EQUINET NEWSLETTER 226 : 01 December 2020

1. Editorial

Putting the public back into public health: communities organising solidarity responses to COVID-19
Eleanor Whyle, University of Cape Town, Manya van Ryneveld, University of the Western Cape, Leanne Brady, University of Cape Town, Rene Loewenson, TARSC

The COVID-19 pandemic and its socioeconomic consequences have affected all Eastern and Southern African (ESA) countries. The long-term impacts still remain to be seen. While COVID-19 affects everyone, it does not affect everyone equally. It has entrenched and exacerbated the extreme inequalities and injustices that existed before the pandemic.

The collective insecurity generated by the pandemic requires a decisive public health response. This response has, however, tended to apply centralised, top-down and undemocratic decision-making, often using ‘war’ narratives that prompt or reinforce fear, and that promote individual self-protection. Reactive interventions have not adequately taken local conditions and rights into account, prevented longer-term harms to health, including from gender violence, nor protected income, food security or social trust.

However, the pandemic also offers an important opportunity to demonstrate that alternative, people-centred, democratic and collective responses are possible. Indeed they are essential, not just to prevent and contain infection and mitigate the impact of the pandemic, but also to ‘build back’ using a stronger, more compassionate and equity-driven form of public health.

In October, EQUINET published 42 case studies of community action on COVID-19 that collectively demonstrate examples of this (see https://tinyurl.com/yxrekzre). The case studies come from different settings, income levels and dimensions of the response. They show innovative and solidarity-based approaches to prevent and care for COVID-19, to address social needs and hold states accountable. They provide a powerful argument for public participation and collective action in health.

One of the case studies, the Cape Town Together Community Action Network (CAN), tells the story of a self-organising network that emerged in March 2020 in South Africa as a community-led response to COVID-19.

In early March, it was clear from other countries that formal responses would struggle to keep up with the pace of the virus. As a network of autonomous, neighbourhood-level groups working together to respond to local challenges as and when they emerge, Cape Town Together felt that bottom-up community organising could spread faster than the virus and could rapidly identify and respond to its emerging health, social and economic impacts.

The Community Action Networks (CANs) actively work against a tendency to centralise planning, decision-making and management. They reject hierarchies of knowledge, resources and power. Each neighbourhood CAN operates independently and autonomously, while drawing on the collective energy and wisdom of the network as a whole. The hyper-local nature of the CANs allows for street-level organising, reminiscent of anti-apartheid activism. Generosity, trust and solidarity are important foundational principles. The CANs prioritise relationships over bureaucracy. They are enabled by inter-personal connections built during lockdown conditions largely through online co-learning, WhatsApp groups and Zoom meetings.

At the peak of the pandemic this decentralised, self-governing structure provided vital support where formal social safety nets failed, including public health guidance, mask-making clubs, community gardens, community care centres for COVID-positive people who could not safely self-isolate at home, and food and medicine deliveries to elderly people.

A few weeks after South Africa initiated its hard lockdown, 47% of households were suffering from extreme food insecurity. Across Cape Town, CANs distributed food parcels and established community kitchens. With rapid communication across the network, CANs shared experience and resources, learned from each other and worked with public health services to follow COVID-19 safety protocols in the community kitchens. Beyond the hot meals provided, the community kitchens became safe, organic spaces, enabling protective behaviours and information sharing. They responded to local social needs in a way that was inclusive, welcoming and free of stigma and shame.

The CANs generated community-level intelligence. In their inclusion of community members, researchers and local public servants, they enabled informal communication. They built trust between communities and health system actors, through dialogue and co-learning forums between CANs and health sector decision-makers. They made input into educational materials developed by the health department. With the lived local realities of those most affected by the pandemic often very different to that of health department officials, these connections proved invaluable in framing appropriate measures.

The CANs aim to support and not substitute state efforts, and this was initially possible. However, the shortcomings within state efforts became a subject of an increasingly politicised debate. For example, some CANs and local civil society organisations formed a coalition that protested the unlawful eviction of residents in informal settlements. Political actors reacted by asserting that the CANs were acting unlawfully and presented a political threat. When another CAN renovated a badly vandalised and unused public community hall, the local ward councillor accused them of unlawfully occupying the space.

Such tensions may be inevitable where community initiatives highlight deficits in state responses and provide different approaches. Bottom-up initiatives such as the CANs call for and contribute to alternative forms of governance that celebrate, enable and invest in community-led public health responses.

The case studies in the EQUINET report show that community-engaged and -led responses and relationships are more likely when they build on prior histories of social networking and organisation around social justice. The relationships, the citizen scientist and activist leadership, the connections with public, professional and civil society organisations and prior activities on different dimensions of wellbeing enabled a relatively rapid, collectively-organised range of health responses to the pandemic. Information technology was used to organise collective understanding and action. The case studies also show the importance of investing in comprehensive primary health care systems for an effective and equitable response to pandemics. If we continue to frame our health systems only in terms of efficiency-led measures to treat particular diseases and top-down responses to emergencies, we weaken the ability mobilise the relationships, capacities and creativity within communities, networks and service personnel, or the multi-sectoral responses needed to prevent and address the many health challenges we face from such crises.

