EQUINET NEWSLETTER 230 : 01 December 2021

1. Editorial

A huge thanks and wishes for wellbeing as we end 2021
EQUINET Steering committee

We thank the many people we have exchanged, interacted, worked and struggled with in 2021 for the reflections, perspectives, experiences and energy you bring to efforts to advance equity and justice in our countries, region and globally. We see clearly the many challenges we face, old and new, but also the opportunities, alliances, ideas and capacities we can build on to confront and propose alternatives to the baggage of policies, systems and injustices that undermine our physical, social, economic, ecological health and well-being. Wishing you a healthy, restful year end. We look forward to our joint endeavours in 2022!

Inter-sectoral financing is essential to address the social determinants of health
Peter Binyaruka, Ifakara Health Institute, Tanzania

The Commission on Social determinants of Health showed persuasively in 2008 that health is determined by the social conditions in which people are born, grow, live, work and age, referred to as the social determinants of health (SDH). These conditions are shaped by the distribution of money, power and resources from global, to local levels.

Health is therefore everyone’s business. Efforts to address SDH should be taken by all policy makers, and not just those within the health sector. Health services play a role but cannot do it on their own. For example, Kuruvilla and others in 2014 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121875/) showed that almost a half of the reduction in under-5 children’s deaths globally between 1990 and 2010 resulted from investments outside the health sector, such as in education and infrastructure. This was also recognised in the 1978 Alma-Ata Declaration on primary health care (PHC), with inter-sectoral action central to comprehensive PHC and ‘Health for All’. The Sustainable Development Goals (SDGs) also call for simultaneous, coordinated action across a range of sectors.

Despite this recognition, economists particularly in a ‘STRIVE’ consortium noted that cross–sectoral interventions are often underfinanced and their potentials benefits undervalued.

The consortium, with others such as UNDP, identified ‘co-financing’ as an approach where two or more sectors or budget holders, each with different development objectives, can co-fund an intervention or investment to advance their respective objectives simultaneously. Cross-sectoral co-financing does not necessarily need additional resources, therefore, but rather optimal allocation of existing resources. It is a relevant approach in financing high-impact interventions that leads to multi-sectoral benefits across the interconnected development goals and targets.

One example of such co-financing to address SDH is a conditional cash transfer that aims for multiple outcomes across sectors. In Mexico, for example, two social protection programmes, PROGRESA in 1997 and OPORTUNIDADES from 2002 gave such cash transfers directly to low-income rural households to enable and encourage parents to send their children to school, to use preventive and care services, and to improve child feeding and nutrition. Positive experience of this multi-sectoral approach has stimulated its spread to other Latin American countries. Malawi’s introduction of a cash transfer in 2008/9 to keep girls in school was found after 18 months to have led to improved girls’ school enrolment, test scores and reduced school drop-out, to have reduced girl’ risk of HIV by 64%, and to have reduced teen pregnancy and depression (https://tinyurl.com/96ktkyuj).

Economists argue for co-financing for SDH to improve public policy intervention, and value for money.

Public intervention is argued to be essential in SDH to correct for market failures in relation to efficiency, to deliver maximum outcomes at the lowest cost. Public intervention is needed to address market failures in relation to equity and the distribution of outcomes according to need. These market failures arise for various reasons, including asymmetries in access to information, barriers to using services and as a profit-focused market is a poor performer on public good. With many SDH influenced by markets in our current global and national economies, there is a clear economic rationale for public intervention to ensure equity in health.

Economists also argue that we need to integrate ‘health value for money’ to make optimal use of limited available funds, including by using innovative cross-sectoral co-financing approaches to address multiple SDH. Economic evaluations thus prefer cost-benefit analysis to assess whether multiple benefits across sectors outweigh the associated costs, to be able to point to ‘good value for money’. This does face challenges of measuring the multiple benefits accrued from multiple sectors, and the various opportunity and inter-sectoral costs. Notwithstanding these challenges, a cost-benefit analysis is argued to be more useful for public policy than cost-effectiveness analyses, as the latter have limited scope and focus on single outcomes, undermining the potential for achieving benefits across multiple sectors.

We thus have public health and economic arguments to encourage and inform co-financing investments to address SDH. In doing this, there are some issues to consider.

Countries in our region are already facing constraints, fluctuations and uncertainty in domestic and public financing. There is also limited financial autonomy within and between sectors. This implies that the resources for co-financing should be mobilised and pooled from multiple funders/ sectors and are best spent in the first instance on SDH that will have highest impact, to generate confidence in the approach.

Co-financing needs to address budgeting and reporting issues. In most setting, governments have siloed budgeting within single sectors, with little focus on cross-sectoral budgeting. The resource allocation and spending approach is also rigid, constrained, and slow to reform. Going forward, co-financing calls for a change in public budgeting and accounting and a move from input-based to output-based budgeting, that is the allocation of resources based on shared interventions and goals across sectors.

We need to recognise that the involvement of many funders may lead to mistrust in managing the pooled funds, including between ministries. Ministries may fear losing budget control and visibility with pooled funds and co-financers may fear weak accountability or corruption in use of such pooled funds. Strengthening the public finance management system to ensure transparency and accountability can help to address such mistrust, while visibly showing joint ministry contributions to a common programme, as was the case in Oportunidades in Mexico, can help to promote visibility in co-financing.

