EQUINET NEWSLETTER 227 : 01 March 2021

1. Editorial

Working people have experienced COVID-19’s blows, but are central to the region’s recovery
Matsiame Mafa, Rene Loewenson, Paliani Chinguwo, Mavis Koogotsitse

There is no doubt that the COVID-19 pandemic has affected working people. In September 2020, the International Labour Organisation (ILO) reported that beyond workers exposure to COVID-19 infection in their living and working conditions and experience of COVID-19-related disease, workplace closures and job losses have significantly reduced workers’ incomes.

An EQUINET information sheet included in this newsletter, produced jointly with the Southern African Trade Union Co-ordination Council (SATUCC), outlines how COVID-19 has affected working people in the East and Southern Africa region, and the responses to these impacts.

Publicly reported data on COVID-19 is not disaggregated by economic activity or occupation. It is thus difficult to know how the pandemic has differently affected different categories of workers. Health workers (HWs) are, however, widely understood to be at greater risk of infection due to the nature of their work, especially when they work without adequate personal protective equipment (PPE) or in conditions that lack adequate infection control measures.

However other workers are also at risk, such as those who work in crowded, poorly ventilated workplaces. The Minerals Council of South Africa reported in June 2020, for example, that mineworkers had twice the rates of infection than the general population. Carers, vendors or service providers who are in common contact with the public may also have higher risk of exposure. There is a gender dimension to this, as many of these workers are women. Most HWs are female and African countries that disaggregate their data found that 72% of all HWs testing positive for COVID-19 were women.

Migrant labour is common in the region. Migrant workers have faced challenges in accessing services or been trapped when lockdowns close borders on them. Border closures and costs of testing can lead to crowding at borders and an increase in use of irregular travel routes across frontiers, as was reported when migrants returned home at the end of 2020.

While remote work is indicated as an option to prevent transmission, only about 10% of workers are estimated to be able to do this in the region, largely those at higher incomes who can afford data charges to the internet. This is not possible for most workers. While workers are increasingly aware of what raises their risk of infection, the precarious nature of many jobs and incomes in the region mean that many continue to work in environments that they know put them at risk. As a union official from the metal workers union in South Africa (NUMSA) noted: “The workers are aware that these are extremely dangerous spaces, but decide to risk it simply because they don’t have the means to stay in isolation, feed their children, or care for themselves without due pay.”

Beyond the risks of infection, the response to COVID-19 has raised its own stresses for working people. Lockdowns and blocks in supply chains have disrupted jobs, livelihoods and mental health.

A SATUCC study found that by mid-2020 over 42 000 labour contracts had been suspended in Mozambique; 680 000 employees had lost jobs in Malawi, and 70 000 in Zambia. An East African Confederation of Trade Unions (EATUC) assessment found that already by mid-May 2020, one million informal jobs and over 200 000 formal jobs had been lost in Kenya in the wake of the pandemic. The pandemic meant that 68% of people with disabilities in Kenya were not able to work and perceived their jobs to be insecure due to their disability. Where COVID-19-related messages have induced fear of outsiders, migrant workers may be stigmatized. Migrant job losses are reported to have reduced remittances that many families in the region rely on.

There is now guidance, including from the ILO and World Health Organisation, on the public health, workplace infection control and personal protective equipment measures required for different employment settings. Some ESA governments have also reduced income tax and VAT, provided wage subsidies and distributed food and other basic goods, as important areas of support for working people.

However, there has often been a gap between guidance and practice, and schemes have not always reached the most insecure workers who need them the most. HWs in Zimbabwe, Kenya and South Africa have protested over lack of PPE, and the ILO reports that migrant workers often do not access the testing, treatment, wage subsidy and other social protection measures that are provided to other workers. Informal sector workers have difficulties with the formal documentation that social protection systems ask for. Vital information does not effectively reach workers with disabilities if it is not made available in sign languages, video captioning, or other forms that they can access.

Trade unions have engaged on these issues, even though the pandemic has undermined union communication and operations. Beyond their contribution to national task forces on COVID-19 in some countries, unions have engaged when employers have taken wage subsidies but still imposed unpaid leave on or retrenched workers, or failed to provide PPE. Unions have also flagged wider concerns, such as how the conditions accompanying with international funding of rescheduled debt repayments may further undermine employment and the funding of public services.

While there is now a significant focus on access to vaccines and technologies, a comprehensive public health response to the pandemic, including to distribute vaccines, depends on formal and informal, male and female workers from many sectors, and the full involvement and protection of communities.

This link between workers and communities is fundamental. As a union shop-steward noted in the recent Alternative Mining Indaba, “in the day I am a mineworker, but when I go home to my family I am the community.”

