A closer look at urban health equity and other EQUINET developments
Editor, EQUINET newsletter

Over the past few months we have begun to develop work in prioritised areas arising from a strategic review of the drivers of health equity in our region, drawing also on the diverse and rich inputs to and resolutions from the 2022 EQUINET conference (you will find the recordings on sessions and the resolutions on our website). We welcome new institutions and individuals to the EQUINET steering committee on areas such as tax justice, addressing the health needs of young people and climate justice and thank those who are continuing in the steering committee to lead work in areas that remain persistently relevant. We also thank those who have steered EQUINET work over many past years who join our policy and strategy reference group.

One of the areas that is engaging diverse new constituencies is that of integrated, holistic approaches to urban health, including urban food systems. We include publications from work in this issue of the newsletter, welcome links with those working in this area and will be giving focus to it in future grant calls, so keep an eye on our website! We will also be holding a series of webinars on climate justice and health equity, integrating climate justice as an intersecting issue in the various areas of thematic work on health equity. The first webinar will be on 11th July focusing on climate justice and the right to health, hosted by CEHURD Uganda. Find more information and the registration link in the 'Latest EQUINET Updates' section in this newsletter and visit the EQUINET website for details of further forthcoming webinars and discussions!

Conflict of Interest in health research – how do we find the green light for ethical practice?
Leslie London, University of Cape Town, South Africa

Research is key to promoting and health and preventing disease to the extent that international human rights law recognises the right of everyone to benefit from scientific progress. But what if health research is subverted from its aim by the presence of conflict of interest?

We have already seen this, such as in how some researchers failed to disclose their conflicts of interest when producing research that downplayed the health hazards of chrysotile asbestos (https://tinyurl.com/52hpah2p), findings that allowed this toxin and the asbestos industry an extended shelf-life at the expense of human lives.

The gatekeepers of ethical research are institutions – typically, science granting councils which allocate research funding and shape science policy at country level, and Research Ethics Committees (RECs), which provide oversight to ensure that health research is implemented in line with generally accepted ethical standards.

But in a context of scarce resources for health research, even these institutions can fail, when research funding provided by corporations, or sometimes even governments, with vested interests compromises the independence of the research process, producing research findings that undermine evidence-based policy. A 2020 study of the willingness of Schools of Public Health in the African, Eastern Mediterranean, European and US regions found widespread openness amongst respondents to the idea of accepting funding from corporate sources with vested interests in research on non-communicable diseases (https://tinyurl.com/nmpxcxwd). This is not surprising, given the pressures under which low-income country researchers operate, often with little or no research funding, in contrast to the immense power and financial resources available to corporates wishing to influence health policy to protect their profits.

Even the most powerful Science Councils can fall prey to conflict of interest. This was illustrated, for example, when the collusion was exposed between officials of the US National Institute of Health, contrary to NIH policy, and representatives of the alcohol beverage industry, in setting up a huge study of moderate alcohol consumption, called the MACH study. The study was plagued by questionable design and by a clear vested interest in choosing a research question that was likely to benefit industry sales, rather than generating evidence pertinent for health policy (https://tinyurl.com/ak57wdj2).

Empowering Science Council staff and REC members with the skills to identify, obviate and manage conflict of interest effectively is thus essential if health research is to realise the benefits of scientific progress for people most in need. This is particularly the case in sub-Saharan Africa, where research systems are fragile and starved of the resources needed to ensure researcher independence.

Conflict of interest (COI) is defined as circumstances in which professional judgment concerning a primary interest (such the validity of research) tend to be unduly influenced by a secondary interest (such as financial gain). It can be effectively addressed if systems are designed to insulate decision-making processes from vested interests, and to protect researcher independence, objectivity and impartiality. This is possible if the people in those systems can gain skills to manage COI better. This applies as much to research as to broader policy making, which may also be heavily influenced by corporate activities and strategies.