High-level policy stakeholders have critical role in decisions on co-financing, including in supporting its implementation in practice. For example, there might be a clear agreement to co-finance but political uncertainty and bureaucratic issues may limit the disbursements of funds to it. This needs time and engagement to inform and ensure the ‘buy-in’ of co-financing by national leaders and ministries. We also need to build the necessary cross sectoral dialogue and coordination mechanisms, and to facilitate the leadership and capacities for the approach.

All of this calls for evidence, including on successful experiences of cross-sectoral financing. Here we need to acknowledge an evidence gap in making the case in our region. We need in our region to generate and share evidence on the impacts and value for money evidence when making multi-sectoral interventions on SDH. This includes addressing the currently weak monitoring and evaluation of these initiatives and implementing research that informs policy decisions towards co-financing.

It is clear that we not only need attention to innovative ways of raising resources for health, but also innovative ways of using those resources to address SDH, especially those that are leading to inequities across multiple health and wellbeing outcomes. Co-financing offers one such approach. It calls for evidence and processes to build political and implementer support, trust and confidence, including to lever necessary reforms in our public finance management systems. If we can address the challenges, even for focused initiatives that we can learn from, we have the opportunity to use co-financing to support interventions that have greater value for money and multiple benefits across sectors, including for equity.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the STRIVE consortium can be found at http://strive.lshtm.ac.uk/.

Reflections on participating in the Regional People Health University
Mevice Makandwa, EQUINET newsletter team

Every three months, together with others, I read and capture a wide range of materials on health equity in the region for the EQUINET newsletter. But the East and Southern Africa Regional People’s Health University (RPHU) has been a learning curve for me in many ways! I learned a lot in terms of the struggles for health equity. The information shared depend my understanding of the political economy of health, reclaiming the resources for health, of equity in health technology, and the commodification, privatisation in health and on building a movement for health equity. The sessions provided me with insight on how the corporate world is affecting health in the region and why. I learned about multiple dimensions of injustice bedevilling our health systems and our need to strengthen our various platforms that are engaging on health equity.

Our sessions were organised and flowed. From the coordination between PHM and EQUINET we were exposed to different areas of expertise from within our region, and to people who shared vast experience with us. We heard contributions, rich in evidence based research, and exchanged ideas and experiences from countries in the region that demonstrated solidarity in action. COVID-19 was not dealt with separately on the agenda but was a topical issue in different sessions as many countries in the region are grappling with funding, vaccines and information related to the pandemic and its impacts. What I heard towards the end of the sessions about how solidarity movements are built has made me rethink what I must do in my own actions towards health equity. The RPHU raised the value of actively participating in platforms that might contribute to the health equity agenda through sharing information and experiences and acting upon this.

Overall, I realised from the sessions on reclaiming the resources for health, reclaiming public health, the discussions on trade and health, on health rights and on social participation in health of the link of local to national to regional links that we need to build to champion health equity issues. The group work we did gave me a lot of ideas on regional contributions towards health equity through organised work.

My expectations of the RPHU were surpassed! Despite my own experience in this area, the sessions opened me to thinking more critically about what the individuals could do better to advance health equity. Building a consortium is a fantastic way of information dissemination and sharing. In that we need to keep doing better in ensuring equity in our own work. Health equity is about not leaving anyone behind. While most voices were heard in the RPHU, we did not hear the perspectives of people living with disability, including on their concerns around COVID-19, and we need to. The regional organisers (PHM and EQUINET) have spread to different countries in the region, but the grassroots level still remains too silent, including in our networks. I realised that strengthening grassroots level participation and action will be critical, if we are to build an effective movement for health equity across the countries of the region.

We are struggling for health equity in Africa… is victory certain?
Danny Gotto, Executive Director, Innovations for Development, Uganda

On the 29th July this year, I embarked on a three-month training program of an East and Southern African Regional People’s Health University (RPHU) themed “Past, Present and Future struggles for Health equity”. The RPHU was organized by EQUINET and PHM for health activists from the region. As a member of PHM-Uganda and an activist for the struggle for health for all, I couldn’t miss the opportunity. I was enthusiastic to join others from the region to explore these issues further. I wanted to ground myself in the discourse of health equity, to get a firm understanding of what it means in the context and reality of my country and the region, and to appreciate how equity can be achieved for the millions that continue to suffer a wider spectrum of different forms of health injustice. I wanted to learn from others in the region how the struggle for health equity and social justice has evolved over the years, the successes and failures but also opportunities to fight back against systems of oppression and to build a people-centred health system.

Like the rest of sub-Saharan Africa, Uganda has been battered by the COVID-19 pandemic. The social pains of COVID-19 have been profound in the areas of health, livelihoods, education and governance. Although the COVID-19 pandemic can’t be blamed on anyone in Africa, Africans, and especially the leadership, can’t be excused for any failures to adequately respond to it, for our weak health systems and for an unacceptable absence of an Afro-centric power and strategy to counter the hegemony of global powers in access to essential health technologies.

The RPHU brought together a diverse pool of well-informed persons on all the topics covered. The topics and issues included for discussion exposed the wide range of issues affecting health equity. In fact the topics needed more time to articulate and especially for participants to have time to share and reflect on their own lived country-specific experiences. However, the resources availed before and after sessions were sufficient to help those interested to immerse in the literature, to further grasp the subject matter.

