Equity issues infuse our experience of COVID-19 in the region and globally. It should also infuse the response.
It is not well measured in the aggregate data commonly reported, nor in the media profile given to individual cases in elite groups, but COVID-19 spreads through and worsens social inequality. While the first spread of the pandemic may have come through richer, more mobile people and while all social classes have been affected by COVID-19, it would appear that the spread of the coronavirus exploits and exacerbates the social inequalities in the way we live, work, trade and travel in the region.
People living in lower income areas are often crowded in smaller, poorly ventilated homes, with many generations living in the same crowded home, without safe water supplies to wash hands and immune systems are already battered by undernutrition, infectious and chronic diseases. Crowded transport systems, dusty, poorly ventilated working environments and pollution from cooking fuels and houses sited near landfills and industries raise the risk of respiratory diseases, asthma and occupational lung diseases, making people more susceptible to severe effects of the virus. If resilience refers to the ability to restore the ‘normal’ that we had before COVID-19 and all the inequalities that put people at risk, then we should not aim for resilience. We should aim for change.
There are also social inequalities in a response to COVID-19 that provides less access to and continuity of care for COVID-19 and other health problems. It raises burdens on those who are already more vulnerable. As is happening in all countries affected by austerity, the chronic underfunding of and weaknesses in our public health services undermine care for poorer communities and protection of the health workers who work in them, notwithstanding the efforts being made by health ministries and other stakeholders. Private providers have expanded their role, but often without adequate public co-ordination and leadership and generally unaffordable for low income communities and enterprises. As noted by UNFPA, women represent a large share of health and social sector workers who are more at risk, while increased household tensions during lockdowns are increasing domestic and gender violence.
We are learning that a well-funded public health infrastructure is essential to keep all healthy and safe, that investing in prevention is primary and that transparency on resource flows is critical. Globally, with protectionist responses from high income countries, patent barriers and past policies of importing rather than locally producing medicines and other health technologies in the region, ESA countries, like poor households, are last in the purchase queue. ESA countries are often dependent on charitable contributions or rising debt to obtain health technologies that should be regarded as a right and as public goods. Global mechanisms that depend on charity and two tier systems risk aggravating inequality in access across countries.
Without a vaccine, the response has largely been one of command and control, sometimes militarised, putting whole sectors, areas and communities into lockdown. Many households in the region already live hand-to-mouth and do not have the social security to stop work, or the means to work remotely, so lockdowns increase income inequality. Restrictions on public transport without safe alternatives leave poor households trying to reach essential services stranded. Macro-economic concerns have motivated formal sectors like mining to restart, but do not address these socio-economic insecurities in more marginalised communities. Migrants returning home or located away from home are sometimes stigmatised and treated more as a public health risk than a vulnerable community.
These inequities call for local, national and regional responses. Social isolation measures have proved critical for the technical response to COVID-19. Yet for people who are compelled to work to secure daily incomes for their families, dialogue to find the best ways to protect both public health and livelihoods would seem to be more effective and sustainable than criminalising their actions. A biosecurity, top-down, secretive and militarised response to COVID-19 in the name of public health damages the trust, participation and collective solidarity that are essential for effective public health. In part this reflects whose knowledge and experience counts. Importing modelled concerns from high income countries on the adequacy of hospital resources can focus attention away from areas that the specific epidemiological and health system conditions in the region demand. While journal articles and scientific advisors compete for political attention, the experience, ideas and agency of those directly affected by the epidemic is often marginalised.
Yet there are many positive experiences in the region to report. Public officials, health workers, volunteers, including community health workers and health facility committees, have worked overtime to reach households, trace contacts and organise responses. Communities have formed solidarity networks to support vulnerable households with food and care and have held the state accountable for interventions. Parents have schooled children and teachers have found alternative ways to teach students during lockdowns. Small enterprises and local universities have produced affordable face masks and other technologies; local producers have switched lines to produce ventilators and local artists have produced music and murals to promote social awareness. Communities have provided support for returning migrants; diaspora and local people have crowd funded for support initiatives and local enterprises have contributed to solidarity funding of health technologies. COVID-19 has provoked social attention on health worker and gender rights. It has shown that ignoring social inequalities in health and their determinants and under-investing in comprehensive primary health care and public health threaten our society and economies as a whole.
We need to measure, publicly report on and visibly address these dimensions of inequality and to integrate the experience and ideas of all those affected. Not doing so undermines the effectiveness of our current and future responses. As Anand Giridharadas has said: “Your health is as safe as that of the worst-insured, worst-cared-for person in your society. It will be decided by the height of the floor, not the ceiling”. Even while African political leaderships are calling for global leaders to stop the debt outflow and patent and procurement barriers that are undermining responses within the region, we need to also confront the inequality that COVID-19 is intensifying within our countries.
