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issn:1472-698
1.  Assessing the universal health coverage target in the Sustainable Development Goals from a human rights perspective 
Background
The UN’s Sustainable Development Goals (SDGs), adopted in September 2015, include a comprehensive health goal, “to ensure healthy lives and promote well-being at all ages.” The health goal (SDG 3) has nine substantive targets and four additional targets which are identified as a means of implementation. One of these commitments, to achieve universal health coverage (UHC), has been acknowledged as central to the achievement of all of the other health targets. As defined in the SDGs, UHC includes financial risk protection, access to quality essential health-care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all.
Discussion
This article evaluates the extent to which the UHC target in the SDGs conforms with the requirements of the right to health enumerated in the International Covenant on Economic, Social and Cultural Rights, the Convention on the Rights of the Child, and other international human rights instruments and interpreted by international human rights bodies. It does so as a means to identify strengths and weaknesses in the framing of the UHC target that are likely to affect its implementation.
Summary
While UHC as defined in the SDGs overlaps with human rights standards, there are important human rights omissions that will likely weaken the implementation and reduce the potential benefits of the UHC target. The most important of these is the failure to confer priority to providing access to health services to poor and disadvantaged communities in the process of expanding health coverage and in determining which health services to provide. Unless the furthest behind are given priority and strategies adopted to secure their participation in the development of national health plans, the SDGs, like the MDGs, are likely to leave the most disadvantaged and vulnerable communities behind.
doi:10.1186/s12914-016-0106-y
PMCID: PMC5159947  PMID: 27978827
Universal health coverage; Rights-based; Financial risk protection; Access to health services; Priority to the disadvantaged
2.  Why the Convention on the Rights of the Child must become a guiding framework for the realization of the rights of children affected by tuberculosis 
Background
Until recently, paediatric tuberculosis (TB) has been relatively neglected by the broader TB and the maternal and child health communities. Human rights-based approaches to children affected by TB could be powerful; however, awareness and application of such strategies is not widespread.
Discussion
We summarize the current challenges faced by children affected by TB, including: consideration of their family context; the limitations of preventive, diagnostic and treatment options; paucity of paediatric-specific research; failure in implementation of interventions; and stigma. We examine the articles of the Convention on the Rights of the Child (CRC) and relate them to childhood TB. Specifically, we focus on the five core principles of the CRC: children’s inherent right to life and States’ duties towards their survival and development; children’s right to enjoyment of the highest attainable standard of health; non-discrimination; best interests of the child; and respect for the views of the child. We highlight where children’s rights are violated and how a human rights-based approach should be used as a tool to help children affected by TB, particularly in light of the Sustainable Development Goals and their focus on universality and leaving no one behind.
Summary
The article aims to bridge the gap between those providing paediatric TB clinical care and conducting research, and those working in the fields of human rights policy and advocacy to promote a human rights-based approach for children affected by TB based upon the Convention on the Rights of the Child.
doi:10.1186/s12914-016-0105-z
PMCID: PMC5146903  PMID: 27931215
Human Rights; Tuberculosis; Paediatrics/Pediatrics; Human Rights-Based Approach; Stigma; Non-discrimination; Autonomy; Medical ethics; Child health; Child survival
3.  Race trouble: experiences of Black medical specialist trainees in South Africa 
Background
This research aimed to identify and explore the experiences of Black registrars in their training in the Western Cape’s academic hospitals in order to identify structures, practices, attitudes and ideologies that may promote or impede the advancement of Black doctors into specialist medicine. This is justified by the requirement for universities to work towards monitoring and evaluating efforts to create non-discriminatory and inclusive training environments.
Methods
This study employed qualitative research methods. Ten Black African medical specialists were interviewed about their training experiences in two university training hospitals in the Western Cape Province, South Africa. Interview data was collected using open-ended questions and coded and analysed using thematic and critical discursive analysis techniques.
Results
Four experiential themes emerged from the interview data, they included: 1) experiences of everyday racism during work hours, 2) the physical and psychological effects of tokenism and an increased need to perform, 3) institutional racism as a result of inconsistent and unclear methods of promotion and clinical competence building, and 4) an organisational culture that was experienced as having a race and gender bias.
Conclusion
This is a pilot study and there are limits on the generalizability of the data due to the small sample. What is clear from our participants, though, is the strong experiential component of finding it challenging to be a Black trainee in a White-dominated profession. We are undertaking further research to explore the issues raised in more detail.
doi:10.1186/s12914-016-0108-9
PMCID: PMC5135758  PMID: 27914479
Black doctors; Transformation in higher education; Systemic racism; Medical training
4.  Knowledge and exercise of human rights, and barriers and facilitators to claiming rights: a cross-sectional study of female sex workers and high-risk men who have sex with men in Andhra Pradesh, India 
Background
HIV prevention interventions recognize the need to protect the rights of key populations and support them to claim their rights as a vulnerability reduction strategy. This study explores knowledge of human rights, and barriers and facilitators to claiming rights, among female sex workers (FSWs) and high-risk men who have sex with men (HR-MSM) who are beneficiaries of a community mobilization intervention in Andhra Pradesh, India.