Working people of different types fill the gaps in the social protection systems in the region so that vulnerable people in communities are not further impoverished by the pandemic. The economic recovery that is now critical in our region will not be possible without workers and communities. It will also not be meaningful unless it is a recovery of the productive opportunities, jobs, incomes, capacities and protection of all working people in the region.

Young public health professionals reflect on leadership for just health systems
Ghiwa Nasser Eddine, Laura Haywood, Malvikha Manoj, Magali Collonnaz, IWG

For emerging public health professionals like ourselves, the COVID-19 pandemic has lifted a smokescreen on inequities in health and made clear that we need to invest in and strengthen our health systems. While the pandemic is all consuming, other challenges have not stopped, and we face public health demands on many fronts. Antimicrobial resistance, social injustice, forced displacement, non-communicable diseases, and climate change are real concerns.

While it should not have taken a pandemic to provoke self-reflection, it has opened a window of opportunity for new thinking, to transcend silos that have traditionally existed within public health, and to re-imagine a world where health systems work for all and not just for some.

This takes leadership. So as emerging public health professionals in the International Working Group for Health Systems Strengthening (IWG) we have been exploring and stimulating open discussion between ourselves on what it takes to build the sort of bold, committed, responsible and innovative health leadership that can face such challenges in a world that we see as ever-changing and often chaotic. We also do this by learning from health trailblazers that have accumulated experience, such as in a fireside chat we held at the end of 2020 on the theme ‘Looking Back, Looking Forward’ (at https://iwghss.org/2021/02/09/iwg-fireside-chat/).

These interactions have pointed to the importance of core values as the basis for a leadership that can guide efforts and rally others to collaborate on a common cause. We have seen how public health efforts to tackle challenges advance when collective success is valued over individual success. In public health, the success of one requires the success of many. We also understand that health leadership means building people-centered comprehensive public health systems, where public health professionals consider, dialogue and work with the members of the community as the most critical aspect of every intervention or initiative they work on.

These insights led us to reflect on what health leadership means for us as emerging public health professionals, as we move forward on our career paths.

First, we believe that we need to understand the history that lies behind today’s realities and power, if we are to understand how the work we do will confront or shape this distribution of power. For example, colonial legacies that informed the emergence of global ideas in health persist today and continue to affect power imbalances across gender, race, and geography, among others. We see this when northern institutions and knowledge sources frame the dominant narrative in a way that minimizes the rich history of leadership and innovation in the global south. It is our responsibility to understand this history of health and development and what it has meant for public health today, to shape the actions we take.

Secondly, in our reflections, we perceive that we must constantly return to our values and convictions. These are not just words to write down, but actions to live by, whether in the organizations we work in, the work we do, or in our interactions with people. For example, ‘respect for diversity, equity, and equality’ is a core value for IWG, so we see that we need to reflect this in our own processes, by giving space for different perspectives, and co-producing outcomes that are the result of a united team effort that captures the diversity among all our members.

Finally, in the face of pressures to compete, we see finding your team and collaborating as a critical feature of leadership in health. Health systems that work for all need diverse, empowered voices that work as a team, where we keep asking who is at the table, and more importantly, who is not at the table; and why. Having a collaborative, interdisciplinary, diverse team seems to not only strengthen practice, but also to mitigate blind-spots that may otherwise be ignored, particularly in efforts to advance justice and equity.

As emergent public health professionals we appreciate that the field we are in is complex and dynamic, but also fulfilling. What we think and do now is shaping our futures, but also the future of public health. Ultimately, it is up to each of us to be the change we want to see around us. The pandemic has opened a window of opportunity for us to step up and step into a more just vision for public health. Now, it is our turn as young professionals to make that vision happen.

Please send feedback or queries on the issues raised in the two editorials to the EQUINET secretariat: admin@equinetafrica.org.

2. Latest Equinet Updates

A People’s Vaccine or Apartheid Vaccine? Challenging WTO and Big Pharma
Daraja Press, January 2021

Access to health technologies (vaccines, medicines, diagnostics, PPE, ventilators etc) depends on distributed local production. Nationalism and protectionism on these technologies has implied a sustained struggle to get sufficient access to meet population needs, and global measures such as CTAP (for voluntary patent pooling) and COVAX (for vaccine and technology pooling) have not had the support that matches need. One of the barriers is the patent protection in the TRIPS agreement. In this interview, Firoze Manji speaks with Leslie London, Professor of Public Health in the School of Public Health and Family Medicine University at the Cape Town (and an EQUINET steering committee member), and Jens Pedersen from Medicins Sans Frontiers on the issues of access.

