EQUINET NEWSLETTER 236 : 01 September 2023

1. Editorial

Artificial intelligence in our health systems – who really needs it?
Bona Chitah, University of Zambia, Lusaka

Media and discourse is full of statements that artificial intelligence (AI) is here to stay. While less commonly discussed, when AI is linked to health and health care, optimism is expressed that it will be a positive development, offering new diagnostic capabilities and care, helping to organise services, supporting patient adherence to treatment and performing administrative tasks. But is this really the case? Is this really the technology that will, as it claims, promote healthy lifestyles, prevent disease and support care from primary health care to complex curative care?

The total global AI market size was valued at USd454 billion in 2022. In relation to AI in the health sector, the global market value is currently estimated at USd120 million, but is projected to rise to between USd200 billion and USd1.5 trillion by 2030. While still projections to be tested, these estimates suggest AI growth in health care could be one of its fastest growing markets.

While AI is already prevalent and used in many aspects of business and society, its use in health care is already being debated, for a range of reasons. This is a debate that we should be informed and ahead of and not simply reactive to in our region.

Firstly there is the issue of its relevance and application. Health systems in different parts of the world face different population health challenges, with varying needs and levels and types of resources to meet them. While public health profiles are in transition towards greater chronic disease and ageing populations, there is still diversity in demographic and health conditions. Health system approaches are thus not homogeneous, including in terms of what is relevant for their design and their integration of technologies and interventions. Using AI may have relevance for precision spotting of malignant tumours in high income countries, but may be viewed as a less relevant technology or use of resources for the common population health profiles and public health needs of low and middle income countries. Even in higher income settings, while AI diagnostic systems have been tested since the 1970s, they have largely not been adopted for clinical practice as they did not outperform human diagnosticians, nor fit well in workflows.

Secondly, there is a question of who controls the technology innovation and how equitable its diffusion is. While smartphone and information technology innovations are expanding in Africa, as witnessed by the range of innovations produced on the continent during the COVID-19 pandemic, the gap between low and high income countries in AI technology innovation is vast, with challenges in catching up with capacities for local innovation and production of the technology. This may raise the same investment, intellectual property and infrastructure barriers faced with advancing local production of other health technologies. If these barriers are not addressed, integration of AI may raise areas of technology dependency, limiting relevant innovation and use in settings of high health need.

Thirdly, there are ethical issues in applying AI in health systems, including issues of accountability, transparency, permission and privacy. What personal data and processes will AI be applied to, at what cost, and who will access this data? As experiences from COVID-19 showed, technology expanded but social factors played a key role in its uptake. Debates emerged during the pandemic on who controlled the various forms of digital monitoring used to gather and use data, such as for travel or access to services, and what support or benefit was triggered by data collected in these applications. These debates would be equally relevant to the wider use of AI. Who guarantees access and availability, including in contexts of inequity in digital access, and with what measures for permission and privacy?

Fourthly, and related to all of the others, there are emerging pronouncements by experts that the extremely rapid development of AI and expansion of its use should be halted, significantly slowed or better assessed and guided, given concerns on the lack guarantee of the safety of the technology. Most countries, including those in our region, still have limited or no legal provisions ensuring AI safety and ethics in areas where its use may bring public harm, such as in use of false or unexpected outcomes, in amplifying social bias and economic inequality, breaching privacy, displacing jobs or in the loss of human connection. What needs to be put in place first to ensure better guidance and control?

Health systems have a duty to provide the functions and services to ensure health outcomes that are socially defined as acceptable, considering population health needs. In our region, priorities are weighted towards conditions and programmes like immunisation, maternal, new-born and child health, adolescent and reproductive health, control of infectious disease and prevention and management of chronic disease. The primary health care (PHC) services for these interventions are under-resourced, but not complex.

AI may be argued to play a role in the region in population health; in supporting in person contacts, such as by community health workers; in telemedicine, or in data storage and retrieval systems. However, for its relevance in east and southern Africa, AI needs to have observable benefit for PHC as the entry point into the health system, for frontline health workers who support the systems equitable functioning, and for those communities with highest health need. AI needs to be assessed for and visibly demonstrate whether it can strengthen quality and reduce inequities in our health system. Using it would also need to address the issues noted earlier, including relevance, sustainable operation; data privacy, ethical practice, ownership and control of the technology; trust and regulation, with duties and standards for monitoring and assessing impact, including on equity and the distribution of benefit.

These measures call for regulation. But drafting law and policy on AI requires public consultation, which in turn requires significantly greater public and professional literacy on AI-related issues than is currently the case. The issues raised need informed debate. Questions should be asked, including why, when the labour force and social capacities in our region are growing, we shouldn’t rather invest in them than replace them with AI? Who really needs it?

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

Reclaiming Uganda's food system through a systemic, people-centred transformation
Danny Gotto, Executive Director, Innovations for Development, Uganda

The intricate tapestry of Uganda's food system, woven over centuries, underwent a tectonic shift due to colonialism. The reverberations of this historical trauma continue to shape the country's food landscape, underscoring the pressing need to untangle the threads of colonization and breathe new life into an ailing system.

Before it was colonised, Uganda's land was a patchwork of kingdoms and chiefdoms, in a communal system where land wasn't just a resource, but a collective heritage. It provided fertile ground for families to cultivate food and other crops for their subsistence and to share with their communities, an arrangement steeped in tradition, reciprocity and co-existence.