A collaborative initiative, funded by the IDRC, and involving researchers from South Africa, Kenya, Cameroon and Lebanon, developed over two years, an online course (https://tinyurl.com/dp9madje) and a toolkit (https://tinyurl.com/c742bb63) that aimed to empower REC members and Science Council staff to better manage COI in the research process. These resources are open access and available to all interested in improving the integrity of evidence used in health policy decisions.

The toolkit offers examples of how to identify and manage COI, ranging from prohibition and disclosure through to mitigation or resolution. It emphasizes that reliance on disclosure alone is insufficient. It may be counter-productive if it legitimises any kind of COI, including COIs that, in a traffic light analogy, should trigger red lights.

The toolkit outlines three scenarios. The first is where ‘moral certainty’ exists that that the research should not proceed, such as when the funding source is an organisation whose products are harmful and where the organisation holds a direct interest in the outcome of the research, as in the example of tobacco industry funding for tobacco-related research. In the second scenario, such as when the funding source has no interest in the study outcome and does not produce commodities harmful to health, it is also easy to conclude the study should proceed.

But usually, it is a third scenario where there is uncertainty on the interests.

In this situation, the toolkit proposes a series of key questions that could be used to identify COI and characterise its scope. Such questions include whether anyone on the REC or science council will benefit financially from the research, whether a financial loss will be avoided if the research is approved, or whether the research serves a marketing purpose for the funder. Depending on the case, different strategies may be applied. The strategies include recusal of a committee member or science council employee who has direct interest in the outcome of the decision, barring a funder from any say in publication decisions, or mandating an independent oversight committee to monitor study implementation. The toolkit also maps the elements of policy that institutions might adopt to manage COI more effectively. Coupled with skills development, such initiatives are important to finding the right balance between diversifying funding and retaining independence of the research process.

To continue the traffic light analogy, finding the green light for health research is the ultimate goal. But much of what we encounter in practice is amber. It is located in that space where careful reasoning, drawing on ethical principles is needed to ensure that health research findings can provide the necessary unbiased evidence, free from vested interests, to advance health in our region.

For further information on the Toolkit and online course visit the Conflict of Interest in Health Research website at the University of Cape Town, https://tinyurl.com/5bp4k8b7. Feedback to the team would be very welcome.

As 2022 ends, thanks for joint actions and wishing you a heathy start to 2023
EQUINET Steering Committee

We appreciate the ideas, actions, initiatives on health equity we've shared in 2022. The context is challenging, but our conference in 2022, profiled in this issue, showed the rich perspectives, evidence, experiences and creativity people in the region bring to our struggles for social justice in health. We wish you wellbeing and progress in 2023! In 2022 our EQUINET Conference and various steering committee meetings identified key areas of work on health equity within our three strategic directions - Reclaiming the resources; Reclaiming the state; Reclaiming collective agency and solidarity. We are building on past work and alliances, renewing network leadership and developing a programe of research, work, dialogue, and engagement to put the resolutions of our Conference into action. To give time for this we will not have the quarterly newsletter in March 1 2023. Watch out for our next newsletter on June 1 2023- it will be a bumper issue!

Catalysing change for equity and social justice in health: Resolutions for action
EQUINET Conference 2022: Headline resolutions, November 2022

Delegates at the EQUINET Conference 2022 comprised representatives of civil society organisations, community members, parliament, central and local government leaders and officials, trade unions, media, academia, researchers, and personnel from regional and international organisations. We came together virtually under the umbrella of the Regional Network for Equity in Health in East and Southern Africa (EQUINET) to deliberate the actions needed to Catalyse change for health and social justice in this region.

Our deliberations took place at a time of deep-seated and multiple crises that have decimated the basic foundations for provision of public goods (the state, resources and collective agency) in our region, with the poor and marginalised communities left behind to shoulder the burden.
• Are alarmed by the: deepening resource extraction from our region that harms our environment and depletes resources for current and future generations; by inequalities in health, wellbeing and access to services, especially in urban areas and with particular consequences for young people, that are exacerbated by harmful commercial practices; underfunding, privatisation and commodification of public sector services; and by local to global political and economic systems that promote profit over people, disempower people and disrupt collective agency, dignity and social solidarity.
• Are greatly concerned with the limit and slow pace of action to address these challenges and make the change needed to promote equity in health and wellbeing at local, national and regional levels.
• Recognise that public sector-led health systems and comprehensive primary health care are central elements of the robust, redistributive and participatory states that are essential to meet our challenges, including from pandemic, conflict and climate injustice and address global drivers of injustice and inequity.
• Unequivocally identify the pivotal contribution that human rights, solidarity values, collective organisation and social power make in supporting self-determined action towards social, economic and ecological justice.

