EQUINET NEWSLETTER 225 : 01 September 2020

1. Editorial

Experiences and insights on COVID-19 and equity
EQUINET steering committee

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.

2. Latest Equinet Updates

Brief: COVID-19 in East and Southern Africa: developments in the pandemic, July 2020
EQUINET and ECSA HC: Mimeo, 2020

This information sheet is the second presenting work summarising evidence as of July 17 2020 from official and scientific population data across countries in east and southern Africa (ESA) on the COVID-19 pandemic, the responses to it and the relationship with other indicators of population health, health systems and health determinants. The information sheet aims to address four questions: What is happening with COVID-19 testing and detection? How and where is the epidemic progressing over time? How has the health system responded? What are the implications for wider vulnerability? In terms of the epidemic profile, increased testing has improved case detection, although still at low levels for an effective public health response. The pandemic continued to take different forms in different ESA countries. In terms of the health system response, the evidence in July indicated continued constraints in accessing diagnostics, limiting case detection, despite reasonable surveillance capacities. In terms of wider vulnerability, the slower, sustained increase in cases in the ESA region were noted to raise concern on the effects of sustained implementation of measures such as school and workplace closures.

COVID-19 in East and Southern Africa: Rebuilding Differently and Better Must Start Now
Loewenson R: MEDICC Review 22(3), doi: https://doi.org/10.37757/MR2020.V22.N3.13, 2020

This paper outlines how for ESA countries, COVID-19 has exposed the weakness in being dependent on research and production outside the region of commodities that are needed in good time for communities and services across the region. This not only relates to current demand, like test kits. It forewarns that African countries will be last in the queue when COVID-19 treatments and vaccines are approved. Tariff reductions and reduced protections for domestic industry have suited a global strategy of ‘lowest-cost-production’ but leave ESA countries vulnerable in the global competition for products. The author also notes that COVID-19 has pointed to resources in the region that could play a more significant role in public health. The Ebola experience showed that an effective response demands collaborative work that involves communities and is supported by professionals, governments and accessible, capable public services. This is the same lesson learned from the gains made in health by applying primary health care strategies in the region, despite their being weakened by underfunding of public services. In contrast, the response to COVID-19 has often generated a self-protective response across countries in global trade and a command-and-control response within countries. Yet neither are effective strategies for a global pandemic that demands distributed local capacities and action. Noting the UN call to use COVID-19 as an opportunity “to rebuild differently and better, the author observes that this begins with how we respond to COVID-19 today, and raises what this implies.

Trends in climate, extractives and health equity in the east and southern Africa
Zimbabwe Environmental Law Association for the Regional Network for Equity in Health in East and Southern Africa (EQUINET), 2020

This paper presents the current situation and projected trends related to climate change in east and southern Africa (ESA); the implications for the health of current and future generations of these trends and; the policy choices and alternatives to respond to them. ESA contributes the least of any world region to global greenhouse gas emissions yet will be more vulnerable to the impacts of climate change than any other region. Extractive sectors exacerbate climate change through deforestation and high emission levels of greenhouse gases. Climate change is expected to cause reduced rainfall and a greater frequency of extreme events in the region, and ESA countries will be vulnerable due to their economic reliance on rainfed agriculture and water resources.The region faces resource and other constraints to implement adaptation policies, or for key areas such as the development and production of green technologies.

Trends in extraction of biodiversity and genetic resources in east and southern Africa
Mayet M, Mentz-Lagrange S, African Centre for Biodiversity: EQUINET, 2020

This paper presents the current situation and projected trends related to biodiversity and genetic resources in east and southern Africa (ESA), the implications for the wellbeing of current and future generations of these trends, and the policy choices and alternatives to respond to these trends and the factors that influence policy design and uptake of choices. The biodiversity, genetic diversity of plants, animals and forests in ESA countries are declining at alarming rates, risking the health and wellbeing of populations in the region. Losses of biodiversity and genetic resources have led to poorer diets, poorer living conditions, encroachment on areas with animal populations and an erosion of wild foods and medicinal plants that raise the risk of chronic and zoonotic diseases and pandemics. Current policies have not reversed these trends, nor met the targets of the Convention on Biodiversity (CBD). The authors argue that this calls for an urgent paradigm shift from industrial agriculture to diversified agro-ecological systems and a one health approach, that recognise the complex, intergenerational interconnections between human and animal health, plants and a shared environment. The authors call for a movement to defend genetic diversity as a common good, not something that can be extracted and privately profited from.

