Values, Policies and Rights

Ethics of instantaneous contact tracing using mobile phone apps in the control of the COVID-19 pandemic
Parker M; Fraser C; Abeler-Dörner L: Journal of Medical Ethics, doi:10.1136/medethics-2020-106314, May 2020

In this paper the authors discuss ethical implications of the use of mobile phone apps in the control of COVID-19. Contact tracing is a well-established feature of public health practice during infectious disease outbreaks but the high proportion of pre-symptomatic transmission in COVID-19 means that standard contact tracing methods are too slow to stop the progression of infection through the population. To address this many countries globally have deployed or are developing mobile phone apps capable of supporting instantaneous contact tracing. Informed by the on-going mapping of ‘proximity events’ these apps are intended both to inform public health policy and to provide alerts to individuals who have been in contact with a person with the infection. The proposed use of mobile phone data for ‘intelligent physical distancing’ in such contexts raises a number of important ethical questions that need to be understood and analysed against the public health benefits. The authors explore the relative benefit and harms; the impact on identified individuals; the implications for privacy and liberty; the responsibilities of institutions and professionals; and the longer term equity, ethical and public trust issues of how the data is deleted or used, issues that are not only relevant for COVID-19 but also for future outbreaks.

Busting four myths about Universal Health Coverage
Samman E: Overseas Development Institute, December 2020

New research sheds light on the experience of almost 50 countries that have attained Universal Health Coverage (UHC) or made strides toward doing so. This research indicates that while there isn’t a one-size-fits-all approach, there are parallels – and opinions on what aids or prevents UHC are often misinformed. It’s often thought that countries strive for UHC during periods of stability but research shows that most major moves towards UHC are triggered by a change in circumstances that breaks a country’s usual pattern that has prevented healthcare reform. It’s much more difficult to roll out UHC during fragile times – finances are often limited and subject to competing claims. But fragility appears to be a powerful motivation for UHC: disruption weakens powerbases that may oppose UHC and governments use healthcare to build legitimacy. Cost is often cited as a barrier to UHC but the gross national income in low- and middle-income countries where UHC is seen as cost-effective is only $1,524 more than those that think it is not – a 13% difference. Healthcare can be a contentious political issue. Dissatisfaction often remains strong until countries reach universality. But once achieved, UHC is usually robustly accepted across the political spectrum. Moreover, this consensus tends to prevail even in difficult situations. Around eight countries in the sample (15%) appear to have faced threats to their health system – including armed conflict in Ukraine and state fragility in Tanzania. The implications are argued to be clear: all countries have the potential to move towards UHC. The main barriers to UHC roll-out are political.

Legislative landscape for traditional health practitioners in Southern African development community countries: a scoping review
Abrams A; Falkenberg T; Rautenbach C; et al: BMJ Open 10(1) 1-10, 2019

This study mapped and reviewed traditional health practitioners (THPs) -related legislation among SADC countries. Four of 14 Southern African countries have legislation relating to THPs. South Africa, Namibia and Zimbabwe have acknowledged the roles and importance of THPs in healthcare delivery by creating a council to register and formalise practices, although they have not operationalised nor registered and defined THPs. In contrast, Tanzania has established a definition couched in terms that acknowledge the context-specific and situational knowledge of THPs, while also outlining methods and the importance of local recognition. Tanzanian legislation; thus, provides a definition of THP that specifically operationalises THPs, whereas legislation in South Africa, Namibia and Zimbabwe allocates the power to a council to decide or recognise who a THP is. This council can prescribe procedures to be followed for the registration of a THP. While South Africa, Tanzania, Namibia and Zimbabwe have legislation that provides guidance as to THP recognition, registration and practices, THPs continue to be loosely defined in most of these countries. Not having an exact definition for THPs are argued to hamper the promotion and inclusion of THPs in national health systems, but it may also be something that is unavoidable given the tensions between lived practices and rigid legalistic frameworks.

The access paradox: abortion law, policy and practice in Ethiopia, Tanzania and Zambia
Blystad A; Haukanes H; Tadele G; Haaland M; et al: International Journal for Equity in Health 18 (126) 1-15, 2019

This paper explored the relationship between abortion law, policy and women’s access to safe abortion services within the different legal and political contexts of Ethiopia, Tanzania and Zambia. Semi-structured interviews were carried out with study participants differently situated vis-à-vis abortion, exploring their views on abortion-related legal- and policy frames and their perceived implications for access. The abortion laws have been classified as ‘liberal’ in Zambia, ‘semi-liberal’ in Ethiopia and ‘restrictive’ in Tanzania, but what the authors encountered in the three study contexts was a paradoxical relationship between national abortion laws, abortion policy and women’s actual access to safe abortion services, and that the texts that make up the three national abortion laws are highly ambiguous. While Zambian and Ethiopian laws are more liberal on paper, they in no way ensure access, while the strict Tanzanian law does not prevent young women from seeking and obtaining abortion. The authors observe that the findings demonstrate that the connection between law, health policy and access to health services is complex and dependent on contexts for implementation. They suggest that broad contextualized studies rather than classifications of law along a liberal-restrictive continuum provide better evidence of real access to safe abortion services.

