Our editorials usually provide a lens on a perspective and issue occurring within east and southern Africa. But what we currently see in different parts of the world are a call to solidarity and people's connection across regions, including to ensure that what is happening locally is not rendered invisible in global policy and accountability. We have seen scenes of human tragedy unfolding in Gaza and India and military violence faced by people protesting against the privatisation of health care in Colombia. In region to region solidarity this newsletter includes a message from the People's Health Movement in our region protesting those facing injury and threats to health in Colombia.
Connecting across regions and peoples seems critical at this moment for what sort of world we will create. Arundhati Roy in 'The pandemic is a portal' (open access) wrote "Whatever it is, coronavirus has made the mighty kneel and brought the world to a halt like nothing else could. Our minds are still racing back and forth, longing for a return to “normality”, trying to stitch our future to our past and refusing to acknowledge the rupture. But the rupture exists. And in the midst of this terrible despair, it offers us a chance to rethink the doomsday machine we have built for ourselves. Nothing could be worse than a return to normality. Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it".
Our two editorials both point to global processes that demand engagement, vigilance, support and sustained activism across regions and peoples if we are to use this rupture for change.
1. Editorial
Without any doubt, it is a success for South Africa, India and other co-sponsors of the TRIPS Waiver proposal, along with progressive political, professional and civil society voices, that the United States of America changed its position on the TRIPS Waiver. The waiver proposes a time-limited waive of patents and other rights related to essential health products for COVID-19 in the World Trade Organisation (WTO) TRIPS agreement.
The TRIPS Waiver proposals are now moving to text-based negotiations. If historical experience on access to medicines and the current power relations are anything to go by, the waiver proposers have grabbed the tail of the proverbial tiger in pushing for more distributed production of vaccines, diagnostics and therapeutics. What is to be done now that the US has agreed to talks?
It is important to understand that this stage does not represent agreement on the waiver. It has now merely advanced as an agenda item for discussion. The terms of the waiver have yet to be worked out. Even once agreed, implementation demands rapid support to increase production capacities for the range of products and systems that are able to distribute them, particularly in resource constrained settings. For all products covered, and particularly for vaccines and therapeutics, the waiver time frame and production capacities would need to be able to deal with current and emergent viral mutations and the updates required for a potentially endemic situation of an evolving virus.
Much remains to be done and the convergence of progressive forces that have pushed the waiver to this point need to robustly take on these remaining challenges to realise equitable access to vaccines, diagnostics and therapeutics.
The text-based negotiations and counter-lobbying by big pharma and others pose a risk of the proposals being diluted. As faced by HIV treatment activists in struggles over access to medicines, the proposals will face an incremental detraction from the largely wealthy countries seeking to preserve economic interests. Germany, the influential European power, remains opposed to the waiver, notwithstanding the US change in position. The tables seem to have turned on this. In the HIV-related Doha negotiations in 2001, the US played the ‘bad cop’ and the Europeans the ‘good cop’. While the European Parliament is largely supportive of the waiver it has limited legislative power, as intellectual property is in the European Commission’s domain. Further, the US trade representative to the WTO has said these negotiations will take time, as if they and not they virus are setting the timeline.
Already, the revisions that South Africa and India have made point to some of the areas that may be weakened: The duration of the waiver, with proposals for 3 years subject to renewal, must be adequate for the distributed transfer of capacities in an evolving situation. The necessary scope of technologies -vaccines, diagnostics, medical devices and therapeutics – is in the revised text and should not be whittled down. It is unclear if it will apply to patents only, or as in the current waiver proposal, to other key elements of intellectual property such as trade secrets, industrial designs and copyright.
The struggle for access to HIV-related medicines has much to teach. Two agreements were reached at the WTO, the 2001 Doha Declaration on Public Health, and the 2003 ‘August 30th Decision’. Both were victories to build on, but proved to fall short in meaningfully addressing access. They allowed rich countries that could not be seen to deny access to HIV treatments to virtue signal, but sustained hurdles for countries in applying the flexibilities they provided. This largely sustained dependency on imports for the lower income countries most affected by HIV.
The Doha declaration did establish the important principle of trade agreements being “interpreted and implemented in a manner supportive of WTO members' right to protect public health”, and levered improved, albeit not universal, access to HIV-related medicines. But, as the current pandemic has shown, they do not provide adequate measures for vaccines, diagnostics and other technologies essential for a public health response, and did not adequately shift priorities, power or production capacities to address unfair barriers in global trade rules to meeting public health challenges.
