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.
1. Editorial
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.
2. Latest Equinet Updates
This is a call for a desk review of public private partnerships (PPPs) in the health sector (health services) in east and southern African countries commissioned by the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The paper aims to inform public sector professionals, policy makers, civil society and parliamentarians on the health sector and health equity impacts of PPPs in health services in the countries of east and southern Africa. It will cover the full spectrum of services provided in the health sector, viz promotive, preventive, curative and rehabilitative in East and Southern African countries.. The paper will be drafted, reviewed and final version produced between March and end July 2020. EQUINET will organise internal and external review. The commissioned author will be paid a gross fee of US$6000 for the paper. See the website for further detail.
EQUINET, SATUCC, SADC CNGO and Benchmarks Foundation have co-operated on regional engagement on extractives and health at the Alternative Mining Indaba, and with the Southern African ex mineworkers Association met in a regional meeting on health literacy in the mining sector in March 2019 to form a mining and health group to strengthen alliances and co-operation in the grassroots to regional and global engagement on the issue. The March 2019 meeting agreed to hold a follow up meeting at the time of the Alternative Mining Indaba (AMI) in February 2020 to follow up on the agreed actions, exchange information and widen the alliances and health literacy activities and processes in the region. The meeting was organised by TARSC / EQUINET and held in co-operation with SATUCC, SAMA and Benchmarks. It was held in Cape Town in the two days before the AMI to enable delegates to also engage in the AMI. It was supported by Medico International and OSF and by TARSC and all the organisations involved who also contributed own resources to their participation. The meeting aimed to i. Share information on mining and health in the region in terms of the risks, responses, rights and actions ii. Review activities on health literacy in mining and use of the EQUINET health literacy module on Mining and health iii. Review the work of the mining and health working group and its members in various platforms and proposed work on extractives and health equity in the region and identify priorities, alliances, actions and roles for follow up and iv. Identify issues to take forward in the AMI and other regional platforms. This report presents the information shared and discussions at the meeting and the plans for follow up work.
3. Equity in Health
Inequalities in human development are a roadblock to achieving the 2030 Agenda for Sustainable Development. They are not just about disparities in income and wealth and cannot be accounted for simply by using summary measures of inequality that focus on a single dimension. This 2019 Report explores inequalities in human development by going beyond income, beyond averages and beyond today. It asks what forms of inequality matter and what drives them, recognizing that pernicious inequalities are generally better thought of as a symptom of broader problems in a society and economy. It also asks what policies can tackle those drivers—policies that can simultaneously help nations to grow their economies, improve human development and reduce inequality.
This paper presents evidence on the potential for social capital to be a protective health resource by mediating the relationship between socioeconomic status and wellbeing of Ghanaian adolescents. A cross-sectional survey involving a randomly selected 2068 adolescents from 15 schools in Ghana was conducted. Relationships were assessed using multivariate regression models. Three measures of familial social capital were found to protect adolescents’ life satisfaction and happiness against the effects of socioeconomic status. There were variations in how socioeconomic status and social capital related to the different dimensions of adolescents’ wellbeing. Social capital was reported to be a significant mechanism through which socioeconomic status impacts the wellbeing of adolescents. The authors suggest that it can be utilised by public health and that the findings show that the role of the family in promoting adolescents’ wellbeing is superior to that of the school.
4. Values, Policies and Rights
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.
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.
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.
5. Health equity in economic and trade policies
A group of about 70 people from the Alternative Mining Indaba marched to the Mining Indaba 2020 held at Cape Town International Conference Centre to highlight their concerns over the problems extractive mining is causing for communities who live near mines. Rev. Martha Mutswakatira, from the Reformed Church in Zimbabwe, who had walked down Adderley Street with the civil society activists in her white collar on Wednesday, said communities are carrying the cost of damages caused by extractive mining. One man from Angola among the Alternative Mining Indaba picket said: "When you come to Africa you need to invest in people: You should not only take oil and diamonds, and leave people with their hands empty." They demanded legal reforms, responsible supply chains, and that mines that pollute be prosecuted. They also called for the legalisation of artisanal mining, with licences being granted to these miners, and that miners and mineworkers be entitled to health and social care. They recommend carbon taxing of mining companies, not allowing social initiatives by mines to be tax deductible, and a move away from fossil fuels. The group also called for the mining industry to provide compensation for former miners' whose health has been adversely affected. Their memorandum was accepted by a delegation which included the International Council on Mining and Minerals; the Department of Minerals and Energy and the Minerals Council South Africa.