Committing to reclaim our resources, our states and our collective agency and solidarity for health and social justice, and as a catalyst for a political economy and systems that are rooted in values of equity, social justice, collective wellbeing and protection of nature, we propose a set of inter-linked areas of action to address our most critical challenges and tap our assets for health.

Building on our past 25 years, we understand that equity demands sustained, longer-term action. Over the next five years, we will:

1. Take action to:
a. Build and amplify a clear and affirmative pro-equity, pro-public discourse to affirm values, claim rights, resist inequity and demand action.
b. Track, generate evidence and knowledge on inequities and rights violations in health and wellbeing, and on the opportunities for and feasibility of social justice change that promotes both sustained human and ecosystem wellbeing.
c. Promote, demonstrate, advocate for and contribute to the implementation of specific equity-promoting laws, policies, practices and reforms for equity in health and wellbeing.
d. Build the capacities, leadership and activism needed to promote active participation and communities as agents of change; and to engage in participatory democracy around the policies, laws and systems that are critical in catalysing equity-oriented change.
e. Develop, sustain and work with pro-equity networks and alliances for action within and across countries in the east and southern Africa (ESA) region, in exchanges and engagement with other regions, with global actors and in global processes.

2. With a particular focus on the following issues:
• Development and implementation of constitutional and legal provisions that protect the right to health and enable action on equity in health and wellbeing.
• Healthy living, working and ecological conditions and food sovereignty, including specific concern on the extractive sectors, corporate practices, climate and eco-social justice, and for youth health and urban wellbeing.
• Adequate and progressive public sector resourcing (financial, health worker, commodities, infrastructures) and fair allocation for comprehensive primary health care oriented, universal, equitable, socially accountable public sector health, social and essential services, including in pandemics, and on disaggregated and publicly accessible information, monitoring and public health surveillance systems that integrate community evidence.
• Investment in local production of essential health products and tax justice, and the rule systems, measures and institutional reforms for this within the region and at global level.
• Regional counterproposals to paradigms, narratives, and local to global economic, political and procedural drivers of policies and practices that harm equity health and wellbeing and participatory democracy in health systems and services.

These headline resolutions were adopted by the conference on its final day. Further detail on the issues and areas of action is shown at https://www.equinetafrica.org/conference/resolutions.html.

Share your stories of change in promoting health and social justice in the region
Editor, EQUINET newsletter

In exchanges and work in the region and in the 2022 EQUINET conference 'Catalysing change for health and social justice' we have heard and shared creative, committed and often sustained experiences that promote health equity and social justice at local, national and regional level, and in engaging in global processes. In future newsletters we thus plan to share these stories of change together with our usual editorials. Please contribute and share your work! We invite submissions of about 1000 words that tell the story with links where available to further information that we can feature in future issues. If you need edit support to write it we can assist. Please email your submission to the EQUINET secretariat (email address on the website) with 'Story of Change' in the subject line. If you haven't yet joined the online EQUINET conference you are still in time to register for and join the remaining days. Details are on the EQUINET website.

STORIES OF CHANGE: Opening doors for young people through affordable e-learning in South Africa
Nadine Nanji, Public Health Researcher, University of Cape Town, South Africa

South Africa has high levels of socio-economic inequality and youth unemployment. The COVID-19 pandemic has created many economic challenges, especially for those who are already insecure or who live and work in precarious conditions, many of whom are young people. Poverty and lack of opportunity in a country where there is a visible display of wealth has led to frustration and social unrest. Unemployed youth and those in precarious employment and in lowest income communities are vulnerable to many risks, including mental stress, gender-based violence, sexual abuse, teenage pregnancies, and use of harmful substances.