I enjoyed the discussions around the social determinants of health, linking health systems to comprehensive Primary Health Care. These concerns and those of power, values, and laws remain central in building health equity in Africa. The exposure I got to the external factors driving health inequity in our region was a wake-up call, including when global governance frameworks are championed and imposed on Africa by international agencies and western countries. .

Indeed, I am rethinking my approach to activism and advocacy in general. My quest and challenges continue to be around building a community-driven, people-centred activism that is self-sustaining and able to drive change. In Uganda, the public is often passive and inclined to fall into despondency, especially on political matters. My take-home struggle is to build a mass movement of actors collectively working for a common purpose of health equity. Financing that struggle for health equity, and particularly our dependency on western philanthropy continues, however, to be the “elephant in the room” for me. It must be confronted head-on. If indeed we are to achieve health equity on the continent, we must find the drive, resources and strategy within ourselves.

As the days of the training moved towards the end, key questions continue to linger in my mind. Is there a correct order in the sequence of actions to realize health equity? What should a country like Uganda prioritize, given the limited resources? Can a country achieve health equity without democracy, or should the struggle first centre on political liberation, and then the rest follows? The RPHU couldn’t cover all these wider issues, but in my mind, I can’t see health equity being realized in a corrupt, inept and undemocratic space, where the voice of a common person doesn’t matter and the abused are so powerless to fight back.

As we go into the final week, I recommend to the organizers, lets reimagine the post-training initiatives. We are still discussing the post RPHU activities, but what participants do after the training is the most fundamental aspect. How can the organizers continue to nurture collaboration, and partnership beyond the training? Can EQUINET and PHM continue to provide a platform where peer-activists from the RPHU can continue to share and learn from one another, or engage in joint initiatives of common interest in the region? As was well articulated in the RPHU, no country can achieve health equity alone. We need a concerted effort across the region.

2. Latest Equinet Updates

Information sheet 6 on COVID-19: Long COVID in East and Southern Africa
EQUINET, TARSC and the Post COVID Treatment Network - Africa: Harare, 2021

This sixth EQUINET/TARSC information sheet on the COVID-19 pandemic in east and southern African (ESA) countries has been produced in co-operation with the Post COVID Treatment Network - Africa. In a prolonged pandemic, capacities and understanding have grown around various dimensions of the management of COVID-19. There is now growing evidence of people who continue experience symptoms more than 12 weeks after their initial infection, or ‘long COVID’. This information sheet summarises information on long COVID, and its distribution in the ESA region, responses to it and the equity issues it raises.

Videos and readings on health equity on the East and Southern Africa Regional Peoples Health University (ESA RPHU) resources page
EQUINET and PHM, 2021

The 10 week EQUINET and PHM ESA RPHU ended in mid-November. There are a number of interesting resources and reading materials on the RPHU website and videos of many of the presentations, that we welcome you to read, view and share more widely and use on your own activities. These materials, made available under fair use for your non-commercial educational purposes, cover topics from the course including on: Political economy and reclaiming resources for health; Ideas of health and wellbeing, SDH and reclaiming comprehensive public health; Health systems and Comprehensive primary health care (PHC); Power, values, rights, law and reclaiming collective agency; Commodification, privatization in health and reclaiming the state; Equity in health technology; Social participation and organising activism for health; and Building a movement for health equity.

3. Equity in Health

COP26 Special Report on Climate Change and Health: The Health Argument for Climate Action
World Health Organisation: WHO, Geneva, 2021

The 10 recommendations in the COP26 Special Report on Climate Change and Health propose a set of priority actions from the global health community to governments and policy makers, calling on them to act with urgency on the current climate and health crises. The recommendations were developed in consultation with over 150 organizations and 400 experts and health professionals. They were intended to inform governments and other stakeholders ahead of the 26th Conference of the Parties (COP26) of the United Nations Framework Convention on Climate Change (UNFCCC) and to highlight various opportunities for governments to prioritize health and equity in the international climate movement and sustainable development agenda. Each recommendation comes with a selection of resources and case studies to help inspire and guide policymakers and practitioners in implementing the suggested solutions.

Neoliberal disease: COVID-19, co-pathogenesis and global health insecurities
Sparke M; Williams O: Environment and Planning A: Economy and Space, 1-18, 2021

The authors present how COVID-19 has exposed, exploited and exacerbated the health-damaging transformations of neoliberal globalization. To explain why, the authors point to a combinatory cascade of socio-viral co-pathogenesis that they call neoliberal disease. From the vectors of vulnerability created by unequal and unstable market societies, to the reduced response capacities of market states and health systems, to the constrained ability of official global health security agencies and regulations to offer effective global health governance, they authors show how the virus has found weaknesses in a market-transformed global body politic. Turning the inequalities and inadequacies of neoliberal societies and states into global health insecurities, the pandemic raises questions about whether the world now faces an inflection point when political dis-ease with neoliberal norms will lead to new kinds of post-neoliberal policy-making. The authors conclude, however, that the prospects for such political-economic transformation on a global scale remain quite limited. despite the evidence of the extraordinary damage described.