Brief: Ensuring access to COVID-19 related vaccines and health technologies in East and Southern Africa

The ability of African countries to mount effective and equitable responses to COVID-19 reflects in part the access that countries have to reliable, sustained, distributed supplies of diagnostics, medicines, vaccines and other health technologies. By 2021 significant inequality in access to vaccines has become clearly evident, a situation that the World Health Organisation director-general called a “catastrophic moral failure” in January 2021. While noting that vaccine roll out in East and Southern Africa (ESA) is a dynamic situation, this brief discusses the different vaccines and the distribution of vaccines in the region and issues involved in the development and production of vaccines and other health technologies in the region. It raises areas where regional co-operation is taking place and suggests where it could be strengthened.

EQUINET Information sheet 5 on COVID-19: Pandemic impacts on labour – experience and responses

This fifth information sheet in the COVID-19 series summarises information on how COVID-19 has affected working people in the ESA region, and the response by workers, unions, states and others, with recommendations for how to better address the impacts. Nearly a million African workers are estimated to have had COVID-19 in 2020, probably more given the low level of testing. Health workers (HWs), those in crowded or poorly protected workplaces or in crowded accommodation, those in common contact with the public and those in caring roles may be more at risk. Informal, migrant, young, disabled and female workers may be more vulnerable to COVID-related disease. Lockdowns and blocks in supply chains have disrupted key areas of employment, affecting working people’s livelihoods, jobs and mental health, and leading to stigma and social insecurity and falling remittances from African migrants and revenues for social protection. Possible responses include public health measures, including now equitable access and vaccines; workplace infection control; social protection to prevent impoverishment; protection of jobs and wage subsidies. Workers and unions have contributed to these responses, despite the pandemic undermining union operations. The brief outlines recommendations to protect workers and their rights at work, noting that not implementing such measures makes the whole of society vulnerable.

Putting the public back into public health: Communities organising solidarity responses to Covid-19
Whyle E; van Ryneveld M; Brady L; Loewenson R: Maverick Citizen, December 2020

This oped draws on EQUINETs 42 case studies of community action on Covid-19 that collectively show innovative and solidarity-based approaches to prevent and care for Covid-19, to address social needs and hold states accountable, and in more detail on the experience with the Community Action Networks in South Africa.

What do we know about COVID-19 spread in Africa?
Daraja Press, 5 February 2021

This interview between Firoze Manji Daraja press and Dr Rene Loewenson, Training and Research Support Centre explores evidence and knowledge gaps on COVID-19 in east and southern Africa, drawing on EQUINET information briefs and other sources. The interview identifies positive examples of state and public proactive responses to the pandemic in the region, the challenges faced and what learning that brings for equity in responding to pandemics.

3. Equity in Health

Covid-19 deaths in Africa: prospective systematic postmortem surveillance study
Mwananyanda L; Gill C; MacLeod W et al., :BMJ 372 :n334, 2021

The authors measured the fatalities from Covid-19 in Lusaka. PCR tests were done post mortem on 372 deceased people of all ages at the University Teaching Hospital morgue in Lusaka, Zambia, enrolled within 48 hours of death between June and September 2020; PCR results were available for 364 (97.8%). SARS-CoV-2 was detected in 58/364 (15.9%). Most deaths in people positive for covid-19 (51/70; 73%) occurred in the community and none had been tested for Covid-19 before death. Among the 19/70 people who died in hospital, six were tested before death, while for the 52/70 people with data on Covid-19 related symptoms, only five were tested before death. Covid-19 was identified in seven children, only one of whom had been tested before death. While the proportion of deaths with covid-19 increased with age, 76% were aged under 60 years. The authors conclude that deaths with covid-19 were more common in Lusaka than indicated in official reports, with most occurring in the community, where testing capacity is lacking, but also due to lower levels of testing in facilities and in those presenting with typical symptoms of covid-19.

Prevalence and Factors Associated with Mental and Emotional Health Outcomes among Africans during the COVID-19 Lockdown Period—A Web-based Cross-Sectional Study
Langsi R; Osuagwu U; Goson P; Abu E; et al: International Journal of Environmental Research and Public Health 18(3), 899, 2021

This online study assessed the prevalence of mental health symptoms as well as emotional reactions among 2005 respondents aged 18 years and older in seven African countries between 17 April and 17 May 2020 corresponding to the lockdown period in these countries. Respondents self-reported feeling anxious, worried, angry, bored and frustrated. Multivariate analysis revealed that males, those aged >28 years, those who lived in Central and Southern Africa, those who were not married, the unemployed, those living with more than six persons in a household, had higher odds of mental health and emotional symptoms. Health care workers were less likely to report feeling angry than other types of workers.