This study aimed to assess developments over the last 5 years in providing compensation, quantify shortfalls and explore underlying challenges for ex mineworkers and their families. Using the database with compensable disease claims from over 200,000 miners, the medical assessment database of 400,000 health records and the employment database with 1.6 million miners, rates of claims, unpaid claims and shortfall in claim filing were calculated for each of the southern African countries with at least 25,000 miners who worked in South African mines, by disease type and gender. Interviews were also conducted in Johannesburg, Eastern Cape, Lesotho and a local service unit near a mine site, supplemented by document review and auto-reflection, adopting the lens of a critical rights-based approach. A myriad of diverse systemic barriers persist, especially for workers and their families outside South Africa. Calculating predicted burden of occupational lung disease compared to compensable claims paid suggests a major shortfall in filing claims in addition to the large burden of still unpaid claims. Despite progress made, our analysis reveals ongoing complex barriers and illustrates that the considerable underfunding of the systems required for sustained prevention and social protection (including compensation) needs urgent attention. With class action suits in the process of settlement, the globalized mining sector is now beginning to be held accountable.
In 2013, the World Health Assembly endorsed the World Health Organization’s (WHO) Global action plan for the prevention and control of noncommunicable diseases (NCDs) 2013–2020 to achieve a 25% reduction in mortality from NCDs by 2025. WHO’s Global Action Plan is ambitious. In the late 1990s, WHO used its treaty- making powers to address the issue of tobacco use, leading to the Frame-work Convention on Tobacco Control (FCTC). It enabled WHO to have a greater presence at World Trade Organization (WTO) meetings, supporting countries in their efforts to protect their populations against the harms from tobacco. While WHO was present when tobacco trade may conflict with public health concerns, this was not the case in WTO discussions concerning nutrition policy. Even though the Global action plan for the prevention and control of NCDs 2013–2020, fully recognizes the need for action on trade in certain foods and beverages, it was not possible to find any evidence of WHO participation in nutrition-related trade challenges, such as those related to unhealthy food high in salt, fat and sugar, alcohol, soft-drinks and infant milk formulae. The authors suggest that WHO can learn from its past successes in championing tobacco control at the WTO. The lack of a treaty similar to the FCTC for nutrition-related diseases may discourage WHO participation because such absence limits the perceived legitimacy of WHO input. Further investigations are necessary to understand why WHO has yet to comment on food and beverage regulations at WTO’s committee.
6. Poverty and health
Centre for Natural Resource Governance shared, with sorrow, news of the death of a Hwange woman after a tunnel she was using to sneak into Hwange Colliery Company Limited’s (HCCL) premises collapsed on her and her colleague. As Zimbabwe’s economy declines the Hwange Community now survives largely through several illicit activities, which include sneaking into the company premised through a tunnel to steal coking coke. The centre makes several recommendations. Firstly, that the Ministry of Finance and Ministry of Women Affairs and Small to Medium Enterprises should immediately avail grants for income generating projects to support women in Hwange. This will help women who are not on formal employment to avoid risky livelihood options. They propose that the HCCL must provide safety and security measures that will inhibit people from illegally taking coal coke in their premises. HCCL should also fully implement safety, health and environment initiatives around their premises so that lives can be saved. The centre also recommends that the government provides social and economic security for women mining affected areas and that the Environmental Management Agency regularly monitors SHE compliance in all companies without bias.
This study determined the socioeconomic risk factors for overweight and obesity in non-pregnant adult Zimbabwean women. A cross-sectional study was conducted using the 2015 Zimbabwe Demographic Health Survey data on the adult female population aged 15 to 49. The weighted prevalence of overweight and obesity in adult females was 34% and 12% respectively. The prevalence of overweight and obesity among women in Zimbabwe was high. The key social factors associated were older age, being married, being wealthy and using hormonal contraception. Having a higher education and being Christian also increased the risk of being obese and overweight respectively. The design of multi-faceted overweight and obesity reduction programs for women that focus on increasing physical activity and strengthening of social support systems are argued by the authors to be necessary to combat this epidemic.
