Globalization and Women s Health in East and Southern Africa

Transcription

1 Globalization and Women s Health in East and Southern Africa RESEARCH WORKSHOP REPORT M Ndlovu, TARSC 2007 African Institute for Health & Development (AIHD), Training and Research Support Centre (TARSC), Karolinska Institute Nairobi Kenya, May 20-21, 2011 With support from SAREC, Sweden

2 Table of Contents 1. Background Introductions, welcome and objectives Research on globalisation and womens health in Africa Towards an agenda of research on globalisation and womens health in Africa Methods issues in research on globalisation and womens health in Africa Bringing evidence to policy and practice Conference guest speaker, next steps and closing Appendix 1: Programme Appendix 2: Participant List Cite as: African Institute for Health & Development (AIHD), Training and Research Support Centre (TARSC), Karolinska Institute (2011) Globalization and Women s Health in East and Southern Africa Research workshop report, Nairobi Kenya, May 20-21, 2011 Abbreviations AIDS - Acquired Immuno-deficiency Syndrome AIHD - African Institutive for Health & Development AU - African Union APHRC - African Population Health and Research Centre AWCFS - African Women and Child Features Services CARMMA - Campaign on Accelerated Reduction of Maternal Mortality COTU - Central Organization for Trade Union CSO - Civil Society Organizations DfID - Department for International Development DHS - Demographic Health Survey DSS - Demographic Surveillance System EPZ - Export Processing Zone EQUINET - Regional Network for Equity in Health in East and Southern Africa HIV - Human Immune deficiency Virus IDRC - International Development Research Centre IDS - Institute for Development Studies ILRIG - International Labour Research and Information Group KDHS - Kenya Demographic Health Survey KSPA - Kenya Service Provision Assessment MDG - Millennium Development Goals MMR - Maternal Mortality Rate NCD - Non Communicable Diseases RH/OBA - Reproductive Health/Output Based Approach TARSC - Training and Research Support Centre UNFPA - United Nations Funds for Population Activities UNICEF - United Nations Children Education Funds USAID - United States Agency for International Development VCT - Voluntary Testing and Counselling 1

3 1. Background The research project on globalization and women s health in east and southern Africa has been co-ordinated by Karolinska Institute and Training and Research Support Centre with support from SAREC Sweden. It has in implemented field studies, data gathering, analysis and desk studies. The project aimed to analyse the impact of globalisation on women s occupational roles and health in Sub-Saharan Africa, and the consequences for household food security, health and nutrition. The case studies were performed in urban Dar es Salaam, Tanzania, urban Nakuru in Kenya and rural Ntungamo in Uganda. The country co-ordination was done by the Training and Research Support Centre (TARSC) Tanzania, the University of Makerere in Uganda and African Institute for Health and Development, Kenya. Analysis of indicators from the Millennium Development Goals (MDGs) database to investigate the association between globalisation and women s health in Sub-Saharan Africa found that developing countries are becoming more integrated with world markets through some lowering of trade barriers, that women s occupational roles are changing, but that the impact of these changes on women s health is difficult to assess from the MDG database due to lack of adequate disaggregation. The literature review suggested that globalisation related economic and trade policies have on balance been associated with shifts in women s occupational roles and resources that contribute to documented poor nutritional outcomes in Africa. These results have been presented in published scientific research papers in peer reviewed journals. Follow up field case study findings were presented orally at the Regional Network on Equity in Health in Southern Africa (EQUINET) conference held in September 2009 and two have been submitted to peer reviewed journals.. The research workshop was thus held by Training and Research Support Centre (TARSC)/ EQUINET, Karolinska Institute, Sweden, African Institute for Health & Development (AIHD) and locally hosted by African Institute for Health & Development (AIHD) to report back on the findings of the project and share evidence among stakeholders involved in research globalization and women s health issues; to discuss a research agenda for future work; to identify methods issues and options for work on globalization and health; and to explore and build partnerships in future research, policy engagement and information dissemination. The programme is shown in Appendix 1. The workshop brought together participants from Zimbabwe, Uganda, Tanzania, Kenya and Canada as well as regional organisations. The delegate list is shown in Appendix 2. The workshop was held at the Sarova Panafric Hotel in Nairobi, Kenya from 20 th to 21 st May, AIHD organised the logistics and provided the rapporteuring. The overall facilitation was from Dr. Rene Loewenson, (TARSC/ Regional Network for Equity in Health in east and southern Africa (EQUINET)) and Dr. Mary Amuyunzu-Nyamongo (AIHD). Dr. Sarah Wamala of Karolinska Institute, Sweden who coplanned the meeting was not able to attend due to unforeseen circumstances. The report notes were prepared by F Opundo, Mary Nyamongo and the report finalised by Rene Loewenson. We are grateful to facilitation of sessions by F Muli-Musiime, C Kisia and presentations from J Kanyamurwa, S Muluka, F Gasengayire, R Ettarh, T Shrecker, J Olenja, C. Lalobo Lore, C Dulo/E Mpapale, T Deve and R Saunders as outlined in the programme. 2. Introductions, welcome and objectives Dr. Rene Loewenson, TARSC introduced the meeting, welcomed delegates and outlined the objectives of the meeting. She introduced TARSC as a public interest organisation involved in research, training, information exchange and publication for policy engagement on health and social development, including through policy analysis, community surveillance, and participatory methodologies. She also introduced the scope of work and resources available through EQUINET. She facilitated self introductions of the participants on their organizations, 2