Trends in extraction of mineral resources in east and southern Africa
Caramento A: EQUINET, 2020

This paper presents the current situation and projected trends related to extraction of mineral resources in east and southern Africa (ESA), the implications for the wellbeing of current and future generations of these trends, and the policy choices and alternatives to respond to these trends and the factors that influence policy design and uptake of choices. The author notes several changes in the coming decades that have numerous implications for health and wellbeing in ESA, including as a result of land displacement and precarious jobs. A demand for greater and wider health and developmental benefits from current and future mineral extraction has led to resource nationalism. The paper notes that it means effectively projecting, monitoring and preventing the impacts of mineral extraction on health and environments; adopting financial transparency and accountability measures and employing strategies and responses that are built from bottom-up through consultation with small scale miners, communities, workers and the wider public.

Trends in water resources in east and southern Africa
Loewenson R, Training and Research Support Centre: EQUINET, 2020

This paper presents the current situation and projected trends related to water in east and southern Africa (ESA), the implications for the wellbeing of current and future generations of these trends, and the policy choices and alternatives to respond to these trends and the factors that influence policy design and uptake of choices. Maldistribution and water scarcity and stress are predicted to intensify in coming decades. Southern countries will become significantly drier and east Africa will have higher rainfall. Climate change will amplify existing variability but may be less critical than growing demand for water. A growing, urbanised population, expanded enterprise and agriculture will deplete and can pollute water resources, with lowest income households least served. Water scarcity contributes to ill health, food insecurity, poverty and increases women’s burdens. There is a potential for vicious or virtuous cycles between these impacts and water resources, depending on the policy choices made. Inequality and stress is not inevitable. There is potentially adequate water to meet the basic needs of all in the region and for sustaining ecosystems if managed through co-operation, paying attention to equity, interdependence and long-term outcomes. The dividends from investments in water systems thus need to be made more visible as well as the harms of competitive, short term choices.

Universal Health Coverage: From aspirations to reality
Mamdani M: Global Social Policy 20(2) 242-246, doi: https://doi.org/10.1177/1468018120922227, 2020

Written in response to the United Nation’s High Level Political Declaration on UHC in September 2019, this issue has a focus on universal health coverage (UHC). Written before the COVID-19 pandemic, the articles reiterate that robust health systems matter and that the implications of a system’s universality, accessibility and quality reach far beyond any particular nation. The articles are open access for a limited period of time. This paper in the series examines the experience of advancing UHC in East and Southern Africa, drawing in part on learning from work in EQUINET. Underpinning the UHC agenda is the belief that access to health care is a fundamental human right that advances equality and safeguards human dignity. Achieving UHC is a huge endeavour and requires buy-in at all levels of the system. It calls for strategic leadership, evidence and review. There has been a significant expansion in the technical information and knowledge available to support UHC. Making progress towards achieving it is, however, not simply a technical issue: it is an issue of power, political choice and leadership.

3. Equity in Health

Comparisons of social and demographic determinants of tobacco use in the Democratic Republic of the Congo
Colwell B; Mosema K; Bramble M; et al: Globalization and Health 16(66), doi: https://doi.org/10.1186/s12992-020-00593-0, 2020

This study examined social determinants of tobacco use in the Democratic Republic of the Congo (DRC), including region, sex, ethnicity, education, literacy, wealth index and place of residence, to gain insights on tobacco use among sub-national groups. The project analysed data from the DRC 2013–2014 Demographics and Health Survey. Tobacco use was found to be highest among working poor people, those with less education and low literacy. Older age people and those living in larger cities were more likely to smoke , although the relationship between age and smoking was not linear. Wealth was strongly related to smoking as was being engaged in services, skilled and unskilled manual labour and the army. Being in a professional, technical or managerial position was highly protective against smoking. The authors observe that the data indicate that tobacco use in the DRC, as is common in low income countries, is heavily concentrated in working poor people with lower educational status. Higher educational status is consistently predictive of avoiding tobacco use. They argue that examining only national-level data to ascertain tobacco use levels and patterns may lead to mistaken conclusions and inefficient and ineffective allocation of resources for control of tobacco use.

