core to their dignity and identity. Rather than being a topic or a strategy, human rights were described as a fundamental part of who they were, what they believed in and how they saw the world.

I expected that groups would choose human rights over other approaches because they are linked to legal enforcement, in ways that development work or public health may not be. I thought perhaps the choice to use human rights in advocacy was rooted in an expectation of a government response and legal accountability. Instead, respondents saw the most important impact of human rights as their empowering effect for individuals, particularly amongst those seeking health care. They saw rights as empowering people living with HIV to demand services owed to them, and to make requests from a position of power and entitlement, rather than one of weakness and desperation.

One respondent described the shift in mindset that she saw accompanying rights-based advocacy, as “creating in people’s minds” the idea that they “have the right to demand better.” Respondents gave accounts of these demands: “When you say, ‘It’s my constitutional right, doctor. I am not going to leave this room without having treatment,’ therefore the doctor will make sure that you get the treatment […] They don’t make a mistake.”

While the above quotation is from South Africa, where health rights are included in the Constitution, even in settings without such constitutional provisions respondents gave very similar accounts. They saw rights language as transforming people from passive recipients of care to active participants engaged in their own health, and as engaged citizens rightfully demanding services from the state.

The findings indicated that “human rights” may yield important effects in places that human rights scholars seldom look. Beyond state actions and high-profile venues such as the United Nations and national courts, people are wielding human rights in their day-to-day interactions in ways that have meaningful influence on their lives. It appears that human rights-based advocacy has a unique impact. It changes people’s self- perceptions of power in relation to the state and enables them to claim services to which they are entitled from a position of greater strength. Those exposed to human rights-based advocacy were reportedly more likely to seek health care services, to be more informed about their rights, to ask questions of health care providers, and to query delays or denials of service.

It would be interesting to see what these findings imply for other areas of public health. They suggest that human rights-based activism could be an overlooked, but powerful positive determinant of health.

A version of this oped was originally published in Open Global Rights: www.openglobalrights.org/empowering-language-of-rights-underlies-increasing-use-in-hiv-advocacy/. Further information can be found in ‘Resilience and Contagion: Invoking Human Rights in African HIV Advocacy’, McGill-Queens University Press, at www.mqup.ca/resilience-and-contagion-products-9780773550995.php?page_id=119256&

2. Latest Equinet Updates

Resource curse or fair benefit?
Loewenson R, EQUINET: Alternative Mining Indaba, Cape Town, February 2018

This plenary presentation at the Alternative Mining Indaba presented work taking place in EQUINET to raise health rights and duties in the extractive sector. Mining was noted to be a key vehicle linking African countries to neoliberal globalisation, with by 2008, developing countries reported to be transferring about a trillion dollars more a year to wealthy countries than they received in FDI. There is evidence of poor return for local wellbeing, with examples of districts with large EI projects having higher poverty and food insecurity and poorest improvements in these areas than those without, despite the wealth generated. The presentation raised the potential to better use the power of public health rights and laws in mining. Various international standards commit to protecting health in mining for workers and communities and the SADC UNECA harmonisation of policies and standards indicated that Member States should develop, adopt and enforce appropriate and uniform health, safety and environmental guidelines for the sector as an immediate milestone area. However, while there has been progress on doing this for TB and HIV and some attention is now being paid to chronic occupational diseases for ex mineworkers, there is as yet no comprehensive focus on public health in the mines. From an analysis of laws in the region no single country provides adequate legal protection, but different countries have good practice clauses that could be used for regional guidance on minimum standards. At regional level she observed that there is both a need and potential to harmonise rights and duties for health in SADC, to ensure health impacts are assessed and prevented before licenses are granted, mines provide living standards, incomes, health infrastructures and health services before people are resettled, the public health and health care of communities living in and around mines is invested in, including to address longer term impacts from mining that may persist even after mines close.

The role of an essential health benefit in the delivery of integrated health services: Learning from practice in East and Southern Africa, Report of a regional research workshop, November 27-28 2017, Zanzibar, United Republic of Tanzania.
EQUINET; Ifakara Health Institute; Training and Research Support Centre