4 the activities they are involved in and their relevance to the workshop theme and their expectations. The participants outlined their previous work on globalization, and its relevance to the workshop. Delegates work ranged from research, teaching and capacity building, activism, policy engagement, social education, surveillance and building learning networks. Their work is on diverse areas, from policies, systems, determinants within the health sector, to wider issues of community, living and work environments, food security, ecosystems and global trade policies. The websites for the organisations present are shown in Box 1 below. Box 1: Websites of the organisations TARSC EQUINET AIHD SEATINI KMWA IDS Tanzania IDRC Canada NONBI JJRTI APHRC IYPF and Citron Wood and GSI and University of Ottawa and ActionAfrica York University and Karolinska Mary Nyamongo, AIHD introduced AIHD and gave brief information on the activities of the Institute. AIHD is involved in evidence-based programming on areas such as noncommunicable diseases (NCDs), community based monitoring on MDGs; crime and violence (C&V) prevention in informal settlements; and social protection. She indicated her appreciation of Rene s presence and role in planning the meeting and communicated the apologies from Sarah Wamala. She welcomed the opportunity the workshop provided for presentation on the research findings, experience sharing, cultivation of partnership and participation in influencing policy. She outlined the administrative issues and session themes including: Identifying a priority research agenda; Identifying methodological approaches; Documenting and disseminating research outcomes; Exploring options for policy engagement and have impact on the community health; and Developing a collective way forward. She welcomed the experience and expertise of the participants in the workshop and the different capacities present, including in intellectual property, social determinants, housing, poverty, HIV, health systems, population health, gender information systems, noncommunicable diseases and information technology (IT) as this would add value to the work on globalization and women s health in Africa. In the introductions some delegates observed that they opposed the current form of globalisation, and some noted that they saw both positive and negative aspects, and Mary posed the question: is globalization positive?. Delegates noted that the meeting was an 3

5 opportunity to explore the specific effects on womens health through evidence and to discuss ways of strengthening methods and links to do this more effectively. 3. Research on globalisation and womens health in Africa Mary Nyamongo, AIHD facilitated a session with presentations by different institutions on globalisation and health in Africa, particularly womens health, and moderated discussions on each paper. The session aimed to exchange information on work underway. Stephen Muluka of Institute for Development Studies (IDS) at the University of Dar es salam, Tanzania on behalf of Peter Kamuzora of IDS and Training and Research Support Centre Tanzania on the Effects of Export processing Zone employment on womens health and household food security. The study that was conducted in the Export Processing Zones (EPZ) and non-epz textile firms in Tanzania, with 190 women in the EPZ firm and 187 women from the non-epz firm. The study found that EPZ firms had preference a preference for employing women, and employed younger women with less secure contracts and shorter term employment, with lower job security. Wages were low in both firms, but EPZ firm employees had longer working hours, lacking opportunities, to supplement their incomes, or time for personal issues or domestic work. Workers in EPZ forms had lower levels of benefits and were less unionised. Women in Working hours in EPZ and non EPZ firms EPZ forms were more likely to be hiring people to look after children than in non EPZ forms, where child care was also more often provided by the workplace, although both firms had low levels of welfare benefits. In both firms diets were mainly made up of cereals, oils, fats, sweets, legumes, nuts and seeds, with more consumption of leafy green vegetables in EPZ firms and more alcohol consumption in non EPZ firms. Age disaggregation of the data is underway but the data suggested that although EPZs have created new employment opportunities, the production activities have wage, time and welfare features that are negative for women s time for domestic roles, including for health. While health outcomes, diets and health services access were equally poor in EPZ and non-epz firms, the higher presence of negative features in EPZ firm suggests that workers and their families may be meeting the costs of concessions given to EPZ employers. In the discussion, delegates noted the need for more information on the methods, the tools used, and the qualitative findings. It was noted that this was available but time had limited the presentation. To better understand the motivations of EPZ firms, further information was requested on the specific nature of the contracts and their duration (noting that casual contracts are time limited), the links between age and gender of workers and wages, whether any child labour is employed in EPZs, the specific context of the textile sector, and the working conditions of the women and their health, safety and environment issues. It was urged that the paper make the connection to the globalization issues (ie in the background on the owners of EPZ; the globalisation related concessions given) clearer. Delegates from Kenya noted that EPZs are lauded for having created work, but it is difficult to understand if the process has really helped in reducing unemployment or whether it is another means of exploiting the energy of the young population in Africa. It was reported that the Central Organization of Trade Unions (COTU-K) has been concerned about the EPZ and workers EPZ Non-EPZ 0-4 hours 5-8 hours 8-12 hours 12+ hours 4