SADC Regional Response to COVID-19
Southern African Development Community: Bulletin 11, SADC, Botswana, August 2020

The 11th Bulletin of the SADC Response to COVID-19 in English, French and Portuguese provides an overview of the global, continental and regional situation as well as the measures that have been put in place with the support of WHO. It reports that the COVID-19 situation continues to rise in some states in the region, destabilizing the economies and other systems, and leading to a precarious food and nutrition situation. The report provides the short, medium and long term interventions that countries can put in place to address the situation in relation to issues such as food security, transport, health and economic recovery. Transport and trade facilitation is noted to remain a major challenge while noting achievements in this, including the Tripartite Guidelines on Trade and Transport Facilitation for Safe, Efficient and Cost Effective Movement of Goods and Services during the COVID-19 Pandemic which harmonise the guidelines of SADC, East African Community (EAC) and the Common Market for Eastern and Southern Africa (COMESA).

Status of COVID-19-in East and Southern Africa
Minja C: The East Central and Southern Africa Health Community (ECSA-HC), July 2020

The East Central and Southern Africa Health Community has continued to monitor the status of COVID-19 in Burundi, Eswatini, Kenya, Lesotho, Malawi, Mozambique, Mauritius, Rwanda, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe and to support countries mitigate effects of COVID-19. Due to the prevailing restrictions of travel, much has been provided through online discussions and support. The report indicates that the number of reported confirmed cases of COVID-19 and cases under care in the region is increasing, in spite of the context of under-reporting. The authors note that governments wish to open up economies to take care of individual and national economic survival and call for targeted and population interventions for modified social distancing mechanisms and for support for diagnostics, care of recovering cases, contact tracing and surveillance across countries, taking note of the fluid movement of people across borders. Adopting regional collaborative efforts is argued to be cost-efficient.

The COVID-19 pandemic and health inequalities
Bambra C; Riordan R; Ford J: et al: Epidemiology & Community Health, doi: 10.1136/jech-2020-214401, 2020

This essay examines the implications of the COVID-19 pandemic for health inequalities. It outlines historical and contemporary evidence of inequalities in pandemics—drawing on international research into the Spanish influenza pandemic of 1918, the H1N1 outbreak of 2009 and the emerging international estimates of socio-economic, ethnic and geographical inequalities in COVID-19 infection and mortality rates. It then examines how these inequalities in COVID-19 are related to existing inequalities in chronic diseases and the social determinants of health, arguing that this is a syndemic pandemic. The authors explore the potential consequences for health inequalities of the lockdown measures implemented internationally as a response to the COVID-19 pandemic, focusing on the likely unequal impacts of the economic crisis. The essay concludes by reflecting on the longer-term public health policy responses needed to ensure that the COVID-19 pandemic does not increase health inequalities for future generations.

4. Values, Policies and Rights

COVID-19: The place of the right to health in the national response for Uganda
Mulumba M: Center for Health Human Rights and Development (CEHURD), May 2020

As the state and non-state actors take steps in dealing with COVID-19, the author argues for an awareness of the need to urgently strike a balance between prevention approaches and rights with collective responsibilities. From a right to health perspective, it is important for the government of Uganda to ensure that prevention and treatment measures and commodities are available, accessible, and affordable for the most vulnerable communities including: the older persons, those under incarceration, refugees and very poor people. Community participation and solidarity are pillars that have historically been critical in controlling and managing similar outbreaks in Uganda. The author argues for an attentiveness to ensure that research and clinical trials comply with key ethical and human rights principles and that government makes full use of the policy space Uganda has in intellectual property as an LDC to enable it utilise new innovations. The paper points to the need to review and ensure provisions under the Public Health Act enable an effective and equitable response to pandemics like COVID-19, to ensure regulatory approval for new medicines and attention to developing new formulations for the prevention and treatment of COVID-19.

South Africa, Kenya and Zimbabwe: Repression and state violence are not public health strategies
Essop T; the Anti-Repression Working Group of the C-19 People’s Coalition: Daily Maverick, South Africa, August 2020

The securitised interventions by the South African, Kenyan and Zimbabwean governments are argued by the author to be fundamentally out of tune with the needs of the moment and ineffective in dealing with the pandemic’s multiple crises. They note that lockdown regulations have been used as a cover for suppressing legitimate concerns around the socio-economic fallout from nationwide lockdown measures that have undermined livelihoods and disproportionately affected poor people. This pattern of conduct calls into question the use of securitised approaches to the global health emergency and what it means for the broader public health response that is needed. In South Africa, Kenya and Zimbabwe, the brutality and heavy-handedness of the security forces is argued to not be new and that the current responses are rooted in systemic problems and failures of accountability in policing in poor communities.