An Essential Health Benefit (EHB) is a policy intervention designed to direct resources to priority areas of health service delivery to reduce disease burdens and ensure equity in health. Many east and southern Africa (ESA) countries have introduced or updated EHB in the 2000s. Recognising this, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), through Ifakara Health Institute (IHI) and Training and Research Support Centre (TARSC), with country partners from Ministries of Health (MoH) in Swaziland, Tanzania, Uganda and Zambia, implemented research to understand the facilitators and the barriers in nationwide application of the EHB in resourcing, organising and in accountability on integrated, equitable universal health services. A regional review of literature on EHBs in the four country case study reports from the research programme are available on the EQUINET website. This report presents the proceedings of a regional consultative meeting convened on November 27-28, 2017 to present and discuss evidence from the research programme. The regional document review covering 16 east and southern African (ESA) countries, the findings from the country case studies in Swaziland, Tanzania, Uganda and Zambia, experiences from South Africa and Zanzibar and a regional synthesis of the evidence from across the programme were presented at the meeting, and background documents made available. The meeting aimed to: a. Identify issues arising in the motivations for developing the EHB; the methods used to develop, define and cost them; their dissemination, communication and use within countries, including in budgeting, resourcing and purchasing health services; and, in monitoring health system performance for accountability; b. Identify policy-relevant and operational national and regional level recommendations on the role, design and use of EHB; and c. Propose areas for follow up policy, action and research.

Training materials for Health centre committees – building community participation in health systems
Health Rights learning network; UCT, Cape Town, 2018

Health Centre Committees are potentially critical vehicles for community voice in health systems. They play not only a service and mobilisation role, but can be effective tools to improve the responsiveness and accountability of services – and thus have an important governance role to play. UCT’s Health and Human Rights programme in the School of Public Health and Family Medicine has been working with Zimbabwean and Zambian partners in EQUINET, on a project under the leadership of the Community Working Group on Health (CWGH) to strengthen Health Centre Committees (HCC’s) as vehicles for social participation in health systems in East and Southern Africa (ESA). UCT has led work to review and assemble capacity building materials for Health Committee training. . They found HCC training materials and processes in a number of countries, including Ethiopia, Kenya, South Africa, Tanzania, Uganda, Zimbabwe and Zambia. The training commonly covered introductions to the health system, its governance, planning and budget processes and HCC roles. It included information on HCCs functions such as problem solving, monitoring and accountability and social mobilization. There were gaps in some areas, such as on conflict management, fundraising, inter-sectoral work and deeper analysis of the causes of social inequalities in ill health and how to address them.

3. Equity in Health

Socioeconomic differential in self-assessment of health and happiness in 5 African countries: Finding from World Value Survey
Adesanya A; Rojas B; Darboe A; et al.,: PLOS One 12(11) doi: https://doi.org/10.1371/ journal.pone.0188281, 2017

This study compared socioeconomic differentials in self-rated health and happiness in five sub-Saharan countries. Using the 2010/2014 World Values Survey, the authors obtained a sample of 9,869 participants of age 16 and above from five sub-Saharan countries. Socioeconomic inequalities were quantified using the concentration index. Poor self-rated health ranges from approximately 9% in Nigeria to 20% in Zimbabwe, whereas unhappiness was lower in Rwanda and higher in South Africa. Poor self-rated health and unhappiness were excessively concentrated among the poorest socioeconomic strata. Although magnitudes differ across countries, however, the major contributor to wealth-related inequality in poor self-rated health is satisfaction with financial situation whereas for unhappiness the major contributors are level of income and satisfaction with financial situation. This study underscores an association between wealth related inequalities and poor self-rated health and unhappiness in the context of sub-Saharan countries. Improving equity in health may be useful in fighting against the unfair distribution of resources. The authors suggest that knowledge about the self-rating of health and happiness can serve as proxy estimates for understanding the distribution of health care access and economic resources for well-being.

4. Values, Policies and Rights

Factors associated with gender equality among church-going young men in Kinshasa, Democratic Republic of Congo: a cross-sectional study
Lusey H; Sebastian M; Christianson M; et al: International Journal for Equity in Health 16(1), doi: 10.1186/s12939-017-0707-7, 2017

This study assessed gender-equitable norms and their determinants among church-going young men in Kinshasa, the Democratic Republic of Congo. A cross-sectional study was carried out among 289 church-going young men, aged 18–24 years, residing in three disadvantaged communes of Kinshasa. The findings provide evidence of attitudes and beliefs that act as barriers to gender equality. For instance, the majority of church-going young men agreed that a man is the only decision maker in the home and about half of the respondents supported the statement “There are times a woman deserves to be beaten”. Similarly, around half of the participants agreed with the idea of men’s uncontrollable sex drive and men’s toughness. Close to half of the participants agreed that it is women’s responsibility to prevent pregnancy. These attitudes co-existed with a few gender-equitable norms as 82% agreed on the importance of joint decisions concerning family planning. An association between education, certain places of residence, being single or separated, and supportive attitudes towards gender equality was found. The study findings indicated that a high proportion of church-going young men do not endorse gender equitable norms. The authors argue that churches and schools urgently need comprehensive gender equality and masculinity policies and programmes to influence young men’s attitudes and behaviours.

