EQUINET NEWSLETTER 235 : 01 June 2023

1. Editorial

A closer look at urban health equity and other EQUINET developments
Editor, EQUINET newsletter

Over the past few months we have begun to develop work in prioritised areas arising from a strategic review of the drivers of health equity in our region, drawing also on the diverse and rich inputs to and resolutions from the 2022 EQUINET conference (you will find the recordings on sessions and the resolutions on our website). We welcome new institutions and individuals to the EQUINET steering committee on areas such as tax justice, addressing the health needs of young people and climate justice and thank those who are continuing in the steering committee to lead work in areas that remain persistently relevant. We also thank those who have steered EQUINET work over many past years who join our policy and strategy reference group.

One of the areas that is engaging diverse new constituencies is that of integrated, holistic approaches to urban health, including urban food systems. We include publications from work in this issue of the newsletter, welcome links with those working in this area and will be giving focus to it in future grant calls, so keep an eye on our website! We will also be holding a series of webinars on climate justice and health equity, integrating climate justice as an intersecting issue in the various areas of thematic work on health equity. The first webinar will be on 11th July focusing on climate justice and the right to health, hosted by CEHURD Uganda. Find more information and the registration link in the 'Latest EQUINET Updates' section in this newsletter and visit the EQUINET website for details of further forthcoming webinars and discussions!

Conflict of Interest in health research – how do we find the green light for ethical practice?
Leslie London, University of Cape Town, South Africa

Research is key to promoting and health and preventing disease to the extent that international human rights law recognises the right of everyone to benefit from scientific progress. But what if health research is subverted from its aim by the presence of conflict of interest?

We have already seen this, such as in how some researchers failed to disclose their conflicts of interest when producing research that downplayed the health hazards of chrysotile asbestos (https://tinyurl.com/52hpah2p), findings that allowed this toxin and the asbestos industry an extended shelf-life at the expense of human lives.

The gatekeepers of ethical research are institutions – typically, science granting councils which allocate research funding and shape science policy at country level, and Research Ethics Committees (RECs), which provide oversight to ensure that health research is implemented in line with generally accepted ethical standards.

But in a context of scarce resources for health research, even these institutions can fail, when research funding provided by corporations, or sometimes even governments, with vested interests compromises the independence of the research process, producing research findings that undermine evidence-based policy. A 2020 study of the willingness of Schools of Public Health in the African, Eastern Mediterranean, European and US regions found widespread openness amongst respondents to the idea of accepting funding from corporate sources with vested interests in research on non-communicable diseases (https://tinyurl.com/nmpxcxwd). This is not surprising, given the pressures under which low-income country researchers operate, often with little or no research funding, in contrast to the immense power and financial resources available to corporates wishing to influence health policy to protect their profits.

Even the most powerful Science Councils can fall prey to conflict of interest. This was illustrated, for example, when the collusion was exposed between officials of the US National Institute of Health, contrary to NIH policy, and representatives of the alcohol beverage industry, in setting up a huge study of moderate alcohol consumption, called the MACH study. The study was plagued by questionable design and by a clear vested interest in choosing a research question that was likely to benefit industry sales, rather than generating evidence pertinent for health policy (https://tinyurl.com/ak57wdj2).

Empowering Science Council staff and REC members with the skills to identify, obviate and manage conflict of interest effectively is thus essential if health research is to realise the benefits of scientific progress for people most in need. This is particularly the case in sub-Saharan Africa, where research systems are fragile and starved of the resources needed to ensure researcher independence.

Conflict of interest (COI) is defined as circumstances in which professional judgment concerning a primary interest (such the validity of research) tend to be unduly influenced by a secondary interest (such as financial gain). It can be effectively addressed if systems are designed to insulate decision-making processes from vested interests, and to protect researcher independence, objectivity and impartiality. This is possible if the people in those systems can gain skills to manage COI better. This applies as much to research as to broader policy making, which may also be heavily influenced by corporate activities and strategies.

A collaborative initiative, funded by the IDRC, and involving researchers from South Africa, Kenya, Cameroon and Lebanon, developed over two years, an online course (https://tinyurl.com/dp9madje) and a toolkit (https://tinyurl.com/c742bb63) that aimed to empower REC members and Science Council staff to better manage COI in the research process. These resources are open access and available to all interested in improving the integrity of evidence used in health policy decisions.

The toolkit offers examples of how to identify and manage COI, ranging from prohibition and disclosure through to mitigation or resolution. It emphasizes that reliance on disclosure alone is insufficient. It may be counter-productive if it legitimises any kind of COI, including COIs that, in a traffic light analogy, should trigger red lights.

The toolkit outlines three scenarios. The first is where ‘moral certainty’ exists that that the research should not proceed, such as when the funding source is an organisation whose products are harmful and where the organisation holds a direct interest in the outcome of the research, as in the example of tobacco industry funding for tobacco-related research. In the second scenario, such as when the funding source has no interest in the study outcome and does not produce commodities harmful to health, it is also easy to conclude the study should proceed.

But usually, it is a third scenario where there is uncertainty on the interests.