Methods
Data are drawn from a cross-sectional survey (2014) among 2400 FSWs and 1200 HR-MSM. Human rights awareness was assessed by asking respondents if they had heard of human rights (yes/no); those reporting awareness of rights were asked to spontaneously name specific rights from the following five pre-defined categories: right to health; dignity/equality; education; property; and freedom from discrimination. Respondents were classified into two groups: more knowledgeable (could identify two or more rights) and less knowledgeable (could identify one or no right). Univariate and bivariate analyses and chi-square tests were used. Data were analyzed using STATA 11.2.
Results
Overall 17% FSWs and 8% HR-MSM were not aware of their rights. Among those aware, 62% and 31% respectively were aware of just one or no right (less knowledgeable); only around half (54% vs 57%) were aware of health rights, and fewer (20% vs 16%) aware of their right to freedom from discrimination. Notably, 27% and 17% respectively had not exercised their rights. Barriers to claiming rights among FSWs and HR-MSM were neighbors (35% vs 37%), lack of knowledge (15% vs 14%), stigma (13% vs 22%) and spouse (19% FSWs). Community organizations (COs) were by far the leading facilitator in claiming rights (57% vs 72%).
Conclusions
The study findings show that awareness of human rights is limited among FSWs and HR-MSM, and a large proportion have not claimed their rights, elevating their HIV vulnerability. For a sustained HIV response, community mobilization efforts must focus on building key populations’ awareness of rights, and addressing the multiple barriers to claiming rights, with a view to creating a safe environment where vulnerable groups can demand and use services without fear of stigma, discrimination and violation of rights.
doi:10.1186/s12914-016-0102-2
PMCID: PMC5112884  PMID: 27855692
Human rights; India; Female sex workers; Men who have sex with men; HIV; Community mobilization
5.  Condoms and sexual health education as evidence: impact of criminalization of in-call venues and managers on migrant sex workers access to HIV/STI prevention in a Canadian setting 
Background
Despite a large body of evidence globally demonstrating that the criminalization of sex workers increases HIV/STI risks, we know far less about the impact of criminalization and policing of managers and in-call establishments on HIV/STI prevention among sex workers, and even less so among migrant sex workers.
Methods
Analysis draws on ethnographic fieldwork and 46 qualitative interviews with migrant sex workers, managers and business owners of in-call sex work venues in Metro Vancouver, Canada.
Results
The criminalization of in-call venues and third parties explicitly limits sex workers’ access to HIV/STI prevention, including manager restrictions on condoms and limited onsite access to sexual health information and HIV/STI testing. With limited labour protections and socio-cultural barriers, criminalization and policing undermine the health and human rights of migrant sex workers working in –call venues.
Conclusions
This research supports growing evidence-based calls for decriminalization of sex work, including the removal of criminal sanctions targeting third parties and in-call venues, alongside programs and policies that better protect the working conditions of migrant sex workers as critical to HIV/STI prevention and human rights.
doi:10.1186/s12914-016-0104-0
PMCID: PMC5114757  PMID: 27855677
Migrant sex workers; Criminalization; Third party actors; HIV/AIDS; Sexual health
6.  Is the UN Convention on the Rights of Persons with Disabilities Impacting Mental Health Laws and Policies in High-Income Countries? A Case Study of Implementation in Canada 
Background
Persons with psychosocial disabilities face disparate access to healthcare and social services worldwide, along with systemic discrimination, structural inequalities, and widespread human rights abuses. Accordingly, many people have looked to international human rights law to help address mental health challenges. On December 13, 2006, the United Nations formally adopted the Convention on the Rights of Persons with Disabilities (CRPD) – the first human rights treaty of the 21st century and the fastest ever negotiated.
Methods
This study assesses the CRPD’s potential impact on mental health systems and presents a legal and public policy analysis of its implementation in one high-income country: Canada. As part of this analysis, a critical review was undertaken of the CRPD’s implementation in Canadian legislation, public policy, and jurisprudence related to mental health.
Results
While the Convention is clearly an important step forward, there remains a divide, even in Canada, between the Convention’s goals and the experiences of Canadians with disabilities. Its implementation is perhaps hindered most by Canada’s reservations to Article 12 of the CRPD on legal capacity for persons with psychosocial disabilities. The overseeing CRPD Committee has stated that Article 12 only permits “supported decision-making” regimes, yet most Canadian jurisdictions maintain their “substitute decision-making” regimes. This means that many Canadians with mental health challenges continue to be denied legal capacity to make decisions related to their healthcare, housing, and finances. But changes are afoot: new legislation has been introduced in different jurisdictions across the country, and recent court decisions have started to push policymakers in this direction.