While the World Health Organisation (WHO) Director General has stood fast in articulating support for the waiver and called the inequity in vaccine access ‘vaccine apartheid’, WHO has less power in this debate and lacks the enforcement mechanism that the WTO has for its rules. WHO was out-manoeuvred by the Gates Foundation and rich countries’ preference for the ACT-Accelerator and COVAX at a time when the deeper proposals for patent pooling and technology transfer were made through the COVID-19 Technology Access Pool (C-TAP). The delay in enabling distributed production and weakness of COVAX is already evident in the shortfalls in supplies reaching low and middle income countries through COVAX, more sharply now with the pandemic demand in India restricting vaccine exports. The African Union recently warned African countries that delays in supplies may mean that they will need to restart their two dose vaccine programmes, or complete them with one dose vaccines that may not be distributed until late 2021. This global failure to meet health need makes virtue signalling on solidarity at the same time as self-protecting a profitable system reliant on patents and other monopoly rights particularly hollow. This is especially so in the context of the massive amounts of public funding that enabled innovations and the public support in opposing high income western countries for the waiver.
It can of course be argued that diplomacy involves compromise and that radical change demands sustained struggle. But the process is itself taking place in a space that is biased towards existing wealth. Negotiations at the WTO run on arcane principles and are largely not transparent. The rich countries hold much sway, including through supportive WTO officials. Important negotiations take place in so-called ‘green rooms,’ where experience indicates that consensus is achieved largely by excluding dissenters from the table. A current proposal by some high income countries to prioritise voluntary licensing arrangements as a solution is a symptomatic treatment, still under the control of big pharma, fails to address the causes of import dependency in Africa and other low and middle income countries and should not be used as a lever to delay or focus attention away from the waiver.
Proposers and supporters of the Waiver have grabbed the tail of the tiger. If the proposals are to avoid a death by a thousand cuts, this is the time to intensify focus. The transparency of these negotiations at the WTO and active vigilance, support and sustained activism will be essential to ensure that the outcomes achieved protect the public health rights and aspirations that have been behind the TRIPS Waiver to date.
The Independent Panel for Pandemic Preparedness and Response (https://theindependentpanel.org), tasked by WHO with reviewing the global management of the COVID-19 pandemic has fulfilled its terms of reference. But despite the best efforts of the panelists, it did not meet the moment. The world might still need an Independent Panel -- but one that is transparent, accountable and participatory.
This Independent Panel report does summarize many of the issues the world has witnessed in the past 14 months: weak pandemic preparedness, lugubrious bureaucracies, and government passivity. It poetically describes global inequalities, including the stark sacrifices of healthcare workers. However, its narrow recommendations sidestep many of these tough challenges in favour of expanding global governance: a Global Health Threats Council with heads of state, adopting new global statements and treaties, greater funding and authority for WHO, and a massive new $10 billion pandemic financing facility. It calls for countries to unite to establish a new international system for outbreak monitoring and alerts.
Some of these recommendations are sensible, others less likely, but in seeking to avoid assigning blame, the panel ducks accountability, and its vision falls short of the scale of the problems revealed by COVID-19.
The recommendations on vaccine access exemplify this. The panel urges funding for COVAX, a worthy goal; but COVAX’s 20% coverage targets cannot reach global herd immunity and prevent the spread of potentially dangerous new variants, and there is no clear plan for the remaining 80%. The panel called for high-income countries to speedily negotiate an intellectual property waiver and donate 1 billion doses by September 1 to low- and middle-income countries. Given the global need of 10 billion doses today, as Madhu Pai argued in his powerful intervention at the launch event of the report, this is vaccine charity, not vaccine equity. The panel does not address the stark inequalities among countries that have fueled the virus.
Troublingly, considering that several of the panelists have been outspoken human rights advocates in the past, the Independent Panel also sidestepped numerous grave human rights abuses in the COVID-19 pandemic: praising the world’s most brutal authoritarian lockdowns as models, without a single caveat about government overreach. In particular, as critics have pointed out, the report omits mention of Chinese suppression of health data, though it is well-documented that this has caused numerous real headaches for WHO.