In this situation, the toolkit proposes a series of key questions that could be used to identify COI and characterise its scope. Such questions include whether anyone on the REC or science council will benefit financially from the research, whether a financial loss will be avoided if the research is approved, or whether the research serves a marketing purpose for the funder. Depending on the case, different strategies may be applied. The strategies include recusal of a committee member or science council employee who has direct interest in the outcome of the decision, barring a funder from any say in publication decisions, or mandating an independent oversight committee to monitor study implementation. The toolkit also maps the elements of policy that institutions might adopt to manage COI more effectively. Coupled with skills development, such initiatives are important to finding the right balance between diversifying funding and retaining independence of the research process.

To continue the traffic light analogy, finding the green light for health research is the ultimate goal. But much of what we encounter in practice is amber. It is located in that space where careful reasoning, drawing on ethical principles is needed to ensure that health research findings can provide the necessary unbiased evidence, free from vested interests, to advance health in our region.

For further information on the Toolkit and online course visit the Conflict of Interest in Health Research website at the University of Cape Town, https://tinyurl.com/5bp4k8b7. Feedback to the team would be very welcome.

2. Latest Equinet Updates

Equity dimensions in initiatives promoting urban health and wellbeing in east and southern Africa
Loewenson R, Mhlanga G, Gotto D, et al: Frontiers in Public Health, section Public Health Policy, 11: 1-18, 2023

Urbanisation in east and southern Africa (ESA) has brought opportunity and wealth together with multiple dimensions of deprivation. Less well documented in published literature on the ESA region are features of urban practice that promote health equity. This work thus aimed to explore features of urban initiatives aimed at improving health and wellbeing in ESA countries and their contribution to different dimensions of health equity. The paper discusses learning on local process and design features to strengthen to promote the different dimensions of equity found, and issues to address beyond the local level to support such equity-oriented urban initiatives.

A review of public health-related food laws in east and southern Africa
Kasapila W: EQUINET Discussion paper 129, EQUINET, with ECSA HC, MoHCC Zimbabwe, TARSC, Harare, 2023

Food systems have a key role in promoting health and nutrition. National constitutions in many East and southern Africa (ESA) countries provide for a right to food or adequate nutrition, and food law is increasingly important, given expanding food products, trade and risks to health. This report presents findings from a desk review of current food-related laws of 17 countries in the ESA region and international and regional standards. In terms of key areas of food safety and risks covered, most countries include provisions for food labelling, standards for premises used for food production, storage and processing, as well as provisions prohibiting the sale of unwholesome, poisonous or adulterated food; food preparation under unsanitary conditions, inspection of food establishments, testing and recall.The laws generally include provisions for setting of standards, monitoring, inspection, food-testing and disposal of unsafe foods, and for food labelling and consumer information. Few countries have provisions for risk assessment, scientific research, testing, and labelling of novel and GMO foods. The report identifies specific legal clauses in ESA laws that may serve as useful text for law reform.

An invitation to a webinar on Climate justice and the right to health and wellbeing
Tuesday 11 July, 2023 11:00-1300 East African time 10.00-12.00 Southern African time

Climate-related challenges affect every experience and dimension of health equity in the region. EQUINET invites you to explore this with us in a series of cross-cutting webinars in the coming months. In the first we ask, how do issues of climate justice intersect with constitutional and legal protection of health rights? What issues, advocacy and actions does this raise for the region? The Center for Health, Human Rights and Development (CEHURD), lead for the work on legal protection of the right to health in EQUINET is convening this first webinar with speakers from community, national and international level. The webinar will invite participant input and discussion during the webinar. Register now in advance to receive a confirmation email with further information on the meeting and your link to join. And watch the EQUINET website for the forthcoming webinars in the series!

Case study on health-promoting urban food systems in Bulawayo
City of Bulawayo, Urban Councils Association of Zimbabwe (UCAZ), Training and Research Support Centre (TARSC): EQUINET, 2023

UCAZ and TARSC in EQUINET with review input from Ministry of Health and Child Care (implemented work in 2022-23 to gather and share evidence on initiatives underway in Zimbabwean cities/ towns to promote healthy food systems, to share and promote uptake of promising practice. Bulawayo is one of the urban case studies, using a collectively developed shared framework. Dietary diversity in Bulawayo was higher than the national average in 2018. The major foods consumed, as for the rest of the country, are maize and vegetables, with access to food dependent on household socio-economic features. Bulawayo residents engage in peri-urban and urban agriculture in residential stands, in peri-urban plots and on available vacant land. Modernisation has, however, changed diets in the city, with a shift towards processed foods. The lack of legislation controlling production and marketing of these foods hampers efforts to promote healthy diets. Various interventions are underway to promote health in the city’s food system, including providing an enabling environment for urban agriculture; promoting consumption of unprocessed foods and healthy diets; fortifying staple foods to provide micro nutrients to under-five year old children and their mothers, and inspecting foods to prevent falsification and adulteration. These and other areas of practice are described in the case study.

Case study on health-promoting urban food systems in Chegutu
Chegutu Municipality, Urban Councils Association of Zimbabwe (UCAZ), Training and Research Support Centre (TARSC): EQUINET, 2023

UCAZ and TARSC in EQUINET with review input from Ministry of Health and Child Care (implemented work in 2022-23 to gather and share evidence on initiatives underway in Zimbabwean cities/ towns to promote healthy food systems, to share and promote uptake of promising practice. Chegutu is one of the urban case studies, using a collectively developed shared framework. In 2018, nearly half (49%) of Chegutu’s urban population was food insecure, compared to the national urban average of 37%, and compared to 31% in 2016. The situation was worsened by the impact of COVID-19, with lockdowns and interrupted economic activities undermining urban household access food and basic services. The local authority with partners has implemented an Urban Resilience Building Program, where community members were capacitated with startup and skills training in sustainable livelihood value chains in agriculture and nutrition, water and sanitation, and in financial literacy and social protection. Two areas of food systems, poultry production and peanut butter processing, implemented by the Shasha Community Group are detailed in this case study, with other initiatives on the food system.