Digital courses are available, but are often unaffordable for the lowest income youth, as are university courses and other formal training programmes. Digital skills have high value, but how do unemployed, underserved or economically disadvantaged South African youth access these skills? This generates new forms of digital inequity that add to the country’s other dimensions of inequality. While young people have many interests, they want to follow learning tracks that improve their incomes, working lives and wellbeing. They also don’t want to have to high jump over huge demands for formal educational qualifications to have the chance to learn new skills.

In 2021, an initiative was launched to tackle these issues facing the disadvantaged young people, triggered also by the increased demand for online interaction during the COVID-19 pandemic. Afrika Tikkun, a South African non-profit organisation, aims to improve the lives of young people, leveraging solidarity partnerships with other organisations. Afrika Tikkun saw an opportunity to tackle inequities in youth unemployment through education, skills development and placement programmes. They found a partner in Nedbank, who, having done an assessment in 2020 on social issues that could be rectified through financial investment, identified a huge gap in the digital job market in South Africa, with an unmet demand due to a shortfall in skills. Any programme aimed the lowest income young people tapping this opportunity would need to address the multiple barriers they face in access to and the costs of online platforms, to avoid entry barriers from a demand for high formal education levels, and to encourage and guide learning through mentoring and peer support. Afrika Tikkun and Nedbank partnered with Microsoft to draw on their experience in digital skills building, in a collaboration that brought different capacities and roles towards a shared goal.

These partners established an e-learning platform called DigiSkills, with an explicit goal of supporting digital equity for young people. No formal education was needed to join the programme, the program provides in a low bandwidth five free online short courses on professional digital skills with constant support through facilitators, mentors and peer groups to encourage and support participation. The app provides free access to online learning, although data charges to get online still need to be met. The equity test and sustainability of the initiative lies, however, not so much in the resources of the launching partners, but in the reach to and social and economic value it has for the participating young people, particularly those normally excluded from such skills programmes.

By the end of 2021, 1000 students had completed the online digital skills training, with prior screening ensuring that there were drawn from disadvantaged, unemployed or displaced youth. Over 400 of these young people found job opportunities. In 2022, a further 4000 young South Africans are undergoing the training. The DigiSKills program is supporting students to link learning pathways to job creation and entrepreneurial opportunities, and to solidarity with other young people. 26-year-old David, previously unemployed, who took the course and now works as a developer at MLab, commented that the opportunity has given him a power he did not have before to sustain himself and his family. 31-year old Thabani, also a graduate courses, is now assisting other young people to sign up and intends to start his own IT training company to help more youth in South Africa.

There are no magic bullets however. These programmes don’t intend to substitute pathways to higher levels of skills, research and development and on their own don’t stop the brain drain from South Africa. They don’t replace more significant levels of investment in self-determined research and innovation in the country. They don’t yet address the wider cost barriers to internet and data and to capital for young people to create new enterprises. All these areas need state and political attention and a wider level of change on the multiple institutions involved in the systems for skills development, research, innovation and entrepreneurship, including from early child development and in schools.

However, there are some lessons from the story of change on how partnerships can bring together actors with different background and capabilities, based on evidence and embedding clear values, towards a shared vision and implementation. The initiative is perhaps not perfect, not adequate for the significant inequities faced and still to be tested in the longer term. It suggests, however, that individually the young people and each of the institutions involved are not drivers of transformation. It is perhaps in their convergence, and their mindfulness and consistency in addressing an equity goal, that there is a possibility for producing change or shifting power in this key area of inequity for young people in South Africa.

EQUINET, through its Equity Watch Cluster invites your stories of change on any areas that reflect change in health equity and social justice, locally, within countries and regionally in east and southern Africa. In about 1000 words they tell the story of how a change came about, and who made it happen. To send feedback on the issues raised in this oped or to send a story please email the EQUINET secretariat: admin@equinetafrica.org. Further information on Digiskills can be found at the Africa Tikkun website (https://afrikatikkun.org/ ) and at https://www.digiskills.careers/.

