EQUINET NEWSLETTER 229 : 01 September 2021

1. Editorial

Youth mental health facing a deficit of caring
Pelagia Nziramwoyo, Wilson Asibu, Joy Muhia, Nadine Nanji, Rene Loewenson

Jacob, an 18 year old youth, lives in an East African country. When the pandemic came to his city, his boarding school shut and he left everything, including his friends, and travelled to be at home during the lockdown. He thought this would be the best place, but once home he felt rising stress over lack of privacy in an overcrowded home, over trying to keep learning without adequate internet access, and over high data charges to keep in contact with teachers or friends. He felt pressure from his parents to keep costs down while sustaining his learning to merit the fees they had paid. They didn’t seem to understand how the isolation and pressure was affecting him, and were preoccupied with their own demands. He became more and more withdrawn and depressed, couldn’t talk to anyone, and fell further and further behind in his studies. When the school re-opened he didn’t have the confidence to return. He felt depressed about his future, and that his life was not worth continuing.

Jacob’s story is not unique. Young people from different east and southern Africa countries have reported or been found to experience a range of stresses and anxieties as a result of the COVID-19 pandemic. Even before the pandemic, young people in the east and southern Africa (ESA) region were documented to experience depression, anxiety, post-traumatic stress disorders and suicidal ideas, while studies also noted the under-reporting of mental illness in young people.

In conversations with forty youth over 18 years of age from two ESA countries, many reported anxieties over relationships, parental expectations and school performance, as well as stresses from living in conditions of poverty, insecurity, hunger and social violence. These conditions were present before the pandemic. However, the pandemic was said to have worsened these sources of stress. Lockdowns in overcrowded homes, closures of schools and community centres disrupted various forms of peer and adult support, and young people reported feeling rising anxiety and frustration over their education and future. The youth pointed to stresses during the pandemic from increased risks of domestic violence and sexual abuse during lockdowns, from lost income, high food, data and other costs, and from uncertainty over the future.

Young people noted in the conversations how they were coping with these stresses. They said that social support from friends and peers, from supportive adults in and beyond the family, and from religious institutions played an important role in helping them cope with mental stress. So too did having funds to face challenges and sustain education, and having access to outdoor recreation and cultural activities. Online information, education, games and communication helped to sustain relationships and activities, although data charges were often not affordable. Some reported more harmful coping strategies, such as consumption of alcohol and harmful drugs to suppress anxieties.

The literature and the reports from young people themselves indicate that local services generally deal with youth mental health poorly, or not at all, and that there are limited youth-friendly mental health services. This has often placed the burden of care on families who themselves lack the information and tools to respond, and who still experience a stigma around mental disorders. While there is some report of youth counselling services, art therapy, online counselling, and digital applications to promote wellbeing, there is an evident need to expand the availability of a range of mental health services and capacities to manage the spectrum of disorders affecting young people. In the conversations the youth also observed that families, youth peer counsellors and key adults should get greater support to promote communication and to help those facing mental health challenges. They prioritised prevention of mental ill-health, and recommended investment to tackle drivers of mental stress. They called for investment in jobs and enterprise opportunities, recreation facilities, school services, safe communities and information, and in opportunities for young people to participate in decisions affecting their lives in more mutually respectful interactions with authorities.

The way the region deals with this issue, including in the plans for the recovery from the pandemic, will have long term consequences. Jacob and others like him are the future. In one conversation, one young woman facing stress and feeling excluded from support said “We are in a country living alone and no one cares”. This is a cry for us to address the unfair and unacceptable gap in recognising and responding to youth mental health, as a critical element of the ‘complete mental, physical and social wellbeing’ envisaged in the definition of ‘health’.

We welcome your feedback or queries on the issues raised in this oped or interest in this work– please contact the EQUINET secretariat. You can read the literature review on youth mental health (EQUINET Discussion paper 122) at https://tinyurl.com/4vbj87rn

2. Latest Equinet Updates

Diss 123: Equity in the public and private health sector responses to COVID-19 in east and southern Africa
Chanda-Kapata P: EQUINET, Harare, 2021

The COVID-19 pandemic has strained the already stretched health systems in East and Southern Africa (ESA) countries, and was affected by previous levels of public leadership and engagement with the private sector. The response involved a range of collaborations between the public and private sectors. Country plans were public sector-led, in co-operation with international development partners, with partnerships between the public and private sectors in the response both in and beyond the health sector. This desk review commissioned by EQUINET presents evidence from online materials and EQUINET steering committee key informants on features of the public and private sector health system roles in the response to COVID-19. The work differentiates the private for-profit sector from the private not-for-profit sector. The review explores the equity implications of these responses, and suggests implications for (re)investing in strengthened public health system preparedness and functioning and private sector co-ordination in ESA countries.