Case study on health-promoting urban food systems in Harare
Harare City Council, Urban Councils Association of Zimbabwe (UCAZ), Training and Research Support Centre (TARSC): EQUINET, 2023

UCAZ and TARSC in EQUINET with review input from Ministry of Health and Child Care (implemented work in 2022-23 to gather and share evidence on initiatives underway in Zimbabwean cities/ towns to promote healthy food systems, to share and promote uptake of promising practice. Harare is one of the urban case studies, using a collectively developed shared framework. In Harare city 13.7 % of children under 18 years are poor, and 2,2% food poor, living in households that are below the poverty datum line The city’s food supply comes from food industries located in the city and other urban areas of Zimbabwe, and food imported from other countries. Fresh fruits and vegetables are mostly obtained from the people’s markets, shops, hawkers, unlicensed vendors and from production in resident’s back yards for home consumption and sometimes for sale to supplement incomes. The City Health Department’s Environmental Health Division conducts regular monitoring to ensure the food sold to the Harare public is safe, from the planning stage of buildings where food will be handled, through to food handlers, informal food vendors and food business operators. Community Services officers and agricultural extension (Agritex) officers train women groups in high density areas of the city on food-related skills, including cooking, baking, fish farming and mushroom growing. The city convenes competitions involving preparation and cooking of traditional foods by women from the community groups. A range of traditional foods and dishes are showcased, including boiled roundnuts, peanuts, cowpeas, whole maize grain (mutakura in Shona), and dried vegetables (mufushwa) with peanut butter. The case study outlines these and other practices in the city.

Case study on health-promoting urban food systems in Kariba
Kariba Municipality, Urban Councils Association of Zimbabwe (UCAZ), Training and Research Support Centre (TARSC): EQUINET 2023

UCAZ, TARSC in EQUINET, with review input from Ministry of Health and Child Care (MoHCC) implemented work in 2022-23 to gather and share evidence on initiatives underway in Zimbabwean cities/ towns to promote healthy food systems. Kariba is one of the urban case studies, using a collectively developed shared framework. Kariba is a small tourist resort town in north-eastern Zimbabwe near the border with Zambia and is located in a National Parks area. The town was initially developed to house workers involved in the construction of Lake Kariba on the Zambezi River for hydro-electricity generation. Most of the food consumed in Kariba town is sourced from far away as farming around the town is not viable because of wildlife. Kariba town is located on a border, raising the challenge of managing cross-border trade and food imports. While there are challenges to urban agriculture and local food processing in Kariba, noted earlier, there are also a number of initiatives to promote health food options in the town, including aquaculture, hydroponics, and recycling of bio-waste to support urban agriculture. The Municipality is also represented in cross-border dialogue mechanisms, such as a Technical Committee between Zimbabwe and Zambia on Kapenta fishing in Lake Kariba. This case study outlines the various processes underway.

Case study on health-promoting urban food systems in Kwekwe
Kwekwe City Council, Urban Councils Association of Zimbabwe (UCAZ), Training and Research Support Centre (TARSC): EQUINET, 2023

UCAZ and TARSC in EQUINET with review input from Ministry of Health and Child Care (implemented work in 2022-23 to gather and share evidence on initiatives underway in Zimbabwean cities/ towns to promote healthy food systems, to share and promote uptake of promising practice. Kwekwe is one of the urban case studies, using a collectively developed shared framework. Kwekwe city in Zimbabwe’s Midlands region is in a mining and industrial area. Over half of the city population are self-employed in the informal economy, with activities including open food preparation and sale, vending farm produce, and grocery tuck shops. Kwekwe City Council has made several urban food system interventions described in this case study, including constructing farm produce/vegetable markets in over 15 locations in the city. In 2010, Council entered into a public-private ‘build-own-operate-transfer’ (BOOT) partnership with a local company to build shops to accommodate small to medium businesses, including for food vending and processing. The city health department established an environmental health post in 2021 to monitor and ensure food hygiene and health standards, and has set enabling legislation for this.

Case study on health-promoting urban food systems in Masvingo
City of Masvingo, Urban Councils Association of Zimbabwe (UCAZ), Training and Research Support Centre (TARSC): EQUINET, 2023

UCAZ and TARSC in EQUINET with review input from Ministry of Health and Child Care implemented work in 2022-23 to gather and share evidence on initiatives underway in Zimbabwean cities/ towns to promote healthy food systems, to share and promote uptake of promising practice. Masvingo is one of the urban case studies, using a collectively developed shared framework. Masvingo is one of the oldest cities in Zimbabwe. Food security in Masvingo city, as for the wider country, has been affected by drought, economic challenges and household poverty, with the COVID-19 pandemic adding to this. Ultra-processed foods such as sweetened drinks, crisps, sweets, and other foods containing high levels of sugar, fats, salt and additives are mainly imported into the city. The city identifies urban agriculture as one of the important livelihood strategies for many urban residents and a method for alleviating poverty and improving household food security. To facilitate multi-sectoral broad-based collaborative approaches, the local authority identified open spaces to be used for agricultural purposes, and set aside land for this within the city. The council is implementing the various activities outlined in this case study brief, making resources such as land available for urban agriculture, engaging non-state agencies to collaborate on infrastructure for initiatives, and community members to collaborate on interventions. Having a Council policy helps to align different actors and personnel.