5. Health equity in economic and trade policies

Conclusions and outcomes from SATUCC seminars during the 16th Southern African Civil Society Forum
SATUCC: Botswana, August 2020

The 16th Southern African Civil Society Forum (CSF) was held remotely in late August due to the challenges posed by COVID-19. In seminars at the forum hosted by SATUCC, and with evidence presented from studies implemented for SATUCC, it was noted that the pandemic has amplified a number of challenges that workers were already facing before COVID-19, such as increase of insecure and informal work, lack of social protection and rising unemployment, exacerbating poverty and inequalities. Youth were found to be more vulnerable due to high youth working poverty rates and because the youth are over-represented in vulnerable and informal employment. Young women are facing an increasing double burden to manage both paid work and unpaid care and household work due to widespread school closures. The sessions identified that trade unions should be actively involved in the formulation and implementation of responses to COVID-19 at both national and regional level and that the issues facing workers should be addressed in social dialogue and in the collective bargaining agreements. Trade unions should be pro-active in bringing alternative proposals for building sustainable economies after the pandemic.

COVID-19: South Africa, India call for enabling technology transfer in TRIPS
Third World Network: TWN Info Service on Health Issues, August 2020

At the WTO’s TRIPS Council meeting on 30 July, members discussed South Africa’s proposal (IP/C/W/665) for members to come up with proposals, share information and national experiences, pointing out how the 2030 SDGs may be achieved through an effective framework for technology transfer. India reminded the TRIPS Council that any discussion on “E-Commerce will lack meaning if the gaping digital divide, partly arising out of lack of access to technologies and furthered by the pandemic, continues to exist.” In conclusion, India said that “it is of utmost importance for developing countries to adopt e-commerce and IP policies that are mutually supportive and in line with their developmental goals and policy specificities.”

Fostering local production of essential medicines in Nigeria
Fatokun O: Bulletin of the World Health Organisation 98, doi: http://dx.doi.org/10.2471/BLT.19.249508, 2020

Consistent availability and access to medicines in low- and middle-income countries is a challenge. As a result, the governments in these countries have shown increasing interest in local pharmaceutical production as a means of promoting technology transfer, building capacity and improving access to essential medicines. In Nigeria, the Five Plus Five-Year Validity (Migration to Local Production) policy aims to reduce the number of pharmaceutical products imported into Nigeria and encourage local production of essential medicines. The Five Plus policy follows a fiscal policy measure implemented since 2016 which reduced the import adjustment tax under the Economic Community of West African States Common External Tariff on pharmaceutical raw materials from 5–20% to 0% and imposed a 20% import adjustment tax on four groups of imported drugs that can be produced by local manufacturers, including antimalarials, antibiotics, alkaloid derivatives and vitamins. While local pharmaceutical production in some low-income countries is not viable because of limited local technical expertise or low economies of scale, this issue may not be the case in Nigeria, given its large population, huge potential market and local expertise and experience for the manufacture of essential medicines.

Lessons from COVID-19: Pharmaceutical Production as a Strategic Goal
Correa C: South Centre, South Views 202, 2020

The economic and financial crisis generated by COVID-19 has deepened initiatives - which are not entirely new - to sustain local production of pharmaceuticals through a variety of mechanisms aimed at recovering 'strategic autonomy'. The pharmaceutical industry (including biotechnological products) can be one of the axes in new policy frameworks oriented to local production. A UNCTAD study concluded that in many developing countries companies have achieved the economies of scale required to produce medicines competitively and will expand over the next decade. Taking advantage of these opportunities to strengthen a pharmaceutical/ biotechnology industry may require the reformulation of industrial policies, to promote the sector as a generator of value added, employment and foreign exchange, as well as an instrument for achieving health autonomy to address public health needs. The author argues that this requires the deployment of well-articulated instruments, in line with the concept of 'mission-oriented industrial strategy'.

6. Poverty and health

Inequalities in access to water and soap matter for the COVID-19 response in sub-Saharan Africa
Jiwani S; Antiporta D: International Journal for Equity in Health 19(82) doi: https://doi.org/10.1186/s12939-020-01199-z, 2020

This paper explored the inequalities in access to water and soap for the COVID-19 responses since December 2019. . Although access to clean water and soap is universal in high-income settings, it remains a basic need many do not have in low- and middle-income settings. according to data from Demographic and Health Surveys of 16 countries in sub-Saharan Africa, using the most recent survey since 2015. The authors propose that interventions such as mass distribution of soap and ensuring access to clean water, along with other preventive strategies should be scaled up to reach the most vulnerable populations.