6 engagement in Kenya and advocated to have the Kenyan EPZ workers unionised, but this has not been successful. The effect on labour rights was a policy issue to address. Delegates noted that while the health outcomes were not very different, EPZ workers had less time for health seeking, which may affect their response to pregnancy related needs. John Mary Kanyamurwa of Makerere University, Uganda presented a case study on Globalization and womens health in women farmers in rural Uganda. The research was done in Western region of Uganda and involved farmers primarily engaged on coffee production and farmers primarily engaged in food production, with coffee a crop more linked to export and global markets and food more marketed in local markets. Qualitative and quantitative methods of data collection were used and the sample of 190 coffee farmers and 191 food producers selected through cluster sampling and a snowballing process. In brief, the results indicated that households engaged in coffee farming reported higher earnings., but that this did not translate to better nutrition or dietary outcomes. Coffee farmers would get more money but had poorer food security and significantly worse diets, despite better housing and sanitation. Despite coffee farmers having higher incomes, their self rated health was the same as the food producers. In the discussion, further information was sought on how health status was assessed, (through self reported rating of health); how food and diets were assessed, and on the other factors that may have affected self reported health outcomes, which were noted to have not been different between the groups, as well as of health seeking behaviours and access to health services. The role of government as provider of health services, and the implications of government withdrawing from this role was discussed. It was noted that the background for the study should make clear the context of coffee and food production and the links to globalisation. It was noted that both coffee and food producers produce for markets (expert or local) so the term subsistence and cash crop is not appropriate to use in discussing these issues. The researchers reported that the terms used in the study were food producers and coffee producers and not subsistence or peasant farmers. However the marketing of coffee for expert makes it more integrated with global markets. It was noted that farmers concentrating on coffee production were more dependent on income used for purchasing food. It was noted that in Kenya coffee farmers do not see this production as bearing good returns and some have uprooted it and turned to other crops. It was noted to be important to contextualize and understand how globalization is affecting food production and consumption, to look at food as a social determinant of health, dietary patterns in households, self-reported satisfaction in the food consumed to assess how globalisation measures are affecting these outcomes, and not to make blanket statements about whether globalisation is good or bad Mary Amuyunzu-Nyamongo, AIHD presented a case study on the consequences of changes in health provisioning on food and nutrition among women in Kaptembwo slums, in Nakuru, Kenya. The study did not have a control study site, and used qualitative and quantitative methods of data collection. A total of 450 women, aged years with children under five years were interviewed using an interviewer-based questionnaire, and qualitative methods included social mapping of health facilities, in-depth interviews and focus group discussions. Lack of clean and sufficient water was identified as a major problem, and delegates noted this to also be a globalisation related issue. She presented the situation of health provisioning in Kenya, the liberalisation related reforms in 1989 and how these health provisioning changes affected women s access to and use of health services. Government did not withdraw from providing health services to the community but made it possible for other actors, particularly the private health facilities, but with little control mechanisms. In Kenya health care for children under 5 and pregnant women does not have fee charges in the public sector. The case study found that mothers mainly sought healthcare from health facilities, but 37% bought medicines from chemists/kiosks, with quality of care, proximity and cost the main determining factors. Over a third (37.8%) reported that a member of their 5