So we are reaching out to you! Are you working on or concerned by any of these dimensions of inequality? Are there others that you want to raise? If so, please share your concerns, ideas and work! As a community that promotes equity values, EQUINET would like to learn more, share more, inform and voice more on these issues. If you have blogs, webinars, poems, art, stories, case studies, published work or videos on these issues or other equity concerns in the region that you want to share, please let us know so we can provide a platform to share them. Let us know if there are interesting case studies that we can support, or if you have ideas for joint work with EQUINET. Send feedback to us by email or on the feedback form on the EQUINET website and we will follow up with you.
The pandemic is a threat. It must also be an opportunity in our region to confront conditions and mantras that have generated the worsening inequality, rights violations, precarious labour, capital outflows, underfunded and commercialised systems and ecological decline that make us vulnerable to epidemics and that undermine capacities to respond in our collective interest.
We welcome your feedback on the issues and invitation in this oped – please send them to the EQUINET secretariat: admin@equinetafrica.org. Please visit our website for information sheets produced by EQUINET.
Editorial
In the past two months, drawing on a diversity of inputs, EQUINET has produced a series of information sheets on different aspects of COVID-19 in ESA countries. For 1st June we take a pause on these information briefs to send out our regular quarterly newsletter, with thanks to the newsletter team for meeting the challenges of co-production from various corners of a lockdown. Given the context, there are many articles and resources in the newsletter relating to COVID-19, but there are also those relating to other health challenges and health system developments that continue to be present, to offer learning and to demand attention in our region.
Yet we are in a crisis, not understood as an event to recover from, but in the way the Chinese word for crisis brings together two characters – “wei ji”, with wei standing for danger and ji standing for opportunity. A crisis to learn and change from.
Different dangers and risks in the COVID-19 pandemic are emerging and are the subject of an explosion of information and exchanges across countries, institutions and disciplines. The information exchanges range from stories of lived experience, responses and ideas to evidence from trials, information systems, global case tracking, reviews and analyses. Constrained by size, the newsletter only points to some of these in the region and many many more are reported daily in different platforms.
The pandemic tells us a lot about the status of our societies. COVID-19 has shown us how globalisation has opened up multiple digital channels for information to flow, how scientific collaboration can rapidly advance and share knowledge and how communities show solidarity, initiative and empathy.
It also shows where there are gaps. We talk about the poorest but the voices of the poorest communities and poorest countries are often overshadowed or absent, sometimes even silenced by the very responses to COVID-19. We see the limits in global solidarity as many African countries struggle with the diversion of critical resources to debt repayment and fail to access key diagnostics and medicines. We talk about causes, but treat each outbreak, including COVID-19, as disconnected emergencies, delinked from their deeper, sustained and common drivers in the nature of production and commercial systems, in the destruction of habitats and biodiversity and in the lack of investment in basic standards of water, sanitation, housing, clean energy and other public health inputs, drivers that converge to expose significant concentrations of people to new and old pathogens and to repeated pandemics. The 2008 Commission on the Social Determinants of Health used to say of the health sector “we cannot keep treating people to send them back to the same conditions that made them ill”. It seems we need to expand this to “we cannot keep responding to public health and climate emergencies and sending ourselves as a global community back to the same conditions that led to them.”
There are also signs of opportunities for recalibrating this pathway that is externalising and distributing pollution, climate change, precarious employment, different forms of malnutrition, pandemics, violence and other harms that threaten us as a society and as a species. The online conversations often flag responses to COVID-19 that work with and support communities and local health workers as more successful, especially when built on prior investments in distributed primary health care and socio-economic well-being. There are items in the newsletter that raise similar themes around responses to HIV, health workforce management or gender based violence.
But recalibration also needs to take place at global level. The recent World Health Assembly (WHA) resolution on COVID-19 (included in the newsletter) refers to vaccines as a global public good (implying free from intellectual property protection). There is also a link to a call from leaderships from across all regions that COVID-19 vaccines, diagnostics, tests and treatments be provided free of charge to everyone, everywhere. At the opening of the WHA, the UN Secretary General Antonio Guterres stated that “the recovery from the COVID-19 crisis must lead to more equal, inclusive and sustainable economies and societies” , as “an opportunity to address the climate crisis and inequality of all kinds”… and “to rebuild differently and better”.
The pandemic has provoked a sense that it cannot be ‘business as usual’ . For example, the Africa Group, Zambia and other country inputs to the WHA, and an ECSA HC and EQUINET brief included in this issue, raise some immediate, practical issues, including debt relief or cancellation for African countries to invest in the response and rebuild, and the removal of barriers to innovation and technology transfer for local manufacturing of diagnostics, medicines, vaccines for COVID-19 in Africa. How such issues are now treated in global forums, such as the forthcoming World Trade Organisation Ministerial and beyond, and how far our international, national and local responses reflect ‘more equal, inclusive and sustainable economies and societies’ will signal how far and for whom this crisis has been an opportunity for change, or a continuity of danger.