Conclusion
Despite the lack of explicit implementation, the CRPD has helped to facilitate a larger shift in social and cultural paradigms of mental health and disability in Canada. But ratification and passive implementation are not enough. Further efforts are needed to implement the CRPD’s provisions and promote the equal enjoyment of human rights by all Canadian citizens – and presumably for all other people too, from the poorest to the wealthiest countries.
doi:10.1186/s12914-016-0103-1
PMCID: PMC5105274  PMID: 27836014
Psychosocial Disabilities; Human Rights; International Law; Mental Health Law
7.  The impact of a microsavings intervention on reducing violence against women engaged in sex work: a randomized controlled study 
Background
Women who engage in sex work are at risk for experiencing violence from numerous perpetrators, including paying partners. Empirical evidence has shown mixed results regarding the impact of participation in microfinance interventions on women’s experiences of violence, with some studies demonstrating reductions in intimate partner violence (IPV) and others showing heightened risk for IPV. The current study reports on the impact of participation in a microsavings intervention on experiences of paying partner violence among women engaged in sex work in Mongolia.
Methods
Between 2011 and 2013, we conducted a two-arm, non-blinded randomized controlled trial (RCT) comparing an HIV/STI risk reduction intervention (HIVSRR) (control condition) to a combined microsavings and HIVSRR intervention (treatment condition). Eligible women (aged 18 or older, reported having engaged in unprotected sex with paying partner in past 90 days, expressed interest in microsavings intervention) were invited to participate. One hundred seven were randomized, including 50 in the control and 57 in the treatment condition. Participants completed assessments at baseline, immediate post-test following HIVSRR, and at 3-months and 6-months after completion of the treatment group intervention. Outcomes for the current study include any violence (physical and/or sexual), sexual violence, and physical violence from paying partners in the past 90 days.
Results
An intention-to-treat approach was utilized. Linear growth models revealed significant reductions over time in both conditions for any violence (β = −0.867, p < 0.001), physical violence (β = −0.0923, p < 0.001), and sexual violence (β = −1.639, p = 0.001) from paying partners. No significant differences between groups were found for any violence (β = 0.118, p = 0.389), physical violence (β = 0.091, p = 0.792), or sexual violence (β = 0.379, p = 0.114) from paying partners.
Conclusions
Microsavings participation did not significantly impact women’s risk for paying partner violence. Qualitative research is recommended to understand the cause for reductions in paying partner violence in both study conditions.
Trial registration
Evaluating a Microfinance Intervention for High Risk Women in Mongolia; NCT01861431; May 20, 2013.
doi:10.1186/s12914-016-0101-3
PMCID: PMC5086041  PMID: 27793147
Gender-based violence; Microfinance; Economic empowerment; Randomized controlled trial; Central Asia
8.  Early child health in an informal settlement in the Peruvian Amazon 
Background
Informal settlements are common throughout the developing world. In Peru, land occupations, commonly “invasions” in Spanish, are a means by which the extremely poor attempt to obtain access to land. Here, we examine difference in child health between two communities in the Peruvian Amazon, one well-established and one newly formed by ‘invasion’, as captured incidentally by a prospective epidemiological cohort study.
Methods
Between 2002 and 2006 a study designed to describe the epidemiology of pediatric enteric infections and child growth in a community-based setting enrolled 442 children in Santa Clara de Nanay, a community adjacent to the city of Iquitos, in Loreto, Peru. In early 2003, a land occupation, commonly called an “invasion” in Spanish, was organized by members of the Santa Clara community, and approximately 20 % of participating study families began occupying privately owned agricultural land adjacent to Santa Clara, thus forming the new community of La Union.
Results
Parents in families that chose to invade reported less education than parents in families that chose not to. Children in the new community experienced a higher incidence of diarrheal disease and non-specific fevers, although fewer helminth infections, than children who remained in the established community. At the time of the invasion, there were no differences in anthropometric status between the two groups; however children in the new community experienced greater progressive growth faltering over the course of the longitudinal study.
Conclusions
Growth faltering in early childhood represents an enduring loss of human potential. Therefore, our data suggests the human cost of land invasion may be disproportionately borne by the youngest individuals. Innovative policy strategies may be needed to protect this vulnerable group.
doi:10.1186/s12914-016-0099-6
PMCID: PMC5062939  PMID: 27733147
Peru; Informal settlement; Child health; Height-for-age; Natural experiment
9.  Knowledge and utilization of sexual and reproductive healthcare services among Thai immigrant women in Sweden 
Background
Migration from Thailand to Sweden has increased threefold over the last 10 years. Today Thailand is one of the most common countries of origin among immigrants in Sweden. Since the year 2000, new HIV cases are also more prevalent among Thai immigrants compared to other immigrant nationalities in Sweden. The purpose of this study was to investigate the association between knowledge and utilization of sexual and reproductive healthcare services, contraceptive knowledge and socio-demographic characteristics and social capital among Thai immigrant women in Sweden.