Colonial geo-political shifts shattered this communal system. The establishment of the British Protectorate of Uganda in the 1900s changed the relationship between society, land and food. A treaty signed between the British Protectorate government and the Buganda Kingdom in 1900 segregated land into two categories: In one, over 9100 square miles of game reserves, forests, mineral-rich expanses, and water bodies were seized as ‘Crown Land’, by the Imperial British East Africa Company, and transferred in the 1930s to various private and state landholders.

In the other segment, 10000 square miles share of less fertile ‘mailo land’ was allocated as private land to the king (Kabaka) and his family, chiefs, and religious institutions, making over 1.5 million indigenous residents squatters on the land, requiring permission and having to pay taxes to live on or farm the land. Ordinary Ugandans, once stewards of their land, were thus displaced, marginalised, and impoverished. Forced migration, and violent conflicts with the colonial government intensified displacement, famine, human and livestock disease, poverty and death.

Landless, indigenous people were compelled to work as poorly paid wage labour for foreign plantation owners, mostly British and Asian, producing cash crops for export, including food, coffee, cotton, tea, and cocoa. Poor wages, substandard conditions, colonial expansion wars and landlessness drove urbanisation. Those migrating to towns and cities often lived in informal settlements, in racially segregated cities, within crowded, substandard living conditions. That situation has evolved into today's unplanned, poorly-serviced areas of towns and cities. The food system also changed. The indigenous food culture, with a diet of nutritious of millet and sorghum slowly yielded to imported influences and local economic pressures.

Between 1910 and Uganda’s independence in 1962, smallholder farmers who were the backbone of local food subsistence would sell to exploitative local middlemen. The meagre payments they received drove farmers towards better-paid non-food crops such as cotton, coffee, tea, and tobacco. Low investment and a fall in indigenous food production led to intermittent famines in many regions in the early 1900s. In response, the colonial government introduced fast-growing crops like cabbages and potatoes (locally referred to as ‘Irish Potatoes’ given their Irish origin) to contain famines. Urban communities increasingly depended on commercial and informal food markets, with poor food hygiene and high levels of additives in imported fast-foods exposing them to communicable and nutritional diseases.

Landless people joined the struggle for Uganda’s independence, seeking change to these forms of exploitation. Independence brought them political change, but limited socio-economic change. Colonially confiscated ‘crown land’ became national public land, still producing cash crops, without restoring land to or compensating original inhabitants who were displaced from their land. Despite key new constitutional political freedoms, a priority for development over decolonisation, and adoption of a neoliberal economic model sustained inequalities in wealth and weakened economic self-determination.

Today’s burgeoning urban population grapples with exorbitant food prices, in commodified food markets. Food prices are affected by international commodity prices, conflicts, emergencies and pandemics like COVID-19 that destabilise food supply chains, particularly as where imported foods such as wheat or rice have supplanted local staples. Climate change compounds this vulnerability, with water-stressed regions facing challenges in producing food from rain-fed agriculture. Under-investment in largely female smallholder farmers constrains their ability to generate livelihoods or to apply technological innovation, at a time when commercial seeds demand increasingly costly synthetic fertilisers and pesticides.

Policy deficits related to food systems extend down other policy corridors. Neoliberal economic policies in the last three decades, influenced by international financial institutions, have focused on finance and export sectors, while starving the food sector. The formal private sector, pivotal in shaping the policy landscape, focuses on export-oriented production at the expense of indigenous, locally-consumed food. Trade liberalisation has promoted a further surge in unhealthy, food imports, further disconnecting people from their indigenous dietary roots. Markets flooded with ultra-processed foods catalyse a rise in food-related non-communicable diseases (NCDs) such as hypertension and diabetes, from 22% of total national deaths a decade ago to 35% today. Kampala contributes to nearly 50% of all cases of NCDs.

The urgency to halt this trajectory cannot be overstated. Systemic transformation hinges on a multifaceted, people-centred approach towards food sovereignty. Closing knowledge and resource gaps to facilitate appropriate modern farming techniques, protecting indigenous seed stocks, and implementing inclusive land reforms are pivotal, as is recognising and supporting the role of urban agriculture. Restoring indigenous seeds, practices and foods in ways that prevent local resource depletion can make healthier, affordable foods available and accessible. Legal and tax measures can curb marketing of unhealthy foods, together with promotion of a seismic shift in public awareness to alter consumption patterns.

Reclaiming a healthy and self-determined food system isn't confined to Uganda's borders.
The trends outlined are found in other African countries, and the Alliance for Food Sovereignty in Africa has engaged on their global corporate drivers. A global forum on food sovereignty is bringing together thousands of indigenous, small-scale farmer, worker and other movements in a ‘Nyeleni process’ to advance food sovereignty at all levels (https://www.foodsovereignty.org/nyeleni-process/) In east and southern Africa (ESA), as noted elsewhere in this newsletter, we need to and can collaborate regionally to dismantle the colonial and neo-colonial features of our food systems and to strengthen food sovereignty, supported by updated and harmonised food system laws, taxation to discourage harmful foods and by promotion of climate-relevant healthy approaches for farming, producing, processing and promoting consumption of healthy foods.

Uganda stands at a pivotal juncture in its food system trajectory. The path to decolonising its food system and building food sovereignty may raise challenges. It is, however, a path that can and must be traversed, to reach a future where food is not just to survive, but a testament to self-determination.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. You can read further information on EQUINET work on issues raised in this oped on the EQUINET website.