Minding the gaps: health financing, universal health coverage and gender
Witter S; Govender V; Ravindran S; et al: Health Policy and Planning 32(Suppl 5)ppv4–v12, 2017

This article provides a reflection on the question of why there is a need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage will automatically be equitable and gender balanced, from a panel of health financing and gender experts. The authors traced the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. The authors found that unless explicit attention is paid to gender and its inter-sectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations, movement towards Universal Health Coverage can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to Universal Health Coverage and the needs of less powerful groups, which can include women and children, are not necessarily given priority. The authors identified the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of Universal Health Coverage decisions, political economy as well as technical research should be prioritized. The authors concluded that countries should adopt an equitable approach towards achieving Universal Health Coverage and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children.

Universal health coverage law approved in Egypt
Devi S: The Lancet 391(10117), doi: https://doi.org/10.1016/S0140-6736(18)30091-6, 2018

A new universal health coverage law received parliamentary approval in mid-December in Europe after years of discussion and planning. Health care will be provided for everyone including the estimated 30% of Egyptians who cannot afford to pay at present. Enrolment in the scheme will be obligatory, with fees set according to income with additional sources of funding to include taxes on tobacco and polluting industries including cement. Egypt's population is forecast by the UN Population Fund to reach 119 million in 2030. UNICEF says about three in every ten children suffer from multidimensional poverty, which includes factors such as poor health and lack of education. Tedros Adhanom, director-general of WHO, praised the law for including people with major catastrophic conditions such as cancer. The scheme will be mandatory, with those on low incomes to be covered by the state; with split roles for health-care providers and those bodies to oversee quality and accreditation; and patients would be allowed to choose their own doctor and hospital. However, he raised worries about the level of co-payments that patients might have to make and the long period of implementation that might lead to worsening health disparities.

WHO Independent Global High-level Commission on NCDs
World Health Organization: WHO, Geneva, February 2018

The first-ever WHO Independent Global High-level Commission on Noncommunicable Diseases (NCDs) aims to identify and propose bold and practical ways to curb the world’s leading causes of death and illness. The Commission was announced in 2017 by Dr Tedros Adhanom Ghebreyesus, Director-General WHO. The Commissioners will recommend actions to accelerate progress in tackling NCDs, primarily cardiovascular disease, cancers, diabetes and respiratory disease, and promoting mental health and well-being. NCDs kill 15 million people between the ages of 30 and 69 each year. Low- and lower-middle income countries are particularly affected by NCDs with almost 50% of premature deaths from NCDs occurring in these countries. In addition, NCDs are responsible for the deaths of 7 in 10 people across all ages globally, equivalent to approximately 40 million people. In 2015, world leaders committed to reduce premature deaths from NCDs by one third by 2030 as part of the Sustainable Development Goals. Recent WHO reports indicate that the world will struggle to meet that target.

5. Health equity in economic and trade policies

Alternative Mining Indaba 2018
Economic Justice Network et al.,: Alternative Mining Indaba, Cape Town, February 2018

The Alternative Mining Indaba (AMI) started in 2010 with a small group of approximately 40 participants lead by Faith Based Organisations. It intended to create space for communities living in and around mines affected by and left out of key discussions of extractive industries in Africa. The theme for the 2018 AMI was: “Making Natural Resources Work for the People: Towards Just Legal, Policy and Institutional Reform”. The Thematic issues for discussion included: human rights defenders; the curse of natural resource policies; gender and legal reforms; the independent problem solving mechanism; policies and laws that facilitate the benefit sharing for local people and faith and the extractives sector. The meeting gathered representatives of over 400 members of faith-based organisations, civil society organisations, community-based organisations, pan-African networks and organisations, labour movements, women movements, human rights activists, media, students from African countries and international partners on February 5 – 7, 2018 in Cape Town. The AMI site provides presentations and proceedings from the indaba.

Foresight Africa: Top priorities for the continent in 2018
Kagame P; Coulibaly B; Signé L; et al: Brookings, January 2018

The Foresight Africa, African Growth Initiative invited scholars and experts to delve into six overarching themes that highlight areas in which African countries and their citizens are taking the lead to achieve inclusive growth. In a world where China and other emerging economies are ascendant, where cooperation on global governance is under challenge, and where free trade faces headwinds, Africa is argued to need its own institutions to play a more assertive role in advancing the continent’s agenda. The report emphasizes that Africa’s future lies in its own hands and that it already has the power to reach its goals. The authors describe, and argue for, new and innovative instruments to better mobilize and leverage resources for development financing. They authors explore and offer recommendations on policy interventions to broaden the benefits of future economic growth. Further chapters explore technological innovations and their potential to transform the continent. The final chapter explores a shifting global landscape of diplomacy – what will the impact of reduced engagement from the United States be? How do development, defence, and diplomacy best fit into foreign policies toward the continent?