We hear many negative stories about COVID-19. Yet these compassionate stories of equity, rights-driven and holistic responses also need to be documented and told. They show a solidarity-driven response to COVID-19, and that people are subjects not objects in health.

Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the CANs please visit the https://capetowntogether.net/ and https://www.facebook.com/groups/CapeTownTogether

Reclaiming Comprehensive Public Health: A Call to Action

A growing group of public health, social justice and human rights advocates, including a number from EQUINET, have released a Call to Action to heads of state and government at the 3-4 December UN General Assembly Special Session on COVID-19 to promote comprehensive, equity-focused and participatory public health approaches in countering the pandemic, drawing on and using diverse sources of knowledge, disciplines and capabilities.

The Call builds on a recent commentary by on Reclaiming Comprehensive Public Health in BMJ Global Health (the link is included in a later section in this newsletter) and contributions by a group of people working in public health from different regions globally, including a number from east and southern Africa. Over 250 individuals and leading organisations and networks have signed the Call so far and signatories are still invited. The full Call is at https://bit.ly/RCPHcall together with a link to sign on and other resources.

2. Latest Equinet Updates

'We are subjects, not objects in health’: Communities taking action on COVID-19
Loewenson R; Colvin C; Rome N; Nolan E; et al: Training and Research Support Centre in the Regional Network for Equity in Health in East and Southern Africa (EQUINET) and Shaping Health, September 2020

This document provides evidence of practical and affirmative options of people-centred, participatory forms of community organising and engagement in diverse areas of prevention, care and wider social protection in responding to COVID-19. The 42 case studies from different regions intend to inspire, inform and support. They report the creative development and use of social media platforms for action across all areas of response, connecting people within and across communities and countries, giving voice and visibility to community experiences and linking people to key resources and services. They demonstrate that a compassionate society enhances public health. Many build on histories, ideologies, structures, organisation and relationships that began long before the pandemic, enabling a relatively rapid response to new challenges posed by COVID-19 and with an intention to sustain relevant innovations after the pandemic. They reach to socio-economically disadvantaged groups within communities, strengthening collective organisation, investing in capacities and leadership and making links with more powerful groups to address local priorities and negotiate delivery on state obligations. They build new relationships between communities and producers and between communities and health workers, and solidarity interactions with international agencies and diaspora communities. The challenges presented by the pandemic are creating demand and space for innovation, and in many settings communities are rising to that demand. The mobilization of affirmative community effort and creativity needs to be recognised in the story of the 2020 pandemic.

Using evidence and analysis for an adaptive health system response to COVID-19 in Uganda in 2020
Kadowa I: EQUINET Case study paper, Ministry of Health Uganda, TARSC: EQUINET: Harare, 2020

Uganda reported its first confirmed case of COVID-19 on 21 March 2020. The country has since implemented a series of public health measures to limit the spread of the virus. The pandemic has progressed from imported cases through sporadic community cases to stage four, with widespread community transmission. This paper documents how evidence and analysis were used to support decision-making for an adaptive health system response to COVID-19 in Uganda in 2020. A desk review was thus implemented using published and grey literature covering the period from February to October 2020 to document the nature and organisation of different data and related evidence used to support projections, planning and decision-making on the surveillance, prevention, care and health system response to COVID-19. The desk review also looked at how evidence was used and communicated across different actors to support adaptive responses. While there have been challenges, Uganda’s response to COVID-19is reported to have been dynamic, responding to different sources of evidence, and through different institutional channels and actions, with the latter generating evidence and experience that feeds back to the response.

3. Equity in Health

An overview of reviews on strategies to reduce health inequalities
Garzón-Orjuela N; Samacá-Samacá D; Angulo S; et al: International Journal for Equity in Health 19(192), doi: https://doi.org/10.1186/s12939-020-01299-w, 2020

Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions. This study identified strategies that facilitate the reduction of health inequalities. A systematic search strategy identified 4095 articles, of which 97 were included in the synthesis. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes. The authors note that the strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors with the health system.

4. Values, Policies and Rights

Announcement on the Maternal Health Judgement, Uganda
Centre for Human Rights and Development: Youtube, Uganda, 2020

After a long nine years of waiting, the Centre for Human Rights and Development (CEHURD) finally received the judgment in the famous Petition 16 maternal health case on 19th August, 2020. The Constitutional Court agreed with CEHURD submissions and all judges accepted all the grounds of the petition. Through this judgment, the right to maternal health care (and the right to health broadly) has been granted a place in Uganda’s Constitution. This judgment recognizes provision of basic maternal health care services and emergency obstetric care as an obligation by the government. It’s through unremitting advocacy, litigation and activism that CEHURD achieved this landmark decision. It took a whole movement/coalition on maternal health to realize what a few thought would be possible. CEHURD now turn their efforts to the implementation. Investing in maternal health is a political and social imperative, as well as a cost effective investment in strong health systems overall. The #Petition16 judgment entails some very powerful declarations and orders on health financing. This case creates positive jurisprudence and makes it possible for people to sustain a cause of action in the right to health against the state for failing to provide the basic minimum health care package.