In March 2020, China’s State Council cracked down on independent research, issuing a directive requiring political vetting of any research on the coronavirus. A Chinese scientist publishing the coronavirus genome sequence on an open platform had his laboratory closed. Over 800 Chinese individuals were sanctioned by police for COVID-related speech, and individual citizen journalists were disappeared while patients who organized online had their chat groups deleted. This is all consistent with the modern history of China’s health system struggling with whether to report up or censor outbreak alerts, from HIV to SARS to, most recently, H1N1.
Given this tortured history with health data, which has been repeated in other countries, it would have been reasonable for the Independent Panel to query when and whether the world will learn of the next outbreak of a new virus. If a UN panel cannot state that suppression of scientists is incompatible with the International Health Regulations, or even with the founding principles of the UN itself, how many doctors might hesitate to blow the whistle?
However, this aversion to sensitive political realities threads through the report, which mentions human rights only once, at the end. The report does describe staggering global inequalities, but without recommendations, though these could have been drawn from many sources: guidance from the UN Human Rights Office, from UNAIDS, from global associations of nurses and other medical workers, or even from the panel’s own commissioned background papers .
These omissions are concerning, but rather than blaming the panellists, we might reflect on the largely closed process. A process grounded in a robust, public consultation with civil society and community voices, frontline health care workers and trade unions, might have produced a different result.
To put an end to and recover from a catastrophe on the scale of COVID-19 requires greater scope. A democratic and public review of what happened and what did not happen in each region, with the public participating to reflect on what we lived through and bore witness to, could build the global public momentum for real learning and change.
Such open and transparent processes have taken place effectively as part of transitional justice in many countries. For example, we can reflect on the Global Commission on HIV and the Law: a global commission on a pandemic hosted by UNDP, it included regional desk reviews based on open submissions, public hearings recorded and archived online, and participation of community activists, who could then use the recommendations and tools that came out of the process to advocate for law and policy reforms at the national level. Its reports continue to be a reliable – and independent -- resource for scholars, officials, policymakers and activists.
An independent commission on pandemic policy could enable wider consultation that creates a lasting historical record, greater trust in science, and a global movement for transformational change. Are we ready to face the difficult truths that such a panel might show us?
This oped is reproduced with permission from Geneva Health Files Newsletter #57 (https://genevahealthfiles.substack.com/p/at-risk-covax-plans-to-vaccinate ) The report of the Independent Panel for Pandemic Preparedness and Response ‘COVID-19: Make it the Last Pandemic’ is included in this newsletter issue and the launch of the report can be viewed at https://www.youtube.com/watch?v=_-OSqIrF0qA&t=2662s. Please send feedback or queries on the issues raised in the oped to the author at sara.davis[at]graduateinstitute.ch.
2. Latest Equinet Updates
The first East and Southern Africa Regional People’s Health University (ESA RPHU) jointly convened by PHM and EQUINET is being held virtually between 29 July and 12 November with the theme ‘Past, present and future struggles for Health equity’. The course aims to build and share evidence, experience, analysis and knowledge on the drivers of health equity to support efforts and activism within countries, as new and existing members of PHM and EQUINET, and in regional co-operation and joint engagement, from local to global level, on shared priorities. The course aims to link key areas of evidence and knowledge to practical experiences and action to share insights and build learning from action. We invite applicants based / working in the east and southern Africa region in state, non-state, community-based institutions involved in health-related work, from health and other sectors and disciplines that have an impact on health equity. See the website link for further details on the course, features for applicant eligibility, and for the online application form. Applicant forms must be received by 25 June 2021. Applicants will be informed by 12 July.
3. Equity in Health
The new Global AIDS Strategy (2021–2026) uses an inequalities lens to identify, reduce and end inequalities that represent barriers to people living with and affected by HIV, countries and communities from ending AIDS. The Strategy outlines a comprehensive framework for transformative actions to confront these inequalities and to respect, protect human rights in the HIV response. It puts people at the centre to ensure that they benefit from optimal standards in service planning and delivery, to remove social and structural barriers that prevent people from accessing HIV services, to empower communities to lead the way, to strengthen and adapt systems so they work for the people who are most acutely affected by inequalities, and to fully mobilize the resources needed to end AIDS.