Intimate partner violence (IPV) is a widespread problem affecting all cultures and socioeconomic groups. This study explored the trends in prevalence and risk factors associated with IPV among Zimbabwean women of reproductive age (15–49 years) from 2005 to 2015, analysing data from the 2005/2006, 2010/2011 and 2015 Zimbabwe Demographic and Health Surveys. The prevalence of Intimate partner violence was found to have decreased from 45% in 2005 to 41% in 2010, and then increased to 43% in 2015. Some of the risk factors associated with Intimate partner violence were younger age, low economic status, cohabitation and rural residence. Educational attainment of women was not significantly associated with Intimate partner violence. The findings indicate that women of reproductive age are at high and increasing risk of physical and emotional violence. The authors argue that there is a need for an integrated policy approach to address the rise of IPV related physical and emotional violence against women in Zimbabwe.
7. Equitable health services
This study assessed the feasibility and impact of decentralised care for non-communicable diseases (NCDs) within nurse-led clinics in order improve access and inform healthcare planning in Eswatini and similar settings. In collaboration with the Eswatini Ministry of Health, the authors developed and implemented a package of interventions to support nurse-led delivery of care, including clinical desk-guide for hypertension and diabetes, training modules, treatment cards and registries and patient leaflets. One thousand one hundred twenty-five patients were recruited to the study. Of these patients, 573 attended for at least 4 appointments. There was a significant reduction in mean blood pressure among hypertensive patients after four visits of 9.9 mmHg systolic and 4.7 mmHg diastolic, and a non-significant reduction in fasting blood glucose among diabetic patients of 1.2 mmol/l. Key components of non-communicable disease care were completed consistently by nurses throughout the intervention period, including a trend towards patients progressing from monotherapy to dual therapy in accordance with prescribing guidelines. The findings suggest that management of diabetes and hypertension care in a rural district setting can be safely delivered by nurses in community clinics according to a shared care protocol. Improved access is likely to lead to improved patient compliance with treatment.
This study assessed how maternity waiting homes (MWHs) affect the health workforce and maternal health service delivery at their associated rural health centres. Four rounds of in-depth interviews with district health staff and health centre staff were conducted at intervention and control sites over 24 months. Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman’s final stage of pregnancy and labour onset, detect complications earlier, and either more confidently manage those complications at the health centre or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. The authors recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities and strategic selection of locations for new MWHs.
KidzAlive is a child-centred intervention aimed at improving the quality of HIV care for children in South Africa. The authors conducted qualitative interviews with children, their primary caregivers, and KidzAlive trained healthcare workers using and providing child-friendly spaces, respectively. Child-friendly spaces contributed to child-centred care in primary healthcare centres. This was evidenced by the increased involvement and participation of children, increased primary caregivers participation in the care of their children and a positive transformation of the primary healthcare centre to a therapeutic environment for children. Several barriers impeding the success of child-friendly spaces were reported including space challenges; clashing health facility priorities; inadequate management support; inadequate training on how to maximise the child-friendly spaces and lastly the inappropriateness of existing child-friendly spaces for much older children. Child-friendly spaces are observed to promote HIV positive children’s right to participation and agency in accessing care. However, more rigorous quantitative evaluation is required to determine their impact on children’s HIV-related health outcomes.
8. Human Resources
This study estimated the level and trend of development assistance for community health worker-related projects in low- and middle- income countries between 2007 and 2017. Data was extracted from the Organisation for Economic Co-operation and Development’s creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007–2017. Between 2007 and 2017, total development assistance targeting CHW projects was around US$ 5 298 million, accounting for 2.5% of the US$ 209 278 million total development assistance for health. Sub-Saharan Africa received a total US$ 3 718 million, the largest per capita assistance over 11 years. Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period. The share of development assistance invested in the CHW projects was, however, small, unstable and decreasing in recent years.