The ongoing extraction of minerals and biodiversity from Africa is not only a contributor to climate change. It leaves us less able to respond to climate change and is generating a social, health and natural resource debt burden for current and future generations.
That is why in the recent 2020 Alternative Mining Indaba (AMI), delegates from trade unions, ex-mineworkers, civil society and technical institutions who came together in Extractives and Health Group claimed that any framing of a just transition to address climate change must at the same time address the legacy of past health burdens and prevent such burdens now and into the future.
What are these ‘debts’? They don’t appear in the balance sheets of banks, ministries of finance or international finance institutions. They appear in the form of lead poisoning in children living in the shadow of mines, undermining their development; as mercury poisoning in communities living near mine dumps; or as chronic silicosis in thousands of ex- mineworkers across the region. They appear in the displacement of people away from fertile land, in contamination of drinking water, land and air and in the cancers, respiratory and other diseases this causes. The debt grows as an opportunity cost when mining companies do not contribute to local infrastructures, economies and services, or to skills and capacities for technological innovation, or when taxes collected do not return to develop local communities. The debt is there in the absence of information and voice given to communities in decisions and claims that affect their lives.
Sometimes part of the debt is translated into a number. In July 2019, the South Gauteng High Court approved a class action settlement worth at least 5 billion Rand (approximately USd350 million), to be paid as compensation for injury and illness for eligible ex-mineworkers and their dependents in Southern Africa. However, the Southern African Miners Association (SAMA), who organise ex-mineworkers, told the AMI that this figure is only the tip of the still buried level of occupational illness in ex-mineworkers.
At a regional workshop held before the AMI, convened by EQUINET with the regional trade union body, SATUCC and with SAMA and Benchmarks Foundation, delegates from organisations representing or working with mineworker, ex-mineworker, community, health and economic justice constituencies identified a shared concern over the way mining is affecting our current and future environments for health. It was perceived that we are not getting the current or future economic and social benefit we should get from mining and that rights are not being protected and claims ignored.
From the work that different organisations are already doing on these issues and from work in the region on HIV, TB and occupational health, it was evident that we have a platform to build on to address this. The meeting identified the building blocks of what needs to be done, not as isolated pockets of activity, but in a more integrated way across all countries of the region.
We must prevent the harms. The information, tools and capacities to map, assess and report on the conditions affecting health should be in the hands of communities, workers and ex-mine workers across the region, to be able to bring conditions affecting health to wider attention. While environment impact assessments are done in many countries, this is not enough. There should be a legal duty to carry out health impact assessments before licensing and during mine operations in all countries. These assessments should ensure, implement and monitor plans to prevent risks to health from mining. They should also assess the living conditions, the potential impacts on displaced communities and post closure and set plans to prevent negative impacts. They should be done jointly with workers and communities and publicly reported.
The rights of current and future generations should be protected. In many of our countries the laws are outdated, have gaps, or are not well enforced. As the AMI declaration stated, the right to life and to health for current and future generations must be central in whatever laws, policies and practices we design and implement. Health cannot be left to voluntary corporate social responsibility. There are over 25 international standards from United Nations and other institutions on the social obligations of the sector. SADC itself said in 2006 that it should set harmonised health standards in mining and that ‘member States should develop, adopt and enforce appropriate and uniform health, safety and environmental guidelines for the sector as an immediate milestone area’. It is time we implemented this commitment, not just for TB, HIV and occupational diseases, but for all the public health issues being faced in the sector.
The regional meeting shared information on efforts underway to inform and organise affected communities in the region. They included health literacy activities and the Tunatazama action voices alert where community activists share their knowledge and experiences on mining on a website at http://communitymonitors.net/. There are efforts underway to identify clean energy and green technologies that can limit health damage at source and measures to promote recycling and reuse of metal products. Accessing such information, building capacities for healthy innovation and having a voice in decisions is a right and an investment, especially for the young people whose futures depend on the choices we make today. The trickle of resources that goes to this in comparison to the flow of investment funds that go to the extraction of materials suggest that we have an imbalance that needs to be addressed in the value we are placing on the relative contribution of economic, social and natural resource inputs to our future wellbeing.
The regional meeting and the AMI highlighted many practical things we can do to meet the health and natural resource debt and to rebalance future policies and practices. We know that the right to life and health supersedes all other claims and that the natural resources of the region are ours to guard for future generations. We also know, as stated in the 2020 AMI declaration, that these rights “have been won through social struggle and are a source of social power and organization”. The formation of an Extractives and Health Group that crosscuts different constituencies and disciplines recognises the need to work collectively if we are to advance alternatives that meet past debts and that prevent the current and future liabilities of extraction.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. You can read the meeting report and further information on this work on the EQUINET website. Please also find further information on the websites of the partner institutions named in the oped and of the Alternative Mining Indaba.
Industry marketing aimed at children presents a major challenge to efforts to control the global crisis of non-communicable diseases (NCDs). Advertising and promotion of tobacco, alcohol, sugar-sweetened drinks and other unhealthy processed foods are common in all countries. They are a particular threat in countries with weak laws, poor enforcement and political cultures that are beholden to foreign investment. Africa is particularly vulnerable to unhealthy marketing by corporates.