Methods
This is a cross-sectional study using a postal questionnaire to all Thai women (18–64) in two Swedish regions, who immigrated to the country between 2006 and 2011. The questionnaire was answered by 804 women (response rate 62.3 %). Bivariate and multivariate logistic regression analyses were used.
Results
The majority (52.1 %) of Thai women had poor knowledge of where they should turn when they need sexual and reproductive healthcare services. After controlling for potential confounders, living without a partner (OR = 2.02, CI: 1.16–3.54), having low trust in others (OR = 1.61, CI: 1.10–2.35), having predominantly bonding social capital (OR = 1.50, CI: 1.02–2.23) and belonging to the oldest age group (OR = 2.65, CI: 1.32–5.29) were identified as risk factors for having poor knowledge. The majority (56.7 %) had never been in contact with healthcare services to get advice on contraception, and about 75 % had never been HIV/STI tested in Sweden. Low utilization of healthcare was associated with poor knowledge about healthcare services (OR = 6.07, CI: 3.94–9.34) and living without a partner (OR = 2.53, CI: 1.30–4.90). Most Thai women had knowledge of how to prevent an unwanted pregnancy (91.6 %) and infection with HIV/STI (91.1 %).
Conclusions
The findings indicate that social capital factors such as high trust in others and predominantly bridging social capital promote access to knowledge about healthcare services.
However, only one-fourth of the women had been HIV/STI tested, and due to the HIV prevalence among Thai immigrants in Sweden, policy makers and health professionals need to include Thai immigrants in planning health promotion efforts and healthcare interventions.
doi:10.1186/s12914-016-0100-4
PMCID: PMC5057435  PMID: 27724904
Social capital; Immigration; Thai women; Healthcare utilization; HIV/STI
11.  Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana 
Background
In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana’s health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC.
Methods
Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers.
A stakeholders’ workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from respondents for the achievement of the goals of UHC and PHC.
Results
The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS; inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC.
Conclusion
This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC.
doi:10.1186/s12914-016-0095-x
PMCID: PMC5011972  PMID: 27595842
Misalignment; Universal Health Coverage; National Health Insurance; Primary health care; Upper East region; Ghana
12.  Diabetes self-management among Arab Americans: patient and provider perspectives 
Background
Arab Americans have a high burden of diabetes and poor outcomes compared to the general U.S. population. Diabetes self-management (DSM) requires a partnership between patients and providers that fosters mutual understanding and shared decision-making. Cultural factors influence this process; however, little is known regarding the cultural impact on DSM or if perceptions differ between patients and providers.
Methods
Qualitative content analysis was used to analyze five focus groups–two groups with Arab American providers (n = 8) and three groups with adult Arab Americans with diabetes (n = 23). Focus groups examined patient and provider perspectives on the meaning of DSM and cultural barriers and facilitators among Arab American patients.
Results
Four distinct themes included limited resources for DSM education and support, stigma as a barrier to ongoing support, family support as an opportunity and challenge, and Arab American patient-provider relationships.
Conclusions
Findings indicate several domains should be considered for clinical practice including a need to develop linguistically and culturally reliant educational materials and relevant supports for use in the Arab American population. Findings highlight differing views among providers and patients on the familial role in supporting DSM efforts and why some patients feel dissatisfied with clinical encounters.
doi:10.1186/s12914-016-0097-8
PMCID: PMC5006513  PMID: 27582174
Diabetes mellitus; Vulnerable populations; Focus groups; Primary health care; Minority groups
13.  Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana 
Background
In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana’s health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC.
Methods
Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers.
A stakeholders’ workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from participants for the achievement of the goals of UHC and PHC.
Results
The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS, inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC.
Conclusion
This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC.
doi:10.1186/s12914-016-0096-9
PMCID: PMC5006541  PMID: 27576456
Misalignment; Universal Health Coverage; National Health Insurance; Primary health care; Upper East region; Ghana
14.  Assessment of prison life of persons with disability in Ghana 
Background
Persons with Disabilities (PWDs) are a unique group that are often overlooked in many developing countries due to systemic weaknesses, lack of political commitment and inadequate support from government and non-governmental agencies. The population of these individuals is however steadily on the increase and currently corresponds to 15 % of the world population. Although much data exist on lifestyle and conditions of prisoners with disabilities in the western world, scanty information is available in Africa. In Ghana, there is insufficient data on the occurrence and social characteristics of prisoners with disabilities. The purpose of this current study was therefore to identify the occurrence, types and causes of disabilities among prisoners serving sentences in Ghanaian prisons.