7 households had gone to bed hungry in the four weeks preceding the survey. Skipping meals was a common coping strategy to lack of resources to buy food. Households mainly consumed carbohydrates. Worries about food were a major concern to the women. Most mothers of children under 24 months (94%) sought antenatal care when they were pregnant (similar to national average). 62% delivered in a health facility (lower than the urban average at 75%) but higher than the national average (42%). 47.7% of the mothers reported that their children had been ill in the two weeks preceding the study. 21.5% of women who needed healthcare did not access it mainly due to cost. In the discussion, questions were raised about the role of urban poverty or access to services, the environmental determinants (water and sanitation), the community attitude to cost sharing, whether policy recognition of the slums has led to policy change and who controls and owns the informal settlements. The economic issues involved in this area in terms of benefits from the slums should be included in the policy discussion in the paper. There was also debate on the power dynamics in the slum areas, with rich politicians elected by poor slum residents. It was noted that women prefer public health facilities because they have greater trust in The main water source in Kaptembwo slums AIHD their staff as they perceive them to be more qualified. There was debate on the proposal for cash transfers to assist poor women, rather than ensuring that services are free. UNICEF has a project in Northern Kenya where women are given vouchers to deliver in the health facilities; and this has increased access to skilled care during delivery in the region. Delegates observed that future work should explore determinants of health in poor urban areas that expose the people to preventable diseases; measures to widen access to health care in ways that reduce out-of-pocket expenditures, and that recommendations on use of voucher schemes and/or cash transfers for poor households need to be made cautiously given conflicting evidence of their effectiveness. Francois Gasengayire of International Development and Research Centre (IDRC) introduced IDRCs Ecosystem & Human Health Programmes. He begun by posing the question: why do we need an ecosystem approach to health and a change in cropping practices? He urged the participants to read the new book on Eco-health research in practice which is edited by Dominique Charron and is available on the IDRC website. He reported that IDRC supports research and research capacity in developing countries to promote innovative, lasting local solutions that aim to bring choice and change to those who need it most. IDRC broad ecosystem programme areas include: Agriculture and Environnent ; Innovation, Policy, and Science ; Social and Economic Policy; and Health Equity and Health Systems. Research has been implemented on health issues arising from interactions between people and ecosystems in developing countries, such as: In Malawi: growing legumes for better nutrition and improved crop yields without chemical fertilizer; In Nepal: profound changes in slum neighborhood led to new national meat hygiene laws and reduced food borne disease; In Indonesia: dengue incidence reduction through community and government collaboration on waste and water management; and In Peru: malaria reduction and improved crop yield and margins result from change to intermittent irrigation in rice cultivation The programme focuses on generating new knowledge on environment and health linkages (environment, economy and community linkage with health). It emphazises the innovative 6

8 applications of an ecosystem approach to health. The programme was well received by delegates and it was noted that it would be useful to make links with it on globalisation related issues, given the role of globalisation in the land, food, climate and production issues covered. Remare Ettarh of African Population Health and Research Centre (APHRC), presented proposed research on the influence of urbanization and globalization on household food and security in Nairobi slums. APHRC has developed a proposal in conjunction with the University of Ottawa on the influence of urbanization and globalization on household food and security in the slums of Nairobi, to better understand the local and global determinants of food security and the linkages to health outcomes in slums of Nairobi. It was noted that in In Kenya, the urban population almost doubled between 1980 and 1998, increasing from 16% to 31%. Slums are characterized by extreme poverty, poor access to water and sanitation, inadequate housing and poor socio-economic opportunities. Slum residents have high levels of morbidity and low survival rates. Changes in the global economy impact on food systems, which in turn impact food diversity and consumption patterns, as well as nutritional status and health outcomes. Understanding the impact of globalization is thus key to development of effective policies and programmes to address challenges in the slums. The work also sought to determine the perceptions of slum residents and key stakeholders and policymakers with regards to the causes and consequences of food insecurity, and to investigate the impact of globalization and urbanization on food security in urban slums by linking national and global economic and agricultural indicators with trends in food insecurity in the slums. The study will include four components which will be implemented over 30- months: Development of food security profiles and identification of determinants of food security (Yr1); Linkages to health outcomes in the NUHDSS (Yr1); Perceptions of slum residents and key policy makers/stakeholders (Yr 2); and exploration of issues in globalization and food security (Yr 3). In the discussion it was appreciated that APHRC has a rich data resource through the demographic surveillance system (DSS) that can make links between global, national and local data, but that this needed to be based on more focus on the pathways between globalisation and the outcomes identified, and factors affecting this like oil prices, to identify the determinants and indicators to be used. APHRC noted that the rich data available will assist to manage confounders. The organization wants to track fluctuations in food prices and coping mechanisms in the slums and link it to global factors. The inclusion of policy makers dimensions and the community dimensions was seen as valuable, particularly of it addressed the political dimensions of policy responses. It was noted also that AIHD is working on crime and violence, and social protection programmes that will add value to the proposal. 4. Towards an agenda of research on globalisation and womens health in Africa Rene Loewenson, TARSC facilitated this session. She raised three issues for consideration: 1. Research agenda: where are we locating ourselves in agenda? 2. What is the focus for us in the research agenda? 3. Where do you see yourself in the agenda? She introduced two presenters addressing this at global and national level. Ted Shrecker, University of Ottawa raised as context work of the Commission on the Social Determinants of Health (CSDH) in 2008, the financial crisis in October 2008 and the triple crises in 2010 fuel increases, food insecurity and natural calamities. He suggested that globalization studies must be transdisciplinary, use political economic analysis, make systemic connections and be with engaged scholarship. 7