2. Latest Equinet Updates

A CALL FOR APPLICANTS: Online capacity building on health impact assessment in east and southern Africa
Call closes 5pm Southern Africa time October 6 2023

Health impact assessment (HIA) is a structured process that helps to identify where changes to project design or operation provide health benefits and mitigate health risks, While HIA is being more widely practiced, in ESA countries HIA is sometimes implemented in a more limited manner as a part of environmental impact assessment. The lack of a specific process and legal requirement for HIA leaves the region with inadequate capacities, practice and evidence on health impacts of policies and activities, at a time when new health challenges, changes in trade policy and production systems make it even more necessary. EQUINET is thus, in association with regional and international partners, convening training in 12 online sessions in February to May 2024, including mentored case work to build HIA capacities in different actors in ESA countries. The course is being held free of any fee cost for participants. Applicants for the call should be from an ESA country, should be from state, non- state, labour, professional or academic institutions, and have roles in or an intention to implement HIA. We encourage applicants to apply as a team of up to 4 people from these groups from a country or setting, but will also consider individual applicants and if selected include them within the teams for their country. Further information is available on the EQUINET website, including the information applicants for the call are asked to provide before the closing date. Applicants will be informed of the outcome of their application before or by 1 November 2023 and be provided with further course information and materials.

A conceptual framework for healthy urban systems for food and waste management in ESA countries
Urban health community of practice: EQUINET, Harare, 2023

Food and waste management systems are key entry points to foster innovation, collaboration, accountability, literacy and system-wide change to support healthy people, healthy ecosystems (including green spaces, energy and water) and an inclusive, productive, regenerative and circular urban economy. This document outlines a conceptual framework and features of key elements for urban systems to achieve this, organised within 5 key areas for such systems to provide affordable, safe, nutritious foods in healthy urban food neighbourhoods and green spaces, in ways that respect and protect ecosystems and provide an inclusive, poverty-reducing and equity oriented circular economy, that reduces, recycles and reuses urban food and other waste to support other needs and benefits, including for water, energy and green spaces. This framework is being applied in ongoing case studies and work in EQUINET.

Brief from the webinar: Climate justice and the right to health and wellbeing

In 2023 – 24 EQUINET is organising a series of online dialogues to share knowledge and perspectives from community/local, national and international level on the impact of climate trends, the intersect with the other drivers/ determinants of inequity, the implications for policy and action that links climate to health equity and vice versa, and the . proposals for policy, practice, research, and action. This brief reports on the issues raised in the first webinar in the series on climate justice and health rights, convened by the Center for Health, Human Rights and Development (CEHURD), and EQUINET steering committee member. The full webinar is available on the EQUINET site. This brief summarises key points raised by speakers and participants on how climate features are impacting on the right to health; the actions that need to be taken to address these issues at local, national and regional level and in international/ global level processes and forums from a regional lens; and issues raised to be further discussed in the other thematic webinars. The brief is shared to draw further comment and input on the issue.

Delving into the Cityscape: Transforming the connections between urban environments, social factors, and public health in Nairobi, Kenya
Oranga A, Kounkuey Design Initiative: EQUINET Photojournalism brief, Kenya, 2023

Kibera, an informal settlement in Nairobi, is situated alongside Ngong River, running along its southern edge. The dam water became hazardous for consumption due to pollutants accumulated during the course of the river, spreading diseases such as malaria, typhoid and cholera, and illnesses caused by chemical effluents pumped into the river from industries. Together with New Nairobi Dam Community, Kounkuey Design Initiative (KDI) conducted a series of workshops with community members and the local administration to identify the challenges, with a series of workshops planning and designing solutions to the pressing issues they had raised, including flood protection, improved sanitation, opportunities for youth, and income generation. Planting, landscaping-driven engineering, solid waste management activities carried out from 2006 to date and improved sanitation services were coupled with community-led site operations and maintenance. The activities changes polluted unhealthy conditions into green, clean environments and improved health for community members living near the river and dam. Beyond these environment and health infrastructures, the community set up childcare services, a school feeding program, and a greenhouse for urban agriculture. The transformation demonstrates the power of co- designing solutions with communities that prioritise a combination of social, ecological, and health benefits.

Effective Waste Management in a Local Food Market: The Longacres experience in Lusaka, Zambia
Phiri P, Centre for Primary Care Research: Photojournalism brief, EQUINET, 2023

This brief describes a story of the change at Longacres. Solid waste generated in this food market is sorted at the source, separated by type and placed into designated bins, as receptacles that receive the waste. Stakeholder meetings were organised by BORDA Zambia in collaboration with the Lusaka City Council to train marketeers on how to separate waste at the source and discard it in specific bins for further processing. In 2021 BORDA Zambia met representatives from the Lusaka City Council, school authorities, marketeers and a ‘Market Advisory Committee’ of those involved and developed a shared framework for the smooth running of the pilot. A decentralised organic solid waste management treatment system and biodigester were locally designed and made, The initiative has installed a functional end-to-end chain for waste disposal and management at the market and Lusaka City Council is now planning to replicate the concept in other markets throughout Lusaka. The story of change is being shared as it could also be applied in food markets in other urban settings in the region.

Enhancing sustainable access to safe clean water and gender-sensitive sanitation services in Epworth
Ndlovu T, Civic Forum on Human Development: EQUINET Photojournalism brief, Harare, 2023

Epworth, a peri-urban settlement about 15 kilometres southeast of Zimbabwe's capital, Harare faces water stress and poor santiation. The Civic Forum on Human Development (CFHD) worked with Epworth households and identified with the community a priority to to build better toilets and hygiene facilities. In community-Based planning, information was gathered through a rapid assessment and focus group discussions with community members and organisations, Realising the challenges of water in Epworth, a two litre flush system was introduced as a more appropriate toilet system and pump minders trained. This process combined local technology and social processes to improve water and sanitation in a community with limited infrastructure, and water scarcity.