Monitoring SO2 emission trends and residents’ perceived health risks from PGM smelting at Selous Metallurgical Complex in Zimbabwe
Gwimbi P: International Journal for Equity in Health 16(1) doi:https://doi.org/10.1186/s12939-017-0696-6 , 2017

This paper examined sulphur dioxide (SO2) emission trends, emission regulations and residents’ perceived health risks from exposures to such emissions at Selous Metallurgical Complex platinum group metal smelting facility in Zimbabwe. SO2 data from roof monitoring sites at the smelter furnace were aggregated into annual, quarterly and monthly emission trends from 2008 to 2015. The regulatory regime’s ability to protect human health from SO2 pollution in communities located around the smelter was examined. Questionnaire responses to perceived health risks from SO2 exposure from 40 purposively sampled residents were assessed. Between 2008 and 2015, annual SO2emissions increased from 7951 to 2500 tonnes. Emissions exceeded the recommended standard limit of 50 mg/Nm3, presenting considerable adverse health risks to local residents. Concerns relating to inefficient environmental impact assessment licensing system, poor monitoring and auditing by the environmental management agency, as well as non-deterring SO2emission exceedance penalties were identified as major drivers of emission increase. Thirty-two of the forty respondents perceived exposure to SO2 emissions as adverse and the cause of their illnesses, with coughing, nasal congestion and shortness of breath the most frequently self-reported symptoms. A set of legally-binding SO2 emission standards supported by stringent environmental impact assessment licensing arrangements for smelting industries are suggested for development and enforcement to reduce the SO2 emission problem. Community participation in SO2 emissions monitoring was also proposed as a core part of sustainable environmental management in communities located around smelters.

New evidence of Africa’s systematic looting, provided by an increasingly schizophrenic World Bank
Bond P: Pambazuka News, February 2018

A recent World Bank report, The Changing Wealth of Nations 2018, offers evidence of how much poorer Africa is becoming thanks to rampant minerals, oil and gas extraction. Yet the author notes that World Bank policies and practices remain oriented to enforcing foreign loan repayments and transnational corporate profit repatriation. Central to its “natural capital accounting,” the Bank uses an “Adjusted Net Savings” (ANS) measure for changes in economic, ecological and educational wealth. The Bank asks, “How does sub-Saharan Africa compare to other regions? Not favourably.” The ANS decline for sub-Saharan Africa was worst from 2001-09 and 2013-15. The author observes that there are two ways to address transnational corporate (TNC) capture of African wealth: bottom-up through direct action blocking extraction, or top-down through reforms. He critiques the latter, such as in the African Union’s 2009 Alternative Mining Vision (AMV) position that foreign resource investors with capital, skills and expertise are critical to development, which ignores these evident trends on the continent.

6. Poverty and health

Psychosocial support for adolescent girls in post-conflict settings: beyond a health systems approach
Samuels F; Jones N; Hamad B: Health Policy and Planning 32(Suppl 5) v40–v51 2017

This paper focuses on the importance of psychosocial support services for adolescent girls in fragile contexts. Its starting point is that adolescence is a pivotal time in the life course but given the physical, cognitive and emotional changes triggered by the onset of puberty, it can also be a period of heightened sensitivity and vulnerability to trauma, social isolation, bullying by peers, a lack of supportive adults and gender-based and sexual violence. The authors’ findings highlighted why humanitarian and biomedical approaches in their current form are inadequate to address these complexities. Drawing on qualitative fieldwork, the authors argued that going beyond biomedical approaches and considering the social determinants of health, including approaches to tackle discriminatory gendered norms and barriers to service access, are critical for achieving broader health and wellbeing. While all three case study countries are classified as post-conflict, the political economy dynamics vary with associated implications for experiences of psychosocial vulnerabilities and the service environment. The study concludes by reflecting on actions to address psychosocial vulnerabilities facing adolescent girls through tailoring services to ensure gender and age-sensitivity, investing in capacity building of service providers to promote service uptake and enhancing strategies to regulate and coordinate actors providing mental health and psychosocial support services.