Internationally, attention is growing on what works best to reduce the risk of NCDs, and to the role that human rights-based approaches have in this. In particular, the Convention on the Rights of the Child (CRC) can act as a strategic lever against health risks from corporate practice. Under the CRC, governments have obligations to protect children from economic exploitation and harm generated by the activities and products of tobacco, food and beverages industries. Governments are also obliged to protect children from information harmful to their health and development. This includes the marketing of unhealthy goods. However few governments in low-income countries implement measures to meet these particular obligations to protect the best interest of the child.
The European Scientific Network on Law and Tobacco (ESNLT) hosted a roundtable in mid-2019 to generate a better understanding of the successes and potential constraints of a child rights-based approach to address the global NCD epidemic. (See https://www.rug.nl/rechten/onderzoek/expertisecentra/ghlg/outcome_document_25_june_geneva.pdf). Participants were researchers, mainly from high-income countries, with some from low- and middle-income countries. The meeting also involved personnel from World Health Organisation and UNICEF staff working on NCDs and human rights. In the meeting, participants shared experiences of using a child-rights approach in domestic and international responses to NCDs and identified new opportunities to use a child-rights approach and to advocate for these approaches to be applied in addressing industry behaviours relevant to the risk factors for NCD.
Participants in the meeting explored how to apply a child rights-based approach to support regulation of NCD-related risks, particularly in low-income countries, vulnerable settings and trade policies, and how best to disseminate this knowledge more widely. Various recommendations were made in the meeting. Participants proposed networking with academics and civil society working with broader child rights and health equity issues to advance awareness, advocacy and implementation of these approaches, working also with public health networks like EQUINET in low- and middle-income countries, especially where civil society space is constrained. It was proposed that regional blocs such as the East Africa Community and Southern African Development Community be engaged to promote effective regulation of NCD risks related to marketing practices, including in relation to online and cross-border marketing and trading. Participants observed that evidence needed to be generated and shared on effective strategies and that this knowledge be brought into online and distance training courses to strengthen regulatory capacities and into postgraduate training linking human rights, law and public health. One suggestion was for a test case to be brought in one country that has constitutional provisions protecting these rights, such as South Africa. These actions could tap into existing resources. For example, the World Federation of Public Health Nutritionists has set up a mechanism for reporting conflicts of interest. The learning from this could be consolidated and shared.
It was significant that the ESNLT engaged beyond high-income countries and is addressing wider risk factors for NCDs. Bringing together a diverse set of actors in the meeting helped to build links across different disciplines and opened avenues for future collaboration. Linking with existing networks can help to identify capacity gaps and to stimulate and support research and advocacy. Education of both public health and law professionals can expose each to the respective field of the other to promote collaboration and team approaches. This interaction has already been stimulated by the meeting. For example, soon after it, one of the participants was invited to give a keynote address at the Association of Schools of Public Health Conference in Africa to highlight the role of law in public health.
The meeting also proposed that international organizations, such as WHO, UNICEF, the Office of the United Nations High Commissioner for Human Rights, the UN Human Rights Committee and the UN Committee on the Rights of the Child, link to reduce capacity gaps and overlaps in their work and outputs. A child rights-based approach and qualitative assessment of country performance could be included in WHO assessments of how far regulations targeting the main risk factors are implemented. Evidence on NCD-related issues could be included in country reporting to the Committee on the Rights of the Child and shadow reporting by civil society promoted.
This is not simply a technical matter. Industry actors are well-resourced, powerful and able to thwart regulation of NCD risk factors. This power imbalance calls for co-operation across international and national organizations, civil society organizations, academia and public officials. For regional networks such as EQUINET, the fact that every country in Africa has ratified the CRC and all but 6 have ratified the African Charter on the Rights and Welfare of the Child offers an opportunity and policy space to use human and child rights-based approaches to tackle health equity challenges, including the prevention of corporate and market-induced risks for NCDs.
When EQUINET was formed in 1998, all east and southern African countries had public policy commitments to improve health equity. This was a statement of values, and needed to be protected socially, as much as it demanded information on how to achieve it. As people from government, unions, civil society, parliament, academia from other institutions in the region, we saw that research could inform and reinforce this policy intention. We could expose the extent and forms of avoidable, unfair inequality and their determinants and propose ways of advancing equity in health. With inequalities a reflection of the power people have to direct resources towards their wellbeing, we saw research and knowledge as not neutral in these power relations.
This year we reflected on our experience from over two decades of EQUINET research on how, and how far our research practice had achieved these intentions.