9 He discussed the effects of IMF expenditure ceilings and other forms of conditionality in the structural adjustment era where the effects of the damage still continue to cast a dark shadow on health in Africa and beyond. He reported that the expenditure restrictions limit public expenditure on health, education and even donor funds leading to chronic underfinancing. The political economy of financial crisis implied a speeding of profit making through lower wages, and a quest for lower costs of providing health care. At the same time the financial crisis suggested that financial stability was itself a global public good. The financial crisis could thus be a case study to look at the collapse of the markets, unemployment, World bank and IMF social protection and the effect on employment. Research issues include the effects of IMF conditionalities and expenditure ceilings and financial instability and capital flight on women s health care; and on health equity. In the case study on food security; the presentation reported on how the food crisis escalated in 2003 as a result of oil price increases in the world market; a shortage of supplies; lack of growth in agriculture. The food price increases worsened the effect of financial crisis; and would lead to probable long-term, even intergenerational consequences. A new element in the equation was now large scale agricultural land acquisitions: an emerging trend of purchases or long-term leases for agricultural land at the expense of the community. The purchase or lease of agricultural land and contracts are being done secretively; involving key government officials and the investors. He raised issues for research, including to map the current situation with respect to land grabs in sub-saharan Africa, the implications for women s income and nutritional status; how it fits into the broader political economy agrifood systems and when it threatens to increase inequity in nutrition, health and access to livelihoods. Human rights to health and other economic and social rights related to SDH were noted to be a further area of global concern, given the consequences of globalization. For example study of experiences of litigation on health would identify accountability mechanisms and constraints in national governance and civil society in addressing global rights. Prof. Joyce Olenja, University Of Nairobi explored the role of globalization in Maternal health in Africa. She indicated that maternal health is an old problem that has been discussed in women s conferences since 1975, with new levels of international and regional attention, including at the Global Millennium Summit 2000 and the Campaign on Accelerated Reduction of Maternal Mortality (CARMMA) in Africa 2009 and Regional Commision for Women s health in the Africa Region Sub-Saharan Africa has the highest MMR at 900 maternal deaths per 100,000 live births, and measures need to be taken in improving health services and addressing barriers to use of health services and contraception, such as high cost of transport and services, and social factors in communities. Within Africa, constraints include availability of skilled health care and infrastructure, with poor physical access leading to negative consequences for women who develop complications, such as obstetric fistula. She suggested that globalisation has both negative and positive effects on the situation, providing research and technological advancements that have imptoved care, developments in travel and communication and a push for human rights that has resulted in awareness and a demand for equity and rights for women, and education and activism around the abandonment of traditional harmful practices such as female genital cut and early/child marriages. At the same time globalisation has been associated with commercialised health care, user fees, reduced public funding and staff constraints, resulting in poor quality of service and reduced utilization. Low levels of national funding have made contries dependent on international funding, and while international resources have been forthcoming, unmet international pledges and international funds linked to conditions, such as contributions not being used to fund abortion limit national initiatives and responses. Hence while many countries have taken initiative to develop road maps for maternal health, 8

10 improve infrastructure and staff, including midwives, improve transport and referral systems, extend social protection and outreach to communities, and engage communities, challenges remain. These include issues of sustainability, positioning women s health as a development issue to reposition it for resource allocation; getting a better understanding of innovative approaches, social protection mechanisms, technologies for increasing access to information and care, particularly for adolescents and youths. In particular she asked what role globalization measures can play in addressing these constraints. Dr. Rene Loewenson, TARSC/ EQUINET, concluded the inputs for the session with a presentation on globalisation and women s Health in Africa-research issues and knowledge gaps. She defined globalization as a complex series of economic, social, technological, cultural and political changes seen as increasing interdependence, integration and interaction between people and companies in disparate locations, An economic process, marketization through privatization, liberalization and deregulation; Liberalization of trade in goods and services and export promotion; Financial liberalization; Global reorganization of production; Global diffusion of norms, ideas and information; and Global institutions, social movements and rules. She noted that globalisation can be tracked at different levels and through different elements (see slide) She suggested that there are 5 Ins that relate to globalisations effects in health: ie Negatives, Influence global to local Incoherence across policies Inequity in the benefits of globalization And positives, Investment in solidarity, security Information flow and interaction from local to global She provided specific examples of these 5 Ins. In relation to a research agenda, she suggested three broad gapso Firstly in highlighting local evidence and voice in global policy and funds o Secondly in highlighting the gap between global policy and local reality, and o Thirdly, in acknowledging the contested nature of policy and highlighting and asking WHAT IF? questions to explore alternatives to current processes and their health implications, and raise advocacy and activism around it. The first two raise evidence to engage current global policies. This third raises the possibility of repositioning the questions and debate. From the presentations in the prior sessions, she showed how the issues raised related to these three categories, that is 1: highlighting local evidence and voice in global policy and funds raises issues of IMF conditionalities, the mapping and local effects of land grabs, the manner in which food policies are affecting households in slums, and the way commercialisation or 9