Socioeconomic inequalities in food insecurity and malnutrition among under-five children: within and between-group inequalities in Zimbabwe
Lukwa A; Siya A; Zablon K; Azam J; et al: BMC Public Health 20(1199), doi: https://doi.org/10.1186/s12889-020-09295-z, 2020

The authors explored socioeconomic inequalities trend in child health using Demographic Health Survey data sets of 2010\11 and 2015. Food insecurity in under-five children was determined based on the World Health Organisation dietary diversity score. Theil indices for nutrition status showed socioeconomic inequality gaps to have widened, while food security status socioeconomic inequality gaps contracted for the period under review. The study concluded that unequal distribution of household wealth and residence status play critical roles in driving socioeconomic inequalities in child food insecurity and malnutrition. Child food insecurity and malnutrition are greatly influenced by where a child lives and their parental wealth.

Water, sanitation, hygiene, and waste management for SARS-CoV-2, the virus that causes COVID-19
World Health Organisation, WHO/2019-nCoV/IPC_WASH/2020.4, July 2020

The provision of safe water, sanitation and waste management and hygienic conditions are essential for protecting human health during all infectious disease outbreaks, including of COVID-19. Ensuring evidenced-based and consistently applied WASH and waste management practices in communities, homes, schools, marketplaces, and healthcare facilities will help prevent human-to-human transmission of COVID-19. This guidance provides additional details on risks associated with excreta and untreated sewage, hand hygiene, protecting WASH workers and supporting the continuation and strengthening of WASH services, especially in underserved areas.

7. Equitable health services

Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region
Wehrmeister F; Mbacké Fayé C; da Silva I; et al: Bulletin of the World Health Organization 98(6), 2020

The authors investigated whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions, using post 1995 survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions. Wealth-related inequalities were prevalent in all subregions, highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as higher coverage was observed in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and no evidence was found of inequality reduction in Central Africa. The data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability

8. Human Resources

Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique’s community health workforce
Steege R; Taegtmeyer M; Ndima S; Give C; et al: Human Resources for Health 18(37) doi: https://doi.org/10.1186/s12960-020-00476-w, 2020

Mozambique’s community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). This paper seeks to explore the current recruitment imbalance processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique. The authors employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors, younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain. The authors suggest that responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre.

Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya
Karman E; Wilson K; Mugo C; Slyke J; et al: Journal of the International Association of Providers of AIDS Care (19) doi: https://doi.org/10.1177/2325958220935264, 2020

This paper examined the training coverage and self-reported competence, knowledge, abilities, and attitudes, of health care workers caring for adolescents living with HIV in Kenya. Surveys were conducted with 24 managers and 142 health care workers. Health care workers had a median of 3 years of experience working with adolescents living with HIV, and 40% reported exposure to any adolescents living with HIV training. Median overall competence was 78%. More years caring for adolescents living with HIV and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains sub-optimal. The authors suggest that targeting health care workers with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services.

9. Public-Private Mix

An overview of the commercial determinants of health
Mialon M: Globalization and Health 16(74), doi: https://doi.org/10.1186/s12992-020-00607-x, 2020

This desk review provides an overview of the commercial determinants of health. The commercial determinants of health are reported to cover three areas. First, they relate to unhealthy commodities that are contributing to ill-health. Secondly, they include business, market and political practices that are harmful to health and used to sell these commodities and secure a favourable policy environment. Finally, they include the global drivers of ill-health, such as market-driven economies and globalisation, that have facilitated the use of such harmful practices. The discussion on the commercial determinants of health is argued to offer an opportunity to shift the dominant paradigm in public health, so ill-health, damages to the environment, and health and social inequalities, might be better understood through a commercial determinant lens.

10. Resource allocation and health financing

Access to sexual and reproductive health commodities in East and Southern Africa: a cross-country comparison of availability, affordability and stock-outs in Kenya, Tanzania, Uganda and Zambia
Ooms G; Kibira D; Reed T; van den Ham H; et al: BMC Public Health 20(1053) doi: https://doi.org/10.1186/s12889-020-09155-w, 2020

Price, availability and stock-out data was collected in July 2019 for over fifty lowest-priced sexual and reproductive health (SRH) commodities from public, private and private not-for-profit health facilities in Kenya, Tanzania, Uganda and Zambia. Affordability was calculated using the wage of a lowest-paid government worker. Accessibility was illustrated by combining the availability and affordability measures. Overall availability of SRHC was low at less than 50% in all sectors, areas and countries, with highest mean availability found in Kenyan public facilities. Stock-outs were common; the average number of stock-out days per month ranged from 3 days in Kenya’s private and private not-for-profit sectors, to 12 days in Zambia’s public sector. In the public sectors of Kenya, Uganda and Zambia, as well as in Zambia’s private not-for-profit sector, all were free for the patient. In the other sectors unaffordability ranged from 2 to 9 SRH commodities being unaffordable. Accessibility was low across the countries, with Kenya’s and Zambia’s public sectors having six SRH commodities that met the accessibility threshold, while the private sector of Uganda had only one meeting the threshold. Accessibility of SRH commodities remains a challenge. Low availability in the public sector is compounded by regular stock-outs, forcing patients to seek care in other sectors where there are availability and affordability challenges. The authors propose that the findings be used by national governments to identify the gaps and shortcomings in their supply chains.