Be part of the exchanges at #EQUINETConf22 on Catalysing Change for Health and Social Justice!
EQUINET steering committee

The EQUINET Conference 2022 “Catalysing change for health and social justice” welcomes community members, workers, state personnel at all levels, civil society, parliamentarians, academics, trade unions, diverse professionals, innovators, producers and others to present ideas and hear experience from the east and southern Africa region. We will also learn how other regions are confronting equity challenges and discuss and propose key areas of action and policy to promote health equity and social justice. We need your input so please don't get left behind! Find out more in the EQUINET update section of the newsletter, follow @EQUINETConf22 on twitter or visit the conference website at https://www.equinetafrica.org/conference/home.html.

Confronting inequities in the ‘donor’-‘recipient’ relationship in health in Uganda
Danny Gotto, Innovations for Development, Uganda

Like many other countries in East and Southern Africa, Uganda’s health sector is highly dependent on overseas development aid (ODA). The country receives considerable sums from external funders through grants, loans, and other forms. As initially conceived of, ODA intended to reduce poverty, and to support socio-economic development. Although initially conceived to be a form of temporary assistance, Uganda, like many other countries in the east and southern Africa, has continued to face financing gaps for these development aspirations. ‘Short-term’ foreign funding has become ‘long-term’ and Uganda, like others, has become increasingly dependent on aid to meet key health service obligations.

The COVID-19 pandemic threatens to turn this dependency into debt. In a 2021 analysis of aid flows to Uganda before and during COVID-19, Owori (https://devinit.org/resources/aid-uganda-covid-19/) reported bilateral grants to be the largest source of ODA to Uganda in 2020. The United States was noted to be the largest external funder, followed by the European Commission. However, Owori also found that the profile of official development assistance had switched in 2020 from grants to increased proportions of concessional loans from international financial institutions. At a time when the country faces significant liabilities from the pandemic, and a rise in the debt to GDP ratio from 48% before COVID-19 to 52% in 2022, the shift from grants to loans adds further pressures to the public purse. The ‘East African’ reported in February 2021 that the National Budget Framework Paper 2021/2022, approved by parliament, projected that Uganda will spend 97% of its total domestic revenue on debt servicing, with the US$231 million for this six times the health sector budget. Efforts to re-negotiate or restructure loans have not yet yielded meaningful progress. Uganda is yet to benefit from G20 Debt Service Suspension Initiative (DSSI) and China, the largest creditors is not part of the DSSI. This means that Uganda has to borrow to pay.

The level of global inequality between countries and between elites and many in society clearly calls for redistributive financing within and between countries. Foreign funding to the health sector has led to impressive areas of progress in Uganda, such as in relation to reducing HIV and responding to treatment and care needs for AIDS.

However, concerns have been raised in the past over the way ODA from high to low and middle income countries can encourage corruption, distort priorities, mask inefficiencies and shift attention away from domestic budget commitments, and from deeper international economic and investment issues. Despite long-standing and significant levels of external aid, Uganda’s health sector still suffers from inadequate funding and infrastructure, wider health system deficits and weaknesses in governance. The provision of foreign assistance appears to have generated a culture of dependency from recipients and paternalism from funders. A ‘donor’ - ‘recipient’ relationship risks local expertise, knowledge and capacities being ignored, and can encourage neo-colonial and racist assumptions and attitudes. A northern aid industry has often placed itself in the position of managers, intermediaries, implementers, and monitors of ODA. On the other side, it also leads to an unhealthy reliance on foreign funding to meet state and sector obligations in health, such as immunizing children that should be funded by the Uganda government.