Policies have been articulated and knowledge generated in our region by many, including ourselves on the inclusive economic policies, comprehensive public services and rights-based approaches to addressing social inequality. Yet our realities are increasingly driven by a global economy and a regional response that is generating instability, environmental and social costs; increasing extraction and export of natural resources; rising levels of precarious labour, social deficits and destruction of cultures. Our public institutions have become weaker and even basic forms of wellbeing commodified, disrupting cohesion, solidarity and collective agency. ESA countries are framed as ‘under-developed’ and ‘aid recipients’, with populations undergoing a ‘development pathway’, despite the economic insecurity, resource depletion and social deficits associated with this pathway. Responding to these trends, people in the network have done work to expose and show the harms and violations in people’s experience of these trends, and to point to opportunities for alternative policy and practice.
Research on these issues has involved relationships and dialogue with key constituencies, from the onset and throughout the process, and efforts to ensure rigour, quality, validity and ethical practice. We have shared results in a range of media and interactions. Implementation research, appreciative inquiry, realist review, benefit incidence analysis, policy analysis and other designs have, with the new lenses brought by diverse disciplines in the network, taken us outside biomedical paradigms and the ‘core curative care business’ that the health sector has retreated to, exploring the choices made in a range of sectors and what this means for the wellbeing of current and future generations.
However, the battle of ideas and struggle over wealth and power that lies at the heart of the trends generating inequalities in health in our region raise not just WHAT is investigated, but also WHO asks the questions, WHOSE assumptions are brought to bear and HOW the research is done. Research can explain and show alternatives to disempowering narratives of the inevitability of the status quo and generate knowledge in ways that empower those affected to affirm their reality, to reflect on the causes of their problems and to more directly articulate alternative explanations and build the self-confidence and organisation to produce change and to learn from actions taken.
Like others working on social justice, we are on a constant learning curve on how to do this. Participatory action research has, for example, provided a particularly powerful means for people to create counter-narratives to dominant characterizations that ignore or undermine them, transforming people from objects to subjects and strengthening strategic action and review. Yet we are still learning how to embed PAR within the democratic functioning of social organisations as well as testing, such as through online PAR, how to amplify the organisation, consciousness and voice from largely local PAR processes to engage global level drivers of inequity, without losing their authenticity. We’ve been excited by methods and capacities that allow for the complexity of the many overlapping stories in our lives and countries, including narrative research, ‘fiction’, theatre, photography, and social media, We’ve appreciated how technologies used in research are deeply connected to the processes and interests that use them.
Doing this work excites, reveals, generates energy and many collective ‘aha’ moments!. But it also exhausts, demands many hours of time and absorbs all those involved in social processes. Many talk about facing the double task of researching on inequities, while also challenging inequity in a global research system that undervalues the cross disciplinary, reflexive and participatory approaches and interactions that are features of equity related research. People in the region, particularly at local level, face travel, visa, cost, gender, class and racial barriers that exclude them from engaging in northern-based global processes.
In this context, being in a consortium network and the partnerships with the network have provided support, resources, exchanges and peer review for more self-determined work. The wide range of disciplines, lenses and constituencies in the network have provoked us to be more creative. Yet our region is changing, encountering new opportunities and challenges. We cannot afford to be over-comfortable in old relationships, methods and practice. So the question stays on the agenda: how can our research practice better promote equity and justice in health?
We welcome your feedback or queries on the issues raised in this oped – please send them to the EQUINET secretariat: admin@equinetafrica.org. Please visit http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Diss120%20Research%20for%20HE%202019%20lfs.pdf to read the discussions, ideas and examples in the full paper that the editorial draws from. Several papers included in this newsletter also provide interesting experiences and reflections on research for equity and equity in research systems.
Six months after Cyclone Idai ravaged the eastern province of Manicaland in Zimbabwe, the devastating effects show that there is need for more work to do for the recovery. The survivors are still in dire straits, psychologically, emotionally and materially.
The traumatic events of 15 March 2019 remain etched on the minds of the survivors. Any rumbling sound, even light rain, sends them quaking, as a reminder of the tragic events of that ‘night of death’, when torrential rains and heavy winds claimed their loved ones and left them scarred.
Cyclone Idai resulted in a massive loss of life and injury, as well as destruction of critical infrastructure, including clinics, schools, roads, bridges, electricity base stations and houses. Manicaland province was the most affected, followed by Masvingo and Mashonaland East. The destruction also affected parts of neighbouring Mozambique and Malawi.
Government statistics indicate that 341 people died, 344 were missing, 183 were injured and 2213 people were displaced. Further, 230 dams burst and 20 000 livestock were lost. The loss of electricity compromised communication systems and hampered search and rescue efforts. The damage to communication networks means that many communities remain cut off from essential services. Despite government, with assistance from South Africa, having mobilized earth-moving equipment, some roads are still not passable.
This situation presented a public health threat of water and vector borne diseases, such as cholera, typhoid and malaria. Malaria deaths have spiked in Manicaland following the Cyclone. The trauma and loss has certainly led to mental health problems. The damage to infrastructure has impeded access to health services, raising the risk that people cannot access or default on treatment and care. In addition, local health services are understaffed and lack adequate medicines.