This paper explores the features and drivers of frameworks for healthy societies that had wide or sustained policy influence post-1978, globally and in selected southern regions, in India, Latin America and East and Southern Africa. The authors implemented a thematic analysis of 150 online documents and reviewed the findings with expertise from the regions covered. Globally, comprehensive primary healthcare, whole-of-government and rights-based approaches have focused on social determinants and social agency to improve health as a basis for development. Biomedical, selective and disease-focused technology-driven approaches have, however, generally dominated, positioning health improvements as subsequent to macroeconomic growth. Historical approaches in the three southern regions that integrated reciprocity and harmony with nature were suppressed by biomedical models during colonialism and by postcolonial neoliberal economic reforms. With widening differences between biosecurity approaches on the one hand and holistic, ecological approaches on the other, economic, the context in the 2000s of ecological, pandemic crises and social inequality is argued to imply that which ideas dominate will be critical for health futures. The authors point to what this implies for building approaches to healthy societies, including for a more equitable circulation of ideas between regions in framing global ideas.
4. Values, Policies and Rights
More than half way into the 74th World Health Assembly, a serious discussion on the efforts to address vaccine inequities is noted in this article to have been conspicuous by its absence. What has instead dominated much of the Assembly proceedings are talks for a pandemic treaty to address health emergencies in the future, and the important, but continuing push towards investigations on the origins of the virus, among other matters. In an issue that recaps the discussions at the current World Health Assembly, the Geneva Health Files in this piece notes "it seems that there has not been enough attention on the here and the now in the midst of all the discussions on preparedness. In our view, this risks looking away from and a silent acceptance to the mounting deaths from COVID-19. It also shows unwillingness to acknowledge and accept the limitations of the current mechanisms that have not met expectations on not only vaccine equity but an overall international mechanism for meeting the needs on diagnostics and treatments for COVID-19". In a packed agenda for the week long remote meeting, the question is raised of why there is no dedicated forum to discuss why vaccines have not been delivered as promised, including to seek accountability for this and to revisit assumptions made about the mechanisms set up for this, including the ACT Accelerator and COVAX.
A recent joint communiqué by 25 Heads of Government and the WHO Director-General have called for the negotiation of a pandemic treaty to enable countries around the world to strengthen national, regional and global capacities and resilience to future pandemics, as a binding instrument to promote and protect health in the context of pandemics. The authors recommend that if WHO Member States decide that an international treaty is the way forward, it would be important to have clarity from the outset on the elements and areas that will be the subject of negotiation, by identifying aspects that the current crisis has revealed are not working. They recommend building on the existing instruments, notably the International Health Regulations and discuss critical issues that should be addressed in such a treaty if negotiations are launched,given that countries differ in needs, levels of development and capacities to implement treaty obligations.
The Independent Panel for Pandemic Preparedness and Response was set up by WHO to review the state of pandemic preparedness before COVID-19, the circumstances of the identification of SARS-CoV-2 and responses globally, regionally, and nationally, particularly in the early months of the pandemic, and its health system, social and economic consequences. This report of the panel indicates that preparedness was limited and disjointed, leaving health systems overwhelmed when actually confronted by a fast-moving and exponentially spreading virus. The panel concluded addressing this gap not requires sustained investment, and new approaches to peer review of country preparedness, and to the international alert system. The panel suggests that the legally binding International Health Regulations (IHR) (2005) did not facilitate rapid action, and that the consequence of delays in response impacted most on already disadvantaged people.
In an open letter to the Ambassador Extraordinary and Plenipotentiary, Colombia, the Peoples' Health Movement urged the government to abide by the Constitution, stop the violence, and join hands with citizens in defeating COVID urgently, and enacting policies that promote people’s health, equality and social justice. The PHM wrote: "We note with deep concern the criminalisation of protest and high levels of violence perpetrated on legitimate and peaceful protestors by the Colombian government security forces and armed civilian groupings. Credible sources report the use of lethal weapons, including rifles and semi-automatic guns, against protesters around the country by police. At least 37 people have been killed; some reports give larger numbers. There are also reports of disappearances. As a result of extreme militarisation, some cities, including Cali and Palmira, are running out of food and medicine supplies; Internet signals and social networks essential for communication among citizens and communities have been blocked; and levels of fear and uncertainty are growing among the population. The protests occur against the background of the COVID-19 pandemic. COVID is exacerbating poverty and inequality. The number of Colombian people living in extreme poverty grew by 2.8 million last year. And more and more people face hunger.