11 expert oriented production associated with globalisation has affected household access to health. 2: highlighting the gap between global policy and local reality such as in the gap between human rights policies and the reality of access to SDH; in the commitments to MDG5 on maternal health and the reality of gaps in funding for or access to basic services 3: Asking WHAT IF? questions to explore alternatives to current processes and their health implications, and raise advocacy and activism around it such as in the IDRC reported work exploring the use of local crop production processes for improving soil fertility rather than imported chemicals, in work exploring the impact of lifting user fees or ways of raising domestic resources for health, or tracking local innovations for addressing maternal health to negotiate and align external resources to what works. In the discussion, delegates noted that there is a significant body of evidence at local and regional level that could be useful for engaging with globalisation measures, but it needs to be linked to globalisation policies, synthesised and translated into action or it loses relevance and impact. This means getting a greater understanding of and critical engagement with global policies, from a social and health lens rather than a business lens, and repackaging evidence to speak to policy and activist audiences. In the recap of research issues on Day two these points were again emphasised. Ezekiel Mpapale, Gender Sensitive Initiatives noted the importance of research that influences programming, particularly the what if research, and Charles Dulo, Kenya Health Equity Network noted the disconnect at the international levels between policy and practice, particularly on the human rights, that influencing policy calls for note of the political situation, participatory community level approaches and a shift in agenda formulation starting from locally driven processes and agenda and organising to influence the international agenda. 5. Methods issues in research on globalisation and womens health in Africa This session was carried out through group discussion by participants, introduced and facilitated by Caroline Kisia, AAH-I and Florence Muli-Musime, Daystar University. The questions guiding the discussion were 1. What are the methodological challenges? 2. What innovative approaches can be employed? The delegates were divided into three groups to discuss issues raised in the earlier sessions. The report presents the combined findings of the three groups on challenges and innovations below, within the broad areas of the challenges: CHALLENGES Globalisation research calls for an understanding of policy processes, a paradigm shift and multiple disciplines that may not be found in the health research institutions. The chain of determinants is complex, multifactorial and attribution difficult from global to local level. This makes the framing of the research questions a major challenge. INNOVATIONS TO ADDRESS CHALLENGES The challenges can be addressed by involvement of policy actors and multiple disciplines in setting the questions and the methods; Time should be given to formulate the problem statement and set the research questions, including through participatory dialogue with policy and affected communities. Understanding the paradigms and concepts calls for training on globalisation and health, and access to publication in other languages and contexts. Multicountry networks can combine skills and learning, and be useful for cross country research. 10

12 CHALLENGES There is a challenge of lack of credible data, including baseline and surveillance data specifically relating to globalisation and health. There is also a problem of information access, including of private and global processes not accessible to local actors. There are challenges on study design, and the capacities to meet these challenges. These include the balance between qualitative and quantitative forms of evidence, the absence of and difficulty with longitudinal research and reliance on cross sectional studies, the lack of understanding of the role of single case studies and the transnational nature of processes raising demand for working covering multiple countries. There are challenges to fund and resource research on local agendas relating to globalisation. Researcher have challenges in engaging with communities and policy audiences, including in linking globalisation with local issues. INNOVATIONS TO ADDRESS CHALLENGES Approaches to address this include building in and using data from monitoring and evaluation of programmes and policies, carrying out systematic reviews of existing data to address questions that have global relevance on globalisation and womens health, asking what if questions where data may be more locally accessible, and linking work across countries to track and compare the performance of global actors (corporate actors, global initiatives) in multiple settings. Finally participatory approaches allow for greater ownership of the evidence. The innovations addressing the two prior challenges will also be useful for this area. Further options raised were: o Focusing on the nation -state as a proxy on the global trends, ie comparative work on how the experience of globalization measures in the community level is influenced by the nation state. South- North and South- South partnering, drawing on the expertise of other regions Building the evidence base for the role of the single case study. Scenario building to answer the what if question, to explore the implications of alternative features; connections and gaps. Public schools/university needs to include globalisation related policies and issues in their programmes. Build monitoring and evaluation and research support into wider processes. Build a feedback loop between research and capacity building. Multi - disciplinary teams and partnership may combine resources. Ensure research provides evidence on options and recommendations for African governments. Comparative studies tracking global actors across countries, processes that involve actors in framing the problem and setting the research, organising local evidence to address global issues can help to make a better connect between the research and policy and community actors. Develop partnerships between community, academia, civil society and political leaders, including sectors such as foreign affairs, transport, agriculture. Finally it was noted in the discussion that unless Public Health goes back to the multi sector approach in health and moves away from disease based research it will be difficult to pursue an effective programme of work on globalisation and health this calls for efforts to reclaim public health. Public health training institutes need to strengthened, the disconnect between research and programmes needs to be addressed, the contribution of other disciplines needs to be recognised, silos broken and research needs to be rejuvenated at community level. 11