The magnitude of the disaster was greater than government alone could cope with. The international community, United Nations agencies, civil society organisations and individuals all contributed. For example, the Community Working Group on Health (CWGH) with Medico International provided relief and aid to 171 households in holding camps in April to June 2019. This interaction also led to input to recommendations to the Civil Protection Unit and other inter-ministerial committees responsible for preventing disease outbreaks and ensuring provision of safe and clean water in the holding camps. Yet the high death toll from Cyclone Idai indicated the lack of disaster preparedness and planned mitigation by government, considering the earlier heavy loss from Cyclone Eline in 2000. Many lives could have been saved had the warnings for Cyclone Idai been widely disseminated in the local media to warn households and a response mobilized to evacuate people from the affected areas.
The situation continues to be precarious up to today. Manicaland Provincial Affairs Minister Dr Ellen Gwaradzimba noted that the situation in that province is now worsened by drought, affecting about 1.7 million people, in a situation where food reserves and fields were destroyed. Even while the response moves from an emergency to a recovery phase, the need to both learn from the experience and to sustain intervention is clear, including to respond to continuing vulnerability and to resettle internally-displaced people.
At a Provincial All-stakeholder Dialogue Meeting on Cyclone Idai in June concern was raised over the weak execution of the disaster emergency plans for evacuation and rescue and the absence of community-based emergency plans. For example, the reluctance of people to leave their ancestral land, even after being alerted of the disaster, was one factor that impeded evaluation. The dialogue meeting recommended that a government emergency response fund be set up; that communities be educated on first aid and disaster risk management in schools and in the community; and that campaigns be undertaken on disaster preparedness and mitigation.
While much effort has already been made in improving access to public and social services, resources are needed to restore roads, bridges, houses and sanitary facilities. Survivors need counseling and psychosocial support services. Displaced people and affected communities need new land for more rapid permanent resettlement and investments in their livelihoods and social services.
In all these inputs the planning, preparations, decisions and responses need to be people-centered. Putting people at the centre of the next steps, including in the planning for any future emergencies, is central to the response.
In June, at the East, Central and Southern Africa Health Community (ECSA HC) 12th Best Practices Forum held under the theme: Innovation and Accountability in Health Towards Achieving Universal Health Coverage, about 130 participants deliberated for three days and proposed recommendations for policy and practice, including to enhance delivery on existing policy commitments. The recommendations covered diverse areas relating to the theme, covering: improving adolescent and young people’s health; equity in access to eye health; innovative approaches for food safety and improved quality of life; addressing harmful substance use and mental health problems; achieving water and sanitation global health targets; tackling emerging and re-emerging health threats and a regional ’One Health Approach’ for managing recurrent outbreaks. The full recommendations can be found on the ECSA HC website. What is also important, however, is the process by which these proposals are made and reviewed.
The East, Central and Southern Africa Health Community (ECSA HC) is a regional inter-governmental organisation. It reports to, and receives guidance from the Conference of Health Ministers (HMC).
Over the years, ECSA HC has held a Best Practices Forum (BPF). The BPF aims to encourage and strengthen policy dialogue among the diverse stakeholders involved in evidence-based policy decision making. The BPF attracts a wide range of health actors, including senior officials from ministries of health of ECSA-HC member states, the constituent health professions colleges of the ECSA College of Health Sciences, health research institutions, collaborating partners, civil society organisations and other health experts and implementers from the region and beyond.
While the HMC is the highest policy organ of ECSA HC, the Directors Joint Consultative Committee (DJCC) is its highest technical organ. The DJCC consists of the directors of health services, the deans or heads of health faculties and training institutions, the heads of health research institutions and senior officials in the constituent colleges within the ECSA College of Health Sciences. The DJCC informs the health ministers through persuasive evidence-based recommendations. The BPF, in turn, is a critical step and an important platform for presenting and interrogating findings from the member states, from the region and beyond. It provides a platform for a free participation and open exchange of ideas by technical people, researchers, civil society, partner organisations and ministry of health senior officials. The experience, evidence and analysis from the region presented and debated in this forum inform the recommendations to the DJCC and from there to the health ministers in the HMC.
As applied in the recent 12th BPF, the main theme and sub-themes are set by the health ministers at their previous HMC. Submissions are then invited from the countries and from ECSA HC partners, stakeholders and researchers within the thematic areas. Suitable abstracts are then selected for presentation to prime the discussions in these areas at the BPF. It is a unique feature of the BPF that at the start of the meeting there are no draft recommendations tabled for discussion. Rather the participants draft them in an open and free spirit of intellectual engagement, drawing on their collective experience and the evidence presented. These recommendations are then submitted to the DJCC for their consideration.