The authors investigated how gender power relations within households affected women’s health outcomes in Simiyu region, Tanzania. Women who reported being able to make their own health decisions were 1.57 times more likely to use condoms. Women who reported that they decide how many children they had also reported high contraception use. Seeking care at the health facility was also associated with women’s autonomy for making major household purchases. The authors observe that the association between decision-making and other gender domains with women’s health outcomes highlights the need for heightened attention to gender dimensions of intervention coverage in maternal health. They suggest that future studies should integrate and analyze gender-sensitive questions within coverage surveys.
5. Health equity in economic and trade policies
This paper alerts to the implications of a Gate’s funded project, Water Efficient Maize for Africa (WEMA), now known as TELA, for sub-Saharan countries. Bayer, with a stated aim of solving smallholder farmers’ poverty woes, is stated by the authors to be using South Africa’s permissive biosafety regulatory environment to multiply obsolete and deficient genetically modified (GM) seeds, for export to the countries in the project, despite lack of success with drought tolerance and insect resistance in South Africa. The paper indicates that the industry’s claims of the insect resistant trait’s ability to combat the now persistent fall armyworm in Africa have been invalidated with the emergence of resistance in countries in North and South America, including Brazil. The authors question why African countries are allowing the dumping of these obsolete technologies into their countries and urge African governments to reject the imposition of outdated GM technologies and to adopt workable and holistic solutions, including to support food systems.
With the Biden-Harris Administration taking the United States out of the "blocking" countries, all eyes are now on Europe and Japan among others as momentum grows for text-based negotiations on the temporary TRIPS waiver for combating the Covid-19 pandemic. The World Trade Organisation director-general Ms Okonjo-Iweala met with German Chancellor Angela Merkel and the TRIPS waiver is likely to have been included in the talks cannot be ruled out in the wake of a global call from 100 former leaders, including half of the US Democratic Congressmen and women, Nobel Laureates, and around 400 international civil society organizations, to agree to the TRIPS waiver. The EU's evolving positions seem to be focused on a "third way" approach—promoted by the European Union and several members of the Ottawa Group- that seeks to address issues such as export restrictions, more bilateral and other licensing agreements, and ensuring the supply of vaccines by countries which have huge stocks of unused vaccines. The authors note that the insistence on a "360 degree view" on the waiver could involve a payment from the waiver co-sponsors, as powerful pharmaceutical companies have also stepped up their campaign against the waiver.
The African Centre for Biodiversity (ACB) exposes how the two cyclones that battered Mozambique and parts of Malawi and Zimbabwe in March and April 2019 must be understood against the backdrop of the political and economic drivers of ecological degradation. These include development loans and aid, rapacious natural resource extraction and social and cultural displacement. The authors examine the interconnections between climate change, deforestation, agricultural expansion and resource extractivism, as drivers of social and political instability and food insecurity in these countries, while enriching a small political elite. The paper unpacks how the national and international disaster response to the cyclones inadequately addressed the scale of the overlapping crises that the cyclones revealed, calling for approaches that go beyond narrow disaster management to one based on equity and justice in local economies and in relationships with the global economy.
By refusing to lift the patents on vaccines against Covid-19, the author argues that western high income countries have shown an inability to take into account the needs of the South. Beyond the right to produce, the commentary proposes that the debate on the reform of international taxation cannot be reduced to a discussion between rich countries aimed at sharing the profits currently located in tax havens. Plans being discussed at the Organisation for Economic Cooperation and Development envisage that multinationals will make a single declaration of their profits at the global level, in itself is an excellent thing. But when it comes to allocating this tax base between countries, the plan is to use a mixture of criteria (wage bills and sales in different territories) which in practice will result in rich countries receiving more than 95% of the reallocated profits, leaving negligible funds for poor countries. The author suggests that low income countries need to be at the table in such discussions.
6. Poverty and health
This report provides a comprehensive summary of global progress on improving water, sanitation, hygiene, waste management and environmental cleaning (WASH) in health care facilities and is intended to stimulate solution driven country and partner actions to further address major gaps. It provides practical steps to improving WASH in health care facilities, selected country case studies illustrating bottlenecks, gaps, and successful strategies, and recommendations for addressing gaps and sustaining services.