Risk assessment for COVID‐19 transmission at household level in sub‐Saharan Africa: evidence from DHS
Makinde O; Akinyemi J; Ntoimo L; et al: Genus 77:24, 1-20, 2021

Although household habitat conditions matter for disease transmission and control, especially in the case of COVID-19, inadequate attention is being given to these risk factors, especially in Africa, where household living conditions are largely suboptimal. This study assesses household sanitation and isolation capacities to understand the COVID-19 transmission risk at household level across Africa, using a secondary analysis of the Demographic and Health Surveys of 16 African countries implemented between 2015 and 2018, exploring handwashing and self-isolation capacities and households with elderly persons most at risk of the disease. Handwashing capacity was highest in Tanzania (48%), and lowest in Chad (4%), varying by household location (urban or rural), as well as household wealth. Isolation capacity was highest in South Africa (77%), and lowest in Ethiopia (31%). Senegal had the largest proportion of households with an elderly person (42%), while Angola (16%) had the lowest. There were strong, independent relationships between handwashing and isolation capacities in a majority of countries. Also, strong associations were found between isolation capacity and presence of older persons in households. Household capacity for COVID-19 prevention varied significantly across countries, with those having elderly household members not necessarily having the best handwashing or isolation capacity. The authors propose from the findings that each country needs to use such information on household risk at population level to shape communication and intervention strategies.

WHO Estimates Africa’s COVID-19 Caseload is Seven Times Higher Than Official Count
Cullinan K: Health Policy Watch, 2021

Africa is estimated to have seven times more COVID-19 cases and three times as many deaths as officially reported, according to the World Health Organization (WHO) Africa region. This means that the continent could have around 59 million cases and 634,500 deaths. “We’re using a model to estimate the degree of under-estimation. The analysis indicates that as few as one in seven cases is being detected, meaning that the true COVID-19 burden in Africa could be around 59 million people,” said Dr Matshidiso Moeti, WHO’s Africa executive director. WHO recommends that countries perform 10 tests per 10,000 people each week yet around 20 countries – more than a third of African countries – do not reach this benchmark, said Moeti. The WHO has thus decided to invest $1.8 million to roll out COVID-19 rapid tests in hot spots, starting with pilots in eight countries. Despite this undercount, WHO Africa officials observe lower deaths in Africa than other global regions.

4. Values, Policies and Rights

Beyond Corporate Social Responsibility: Strengthening Human Rights Due Diligence through the Legally Binding Instrument on Business and Human Rights
Terán D: The South Centre, Research Paper 138, 2021

Mandatory human rights due diligence (HRDD) requirements can serve to promote the adoption of a strong international framework of corporate accountability and remedy for human rights violations in the context of business activities. This paper identifies the elements of a human rights due diligence and their implementation through analysing current regional and State practice in the adoption of mandatory HRDD legislation in different sectors. It discusses the principles that characterize the approach taken by the United Nations Open-ended Intergovernmental Working Group on the adoption of a Legally Binding Instrument on transnational corporations and other business enterprises and how it could serve as an important cornerstone for modern rule making on the issue of business and human rights.

5. Health equity in economic and trade policies

Do international trade and investment agreements generate regulatory chill in public health policymaking? A case study of nutrition and alcohol policy in South Africa
Milsom P; Smith R; Modisenyane S M and Walls H: Globalization and Health 17:104, 1-17, 2021

This study identified barriers to setting regulation (regulatory chill) and implementing regulation related to nutrition and alcohol as a result of trade or investment dispute measures in South Africa. The work was implemented through semi-structured interviews with 36 policy actors, analysed using thematic analysis. Trade obligations were found to generate a significantly greater anticipatory-type chilling effect on nutrition and alcohol regulation than investment treaty obligations, and investor-state and WTO state-state disputes affected implementation of regulation. No cases were reported of trade threats an investor disputes but there were reported cases of these actors using arguments related to South Africa’s trade obligations to oppose policy action in these areas. The risk of policy action was related to the perceived legitimacy or bias of the dispute system, costs involved in pursuing and capacity to pay costs of regulation/defending disputes and social views and confidence in a successful dispute outcome. The authors observe that currently, South Africa’s trade obligations have a more prominent role in inhibiting nutrition and alcohol regulation than investment treaty-related concerns, but that strategies to protect public health policy space in the context of both international trade and investment treaty and dispute settlement contexts remain important.

Feminists for a People’s Vaccine
Development Alternatives with Women for a New Era (DAWN) and Third World Network (TWN): 2021

DAWN and TWN are facilitating the Feminists for a People’s Vaccine Campaign (FPV) for equitable, accessible, and affordable COVID-19 vaccines, drugs, therapeutics, and equipment and access to Medicines. The campaign brings the perspective of feminists from the Global South and partners and allies in the North to challenge the causes and consequences of extreme inequalities in access to medicines. Geography, wealth, income, gender, race, caste, ethnicity, disability, sexual orientation, gender identity and other factors shape who has access and who has not, who will live and who will die. The FPV Campaign analyses the changing pandemic panorama and initiatives such as the Trade-Related Aspects of Intellectual Property Rights Agreement (TRIPS) Waiver proposal, the COVAX Facility and South versus North imbalances in global trade, investment and financing affecting access to these technologies.