Engaging with faith groups to prevent violence against women in conflict-affected communities: results from two community surveys in the DRC
Le Roux E; Corboz J; Scott N; Sandilands M; et al: BMC International Health and Human Rights 20(27), 1-20, doi: https://doi.org/10.1186/s12914-020-00246-8, 2020

This paper addresses interventions to address intimate partner violence (IPV) against women and girls by engaging with faith communities and their leaders. Two community surveys were conducted, one before and one after the intervention, in three health areas in Ituri Province in the Democratic Republic of Congo. Questionnaires were interviewer-administered, with sensitive questions related to experience or perpetration of violence self-completed by participants. The study showed significantly more equitable gender attitudes and less tolerance for IPV after the interventions. Positive attitude change was not limited to those actively engaged within faith communities, with a positive shift across the entire community in terms of gender attitudes, rape myths and rape stigma scores, regardless of level of faith engagement. There was a significant decline in all aspects of IPV in the communities who experienced the intervention. This intervention was premised on the assumption that faith leaders and faith communities are a key entry point to influence an entire community. The research affirmed this assumption.

Examining determinants of gender attitudes: evidence among Tanzanian adolescents
Palermo T: Chzhen Y: Balvin N; Kajula L; et al: BMC Women's Health 20(195), doi: https://doi.org/10.1186/s12905-020-01057-8, 2020

This study examines determinants of gender attitudes among some of the poorest and most vulnerable adolescents in Tanzania using an ecological model. Data come from baseline interviews with 2458 males and females aged 14–19 years conducted within a larger impact evaluation. Secondary school attendance was associated with more equitable gender attitudes. Females had less equitable gender attitudes than males in the sample. Having had sexual intercourse was associated with more gender equitable attitudes among females, but the reverse was true among males. Addressing gender inequity requires understanding gender socialisation at the level of social interactions. The finding that females had more inequitable gender attitudes than males in the study is argued by the authors to suggest that more emphasis be given to highlighting the rights of women with female adolescents.

Legal and institutional foundations for universal health coverage, Kenya
Mbindyo R; Kioko J; Siyoi F; et al: Bulletin of the World Health Organisation 98, 706–718, doi: http://dx.doi.org/10.2471/BLT.19.237297, 2020

To gain a picture of the extent of the health reforms over the first 10 years of the Kenyan constitution, the authors developed an adapted health-system framework, guided by World Health Organization concepts and definitions. The analysis revealed multiple structures (laws and implementing public bodies) formed across the health system, with many new stewardship structures aligned to devolution, but with fragmentation within the regulation sub-function. By deconstructing normative health-system functions, the framework enabled an all-inclusive mapping of various health-system attributes (functions, laws and implementing bodies). The authors believe their framework is a useful tool for countries who wish to develop and implement a conducive legal foundation for universal health coverage. Constitutional reform is argued to be a mobilizing force for large leaps in health institutional change, boosting stakeholder acceptance and authority to proceed.

Reclaiming comprehensive public health
Loewenson R; Accoe K; Bajpai N: Buse K: et al: BMJ Global Health 5(9) 1-5, doi: http://dx.doi.org/10.1136/bmjgh-2020-003886, 2020

Global and national responses to the COVID-19 pandemic highlight a long-standing tension between biosecurity-focused, authoritarian and sometimes militarised approaches to public health and, in contrast, comprehensive, social determinants, participatory and rights-based approaches. Notwithstanding principles that may limit rights in the interests of public health and the role of central measures in some circumstances, effective public health in a protracted pandemic like COVID-19 requires cooperation, communication, participatory decision-making and action that safeguards the Siracusa principles, respect for people’s dignity and local-level realities and capacities. Yet there is mounting evidence of a dominant response to COVID-19 where decisions are being made and enforced in an overcentralised, non-transparent, top-down manner, often involving military coercion and abuse in communities, even while evidence shows the long-term harm to public health and human rights. In contrast, experiences of comprehensive, equity-focused, participatory public health approaches, which use diverse sources of knowledge, disciplines and capabilities, show the type of public health approach that will be more effective to meet the 21st century challenges of pandemics, climate, food and energy crises, growing social inequality, conflict and other threats to health.

5. Health equity in economic and trade policies

Developed countries continue to block TRIPS waiver proposal
TWN: Info Service on WTO and Trade Issues (Nov20/24), November 2020

Following the waiver proposal to suspend various provisions of the WTO’s TRIPS Agreement in combating the COVID-19 pandemic, the United States, the European Union, Japan, and Switzerland among others are reported to have adopted “stonewalling” tactics to block progress towards a General Council decision on this issue. These countries have described the waiver as a departure from the past WTO agreements, lacking specific measures, arguing also that not protecting intellectual property (IP) will reduce investment in medical technology. In response South Africa commented that current “bilateral deals do not demonstrate global collaboration but rather reinforce nationalism, enlarging chasms of inequality.” India said that while “the TRIPS flexibilities do allow limited policy space for public health, they were never designed to address a health crisis of this magnitude (such as the COVID-19 pandemic).” The waiver proposal has come into a global stage where it is increasingly clear that the developing and least-developed countries are unlikely to get easy and affordable access for the new therapeutics and vaccines for COVID-19, calling for human lives to take precedence over the profits of the big pharmaceutical companies.