Expanding promising practice for sustained urban and peri-urban wellbeing in east and southern Africa
EQUINET, TARSC: Regional Workshop Report, Nairobi, Kenya, March 2023

Delegates at the EQUINET Regional Meeting on urban health in east and southern Africa noted that rising urbanization, including around extractives, with increasing commercial and climate impacts calls for us to move from single issue interventions to comprehensive, integrated, area-based approaches for urban health; and to shift from project- to process-thinking, designing for sustainability from the onset. Promising practices are taking place locally, but need to be scaled up. Scale-up is enabled when practices link social and economic benefit; when they mobilise public and institutional resources, including collective savings and innovation funds, and facilitate local technology development. Inequity in the burdens of climate change makes these multi-actor, holistic approaches even more critical, for our eyes to shift from effects to root causes, from a focus on technocrats to communities, and from reactive emergency responses to climate to sustained, integrated long term approaches. The meeting report outlines the experiences and proposals for action raised by delegates from diverse ESA countries, levels, institutions, disciplines, skills to improve urban health in ESA countries.

3. Equity in Health

Individual and area-level socioeconomic correlates of hypertension prevalence, awareness, treatment, and control in uMgungundlovu, KwaZulu-Natal, South Africa
Madela S L M, Harriman N W, Sewpaul R et al. BMC Public Health 23:417; 1-15, 2023

This analysis explores the relationship between individual and area-level socioeconomic status and hypertension prevalence, awareness, treatment, and control within a sample of 7,303 Black South Africans in three municipalities of the uMgungundlovu district in KwaZulu-Natal province. The prevalence of hypertension in the sample was 44% (n = 3,240). Of those, 2,324 were aware of their diagnosis, 1,928 were receiving treatment, and 1,051 had their hypertension controlled. Educational attainment was negatively associated with hypertension prevalence and positively associated with its control. Employment status was negatively associated with hypertension control. Black South Africans living in more deprived wards had higher odds of being hypertensive and lower odds of having their hypertension controlled. Potential interventions proposed by the authors include community-based programs that deliver medication to households, workplaces, or community centers.

4. Values, Policies and Rights

Developing countries defend principle of ‘common but differentiated responsibilities’
Bozman P: Third World Resurgence 354: 19-22, 2023

The need to uphold the principle of ‘common but differentiated responsibilities’ (CBD) between developed and developing countries in global actions to address biodiversity and climate change was a major bone of contention at COP 15. The deadlock at COP 15 on whether or not to retain the CBD principle, which was placed in square brackets (indicating lack of consensus) throughout the evolution of the negotiating texts, stemmed from extremely divergent views between developed and developing countries, with the former refusing to accept it as a principle. The latter pointed out that it is an overarching principle enshrined in Principle 7 of the 1992 Rio Declaration on Environment and Development.

How gender is socially constructed in policy making processes: a case study of the Adolescent and Youth Health Policy in South Africa
Jacobs T, George AS: International Journal for Equity in Health 22:36;1-15, 2023

This paper explores the range of policy actors, narratives and different framings of gender, through Adolescent Youth Health Policy (AYHP), using a case study design and analysis of reporting of government, academia, youth and other members of the Adolescent Youth Health Policy Advisory Panel, and civil society. Gender power relations and more gender-transformative approaches discussed during the policy making process were not reflected in the final policy. Diverse gender narratives were juxtaposed, some becoming dominant in the policy-making process and consequently included in the final policy document. The constellation of actors’ gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. The authors note that understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda.

Stricter rules: Why better food regulations will help us fight obesity
Moloi M, Pretorius L: Bhekisisa, 16 May 2023

About one in four South Africans are reported to be obese, and almost as many are overweight. Obesity is a massive public health problem — affecting more than 650-million people worldwide — because it also leads to other health problems, such as diabetes, high blood pressure (also called hypertension) and heart disease. Often eating highly processed foods with lots of sugar, salt or fat, and fast food generally being cheaper than healthier options add to the country’s obesity problem. In the latest episode of Health Beat, Bhekisisa’s monthly TV show, Mia Malan speaks to public health researcher Susan Goldstein about what policymakers can do to help make South Africans healthier. Goldstein discusses the burden on the healthcare system, the need to ban advertising of ultra-processed foods to children, dismantling a food system that’s dominated by big, multinational companies and rethinking food systems towards healthier, more local and equitable alternatives. She explains why regulating the sale and advertising of highly processed foods (which can make us fat) and making it easier for people to buy healthy food at low prices are as crucial as finding medicines to fight obesity.

WHO: Zero Draft of the pandemic instrument creates an “illusion” of equity
Ramakrishnan N, Gopakumar K: Third World Network, February 2023

The zero draft of the proposed pandemic instrument being negotiated at the World Health Organization is argued by the authors to create an illusion of equity. Most of the inputs given by developing countries are observed to have been ignored. The authors are that proposed structure neglects two demands from developing countries. First, a different chapter scheme should be used which would reflect the logical order of the pandemic prevention, preparedness, response and recovery processes on the ground. Secondly, the broader phrase of “pandemic prevention, preparedness, response and recovery” should be used instead of “pandemic and recovery of health systems”. The zero draft continues to be silent on the determination of the pandemic status of a public health event and WHO’s role in determining the same. In effect, the text is viewed as simply seeking to generate “political will and commitment” on equity.