Methods
This study was a descriptive cross-sectional survey conducted in the Male and Female Regional Prisons in Kumasi, Sunyani and the Nsawam Medium Security Prison, from November to December 2011. PWDs were selected by prisons officers and interviewed using structured questionnaires on variables such as socio-demographic characteristics, causes of disabilities and accessibility to recreational facilities. Ethical approval was obtained from the security services and the Committee of Human Research Publications and Ethics (CHRPE) of the School of Medical Sciences, Kwame Nkrumah University of Science and Technology (KNUST).
Results
We screened 6114 records of prisoners of which 1852 (30.3 %) were from the Kumasi Central Prisons, 3483 (57 %) from the Nsawam Medium Security and 779 (12.8 %) from the Sunyani Central Prisons. A total of 99 PWDs were identified with the commonest disability being physical, followed by visual, hearing, speech, mental and albinism. Most of the disabilities were caused by trauma (68.8 %) followed by infection (16.7 %), and drug related mental disabilities (6.3 %). Fifty (50.5 %) out of the 99 PWDs were not provided with assistive devices although they admitted the need for such.
Conclusion
The present study has demonstrated the occurrence and conditions of PWDs in Ghanaian prisons. Major stakeholders including government agencies and other organisations could develop policies that would improve the conditions and livelihood of prisoners with disabilities in Ghana.
doi:10.1186/s12914-016-0094-y
PMCID: PMC4977685  PMID: 27501790
Disability; Ghana; Prisons
15.  Civil society advocacy in Nigeria: promoting democratic norms or donor demands? 
Background
Civil society organizations (CSOs) are often assumed to be institutions that facilitate communication between citizens and policymakers. However, CSO advocacy is only as effective as the space allowed by government, the resources available from funders, and their own internal capacity. This article presents findings from a study in Nigeria that explores the advocacy and service delivery roles of CSOs working in Human Immunodeficiency Virus (HIV) prevention and mitigation. We will argue that donor and government treatment of civil society as service delivery organizations, rather than as organizations that participate in democratic norms, have shaped how civil society organizations work to mitigate and prevent HIV.
Methods
From February to April 2012, a team of Health Systems 20/20 staff and one consultant conducted 48 in-depth interviews with civil society organizations, State AIDS Control Agencies (SACAs), donors, international organizations, and networks of people living with HIV to examine a wide range of advocacy efforts by CSOs. For quantitative data collection, sampling frames were assembled from lists of HIV-oriented or involved CSOs. This sampling frame consisted of 2548 CSOs from all 36 states and the Federal Capital Territory. A random sample was then taken from the sampling frame, and we contacted 665 CSOs to arrange interviews. With a response rate of 80.2 %, the project conducted 533 surveys in February 2012.
Results
These surveys showed that CSOs advocacy efforts focused on community mobilization related to behavior change, such as peer education (54.9 % of CSOs) and rallies (58.2 % of CSOs), and not on changing government policies. In-depth interviews highlighted the role of donors and government in shaping a purely apolitical role for most CSOs through funding constraints, regulations, and capacity development choices.
Conclusions
In light of these findings, we present key points for considering the influence of donors and government on civil society advocacy for HIV services and rights. We present evidence that donors, and international organizations, conceive of civil society as apolitical, and not as independent actors that compete for political space. More democratic and rights-based views of civil society’s role, such as holding government accountable for providing services or promoting policy change, are not emphasized.
doi:10.1186/s12914-016-0093-z
PMCID: PMC4940692  PMID: 27400871
Advocacy; Civil society; Policy; Nigeria; HIV; Governance; HIV prevention; Rights
16.  “It’s for us –newcomers, LGBTQ persons, and HIV-positive persons. You feel free to be”: a qualitative study exploring social support group participation among African and Caribbean lesbian, gay, bisexual and transgender newcomers and refugees in Toronto, Canada 
Background
Stigma and discrimination harm the wellbeing of lesbian, gay, bisexual and transgender (LGBT) people and contribute to migration from contexts of sexual persecution and criminalization. Yet LGBT newcomers and refugees often face marginalization and struggles meeting the social determinants of health (SDOH) following immigration to countries such as Canada. Social isolation is a key social determinant of health that may play a significant role in shaping health disparities among LGBT newcomers and refugees. Social support may moderate the effect of stressors on mental health, reduce social isolation, and build social networks. Scant research, however, has examined social support groups targeting LGBT newcomers and refugees. The purpose of this qualitative study was to explore experiences of social support group participation among LGBT African and Caribbean newcomers and refugees in an urban Canadian city.
Methods
We conducted 3 focus groups with a venue-based sample of LGBT African and Caribbean newcomers and refugees (n = 29) who attended social support groups at an ethno-specific AIDS Service Organization. Focus groups followed a semi-structured interview guide and were analyzed using narrative thematic techniques.
Results
Participant narratives highlighted immigration stressors, social isolation, mental health issues, and challenges meeting the SDOH. Findings reveal multi-level benefits of social support group participation at intrapersonal (self-acceptance, improved mental health), interpersonal (reduced isolation, friendships), community (reciprocity, reduced stigma and discrimination), and structural (housing, employment, immigration, health care) levels.