Feral Atlas: The More-Than-Human Anthropocene
Tsing A; Deger J; Saxena A; Zhou F: Stanford University, doi: 10.21627/2020fa, 2020

Feral Atlas invites you to explore the ecological worlds created when nonhuman entities become tangled up with human infrastructure projects. Seventy-nine field reports from scientists, humanists, and artists show you how to recognize “feral” ecologies, that is, ecologies that have been encouraged by human-built infrastructures, but which have developed and spread beyond human control. These infrastructural effects, Feral Atlas argues, are the Anthropocene. Playful, political, and insistently attuned to more-than-human histories, Feral Atlas does more than catalogue sites of imperial and industrial ruin. Stretching conventional notions of maps and mapping, it draws on the relational potential of the digital to offer new ways of analysing—and apprehending—the Anthropocene; while acknowledging danger, it demonstrates how in situ observation and transdisciplinary collaboration can cultivate vital forms of recognition and response to the urgent environmental challenges of our times.

Letter supporting proposal by India and South Africa on waiver from certain provisions of the TRIPS agreement for the prevention, containment and treatment of COVID-19
Civil society signatories: 2020

This open letter calls on WTO Members to strongly support the adoption of the text proposed by India and South Africa in their proposal for “Waiver from certain provisions of the TRIPS Agreement for the prevention, containment and treatment of COVID19” (Waiver Proposal), recognising the consensus that curbing the spread of COVID-19 demands international collaboration to speed and scale up development, manufacturing, and supply of effective medical technologies, with calls including from several Heads of State for medical products for COVID-19 to be treated as global public goods. Seven months into the pandemic, there is no meaningful global policy solution to ensure access, inequality in access to critical technologies, rejection by the pharmaceutical industry of the COVID-19 Technology Access Pool (C-TAP) launched by WHO to voluntarily share knowledge, IP and data, has been rejected by the pharmaceutical industry and intellectual property infringement disputes. While the TRIPS Agreement contains flexibilities that can promote access, many WTO Members may face challenges in using them promptly and effectively. The signatories argue that unless concrete steps are taken at the global level to address intellectual property and technology barriers, the above mentioned failures and shortcomings will replay as new medicines, vaccines and other medical products are rolled out.

Over 80 per cent of IMF Covid-19 loans will push austerity on poor countries
Oxfam: Oxfam UK, United Kingdom, 2020

Over 80% of the International Monetary Fund’s (IMF) Covid-19 loans recommend that poor countries hit hard by the economic fallout from the COVID-19 pandemic adopt tough new austerity measures in the aftermath of the health crisis. Since the pandemic was declared in March, 76 out of 91 IMF loans – 84% – negotiated with 81 countries push for belt-tightening that could result in deep cuts to public healthcare systems and social protection. Government failure to tackle inequality ―through support for public services, workers’ rights and a fair tax system― left them woefully ill-equipped to tackle the Covid-19 pandemic. The authors argue that the IMF has contributed to these failures by consistently pushing a policy agenda that seeks to balance national budgets through cuts to public services, increases in taxes paid by the poorest, and moves to undermine labour rights and protections. As a result, when Covid-19 hit, only one in three countries, covering less than a third of the global workforce, had safety nets for workers to fall back on if they lost their job or became sick. The analysis also found that just 8 out of 71 World Bank health emergency response projects approved between April and end of June this year aim to eliminate healthcare fees, which are prohibitive in at least 56 of these countries.

Recovering Better from COVID-19 Will Need a Rethink of Multilateralism
Kozul-Wright R: Development (2020) 1-5, doi: https://doi.org/10.1057/s41301-020-00264-y, 2020

The world economy is experiencing a deep recession amid a still unchecked pandemic. The author argues that the commitment to recovering better will not materialize if, as happened after the global financial crisis, high income countries resort to a policy mix of austerity, liberalization and quantitative easing. Such an approach will only worsen a whole set of pre-existing conditions and in particular, high inequality, excessive debt (both public and private and weak investment—that will lead to a lost decade, particularly for low income countries. What is proposed to be needed instead is an expansionary plan for global recovery, that can return even the most vulnerable countries to a stronger position than before the crisis. This paper sets out some of the key elements of such a plan and argues that its implementation will require systematic reforms to the multilateral trade and financial system if a more resilient recovery is to turn into a sustainable and inclusive future.

Thandika Mkandawire: A ‘young’ African economist’s appreciation
Chelwa G: Journal of African Studies, doi: 10.1080/00020184.2020.1836913, 2020

At the invitation of African Studies, Grieve Chelwa reflects on Thandika Mkwandawire’s life and work and impact on the social and economic sciences in Africa. Mkwandawire’s career spanned over four decades with a long and diverse list of publications. Chelwa refers to five specific publications that have helped to make sense of Africa’s place and the place of African economists in the seemingly never-ending debates about the continent’s prospects for economic development. Chelwa calls these his favourite things, ‘because Thandika was African development scholarship’s saxophonist.’