Health-promoting urban food systems in selected local authorities in Zimbabwe
Loewenson R, Kadungure A, Machinda T, et al: UCAZ, TARSC, Bulawayo, Chegutu, Harare, Kariba, Kwekwe, Masvingo and Victoria Falls local authorities, MoHCC, EQUINET, 2023

Evidence suggests that Zimbabwe’s urban households are becoming more food insecure post-2018, including from the impact of COVID-19 and a shift to ultra-processed foods increasing food–related non communicable diseases (NCDs). Case studies from seven urban local authorities (Bulawayo, Chegutu, Harare, Kariba, Kwekwe, Masvingo and Victoria Falls) in Zimbabwe point to range of initiatives underway to support healthy food systems. This synthesis report provides a structured thematic content analysis of and common findings from the seven case study reports, for wider exchange with other urban settings. Urban agriculture (UA) is being actively promoted with innovations to address local water and land constraints, including hydroponics, aquaculture; using available land in hospitals, schools and public spaces; replacing areas of waste dumping with nutrition gardens and recycling bio-waste to fertilise UA. Local technology has been developed and support provided for maize meal fortification, peanut butter processing, fish and livestock farming and vending, supported by solar energy and boreholes for more reliable inputs.These and other activities documented indicate the scope of interventions for urban food systems that could be extended to other local authorities.

Solid waste management in Slum Communities of Bwaise III Parish: Transforming Solid Waste into Valuable Resources
Gramsen Kizza F, Innovations for Development: EQUINET photojournalism brief, Kampala, 2023

Bwaise is an urban locality in the Kawempe Division, Kampala. The inadequate management of solid waste in Bwaise presents numerous difficulties, including sporadic flooding and outbreaks of diseases. Recognizing the need to address these challenges and the economic struggles faced by the community, the local chairpersons took the initiative to motivate the residents. They initiated training programs, facilitated through saving groups, to promote use of the waste as a resource for energy in the form of briquettes. Under the guidance of the local chairpersons, the community chose members, primarily women and youth, from different community groups. The groups promote waste collection and use the waste for briquettes used for household energy. The groups have also set up plastic waste collection centres to aid the removal of plastic waste in the communities. Fostering collaboration among all stakeholders within the communities has enabled solutions to be designed and implemented to address the challenges encountered.

Taxing for health: taxes on sugar-sweetened beverages in east and southern African countries
Kadungure A, Loewenson R: TARSC EQUINET Discussion paper 130, EQUINET, Harare 2023

This paper explores sugar-sweetened beverage (SSB) taxes and their role in a public health response to the challenges of rising consumption of SSBs. The paper outlines the global and regional standards, guidance and areas of legal or policy debate on the control of SSB health risks, particularly through taxation; it provides evidence on the design, taxation levels and products covered in SSB taxation in different regions globally and in east and southern Africa (ESA) countries. It also discusses experiences of and issues around using SSB-related taxation for health in ESA countries. Drawing on the evidence identified, it proposes actions and issues for policy dialogue in ESA countries and in the region.

Webinar on Climate Justice and Comprehensive PHC systems in East and Southern Africa
EQUINET, REACH Trust, IWG: Online October 25th 2023 2-4pm Southern Africa 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. Following webinars held on health rights and climate Justice in July and on urban health and climate justice in August the next webinar will explore the intersect between climate justice and comprehensive PHC oriented health systems in east and southern Africa on October 25th 2023 2-4pm Southern Africa time (3-5pm East Africa time). We will hear from speakers with experience on these issues at community/local level, at national level and at global level, and provide time for participant discussions and proposals for engaging on the issues raised for the region. Visit the link to register in advance for the meeting, providing your name, institution and contact email.

3. Equity in Health

Elevated blood pressure among adolescents in sub-Saharan Africa: a systematic review and meta-analysis
Chen A, Waite L, Mocumbi A, et al: The Lancet Global Health 11:8; E1238-E1248, 2023

More people from sub-Saharan Africa aged between 20 years and 60 years are affected by end-organ damage due to underlying hypertension than people in high-income countries, but we lack data on the pattern of elevated blood pressure among adolescents aged 10–19 years in sub-Saharan Africa. This study aimed to fill this gap, through systematic review and meta-analysis of studies published from Jan 2010, to Dec 2021. 36 studies comprising 37 926 participants aged 10–19 years from sub-Saharan African countries were eligible. A pooled sample of 29 696 adolescents informed meta-analyses of elevated blood pressure and 27 155 adolescents informed meta-analyses of mean blood pressure. The reported prevalence of elevated blood pressure ranged from 0·2% to 25·1% of adolescents. with 13·4% of male participants compared with 11·9% of female participants having elevated blood pressure, Although many low-income countries were not represented in the study, the findings suggest that approximately one in ten adolescents have elevated blood pressure across sub-Saharan Africa. The authors observe that there is an urgent need to improve preventive heart-health programmes in the region.