The Inequality Virus: Bringing together a world torn apart by coronavirus through a fair, just and sustainable economy
Berkhout E; Galasso N; Lawson M; Morales P; et al: Oxfam Briefing Paper, Oxfam International, 2021

This report highlights the ways that the coronavirus pandemic has the potential to lead to an increase in inequality in almost every country at once, the first time this has happened since records began. The virus has exposed, fed off and increased existing inequalities of wealth, gender and race. Over two million people have died, and hundreds of millions of people are being forced into poverty while many of the richest – individuals and corporations – are thriving. Billionaire fortunes returned to their pre-pandemic highs in just nine months, while recovery for the world’s poorest people could take over a decade. While the pandemic has exposed a collective frailty and the inability of a deeply unequal economy to work for all, it has also shown the vital importance of government action to protect health and livelihoods. Transformative policies that seemed unthinkable before the crisis have suddenly been shown to be possible.

4. Values, Policies and Rights

Equitable recovery from COVID-19: bring global commitments to community level
Loewenson R; D’Ambruoso L; Minh Duc D; Hjermann R; et al: BMJ Global Health 6:e004757, 2021

High level speakers at the December 2020 United Nations General Assembly pointed to the growing inequalities and stress to health, social, economic and democratic systems caused by COVID-19, calling for a range of collective interest driven responses and measures for a sustainable recovery. The pandemic, lockdown and other responses, along with underfunded, poorly prepared and overstretched public sector social and health systems in many countries worsened many dimensions of health and well-being that were already facing deficits, generating a rising health and social debt in communities, the scale and long-term consequences of which are as yet unknown, especially for the most marginalised in society. Rather than ‘getting back to normal’, the authors argue that recovery and ‘reset’ demands change to tackle the inequalities, conditions, services, socioeconomic and environmental policies that made people susceptible and vulnerable to COVID-19. Economic recovery should not replicate the features of the global economy that are generating pandemic and other crises. The authors suggest further that for global aspirations to translate into benefit for communities, an equitable recovery should include significant investment in: (1) universal, public sector, primary health care-oriented health services; (2) redistributive, universal rights-based and life course based social protection; and (3) people, especially in early childhood and in youth, as drivers of change.

Immunity certification for COVID-19: ethical considerations
Voo T; Reis A; Thomé B; Ho C; et al: Bulletin of the World Health Organisation99(2),155–161, 2021

Some countries have considered using immunity certification as a strategy to relax restrictive measures by issuing an immunity passport for people certified as having protective immunity against SARS-CoV-2, the virus that causes COVID-19. The World Health Organization has advised against the implementation of immunity certification because of uncertainty about the length of time of immunity and concerns over the reliability of methods for determining immunity. However, even if immunity certification became well supported by science, the authors note many ethical issues in terms of the implementation process, its uses, measures in place to reduce potential harms, prevention of disproportionate burdens on non-certified individuals and potential violation of individual liberties and rights.

Tanzania’s Ministry of Health now urges precaution against Covid-19
Owere P: The Citizen, Tanzania, February 2021

The Tanzanian Ministry of Health has now urged citizens to take all the required precautions against Covid-19 including wearing face masks. The statement issued on Sunday, February 21, 2021 by the Head of the Public Relations Unit, Gerard Chami said the Ministry continues to monitor and stress the implementation of precautionary measures against various non-communicable and communicable diseases including outbreaks and Covid-19. Precautions included hand washing, use of sanitizer, exercising, and protection for all those at risk such as the elderly, obese people, and those with chronic illnesses. The statement also urged Tanzanians to get proper nutrition including fruits and vegetables, use natural remedies registered by the council of traditional healers and as advised by relevant professionals and to visit health facilities on witnessing symptoms of illness.

Unhealthy geopolitics: can the response to COVID-19 reform climate change policy?
Cole J; Dodds K: Bulletin of the World Health Organisation 99(2), 77-168, 2021

The geopolitics of pandemics and climate change intersect. Both are complex and urgent problems that demand collective action in the light of their global and trans-boundary scope. In this article a geopolitical framework is used to examine some of the tensions and contradictions in global governance and cooperation that are revealed by COVID-19. The authors argue that the pandemic provides an early warning of the dangers inherent in weakened international cooperation. The world’s states, with their distinct national territories, are reacting individually rather than collectively to the COVID-19 pandemic. Many countries have introduced extraordinary measures that have closed, rather than opened up, international partnership and cooperation, including in border closures, restrictions on social mixing, domestic purchase of public health supplies and subsidies for local industry and commerce. For the poorest countries of the world, pandemics join a list of other challenges that are exacerbated by pressures of scarce resources, population density and climate disruption, and have a disproportionate impact on those living with environmental stresses. The authors highlight the need for a coordinated global response to addressing challenges that cannot be approached unilaterally.