13 5. Bringing evidence to policy and practice Rene Loewenson facilitated this session. She introduced two presenters on the dissemination channels for research on globalisation and health and on potential entry points for knowledge to policy links, including through north-south and south-south collaboration. Thomas Deve, SEATINI using photographs from experience raised the connections and engagements between the state- society and the market, including in the streets, local markets and social forums in Africa. He observed that the street university society, is informative and educative through experience. This interaction of state- society and market means that those generating and using evidence we must understand negotiation processes. He showed how this has been an important skill in addressing social interests in trade in the global circles, where the interests of the local market may be lost. He suggested that towards this access to key information needs to be widened and the research agenda to be community driven. Policy briefings are needed on issues such as opening hospital services and health insurance to foreign investors and providers; promoting health tourism where patients travel abroad for medical care; bilateral trade and patent legislation and on reclaiming the role of the nation state in global processes. He gave examples of libraries of alternatives (as resources for participants), from ILRIG Peoples health movement (PHM, ); Khanya college, Kisima school for activists, EQUINET ( ); Centre for civil society South Africa; ANSA - Alternative to neo liberalization in SA; World social forum; TARSC ( and SEATINI ( Finally he said that if, in globalisation processes, transnational corporations put profits before the people and community and governments surrender the management of economies through deregulation and underfunding, then there is need to blend evidence with emotion and activism. Prof. Richard Saunders, York University, reported on options for disseminating evidence so that it translates to policy and activism, noting that when this happens it further energises the research. Currently there are weak links to policy making processes as research is often not packaged in : digestible bites, written in a manner that engages the constituents, and there may be difficulties in linking to policy processes that are hostile. He gave examples of south-south and north-south research and training collaborations o York University web course on civil society and the State in Africa has used internet blogging and skype to widen contribution and exchange of ideas between African researchers and those in Canada, to widen input and access to online library and transcripts, to engage CSOs as disseminators and actors around research; o University of Western Cape School of Public Health regional training with 322 Masters students, in public health and part of a consortium of Universities of Mozambique, Ethiopia, Uganda and SA. o CSOs as disseminator and actors around research through forums such as Kubatana ( through CSO research and advocacy partners, such as trade unions, Treatment Action campaign, Community Working Group on Health; through networks with diverse members taking up policy engagement, such as EQUINET, ANSA and SEATINI and through editors and media networks such as PANOS and Femnet He noted that there are many sites of contestation of globalisation harmful to health and these should be seen as platforms for research that makes a direct link to engagement. They include south-south-north collaborations and global social justice movements. This is not a matter for an add on after research. Popular consumption and deployment of research requires design and strategy at the outset In introducing the discussion on the session Rene noted that the presenters had raised issues for dissemination around the process, the policy content, and the actors. 12