Socioeconomic and geographical inequalities in health care coverage in Mozambique: a repeated cross-sectional study of the 2015 and 2018 national surveys
Daca CSL, San Sebastian M, Arnaldo C, et al. BMC Public Health. 23:1007 https://doi.org/10.1186/s12889-023-15988-y, 2023

Over the past years, Mozambique has implemented several initiatives to ensure equitable coverage to health care services. While there have been some achievements in health care coverage at the population level, the effects of these initiatives on social inequalities have not been analysed. This study aimed to assess changes in socioeconomic and geographical inequalities (education, wealth, region, place of residence) in health care coverage between 2015 and 2018 in Mozambique. The study was based on analysis of measures from repeated cross-sectional surveys from nationally representative sample surveys. The non-use of insecticide-treated nets dropped, whereas the proportion of women with children who were not treated for fever and the prevalence of women who did not take the full Fansidar dose during pregnancy decreased between 2015 and 2018. The authors observed significant reductions of socioeconomic inequalities in insecticide-treated net use, but not in fever treatment of children and Fansidar prophylaxis for pregnant women. They suggest that decision-makers target underserved populations, specifically non-educated, poor people and rural women, to address inequalities in health care coverage.

4. Values, Policies and Rights

Anti-gay law erodes Uganda’s gains in HIV fight ­PEPFAR chief
Nantume G: Monitor, Uganda, 2023

This article summarises points made In July 2023, by Amb Dr. John Nkengasong, the US Global AIDS Coordinator and Special Representative for Global Health Diplomacy, addressing African journalists in Washington DC on the gains of PEPFAR. He noted that the recent signing of the Anti-Homosexuality Act 2023 means that Uganda stands to lose funding of about $400 million from PEPFAR as annual support to HIV/Aids care and treatment.

Artificial intelligence for global health: cautious optimism with safeguards
Pujari S, Reis A, Zhao Y, et al: Bulletin of the World Health Organisation 101:6, 364–364A, 2023

The United Nations Secretary-General has stated that the safe deployment of new technologies, including artificial intelligence (AI), can help the world to achieve the sustainable development goals. Large language models generate responses that can appear authoritative and plausible to an end-user; however, without adequate controls in place, the veracity and accuracy of responses may be extremely poor. These models may be trained on data for which explicit consent may not have been provided, and they may not protect sensitive data (including health data) that users voluntarily feed into the AI-based tool. AI tools are increasingly being applied to public health priorities, and have the potential to assist with pattern recognition and classification problems in medicine – for example, early detection of disease, diagnosis and medical decision-making. For any beneficial impact, especially in low- and middle-income countries, ethical considerations, regulations, standards and governance mechanisms must be placed at the centre of the design, development and deployment of AI -based systems, with oversight by governments and their appropriate regulatory agencies. WHO has published guidance on Ethics and governance of AI for health, and has convened an expert group to develop additional guidance. The authors call for a multiagency global initiative on AI for health to improve coordination, leverage collective agency, and ensure that the evolution of AI steers away from a dystopian future towards one that is safe, secure, trustworthy and equitable.

5. Health equity in economic and trade policies

Common but Differentiated Responsibilities: The Equity Principle Guiding Climate Change, and the Reforms for Pandemic Prevention, Preparedness & Response
Tcholakov Y: Geneva Health Files, Switzerland, 2023

While low and middle income countries have called for the principle of Common but Differentiated Responsibilities (CBDR) to be embedded to meet equity objectives in the on-going global health negotiations on climate change and pandemic preparedness, drawing on environmental policies, they face resistance from other countries. The author suggests two possible scenarios ahead: In the first, the CBDR principle is broadly accepted and implemented in a more equitable and effective pandemic response that acknowledges the differentiated capacities of nations and allocates obligations accordingly, through inclusive global health governance. In a second scenario, if the CBDR principle is rejected or adopted in a very diluted form, the author argues that the pandemic accord may struggle to meet its objectives. An uneven distribution of responsibilities could overwhelm less capable nations during health crises, leading to an inefficient and unjust response. Failure to consider the unique needs and vulnerabilities of developing countries could perpetuate existing global health inequities, diminishing the resilience of the global health system in the face of future crises and putting all populations at greater risk. The author proposes that striving towards equity and inclusion through the careful implementation of the CBDR principle may prove vital in realising a pandemic accord capable of meeting the challenges of global health crises.

Congo’s Forgotten Uranium: How the DRC was used to make the first nuclear bomb
Audu V: The Republic, Nigeria, 2023

On 06 August 1945, the United States dropped the world’s first atomic bomb on Hiroshima, Japan during the Second World War. A large amount of uranium used in making the first atomic weaponry was sourced from the Shinkolobwe mine in the Katanga province of the DRC, mined by workers who worked under secret contracts and low wages for the United States national security. To prevent information from leaking, Shinkolobwe was erased from maps. Misinformation was spread to make it appear that uranium was sourced from Canada, whose ores yielded 0.03% uranium while Congolese ores yielded 65% uranium. In a 2004 assessment of the mine, the United Nations found ‘high risks of mine collapse and potential chronic exposure to ionizing radiation’, recommending that the mine remain closed, while local Congolese families are reported to believe that their history has been tarnished by the uranium exploitation and use.

6. Poverty and health

COVID-19 crisis interlinkage with past pandemics and their effects on food security
Roubík H, Lošťák M, Ketuama C, et al: Globalisation and Health 19:52; 1-16, 2023

This paper explores the impacts of COVID-19 and past pandemics on food security and key strategies that could be put in place to manage these impacts on security. The coronavirus pandemic deepened disruptions in the flow of farm workers and farm operations leading to post-harvest food losses, and diets were affected. The authors recommend future responses to prevent and mitigate the effects of pandemics on food security consider inter-connected pro-active policy, program, and institutional actions.