The authors explored the perceptions and experiences of frontline health managers and community members of the 2017 prolonged health workers’ strikes in Kenya, using informal observations, reflective meetings, individual and group interviews and document reviews, analysed using a thematic approach. In the face of major health facility and service closures and disruptions, frontline health managers enacted a range of strategies to keep key services open, but many were piecemeal, inconsistent and difficult to sustain. Interviewees reported huge negative health and financial impacts on local communities, and especially poor people. They found limited evidence of improved health system preparedness to cope with any future strikes. The 2017 prolonged strikes highlight the underlying and longer-term frustration amongst public sector health workers in Kenya. Reactive responses within the public system and the use of private healthcare led to limited continued activity through the strike, but were not sufficient to confer resilience to the shock of prolonged strikes. To minimise the negative effects of strikes when they occur, the authors suggest that careful monitoring and advanced planning is needed. Planning should aim to ensure that emergency and other essential services are maintained, threats between staff are minimized, health worker demands are reasonable, and that governments respect and honour agreements.
Ensuring health workers’ psychological wellbeing is critical to sustaining their availability and productivity. This study investigated levels of and factors associated with psychological wellbeing of mid-level health workers in Malawi, using a cross-sectional sample of 174 health workers from 33 primary and secondary level health facilities in four districts of Malawi. Twenty-five percent of respondents had World Health Organsation-5 scores indicative of poor psychological wellbeing. Analyses of factors related to psychological wellbeing showed no association with sex, cadre, having dependents, supervision, perceived co-worker support, satisfaction with the physical work environment, satisfaction with remuneration, and motivation; a positive association with respondents’ satisfaction with interpersonal relationships at work; and a negative association with having received professional training recently. The high proportion of health workers with poor wellbeing scores is concerning in light of the general health workforce shortage in Malawi and strong links between wellbeing and work performance. While more research is needed to draw conclusions and provide recommendations as to how to enhance wellbeing, the results are argued to underline the importance of considering wellbeing as a key concern for human resources for health.
Nurses in South Africa - as in the rest of the continent - are the backbone and oxygen of public health care though not adequately acknowledged. This article traces the pattern of public health care spending and its impact on nurses since 1994. Given the nature and quantity of demand for public health care in South Africa, deemed the most unhealthy nation in the world in the 2019 Indigo Wellness Index, the article shows that the 25 year record of democratic South Africa registers low public health care expenditure and nurses are at the coal face of this contradiction.
9. Public-Private Mix
The use of crowdfunding platforms to cover the costs of healthcare is growing rapidly within low-, middle-, and high-income countries as a new funding modality in global health. To map and document how medical crowdfunding is shaped by, and shapes, health disparities, this article offers an exploratory conceptual and empirical analysis of medical crowdfunding platforms and practices around the world. Data are drawn from a mixed-methods analysis of medical crowdfunding campaigns, as well as an ongoing ethnographic study of crowdfunding platforms and the people who use them. Drawing on empirical data and case examples, this article describes three main ways that crowdfunding is impacting health equity and health politics around the world: 1) as a technological determinant of health, wherein data ownership, algorithms and platform politics influence health inequities; 2) as a commercial determinant of health, wherein corporate influence reshapes healthcare markets and health data; 3) and as a determinant of health politics, affecting how citizens view health rights and the future of health coverage. Rather than viewing crowdfunding as a social media fad or a purely beneficial technology, researchers and publics must recognize it as a complex innovation that is reshaping health systems, influencing health disparities, and shifting political norms, even as it introduces new ways of connecting and caring for those in the midst of health crises. More analysis, and better access to data, is needed to inform policy and address crowdfunding as a source of health disparities.
In many African countries, hundreds of health-related non-government organisations (NGOs) are fed by a chaotic tangle of donor funding streams. The case of Mozambique illustrates how this NGO model impedes Universal Health Coverage. In the 1990s, NGOs multiplied across post-war Mozambique: the country’s structural adjustment program constrained public and foreign aid expenditures on the public health system, while donors favoured private contractors and NGOs. In the 2000s, funding for HIV/AIDS and other vertical aid from many donors increased dramatically. In 2004, the United States introduced PEPFAR in Mozambique at nearly 500 million USD per year, roughly equivalent to the entire budget of the Ministry of Health. PEPFAR funding has helped thousands access antiretroviral treatment, but over 90% of resources flow “off-budget” to NGO “implementing partners,” with little left for the public health system. After a decade of this major donor funding to NGOs, public sector health system coverage had barely changed. In 2014, the workforce/ population ratio was still among the five worst in the world at 71/10000; the health facility/per capita ratio worsened since 2009 to only 1 per 16,795. Achieving UHC will require rejection of austerity constraints on public sector health systems, and re-channelling of aid to public systems building rather than to NGOs.