What Does the Seventy-third World Health Assembly Mean For Socio-economic Survival of Countries, Food Security, and International Cooperation in the COVID-19 Pandemic
Ssemakula M: People’s Health Movement (PHM) and Human Rights Research Documentation Centre (HURIC) –UGANDA, 2020

COVID-19 has underpinned unprecedented economic instability and global food supply disruptions in Africa. This has put global cooperation (aid, partnerships and concession finance) on test after the economic downturn in the world economy performance. This article provides a discourse on damaging interruptions caused by the pandemic on socio- economic survival of countries and food security, and how that relates to the gaps in interventions in IHR core principles reported by WHO member states and UN agencies at seventy-third World Health Assembly, which PHM closely followed through its WHO Watch programme.

6. Poverty and health

Hostile Environment(s) – Designing Hostility, Building Refugia
Pezzani L: ar/ge kunst, Bolzano, unibz – Faculty of Design and Art in collaboration with Z33 – House of Contemporary Art, Design & Architecture, Hasselt, 2020

Hostile Environment(s) – Designing Hostility, Building Refugia is an expanded programme investigating the political ecology of migration and border violence. Through a series of lectures, workshops, screenings, commissioned texts and other materials delivered both online and in-person it provides an index and archive of materials that are regularly be updated with new content. The term “hostile environment” draws from legislation in UK, denying migrants from Africa and other countries deemed to be illegal access to work, housing, services and education. Far from being an exceptional condition, however, this process of making (urban) space unlivable for some resonates with the ways in which certain “natural” terrains (oceans, deserts, mountains) have been structured to deter and expel migrants. These materials seeks to capture these interconnected processes, investigating how certain forms of racialized violence have become as pervasive as the climate.

Prevalence and patterns of gender-based violence across adolescent girls and young women in Mombasa, Kenya
Bhattacharjee P; Ma H; Musyoki H; Cheuk E; et al: BMC Women's Health 20(229), 1-11, doi: https://doi.org/10.1186/s12905-020-01081-8, 2020

This study sought to estimate the prevalence of gender-based violence (GBV) in adolescent girls and young women (AGYW) through a cross-sectional survey in Mombasa, Kenya in 2015. The main perpetrators of violence were intimate partners for young women engaged in casual sex, and both intimate partners and regular non-client partners for young women engaged in transactional sex. For young women engaged in sex work, first-time and regular paying clients were the main perpetrators of physical and sexual violence. Alcohol use, ever being pregnant and regular source of income were associated with physical and sexual violence though it differed by subgroup and type of violence. AGYW in these settings experience high vulnerability to physical, sexual and police violence. However, they are not a homogeneous group, and the variation in prevalence and predictors of violence needs to be understood to design effective programmes to address violence.

7. Equitable health services

Communities, universal health coverage and primary health care
Sacks E; Schleiff, M; Were M; Ahmed Mushtaque Chowdhuryc A; et al: Bulletin of the World Health Organisation 98, 773–780, doi: http://dx.doi.org/10.2471/BLT.20.252445, 2020

With much of the world’s population still lacking access to basic health services, evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care (PHC). Policies and actions to improve PHC must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Metrics used for evaluating PHC and Universal health coverage largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand PHC.

Maternal and newborn care during the COVID-19 pandemic in Kenya: re-contextualising the community midwifery model
Kimani R; Maina R; Shumba C; Shaibu S: Human Resources for Health 18(75), 1-5, doi: https://doi.org/10.1186/s12960-020-00518-3, 2020

Peripartum deaths remain significantly high in low- and middle-income countries, including Kenya. The authors outline how the COVID-19 pandemic has disrupted essential services, which could lead to an increase in maternal and neonatal mortality and morbidity. The lockdowns, curfews, and increased risk for contracting COVID-19 may affect how women access health facilities. They argue for a community-centred response, not just hospital-based interventions. In this prolonged health crisis, pregnant women deserve a safe and humanised birth that prioritises the physical and emotional safety of the mother and the baby. The authors propose strengthening community-based midwifery to avoid unnecessary movements, decrease the burden on hospitals, and minimise the risk of COVID-19 infection among women and their newborns.

Measures to strengthen primary health-care systems in low- and middle-income countries
Etienne V Langlois E; Andrew McKenzie A; et al.: Bulletin World Health Organisation 98, 781–791, doi: http://dx.doi.org/10.2471/BLT.20.252742, 2020

In this paper, the primary health-care (PHC) systems in 20 low- and middle-income countries were analysed using a semi-grounded approach. Options for strengthening PHC were identified by thematic content analysis. The authors found that despite the growing burden of non-communicable disease, many low- and middle-income countries lacked funds for preventive services; community health workers were often under-resourced, poorly supported and lacked training; out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in PHC was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of PHC. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. The authors argue for policy-making to be supported by adequate resources for PHC implementation and that government spending on PHC should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of PHC management is also said to be needed.