Adult and young women communication on sexuality: a pilot intervention in Maputo-Mozambique
Frederico M; Arnaldo C; Michielsen K; Decat P: Reproductive Health 16(144) 1-12, 2019

With young women increasingly exposed to sexualized messages, they are argued to need clear, trustful and open communication on sexuality more than ever. However, in Mozambique, communication about sexuality is hampered by strict social norms. This paper evaluates an intervention aimed at reducing the generational barrier in talking about sexuality to contribute to better communication within the family context. The intervention consisted of three weekly one-hour coached sessions in which female adults and young people interacted about sexuality. Realist evaluation was used as a framework to assess context, mechanisms and outcomes of the intervention. Interviews were conducted among 13 participants of the sessions. The interaction sessions were positively appreciated by the participants and contributed to a change in norms and attitudes towards communication on sexuality within families. Recognition of similarities and awareness of differences were key in the mechanisms leading to these outcomes. This was reinforced by the use of visual materials and the atmosphere of respect and freedom of speech that characterized the interactions. Limiting factors were related to the long-standing taboo on sexuality and existing misconceptions on sexuality education and talks about sex. By elucidating mechanisms and contextual factors, the study adds knowledge on strategies to improve transgenerational communication about sexuality.

From primary health care to universal health coverage—one step forward and two steps back
Sanders D, Nandi S, Labonté R, Vance C, Van Damme W: The Lancet, Vol 394; 10199, 619-621, 2019

Primary health care (PHC), codified at the historic 1978 Alma Ata Conference, was advocated as the means to achieve health for all by the year 2000. The principles of PHC included universal access and equitable coverage; comprehensive care emphasising disease prevention and health promotion; community and individual participation in health policy, planning, and provision; intersectoral action on health determinants; and appropriate technology and cost-effective use of available resources. These principles were to inform health-care provision at all levels of the health system and the programmatic elements of PHC that focused primarily on maternal and child health, communicable diseases, and local social and environmental issues. PHC emphasised community participation through a network of workers at all levels who would be trained both “socially and technically”. UHC is concerned with improved access to quality health services and protection from financial risks associated with health care. However, UHC, unlike PHC, is silent on social determinants of health and community participation.

Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania
Sambaiga R; Haukanes H; Moland K; Blystad A: International Journal for Equity in Health 18(135) 1-12, 2019

This paper explores how major global abortion discourses manifest themselves in Tanzania and indicates potential implications of a hybrid abortion regime. The study combined a review of legal and policy documents on abortion, publications on abortion in Tanzanian newspapers between 2000 and 2015 and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health. Tanzania’s abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, reflecting the major global discourses. The paper demonstrates that a hybrid discursive regime relating to abortion is found even in the legally restrictive abortion context of Tanzania. The authors argue that a complex discourse cuts across the restrictive - liberal divide and opens avenues for enhanced access to abortion related knowledge and services.

Launch of the EAC Regional Contingency Plan for Public Health Emergencies
East, Central and Southern African Health Community (ECSA HC): Arusha, July 2019

In 2014, the EAC regional Technical Working Group for Communicable and Non-Communicable Diseases conceived the idea of developing a regional plan for preparedness and response to public health emergencies. ECSA-HC, through the World Bank-funded East Africa Public Health Laboratory Networking Project, supported the drafting and development of the initial version of the plan. This is a multi-hazard preparedness and response plan whose scope includes epidemic prone diseases, and other known and unknown hazards that may have overwhelmed individual countries or are spreading across international border(s) in the EAC region. The Incident Command System describes teams of stakeholders involved in triggering and managing the preparedness, response and recovery phases of public health emergencies, all implemented in a One Health context. The command system is triggered by the national disease surveillance system at a point they determine to be in need of regional assistance. The plan was launched on June 11th 2019 at a ceremony in Namanga at the inauguration of the field simulation exercise for a fictitious Rift Valley fever outbreak spreading across the border between Kenya and Tanzania. ECSA-HC provided technical support in the planning and execution of the World Health Organization-led exercise.

Realizing Universal Health Coverage in East Africa: the relevance of human rights
Yamin A; Maleche A: BMC International Health and Human Rights 17(21) 1-10, 2019

The authors propose that applying a robust human rights framework would change thinking and decision-making in efforts to achieve Universal Health Coverage (UHC), and advance efforts to promote women’s, children’s, and adolescents’ health in East Africa, a priority under the Sustainable Development Agenda. Nevertheless, they point to a gap between global rhetoric of human rights and ongoing health reform efforts. This article seeks to fill part of that gap by setting out principles of human rights-based approaches and then applying those principles to questions that countries face in undertaking efforts toward UHC and promoting women’s, children’s and adolescents’ health, particularly to ensure enabling legal and policy frameworks, establish fair financing and priority-setting and provide meaningful oversight and accountability mechanisms. In a region where democratic institutions are weak, the authors argue that the explicit application of a human rights framework could enhance equity, participation and accountability, and in turn the democratic legitimacy of UHC reforms being undertaken in the region.

Draft WHO global strategy on health, environment and climate change: the transformation needed to improve lives and well-being sustainably through healthy environments
Director-General: World Health Organization, Geneva, April 2019

This proposed strategy provides a vision and way forward on how the world and its health community need to respond to environmental health risks and challenges until 2030, and to ensure safe, enabling and equitable environments for health by transforming ways of living, working, producing, consuming and governing. The Health Assembly noted the report, and requested the Director-General to report back on progress at the 74th World Health Assembly in 2022. The WHO draft global strategy envisions a world in which sustainable development has eliminated the almost one quarter of the disease burden caused by unhealthy environments, through health protection and promotion, good public health standards, preventive action in relevant sectors and healthy life choices, and which manages environmental risks to health. The strategy sets six strategic objectives. Strategic objective 1 aims towards primary prevention: to scale up action on health determinants for health protection and improvement in the 2030 Agenda for Sustainable Development. Strategic objective 2 calls for cross-sectoral action to act on determinants of health in all policies and in all sectors. Strategic objective 3 concerns a strengthening health sector leadership, governance and coordination roles. Strategic objective 4 aims towards building mechanisms for governance, and political and social support. Strategic objective 5 calls for generating the evidence base on risks and solutions, and to efficiently communicate that information to guide choices and investments. Lastly, strategic objective 6 aims to guide actions by monitoring progress towards the Sustainable Development Goals.