10. Resource allocation and health financing
To achieve Sustainable Development Goal 3.4, countries have been urged to introduce sin taxes, such as those on sugar. Others have argued that such taxes may affect employment, economic growth and increase poverty. There is limited or no reliable evidence on this. Using a conceptual framework of relationships among SDGs as contradictory, reinforcing, or neutral, the authors used the recent introduction in Zambia of an equivalent 3% tax on non-alcoholic beverages, implicitly targeted at sugar-sweetened beverages to test the issue. While the goal of reducing non-communicable diseases is stated, concerns were raised that such a tax would be detrimental to the Zambia sugar value chain which contributes about 6% to GDP. The authors discuss that contradictions depend on a number of contextual factors, and make two conclusions about sugar taxation in Zambia. First, they argue that the current tax rate of 3% is likely neutral to be because it is too low to have any health or employment effects. However, the revenue raised can be reinvested to improve livelihoods. Secondly, they suggest increasing the tax rate but taking care to ensure that the rate is not too high to generate contradictions, carefully assessing important parameters such as elasticities and alternative economic livelihoods.
Thousands of ex-gold mineworkers in South Africa are suffering from silicosis and lack the medical screening, compensation, healthcare and support they need and deserve. Action for Southern Africa (ACTSA) led a campaign calling on gold companies to provide decent health and compensation in a campaign for justice for Southern African gold mineworkers with silicosis and tuberculosis. The campaign included: protesting outside the High Court; attending and speaking at many Anglo American AGMs; organising petitions; and producing campaign briefings. On 26 July 2019, the South Gauteng High Court approved a class action settlement worth at least R5 billion (approximately £268 million). The settlement establishes the Tshiamiso Trust, which will be responsible for paying compensation to eligible gold mineworkers and their dependents in Southern Africa.
The authors contend that the priorities of Northern donors dictate the aid agenda, implemented by the non-state and Southern ‘partners’ they fund. These priorities often clash with the needs and concerns of communities, governments and civil society in many countries around the world. The aid space is dominated by powerful interests, while the voices of those most affected by health inequity are regularly tokenised or excluded from the conversation. The authors argue that many actors within the sector – even among communities and civil society – do not question the underlying premise and structures of health aid. Their own ideas and world views have been shaped by, and for, aid and the industry that supports it. Questioning aid poses challenges to the professions, livelihoods and sources of power for those who work within the sector. Furthermore, whilst health aid is important in some situations, on its own aid can never lead to a world where all people can live healthy lives. Signatories of the declaration believe that collective social action in solidarity as one global community, working together to address the root causes of the struggle for health, can transform aid into an equitable means of ensuring health rights. Through the Kampala Initiative, the signatories commit to expose, explore, challenge and transform health aid through dialogue, advocacy, activism and action. They commit to build cooperation and solidarity for health, within and beyond the practice of aid, to build a future where health justice and equity are realised, and aid is no longer a necessity.
As low- and middle-income countries undertake health financing reforms to achieve universal health coverage, there is renewed interest in making allocation of pooled funds to health-care providers more strategic. To make purchasing more strategic, countries are testing different provider payment methods. They therefore need comprehensive data on funding flows to health-care providers from different purchasers to inform decision on payment methods. Tracking funding flow is the focus of several health resource tracking tools including the System of Health Accounts and public expenditure tracking surveys. This study explores whether these health resource tracking tools generate the type of information needed to inform strategic purchasing reforms, using Kenya as an example. A qualitative assessment of three counties in Kenya shows that different public purchasers, that is, county health departments and the national health insurance agency, pay public facilities through a variety of payment methods. Some of these flows are in-kind while others are financial transfers. The nature of flows and financial autonomy of facilities to retain and spend funds varies considerably across counties and levels of care. The government routinely undertakes different health resource tracking activities to inform health policy and planning. However, a good source for comprehensive data on the flow of funds to public facilities is still lacking, because these activities were not originally designed to offer such insights. The authors therefore argue that the methods could be enhanced to track such information and hence improve strategic purchasing, and also offer suggestions how this enhancement can be achieved.