To complete the loop, the recommendations made at the BPF, as validated by the DJCC, are presented to the HMC. For example for the 12th BPF held in June this year followed by the 28th DJCC, the recommendations will be presented to the HMC in October this year. The HMC will be held under the same theme as for the BPF and DJCC, and the recommendations will be tabled for the Ministers to consider as the basis for their resolutions. While the recommendations of the DJCC may be used as a guide to enhance the programming and prioritisation of their activities, until they are affirmed or changed by the HMC, the resolutions of the HMC are binding on member states and on the ECSA HC secretariat.
Most of the follow up work to implement the recommendations happens within the countries. However, there are also regional approaches that are within the mandate of ECSA HC and in association with partners for some priority areas. The action points are thus directed to both the member states and the ECSA HC Secretariat as appropriate.
Over the past twelve years by convening the BPF, ECSA HC has developed and institutionalised a mechanism and processes by which it engages both the ‘consumers’ and ‘producers’ of research evidence in policy dialogue. This is often done in a demand-driven manner, with the HMC and DJCC identifying gaps and calling for evidence in areas that draw presentations at the subsequent BPF. However, some presentations and research findings also emerge ‘bottom-up’ from work by stakeholders in the region that raise new evidence and issues within the broad thematic areas under consideration. Some presentations report on the implementation and findings of work that was mandated in prior DJCCs and HMCs and what it means for the health system. Some also track delivery on prior policy commitments, the outcomes achieved and the barriers faced.
ECSA-HC continues to work towards strengthening this approach in the hope that it helps to close the gaps in evidence for policy dialogue from the region and in channels for researchers and implementers to present their experience and findings in a way that influences policy. In doing this, the organisation hopes that relevant research and policy, which are two sides of the same coin, can be increasingly connected. The BPF model is being replicated in West Africa through the West African Health Organisation (WAHO), suggesting that it is perceived as a worthwhile effort.
One major challenge with the BPF approach, however, is in the identification of ‘best practices’. While this is based on an open call for and submission of abstracts, the ECSA HC does not have the capacity to ensure that all the best practices in each area come to the fore and there may be limited publicity of the BPF as the outlet for relevant research findings. It has also become evident that a lot of experience and research evidence that is seen to be relevant and useful by policy actors in the DJCC and HMC does not make its way into formal journals for wider dissemination.
Notwithstanding such challenges, the BPF stands out as a useful and unique home-grown solution to the false divide between researchers and implementers on the one hand, and decision and policy makers on the other. It does so by providing a platform for the free input, exchange of and debate on ideas, embedding this within the policy processes and structures of the organisation. Looking at the journey over the last twelve years, one is justified to suggest that in the next twelve years, the BPF could itself be identified as a ‘best practice’ for the East, Central and Southern African region.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the ECSA HC BPF please visit https://ecsahc.org/
There has been growing engagement around the inequitable benefit from the extraction of minerals, genetic and biological resources from the continent. Attention is now also growing on the exploitation of local and indigenous knowledge, and as captured in some of the articles in this newsletter, the injustice of knowledge systems that extract empirical evidence for analysis in other countries, and impose barriers to those most directly exposed to conditions being able to travel and participate in scientific programmes and forums, to bring direct knowledge on those conditions into global health forums. This international context contrasts with the experience described in this month's editorial of a sustained initiative within east, central and southern Africa to facilitate dialogue between researchers, service implementers, civil society and government policy makers in and from the region, to share and review knowledge for health and health systems within the region. How actively do we use, engage in and benefit from such platforms? What do we need to do reclaim, build and assert the knowledge systems in the region - and from the region, globally- to advance health equity? We invite you to share your experiences and perspectives as comments, opeds, or links to relevant papers and reports for our next newsletter.
From July 2019 the EQUINET newsletter will be coming out quarterly in March, June, September and December of every year. The next issue will thus be in September 2019. After discussion in the EQUINET steering committee we will try where feasible to have a stronger thematic focus on issues, while still keeping a wide range of coverage of resources, announcements and updates and publications. As a reminder we are keen to share information on and about the region and invite you to share news, information, papers, reports, briefs, announcements and resources of different types and are happy to receive editorials from or on the region. Please submit by visiting the newsletter on the EQUINET site and selecting "submit news" on the online menu. We are also keen to get your feedback on how to improve the newsletter as a resource for you so please do submit your feedback!
Global meetings and processes can seem very distant from the realities at local level, despite the fact that the policies being made in global meetings have profound influence on these local realities. The People’s Health Movement (PHM) has for several years implemented a ‘WHO watch programme’ to follow and provide information, analysis and critical commentary for people on the global health debates taking place at the World Health Organisation (WHO).
In its Global Health Watch activities, PHM follows range of WHO meetings, including the World Health Assembly (WHA) and the WHO Executive Board (EB) and at regional level in the WHO Regional Committees, such as the one for the AFRO region. The analysis that PHM does explores how far these global processes and resolutions respond to local, regional and global contexts and priorities and how far states and other relevant stakeholders’ implement, comply with and are publicly accountable for the resolutions made.
The recently ended ‘WHA72’ that took place in end May 2019 was one such global meeting.