What SA’s dirty water does to your health
Malan M, Mdzeke Y, Moloi M: Health Beat #10,|Bhekisisa, South Africa, 2023

A broken sewerage system in Bophelong near the Vaal River in Gauteng, forces people to live “like pigs”, says environmental activist Lawrence Majoro. The department of water and sanitation acknowledges the Vaal is “one of the worst polluted rivers in South Africa”, leaving residents exposed to diseases like cholera. In this episode of Bhekisisa’s monthly television show, Health Beat, viewers are taken to see the Emfuleni municipality in Vanderbijlpark’s rundown sewers, with input from an infectious diseases expert and a water scientist on the implications if water treatment services don’t improve.

7. Equitable health services

Contribution of the one health approach to strengthening health security in Uganda: a case study
Bakiika H, Obuku E, Bukirwa J, et al: BMC Public Health 23:1498, 1-11, 2023

This study assessed the contribution of the One Health approach to strengthening health security in Uganda. A process evaluation was done between 25th September and 5th October 2020, using a mixed–methods case study. Funding and implementation status from the National Action Plan for Health Security 2019–2023 launch in August 2019 to October 2020 was assessed with a One Health lens. Full funding was available for 36.5% of activities while 40.6% were partially funded and 22.9% were not funded at all. The majority of the activities were still in progress, whereas 8.6% were fully implemented and 14.2% were not yet done. In workforce development, several multi-sectoral trainings were conducted including the frontline public health fellowship program, the One Health fellowship and residency program, advanced field epidemiology training program, in-service veterinary trainings and 21 district One Health teams’ trainings. Real Time Surveillance was achieved through incorporating animal health events reporting in the electronic integrated disease surveillance and response platform. The national and ten regional veterinary laboratories were assessed for capacity to conduct zoonotic disease diagnostics, two of which were integrated into the national specimen referral and transportation network. Multi-sectoral planning for emergency response and the actual response to prioritized zoonotic disease outbreaks was done jointly. This study demonstrates the contribution of ‘One Health’ implementation in strengthening Uganda’s health security.

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

Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda had variable COVID-19 responses. A mixed-methods observational study was conducted including desk review and key informant interviews, to document best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, with learning synthesized across the countries. Surveillance approaches across countries included case investigation, contact tracing, community-based, laboratory-based sentinel, serological, telephone hotlines, and genomic sequencing surveillance. As the COVID-19 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. The authors recommend investments to enhance surveillance approaches and systems including decentralising surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, among others. 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 is also noted to be critical.

Routine health check-ups for adolescents in Mwanza City, Tanzania: stakeholders’ recommendations on its content, venue, and mode of delivery
Sedekia Y, Mshana G, Nsanya M, et al: BMC Public Health 23:1015,1-14, 2023

This study was conducted in 2020 to inform research to define the content and delivery strategies for health check-ups to be performed in young and older adolescents, and to assess whether such services are likely to be acceptable and feasible in Tanzania, using a semi-structured guide with purposively selected stakeholders from government departments, non-governmental and community-based organisations, schools and health facilities. Stakeholders interviewed were supportive of introducing routine health check-ups among adolescents and recommended focusing on non-communicable diseases, physical disabilities, common mental health problems, reproductive health problems, specific communicable diseases, and hygiene-related problems. They also recommended combining counselling and family planning information with these check-ups. Three venues were proposed: schools, community settings, and youth-friendly health facilities. The authors propose further implementation research and cost benefit analysis to help guide policy on this.

8. Human Resources

Incidence of Coronavirus Disease 2019 (COVID-19) among healthcare workers during the first and second wave in the Democratic Republic of the Congo: a descriptive study
Milambo J, Ndirangu J, Mangala S, et al: BMC Infectious Diseases 23:519, 1-7, 2023

Healthcare workers (HCWs) are at the frontline of response to the COVID-19 pandemic. This study investigated the burden of COVID-19 among HCWs and infection prevention and control (IPC) gaps during the first to the third wave of the pandemic in a retrospective cohort study in the Democratic Republic of Congo using its National Department of Health database and a WHO questionnaire. The investigation revealed that about 32% of HCWs were infected from household contacts, 11% were infected by health care facilities, 35% were infected in the community and 22% were infected from unknown exposures. IPC performance was moderate, with lower or minimal performance on triage and screening, hand hygiene, PPE availability, waste segregation, waste disposal, sterilization, and training of HCWs. HCWs who tested positive for the COVID-19 virus was higher among frontline healthcare workers from 6 provinces of DRC. The authors recommend strategies to strengthen IPC capacity building and provide HCWs with sufficient PPE stocks and budgets to improve IPC performance and enable adherence to WHO recommendations to minimize COVID-19 transmission in HCFs, communities, and public gatherings.

The Economic Burden of COVID-19 Infections amongst Health Care Workers
World Bank, Resolve to Save Lives : World Bank, New York, 2023

This report estimates the economic burden of health care worker infection and death during COVID-19 to understand the direct and indirect cost of health care worker (HCW) infections, their contributions to wider community transmissions and the economic toll of disrupted health services. The economic burden of HCW infection was heaviest in the countries that had low HCW density and were most severely affected by staff shortages. The heaviest costs were associated with secondary infections and excess maternal and child deaths. The costs of onward viral transmission outweighed those associated with direct HCW infections, ranging from 13% of total economic costs linked to HCW infections in Kenya to 70% in KwaZulu-Natal, South Africa. The burden in Kenya was estimated at almost $34,000 or 18 x GDP per capita and in Eswatini at almost $36,000 or 9 x GDP per capita. As a percentage of annual health expenditure, the total burden associated with HCW infection and death was highest in Western Cape, South Africa, at 8.4. The report demonstrates the importance of prioritizing the protection of health care workers.