5. Health equity in economic and trade policies

Global Wage Report 2020-21: Wages and minimum wages in the time of COVID-19
International Labour Organisation, Geneva, ILO, 2020

This ILO report examines the evolution of real wages globally and by region, as well as the relationship between minimum wages and inequality, and the wage impacts of COVID-19 . It identifies the conditions under which minimum wages can reduce inequality and how adequate minimum wages, statutory or negotiated, can play a key role in a human-centred recovery from the pandemic.

WTO COVID-19 TRIPS waiver proposal: Myths, realities and an opportunity for governments to protect access to lifesaving medical tools in a pandemic
Medecins Sans Frontieres: Access Campaign, 2021

One of the challenges faced in the COVID-19 pandemic is the negative impact that intellectual property (IP) barriers have had in the past and are anticipated to have on the scale up of manufacturing and supply of lifesaving COVID-19 medical tools across the world. Because the pandemic is an exceptional global crisis, the World Trade Organization (WTO) can invoke a waiver of certain IP rights on these technologies under WTO rules. Given this, South Africa and India submitted a landmark proposal earlier this year to the WTO requesting that WTO members waive four categories of IP rights – copyright, industrial designs, patents and undisclosed information under the Agreement of Trade-Related Intellectual Property Rights (TRIPS) until the majority of the world population receives effective vaccines and develops immunity to COVID-19. In the course of discussion, opponents of the TRIPS waiver proposal have raised arguments against the waiver. This brief presents the reasons for the waiver, and addresses the counter arguments to the points raised by those opposing it.

6. Poverty and health

Evaluating the African food supply against the nutrient intake goals set for preventing diet-related non-communicable diseases: 1990 to 2017 trend analysis
Gebremedhin S; Bekele T: Plos One 16(1), 2021

The authors evaluated African food balances against the recommendations for macronutrients, free sugars, types of fatty acids, cholesterol and fruits and vegetables over 1990 to 2017, with regional, sub-regional and country-level estimates. In Africa the energy supply increased by 16.6% from 2,685 in 1990 to 3,132 kcal/person/day in 2017. However, the energy contribution of carbohydrate, fat and protein remained constant and almost within acceptable range around 73, 10 and 9%, respectively. In 2017, calories from fats surpassed the 20% limit in upper-middle- or high-income and Southern Africa countries. Energy from free sugars remained constant around 7% but the figure exceeded the limit of 10% in upper-middle- or high-income countries (14.7%) and in Southern (14.8%) and Northern (10.5%) sub-regions. Between 1990 and 2017 the availability of dietary cholesterol per person surged by 14% but was below the upper limit of 300 mg/day. The supply of fruits and vegetables increased by 27.5% from 279 to 356 g/capita/day, but remained below the target of 400 g/capita/day in all sub-regions. While most population intake goals were found to be within acceptable range, the supply of fruits and vegetables are suboptimal and the increasing energy contributions of free sugars and fats are emerging concerns in specific sub-regions.

It is painful and unpleasant: experiences of sexual violence among married adolescent girls in Shinyanga, Tanzania
Mwanukuzi C; Nyamhanga T: Reproductive Health 18(1), 1-7, 2021

This article reports on a qualitative study of 20 married girls aged 12-17 years' experiences of sexual violence in the Shinyanga Region, Tanzania where there is high prevalence (59%) of child marriage. The study identified four analytical themes regarding the experience of sexual violence, namely: forced sex; rape; struggling against unpleasant and painful sex; and inculcation of the culture of tolerance of sexual violence. The study found that married adolescent girls suffer sexual coercion in silence, increasing their risk of acquiring sexually transmitted infections and or unwanted pregnancies. The authors make recommendations for sexual violence prevention strategies .

Possible causalities between malnutrition and academic performances among primary schoolchildren: a cross-sectional study in rural Madagascar
Aiga H; Abe K; Randriamampionona E; Razafinombana A: BMJ Nutrition, Prevention & Health 0, 1-12, doi:10.1136/ bmjnph-2020-000192, 2021

A cross-sectional household survey in Antananarivo-Avaradrano district, Madagascar in November to December 2017 in 404 first and second grade pupils 5–14 years of age enrolled in 10 public primary schools explored the link between their nutritional status and academic performances. Not being stunted and attendance rate were identified to be possible causes of higher mathematical proficiency because they satisfied all conditions for a causality. A hypothetical causal path indicates that ‘not being stunted’ is likely to have caused higher ‘attendance rate’ and thereby higher ‘mathematical proficiency’ in a two-step manner.