What Is COVID-19 Teaching Us About Community Health Systems? A Reflection From a Rapid Community-Led Mutual Aid Response in Cape Town, South Africa’
Van Ryneveld M; Whyle E; Brady L; Int Jo Health Policy and Management x(x), 1-4, doi: 10.34172/ijhpm.2020.167, 2020

COVID-19 has exposed the wide gaps in South Africa’s formal social safety net, with the country’s high levels of inequality, unemployment and poor public infrastructure combining to produce devastating consequences for a vast majority in the country living through lockdown. In Cape Town, a movement of self- organising, neighbourhood-level community action networks (CANs) has contributed significantly to the community- based response to COVID-19 and the ensuing epidemiological and social challenges it has wrought. This article describes and explains the organising principles that inform this community response, with the view to reflect on the possibilities and limits of such movements as they interface with the state and its top-down ways of working, often producing contradictions and complexities. This presents an opportunity for recognising and understanding the power of informal networks and collective action in community health systems in times of unprecedented crisis, and brings into focus the importance of finding ways to engage with the state and its formal health system response that do not jeopardise this potential.

8. Human Resources

How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo
Raven J; Wurie H; Idriss A; Bah A; et al: Human Resources for Health 18(58), 1—14, doi: https://doi.org/10.1186/s12960-020-00494-8, 2020

This paper presents evidence from Sierra Leone, Liberia and Democratic Republic of Congo on how community health workers (CHWs) are .managed, the challenges they face and potential solutions. According to the findings: fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role; with implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs’ scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is argued to be vital to the retention and performance of CHWs, as are predictable supervision, supplies, community recognition and allowances.

“They have been neglected for a long time”: a qualitative study on the role and recognition of rural health motivators in the Shiselweni region, Eswatini
Walker C; Burtscher D; Myeni J et al: Human Resources for Health 18(66) 1-9, doi: https://doi.org/10.1186/s12960-020-00504-9, 2020

This study was implemented to understand the role of rural health motivators (RHMs) in decentralised HIV/TB activities. Participants were purposively selected RHMs, community stakeholders and local and non-government personnel. Significant confusion of the RHM role was observed, with community expectations beyond formally endorsed tasks. Community participants expressed dissatisfaction with receiving health information only, preferring physical assistance in the form of goods. Gender emerged as a significant influencing factor on the acceptability of health messages and RHM engagement with community members. The findings highlight the lack of recognition of RHMs at community and national levels, hindering their capacity to successfully contribute to positive health outcomes for rural communities.

9. Public-Private Mix

All Risk and No Reward: How the Government and Mine Companies Fail to Protect the Right to Health of Miners and Ex-Miners in Botswana
Botswana Labour Migrants Association, Centre for Economic and Social Rights, Northwestern Pritzker School of Law Centre for International Human Rights, Botswana, 2020

All Risk and No Reward presents the findings of a two-year investigation into the right to health of miners and ex-miners in Botswana. It describes in vivid detail a series of critical issues for their health and the health of their communities. The report also considers the Government and mine companies' financial responsibilities to equitably generate, allocate and spend sufficient funds for health. The report is based on extensive desk research, and interviews and focus groups discussions with more than 50 miners, ex-miners, family and community members, doctors and nurses, and government and industry officials in Botswana.

10. Resource allocation and health financing

Assessing the geographical distribution of comorbidity among commercially insured individuals in South Africa
Mannie C; Kharrazi H: BMC Public Health 20(1709), 1-11, doi: https://doi.org/10.1186/s12889-020-09771-6, 2020

This study assessed the geographical distribution of comorbidity and its associated financial implications among commercially insured individuals in South Africa. The authors aggregated individual risk scores to determine the average risk score per district, also known as the comorbidity index, to describe the overall disease burden of each district The authors observed consistently high comorbidity index scores in districts of the Free State and KwaZulu-Natal provinces for all population groups before and after age adjustment. Some areas exhibited almost 30% higher healthcare utilization after age adjustment. Districts in the Northern Cape and Limpopo provinces had the lowest comorbidity index scores with 40% lower than expected healthcare utilization in some areas after age adjustment. The results show underlying disparities in the comorbidity index at national, provincial, and district levels.

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), 1-10 doi: https://doi.org/10.1186/s12992-020-00577-0, 2020

This paper presents a qualitative study of perceptions and opinions regarding Chinese-supported health related activities in Africa 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 investment in health. However, they also shared common insights on challenges in communication between health teams; and limited understanding of priorities and expectations, and the need to improve needs assessments, rigorous reporting, and monitoring and evaluation systems.

Spending, Accountability, and Recovery Measures included in IMF COVID-19 loans
Oxfam, United Kingdom, 2020

To respond to the outbreak of the COVID-19 pandemic, the International Monetary Fund (IMF) has committed $1 trillion and so far provided $89 billion worth of financial assistance to countries around the world. Oxfam has tracked this COVID-19 financing and fiscal measures referenced in each of the 91 packages approved so far using official IMF reports for the respective countries. The tracker covers the amounts of funding IMF committed and disbursed to borrowing countries by region, types of financing instruments the Fund has employed, the borrowing countries’ current debt situation, fiscal policy measures, particularly social spending aimed at addressing the crisis, anti-corruption and transparency measures which countries have committed to undertake, and proposed fiscal measures for the recovery period. The text provided in this tracker is a compilation of select and relevant quotes/excerpts from official IMF reports while the debt data was drawn from the World Bank’s Debtor Reporting System. The tracker has been compiled for the benefit of persons and institutions wanting a snapshot view of what governments are borrowing, what they intend to do with these funds, what the IMF is encouraging countries to take during the pandemic and in the recovery period, and to give citizens and civil society a tool to hold their governments and the IMF accountable.