Challenges and Opportunities in China’s Health Aid to Africa: Findings from Qualitative Interviews in Tanzania and Malawi
Daly G; Kaufman J; Lin S; Gao L; et al: Globalization and Health 16(71) doi: https://doi.org/10.1186/s12992-020-00577-0, 2020

Perceptions regarding Chinese-supported health related activities in Africa were gathered through in-depth interviews among local African and Chinese participants in Malawi and Tanzania. The findings revealed shared experiences and views related to challenges in communication; cultural perspectives and historical context; divergence between political and business agendas; organization of aid implementation; management and leadership; and sustainability. Participants were broadly supportive and highly valued Chinese health aid. However, they also shared common insights that relate to challenging coordination between China and recipient countries; impediments to communication between health teams; and limited understanding of priorities and expectations. Further, they share perspectives about the need for shaping the assistance based on needs assessments as well as the importance of rigorous reporting, and monitoring and evaluation systems. The authors’ findings suggested that China faces similar challenges to those experienced by other longstanding development aid and global health funders.

Community Statement on Covid-19 Realities, and Demands for a More Adequate and People-centred Response - Chiawelo Budgeting for Change
Chiawelo Budgeting for Change (CBC) group: Studies in Poverty and Inequality Institute, South Africa, 2020

“In Chiawelo, we are united as a community; people are kind, loving and supportive but most of all it's a place full of diversity- it allows us to learn different cultures, languages and teaches us to respect different people”. These are the words of eighteen-year-old Sanele Nkosi, the youngest member of the Chiawelo Budgeting for Change (CBC) Group, based in Soweto, Johannesburg. The group is a reflection of Sanele’s words, including many different people from many different walks of life: traditional Healers, local community members, clinic workers, community health workers, ward based outreach teams, clinic committee members and local government officials amongst others. In this Community Statement, the group highlight with evidence the health realities and resource gaps faced around the COVID-19 pandemic, including lack of access to social protection, food security, sanitation and adequate health care, gender-based violence, unsafe transport and reopening of educational institutions, youth unemployment, lack of support to the small business sector, for those in chronic unemployment and for community-led COVID-19 responses and safety initiatives and poor working conditions for Community Health Workers. They call for resources for a people- centred response to the COVID-19 pandemic and access to the rights people are entitled to.

What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments
Kwesiga B; Aliti T; Nabukhonzo P; Najuko S; et al: BMC Health Services Research 20(741) doi: https://doi.org/10.1186/s12913-020-05500-, 2020

This study of progress in financial risk protection in Uganda used data from the Uganda National Household Surveys for 2005/06, 2009/10, 2012/13 and 2016/17, measuring financial risk protection in terms of catastrophic health care payments and impoverishment. Although catastrophic health payments at the 10% threshold decreased from 22.4% in 2005/06 to 13.8% in 2012/13, they increased to 14.2% in 2016/17. The percentage of Ugandans pushed below the national poverty line decreased from 5.2% in 2005/06 to 2.7% in 2016/17. The distribution of both catastrophic health payments and impoverishment varied across socio-economic status, location and residence. The authors suggest targeted interventions reduce ‘out-of-pocket’ (OOP) payments among those affected and ensure that public health services are funded adequately, through forms of mandatory prepayment.

11. Equity and HIV/AIDS

COVID-19 Pandemic Disrupts HIV Continuum of Care and Prevention: Implications for Research and Practice Concerning Community-Based Organizations and Frontline Providers
Pinto R; Park S: AIDS and Behaviour 24(286-2489) doi: https://doi.org/10.1007/s10461-020-02893-3, 2020

More quickly than they could have anticipated, people living with (PLWH) and those at-risk for HIV felt the impact of the COVID-19 pandemic, as they were asked to shelter in place and distance themselves from others. In March and April 2020, community-based organizations (CBOs) closed, medical offices cut hours, and medical personnel shifted from primary care to COVID-19 hospital units, affecting the HIV Continuum of Care and Prevention—that is, testing, pre-exposure prophylaxis (PrEP), and primary care. The authors call for further research, review and monitoring to provide evidence on referral practices and links that could help clients access the HIV services to which they are referred (“referral completion”).