Diss paper 122: Youth mental health in the context of COVID-19 in East and Southern Africa: A desk review
Muhia J; Nanji N: IWG, TARSC, EQUINET: Harare, 2021

This desk review reports available published information relating to youth mental health in east and southern Africa (ESA). It was implemented within and informs collaborative work on youth mental health in the region in EQUINET between Training and Research Support Centre (TARSC), the International Working Group for Health Systems Strengthening (IWGHSS) and the pra4equity and PAROnline network, specifically Country Minders for Peoples Development (CMPD), Malawi, and the Centre for Youth Driven Development Initiative (CFYDDI), Uganda. The desk review explored patterns and determinants of youth mental health in the region; how the coronavirus (COVID-19) pandemic and responses to it have affected this; where youth seek and obtain support for mental health needs and the perceived challenges and gaps. It presents recommendations for improving the responses to mental health challenges. The COVID-19 lockdown and social distancing measures led to difficulties, with online learning and loss of work and rising costs intensifying some factors and increasing mental stress, as well as suicidal ideas and substance and alcohol abuse among youth. Youth mental health is a pertinent issue for the ESA region, more so due to the impact of the pandemic, but is not well recognised by formal services and policy. The review evidence points to a need, intensified by COVID-19, to co-create with young people strategies for preventing and responding to youth mental illness and its drivers and consequences.

Video clips from the East and Southern Africa Regional Peoples Health University, Theme: Past, present and future struggles for Health equity
EQUINET and PHM: Clips from weeks 2 and 3, August 2021

The first East and Southern Africa Regional People’s Health University (ESA RPHU) jointly convened by PHM and EQUINET is being held virtually between July 29 and November 12 2021 with 10 weeks of interactive sessions to build and share evidence, experience, analysis and knowledge on health equity to support regional co-operation and joint engagement, from local to global level, on shared priorities. The course programme is at https://www.equinetafrica.org/rphu/rphu-programme with different issues affecting health equity in the region and learning from COVID-19. Open access online dissemination of plenary presentations and resources is available on the RPHU resources page. It currently includes video clips of a panel discussion moderated by Dr Rene Loewenson TARSC/EQUINET with Dr Firoze Manji, Daraja Press and Professor Patrick Bond, University of Western Cape, explored the Political Economy of Health in East and Southern Africa; David van Wyk from Benchmarks Foundation on a case study of health equity in mining in South Africa; Mariam Mayet, Executive Director of the African Centre for Biodiversity on global and corporate activities in industrial agriculture and gene technologies in relation to malaria; Thusang Butale BFTU and Danny Gotto I4Dev on experiences of extractive activities in Botswana and Uganda; Masuma Mamdani, EQUINET on social determinants of health; Shakira Choonora on an Intersectional lens to health inequities; Sue Godt on Emerging commercial determinants of health and the reality in the region and Peter Binyaruka, Ifakara Health Institute (IHI), Tanzania presentation on co-financing to address social determinants of health equity. The Resources page is being updated with new content as the course progresses.

3. Equity in Health

10 Images that illustrate the shameful global vaccine inequity
Pai M: Microbiology online, August 2021

This series of 10 images tell the story behind the ‘great vaccine apartheid’ argued by the author to be the single biggest moral and scientific failure during this the COVID-19 pandemic.

Health Security and the COVID-19 Pandemic: Health and Security for Whom?
Almeida C: Think Global Health, August 2021

The concept of health security has long been prominent and controversial in global efforts to protect health. The author asserts that paradoxically, the COVID-19 pandemic has provided evidence of this concept's failure and reignited interest in it for the post-pandemic world. The article outlines how past shortcomings and present interest highlight the continued failure to address political and economic structural problems that generate inequities and produce neither health nor security for most of the world’s population. Thinking beyond the pandemic, she proposes that policymakers should reject health security and center policy on promoting human solidarity and protecting the human right to life.

Risk Factors, Mental Health and Psychosocial Needs, and Coping Among the Children Under the Care of Female Sex Workers and Adolescent Girls Surviving in Sex Work Settings
Kyomya M; Mukwaya R; Achan E; et al: PEAH – Policies for Equitable Access to Health, Geneva 2021

This assessment identified risk factors, mental health, psychosocial needs and mechanisms of coping by children under the care of female sex workers (FSWs) and adolescent girls surviving in sex work settings of Kampala, Gulu, Mbarara, Wakiso and Busia in Uganda. The study found stigma and discrimination, poor accommodation facilities, sexual abuse by clients of sex workers and substance abuse among children, adolescent girls and mothers, gender-based violence and low levels of literacy, with a high prevalence of mental health disorders, including depression, suicide, post traumatic stress symptoms and generalised anxiety disorder. Adolescent girls surviving in sex work settings, presented higher rates of common mental health disorders. particularly those aged 11-14 years. The study found that the risk factors are not addressed given that children under the care of FSWs and adolescent girls are often neglected by systems.