Whatever the well-meaning intentions, a mix of dependency and paternalism carries the risk of infantilizing leaders, and of absolving states of their responsibilities to their populations through domestic resources. It would be naïve to ignore that ODA carries with it interests of both funder and recipient. This calls for transparency in and negotiation of these interests. Commitments have been stated to increase transparency in this relationship, but these commitments are not always delivered on, and still far too little information is shared with local actors. ODA financing of a large share of health expenditure comes with conditions for close monitoring and reporting by states to external funders, sometimes with stronger state accountability to high income country funders and tax payers that to the citizens and parliaments of recipient countries, marginalizing mechanisms for domestic accountability. While such accountability needs to be demanded within our countries and there have been improvements in aid accountability, Wild and Domingo have observed in the past that what is written on paper is often different from what is practiced (https://tinyurl.com/57jap9jn). A preference for vertical funding of health sector programmes, not all through state systems, and off-budget funding with parallel reporting mechanisms means that evidence is not always shared with domestic actors. It is not easy to access information on external funding when off budget, such as in various forms of private- public partnerships or parallel institutions. Demands for domestic accountability also face power imbalances between funders and communities, and between high and low income countries.

These shortfalls and concerns are being voiced in many countries in the region, and by some stakeholders in high income countries, including those seeking to ‘decolonise’ ODA while still meeting obligations to global public goods and solidarity. This raises questions about how ODA is directed, given and used now and in the longer term, especially if the ‘giving’ creates repayment liabilities that the public will be paying for well into the future.

These issues need to be debated. In writing this oped with the intention to contribute to this dialogue, including on the actions to address the issues raised. For example, I suggest some areas of action.

Transparency and access to information should be at the heart of the negotiation of and accountability on interests in ODA relationships, not only between states, but also to the public on both sides. The lack of transparency and blockages in information flow noted earlier, including between states and citizens need to be addressed. This includes bringing ODA ‘on-budget’ in the health sector to capture and align the resources towards national health priorities and systems, and to enable and improve the mechanisms for and practice of public domain reporting and oversight.

The priorities brought by ODA need to be aligned to national health system priorities. The upward accountability to funders and high income source countries and power imbalances between low- and high-income countries can be argued to generate a reliance on solidarity and inadequate incentives for ODA funders to make good on their commitments under the Paris Declaration and other global commitments. ODA funders need to understand, engage with and align to the contexts, priorities and cultures of countries they engage with, and to invest time and resources upfront to engage to a greater degree in designing their investments and projects with local actors. This is important to avoid overlooking and under-investing in local health problems and priorities, and in the institutional and system needs to implement them. It can be argued that the shift noted earlier in Uganda from grant to loan funding, for example, reflects more the interests of high income country funders than the post-pandemic realities faced by the country and its communities.

This places a demand on states to build strategic capacities and alliances to negotiate domestic interests, to look beyond immediate sums to their implications and future burdens. However, there is also an obligation on ODA funders to not exploit or exacerbate weaknesses in recipient capacities and accountability mechanisms, but reinforce or support their strengths. For both sides this is a business of ‘relationships’ and diplomacy, and one in which power inequities and the institutional barriers on both sides of the relationship need to be more explicitly addressed, to achieve outcomes that matter for sustained population health equity.

We welcome your feedback or queries on the issues raised in this editorial. Please send them to the EQUINET secretariat. You can read more from I4DEV at http://www.i4dev.or.ug/

Meet commitments to public sector financing of public health to walk the talk of’ ‘pandemic preparedness’
Bona Chitah, University of Zambia

After a long period of domestic underfunding of public health services, particularly prevention and promotion services, the COVID-19 pandemic generated massive immediate demand to fund these same services. It arrived at a time when many public health systems in east and southern Africa (ESA) were fragmented, with challenges in service quality and provision and unmet need in the population. An analysis of health financing in ESA countries included in this newsletter showed that the pandemic called for a massive scale up of investment in testing; surveillance; infection prevention; waste management and health promotion. These were all areas that had seen declining investment in most ESA countries in the decade before the pandemic.

The regional analysis reviewed selected indicators available from the WHO Global Health Expenditure database for 2000–2019 of the extent to which governments prioritise health in domestic budget spending; provide financial protection; and spend on primary health care. A country case study then gave a deeper look at the health financing demand for the response to the pandemic, using national ministry of health data for 2020–2021 and projections for 2023.