Conclusions
Findings suggest that social support groups tailored for LGBT African and Caribbean newcomers and refugees can address social isolation, community resilience, and enhance resource access. Health care providers can provide support groups, culturally and LGBT competent health services, and resource access to promote LGBT newcomers and refugees’ health and wellbeing.
doi:10.1186/s12914-016-0092-0
PMCID: PMC4930565  PMID: 27369374
Social support; LGBT; Refugee; Newcomer; Social determinants of health; SDOH; Mental health; Sexual and gender minorities
17.  Maternity care and Human Rights: what do women think? 
Background
A human rights approach to maternal health is considered as a useful framework in international efforts to reduce maternal mortality. Although fundamental human rights principles are incorporated into legal and medical frameworks, human rights have to be translated into measurable actions and outcomes. So far, their substantive applications remain unclear. The aim of this study is to explore women’s perspectives and experiences of maternal health services through a human rights perspective in Magu District, Tanzania.
Methods
This study is a qualitative exploration of perspectives and experiences of women regarding maternity services in government health facilities. The point of departure is a Human Rights perspective. A total of 36 semi-structured interviews were held with 17 women, between the age of 31 and 63, supplemented with one focus group discussion of a selection of the interviewed women, in three rural villages and the town centre in Magu District. Data analysis was performed using a coding scheme based on four human rights principles: dignity, autonomy, equality and safety.
Results
Women’s experiences of maternal health services reflect several sub-standard care factors relating to violations of multiple human rights principles. Women were aware that substandard care was present and described a range of ways how the services could be delivered that would venerate human rights principles. Prominent themes included: ‘being treated well and equal’, ‘being respected’ and ‘being given the appropriate information and medical treatment’.
Conclusion
Women in this rural Tanzanian setting are aware that their experiences of maternity care reflect violations of their basic rights and are able to voice what basic human rights principles mean to them as well as their desired applications in maternal health service provision.
Electronic supplementary material
The online version of this article (doi:10.1186/s12914-016-0091-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12914-016-0091-1
PMCID: PMC4930607  PMID: 27368988
Human rights; Maternal health; Dignity
18.  Persistent misconceptions about HIV transmission among males and females in Malawi 
Background
The prevalence of HIV in Malawi is one of the highest in sub-Saharan Africa, and misconceptions about its mode of transmission are considered a major contributor to the continued spread of the virus.
Methods
Using the 2010 Malawi Demographic and Health Survey, the current study explored factors associated with misconceptions about HIV transmission among males and females.
Results
We found that higher levels of ABC prevention knowledge were associated with lower likelihood of endorsing misconceptions among females and males (OR = 0.85, p < 0.001; OR = 0.85, p < 0.001, respectively). Compared to those in the Northern region, both females and males in the Central (OR = 0.54, p < 0.001; OR = 0.53, p < 0.001, respectively) and Southern regions (OR = 0.49, p < 0.001; OR = 0.43, p < 0.001, respectively) were less likely to endorse misconceptions about HIV transmission. Moreover, marital status and ethnicity were significant predictors of HIV transmission misconceptions among females but not among males. Also, household wealth quintiles, education, religion, and urban–rural residence were significantly associated with endorsing misconceptions about HIV transmission.
Conclusion
Based on our findings, we recommend that education on HIV transmission in Malawi should integrate cultural and ethnic considerations of HIV/AIDS.
doi:10.1186/s12914-016-0089-8
PMCID: PMC4896031  PMID: 27267906
HIV/AIDS Misconceptions; Gender; Malawi; Sub-Saharan Africa
19.  Understanding the futility of countries’ obligations for health rights: realising justice for the global poor 
Background
Although health is a right of all individuals without any distinction, the realisation of this right has remained very difficult for the marginalised populations of poor countries. Inequitable distribution of health opportunities globally is a major factor in explaining why this is the case. Whereas the Protection, Promotion and Fulfilment of the health rights of poor country citizens are a joint responsibility of both domestic and external governments, most governments flout their obligations. So far disproportionate effort has been dedicated to reaffirming and interpreting these obligations as opposed to investigating the fundamental question regarding why these obligations have nevertheless remained largely unfulfilled. Further the normative question regarding what ought to be done about the shortcomings of current obligations has been largely ignored.
Methods
We conduct a critical content analysis of existing literature on efforts towards the realisation of the health rights of marginalised populations in our attempt to ascertain their capacity to guarantee basic health opportunities to marginalised populations. In our analysis we treat issues of ‘health rights’ and ‘justice in global health’ as having unity of purpose – guaranteeing basic health opportunities to the marginalised populations.
Results
We identify two sets of reasons for the failure of present obligations for global distributive justice in general: a set of ‘superficial reasons’ and a set of ‘fundamental reasons’ which account for the superficial reasons.