9. Public-Private Mix

Africa’s High Cancer Deaths Can Be Addressed by Improved Access to Key Medicines
Cullinan K: Health Policy Watch, 2023

Africa has one of the highest cancer death rates in the world, yet this could be markedly improved by better access to treatments already widely available in high-income countries for the continent’s biggest killers – breast, cervical, lung and prostate cancers and Kaposi sarcoma. This is according to a recent study by the Botswana-Rutgers Partnership for Health, which researched which cancer treatments that are effective in other regions could have an impact in sub-Saharan Africa (SSA) – but are not available or hard to get. The partnership propose a framework for how to improve access to the life-saving and life-altering medications that are proven to work that are available elsewhere but not in Africa. While cost-effectiveness concerns are noted to be important in realistically increasing availability of a broad range of oncology drug therapies in SSA, they propose advancing therapeutics would reduce the significantly high case-fatality rates from cancer in SSA as a global imperative, combined with investment in diagnostic and laboratory infrastructure and in the oncology workforce.

10. Resource allocation and health financing

Future health expenditure in the BRICS countries: a forecasting analysis for 2035
Sahoo P, Rout H, Jakovljevic M: Globalization and Health 19:49, 1-17, 2023

The BRICS nations’ economies are distinguishable from other emerging economies due to their rate of expansion and sheer size. Health spending in the BRICS countries (includes South Africa) has been increasing, but is still below health security needs and with high out-of-pocket spending. This study examined the health expenditure trend among the BRICS from 2000 to 2019 and made predictions with an emphasis on public, pre-paid, and out-of-pocket expenditures to 2035. Health expenditure data for 2000–2019 were taken from the OECD iLibrary database. Except for India and Brazil, all of the BRICS countries show a long-term increase in per capita health expenditure, most sharply rising in China, and only India’s health expenditure is expected to decrease as a share of GDP. The authors suggest that BRICS countries have the potential to be important leaders in health policies. Each BRICS country has set a national pledge to the right to health and is working on health system reforms to achieve universal health coverage, and estimations of their future health expenditures may help policymakers decide how to allocate resources to achieve these goals.

11. Equity and HIV/AIDS

Devastating harms of criminalisation laid bare by UNAIDS advisory group
Phillips H: Be in the Know, Online blog, 2023

An advisory group to UNAIDS has released “overwhelming and undeniable” evidence on the harm that criminalisation is having on public health and the goal of ending AIDS by 2030. Criminalising certain groups, such as sex workers, gay and trans people and people who use drugs was found to be driving HIV infections and violating human rights, as a barrier to achieving the goal of ending AIDS by 2030. Their report shows a clear link between the legal status of groups most affected by HIV and the level of stigma and discrimination they experience. The UNAIDS Reference Group on HIV and Human Rights is calling on UN member countries to work with community-led organisations to “immediately repeal or reform” laws that criminalise the following things: consensual same-sex sexual conduct and the expression of gender identity, sex work and related activities, drug use and simple possession of drugs for personal use and HIV transmission and non-disclosure.

People with HIV remain at higher risk of dying from COVID-19 in the Omicron era
Alcorn K: Aidsmap, Australia, 2023

Deaths from COVID-19 have fallen much less sharply in people with HIV compared with the rest of the population since the arrival of the Omicron variant of SARS-CoV-2, the World Health Organization (WHO) reported at the 12th International AIDS Society Conference on HIV Science (IAS 2023). Data from 821331 people admitted to hospital with COVID-19 in 38 countries found that one in five people with HIV admitted to hospital with COVID-19 died during the Omicron wave compared to one in ten people without HIV. The WHO study team say that the consistent finding that low CD4 counts increase the risk of death from COVID-19 highlights the need for intensified HIV testing and treatment initiation to reduce the risk of severe outcomes, and to give booster vaccine doses for all people living with HIV even during the less severe and low incidence SARS-CoV-2 variant waves.

12. Governance and participation in health

Batswana say citizens and government must act to protect the environment
Amouzou M: Afrobarometer Dispatch No. 669, Botswana, 2023

A special survey module included in the Afrobarometer Round 9 questionnaire explored citizens’ experiences and perceptions of pollution, environmental governance, and natural resource extraction. It showed that a majority of Batswana see pollution as a serious problem in their communities, with inadequate trash disposal as the most serious offender. They believe that ordinary citizens must assume primary responsibility for reducing pollution and keeping their communities clean, but they also expect “much more” from the government to protect the environment – including tighter regulation of natural resource extraction.

Kenyan Moderators Behind ChatGPT Want Parliament To Probe OpenAI, Sama Over Exploitation
Musau D: Citizen Digital, Kenya, 2023

The Kenyan content moderators who built the Artificial Intelligence (AI) chatbot ChatGPT have filed a petition in parliament seeking a probe into the bot’s parent company OpenAI and its local moderation partner Samasource. The Sama employees allege exploitation and underpayment during the creation of the popular chatbot and want the Kenyan government to investigate and regulate the work of tech companies operating in the country. They claim they were not properly informed of the nature of the work they would be undertaking, which involved reading and viewing material that depicted sexual and graphic violence and categorizing it accordingly so that ChatGPT's AI could learn it for purposes of its future interactions with people. All through the ChatGPT training process, the workers say they were not afforded psychosocial support and that due to the exposure to the work, they have developed severe mental illnesses including PTSD, paranoia, depression, anxiety, insomnia and sexual dysfunction. Additionally, the moderators say the contract between OpenAI and Sama was terminated abruptly, sending them home despite already suffering from severe mental illness. The moderators want parliament to enact laws regulating the outsourcing of harmful and dangerous technology work and protecting workers engaged in such work.