Between 2000 and 2019, less than half of ESA countries included progressively increased their share of health spending in the budget and by 2019, only two met the Abuja Declaration commitment of 15% of government budget spending on the health sector. By 2019, seven ESA countries had out-of-pocket spending (OOPS) above the upper limit of 20% suggested by WHO to avoid catastrophic expenditures and impoverishment, four of them considerably so. For nine of the 16 ESA countries (including Zambia) in 2019, less than 50% of spending on primary health care (PHC) came from government spending, suggesting a high degree of reliance on external funders for this key area of pro-poor spending.

It can be argued that those countries that gave less priority to public sector health in government spending and that provided less financial protection against impoverishment for users through OOPS could have been in a weaker position at the onset of the COVID-19 pandemic in relation to provide public health sector leadership, protect wider services and protect households during the pandemic. Adequate domestic spending on PHC is necessary to resource the public and community health and primary care levels of health systems that are key in pandemic responses.

While Zambia had low OOPS, its share of government spending on health had also been falling prior to 2020, and, with a low share of government spending in total PHC expenditures, was dependent on external funds for these services. As overall health spending fell in real terms in the years immediately before the pandemic, the budget increasingly focused on curative care, with a falling share of spending on health promotion and prevention.

Hence, while Zambia implemented features of a robust preventive, health promotion and care response, the prior financing trends and a wide reported gap between needs versus resources mobilised suggests funding constraints to achieving the full scope of what intended in policy. The financial plans for the health sector response to the pandemic showed that, contrary to prior spending patterns, the greater share of resources were needed for prevention-related activities including testing, infection prevention and control, including for the health workforce, for health products and waste management systems. These are also areas where the funding gap was noted to be highest. It appeared (excluding vaccination donations) that external funder committed support was more focused on treatment and care, rather than for the wider range of prevention services. This funding gap thus placed high demand for domestic resource mobilisation, at a time when the pandemic also led to economic disruption, recession and increased debt, intensifying resource scarcity, for both households and for health sector spending.

The Zambian health ministry COVID-19 budget showed a sudden, urgent and costly increase imposed by the need to mitigate COVID, with some reports of reversals in gains made in areas such as maternal and child health programmes as resources were redirected to address emergent pandemic needs and health workers were over-stretched.

Estimates of the funding needed for the pandemic response indicate budget needs that are nearly 60 times higher than the last recorded government health spending in the 2016 national health accounts. While the response to an emergency inevitably demands new resources, there is a question of how far a sustained period of under-financing of critical prevention infrastructure, supplies and services over many years contributed to this gap. Conversely, the benefit of areas of previous investment is apparent in Zambia’s ability to make use of existing HIV, malaria and TB related laboratory services to rapidly decentralise laboratory capacity for COVID-19.

As the evidence focused on broad trends in the region and a focus on only one country on pandemic budgets, it would be useful to explore further the experience across other ESA countries. However, for health financing in the region, the evidence suggests that pandemic preparedness is not an acute event, but rather a sustained process of investment in public health services and personnel that may be more likely to enable rapid repurposing and switching to address new pandemic needs. This implies governments meeting the Abuja commitment, not letting the public sector share of financing fall to levels that undermine domestic public sector leadership of the multiple actors in preparing for and responding to public health priorities, and more consistently prioritising prevention and promotion and PHC services in domestic health financing.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information can be found in EQUINET Discussion paper 124 on the EQUINET website.

A huge thanks and wishes for wellbeing as we end 2021
EQUINET Steering committee

We thank the many people we have exchanged, interacted, worked and struggled with in 2021 for the reflections, perspectives, experiences and energy you bring to efforts to advance equity and justice in our countries, region and globally. We see clearly the many challenges we face, old and new, but also the opportunities, alliances, ideas and capacities we can build on to confront and propose alternatives to the baggage of policies, systems and injustices that undermine our physical, social, economic, ecological health and well-being. Wishing you a healthy, restful year end. We look forward to our joint endeavours in 2022!