7. Equitable health services

From bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening
Barasa E; Cloete K; Gilson L: Health Policy and Planning 32(Suppl 3) ii91 – iii94, 2017

Recent health system shocks such as the Ebola disease outbreak have focused global health attention on the notion of resilient health systems. In this commentary, the authors reflect on the current framing of the concept of resilience in health systems discourse and propose a reframing. Specifically, the authors propose that: (1) in addition to sudden shocks, health systems face the ongoing strain of multiple factors. Health systems need the capacity to continue to deliver services of good quality and respond effectively to wider health challenges. The authors call this capacity everyday resilience; (2) health system resilience entails more than bouncing back from shock. In complex adaptive systems, resilience emerges from a combination of absorptive, adaptive and transformative strategies; (3) nurturing the resilience of health systems requires understanding health systems as comprising not only hardware elements (such as finances and infrastructure), but also software elements (such as leadership capacity, power relations, values and appropriate organizational culture). The authors also reflect on current criticisms of the concept of resilient health systems, such as that it assumes that systems are apolitical, ignoring actor agency, promoting inaction, and requiring that there is a need to accept and embrace vulnerability, rather than strive for stronger and more responsive systems. They observe that these criticisms are warranted to the extent that they refer to notions of resilience that are mismatched with the reality of health systems.

Gender dynamics affecting maternal health and health care access and use in Uganda
Morgan R; Tetui M; Kananura R; et al: Health Policy and Planning 32, Supp 5, v13-v21, 2017

In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. This paper reports the key gender dynamics identified, detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need to integrate gender into maternal health care interventions if they are to address the root causes of these barriers to maternal health care.

8. Human Resources

The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts
Witter S; Namakula J; Wurie H; et al.: Health Policy and Planning 32(Suppl 5) v52–v62 2017

The authors examine the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). The authors used a mixed method for research in Sierra Leone, Zimbabwe, northern Uganda and Cambodia to understand how gender influences the health workforce. They applied a gender analysis framework to explore access to resources, occupations, values, and decision-making and draw largely on life histories with male and female health workers to explore their lived experiences, complemented by surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. The findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences shaped by gender, poverty and household structure. Most health worker regulatory frameworks did not sufficiently address gender concerns. The authors argue that unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.

9. Public-Private Mix

One year on, Global Observatory on Health R&D identifies striking gaps and inequalities
World Health Organisation: WHO, Geneva, 2018

Each year, hundreds of billions of dollars are spent on research and development (R&D) into new or improved health products and processes, ranging from medicines to vaccines to diagnostics. But the way these funds are distributed and spent is often poorly aligned with global public health needs. in 2017, the World Health Organization launched an initiative to gather information and provide an accurate picture of where and how R&D monies are being spent. The Global Observatory on Health R&D has identified striking gaps and inequalities in investment both between countries and between health issues, with frequent disconnects between burden of disease and level of research activity. High income countries have an average of 40 times more health researchers than low income countries. Serious imbalances in funding flows mean countries with comparable levels of poverty and health needs receive strikingly different levels of Official development assistance (ODA) for medical research and basic health sectors (health ODA). As little as 1% of all funding for health R&D is allocated to diseases such as malaria and tuberculosis, despite these diseases accounting for more than 12.5% of the global burden of disease. Investing in R&D to discover and develop medicines and vaccines is argued to be key to improving access to medicines and quality health care for people across the world and to achieving universal health coverage.

10. Resource allocation and health financing

Can cash break the cycle of educational risks for young children in high HIV–affected communities? A cross–sectional study in South Africa and Malawi
Sherr L; Tomlinson M; Macedo A; et al.: Journal of Global Health 7(1), doi: 10.7189/jogh.07.010409, 2017

This study describes the impact of cash grants and parenting quality on 854 children aged 5–15 in South African and Malawi on educational outcomes including enrollment, regular attendance, correct class for age and school progress, controlling for cognitive performance. Consecutive attenders at randomly selected Community based organisations were recruited. The effects of cash plus good parenting, HIV status and gender were examined. Overall 73.1% received a grant – significantly less children with HIV (57.3% vs 75.6%). Controlling for cognitive ability, grant receipt was associated with higher odds of being in the correct grade, higher odds of attending school regularly, and much higher odds of having missed less than a week of school recently. Grant receipt was not associated with how well children performed in school compared to their classmates or with school enrollment. Grant receipt was associated with a significant reduction in educational risk for girls.

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme
Goudge J; Olufunke A; Govender V; et al: International Journal for Equity in Health 17(1), doi: https://doi.org/10.1186/s12939-017-0710-z, 2018

The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper, the authors ask whether the scheme has assisted in efforts to move towards UHC. Using a cross-sectional survey across four of South Africa’s nine provinces, the authors interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. A quarter of respondents remained uninsured, even higher among 20–29 year olds (46%) and lower-skilled employees (58%). The scheme generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having one outpatient visits/month compared to 0.6/month with lowest benefits. By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The authors observe that the inequities generated by the scheme have been institutionalised within the country’s financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.