Nutrition related non-communicable diseases and sugar sweetened beverage policies: a landscape analysis in Zambia
Mukanu M; Karim SA; Hofman K; Erzse A; et al: Global Health Action, 14:1, 1-11, 2021

This study identified opportunities to strengthen policies relating to sugar-sweetened beverage taxation in Zambia, through: (1) understanding the policy landscape and political context in which policies for nutrition-related non-communicable diseases are being developed, particularly sugar-sweetened beverage taxation, and exploring the potential use of revenue arising from sugar-sweetened beverage taxation to support improved nutrition. The authors conducted a retrospective qualitative policy analysis and key informant interviews with 10 policy actors. Increased regulation of sugar-sweetened beverages was a priority for the health sector, in conflict with economic interests to grow the manufacturing sector, including the food and beverage industries. The authors suggest that this conflict between public health and economic priorities, poor public information and incoherent policy objectives might have contributed to the adoption of a weakened excise tax. The authors suggest that the fact that it did not prevent the introduction of a differential sugar tax on sugar-sweetened beverages implies that there are opportunities to strengthen the existing taxation of sugar-sweetened beverages in Zambia, especially if backed by inclusive in policy formulation and comprehensive monitoring of risk factors.

Waiver from certain provisions of the TRIPS agreement for the prevention, containment and treatment of COVID-19
Third World Network: TWN, 2021

TWN provides gathers a list of interventions by the co-sponsors, statements and op-eds supporting the waiver proposal and news reports about the proposal made by India, South Africa and others (IP/C/W/669) to the World Trade Organization seeking a waiver from certain provisions of the TRIPS Agreement (patents, trade secrets, copyright and industrial designs) in relation to the containment, prevention and treatment of COVID-19. This proposal is now co-sponsored by 62 developing countries (the Africa Group, the Least Developed Country Group, Bolivia, Fiji, Indonesia, Pakistan, Mongolia, Vanuatu and Venezuela) and has received global support from most of the other developing countries and the international community, but still faces opposition and counter measures from some high income countries, elaborated on the TWN website.

6. Poverty and health

The potential of school-based WASH programming to support children as agents of change in rural Zambian households
Winter J C; Darmstadt G L; Lee S J; Davis J: BMC Public Health 21:1812, 1-13, 2021

Water, sanitation, and hygiene (WASH) interventions frequently assume that students who learn positive WASH behaviours will disseminate this information to their families. School-based programs rely on students to act as “agents of change” to translate impact from school to home. The authors conducted a quasi-experimental, prospective cohort study in 12 schools in rural, southern Zambia to assess this with students in grades 1–4, using in-person interviews with students, their teachers and caregivers. Student knowledge increased significantly, but primarily among students in grade 1. Students reporting sharing messages from the intervention with caregivers rose from 7% to 23%, particularly in students in grade 4. The authors propose that future work should prioritize developing curricula that reflect the variability in needs, capabilities and support in the home and community among primary school students rather than applying a single approach for a wide range of ages and contexts.

7. Equitable health services

Analysis of the management of the tenth Ebola virus disease outbreak in the Democratic Republic of Congo: developing a multidisciplinary response model to strengthen the healthcare system during disease outbreaks
Vivalya B M; Ayodeji O K; Bafwa Y T; et al.: Globalization and Health 17:121, 1-7, 2021

The declaration of any public health emergency in the Democratic Republic of Congo (DRC) is usually followed by the provision of technical and organizational support from international organizations, which build a parallel and short-time healthcare emergency response centred on preventing risks spreading, including to other countries. The authors propose a contrasting model of strengthening of preparedness and response structures to public health emergencies vis-à-vis the existing health systems in DRC. This is argued to be important to reduce tensions between local recruitment, the impact on the quality of wider healthcare in regions affected by EVD on one hand, and the involvement of international recruitment and its impact on social trust in the emergency response on the other. The authors propose providing a local healthcare workforce skilled to treat infectious diseases, the compulsory implementation of training programs focused on the emergency response in countries commonly affected by EVD outbreaks including the DRC. These innovations are proposed to reduce the burden of the range of health problems prior to and in the aftermath of any public health emergency in DRC as well as early recognition and treatment of EVD.

COVID-19: Comparison of the Response in Rwanda, South Africa and Zimbabwe
Dzinamarira T; Mapingure M; Rwibasira G; et al.: MEDICC Review 23:3-4, 15-20, 2021

African countries have mounted different response strategies to COVID-19, eliciting varied outcomes. In this paper the authors compare these response strategies in Rwanda, South Africa and Zimbabwe and discuss lessons that could be shared. In particular, Rwanda has a robust and coordinated national health system that has effectively contained the epidemic. South Africa has considerable testing capacity, which has been used productively in a national response largely funded by local resources, while Zimbabwe has an effective point-of-entry approach that utilizes strategic information. The authors propose meetings between countries to share experiences and lessons learned during the COVD-19 pandemic.

8. Human Resources

It was hell in the community’: a qualitative study of maternal and child health care during health care worker strikes in Kenya
Scanlon M L; Maldonado L Y; Ikemeri J E; et al: International Journal for Equity in Health 20:210, 1-12, 2021

This paper investigated maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers, and health facility managers, using in-depth interviews and focus group discussions. Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt poor households, particularly poor women, were most affected since they were more likely to rely on public services, while community health volunteers highlighted their own poor working conditions. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care and highlighted and exacerbated inequities in the health system.

When will the doctor be around so that I come by?!’ Geo-socio effects on health care supply, access and utilisation: experiences from Kalangala Islands, Uganda
Kwiringira J N; Mugisha J; Akugizibwe M; et al.: BMC Health Services Research 21:1163, 1-13, 2021

This study explored the intersecting geographical, ecological and social factors affecting access to health care in a social epidemiology analysis in Uganda, using literature review and an ethnographic exploration of the lived experiences of community members while seeking and accessing health care, understanding that health system activities are diverse but interconnected in a complex way. When and how to travel for care was beyond a matter of having a health need/ being sick and need arising. A motivated workforce was found to be as critical as health facilities themselves in determining healthcare outcomes, and geography alone is not a sufficient factor in determining health outcomes..