There were many debates at the WHA72, but two merit attention. One was on improving the transparency of markets for medicines, vaccines and other health-related products and technologies. A second was on the Ebola epidemic in the Democratic Republic of Congo (DRC) and the public health emergency response. Both were critical debates for African countries. Both issues need strong intervention from states, by galvanizing comprehensive workforces and capacities for both health systems and emergency responses, to address disease burdens and respond to disease outbreaks.
After the scrutiny and criticism of its response to the Ebola epidemic in West-Africa in 2014, WHO restructured its health emergencies program in 2016 to provide a more effective response. However, the virtual freeze in member state contributions has meant that the core funding for the program has not improved. The current Ebola outbreak in the DRC thus provided an opportunity to assess how successful the measures and resources are for such emergency responses. The DRC outbreak provided a tough test: it has been termed a complex emergency due to its occurrence in a highly volatile and extremely insecure conflict zone, politicizing the epidemic and raising the challenge of dealing with an outbreak in a war zone. At the recent WHA, WHO reported that its use of vaccination strategies enabled it to achieve unprecedented survival rates. It also pointed to other factors that enabled the response and improved survival, including significant investment in planning and capacities for epidemic preparedness, sustained testing for Ebola, improved screening, vaccination of frontline healthcare-workers and training of multidisciplinary teams for a rapid response mechanism.
While this work has been a significant contribution to addressing the Ebola emergency in DRC, there are still issues to address. PHM observe that WHO should mobilise member states and other relevant-stakeholders to find ethical and valid ways of more rapidly testing interventions to combat diseases like Ebola. A rapidly spreading emergency like Ebola calls for an urgent response, including quick advice on the most effective treatments to use. The concern is that the pace of development of new vaccines, drugs and diagnostics is not meeting the pace of rapid spread of health emergencies, such as that faced in the DRC. The time consuming nature and wide population enrolment of current medicine trials doesn’t match the urgency needed for responding to such rapidly spreading epidemics. This raises debate on what flexibilities can be introduced that do not compromise the quality and safety of trials.
At the same time, there is also a more general demand for improved access to medicines. Accessing medicines would have been critical for the approximately 1.6 million Africans who died of malaria, tuberculosis and HIV-related illnesses in 2015. While many of the diseases in Africa can be prevented or treated with timely access to appropriate and affordable medicines, vaccines and other health interventions, less than two percent of medicines consumed in Africa are produced on the continent. Many people cannot access locally produced drugs and many may not afford imported medicines.
The WHA discussed a draft roadmap on access to medicines, vaccines and other health products for 2019-2023. The roadmap proposes strategies to support quality, safety, efficacy and equitable access of health-products. The strategies include strengthening regulation, assessing the quality, safety and efficacy or performance of health products, including through market surveillance and investing in research and development (R&D) that meets public health needs. The strategies also include managing intellectual property so that it contributes to innovation and promotes public health, and ensuring evidence-based selection, fair and affordable pricing, procurement and supply chain management and appropriate prescribing, dispensing and rational use of health products.
The resolution on transparency of markets for medicines, vaccines, and other health-related products and technologies adopted at this year’s WHA is a substantial stride towards improving the affordability of and access to medicines and other technologies. For example, there is currently an information gap on what different countries pay for medicines and on the actual cost of R&D and manufacture of medicines. The lack of transparency on this gives pharmaceutical corporations a significant advantage and allows them to charge extortionate prices, maximizing profit over human life.
Despite the obvious benefit of improved transparency in these issues, the resolution received mixed reactions. Germany, Hungary and the United Kingdom dissociated themselves from the resolution, using a range of procedural reasons. They claimed that the roadmap was “rushed through” and breached procedure, with inadequate consultation with all experts. The dissociation raised governance concerns. However the resolution was approved by a majority of states and will support the space for governments in Africa to negotiate medicine prices. Given the current crisis of unaffordable pricing of many medical technologies, the resolution, if implemented, will support greater public disclosure of prices of medicines and other health-related products. This information should help to reduce the prices of these products, now needed also for rising levels of chronic conditions such as cancers, hepatitis and diabetes, many of which are too costly for universal access in low and middle income countries.
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The resolution was thus welcomed by African countries. It needs to be further monitored for its implementation to assess if it achieves its purpose and goal in relation to universal health coverage (UHC). At the same time, as raised by PHM during a debate at the WHA on UHC, accessing medicines also depends on investing in comprehensive primary health care. Further, as was the original intention of Alma Ata, we need to apply human rights-based and comprehensive approaches not just to treating disease, but also to ensuring health. As we address issues of transparency and of responsiveness to emergencies, that also depends on a deeper redistribution of power and wealth.
You can read more about PHM ‘watch’ activities and findings in the Global Health Watch at https://www.ghwatch.org/wha72 . Commentaries, statements and policy briefs can be found on the WHO Tracker at https://who-track.phmovement.org/.