Which UHC? Features for Equity and Universalism
Loewenson R: International Journal of Health Policy and Management x(x), 104, doi:10.34172/ijhpm.2021.89, 2021

Equity and universality are implicit in universal health coverage (UHC), although ambiguity has led to differing interpretations and policy emphases that limit their achievement. Diverse country experiences indicate a policy focus on differences in service availability and costs of care, and neoliberal policies that have focused UHC on segmented financing and disease-focused benefit packages, ignoring evidence on financing, service, rights-based and social features that enable equity, continuity of care and improved population health. Public policies that do not confront these neoliberal pressures limit equity-promoting features in UHC. In raising the impetus for UHC and widening public awareness of the need for public health systems, COVID-19 presents an opportunity for challenging market driven approaches to UHC, but also a need to make clear the features that are essential for ensuring equity in the progression towards universal health systems.

4. Values, Policies and Rights

A critical cartography of domestic violence policies in Mozambique
Jethá E; Keygnaert I; Seedat M; et al: Reproductive Health 18 (169), 1-11, 2021

The authors mapped the Mozambican legislative and policy responses to domestic violence to analyse their alignment with international treaties and conventions and with each other, using a critical cartography and content analysis. The authors identified a total of fifteen national domestic violence documents of which five were on laws, one on policy and nine institutional strategic/action plans. Most of the national domestic violence documents focused on strategies for assistance/care of victims and prevention of domestic violence. Little focus was found on advocacy, monitoring and evaluation. Mozambique has signed several international and regional treaties and conventions on domestic violence, but the authors found an inconsistency in the alignment of international treaties and conventions with national policies and laws, and a gap in the translation of national policies and laws into strategic plans and multi-sectoral approaches.

COVID-19: the turning point for gender equality
Fisseha S; Sen G; Adhanom Ghebreyesus T; et al: The Lancet 398(10299) 471-474, 2021

The authors raise that the impacts of the COVID-19 pandemic have gone far beyond the disease itself. In addition to the increasing number of COVID-19 deaths, the pandemic has deepened social and economic inequalities. These indirect impacts have been compounded by pervasive gender inequalities, with profound consequences, especially for women, girls, and people of diverse gender identities. There has been an escalation in gender-based violence within households, increasing numbers of child marriages and female genital mutilation, and an increased burden of unpaid care work, with impacts on mental health. Communities of people affected by HIV are, again, at the crossroads of injustice and targeted discrimination. Measures to control the pandemic have reduced access to essential health and social welfare services, including sexual and reproductive health services, reduced employment and labour force participation, and decimated many household incomes. Here again, women have borne the brunt of marginalisation, particularly those working in the informal sector.

Domesticated Poly-Violence Against Women During the 2020 Covid-19 Lockdown in South Africa
Nduna M; Oyama Tshona S: Psychological Studies, doi: https://doi.org/10.1007/s12646-021-00616-9, 2021

In South Africa, an increased risk for gender-based domestic violence against women during the COVID-19 lockdown was reported by various sources including the national gender-based violence call centre (GBVCC), the South African Police Service and the civil society. Public life, which is frequently a coping mechanism and an escape for some women and girls at risk of domestic violence, was curtailed by the lockdown rules that forbade movement. Informal sources of help for victims of abuse were limited due to closure of economic activities, and community-based services for domestic violence were not permitted to open. Some victims of domestic violence struggled with public transport to access informal help, or to visit the police, social workers and other sources of help. Some organisations offered online and telephone services and the authors suggest that the risk of violence during crisis periods could be averted by a more sustained and wider focus on reducing risk of all forms of violations against women.

Proposal for a WHO treaty on pandemics raises concerns
Ramakrishnan N; Gopakumar K: Third World Network, 2021

This policy brief critically analyses the option of a new pandemic treaty or other international legal instrument to enhance the pandemic preparedness and response. Part I provides an account of the origin of the idea of the pandemic treaty. Part II examines whether there is any legal vacuum which prevents the needed pandemic preparedness and response. Part III deals with the fragmentation of international health response and raises the concern that the new treaty will exacerbate fragmentation instead of consolidating the response. Part IV explains what to expect from the new treaty and the major process-related issues involved in the new pandemic treaty negotiations. The authors argue that instead of developing a new international instrument it is better to strengthen or amend the existing IHR.