9. Public-Private Mix

Challenges in health service delivery under public-private partnership in Tanzania: stakeholders’ views from Dar es Salaam region
Nuhu S; Mpambije CJ; Ngussa K: BMC Health Services Research 20, 765, 1-12, 2020

Public-private partnership in the health sector was introduced to improve the delivery of health services in Tanzania, but the expected outcomes have not been fully realised. This study investigated challenges encountered in implementing public-private partnership (PPP) institutional arrangements in health service delivery in Kinondoni Municipality, Dar es Salaam, Tanzania through interviews and document review. Findings revealed that although PPPs are hailed for supplementing the government’s efforts in the provision of health services, institutional arrangements for the smooth provision of these services are lacking. The challenges include inadequate resources, ineffective monitoring and evaluation, insufficient consultations between partners, inadequate legal and policy frameworks and ineffective implementation practices. The authors suggest that these areas need to be addressed in pursuing PPPs.

10. Resource allocation and health financing

Barriers to, and facilitators of, the adoption of a sugar sweetened beverage tax to prevent non-communicable diseases in Uganda: a policy landscape analysis
Ahaibwe G; Karim SA; Thow AM; et al.: Global Health Action, 14:1, 1-9, 2021

Uganda is experiencing an increase in nutrition-related non-communicable diseases (NCDs) including from overconsumption of sugar-sweetened beverages. Fiscal and taxation policies aim to address this, but make their adoption and implementation are constrained by political and economic challenges. The authors investigated the policy and political landscape related to this in Uganda, using a desk-based policy analysis and four key informant consultations. While nutrition-related NCDs were recognised as an emerging problem in Uganda and government has adopted a comprehensive approach to improve diets, its implementation is slow. There is limited recognition of the consumption of sugar and sugar-sweetened beverages as a contributor to these NCDs in policy documents, existing taxes on soft drinks are lower than the WHO recommended rate of 20% and do not target sugar content. The authors report that the soft drink industry has been influential in framing the taxation debate, with the Ministry of Finance reducing taxation of sugar-sweetened beverages to maintain competitiveness in a regional market. The Ministry of Health and other public health actors in civil society have been successful (albeit marginally) in countering reductions in taxation, and a platform for sugar-sweetened beverage taxation advocacy exists in Uganda. Compelling local research that explicitly links soft drink taxes to health goals is argued to be essential to advance sugar-sweetened beverage taxation.

Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania
Amani P J; Hurtig A; Frumence G; et al.: BMC Health Services Research 21:1140, 1-11, 2021

This study explored the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania, using eight focus group discussions with 78 insured and uninsured elderly men and women 60 years of age or older who had utilised healthcare services in the past 12 months prior to the study. Elderly participants appreciated that health insurance had facilitated the access to healthcare and protected them from certain costs, but also complained that health insurance had failed to provide equitable access due to limited-service benefits and restricted use of services within schemes. Although elderly perspectives varied, insured individuals generally expressed dissatisfaction with their healthcare. The authors argue that the national health insurance policy should be revisited to improve its implementation, expand the scope of service coverage and improve service quality issues, including long administrative procedures related to health insurance.

Losses to OECD tax havens could vaccinate global population three times over, study reveals
Mansour M: Tax Justice Network, November 2021

Countries globally are losing a total of $483 billion in tax a year to global tax abuse committed by multinational corporations and wealthy individuals – enough to fully vaccinate the global population against Covid-19 more than three times over. The State of Tax Justice 2021 – published by the Tax Justice Network, the Global Alliance for Tax Justice and the global union federation Public Services International – reports that of the $483 billion in tax that countries lose a year, $312 billion is lost to cross-border corporate tax abuse by multinational corporations and $171 billion is lost to offshore tax evasion by wealthy individuals. The 2021 edition of the State of Tax Justice documents how a small number of rich countries with de facto control over global tax rules are responsible for the majority of tax losses suffered by the rest of the world, with lower income countries hardest hit by these tax losses. The findings are galvanising calls to move rule-making on international tax from the OECD to the UN, and to adopt more equitable unitary systems of tax collection and disbursement that would apply total tax revenue on TNCs to where their production activities and revenue generation is taking place.

11. Equity and HIV/AIDS

Feasibility and acceptability of a peer youth led curriculum to improve HIV knowledge in Northern Tanzania: resilience and intervention experience from the perspective of peer leaders
Hosaka K R J; Mmbaga B T; Gallis J A; Dow D E: BMC Public Health 21:1925, 1-9, 2021

The authors describe the change in 12-24 year old peer leaders' knowledge and leadership of a peer youth led HIV curriculum applied during monthly Saturday adolescent HIV clinics at two clinical sites in Moshi, Tanzania. Peer leaders previously participated in a mental health and life skills intervention called Sauti ya Vijana and were recommended for leadership by Sauti ya Vijana facilitators and clinic staff. Peer leaders demonstrated high fidelity to activities in each lesson and participant feedback was positive for curriculum delivery. Participants’ knowledge improved in nine of ten sessions. Peer leaders reported improved leadership confidence and resilience, and their perception was that the curriculum helped normalize the HIV experience for Youth Living with HIV attending clinic. Nevertheless, anticipated stigma, difficulty disclosing HIV status, and teaching ability remained barriers. This study provides evidence to support efforts to scale and sustain peer youth led interventions for Youth Living with HIV.