Discussion
In order to overcome these reasons we propose a strategy which consists in specifying a number of minimum and less-demanding obligations for both external and domestic governments to guarantee to all individuals a certain threshold of health goods and services. We argue that these minimum obligations can be freely accepted and fully complied with or enforced with “a thin system of enforcement” without significant threat to national sovereignty and autonomy.
Conclusion
The futility of countries’ obligations for the health rights of the global poor as is the case with global distributive injustice is because of lack of political will to specify and enforce such obligations. Minimum obligations should be specified and enforced with a “thin system” which is consistent with principles of national sovereignty and autonomy.
doi:10.1186/s12914-016-0090-2
PMCID: PMC4891878  PMID: 27256289
Health opportunities; Marginalised populations; Right to health; Global distributive justice; Obligations; Low Income Countries; Developing countries
20.  Documenting a long-term development model in the slums of Delhi 
Background
Achieving development outcomes requires the inclusion of marginalised populations that have the least opportunity to participate in and benefit from development. Slum dwellers often see little of the ‘urban advantage’, suffering more from infectious diseases, increasing food costs, poor access to education and health care, inadequate water and sanitation, and informal employment. A recent Cochrane Review of the impact of slum upgrading strategies found a dearth of unbiased studies, making it difficult to draw firm conclusions. The Review calls for greater use of process data, and qualitative alongside quantitative methods of evaluation. India is a lower middle income nation with large gender disparities and around 65 million slum inhabitants. The Asha Community Health and Development Society, a non-governmental organisation based in Delhi, has delivered a multi-sectoral program across 71 slums since 1988. This article reports on a mixed-method study to document measureable health and social impacts, along with Asha’s ethos and processes.
Methods
Several observational visits were made to 12 Asha slums where informal discussions were had with staff and residents (n = 50). Asha data records were analysed for change over time (and differences with greater Delhi) in selected indicators (maternal-child health, education, child sex ratio) using descriptive statistics. 34 semi-structured individual/small group interviews and 14 focus group discussions were held with staff, residents, volunteers, elected officials, civil servants, bankers, diplomats, school principals, slumlords and loan recipients (n = 147).
Results
Key indicators of health and social equity improved over time and compared favourably with those for greater Delhi. The Asha model emphasises rights, responsibilities, equity and non-violence. It employs strategies characterised by long-term involvement, systematic protocols and monitoring, development of civil society (especially women’s and children’s groups) to advocate for rights under the law, and links with foreign volunteers and fund-raisers. Stakeholders agreed that changes in community norms and living conditions were at least partly attributable to the Asha model.
Conclusions
While lacking a control group or complete baseline data, evidence suggested substantial improvements in slum conditions and social equity. The Asha model offers some lessons for slum (and broader) development.
doi:10.1186/s12914-016-0088-9
PMCID: PMC4848816  PMID: 27125373
21.  A household perspective on access to health care in the context of HIV and disability: a qualitative case study from Malawi 
Background
Equitable access to health care is a challenge in many low-income countries. The most vulnerable segments of any population face increased challenges, as their vulnerability amplifies problems of the general population. This implies a heavy burden on informal care-givers in their immediate and extended households. However, research falls short of explaining the particular challenges experienced by these individuals and households. To build an evidence base from the ground, we present a single case study to explore and understand the individual experience, to honour what is distinctive about the story, but also to use the individual story to raise questions about the larger context.
Methods
We use a single qualitative case study approach to provide an in-depth, contextual and household perspective on barriers, facilitators, and consequences of care provided to persons with disability and HIV.
Results
The results from this study emphasise the burden that caring for an HIV positive and disabled family member places on an already impoverished household, and the need for support, not just for the HIV positive and disabled person, but for the entire household.
Conclusions
Disability and HIV do not only affect the individual, but the whole household, immediate and extended. It is crucial to consider the interconnectedness of the challenges faced by an individual and a household. Issues of health (physical and mental), disability, employment, education, infrastructure (transport/terrain) and poverty are all related and interconnected, and should be addressed as a whole in order to secure equity in health.
doi:10.1186/s12914-016-0087-x
PMCID: PMC4818417  PMID: 27036489
Disability; HIV; Care; Household; Malawi
22.  Using international human rights law to improve child health in low-income countries: a framework for healthcare professionals 
Background
The Committee on Economic, Social and Cultural Rights states that the right to health is closely related to, and dependent upon, the realization of other human rights, including the right to food, water, education and shelter which are important determinants of health. Children’s healthcare workers in low income settings may spend the majority of their professional lives trying to mitigate deficiencies of these rights but have little influence over them. In order to advocate successfully at a local level, we should be aware of the proportion of children living in our catchment population who do not have access to their basic rights. In order to carry out a rights audit, a framework within which healthcare workers could play their part is required, as is an agreed minimum core of rights, a timeframe and a set of indicators.