7. Equitable health services

Investigation of an anthrax outbreak in Makoni District, Zimbabwe
Makurumidze R; Tafara Gombe N;Magure T; Tshimanga M: BMC Public Health 21(298), 1-10, 2021

The authors investigated an anthrax outbreak in Makoni District, Zimbabwe, and assessed the environment, district preparedness and response, and outbreak prevention and control measures. They found that most of the cases were managed according to the national guidelines. Multivariable analysis demonstrated that meat sourced from other villages, skinning, and belonging to religions that permit eating meat from cattle killed due to unknown causes or butchered after unobserved death were associated with contracting anthrax. The poor availability of resources in the district caused a delayed response to the outbreak. Although the outbreak was eventually controlled through cattle vaccination and health education and awareness campaigns, the authors report that the response of the district office was initially delayed and insufficient. They call for strengthened emergency preparedness and response capacity at district level, for revival of zoonotic committees, awareness campaigns and improved surveillance, especially during outbreak seasons.

IWG Fireside Chat: Looking Back, Looking Ahead
International Working Group on Health Systems Strengthening: IWG. February 2021

In December, the IWG hosted an event with health professionals with experience in different fields to better understand leadership in health systems, and consolidated the reflections from the discussions. The discussion raised several key features, including: Investing in gender, racial, and geographic equity among global health leaders and health activists; improving teamwork and multidisciplinary collaborations between individuals and communities of diverse skills, capabilities and backgrounds; networking across health leaders and communities and promoting local ownership and leadership. The session also pointed to the importance for the success of public health interventions and initiatives that those affected and implementing them be at the centre of the design and interactions.

Preparedness of health care systems for Ebola outbreak response in Kasese and Rubirizi districts, Western Uganda
Kibuule M; Sekimpi D; Agaba A; Halage A; et al: BMC Public Health 21(236), 1-16, 2021

This study assessed the preparedness of the health care facilities for the Ebola (EVD) outbreak response in Kasese and Rubirizi districts in western Uganda. It involved interviews with 189 health care workers and visits to 22 health facilities. Twelve out of the 22 of the health facilities did not have a line budget to respond to EVD and the majority of the facilities did not have case definition books, rapid response teams and/or committees, burial teams, and simulation drills. There were no personal protective equipment that could be used within 8 h in case of an EVD outbreak in fourteen of the 22 health facilities. All facilities did not have viral haemorrhagic fever incident management centers, isolation units, guidelines for burial, and one-meter distance between a health care worker and a patient during triage. The authors recommend proactively tracking the level of preparedness to inform strategies for building capacity of health centers in terms of infrastructure, logistics and improving knowledge of health care workers.

8. Human Resources

Approaches to motivate physicians and nurses in low- and middle-income countries: a systematic literature review
Gupta J; Patwa M; Khuu A; Creanga A: Hum Resources for Health 19(4), 1-20, 2021

The paper reviews evidence on interventions used to motivate health workers in low- and middle-income countries. The review found supervision, compensation interventions and systems support to play a role. The authors found there is limited evidence on successful interventions to motivate health workers in low- and middle-income countries and the authors call for studies that use validated and culturally appropriate tools to assess worker motivation.

Community health workers’ involvement in the prevention and control of non-communicable diseases in Wakiso District, Uganda
Musoke D; Atusingwize E; Ikhile D; Nalinya S; et al: Globalization and Health 17(7), 1-11, 2021

This paper assessed the involvement of Community health workers (CHWs) in the prevention and control of non-communicable diseases (NCDs)in Wakiso District, Uganda with a focus on their knowledge, attitudes and practices, as well as community perceptions, through a cross-sectional mixed-methods study. The majority of CHWs correctly defined what NCDs are and mentioned high blood pressure, diabetes and cancer. Many CHWs said that healthy diet, physical activity, avoiding smoking/tobacco use, and limiting alcohol consumption were very important to prevent NCDs. The majority of CHWs who were involved in NCDs prevention and control reported challenges including inadequate knowledge, lack of training, and negative community perception towards NCDs. Community members were concerned that CHWs did not have enough training on NCDs and the community did not have much confidence in them regarding NCDs and rarely consulted them concerning these diseases. The authors recommend enhanced training and community engagement for CHWs to contribute to the prevention and control of NCDs.

9. Public-Private Mix

Market strategies used by processed food manufacturers to increase and consolidate their power: a systematic review and document analysis
Wood B; Williams O; Nagarajan V; Sacks G: Globalization and Health 17 (17), 2021

The authors reviewed the market strategies deployed by processed food manufacturers to increase and consolidate their power from a systematic review of public health, business, legal and media content databases and of grey literature. The market strategies identified related to six interconnected objectives: i) reducing competition with equivalent sized rivals and maintaining dominance over smaller rivals; ii) raising barriers to market entry by new competitors; iii) countering the threat of market disruptors and driving dietary displacement in favour of their products; iv) increasing firm buyer power over suppliers; v) increasing firm seller power over retailers and distributors; and vi) leveraging informational power asymmetries in relations with consumers. The authors note that analysing such market strategies promoting unhealthy foods helps to identify countervailing public policies, such as those related to merger control, unfair trading practices, and public procurement, as part of efforts to improve population diets.