5. Health equity in economic and trade policies

Botswana pays equivalent of $15 a dose for Sinovac's COVID-19 vaccine
Reuters: Gaborone, Botswana, July 2021

Botswana's health minister Edwin Dikiloti said on Friday in an address to parliament that the government was paying the equivalent of $15 a dose for the COVID-19 vaccine developed by China's Sinovac Biotech and almost $29 a dose for U.S. company Moderna's vaccine. The minister added that the COVAX facility co-led by the WHO had only delivered 82000 doses despite an upfront payment the government had made as a self-financing participant, in the hopes of securing far more doses. An AU arrangement is expected to deliver over 1.1 million doses of Johnson & Johnson's vaccine in the third and fourth quarters. Apart from the vaccines paid for, the Indian government donated 30000 doses of the COVISHIELD vaccine manufactured by the Serum Institute of India and China donated 200000 doses of Sinovac's vaccine, while Botswana is in talks with Pfizer about a possible 2 million dose deal. In 2019, Botswana had a total population of 2.3 million people.

New consortium working to boost vaccine production in South Africa
World Health Organisation: WHO, Geneva, 2021

The Medicines Patent Pool and the World Health Organization, Afrigen Biologics Limited, the Biologicals and Vaccines Institute of Southern Africa (Biovac), the South African Medical Research Council and Africa Centres for Disease Control and Prevention have signed a letter of intent to bring together partners to establish the South African mRNA technology transfer hub to enable greater and more diversified vaccines manufacturing capability, to respond to the current COVID-19 pandemic and future pandemics.

Profiteering from vaccine inequity: a crime against humanity?
Hassan F, Yarney G, Abbasi K: BMJ, 374:n2027, 2021

The rich world is refusing to share vaccines with poorer countries speedily or equitably. Whereas 60% of the population in the UK is fully vaccinated, in Uganda it is only 1%. The 50 least wealthy nations, home to 20% of the world’s population, have received just 2% of all vaccine doses. The authors argue that the rich world should be ashamed. They present evidence of the corporate profits being made on vaccines and posit that pandemic profiteering is a human rights violation that demands investigation and scrutiny. The Universal Declaration of Human Rights states that everyone has the right “to share in scientific advancement and its benefits. The excess of deaths in Africa, Latin America and Asia is attributed to: a free market, profit driven enterprise based on patent and intellectual property protection, combined with a lack of political will. Contrary to claims, it is possible to make enough vaccines for the world and state that the moral scandal, enabled by corporate and political permission of mass death, is tantamount to a crime against humanity.

Tobacco supply and demand strategies used in African countries
Crosbie E; Defrank V; Egbe CO: Bulletin of the World Health Organisation 99(7), 539-540, 2021

The number of smokers in Africa is anticipated to rise from 15.8% in 2010 to 21.9% by 2030, the largest projected increase in the world. The authors examine the role of the main tobacco companies operating in Africa: Philip Morris International, British American Tobacco, Imperial Brands and Japan Tobacco International, in this rise, and in the illicit trade in tobacco to force market entry into new and emerging markets. The authors point to the tactics used, including: preventing policy measures designed to control illicit tobacco trade by entering into voluntary partnerships with law enforcement and custom agencies, with governments not effectively enforcing existing laws; and using promotional tactics, including price reductions, coupons and giveaways to increase the demand and usage of tobacco. Tobacco companies consistently claim on their websites, in the media and in policy circles that they aim to stop illicit tobacco trade and only market to adult smokers. However, the authors raise that these tactics are recruiting a new generation of smokers in Africa.

6. Poverty and health

Access to water, sanitation and hygiene services in health facilities in sub-Saharan Africa 2013–2018: Results of health facility surveys and implications for COVID-19 transmission
Kanyangarara M; Allen S; Jiwani S S; et al: BMC Health Services Research 21(601), 1-11, 2021

The authors assessed the availability of water, sanitation and hygiene and standard precautions for infection prevention in 16456 health facilities across 18 countries in sub-Saharan Africa, as well as inequalities by location and managing authority, using data from health facility surveys conducted between 2013 and 2018 in 18 sub-Saharan African countries. Across countries, an estimated 88% had an improved water source, 94% had an improved toilet, 74% had soap and running water or alcohol-based hand rub, and 17% had standard precautions for infection prevention available. There was wide variability in access to water, sanitation and hygiene services between rural and urban health facilities and between public and private facilities, with consistently lower access in both rural and public facilities. In both rural and urban areas, access to water, sanitation and hygiene services was better at health facilities than households. Availability of water, sanitation and hygiene services in health facilities in sub-Saharan Africa has improved but remains below the global target of 80 % in many countries, with improvement essential to minimize the risk of COVID-19 transmission.