11. Equity and HIV/AIDS
This study investigated the socio-demographic determinants of recent HIV testing among older persons in selected rural districts in Uganda using a cross-sectional survey of 649 older men and women age 50 years and older, from central and western Uganda. Prevalence of lifetime HIV testing was 82% and recent HIV testing was 53%. HIV testing in the last 12 months was associated with age, self-reported sexually transmitted infections, male circumcision, and sexual activity in the last 12 months. Recent HIV testing among older persons was associated with younger age, self-reported STIs, male circumcision, and sexual activity among older persons in rural Uganda. The authors propose that HIV testing interventions target persons 70 years and older, who were less likely to test.
12. Governance and participation in health
The Bench Marks Foundation developed the concept of the Community Monitoring School because a vacuum of knowledge exists within communities when dealing with big corporations. The message of the Community Monitoring School is “nothing for us without us”. Tunatazama is a Kiswahili word that means “we are watching” and the 2013 school’s motto was “We are Watching You!” For any significant reform in the mines to occur, the present power and knowledge imbalances between corporations and communities need to be overcome. In Phase One of the school programme, the focus is on helping participants develop confidence and skills in documenting and analysing community problems. They write short articles on their observations and post these on the project’s website. Some of these articles appear in the first section of this publication. In Phase Two of the programme, direct action in the community is combined with school sessions on planning, review and evaluation. In the second section a reflective analysis is conducted on the process.
Following Zambia’s independence in 1964, several thousand non-Zambian Africans were identified and progressively removed from the Copperbelt mines as part of a state-driven policy of ‘Zambianisation’. Curiously, this process has been overlooked among the multitude of detailed studies on the mining industry and Zambianisation, which is usually regarded as being about the removal of the industrial colour bar on the mines. This article challenges that perspective by examining the position and fate of non-Zambian African mineworkers, beginning with patterns of labour recruitment established in the colonial period and through the situation following independence to the protracted economic decline in the 1980s. Two arguments are made by the author. First, Zambian nationalism and the creation of Zambian citizenship were accompanied on the Copperbelt by the identification and exclusion of non-Zambians, in contrast to a strand in the literature which stresses that exclusionary nationalism and xenophobia are relatively recent developments. Second, one of the central and consistent aims of Zambianisation was the removal of ‘alien’ Africans from the mining industry and their replacement with Zambian nationals as a key objective of the Zambian government, supported by the mineworkers’ union.
13. Monitoring equity and research policy
This paper presents an evaluation of the current capacity of the national health information systems in Mozambique, and the available indicators to monitor health inequalities, in line with Sustainable Development Goals 3. A data source mapping of the health information system in Mozambique was conducted. Eight data sources contain health information to measure and monitor progress towards health equity in line with the 27 Sustainable Development Goal 3 indicators. Seven indicators bear information with nationally funded data sources, ten with data sources externally funded, and ten indicators either lack information or it does not applicable for the matter of the study. None of the 27 indicators associated with Sustainable Development Goal 3 can be fully disaggregated by equity stratifiers; they either lack some information or do not have information at all. The indicators that contain more information are related to maternal and child health. The authors report that there are important information gaps in Mozambique’s current national health information system which prevents it from being able to comprehensively measure and monitor health equity.
14. Useful Resources
On 31 December 2019, WHO was alerted to several cases of pneumonia in Wuhan City, Hubei Province of China. The virus did not match any other known virus. This raised concern because when a virus is new, it is not known how it affects people. One week later, on 7 January, Chinese authorities confirmed that they had identified a new virus. The new virus is a coronavirus, which is a family of viruses that include the common cold, and viruses such as SARS and MERS. This new virus was temporarily named “2019-nCoV.” The World Health Organisation has released a number of guidelines aimed at preventing the spread and proliferation of the virus.