Sociodemographic Predictors of HIV Infection among Pregnant Women in Botswana: Cross-Sectional Study at 7 Health Facilities
Hamda S; Tshikuka J; Joel D: Journal of the International Association of Providers of AIDS Care (19) doi: https://doi.org/10.1177/2325958220925659, 2020

The authors determined the prevalence and sociodemographic predictors of HIV among pregnant women in Botswana through a cross-sectional study of 407 randomly enrolled women aged 18 to 49 years, attending 7 health facilities between November 2017 and March 2018. The HIV prevalence was 17%. Women aged 35 to 49 years had higher HIV prevalence than those 18 to 24 years. Illiterate and elementary school educated women had higher HIV prevalence than those with a tertiary education. Those with a history of alcohol intake had a higher HIV prevalence than those without. While HIV prevalence was lower than it was in 2011 the authors call for targeted interventions that integrate these identified dimensions of susceptibility.

12. Governance and participation in health

Parent-child communication about sexual issues in Zambia: a cross sectional study of adolescent girls and their parents
Isaksen K; Musonda P; Sandøy I: BMC Public Health 20(1120), doi: https://doi.org/10.1186/s12889-020-09218-y, 2020

This study from Zambia in 2018 examines the sociodemographic and psychosocial factors that are associated with whether parents communicate with their daughters about sexual issues, through structured, face to face interviews with 4343 adolescent girls and 3878 parents. Adolescent girls who felt connected to their parents and those who perceived their parents to be comfortable in communicating about sex were more likely to speak to their parents about sexual issues than those who did not. Girls whose parents used fear-based communication about sexual issues, and those who perceived their parents as being opposed to education about contraception, were less likely to do so. Girls enrolled in school were less likely to communicate with their parents about sex than those out of school. The authors suggest that parents can improve the chances of communicating with their children about sex by conveying non-judgmental attitudes, using open communication styles and neutral messages.

Watch the GAP! A critical civil society perspective on the development, potential impact and implementation of the ‘Global Action Plan for Healthy Lives and Well-Being for All’
Koutsoumpa M; Nsibirwa; Schwarz T; et al: Kampala Initiative, July 2020

The authors review how the global plan fits with national health policies and ownership in Uganda, and global health governance. They report that despite a ‘whole-of-society’ approach, the decision-making power in the global plan remains with governments. Community and civil society participation are highlighted throughout the GAP and comprise one of its seven core themes. However, despite the announcement of the GAP plan in October 2018, it was not until June 2019 that a public consultation process started, seeking feedback from non-state and state actors to some chapters of the GAP. At the same time, the authors raise concern that a ‘whole-of-society’ approach opens the door for the private-for-profit corporate sector to engage in health, further encouraging a move to a privatised, undemocratic and inequitable global health governance. Without explicit and concrete frameworks for monitoring, mutual accountability and clear and effective participation to address ever-growing power imbalances, they question whether the goal of accelerating achievement of health for all by 2030 can be met, and suggest that the COVID-19 pandemic could be a first test case for the GAP.

We all have the same right to have health services: a case study of Namati’s legal empowerment program in Mozambique
Schaaf M; Falcao J; Feinglass E; Kitchell E; et all: BMC Public Health 20(1084) doi: https://doi.org/10.1186/s12889-020-09190-7, 2020

This paper is a case study of legal empowerment through community paralegals and Village Health Committees in Mozambique. The authors explored how community paralegals solved cases, the impact they had on health services, and how their work affected the relationship between the community and the health sector at the local level. Case resolution conferred a sense of empowerment to clients, brought immediate, concrete improvements in health service quality at the health facilities concerned and seemingly instigated a virtuous circle of rights-claiming. The program also engendered improvements in relations between clients and the health system. The authors identified three key mechanisms underlying case resolution, including: bolstered administrative capacity within the health sector, reduced transaction and political costs for health providers, and provider fear of administrative sanction.