Productive public space planning and design for inclusive ownership
Kounkuey Design Initiative (KDI) Kibera, Kenya, 2023

Kounkuey Design Initiative (KDI) is a non-profit design and community development organisation that partners with under- resourced communities to advance equity and activate the unrealized potential in their neighbourhoods and cities. Involving the community in the development of the Kibera Public Space Project automatically creates a sense of care for the local community, through local ownership and management. During this process, public spaces create opportunities for learning, employment, and activism for the community. That kind of contextual and human centred thinking is transferrable. The process that was developed in Kibera has now been replicated in other parts of the world, including in the USA.

13. Monitoring equity and research policy

Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia?
Blanchard A, Jacobs C, Musukuma M, et al: International Journal for Equity in Health 22:109, 1-14, 2023

This study aimed to understand how much more demographic health surveys can reveal about Zambia’s progress in reducing inequalities in under-five mortality rates and reproductive, maternal, newborn and child health intervention coverage, using four nationally-representative Zambia Demographic Health Surveys, comparing wealth quintiles, urban‐rural residence and provinces, and further using multi-tier measures including wealth deciles and double disaggregation between wealth and region. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing composite coverage indices by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and composite coverage indices between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and composite coverage indices. Still, inequalities remained higher in provinces with worse outcomes. Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples.

New global indicator for workers’ health: mortality rate from diseases attributable to selected occupational risk factors
Pega F, Al-Emam R, Cao B, et al: Bulletin of the World Health Organisation 101:6, 418–430Q, 2023

Through sustainable development goals 3 and 8 and other policies, countries have committed to protect and promote workers’ health by reducing the work-related burden of disease. However, while injuries are well monitored, the World Health Organization and the International Labour Organization estimate that only 363 283 (19%) of 1 879 890 work-related deaths globally in 2016 were due to injuries, whereas 1 516 607 (81%) deaths were due to diseases. To address this gap, the authors present a new global indicator: mortality rate from diseases attributable to selected occupational risk factors, by disease, risk factor, sex and age group. The authors outline the policy rationale of the indicator, describe its data sources and methods of calculation, and report and analyse the official indicator for 183 countries. They also provide examples of the use of the indicator in national workers’ health monitoring systems and highlight the indicator’s strengths and limitations.

14. Useful Resources

Call for papers on health systems in a new journal
Editors: Social Science and Medicine – Health Systems, 2023

SSM - Health Systems is a new open access journal, edited by Sally Theobald (Liverpool School of Tropical Medicine, UK) and John Ataguba (University of Manitoba, Canada). The journal specialises in publishing interdisciplinary social science research that focuses on improving health systems and resources, broadly defined to include health systems and social care and support systems that impact on health and well-being of populations around the world. The journal is inviting submissions and waiving all article publishing charges until 31 December 2023.

15. Jobs and Announcements

2023 Public Health Association of South Africa Conference
10 – 13 September in Qheberha, Eastern Cape, South Africa

The Public Health Association of South Africa (PHASA) hosts an annual conference, with the aim of engaging public health practitioners from around the country, region and world to share their experiences and research, discuss topical public health issues, and mentor public health students and young researchers. This year it will be from 10 – 13 September in Qheberha, Eastern Cape. The theme is, Transforming Research Translation, Reimagining Public Health Evidence, Policies and Practice. The 2023 conference will engage with the most recent public health research and evidence, rethinking current models of research translation, identifying barriers and opportunities for change, and exploring new strategies for knowledge exchange and dissemination

The Oliver Tambo Fellowship Programme (OTFP), Faculty of Health Sciences, University of Cape Town
Registration open until 9 December 2023

This health leadership programme directly relates to the manager's workplace within the health system. Nominating people from the same team offers the possibility of greater impact, including across successive cohorts. The Fellowship is affiliated to the University of Cape Town and offers a unique perspective on leadership, rooted in systems thinking & policy analysis, tailored to the complex challenges of our health system. The Programme entails four sequenced and interrelated 6-day learning blocks, covering: the complex nature of health systems and their challenges, leading everyday health system strengthening, engaging health system hard- and software resources for implementing improvement, sustaining workplace-based interventions for system improvement, and mentorship during and after the course. The Programme offers direct engagement with senior health leaders, other experts with national and international insights, as well as peer leaders

Uganda National Conference on Health, Human Rights and Development
26th – 29th September 2023 at Mestil Hotel, Kampala, Uganda

The Ministry of Health - Uganda (MoH) and the Center for Health, Human Rights and Development (CEHURD) are organising the Uganda National Conference on Health, Human Rights and Development, scheduled for 26th – 29th September 2023 under the theme; ''The Right to Health; A vital Component in achieving SDGs''. The conference aims to facilitate an understanding of the trends and progress made on the Right to Health in Uganda in an effort to realise SDGs and accelerate further action. The conference tracks include: Health systems strengthening, Sexual and Reproductive Health and Rights (SRHR), Health, policy and the law, Mental Health, Harm reduction and Wellness, Multi-sectoral Collaborations, and Strategic Partnerships, coalitions and Movements.


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