Who benefits from increased service utilisation? Examining the distributional effects of payment for performance in Tanzania
Binyaruka P; Robberstad B; Torsvik G; et al: International Journal for Equity in Health 17(14), doi: https://doi.org/10.1186/s12939-018-0728-x, 2018

The authors examined pay for performance (P4P) effects on service utilisation across different population subgroups in Tanzania. About 3000 households were surveyed of women who delivered in the last 12 months prior to the interview from seven intervention and four comparison districts in January 2012 and a similar number of households in 13 months later. The household data were used to generate the population subgroups and to measure the incentivised service utilisation outcomes, with a focus on the institutional delivery rate and the uptake of antimalarials for pregnant women. P4P led to a significant increase in the rate of institutional deliveries among women in poorest and in middle wealth status households, but not among women in least poor households. The differential effect was marginally greater among women in the middle wealth households compared to women in the least poor households. The effect of P4P on institutional deliveries was also significantly higher among women in rural districts compared to women in urban districts, and among uninsured women than insured women. The effect of P4P on the uptake of antimalarials was equally distributed across population subgroups. The authors suggest that P4P can enhance equitable healthcare access and use especially when the demand-side barriers to access care such as user fees associated with drug purchase due to stock-outs have been reduced.

11. Equity and HIV/AIDS

Determinants of facility readiness for integration of family planning with HIV testing and counselling services: evidence from the Tanzania service provision assessment survey, 2014–2015
Bintabara D; Nakamura K; Seino K: BMC Health Services Research 17 (1) doi: 10.1186/s12913-017-2809-8 , 2017

This paper examines determinants of facility readiness for integration of family planning with HIV testing and counselling services in Tanzania using data from the 2014–2015 Tanzania Service Provision Assessment Survey. Facilities were considered ready for integration of family planning with HIV testing and counselling services if they scored ≥ 50% on both family planning and HIV testing and counselling service readiness indices as identified by the World Health Organization. A total of 1188 health facilities were included in the study. Of all of the health facilities, 915 reported offering both family planning and HIV testing and counselling services, while only 536 were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned; having routine management meetings, availability of guidelines, in-service training of staff, and availability of laboratories for HIV testing. The proportion of facility readiness for the integration of family planning with HIV testing and counselling in Tanzania was noted to be unsatisfactory. The authors argue that Ministry of Health should distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and the provision of refresher training to health providers, as these were among the determinants of facility readiness.

12. Governance and participation in health

2016 Report of Acute public health events assessed by WHO Regional Offices for Africa, the Americas and Europe under the International Health Regulations (2005)
World Health Organization: WHO, Geneva, 2017

The World Health Organization (WHO) and its Member States have committed, within the framework of the International Health Regulations 2005 (IHR), to detect, verify, assess and report events that may pose a risk to international public health. This report summarizes public health events detected, verified, assessed and reported in three WHO Regions, namely Africa, the Americas and Europe from 2001 to 2016, with a focus on 2016. This report illustrates the relevance and importance of conducting and sustaining epidemic intelligence activities in accordance to alleviate the burden and impact of epidemics and emergencies, and thus avoid interference with travel and trade. Achieving this early detection goal—to rapidly and effectively respond to emergencies—requires dedicated human resources, close collaboration across states, partners and other stakeholders, transparent information-sharing and sustained funding.

People’s everyday practices, not the elites of Davos, hold the human economy answer to inequality
Wegerif M: Pambazuka News, February 2018

The author comments that Oxfam has been successful in highlighting the gross and rapidly growing inequalities in the world in international fora, but critiques the approach of asking rich elites and their allies in governments to do the right thing as perpetuating the myth that there are no alternatives other than to depend on large corporations. The author argues that it is in people’s everyday practices that it is far more likely to find meaningful solutions to inequality and the seeds of a more human economy. He raises, for example, the issue of redistribution of assets, such as to address land inequality, as a more pertinent pathway for peoples practices to address societal inequality and challenge the structural power of the drovers of inequality.

SATUCC Holds Its 10th Delegates Congress in Dar-es-salaam
SATUCC: SATUCC Blog, Botswana, December 2017

SATUCC held a successful 10th Delegates’ Congress in Dar-es-salaam Tanzania under the theme: Defending and promoting democracy, human and trade union rights and decent work for all in SADC Region. The Congress debated and adopted policies on corruption, procurement and ethical guidelines, and on the marginalisation of women and youth in the SADC Region and their exclusion in decision making structures, both within trade unions and in national and regional development processes.