10. Resource allocation and health financing

An Assessment of Domestic Financing for Reproductive, Maternal, Neonatal and Child Health (RMNCH) in Sub-Saharan Africa: Potential Gains and Fiscal Space
Atim C; Arthur E; Achala D; Novignon J: Applied Health Economics and Health Policy 18, 789–799, 2020

This study analysed the gains from increased domestic financing for improving RMNCH outcomes in Sub-Saharan Africa (SSA). While there were significant gains from both domestic and external financing, the estimated elasticities suggest that the gains from domestic public financing were much stronger. The fiscal space options identified include tax revenue performance improvements, improved public financial management, and borrowing, at least in the short to medium term. The results show that fiscal space from improved tax systems ranged from US$34.6 per capita in Uganda to US$310.6 per capita in Nigeria. The authors recommend increased domestic financing for health through innovations in domestic resource mobilization, particularly by improving the performance of tax systems.

The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania
Vossius C; Mduma E; Moshiro R; Mdoe P; et al: BMC Health Services Research 21 (99), 1-9, 2021

This study assessed the impact of introducing user fees on 28 601 births at Haydom Lutheran Hospital, Tanzania, comparing the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. The monthly number of births fell by 17.3% after fees were introduced. After the introduction of ambulance and delivery fees, the study found an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight. The authors suggest that this might indicate that women delayed seeking skilled birth attendance or did not seek help at all, possibly due to financial reasons, and argue that free delivery care should be a high priority.

11. Equity and HIV/AIDS

It’s a secret between us: a qualitative study on children and care-giver experiences of HIV disclosure in Kinshasa, Democratic Republic of Congo
Sumbi E; Venables E; Harrison R; Garcia M: et al: BMC Public Health 21(313), 1-9, 2021

This paper explored child and care-giver experiences of the process of disclosing HIV statuses to children, including reasons for delay, through 22 in-depth interviews with care-givers and 11 in-depth interviews with HIV positive children in Kinshasa. Care-givers included biological parents, grandmothers, siblings and community members and 86% of them were female. Many care-givers had lost family members due to HIV and several were HIV positive themselves. Reasons for non-disclosure included fear of stigmatisation; wanting to protect the child and not having enough knowledge about HIV or the status of the child to disclose. Several children had multiple care-givers, which also delayed disclosure, as responsibility for the child was shared. In addition, some care-givers were struggling to accept their own HIV status and did not want their child to blame them for their own positive status by disclosing to them. The authors identify that child disclosure is a complex process for care-givers, health-care workers and the children themselves.

12. Governance and participation in health

Community perspectives on the COVID-19 response, Zimbabwe
Mackworth-Young C; Chingono R; Mavodza C; Grace G; et al: Bulletin of the World Health Organisation 99(2) 85–91, 2021

The authors investigated community and health-care workers’ perspectives on COVID-19 and on early pandemic responses during the first 2 weeks of national lockdown in Zimbabwe between March and April 2020. Phone interviews were done with with one representative from each of four community-based organizations and 16 health-care workers involved in a trial of community-based services for young people. In addition, information on COVID-19 was collected from social media platforms, news outlets and government announcements. Data were analysed thematically. It emerged that individuals were overloaded with information but lacked trusted sources, which resulted in widespread fear and unanswered questions; communities had limited ability to comply with prevention measures, such as social distancing, because access to long-term food supplies and water at home was limited and because income had to be earned daily; health-care workers perceived themselves to be vulnerable and undervalued because of a shortage of personal protective equipment and inadequate pay and other health conditions were side-lined because resources were redirected, with potentially wide-reaching implications. The authors recommend providing communities with basic needs and reliable information to enable them to follow prevention measures, health-care workers with personal protective equipment and adequate salaries and sustaining health-care services for conditions other than COVID-19.

The Contribution of Social Dialogue to Gender Equality
International Labour Organisation: ILO, Geneva, 2021

This thematic brief discusses actions that governments, employers’ and workers’ organisations, can take to advance gender equality through social dialogue, drawing on case studies from around the world, in different sectors, in the formal or the informal economy, and during the pandemic. It identifies the circumstances and factors that can help bring about transformative change. The brief examines the role of social dialogue in the application of relevant International Labour Standards on gender equality, including the ground-breaking Violence and Harassment Convention, 2019 (No. 190) and Recommendation No. 206 on the same subject matter. It concludes with some key recommendations for governments and employers’ and workers’ organisations.