11. Equity and HIV/AIDS

COVID-19’s impact on HIV treatment less severe than feared
UNAIDS: UNAIDS New York, 2020

Recent data has shown that the COVID-19 pandemic has had an impact on HIV testing services, but the impact on HIV treatment is less than originally feared. As of August 2020, the UNAIDS, World Health Organization and United Nations Children's Fund data collection exercise to identify national, regional and global disruptions of routine HIV services caused by COVID-19 had collected treatment data from 85 countries. Of these, 22 countries reported data over a sufficient number of months to enable the identification of trends. Only five countries reported monthly declines in the number of people on treatment after April—these include Zimbabwe in June, Peru and Guyana in July, the Dominican Republic in April, and Sierra Leone in May through to July. The remaining 18 countries did not show a decline and some countries showed a steady increase (e.g. Kenya, Ukraine, Togo and Tajikistan). However, among the 22 countries with trend data on numbers newly initiating treatment, all countries except Jamaica showed declines for at least one month or more relative to January. Only around eight of those countries showed a rebound in the number of people newly initiating treatment between January and July.

12. Governance and participation in health

Cape Town Together: organizing in a city of islands
Writers’ Community Action Network: ROAR Mag, South Africa, June 2020

An emerging movement of self-organized, decentralized community action networks is responding to the local realities of COVID-19 in Cape Town, South Africa. It reflects an unprecedented city-wide response to COVID-19, based on principles of self-organizing, mutual aid and social solidarity. In early March 2020, just as South Africa was waking up to the spectacle of COVID-19 within its borders, a group of community organizers, activists, public health folk and artists came together and kick-started a community-led response to the pandemic. This became known as Cape Town Together, a growing network of neighbourhood-level Community Action Networks (CANs) spread across the city. The CANs act locally, while also sharing collective wisdom and various resources through the broader network of Cape Town Together. They work collaboratively, recognizing that everyone brings something to the table. Some are weavers and builders, others are storytellers, caregivers or healers. Some are disruptors whilst others are experimenters and guides. The CANs have galvanized a significant number of people from across the city around a shared experience. Many are seeing the inequality exposed by COVID-19 in a new light and will remain galvanized beyond the immediate crisis.

Community engagement: a health promotion guide for universal health coverage in the hands of the people
World Health Organization: WHO, Geneva, 2020

WHO has defined community engagement as “a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes”. The organisation notes undeniable benefits to engaging communities in promoting health and wellbeing. This guide is intended for change agents involved in community work at the level of communities and healthy settings.

In, against, beyond, corona
Butler M, Church Land Programme: Daraja Press, October 2020

The authors raise that the COVID-19 pandemic reveals what is wrong and toxic — in ourselves, in relation with others, and in relation with the rest of non-human nature and ask: 'is it possible to also look for what is good and life-affirming?' The authors argue that the future must be founded on ‘kindness, social solidarity and an appropriate scale of time’, a future that cherishes life and the connections that transcend borders. This pamphlet, part of Daraja Press’s Thinking Freedom Series, distills learnings from the work of activists on the ground in the Church Land programme in KwaZulu-Natal province, South Africa.

None of us are safe, until we are all safe
Valley D; Brady L; Magiligwana A; Mgedle M: Cape Town Together, 2020

This video, accompanying a song by Mzikhona Mgedle from the Langa Community Action Network (CAN), captures the dynamism and energy of Cape Town Together and the Community Action Networks while highlighting the many ways in which COVID-19 has challenged South Africans to demonstrate new and better forms of solidarity. Across the geographic, economic and social barriers that are a consequence of Apartheid history, community-led COVID-response networks are forming partnerships based on trust, inter-personal connection and shared goals. The music video draws footage from a range of CAN projects, including community kitchens, medicine-delivery schemes and food gardens to demonstrate the power of collective action. As the song states, none of us are safe, until we are we are all safe

13. Monitoring equity and research policy

How to talk about COVID-19 in Africa
Nyabola N: The Boston Review, USA, October 2020

To ask why COVID-19 hasn’t been deadlier in Africa is to suggest that more Africans should be dying. We need better questions. Almost every major international news outlet has asked a variation of the question. Some speculate that something structural or physiological has dampened the impact of COVID-19 on Africa’s population; otherwise, Africa would be faring worse. Others argue that African governments are simply doing a better job of managing the disease than other regions, despite evidence to the contrary. Neither analysis reflects the complex realities of COVID-19 in Africa. The question itself, in its crudest form, has provoked considerable, justifiable anger on social media in various African countries. Yet as the deaths mount in Brazil, India, the United States, and the UK, and as Europe prepares for its second wave, the official death toll in African countries remains low. Even in South Africa, the most severely affected African country, confirmed deaths are far fewer than predicted. Experts are left wondering why their predictions were wrong. To ask why more Africans aren’t dying of COVID-19 exposes the expectation that when the world suffers, Africa must suffer more. We can learn collectively from the questions we ask. Knowledge-making is about grappling with useful questions—those that move humanity toward a greater understanding of shared circumstances. But questions that distract from meaningful comparisons dominate the current moment. “Why aren’t more Africans dying of COVID-19,” like so many questions about Africa, fails to illuminate.