13. Monitoring equity and research policy

Child Gauge 2017: Investing in children for sustainable development - Survive. Thrive. Transform
Jamieson L; Berry L; Lake L: The Children's Institute, South Africa, 2017

The South African Child Gauge® is published annually by the Children’s Institute, University of Cape Town, to monitor progress towards realising children’s rights. This issue focuses on children and the Sustainable Development Goals (SDGs). Part one summarises and comments on policy and legislative developments that affect children. These include developments in international and South African law. Part two motivates for greater investment to ensure South Africa’s children not only survive but thrive and reach their full potential, by focusing on the SDGs, ensuring that the 2030 Global Agenda promotes children’s survival and development, identifying local priorities, promoting nurturing care, creating safe environments, improving child nutrition, getting reading right, creating inclusive and enabling environments and reflecting on progress and calling for action. Part three presents child-centred data 2002-2015 to monitor progress and track the realisation of children’s socio-economic rights in South Africa. A set of key indicators tracks progress in demography, income poverty, unemployment and social grants, child health and access to education, housing and basic services.

Data-driven quality improvement in low-and middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia
Wagenaar B; Hirschhorn L; Henley C; et al: BMC Health Services Research 17 (Suppl 3), doi:10.1186/s12913-017-2661-x, 2017

This paper describes the similar and divergent approaches to increase data-driven quality of care improvements and implementation challenge and opportunities encountered in these three countries. Eight semi-structured in-depth interviews were administered to program staff working in each country. Project successes ranged from over 450 collaborative action-plans developed, implemented, and evaluated in Mozambique, to an increase from 80% of basic clinical protocols followed in intervention facilities in rural Zambia, and a shift from a lack of awareness of health data among health system staff to collaborative ownership of data and using data to drive change in Rwanda. Based on common successes across the country experiences, the authors recommend future data-driven quality improvement interventions begin with data quality assessments to promote that rapid health system improvement is possible, ensure confidence in available data, serve as the first step in data-driven targeted improvements, and improve staff data analysis and visualization skills. They pose that explicit Ministry of Health collaborative engagement can ensure performance review is collaborative and internally-driven rather than viewed as an external “audit.”

Research capacity building integrated into PHIT projects: leveraging research and research funding to build national capacity
Hedt-Gauthier B L; Chilengi R; Jackson E; et al,: BMC Health Services Research 17 (Suppl 3) doi: 10.1186/s12913-017-2657-6, 2017

This paper analyses the implementation of health systems strengthening initiatives inclusive of research capacity building. During Population Health Implementation and Training, specific research capacity building activities varied across countries. However, all five countries used African Health Initiative funding to improve research administrative support and infrastructure, implement research training and support mentorship activities and research dissemination. Funders were recommended to provide adequate and flexible funding for research capacity building activities and for institutions to offer a spectrum of research capacity building activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor research capacity building activities.

14. Useful Resources

Wiki Gap Harare
Wiki Gap Harare Nomination Form, 2018

Wikipedia is the world’s largest online and user-generated encyclopaedia, and its content has the potential to colour a global view of the world. But women are under-represented there, like in many other parts of society. Sweden is the first country in the world with a feminist foreign policy. The #Wikigap initiative and event is about realising this policy in both word and deed. #WikiGap gathers people around the world to add more content to Wikipedia about women figures, experts, role models and profiles in various fields. Now it is the turn for Zimbabwe. This initiative invites people to help close the internet gender gap by getting more Zimbabwean women featured on Wikipedia. It invites you to nominate a Zimbabwean woman - past and present- who should have a feature/article on Wikipedia.

15. Jobs and Announcements

5th SA TB Conference 2018
12 15 June 2018 Durban, South Africa

Major advances in TB prevention and care have been made, especially in the six high burden countries (India, Indonesia, China, Nigeria, Pakistan and South Africa) yet an accelerated approach is needed to end TB, despite above 80% treatment success rates for drug sensitive TB, to ensure a more dramatic annual decline in TB incidence and prevention of TB deaths. Furthermore multidrug-resistant TB with an estimated 480 000 cases worldwide and a treatment success rate of just over 50% requires focussed interventions and an aggressive roll-out of available new drug regimens. South Africa has become the leader in the introduction of INH preventive therapy for people living with HIV for latent TB infection. Leadership is also required in other fields affecting progress, i.e. TB research, universal access to care and treatment, continued and energetic efforts for TB/HIV integration and TB financing. This conference brings together those looking to step up strategies and activities to end the TB epidemic.