5. Health equity in economic and trade policies

Climate change and health risks in Mukuru informal settlement in Nairobi, Kenya knowledge, attitudes and practices among residents
Andersen JG, Kallestrup P, Karekezi C et al. BMC Public Health 23:393;1-12, 2023

This study investigated how inhabitants of Mukuru informal settlement in Nairobi, Kenya in 2021 experienced climate change and its health impacts, and assessed related knowledge, attitudes and practices, using a cross-sectional study. Out of 402 study participants, 76% had heard of climate change before the interview, 91% reported that climate change was affecting their community, and 93% were concerned with the health-related impact of climate change. Having lived in Mukuru for more than 10 years and living in a dwelling close to the riverside were factors significantly associated with experiencing a climate change related impact, including chronic respiratory conditions, vector-borne diseases, infectious diarrhoea, malnutrition and cardiovascular disease. With most respondents knowledgeable about climate change and experiencing its impact, the authors propose that policy makers, planners and researchers to work locally with affected communities on mitigation and adaption strategies.

Important Lessons from the African Vaccine Manufacturer That Could Not Sell a Single Dose
Cullinan K: Health Policy Watch, 11 May 2023

Regional vaccine production features in the draft pandemic accord, but there is still a long road before this becomes a reality. Aspen Pharmacare invested millions of dollars in scaling up its South African production plant to make COVID-19 vaccines – yet it never sold a single vial. Three key factors combined to undermine Aspen’s vaccines. First, despite the hype about the need for African-produced vaccines, African governments failed to buy the locally-made vaccines. While the pandemic accord currently being negotiated is almost certain to support regional vaccine production, setting this up is complex and the COVID-era failures offer a number of sobering and cautionary lessons. Then Aspen became caught in a political stand-off between Africa and Europe about the fate of African-produced vaccines which delayed production by months. When that was eventually resolved, the world had fallen for mRNA vaccines and no longer wanted the viral vector vaccine that Aspen had been licensed to produce by Johnson & Johnson. With the waning of COVID-19, maintaining countries’ and companies’ interest in building regional vaccine manufacturing ability is a challenge and the authors suggest that Aspen’s difficulties should be well noted.

Push for African vaccine independence
Musoke R: The Independent, Uganda, March 2023

A consortium of African civil society organisations has kick-started a campaign to change the continent’s situation regarding vaccines and other essential pharmaceutical products. Afya Na Haki, a Kampala-based health policy thinktank is working with partners from Uganda, Nigeria, Rwanda, Tanzania, South Africa, Kenya, Senegal and Zimbabwe in a programme called “Advancing Regional Vaccine Manufacturing and Access in Africa (ARMA). ARMA programme’s objective is “advancing African advocacy and research approaches that strategically enhance vaccine manufacturing and access in Africa,” T to ensure that commitments and resolutions made by the African Union and individual African countries are actually implemented.

Ultra-processed food for infants and toddlers; dynamics of supply and demand
Dunford E, Popkin B: Bulletin of the World Health Organisation 101:5;358–360, 2023

he global baby food market has grown from US$ 9.6 billion in 2010 to US$ 17.9 billion in 2022. Emerging economies offer opportunities for baby food manufacturers and now represent half of all global baby food sales. The authors used data from Euromonitor International to assess sales trends of milk formula, growing-up formula and baby foods during the past decade as well as the level of sugar sold in the infant and toddler feeding sector. The consumption of commercially prepared baby foods in many cases may exceed consumption of homemade foods for infants and toddlers, with concerns about the nutritional composition, sweet taste and long-term health effects of these products. The data raise major questions about the role infant and toddler food companies play in rising global obesity levels and the double burden of malnutrition in low- and middle-income countries. The diets of infants and young children worldwide are undoubtedly becoming increasingly highly processed, a trend mirrored by increased global consumption of ultra-processed foods. The five largest global formula companies are Nestlé, Danone, Abbott, RFC and RBMJ with four out of these five companies present in more than 100 countries. The authors observe that policy-makers need to ensure these products and the companies who manufacture them are more closely monitored and their marketing more tightly regulated.

6. Poverty and health

Concurrence of water and food insecurities, 25 low- and middle-income countries
Young SL, Bethancourt HJ, Frongillo EA et al: Bulletin of the World Health Organisation 101:2;90–101, 2023

This study investigated how water and food insecurity were associated in nationally representative samples of individuals from 25 low- and middle-income countries, using data from the Individual Water Insecurity Experiences Scale and the Food Insecurity Experience Scale administered to 31 755 respondents, measuring insecurity in the previous 12 months. The likelihood of experiencing moderate-to-severe food insecurity was higher among respondents also experiencing water insecurity, including in sub-Saharan Africa. The results suggest that water insecurity should be considered when developing food and nutrition policies and interventions and the authors propose research to understand the paths between these insecurities.