13. Monitoring equity and research policy

Explaining covid-19 performance: what factors might predict national responses?
Baum F; Freedom T; Musolino C; Abramovitz M; et al: BMJ 372(91), 2021

The Global Health Security Index predicted that the world in general was not well prepared for the pandemic but did not predict individual country preparedness. Ten factors seem to have contributed to the index failing to predict country responses, including limited consideration of globalisation, geography, and global governance, bias to high income countries, failure to assess health system capacity, overlooking the role of political leadership and ideology, overlooking the importance of context, the limits of national wealth as a predictive factor, no examination of inequalities within countries, the importance of social security and the provisions to protect people from losing their jobs and homes. The authors note that civil society capacity was not assessed, and the gap between capacity and its application was also not assessed. The authors argue that future assessments of pandemic preparedness need to take these 10 factors into account by adopting a systems approach which enables a focus on critical system components

14. Useful Resources

Corona Diaries: Open source audio stories from around the world
Nieman Foundation for Journalism: USA, 2020

Corona Diaries is an open platform allowing people around the world to voice their experiences during the pandemic. It’s a place for stories big and small, joyful or sad, one off contributions or daily audio blogs. Every story is welcome. Initiated by former fellows of the Nieman Foundation for Journalism, the platform is intended for journalists, artists and creators of all types to then use to make into any media they choose under the Creative Commons licence. It is an open database of recordings forever growing and always accessible.

Covid-19 Vaccine Equity Tracker
Pandem-ic: Online, 2021

This site tracks the COVID-19 pandemic through the lens of the country income classification. It tracks vaccine distribution relative to global needs and the coverage of total and priority populations, dividing countries into high-income; upper middle-income; lower middle-income and low income The site is refreshed daily.

SCORE global report on health data systems and capacity, 2020
World Health Organization: WHO, Geneva, 2021

The World Health Organization provides the first global assessment of country data and health information systems capacities in terms of five 'SCORE' aspects: Survey, Count, Optimize, Review and Enable. The report addresses gaps and inequalities in health information systems and provides recommendations for investment in areas that will have the greatest impact on the quality, availability, analysis, accessibility and use of data. There is a link to the SCORE Online Data Portal and an accompanying Visual Summary of country-level SCORE assessments.

15. Jobs and Announcements

Call for expression of interest for Global Health Systems and Health Security Programme
Closing date for applications Friday 12th March

University of Leeds Crucible programme is inviting early career academics from different disciplines in institutions to apply for a transdisciplinary programme on Health Systems for Health Security. The programme is designed to introduce new ways of thinking and working and create long-term collaborations. it will have facilitated sessions, speakers from WHO, NGOs, private and public sector and time to collaborate. Participants will be invited to form project ideas together and for selected projects, Leeds University offers small funding awards to explore preliminary data. This will be a virtual event via zoom in 2021: 29-30 March; 24-25 June and 8-9 September and participants should commit to all dates and complete and send the expression of interest form by the closing date (contact K Banger for further information).

Further details: /newsletter/id/64830
Environments by Design: Health, Wellbeing and Place: Virtual conference 1-3 December 2021
Call for abstracts: submission date 25 June 2021

It is tempting to see the recent global concern about health and environments as new. The reality is, it has a long history. The public health profession grew in the housing conditions of the 19th century urban poor, demands for walkable neighbourhoods are long standing and the broader healthy cities agenda globally all pre-date COVID-19. This conference seeks to bring recent experiences and responses into dialogue with longer-standing areas of research into health, wellbeing and environments. The event will have multiple thematic strands built around submissions. The conference welcomes case studies, design proposals, research projects, investigative papers and theoretical considerations as written papers, Zoom and pre-recorded presentations.

Planetary Health Online Course
Planetary Health Alliance in partnership et al:Online and registration open

The course includes undergraduate-level modules, quizzes, activities, discussion forums, and supplementary resources on the following topics: Planetary health and climate change, Heat waves and heat stress, Air pollution and health, Infectious diseases sensitive to climate change, Pathways for planetary health: from social participation to management, Mental and relational health, Food and planetary health, Water and planetary health. The course is free.

Recorded sessions at the Alternative Mining Indaba (AMI)
AMI, February 2021

Seven hundred participants gathered in the virtual 2021 Alternative Mining Indaba (AMI) on 8-12 February from trade unions, faith-based organizations, community-based organizations, civil society organizations, mining companies, academics and other stakeholders. The AMI, which supports a “just and people centred” approach to mining, started as a civil society and community grassroots organizations platform to engage with the business-oriented African Mining Indaba, held annually in Cape Town, South Africa. This year, both events were hosted virtually. The sessions under the AMI theme 'Building forward together pivoting the extractives sector for adaptation and resilience against Covid-19' can be viewed online.


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