Burnt by the scorching sun: climate-induced livelihood transformations, reproductive health, and fertility trajectories in drought-affected communities of Zambia
Rosen J G; Mulenga D; Phiri L; et al: BMC Public Health 21(1501), 1-14, 2021

The authors explored the impact of severe and prolonged droughts on gendered livelihood transitions, women’s social and financial wellbeing, and sexual and reproductive health (SRH) outcomes in two Zambian provinces through in-depth interviews and focus group discussions with 165 adult women and men in five drought-affected districts, and key informant interviews with civic leaders and healthcare providers. Across districts, participants emphasized the toll drought had taken on their livelihoods and communities, leaving farming households with reduced income and food, with many turning to alternative income sources. Female-headed households were perceived as particularly vulnerable to drought, as women’s breadwinning and caregiving responsibilities increased, especially in households where women’s partners out-migrated in search of employment. As household incomes declined, women and girls’ vulnerabilities increased: young children increasingly entered the workforce, and young girls were married when families could not afford school fees and struggled to support them financially. With less income due to drought, many participants could not afford travel to health facilities or resorted to purchasing health commodities, including for family planning, from private retail pharmacies when unavailable from government facilities. Women expressed desires for smaller families, fearing drought would constrain their capacity to support larger families. While participants cited some ongoing activities in their communities to support climate change adaptation, most acknowledged current interventions were insufficient.

I can no longer do my work like how I used to’: a mixed methods longitudinal cohort study exploring how informal working mothers balance the requirements of livelihood and safe childcare in South Africa
Horwood C; Hinton R; Haskins L; et al: BMC Women's Health 21(288), 1-15, 2021

A mixed-methods longitudinal cohort study conducted among informal women workers in Kwazulu-Natal, South Africa between July 2018 and August 2019 and a photovoice activity with groups of participants to explore the childcare environment explored informal-sector working women's experience of child care. Women returned to work soon after the baby was born, often earlier than planned, because of financial responsibilities to provide for the household and new baby. They had limited childcare choices and most preferred to leave their babies with family members at home, as the most convenient, low-cost option, or mothers paid carers or formal childcare. Formal childcare was reported to be poor quality, unaffordable and not suited to the needs of informal workers. Mothers expressed concern about carers’ reliability and the safety of the childcare environment. Flexibility of informal work allowed some mothers to adapt their work to care for their child themselves, but others were unable to arrange consistent childcare, sometimes leaving the child with unsuitable carers to avoid losing paid work. Mothers were frequently anxious about leaving the child but felt they had no choice as they needed to work. Maternity protection for informal workers would support these mothers to stay home longer to care for themselves, their family and their baby, and good quality, affordable childcare would provide stability for mothers and give children the opportunity to thrive.

7. Equitable health services

Gaps and opportunities for cervical cancer prevention, diagnosis, treatment and care: evidence from midterm review of the Zimbabwe cervical cancer prevention and control strategy (2016–2020)
Tapera O; Nyakabau A M; Simango N; et al: BMC Public Health 21(1478), 1-13, 2021

This analysis identified the gaps and opportunities for cervical cancer prevention, diagnosis, treatment, and care to inform the next cervical cancer strategy in Zimbabwe. A mixed methods approach was used. This midterm review revealed a myriad of gaps of the strategy particularly in diagnosis, treatment and care of cervical cancer and the primary focus was on secondary prevention. There was no national data on the proportion of women who ever tested for cervical cancer, or to quantify the level of awareness and advocacy for cervical cancer prevention which existed nationally. Some health facilities were inappropriately screening women above 50 years old using VIAC. Gaps were identified in pathology services, in data on investigations at the national level, in limited funding, personnel, equipment, and commodities as well as lack of leadership at the national level to coordinate the various components of the cervical cancer programme. Numerous opportunities were identified to build upon the successes realized to date, with the findings emphasising the importance of effective and holistic planning and public investment in cervical cancer screening.

Limits of neoliberalism: HIV, COVID-19, and the importance of healthcare systems in Malawi
Zhou A: Global Public Health 16(8-9), doi: https://doi.org/10.1080/17441692.2021.1940237, 2021

How have prior experiences with managing HIV prepared African countries for COVID-19? Drawing on qualitative methods, this article examines the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. The author argues that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi’s health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing care to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of external funder priorities, the conditions of public healthcare are said to be lagging, and government providers struggle with shortages of staff, medical resources, and basic infrastructure, all of which has been compounded by COVID-19.