Drivers of child marriage in specific settings of Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia – findings from the Yes I Do baseline study
Kok M C, Kakal T, Kassegne AB, et al: BMC Public Health 23:794; 1-16, 2023

This study explored the drivers of child marriage in specific contexts in Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia, combining a household survey among youth with focus group discussions and interviews conducted with youth, parents and community stakeholders. A lack of education was associated with the occurrence of child marriage in Ethiopia, Kenya and Zambia. In all countries, teenage pregnancy was associated with child marriage. In Ethiopia, Kenya and Mozambique, fathers’ education seemed a protective factor for child marriage. In all countries, child marriage was driven by difficult economic circumstances, which were often intertwined with disapproved social circumstances, in particular teenage pregnancy, in case of Kenya, Malawi, Mozambique and Zambia. These circumstances made child marriage an ‘acceptable practice’. The authors found that child marriage is a manifestation of social norms, particularly related to girls’ sexuality, which are intersecting with other factors at individual, social, material, and institutional level – most prominently poverty or economic constraints. The authors argue that efforts to prevent child marriage need to take these realities of girls and their families into account.

7. Equitable health services

Non-communicable disease burden among inpatients at a rural district hospital in Malawi
Olds P, Kachimanga C, Talama G,et al: Global Health Research and Policy 8:4;1-10, 2023

The authors sought to understand the burden of non communicable diseases (NCDs) among inpatients in a rural district hospital in Malawi between 2017 and 2018. The definition of NCDs was broadened beyond the traditional 4 × 4 set of NCDs, and included neurological disease, psychiatric illness, sickle cell disease, and trauma. A retrospective chart review was conducted of all inpatients who were admitted to the Neno District Hospital between January 2017 and October 2018. Of 2239 total visits at the hospital, 28% were patients with NCDs, making up 40% of total hospital time. Two distinct populations of NCD patients were identified. The first were patients 40 years and older with primary diagnoses of hypertension, heart failure, cancer, and stroke. The second were patients under 40 years old with primary diagnoses of mental health conditions, burns, epilepsy, and asthma. High rates of NCDs in the younger population were noted.

Recovering from COVID lockdowns: Routine public sector PHC services in South Africa, 2019 - 2021
Pillay Y; Museriri H; Barron P; et al: South African Medical Journal 13:1;17-23. 2023

In this article the authors explore the extent to which the third and fourth waves of the COVID-19 pandemic in South Africa affected routine public sector services, drawing on 2019, 2020, and 2021 DHIS data. While there was recovery in some indicators, such as number of children immunised and HIV tests, in many other areas, including primary healthcare visits, the 2019 numbers have yet to be reached - suggesting a slow recovery and continuing impact of the pandemic. Impact indicators of maternal and neonatal mortality continued to worsen in 2021. The authors note that if interventions are not urgently implemented, the country is unlikely to meet the Sustainable Development Goal targets.

8. Human Resources

Experiences of teachers and community-based health workers in addressing adolescents’ sexual reproductive health and rights problems in rural health systems: a case of the RISE project in Zambia
Chilambe K, Mulubwa C, Zulu J, et al.: BMC Public Health 23:335:1-10, 2023

This paper explored teacher and community-based health worker experiences in addressing adolescent sexual, reproductive, health and rights (SRHR) in rural health systems in Zambia through 21 qualitative in-depth interviews. Teachers and community-based health workers mobilise the community for meetings, provide SRHR counselling services to both adolescents and guardians, and strengthen referrals to SRHR services if needed. The challenges experienced included stigmatization associated with difficult experiences such as sexual abuse and pregnancy, shyness among girls to participate when discussing SRHR in the presence of boys and myths about contraception. The suggested strategies for addressing the challenges included creating safe spaces for adolescents to discuss SRHR issues and engaging adolescents in coming up with the solution. The study emphasizes the need to fully engage adolescents in addressing adolescent SRHR problems.

9. Public-Private Mix

R8bn and counting: That’s the cost of Covid-related corruption, says updated SIU report
Heywood M: Daily Maverick, South Africa, May 2023

The South African Presidency released the ‘Third Final Report’ of its investigations into Covid-related corruption in December 2022, probing 5,513 contracts given to 3,058 service providers. Irregularities were identified in 2,965 contracts to the tune of R8.8bn. Although the Special Tribunal has played a pioneering role since it was established, its work has often been hampered by legal challenges to its authority, although now empowered by an important decision in its favour by the Constitutional Court. The authors note that although irregularities to the value of R8.8-billion have so far been found by the SIU, the value of matters enrolled at the Tribunal is less than R2.5-billion and the rand value of cash and/or assets actually recovered so far is a mere R36-million. This is noted to be a vast disjuncture, amounting to less than half a percent, and that there is a lot of work to be done.

10. Resource allocation and health financing

Inequality and private health insurance in Zimbabwe: history, politics and performance
Mhazo T; Maponga C; Mossialos E: International Journal for Equity in Health 22:54;1-13, 2023

Zimbabwe has one of the highest rates of private health insurance (PHI) expenditures as a share of total health expenditures in the world, through medical aid societies. This study considers the roles of history and politics in shaping PHI and determining its impact on health system performance in Zimbabwe. The authors reviewed 50 sources of information using a conceptual framework that integrates economic theory with political and historical aspects and present a timeline from the 1930s to present. The authors observe that Zimbabwe's current PHI coverage is segmented along socio-economic lines due to a long history of elitist and exclusionary politics in coverage patterns. While PHI was considered to perform relatively well up to the mid-1990s, the economic crisis of the 2000s eroded trust among insurers, providers, and patients. That culminated in agency problems which severely lessened PHI coverage quality with concurrent deterioration in efficiency and equity-related performance dimensions. The present design and performance of PHI in Zimbabwe is thus argued to be primarily a function of history and politics rather than informed choice. The authors propose that reform efforts to expand PHI coverage or improve PHI performance explicitly consider the relevant historical, political and economic aspects for successful reform.