12. Governance and participation in health

I don’t know when he will be back”: life-changing events challenge the community ART Group model– a qualitative research study, Tete, Mozambique
Tarquino IAP; Venables E; Simone RR; et al.: BMC Public Health 21:2004, 1-9, 2021

Since 2008 in Mozambique, patients stable on antiretroviral therapy (ART) can join Community ART Groups (CAG), peer groups in which members are involved in adherence support and community ART delivery. More than 10 years after the implementation of the first CAGs, this study explored the impact of changes in circumstances and daily life events of CAG members. The CAG dynamic was affected by life events and changing circumstances including a loss of geographical proximity or a change in social relationships. Family CAGs facilitated reporting and antiretroviral therapy distribution, but conflict between CAG members meant some CAGs ceased to function, pill counts were not carried out, members met less frequently or stopped meeting entirely and ART uptake declined. In a more positive contrast, some CAGs responded to adherence challenges by strengthening peer support through counselling and observed pill intake. Health care providers were reported to push people living with HIV to join CAGs, instead of allowing voluntary participation. They agreed that strengthening CAG rules and membership criteria could help to overcome the identified problems. The authors propose that changing life circumstances of, relationships between and participation by CAG members need to factored into a more flexible implementation model, including intensified peer support and feedback mechanisms between CAG members and health-care providers.

I have started the change I want: advocating for climate change in Zimbabwe
Nyathi N: Voices of Youth, 2020

This young writer explains: "What keeps me on the frontline for climate justice is the notion that I don't only represent my nation but my entire generation because climate justice concerns our future...We deserve to live happily as well, but to attain that healthy, happy living we will not stop speaking out for what we want and what we deserve, to bring about a child-safe and sustainable future. I have dedicated my voice as a voice of the voiceless, to call for immediate action and there is no better time for acting than now". UNICEF teamed up with 'Fridays for Future' to highlight young activists on the front lines of climate change, like Nyathi. Discover other climate activists and stories on how climate change is affecting young people today.

Patient-public engagement strategies for health system improvement in sub-Saharan Africa: a systematic scoping review
Ankomah S E; Fusheini A; Ballard C; et al.: BMC Health Services Research 21:1047, 1-16, 2021

This systematic review of 18 papers published between 1999 and 2019 describes Patient-Public Engagement (PPE) research in Sub-Saharan Africa in relation to theories of PPE; and identifies knowledge gaps to inform future PPE development. Five PPE strategies implemented were traditional leadership support, community advisory boards, community education and sensitisation, community health volunteers or workers, and embedding PPE within existing community structures. PPE initiatives were located at either the ‘involvement’ or ‘consultation’ stages of the engagement continuum, rather than higher-level engagement. Most PPE studies were at the ‘service design’ level of the health system or were focused on engagement in health research. No identified studies reported investigating PPE at the ‘individual treatment’ or ‘macro policy or strategic’ level. The authors suggest that the findings call expanding for PPE at all health system levels and different areas of health system improvement.

Report: Rebels, doctors and merchants of violence: How the fight against Ebola became part of the conflict in Eastern DRC
Congo Research Group; NYU Center on International Cooperation: Online, 2021

Between 2018 and 2020 in the eastern Democratic Republic of the Congo (DRC) the Ebola epidemic hit an area of ongoing hostilities among dozens of belligerents, including Congolese security forces. The Riposte, a combined national and international response to contain the disease, was not only affected by the violence, but the authors argue may have unintentionally contributed to the conflict. Despite the vast sums spent, Ebola continued to spread in North Kivu and Ituri provinces, which were already hard hit by decades of armed violence. On the ground, in an effort to protect itself from armed attacks and reduce community resistance, the Riposte through agents of the National Intelligence Agency (ANR), in collaboration with the Congolese Ministry of Health and the WHO (in contradiction with UN standard operating procedure), agreed to pay both government security forces and non-state armed groups. Over 20 months, between $489 million and $738 million was spent on Ebola in this part of the country. The authors describe the impact of these payments. By engaging with some armed groups in conflict with others the Riposte is reported to have become embroiled in the violence. The authors point to how this monetized the violence, with some armed groups seeking to prolong the epidemic to continue to profit from what has been called “Ebola Business.” The report cautions against making payments to parties to conflict in exchange for access so as not to inadvertently turn humanitarian operations into a source of profit for those involved in conflict and undermine the impartiality of humanitarian action.

13. Monitoring equity and research policy

Female adolescents living with HIV telling their story through ‘my story’ book in Malawi: A visual methodology innovation
Mwalabu G;, Mbendera I; Petrucka P; Manjanja V: PLoS ONE 16(10), e0257126, 2021

Female adolescents living with Human Immunodeficiency Virus (HIV) face lifelong challenges in reproductive and sexual health ranging from relational, social and legal-ethical considerations. A visual method and storybook research innovation was used with young female adolescents in Malawi that initiate sex as early as 15 years, mostly with adult partners, given their reluctance to discuss sexual matters through more direct questions during interviews. The researchers thus used invoke youth-friendly research approaches to address these issues and enable these vulnerable individuals to articulate their experience and advocate their preferred changes.