13. Monitoring equity and research policy

Evidence for decisions in the time of COVID-19: Eyes on Africa
Jessani N; Langer L; van Rooyen C; Stewart R: The Thinker, Vol 84, 2020

In this article the authors argue that many African governments have so far responded more proactively and effectively to Covid-19 than some governments in high income countries (HICs). Much of this capacity to respond effectively can be explained by an existing culture of using evidence to inform policy decision-making. African researchers are producing evidence on how to protect and prioritise already existing health interventions which can increase health system resilience and preparedness for Covid-19. The authors argue that African nations have generated and used evidence for decision- making on solutions to tackle the pandemic. Data-poverty and technology deficits are a challenge. The authors note that partnerships to assist with production, collation, and use of evidence are appearing nationally, regionally, and globally to support quick but measured evidence-informed decisions.

14. Useful Resources

Coronavirus: Ten African innovations to help tackle Covid-19
BBC, August 2020

As Africa passes more than a million confirmed Covid-19 cases, innovators on the continent have responded to the challenges of the pandemic with a wide range of creative inventions. These innovations include the ‘Doctor Car’ designed by students from the Dakar Polytechnic School. This multifunctional robot is designed to lower the risk of Covid-19 contamination from patients to caregivers. The device is equipped with cameras and is remotely controlled via an app. The designers say it can move around the rooms of quarantined patients to take their temperatures and deliver drugs and food. Nine-year-old Kenyan schoolboy Stephen Wamukota invented a wooden hand-washing machine to help curb the spread of coronavirus. The machine allows users to tip a bucket of water to wash their hands by using a foot pedal. This helps users avoid touching surfaces to reduce the risk of infection. Other innovations include portable ventilators designed in Nigeria, 3d printed masks in South Africa, solar powered hand sinks from Ghana, and online platforms for x-rays from Tunisia.

The COVID-19 Action Fund for Africa
Fund oversight committee, 2020

The COVID-19 Action Fund for Africa is an action-oriented collaborative of over 30 organizations dedicated to protecting Community Health Workers (CHWs) on the frontlines of Africa’s COVID-19 response. The Fund’s goal is to raise up to $100 million to supply personal protective equipment (PPE) to CHWs in as many as 24 African countries for approximately one year; shipments have already begun. The Fund matches donated PPE with government-identified gaps and conducts end-use verification processes with in-country partners to document arrival and distribution of the supplies. Integrated with national responses, this is the only known effort that pools resources for PPE items specifically for community health workers in Africa

15. Jobs and Announcements

Postgraduate diploma and Masters in public health, School of Public Health at the University of the Western Cape, South Africa
Applications close 30 September 2020

The School of Public Health at the University of the Western Cape, South Africa, equips graduates with the knowledge and skills to contribute to transforming the health and social development sectors in developing countries and improving the health status of populations. Students can study while they work, and gain credits incrementally towards a Master of Public Health (MPH) or Postgraduate Diploma (PGD) in Public Health. These flexible, modular programmes use e-learning as its key learning and teaching medium, with optional contact sessions in Cape Town in February/March and June/July every year. Entry requirement is a three year Bachelor’s degree or equivalent in any relevant discipline; and a minimum of one year work experience in the health or social development sectors.

Reimagining the Global Symposium on Health Systems Research
HSR 2020: Sixth Global Symposium on Health Systems Research, November 2020

This year the Global symposium on health systems research will take place over a three-phase virtual symposium. During the original dates scheduled for the event in Dubai – 8th to 12th November – there will be a shorter and smaller version of the usual symposium, with skills building sessions, and special panels, and three half days (10th to 12th) of plenary, a parallel sessions, and virtual networking. The second phase will feature two rounds of parallel sessions every two weeks from the end of November through to March 2021. This will enable more opportunities to more speakers than otherwise would have been possible. The second phase will be organised according to the HSR2020 sub-themes and some of these series will be hosted by Thematic Working Groups. The organisers aim for the third phase in March 2021 to take place face-to-face in Dubai, that will seek to synthesize the main learnings coming from HSR2020 and consider how they can best be applied to health systems. This will likely be a smaller invitation-only event and will have a strong focus on engaging with policy and decision-makers who can translate evidence into action.

The South African Health Review (SAHR) 2021 Call for Abstracts
Deadline for Abstracts: 31 October 2030

The editors of the 2021 edition of the South African Health Review (SAHR) invite the submission of abstracts that examine health-sector responses to the COVID-19 pandemic. Preference will be given to abstracts on topics that consider: the impact of COVID-19 on existing health services and programmes; the impact of socio-economic disparities on prevention and treatment; the rationing of healthcare services and implications for equity of access; strengthening of the country’s social compact, and emergence of innovative collaborations and partnerships; impact of measures taken to balance saving lives with saving livelihoods; and/or emerging lessons for the future management and prevention of pandemics and other public health emergencies.


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