11. Equity and HIV/AIDS

Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda
Muyanga N, Isunju J B, Ssekamatte T, et al: BMC Women's Health 23:250;1-13, 2023

This participatory qualitative study using in-depth interviews and focus group discussions explored how gender-based violence affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area, Uganda. At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy. Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level and in services led to fear among transwomen traveling to healthcare facilities, and limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. Given its effects on HIV transmission, the authors argue for strategies/ interventions targeting a reduction in gender-based violence and to sensitize communities to accept transwomen, including in healthcare settings.

12. Governance and participation in health

The lived experience of stigma and Parkinson’s disease in Kenya: a public health challenge
Fothergill-Misbah N: BMC Public Health 23: 364;1-12, 2023

Stigma is a recognised barrier to health-seeking behaviour and a social determinant of population health. This study draws on qualitative data collected from 55 people diagnosed with Parkinson’s and 23 caregivers as part of a wider ethnographic study to explore the lived experience of Parkinson’s disease in Kenya, using the Health Stigma and Discrimination Framework as a tool to understand stigma as a process. Participants reported their lived realities of stigma, and experiences of stigma practices, which had significant negative health and social outcomes, including social isolation and difficulty accessing treatment. Ultimately, stigma had a negative and corrosive effect on the health and wellbeing of patients, highlighting the interplay of structural constraints and the negative consequences of stigma experienced by people living with Parkinson’s in Kenya. Targeted and nuanced ways of tackling stigma are suggested, including educational and awareness campaigns, training, and the development of support groups.

What values drive communities’ nutrition priorities in a resource constrained urban area in South Africa?
Erzse A; Rwafa-Ponela T; Goldstein S et al: BMC Public Health 23:873;1-15, 2023

This study sought through focus group discussions to identify the priorities of community members of a South African township, Soweto, and describe the underlying values driving their prioritisation process, to improve nutrition in the first 1000 days of life. The authors used a modified public engagement tool: Choosing All Together which presented 14 nutrition intervention options and their respective costs. Participants deliberated and collectively determined their nutritional priorities. All groups demonstrated a preference to allocate scarce resources towards three priority interventions school breakfast provisioning, six months paid maternity leave, and improved food safety. All but one group selected community gardens and clubs, and five groups prioritised decreasing the price of healthy food and receiving job search assistance. Participants’ allocative decisions were guided by several values implicit in their choices, such as fairness and equity, efficiency, social justice, financial resilience, relational solidarity, and human development, with a strong focus on children.

13. Monitoring equity and research policy

COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key lessons
Fawole O, Bello S, Adebowale A, et al: BMC Public Health 23:835;1-15, 2023

The four countries in this mixed-methods observational and desk review study were selected based on their variability in COVID-19 response and representation of Francophone and Anglophone countries. The research documented best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, and these learnings were synthesized across the countries. As the pandemic progressed, the health systems moved from aggressive testing and contact tracing to detect virus and triage individual contacts into quarantine and confirmed cases, isolation and clinical care. Surveillance, including case definitions, changed from contact tracing of all contacts of confirmed cases to only symptomatic contacts and travellers. All countries reported inadequate staffing, staff capacity gaps and lack of full integration of data sources, and improved surveillance capacity by training health workers and increasing resources for laboratories, but the disease burden was still under-detected, due to limited decentralization of surveillance at the subnational level and gaps in genomic and post-mortem surveillance, community level sero-prevalence studies, and in digital technologies to provide more timely and accurate surveillance data. The authors call for investments to enhance surveillance approaches and systems including decentralizing surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, investing in health worker capacity, ensuring data quality and availability and improving ability to transmit surveillance data between and across multiple levels of the health care system.

Towards a bottom-up approach for localising SDGS in African cities: findings from Cairo and Dar es Salaam
Nagati O, Gad H, El-Didi A, et al: Africa Development XLVIII:1;79-111, 2023

The authors applied a localisation methodology to analyse the current status of the implementation and monitoring of Sustainable Development Goals (SDGs) 6 and 11.2 in Cairo and Dar es Salaam. It uses comparative, top-down and grounded bottom-up analyses to identify gaps in the existing SDG framework and ultimately proposes a set of evaluation criteria to replace the global indicators with new localised and quantifiable indicators in the two cities. In doing so, it responds to prevalent critiques of SDGs specific to their application in the global South, including difficulties in measuring and monitoring urban conditions, misrepresentation due to the reduction of complex local conditions to abstracted data, and the inadequate capacity of the agenda to consider and assess informal activity. The proposed revisions to targets and indicators for SDG 6.1, 6.2 and 6.b, and SDG 11.2, were discussed with community organisers and residents to bolster their validity, and to negotiate better sustainable-development paradigms policy-makers.