Covid-19 has again demonstrated the significance of safe, accessible and affordable water for all and the enormous disparities in service provision while at the same time dealing a blow to public water and sanitation operators around the world due to massive drops in revenues, rapidly rising costs and concerns about health and safety in the workplace. This book provides the first global overview of the response of public water operators to this crisis, shining a light on the complex challenges they face and how they have responded in different contexts. It looks specifically at ‘public’ water and asks how public ownership and public management have enabled (or not) equitable and democratic emergency services, and how these COVID-19 experiences could contribute to expanded and sustainable forms of public water services in the future
7. Equitable health services
This study explored competing discourses that shape adolescent fertility control in Zambia, through individual interviews and 9 focus group discussions with adolescents and other key-informants. Adolescent fertility discussions were influenced by marital norms and Christian beliefs, as well as health and rights values. While early marriage or child-bearing was discouraged, married adolescents and adolescents who had given birth before faced fewer challenges when accessing Sexual and Reproductive Health information and services compared to their unmarried or nulli-parous counterparts. Parents, teachers and health workers were conflicted about how to package Sexual and Reproductive Health information to young people, due to their roles in the community. The authors assert that the competing moral worlds, correct in their own right, viewed within the historical and social context unearth significant barriers to the success of interventions targeted towards adolescents’ fertility control in Zambia, propagating the growing problem of high adolescent fertility, and suggest proactive consideration of these discourses when designing and implementing adolescent fertility interventions.
Most African countries expected to receive tens of millions of doses manufactured by Indian companies. But now that New Delhi has halted all exports, African officials have no other choice but to look elsewhere — and in many cases, that’s leading them to Chinese and Russian suppliers. So far, Covax’s vaccine distribution has failed to meet the needs of developing countries with just 43.4 million doses spread thinly across 119 countries. According to the USAID fact sheets on the US COVID-19 response, the United States has not provided any aid or relief to African countries so far this year. While Washington is refusing to ship vaccines overseas, Chinese vaccine manufacturing output is steadily rising. Both Sinopharm and Sinovac producers now say they are capable of producing at least 2 billion doses in 2021 alone. The author notes that it is entirely possible that the Chinese will be positioned to fill the supply gap in 2021 for a number of low income countries.
The authors identified gaps in Mozambique in the implementation of existing national policies and laws for domestic violence in the services providing care for domestic violence survivors, through content analysis of guidelines and protocols and interviews with institutional gender focal points. While the guidelines were seen to be relevant, many respondents identified gaps in their implementation, due to weaknesses in penalties for offenders, the scarcity of care providers with appropriate training and socio-cultural factors.
The move towards universal health coverage is premised on having well-functioning health systems. The authors present an approach to provide countries with information on the functionality of their systems in a manner that will facilitate movement towards universal health coverage. They propose four capacities: access to, quality of, demand for essential services and its resilience to external shocks and provide results for the 47 countries of the WHO African Region based on this. The functionality of health systems in these countries ranged from 34.4 to 75.8 on a 0–100 scale. Access to essential services represents the lowest capacity. Funding levels from public and out-of-pocket sources represented the strongest predictors of system functionality. The authors propose that such assessment on the capacities that define system functionality can help countries to identify where to focus to improve the functioning of the health system.
8. Human Resources
This study used physician registry data to analyse patterns of emigration and return migration only among South Africa-trained physicians registered to practice in top destination countries such as Australia, Canada, New Zealand, the USA or the UK between 1991 and 2017, which represent the top five emigration destinations for this group. It found a 6-fold decline in emigration rates from SA between 1991 and 2017, with declines in emigration to all five destination countries. About one in three South Africa physicians returned from destination countries as of 2017. Annual physician emigration fell by 0.16% for every $100 rise in South Africa gross domestic product per capita. As of 2017, 21.6% of all South Africa physicians had active registration in destination nations, down from a peak of 33.5% in 2005, a decline largely due to return migration. Changes to the UK’s licensing regulations were seen to be likely affected migration patterns while the Global Code of Practice on International Recruitment contributed little to changes. The authors propose that return migration monitoring be incorporated into health workforce planning.
9. Public-Private Mix
Corporations across the globe are capturing more and more of the public sphere, encroaching on all aspects of people’s lives. This publication compiles analyses of different country experiences on public-private partnerships that in themselves have become a powerful tool to achieve what the authors observe is starting to look like the privatisation of life itself. Feminist researchers from the Global South have spent a year researching this theme in their home countries, including in Kenya and Zimbabwe. Together they present an analysis and critique of the state of PPPs today, and the consequences for women’s lives, communities’ wellbeing, and public health and social services.