#COP25 can barely break into the news cycle - but the public is well aware by now that business-as-usual is not an option if ecological breakdown is to be averted and move to a fairer, safer and more peaceful ways of co-existing on the planet are to be found. Business-as-usual means maintaining trade rules and treaties that give corporations enormous power to endlessly extract natural resources; sacrificing communities and ecosystems in those places to feed rampant consumerism for the profit of a powerful minority. This film’s calls on us to reject business-as-usual and advocate for a #BindingTreaty on Transnational Corporations and Human Rights and are building solidarity across countries and movements to demand Rights for People, Rules for Corporations.
This website is a space for community activists living near mines in southern Africa to share information, resources and experiences. The countries currently participating in this project are: Lesotho, South Africa, Zimbabwe, Zambia, the Democratic Republic of Congo (DRC), Mozambique and Tanzania. Activists in each country document problems they experience and events they participate in and share this on a WhatsApp group. These posts are then shared on this site in the respective country blogs. Each country, in addition, maintains their own country blog. Additionally, Activists can view the posts on a mobile app called “Action Voices” which can be downloaded on an Android phone from the Google Play store. The activities of this project are managed by the Bench Marks Foundation on behalf of regional organisations.
15. Jobs and Announcements
The 6th South African TB Conference is a platform for stakeholders from government, the private sector, academia, NGO’s, and advocacy groups to share experiences and plan strategic initiatives. The programme will include international faculty and globally recognised local participants that will cover key cross-cutting themes (drug-sensitive TB, drug-resistant TB, paediatric TB, HIV/TB co-infection, EPTB, and prevention, diagnosis and treatment) across 4 thematic tracks (clinical science, basic science, public health including health systems and surveillance and human rights/ stigma/ advocacy).
The purpose of the AIAC Fellowship is to support the production of original work and new knowledge on Africa-related topics that are under-recognized and under-covered in traditional media, new media, and other public forums. It particularly seeks to amplify voices and perspectives from the left that address the major political, social, and economic issues affecting Africans in ways that are original, accessible, and engaging to a variety of audiences. Fellows will be writers and/or other cultural/intellectual producers who can contribute meaningfully to transforming and expanding knowledge about Africa and the diaspora. Each fellow will receive a grant of up to US$3,000 to create original work on a topic of their choice for AIAC over a 9-month period. While most fellows will produce essays and/or reporting and analysis, AIAC are also open to work in other formats, such as photo essays, documentary videos, and more. Fiction, poetry, and fine and performing arts are not eligible for support from this program.
There is an opportunity for postdoctoral researchers in Africa to pursue their own research projects, thereby indirectly strengthening academia in African countries. The scholarship offers access to the Institute's library and other resources that provide for a stimulating research environment. The maximum duration of the stay is 90 days, minimum is 60 days. The scholarship includes a return air-fare (economy class), accommodation, a subsistence allowance plus an installation grant and access to a workspace and desk computer. Guest Researchers have the possibility to present their research at the Nordic Africa Institute and to visit other institutions in the Nordic countries.
In support of early career researchers working in the field of global health from low-income and lower-middle-income countries, BMJ is offering the BMJ Global Health Grant to one successful applicant. Applicants may apply for up to £5,000 to your attendance at the Sixth Global Symposium on Health Systems Research (HSR 2020), taking place in Dubai, United Arab Emirates, 8–12 November 2020. The grant will be used to cover costs of attending the conference, including the event registration fee, return travel and accommodation costs, visa application fee and subsistence for the days on which the conference is held. The grant will be awarded to the applicant whose abstract describes the most original methodological contribution to the field of global health and whose summary demonstrates the greatest importance and potential impact in advancing the field.
The National NCD Research Symposium is an opportunity to bring together researchers, policymakers and practitioners to exchange knowledge on prevention and treatment of diabetes, hypertension, cardiovascular disease risk factors, and related mental health conditions; identify the gaps in knowledge base; and discuss implications for healthcare policy and practices.
The Council for the Development of Social Science Research in Africa invites applications from African scholars to fill a vacant position of Programme Officer in its Training, Grants and fellowships Programme at its pan-African Secretariat located in Dakar, Senegal. Candidates wishing to apply for the position should note that they will work under the supervision of the Senior Programme officer and Head of the Training, Grants and Fellowships Programme.
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