14. Useful Resources

Toolkit and Free Online Course: Conflict of Interest in Health Research
School of Public Health: University of Cape Town, South Africa, 2023

Resource-poor areas in sub-Saharan Africa benefit from collaborative research partnerships between clinicians/researchers and industry, but the scientific rigour and research integrity of such collaborations need to be preserved, and research partnerships protected from threats such as conflicts of interest. Science Councils, and Research Ethics Committees (RECs) play key roles in sustaining science and health research, and are eminently positioned to identify, prevent or manage conflicts of interest. UCT, in partnership with researchers in Kenya, Cameroon, Lebanon and elsewhere in South Africa, is providing a free online course aimed at Research Ethics Committee members and Science Granting Council staff to enhance skills to identify, manage and prevent conflict of interest in the health research process. The project also includes an open access toolkit which is a resource for Research Ethics Committee members, Science Granting Council staff, researchers, managers and administrators involved in the research process.

WHO's health inequality data repository
Hosseinpoor A, Bergen N, Kirkby K, et al: Bulletin of the World Health Organisation 101:5;298–298A, 2023

Launched in April 2023 by WHO, the health inequality data repository aims to make disaggregated data more accessible to diverse global audiences, including policy-makers, analysts, researchers, health professionals and others.6 The repository contains the largest collection of publicly available disaggregated data on health and health-relevant topics, with about 11 million data points. The repository includes over 2000 indicators related to the SDGs; coronavirus disease 2019 (COVID-19); reproductive, maternal, newborn and child health; immunization; HIV, tuberculosis and malaria; adult health; health care; burden of disease; disability; environmental health; WHO Thirteenth General Programme of Work; and other health determinants. A key feature of the repository is its user-friendly interface, which makes it accessible to audiences with a range of technical skills. The repository allows users to explore data through an interactive data visualization software that was specifically developed for health inequality analyses, the health equity assessment toolkit. The repository also opens new opportunities for expanded inequality monitoring.

15. Jobs and Announcements

22nd edition of the International Conference on AIDS and STIs in Africa, ICASA 2023
Deadline for abstract submissions: 31 July 2023

The 22nd edition of the International Conference on AIDS and STIs in Africa (ICASA 2023) offers a space for exchange of ideas and experiences among delegates in general and key actors, in particular, to respond to the AIDS epidemic, to advocate and implement effective, evidence-based AIDS and STIs, Tuberculosis (TB), Malaria and emerging diseases interventions as well as health systems strengthening in their communities, countries and regions. ICASA 2023, through the Community Village, avails a platform for PLHIV, key populations, community leaders, and their partners to showcase their programmes, services, best practices and share experiences and network to scale-up and sustain the response towards the end of AIDS. It further creates a a forum to appreciate and exchange African arts and traditions in relation to HIV, STIs, TB and Malaria. The Community Village Programme will be released on 30th September 2023.

Albertina Sisulu Executive Leadership Programme in Health Fellowship, University of Pretoria
Deadline for applications: 16 October 2023

The Albertina Sisulu Executive Leadership Program in Health (ASELPH) is a unique collaborative program through the University of Pretoria jointly developed and initially implemented with contributions from the Harvard TH Chan School of Public Health, and the National and Provincial Departments of Health in South Africa. The Program is focussed on developing middle and senior health system managers or clinicians for the challenges of the South African health system. It covers modules in Leadership, Ethics, Strategic Planning, Health sector Transformation, Decentralization & health service re-engineering; Complex Problem Solving, Financial Management, Human Resources For Health, Quality Improvement, Strategic Marketing and Communication and Monitoring and Evaluation. Innovative teaching and learning approaches include peer learning, case study methodology, reflective learning and mentorship.

Uganda National Conference on Health, Human Rights and Development (UCHD)
Center for Health, Human Rights and Development (CEHURD): 26th – 29th September 2023, Kampala, Uganda

CEHURD will hold the Uganda National Conference on Health, Human Rights and Development together with the Ministry of Health in Kampala, Uganda for 3-days in September, 2023. This conference is the first of its kind in Uganda and will focus on the country’s advancement on realizing the right to health within the context of sustainable development goals. The right to health is a fundamental part of our human rights and human dignity. It is a development issue, which is incorporated in international and regional human rights treaties and in national laws, policies and strategies. A call for abstracts will be designed and sent out to all partners and potential networks to share papers based on the different conference tracks. Conference registration information will be available on the conference website at CEHURD in due course.

Urban Studies Foundation International Fellowships for urban scholars from the Global South
Deadline for applications: 20 June 2023

Applications are invited to the USF’s International Fellowships for urban scholars from the Global South. Each award will cover the cost of a sabbatical period at a university of the candidate’s choice, worldwide, for the purpose of writing-up the candidate’s existing research findings in the form of publishable articles and/or a book. The proposed work should be completed under the guidance of a chosen mentor in the candidate’s field of study. Funding is available for a period ranging between 3-9 months, and eligible research may cover any theme pertinent to a better understanding of urban realities in the Global South.

Urban Studies Foundation International Fellowships for urban scholars from the Global South
Deadline for applications: 20 June 2023

Applications are invited to the USF’s International Fellowships for urban scholars from the Global South. Each award will cover the cost of a sabbatical period at a university of the candidate’s choice, worldwide, for the purpose of writing-up the candidate’s existing research findings in the form of publishable articles and/or a book. The proposed work should be completed under the guidance of a chosen mentor in the candidate’s field of study. Funding is available for a period ranging between 3-9 months, and eligible research may cover any theme pertinent to a better understanding of urban realities in the Global South.


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