8. Human Resources

Health workers’ perceptions on where and how to integrate tobacco use cessation services into tuberculosis treatment; a qualitative exploratory study in Uganda
Rutebemberwa E; Nyamurungi K; Joshi S; et al: BMC Public Health 21(1464), 1-9, 2021

The authors explored perceptions of health workers on where and how to integrate tobacco use cessation services into TB treatment programs in Uganda, using nine focus group discussions and eight key informant interviews in high volume health centres, general hospitals and referral hospitals. Respondents highlighted that just like TB prevention starts in the community and TB treatment goes beyond health facility stay, integration of tobacco cessation should be started when people are still healthy and extended to those who have been healed as they go back to communities. Tobacco cessation activities should be provided in a continuum with coordination of different organizations like peers, the media and TB treatment supporters. TB patients needed regular follow up and self-management support for both TB and tobacco cessation. Patients needed to be empowered to know their condition and their caretakers needed to be involved. Effective referral between primary health facilities and specialist facilities was needed. Clinical information systems should identify relevant people for proactive care and follow up. In order to achieve effective integration, the health system needed to be strengthened especially health worker training and provision of more space in some of the facilities.

9. Public-Private Mix

An assessment of the knowledge, practices and resources during the delivery of malaria health care services among private health care practitioners: a cross section study in the Mid-Western Region of Uganda
Wanzira H; Tumwine D; Bukoma P; et al: BMC Health Services Research 21(788), 1-12, 2021

This study documented the knowledge, practices and resources during the delivery of malaria care services, among private health practitioners in the Mid- Western region of Uganda, an area of moderate malaria transmission. The authors determined the proportion of health workers that adequately provided malaria case management according to national standards in interviews with 135-health facilities staff. The study revealed sub-optimal malaria case management knowledge and practices at private health facilities with only 14 % of health care workers demonstrating correct malaria case management cascade practices. To strengthen the quality of malaria case management, they recommend guidelines and tools, training; continuous mentorship and supervision; provision of adequate stock of essential medicines; and communication and data management at private health facilities.

The failure of private health services: COVID-19 induced crises in low- and middle-income country (LMIC) health systems
Williams O; Chun Yung K; Grépin K: Global Public Health 16(8-9), 2021

For decades, governments and development partners promoted neoliberal policies in the health sector in many low and middle income countries, largely motivated by the belief that public services were too weak to meet population needs. Private health markets as a governance and policy solution to the delivery of health services enabled forms of market failure to persist in these countries. These were exposed during the COVID-19 pandemic, as analysed by the authors using data from an assembled database of COVID-19 related news items sourced from the Global Database of Events, Language, and Tone. They identify how pre-existing market failure and failures of redistribution have led to the rise of three urgent crises: a financial and liquidity crisis among private providers, a crisis of service provision and pricing, and an attendant crisis in state-provider relations. They note that COVID-19 has exposed important failures of the public-private models of health systems.

10. Resource allocation and health financing

The failure of community-based health insurance schemes in Tanzania: opening the black box of the implementation process
Kigume R; Maluka S: BMC Health Services Research 21(646), 1-8, 2021

This qualitative study investigated the implementation of Tiba Kwa Kadi scheme in four urban districts of Tanzania using semi-structured interviews, focus group discussions and review of documents. While Tiba Kwa Kadi scheme contributed to access to health services, many challenges which hindered its performance, including frequent stock-out of drugs and medical supplies. This frustrated Tiba Kwa Kadi members and contributed to non-renewal of membership. The scheme was also affected by poor collections and management of the revenue collected from members, limited benefit packages and low awareness of the community. Similar to rural-based Community Health Fund, the Tiba Kwa Kadi scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. The authors recommend that government integrate or merge community-based health insurance schemes into a single national pool with decentralised arms.

11. Equity and HIV/AIDS

Costs of integrating HIV self-testing in public health facilities in Malawi, South Africa, Zambia and Zimbabwe
Sande L; Matsimela K; Mwenge L: et al: BMJ Global Health, doi:10.1136/bmjgh-2021-005191, 2021

As countries approach the UNAIDS 95-95-95 targets, there is a need for innovative and cost-saving HIV testing approaches that can increase testing coverage in hard-to-reach populations. The HIV Self-Testing Africa-Initiative distributed HIV self-test (HIVST) kits using unincentivised HIV testing counsellors across 31 public facilities in Malawi, South Africa, Zambia and Zimbabwe. HIVST was distributed either through secondary (partner’s use) distribution alone or primary (own use) and secondary distribution approaches. The authors evaluated the costs of adding HIVST to existing HIV testing from the providers’ perspective in the 31 public health facilities across the four countries between 2018 and 2019 using expenditure analysis and bottom-up costing approaches. They found that costs of integrating HIV self-testing in the public health facilities ranged from US$4.27-US$13.42 per kit distributed. Personnel and cost of test kits were important cost drivers.

Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda
Zakumumpa H; Tumwine C; Milliam K; et al: BMC Health Services Research 21(692), 1-11, 2021

This paper explored the health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. The authors conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, through interviews with district health team leaders, ART clinic managers, representatives of PEPFAR implementing organizations and focus group discussions with recipients of HIV care. Five broad strategies for distributing antiretrovirals during ‘lockdown’ emerged: (i) accelerating home-based delivery of antiretrovirals; (ii) extending multi-month dispensing from three to six months for stable patients; (iii) leveraging the Community Drug Distribution Points model for ART refill pick-ups at outreach sites in the community; (iv) increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings and (v) leveraging Covid-19 outbreak response funding to deliver ART refills to rural homesteads. While Covid-19 ‘lockdown’ restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.

12. Governance and participation in health

Can East African workers overcome cooptation and suppression?
Wilmot P; Pius T: Roar Mag, July 2021

Are radical worker struggles, which waned as a result of protracted government efforts to infiltrate and co-opt organized labour, making a comeback in East Africa? The authors observe that internal and external challenges workers and unions face today do not lend themselves to simply calling strikes to force collective bargaining agreements, with traditional tools taking a backseat to the ingenuity of informally organized workers. They suggest that a 'development' narrative in East Africa must be challenged or communities will be fighting for incremental compensations for land and livelihoods instead of stopping expansionist projects that will pit them against one another in the long run. The authors argue that the hope emerging among organized labour in East Africa may not be found in the offices of general secretaries or even necessarily in registered unions, but in collectives of workers that exercise their agency, courage and creative power at the industry level and in their communities and workplaces.

Conflicts of interest: an invisible force shaping health systems and policies
Rahman-Shepherd A; Balasubramaniam P; Gautham M; et al: The Lancet Global Health 9(8), E1055-E1056, 2021

Despite frustration about why public health evidence does not influence policy decisions as much as it should, there has been little attention to a fundamental force in decision making: conflicts of interest. Conflicts of interest arise when the potential for individual or group gain compromises the professional judgment of policy makers or health-care providers, and underpin rent-seeking and informal practice across the world. The authors characterise three different types of conflicts of interest that are particularly pervasive in mixed or pluralistic health systems that need to be considered in health policy and research: The first type occurs when policy makers or regulators have multiple or dual roles.The second type occurs because of hidden financial relationships between formal and informal health-care providers. The third type occurs when policy makers are influenced into taking a course of action that is more likely to win political support, rather than following public health evidence.

13. Monitoring equity and research policy

Intervention – “Impermanence: On Frantz Fanon’s Geographies”
Aguiar J; Chowdhury A; Falk M; et al: Antipode Online, August 2021

This 'cartographic' and political economy analysis of Frantz Fanon’s ‘geographies’ points to a series of narrative maps that draw attention to the differential geographies of racism and colonialism, using geography, landscape, cartography, architecture, space, place, and borders, to make sense of blackness and oppression and liberation. Fanon’s envisions anti-colonial geographies as always in flux, nested in, yet cannot be fully defined by, the colonial imperative. Stasis – even the street or the walls of the clinic – is impossible. Colonial geographies are thus identified as unsustainable because, even in their heaviness, they are impermanent, in flux, and alterable.

Mapping Algorithms Are Failing to Address Urban Inequalities in the Global South
Costa-Lima M; Freitas C; Farias S: Failed Architecture, 2021

Algorithms act according to what they are trained for, and human beings are the ones training them. Therefore, when algorithms are clearly reinforcing existing inequalities, it is crucial to question who writes these algorithms, and in whose interests they are writing them. More importantly, these people should be held accountable for the socio-spatial effects of their products. As local governments have failed to build a good spatial data infrastructure for informal settlements, other stakeholders are stepping in and the authors raise the threat posed by algorithms moderated by big tech corporations deciding the boundaries ad features of neighbourhoods.

Strengthening Research and Practice in Community Health Systems: A Research Agenda and Manifesto
Tetui M; Hurtig A-K; Jonsson F; et al: International Journal of Health Policy and Management, doi: 10.34172/IJHPM.2021.71, 2021

While there have been increased calls for strengthening community health systems (CHSs), key priorities for this field have not been fully articulated. This paper seeks to fill this gap, presenting a collaboratively defined research agenda, accompanied by a ‘manifesto’ on strengthening research and practice in the CHS. Eight domains of research priorities for CHSs were identified: clarifying the purpose and values of the CHS, ensure inclusivity; design, implementation and monitoring of strategies to strengthen the CHS; social, political and historical contexts of CHS; community health workers (CHWs); social accountability; the interface between the CHS and the broader health system; governance and stewardship; and finally, the ethical methodologies for researching the CHS.