Discussion
A framework to assess how well states and their developmental partners are adhering to human rights principles is discussed, including the role that a healthcare worker might optimally play. A minimum core of economic and social rights seeks to establish a legal minimum set of protections, which should be available with immediate effect and applicable to all nations despite very different resources. Minimum core rights and the impact that progressive realisation may have had on the right to health is discussed, including what they should include from the perspective of children’s health. A set of absolute rights are suggested, based on physiological needs and aligned with the corresponding articles of the United Nations Convention on the Rights of the Child. The development indicators which are likely to be used to monitor progress towards the Sustainable Development Goals is suggested as a way to monitor rights. We consider the ways in which the healthcare worker could use a rights audit to advocate with, and for their community.
Summary
These audits could achieve several objectives. They may legitimise healthcare workers’ interests in the determinants of health and, as they are often highly respected by their community, this may facilitate them to be agents for change at a local level. This may raise awareness on basic human rights and their importance to health and contribute to a needed change in mind-set from one of development needs to absolute rights. The results may catalyse colleagues to analyse further the upstream reasons why children, and the families in which they live, are not having their rights met.
doi:10.1186/s12914-016-0083-1
PMCID: PMC4815083  PMID: 27029469
Human rights; Children; Health professionals; Health; Duty bearers; United Nations Convention on the Rights of the Child
23.  Human rights dimensions of food, health and care in children’s homes in Kampala, Uganda – a qualitative study 
Background
More than 14 % of Ugandan children are orphaned and many live in children’s homes. Ugandan authorities have targeted adolescent girls as a priority group for nutrition interventions as safeguarding nutritional health before pregnancy can reduce the chance of passing on malnutrition to the offspring and thus future generations. Ugandan authorities have obligations under international human rights law to progressively realise the rights to adequate food, health and care for all Ugandan children. Two objectives guided this study in children’s homes: (a) To examine female adolescent residents’ experiences, attitudes and views regarding: (i) eating patterns and food, (ii) health conditions, and (iii) care practices; and (b) to consider if the conditions in the homes comply with human rights standards and principles for the promotion of the rights to adequate food, health and care.
Methods
A human rights-based approach guided the planning and conduct of this study. Five children’s homes in Kampala were included where focus group discussions were held with girls aged 12-14 and 15-17 years. These discussions were analysed through a phenomenological approach. The conditions of food, health and care as experienced by the girls, were compared with international standards for the realisation of the human rights to adequate food, health and care.
Results
Food, health and care conditions varied greatly across the five homes. In some of these the girls consumed only one meal per day and had no access to clean drinking water, soap, toilet paper and sanitary napkins. The realisation of the right to adequate food for the girls was not met in three homes, the realisation of the right to health was not met in two homes, and the realisation of the right to care was not met in one home.
Conclusions
In three of the selected children’s homes human rights standards for food, health or care were not met. Care in the children’s homes was an important contributing factor for whether standards for the rights to adequate food and health were met.
doi:10.1186/s12914-016-0086-y
PMCID: PMC4797151  PMID: 26993271
Adolescent girls; Care; Children’s homes; Child care institutions; Human rights; Nutrition; Right to food
24.  “The others look at you as if you are a grave”: a qualitative study of subjective experiences of patients with epilepsy regarding their treatment and care in Cape Town, South Africa 
Background
Existing evidence shows that the majority of people with epilepsy in lower and middle income countries are not receiving appropriate treatment and care. Although this problem has been reported as one of the factors affecting the quality of lives of people with epilepsy, very few studies have investigated patients’ perspectives and their experiences about the problem. This qualitative study explored perspectives and subjective experiences of people with epilepsy about their illness in an urban township in South Africa.
Methods
Individual face-to-face interviews included twelve people who had epilepsy. A semi-structured interview guide which was based on Kleinman (1980) Explanatory Models Framework was used to elicit participants’ perspectives and subjective experiences about their illness and its treatment. Thematic analysis method was used to analyse the data.
Results
The main theme reflecting participants’ verbatim accounts was about their perceived difficulties affecting their access to treatment and care during their routine clinical follow up visits. These concerned rushed consultations which focussed on seizure frequency and adherence to medication with no attention to personal concerns. They perceived that part of the problem could be that some health care practitioners were not adequately trained and lacked empathy, interest, respect and listening skills. We argue that in a health system where patients feel that they are not respected and their concerns are not listened to or are ignored, they may lack trust in the system and this may violate their right to access treatment and care.
Conclusions
The findings provide a glimpse of the extent to which the power and nature of the routine task-centred system can lead to violation of patients’ health rights – especially with epilepsy which is poorly understood and stigmatized. Appropriate interventions are needed to address health system factors affecting the treatment and care of this marginalized and vulnerable group of patients.
doi:10.1186/s12914-016-0084-0
PMCID: PMC4797135  PMID: 26988561
Patients with epilepsy; Treatment and care; Routine task system; Qualitative study; South Africa

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