65th East, Central and Southern Africa Health Community (ECSA-HC) Health Minister’s Conference
19 - 21 March 2018, Dar Es Salaam, Tanzania

This conference will bring together Ministers of Health, senior officials from ministries of health, experts, health researchers, heads of health training institutions from member states of the ECSA Health Community; diverse collaborating partners in the region and beyond, with the aim of identifying policy issues and making recommendations for strengthening the region’s responses to emerging and re-emerging health concerns, to improve health outcomes. The 65th ECSA Health Ministers Conference will be held under the theme: “Multi-Sectoral Collaboration for Health towards Achievement of the SDGs”. The Conference sub-thematic areas will include: Governance and Leadership Practices in the Health sector; Mitigating the Impact of emerging and re-emerging diseases; Multi-Sectoral responses to Non-communicable Diseases; and Accountability for Women’s, Children’s and Adolescent Health post-2015.

Antipode Foundation Scholar-Activist Project Awards
Deadline for Applications: 31 May 2018

The Antipode Foundation exists for the promotion and advancement of social scientific research, education and scholarship in the field of radical geography. Antipode Foundation Scholar-Activist Project Awards are intended to support collaborations between academics, non-academics and activists (from NGOs, think tanks, social movements, or community grassroots organisations, among other places) that further radical analyses of geographical issues and engender the development of a new and better society. They are aimed at promoting programmes of action-research, participation and engagement, cooperation and co-enquiry, and more publicly-focused forms of geographical investigation. The Antipode Foundation strives to fund work that leads to the exchange of ideas across and beyond the borders of the academy, and builds meaningful relationships and productive partnerships. Projects could take many forms including, but not limited to: collaborative research with artistic, community, cultural, grassroots, or social movement groups; the production of educational materials and other innovative pedagogical initiatives; and the promotion of links between universities and institutions/organisations outside the academy. Anyone can apply for an Antipode Foundation Scholar-Activist Project Award (including academics and students, and activists of all kinds), but the grant must be held and administered by a host institution (these could be research, higher education or community-based institutions).

Call for policymakers to participate in the 5th Global Symposium on Health Systems Research
Deadline for applications: 19th March 2018

Applicants are invited from policy-makers from low- and middle-income countries who are involved and interested in strengthening health systems, to participate in the 5th Global Symposium on Health Systems Research. Policy and decision-makers who are involved in policy and decision making at district, state, regional, provincial, federal or national level, with at least 3 years of senior management and policy-making experience in the health system or related sector are invited to apply. Candidates are also invited if they are confident of retaining such a position for the next three years with a demonstrated interest and commitment to evidence-informed decision-making, including the use of research, is from a low- or middle-income country. Women are especially encouraged to apply and will be given priority. Participants will be expected to share their experiences and contribute to mutual learning and understanding by participating in a daily de-briefing session of approximately 60 minutes to share Symposium experiences and engage with featured guests around the role of health systems research in decision- making. Participants will engage in symposium sessions with researchers and funders to share experiences and discuss the role of policy-making and research for strengthening health systems and addressing the Sustainable Development Goals. All applications will be considered by a selection committee comprised of representatives from the Alliance HPSR and Health Systems Global. The Alliance will cover airfare, accommodation, symposium registration fee, and costs for selected participants.

Engage in World Health Day 7 April 2018
World Health Organization: WHO, Geneva, 2018

In this 70th anniversary year, WHO is calling on world leaders to live up to pledges they made when they agreed to the Sustainable Development Goals in 2015, and commit to concrete steps to advance #HealthForAll. This means ensuring that everyone, everywhere can access essential quality health services without facing financial hardship. WHO invites everyone to play a part, stimulating conversations and contributing to structured dialogue towards policies that help your country achieve and maintain UHC. WHO also encourages governments to engage in structured conversations with a broad range of community stakeholders who are both affected by and essential to ensuring universal health coverage. Individuals, civil society and health workers are encouraged to communicate their needs, opinions and expectations to local policy-makers, politicians, ministers and other people representatives. The media is encouraged to highlight initiatives and interventions that help to improve access to quality services and financial protection for people and communities.

MRI, Senior Research Grants 2018
Deadline for applications: 15 April 2018

In 2017 CODESRIA introduced the Meaning-making Research Initiative (MRI) as a tool for supporting research that contributes to agendas for imagining, planning and creating African futures. MRI aggressively pushes scholars to build on the close observation of African social realities. Projects funded under this initiative should propose research on important aspects of African social realities that fall under CODESRIA’s priority themes as outlined in the CODESRIA Strategic Plan and be guided by clear questions that explore puzzling aspects of the social realities of Africa and its position in the world. Projects should be theoretically ambitious with a clear goal of providing new and innovative ways of understanding and making sense of African social realities and explore multiple spatial, temporal and sectoral settings where this contributes to the process of meaning-making. Interested applicants should submit a proposal, budget, annotated plan of deliverables, cover letter, CV of the scholar and an identification sheet.


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