From August to December 2019, the authors provided free HIV self-test kits, a new product, to 26 pharmacy shops in Shinyanga, Tanzania to sell to the local community. Sales volume, price, customer age and sex were measured using shop records, together with willingness-to-pay to restock test kits. Purchase prices ranged from 1000 to 6000 Tsh. Within shops, prices were 11.3% higher for 25 to 34 and 12.7% higher for 45+ year olds relative to 15 to19 year olds and 13.5% lower for men on average. Although prices varied between shops, prices varied little within shops over time, and did not converge over the study period or cluster geospatially. Shopkeepers charged buyers different prices depending on buyers’ age and sex and there was low demand among shopkeepers to restock at the end of the study. The authors propose that careful consideration is needed to align the motivations of retailers with public health priorities while meeting their private for-profit needs.
10. Resource allocation and health financing
This paper estimated per-day unit costs of COVID-19 case management for patients from costs in three public COVID-19 treatment hospitals in Kenya, and using input prices from a recent costing survey of 20 hospitals in Kenya and from market prices for Kenya. The paper details the per-day, per-patient unit costs for asymptomatic patients and patients with mild-to-moderate COVID-19 disease under home-based care, the significantly higher costs of managing the same patients in an isolation centre or hospital, and the per-day unit costs for patients with severe COVID-19 disease managed in general hospital wards and in intensive care units. COVID-19 case management costs were found to be substantial, ranging between two and four times the average claims value reported by Kenya’s public health insurer. The authors indicate that Kenya will need to mobilise substantial resources and explore service delivery adaptations to reduce unit costs.
The authors investigated what financial changes in low income countries (LICs) lead to childhood immunisation changes, controlling for population density, land area and female years of education. During 2014–2018, gross domestic product per capita, total or private health spending per capita and aggregated development assistance for health per capita were not significant predictors of vaccination coverage in LIC. Government health spending per capita and total/government spending per birth on routine immunisation vaccines were significant positive predictors of vaccination coverage.
11. Equity and HIV/AIDS
This paper assessed the extent in East Africa to which policies reflect calls for HIV-NCD service integration, through document review. Integrated delivery of HIV and NCD care is recommended in high level health policies and treatment guidelines in four countries in the East African region; Kenya, Rwanda, Tanzania and Uganda, mostly relating to integrating NCD care into HIV programmes, in response both to increasing levels of NCDs and more person-centred services for people living with HIV. Other countries, however, have no reported plans for HIV and NCD care integration.
12. Governance and participation in health
This handbook aims to support people across the city of Cape Town assert their democratic rights, and to come together to take charge of their wards. Unemployment, poverty and violence are deeply entrenched in the city which remains spatially divided and stubbornly unequal and the handbook discusses ways to bring everybody living in the ward together, across historical divides, to deliberate and get involved in finding practical solutions to the problems. This handbook supports this with a ‘manifesto of ordinary ideas’ and practical ideas and tactics to reclaim local democracy.
Malawi declared a state of national disaster due to the COVID-19 pandemic on 20th March 2020 and registered its first confirmed coronavirus case on 2 April 2020. This paper documents decisions made in response to the COVID-19 pandemic from January to August 2020. Malawi's response to the pandemic was found to have been multi-sectoral and implemented through 15 focused working groups termed clusters. Each cluster was charged with providing policy direction in their own area of focus. All clusters then fed into one central committee for major decisions and reporting to head of state. This led to a range of responses, including an international travel ban, school closures at all levels, cancellation of public events, decongesting workplaces and public transport, mandatory face coverings and testing symptomatic people. Supportive interventions included risk communication and community engagement in multiple languages and over a variety of mediums, as well as efforts to improve access to water, sanitation, nutrition and unconditional social-cash transfers for poor urban and rural households.
13. Monitoring equity and research policy
The authors explored how health research knowledge is translated into policy in Zambia, and what facilitates or hinders this, from document review and key informant interview. While the document review suggested policy efforts to promote knowledge translation, the interviews raised challenges in coordination and linkages between knowledge and policy-making processes, attributed to lack of research knowledge translation capacity, limited resources and lack of knowledge hubs. However, the authors suggest that emerging local research leadership and a stock of underused local health are an opportunity to enhance knowledge to policy links, if supported.