14 In the process, there is need for advance reading of the signs of global processes, and measures to make this accessible to key communities, such as in the work of the institutions in the library of alternatives raised by Thomas Deve. Using information in key processes needs skills beyond research and publication, but also for negotiation, for making connections with local processes and agenda s and for activism. Many policy entry points were noted, from multilateral forums through to global social justice platforms, and there are strategic issues in making connections to these forums, and knowing when windows of opportunity exist for evidence to be useful and used. Equally a range of potential actors were raised, from global level institutions and networks to national membership based civil society. The presentations suggest that there are diverse tools to connect with these actors, forums and processes, from web based training and dialogue mechanisms to more formal and targeted briefings, that may be ed to politicians in a language they understand. In the discussion delegates again stressed the importance of a bottom up approach informing work on globalisation and health, based on the concerns of the community, giving voice to community evidence and experience in forums where they need to heard, and ensuring that the resources and knowledge within communities is protected within global processes. This means that findings must be simplified and translated to a language that the media and the community can comprehend and diverse media channels need to be trained and involved, including community media, given their influence. To connect the local level processes and evidence to global level processes, we must strengthen the national forum to offer downward (community) and upward (global) connections. 6. Conference guest speaker, next steps and closing A workshop dinner was held on the evening of the first day, attended by the participants and other invited guests from various organizations including Kenya Red Cross, Kenya Medical Women s Association, University of Nairobi and DfID. The guest speaker was Dr. Catherine Labolo-Lore of the Kenya Medical Women s Association, who gave her perspective on the challenges for women s health, and the key role that women played in the response to these challenges, in and beyond the health sector. On the final day, in the last session, participants were asked to identify from their own institutions how they would use the workshop, what opportunities existed for networking and exchange on globalisation and health in Africa, and specific future forums for this. Delegates proposed that they would use the information and insights from the meeting to o Inform (and energise) their teaching and research work and materials; o Provide information to media colleagues to inform their work on globalisation related issues and negotiations; o Try innovative ideas on blogging and use of internet in current learning and research networks; o Inform proposals and case study work under development; o Share information and issues with others, including institutional and research colleagues, civil society, communities; and to o Inform input to a forthcoming meeting on food, health and climate change in southern Africa. Delegates identified a number of opportunities for future research links on the globalisation and health issues raised: o Through research activities in the region, eg an IDS Tanzania multi-university project; through motivating inclusion on the national health research agenda s and networks; 13

15 o Through networks bringing researchers together and sharing information, including: EQUINET, South-South Solidarity Network; African Women and Child Media Network; SEATINI policy meetings; o Through research linked to policy platforms, including the East African Legislative Assembly, ECSA Health Community; the periodic review by the UN rapporteur on the right to health; Future networking and exchange opportunities raised included o As regional level through EQUINET, the African Studies Association, the future IDRC/AIHD conference on Agriculture and ecohealth; the SADC peoples forum o At international level through the 2012 Peoples Health Assembly; the Global Health Conference 2011 Canada November 2011( and o Through mailing lists and online communication, including the EQUINET newsletter; medical anthropology list serve. Mary Amuyunzu-Nyamongo closed the meeting. She observed that the discussions had highlighted both the positive and negative aspects of globalization. The key challenge is how we work, package, channel and involve the community in the process. We need to work and give back to the community. She reflected on the high quality of discussions and noted that all the participants were committed to fostering the discourse on globalisation and health in their various institutions. She urged them to continue exploring opportunities to work together on health in Africa. She thanked Karolinka institutet and SAREC for funding the workshop and noted the key role that Dr. Sarah Wamala played in the workshop; She recognised the effort of Dr. René Loewenson in planning the workshop and in coordinating with Karolinska the programme on globalisation and womens health and the research conducted in Kenya, Uganda and Tanzania. She thanked the presenters and all the participants for attending the workshop. She also thanked the Guest speaker for being with the team in the whole workshop period and the speech delivered at the workshop dinner. The workshop closed at 2.20 and the participant had lunch together before departure. 14

16 Appendix 1: Programme DAY ONE FRIDAY 20 MAY TIME SESSION CONTENT RESPONSIBLE PERSON Registration Rahel Oyugi Introductions, welcome and Rene Loewenson, Mary Nyamongo objectives TEA Review of research on Globalisation and Health in Africa Presentations by African researchers on research on globalization and health M Amuyunzu Nyamongo facilitating Presenters M Nyamongo J Kanyamurwa S Muluka F Gasengayire R Ettarh LUNCH Towards an agenda of research on Globalisation and Health in Africa Ideas for a research agenda on globalisation and health in Africa R Loewenson facilitating Presenters R Loewenson T Shrecker J Olenja 1600 TEA Methods issues in research on Globalisation and Health in Africa Methodological issues in research on globalization and health F Muli-Musiime, C Kisia facilitating 1900 Workshop dinner Dr. Catherine A. Lalobo Lore (speaker) Day end DAY TWO SATURDAY 21 MAY TIME SESSION CONTENT RESPONSIBLE PERSON Recap of day one F Opundo, C Dulo/E Mpapale Taking forward research on Globalisation and Health in Africa Methods options for taking the research questions F Muli-Musiime, C Kisia facilitating identified on day 1 forward TEA Research outputs, targets and collaborations R Loewenson moderating Presenters T Deve, R Saunders F Opundo Consolidation and Summary of next steps Closing M Amuyunzu-Nyamongo 1315pm LUNCH After-noon Informal meetings on future Delegates work Day end 15