14. Useful Resources

Interactive: Who's funding the COVID-19 response and what are the priorities?
Cornish L: Devex, Online, 2021

In this online resource Devex has tracked COVID-19 funding for combating the coronavirus, including the contracts, grants, new programs, tenders, and direct funding from global, bilateral, regional, state and non-state actors. Funding data is available through an interactive dashboard that shows where the funding is going, who is supplying the money, and what funding is focusing on.

Making Change Visible: Evaluating Efforts to Advance Social Participation in Health, An Implementer’s Resource
Loewenson R; Simpson S; Dudding R; Obando F; et al: TARSC, Shaping Health, 2021

If you are responsible for—or engaged or interested in—advancing social/community participation in health (SPH) in your local area, this resource was developed for you. There are a variety of resources available on how to organise SPH, but there is limited guidance on how to evaluate its effectiveness. This publication aims to fill that gap. It is thus not about how to implement SPH, but rather how to evaluate SPH efforts. The Resource outlines how to conduct a baseline assessment, creating a critical reference point at the start of the SPH intervention to plan work and enable you to track changes as they are achieved. It guides you in carrying out a performance evaluation, to assess how well the SPH intervention is performing during implementation, for you to review and make any 'course corrections' needed. Finally, it explains how to conduct an outcome or impact evaluation, assessing the changes achieved, directly and indirectly, as a result of the SPH intervention. The use of the Resource is being piloted in 2022, so if you are interested, please get in touch. .

Practical Epidemiology: Using Epidemiology to Support Primary Health Care
Vaughan JP, Victora C, , Chowdhury AMR: OUP, 2021

This book focuses on district health systems and is intended for those working in primary health care. It presents practical uses for epidemiological concepts and methods and how to use population information to strengthen planning, management and evaluation. It is available open access online as a downloadable pdf, and a hardcopy can also be purchased.

Reporting guidelines: simple and powerful tools to increase the impact and visibility of your research: a virtual course on enhancing the value of research with research reporting standards
PAHO: Virtual Campus for Public Health, Online, 2021

The EQUATOR Network and the Pan American Health Organization / World Health Organization (PAHO) has developed an online course aimed at increasing the value of research by enabling people who are planning to conduct, report, edit, publish or appraise research for health, with current research reporting standards. This introductory course is targeted at a wide range of actors interested in research quality and the use of reports for decision-making. The course provides an overview of good reporting practice at all stages of the research pathway. The ideal time to take this course is as an introductory activity before beginning and finalizing your research proposal.

15. Jobs and Announcements

Emerging Voices for Global Health (EV4GH) 2022
Call for applicants: Submission deadline 15 April 2022

EV4GH 2022 is a blended learning training program that uses innovative training methods and activities to enable emerging researchers, other health system actors, and change agents born after 1 January 1982 to present their work and engage on various global health platforms. It consists of an e-coaching and distance learning phase, followed by a face-to-face training phase held prior to the 2022 Health System Global Symposium. The global network of emerging voices (EVs) fosters networking and learning across contexts and regions. After the training program, EVs become members of the EV4GH thematic working group (TWG) and can then join other HSG TWGs.

Health Systems Performance in the Political Agenda: Sharing lessons for current and future global challenges: 7th Global Symposium on Health Systems Research
October 31 – November 4, 2022, Bogotá, Colombia

The 7th Global Symposium will share and learning from the experiences of the last two years. Strong health systems build on foundation of primary health care and empowered communities. The challenge ahead is to explore the role values such as trust, solidarity, equity, and social justice play moving forward. HSR2022 will explore this in the following sub-themes: The politics and policies of health systems; Intersectoral collaboration and integrative governance on the road for health in all policies; The changing dynamics of health provision models to promote equity and the central role of human resources for health; The role of comprehensive primary care in promoting sustainability and The contribution of new technologies. The deadline for abstract submission for organised sessions is 15th February, 2021, and for individual papers is 15th April, 2021.

New scientific research and writing mentorship initiative towards diversity in research on alcohol control policies
Call for applications: Closing date: 15 December 2020

The World Health Organization’s Less Alcohol Unit, Department of Health Promotion, the Alcohol Research Group (ARG) and the Alliance for Health Policy and Systems Research have launched a new scientific research and writing mentorship initiative. The initiative aims to support early-stage researchers from low- and middle-income countries in their work to analyse, report and publish a study related to strengthening alcohol policies tackling the determinants driving the acceptability, availability and affordability of alcohol consumption. Overall, the initiative seeks to accelerate the finalization of scientific research with the support of expert mentors. Mentees (early-stage researchers) will be paired with mentors (senior academics) to participate in this 9-month initiative commencing no later than 1st January 2022. Through regular, at-distance access to mentors, the initiative aims to ensure researchers have the necessary guidance to finalize a study with contextually relevant results. Mentees are encouraged, and will be supported by their mentors, to submit their study findings for scientific publication. As an output of the initiative, a summary slide deck should be prepared for the further dissemination of results. A maximum of ten (10) mentees will be selected for the initial cohort.

WHO Young Professionals Programme
Call for applications: No closing date indicated

Apply to the WHO's Young Professionals Programme aimed to provide career support, networking, mentoring, and tailored learning opportunities. The Programme intends to increase the representation of nationals from Least Developed Countries in WHO’s workforce and will develop capacity from and for developing countries through a structured program with clear learning objectives.


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