What role can health policy and systems research play in supporting responses to COVID-19 that strengthen socially just health systems?
Gilson L; Marchal B; Ayepong I; Barasa E; et al: Health Policy and Planning (czaa112), doi: https://doi.org/10.1093/heapol/czaa112, 2020

In the context of COVID-19, this paper outlines how health policy and systems research (HPSR) can both address current short-term challenges, and support the system transformations needed to strengthen people-centred and equitable health systems over the long term. Due to the acute nature of the pandemic, few papers have yet focused on how health systems are coping with or adapting to the pandemic, or how health policy-making and decision-making has (or has not) changed in this time of crisis. This paper makes proposals for a structured research agenda to inform health policy and system responses to COVID-19 that can move us beyond the current crisis, and into the future, with a focus on low- and middle-income countries.

14. Useful Resources

Archive of Forgetfulness: Conversations with Neighbours
Tayob H; Kona B: Archive of Forgetfulness, South Africa, November 2020

Archive of Forgetfulness presents a podcast series: Conversations with Neighbours. The conversations explore, among other themes, art in times of crisis, questions around memory and archival absences, and the possibilities and limitations of translation. You will hear from artists, musicians, curators, researchers and theatre-makers in Egypt, Nigeria, Rwanda, South Africa and Sudan. The conversations interrogate ways of narrating movement across borders, suggesting a re-mapping of relations across the continent, north and south, east and west, home and away.

Basic Epidemiological Concepts - 2020 (2nd cohort)
Pan American Health Organisation: PAHO, 2020

This Skills Online Program aims to help public health practitioners develop and strengthen their knowledge and skills in order to make better-informed public health decisions. The EPI1: Basic Epidemiological Concepts module is the first in a set of three modules on epidemiology in public health and is the only one currently being offered through PAHO's Virtual Campus for Public Health. The module provides an introduction to some key epidemiologic concepts, allowing participants the opportunity to enhance their understanding of the fundamentals of epidemiology, and build skills in applying basic epidemiological principles to their work as public health practitioners.

Imagining Impacts – The Goethe-Institut in Africa
African Centre for Cities, October 2020

The African Centre for Cities and the Goethe-Institut are collaborating on a project entitled Imagining Impacts that explores the role of culture on the continent through a range of regionally focused, and locally specific projects related to 1) decolonisation and just transitions in Africa; 2) solidarity, support and social cohesion; 3) spaces for daring and dissent; and 4) power and agency. The project will provide events and activities in 2021 where these issues can be thought through collectively.

15. Jobs and Announcements

Davidson Gwatkin Equity Measurement Prize
Date to submit nominations: 1 May 2021

Metrics for Management is excited to announce the launch of the Davidson Gwatkin Equity Measurement Prize. This annual juried competition will award up to four cash prizes each valued between $5,000 and $10,000 to an individual or team of authors for research that uses the EquityTool and its data to assess and improve services that reach the poor or to gain insight into wealth equity in low- and middle-income countries.

International AIDS Society’s (IAS) COVID-19 Conference: Prevention!
Online, registration closes 14 January 2021

IAS – the International AIDS Society – will host the IAS COVID-19 Conference: Prevention, with a special focus on prevention, on Tuesday, 2 February 2021. In recognition of the urgent need to analyse research, review policy and exchange frontline experiences related to the COVID-19 pandemic. The 2nd IAS COVID-19 Conference with a special focus on prevention will feature the latest in prevention related science, policy and practice. The conference will take place virtually and will include invited-speaker sessions and abstract presentations. The conference programme is designed to include the latest science on COVID-19 and its impact on health and beyond – with perspectives on policy, access and financing.

PHASA 2021: ‘Keeping the promise: closing the gap'
15 - 17 February 2021, University of Pretoria, City of Tshwane, South Africa

The Public Health Conference is organized every year by Public Health Association of South Africa to bring together public health professionals, researchers, policy-makers, academics, students and trainees to strengthen efforts to improve health and well-being, share the latest research and information, to promote best practices and to advocate for public health issues and policies grounded in research. The organisers note that 2020 stands at a cross road of two major events: it marks 20 years’ anniversary of PHASA; and 10 years away from the 2030 sustainable development agenda. The Symposia core themes include: ‘health and wellbeing’, ‘universal health coverage’, and ‘sustainable cities and communities’.

Racial Equity 2030
Deadline for Applications: January 28, 2021

Racial Equity 2030 calls for bold solutions to drive an equitable future for children, their families and communities. This $90 million challenge seeks ideas from anywhere in the world and will scale them over the next decade to transform the systems and institutions that uphold inequity. Solutions may tackle the social, economic, political or institutional inequities one sees today. Teams of visionaries, change agents and community leaders from every sector are invited to join. Up to 10 Finalists will each receive a one-year $1 million planning grant and nine months of capacity-building support to further develop their project and strengthen their application. At least three awardees will each receive a $20 million grant and two will each receive a $10 million grant. Grants will be paid out over nine years.


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