14. Useful Resources

Accredited and non-accredited short courses and programmesin health systems
Health Systems Training Institute: HSTi, South Africa

The Health Systems Training Institute (HSTi) is the training arm of the Health Systems Trust in South Africa. It offers a range of courses with different application dates, including in Primary Care; community healthcare stakeholder engagement; health information, indicators and analysis; Research methods for health; and other health system topics.

Asinakuthula Collective
Asinakuthula Collective: Online archive and resource, 2021

Asinakuthula Collective are a Collective of teachers, students, researchers and creatives invested in breaking the silences, marginalised narratives and vacuums of content surrounding the lives, roles, experiences and complexity of black African women in history. The collective has two public events every year, a memorial lecture and a masterclass, and carries out on-going archival work, knowledge production, teaching and learning that is made available online as a resource for those seeking to integrate women’s voices in their work.

Fast Facts on Climate Change and Health
World Health Organisation: WHO, Geneva, August 2021

Climate change is resulting in poorer health outcomes, increasing mortality and is a driver of health inequities. This fact sheet on climate change and health is part of the Climate Fast Facts series of the United Nations Climate Action team discusses how health is well placed to be a significant part of the solution; the positive health impacts from stronger climate change action can motivate stronger global ambition; how health systems which are resilient to climate change can help protect their populations from the negative impacts (in the short and longer terms); and how sustainable low carbon health systems can make a substantial contribution to reducing national and global emissions.

15. Jobs and Announcements

Incentive grants for young researchers from LMICs: Implementation research to scale up national NCD and mental health-related responses for achieving SDG 3.4
Deadline for Applications: 30 September 2021

These grants support research projects that Identify gaps, implementation challenges, and national priorities, and propose solutions with the potential to influence policy and practices for NCD prevention and control and promotion of mental health and well-being in LMICs; and that engage diverse stakeholders across sectors and actors throughout the research process;. The would should explore the best strategies to create strong partnerships between governments, NGOs, the private sector, researchers, communities, and individuals (particularly vulnerable populations) to address NCD prevention and control and promotion of mental health and well-being and identify lessons about implementation and propose feasible actionable solutions within the context. The results of this work may inform further research into this area in the future, including testing such practices and mechanisms in various settings. The submitted proposals can address a wide variety of issues aimed at scaling up NCD prevention and control and promotion of mental health and well-being, establishing multisectoral and multistakeholder coordination mechanisms, and understanding innovative integrated delivery models to shift from disease-focused treatment approaches to sustainable person-centered health systems.

University of Global Health Equity and Kigali Public Library Hamwe Festival 2021: Short Stories Contest
Deadline for Applications: 12 September 2021

The University of Global Health Equity (UGHE) and Kigali Public Library (KPL) are jointly organising a short stories contest as part of the third edition of Hamwe Festival. The organisers are seeking short stories written in English or in French, about life in the era of COVID-19. Writers from 18 to 30 years old from all countries are invited to participate. With this contest, the organisers wish to highlight stories that showcase how health equity and other areas of social justice have been exacerbated during this global crisis and how the current pandemic has affected the lives of individuals and communities.

Urban Studies Foundation: Postdoctoral Research Fellowships
Deadline for Applications: 1 November 2021

The Urban Studies Foundation (USF) announces a new round of Postdoctoral Research Fellowship funding with up to five fellowships each worth up to a total of £180,000 over a maximum of three years. Successful candidates may be based anywhere globally, and should propose a programme of work which will advance scholarly knowledge of any element of cities and urbanisation to the highest international standards of peer review. The award will be paid to an eligible institute of higher education (HEI) where the fellowship is to be held. A successful applicant should have a Mentor based in that institution with whom they will work closely for the duration of the fellowship.

Virtual Symposium: Finding Joy in Healthcare in Africa
WiSER University of the Witwatersrand, Medical and Health Humanities Africa network, Primary Health Care Directorate, University of Cape Town: 1-2 September, 2021, Online

Dominant perceptions of healthcare in Africa portray it either in terms of failure, disrepair, chaos and disappointment. Little attention is paid, within scholarly research, to the joy that accompanies pursuing or achieving health and wellbeing. This inaugural symposium explores, from past, present and future perspectives, how healthcare practitioners, health systems and people seeking healthcare in Africa approach issues of joy, trust, confidence, or comfort at individual, familial, community or national levels. The organisers invite artists, activists, health practitioners and academics to re-imagine health and healthcare in Africa through workshops, academic papers, discussion forums and two keynote addresses. (Note abstract submission has closed).


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