14. Useful Resources
Dala Kitchen (More Than A Cookbook) is a celebration of the work of Cape Town Together. During 2020, in response to the Covid-19 pandemic, thousands of people came together to support one another in a range of creative and radically generous ways. Through a series of recipes, how-to's, articles and stories Dala Kitchen tells the story of Cape Town Together, the CANs that comprise it, and the people that are at the heart of the network. Together, these stories capture a moment in time and demonstrate that, in the words of Arundhati Roy "[a]nother world is not only possible, she is on her way.". The version on this website is a low resolution version- a higher resolution copy will replace this shortly.
The Health Equity Assessment Toolkit (HEAT) is a software application that facilitates the assessment of within-country health inequalities. It was developed for use on desktop or laptop computers and mobile devices and has a Health Equity Monitor database and a version that allows users to upload and work with their own database. The application allows users to explore current or time trends in inequality in a setting of interest, such as a country, province or district; and compare inequality between settings. Inequalities are visualized in a variety of interactive graphs, maps and tables.
15. Jobs and Announcements
The late Thandika Mkandawire contributed immensely to an intellectual project for a rejuvenation of Africa's developmental. This conference, invites contributions and papers that critically reflect on the exchange between the different literatures and imaginations on development, democracy and social policy, including critical reflections on the social policy responses to COVID-19 in the context of the stratified, segmented, and segregated social policy architecture that has been the staple of international agencies in the last three to four decades. Contributions need not be limited to the African context or experience, but should speak to experiences from the Global South.
The London School of Hygiene & Tropical Medicine invites applications from candidates from Sub-Saharan Africa for fully-funded 4-year PhD studentships to start a research degree programme on 3 January 2022. There are three studentships available, linked to ongoing research projects that address the links between hygiene and health in Sub-Saharan Africa. Further information and applicant entry requirements are provided on the website link shown.
The University of the Witwatersrand’s School of Public Health invites suitably qualified candidates to apply for a full-time funded Master Degree Programme in the field of Implementation Science. The focus is on implementation research on infectious diseases of poverty, including the neglected tropical diseases, malaria, tuberculosis, HIV/TB co-infection and COVID-19. Implementation science is a growing field that supports the identification of health system bottlenecks and approaches to address them, and is particularly useful in low- and middle-income countries where many health interventions do not reach those who need them the most.
The African Programme on Rethinking Development Economics (Aporde) and the South African Research Chair in Industrial Development (SARChI Industrial Development) are delighted to announce the inaugural Thandika Mkandawire Prize for Outstanding Scholarship in African Political Economy and Economic Development. This prize is to be awarded annually to recognise outstanding research papers by African scholars. A second award, the Thandika Mkandawire Prize for Young Scholars in African Political Economy and Economic Development, is specifically for young researchers.
The Emerging African Scholars Program in Africa is hosting a full day virtual PhD Workshop to provide guidance for emerging scholars on career paths, help sharpen research skills and address the challenges that African PhD students face. The program is open to doctoral students from Africa whose research focus is on non-profit management, philanthropy, civil society, social entrepreneurship and voluntary action studies in Africa. Students who have defended a dissertation proposal, not yet defended a dissertation proposal and whose dissertation plans are not yet fully formed are all encouraged to apply. This workshop is free of charge and will be conducted online.
The Global Infectious Disease research training program addresses research training needs related to infectious diseases that are predominantly endemic in or impact upon people living in developing countries. The training focuses on a major endemic or life-threatening emerging infectious disease, neglected tropical disease, infections that frequently occur as a co-infection in HIV infected individuals, or infections associated with non-communicable disease conditions of public health importance in low- and middle-income countries.
The Fogarty Global Environmental and Occupational Health program calls for applicants from institutions in low- or middle-income countries to function as regional hubs for collaborative research, data management, research training, curriculum and outreach material development, and policy support around high-priority local, national and regional environmental and occupational health threats. GEOHealth hubs are supported by two coordinated linked awards to a LMIC institution for research and a U.S. institution to coordinate research training. Together the GEOHealth hubs form the GEOHealth network, a platform for coordinated environmental and occupational health research and research training activities.
This short course aims to provide academic staff, students, researchers, reviewers and editors with the understanding of the global health within the African context and beyond. The course is delivered online over 10 weeks.
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