Mounting piles of dumped waste; polluted air from traffic, industry and waste burning; regular floods from blocked drains; dark nights due to electricity cuts; and taps that produce no water.
This is not the image of urban life that we hope for in our region, but it is one that is often experienced, especially for the most disadvantaged residents. Our cities and towns are sites of growing challenge.
But they are also sites of growing innovation in response to these challenges.
In the EQUINET Regional Meeting on urban health in east and southern Africa (ESA) in Nairobi this year, delegates from eight east and southern African countries shared the many creative ways that local communities, local governments, professionals and other stakeholders are working together to meet these challenges. Even more, these approaches are building constructive linkages across economic, social, health and ecosystem wellbeing, particularly for disadvantaged communities, and as a response to climate change.
The initiatives showed the wealth of experiences and ideas that exist at local level in the region. They reduce, recycle and reuse mounting unmanaged urban waste to produce compost for urban agriculture, bio-energy to light schools, and a range of household products. They yield local incomes for low income groups. The work underway confronts the common aggressively marketed urban shift towards unhealthy ultra-processed foods by producing and marketing nutritious local foods as alternatives. The latter are grown in vertical gardens, hydroponics, community gardens and other forms of urban agriculture, in backyards and public spaces, including those that have been reclaimed from waste dumping. The initiatives stimulate development and use of locally produced technology to process waste and foods.
These efforts not only provide incomes and improve health. They generate more liveable urban environments. They reduce polluting waste burning, flooded drains, enrich soils and climate proof infrastructures. The communities and stakeholders working in these initiatives build new capacities and links, including in schoolchildren. Those involved gain benefits that also increase the social respect for healthy ecosystems. The experiences are diverse, and you can read them in the case studies, photojournalism and technical reports on the EQUINET website.
However, the work shared also showed the barriers and challenges that the implementers faced in securing recognition and support from the national level, and for those implementing them to have a seat and meaningful voice in global level dialogue. These barriers prevent scale-up.
Much of the work is being implemented in already disadvantaged communities by committed local authority and non-state ‘brokers of change’, but without sustainable financing. While local technologies play a key role, they lack accessible innovation funding for research and development (R&D) and field testing. There are weak or uncertain policy, legal and incentive frameworks for key areas such as urban agriculture and domestic food processing, or for health impact assessment to embed health in the design of commercial activities. Key state tools like procurement, community contracting, blended and innovation financing and social tendering that would enable these practices are weakly applied, absent or poorly accessed by informal communities.
Local communities and institutions thus need to overcome the gap between resources and needs and between demand and voice. They face a constant pressure to organise ad hoc, unpredictable funding to support what calls for sustained institutional change. African countries face a similar challenge in global processes, such as on financing for climate adaptation. African leaders have, for example, criticised the huge gap between an annual demand of US$300 billion for climate adaptation and a huge shortfall in real delivery on voluntary pledges and aid. They called in the September 2023 Nairobi Declaration for more predictable, equitable climate financing, through a global tax regime that would apply a carbon tax on the fossil fuel trade, on maritime transport and aviation, and a global financial transaction tax.
The current context clearly demands action at local, national, regional and global level. It also calls for less segmentation between these levels, including for voice to be heard from local to global levels and for resources to flow more equitably from global to local levels.
The community of practice on urban health in the EQUINET regional meeting thus made 10 recommendations to BUILD, ENABLE and AMPLIFY promising practice and policy on local climate-responsive integrated healthy urban food, waste and ecosystems in ESA, that also link these different levels.
To BUILD bottom-up change that has more direct local benefit, the recommendations include measures to expand various forms of innovative urban agriculture to produce quality healthy urban food; linked in a circular economy to widening the practice of 3Rs, - ‘reduce, recycle, reuse’ - in waste management systems, supported by domestic investment in R&D for the technologies that process waste and local foods.
The recommendations cover national measures to ENABLE such practices, including to generate and use disaggregated, relevant and community evidence and health impact assessment that is brought to inclusive multi-stakeholder forums to design and plan urban systems. This calls for another form of 3Rs- ‘relooking, realigning and revising’ policies, laws, and guidance at local and national level, harmonised at regional level, to enable, capacitate and fund these key elements of healthy integrated urban systems.
The community of practice recommended AMPLIFYING such measures across the region, to better connect local, national and regional voice, and to strengthen the region in engaging globally. Networks that connect local, national, regional and international actors, including south-south- are identified to provide important means to support the exchange of knowledge and ideas from within the region, if also backed by investments in regional knowledge, technology and ideas hubs.
We had direct experience of the role of regional networking when the local experiences from the various ESA countries were brought to the regional East Central and Southern African Health Community Best Practices Forum in June 2024. This forum, held annually, provides an important space for dialogue across local, national and regional level on challenges and promising practice. The ideas and local experiences presented and discussed in the session on climate and urban health in the 2024 forum informed the resolutions of the ECSA Regional Health Ministers Conference (ECSA/HMC73/R8) on mitigating the effects of climate change on health. (The resolutions are included in this newsletter).
Having a regional forum that brings policy actors together with local and national implementers enriches learning and action within the region, and can inform the proposals that are brought to global level, adding weight to options and demands, such as the call for more equitable and predictable global financing for responses to climate change. Currently, however, local voices and perspectives are increasingly attenuated as processes rise from local to global level, relying largely on indirect representation or reporting of lived experience and priorities in global forums. Yet increasingly literate, active and engaged local stakeholders and communities are implementing local change, and expect more direct, sustained ways of being included and heard in global discussions on issues that affect their lives.
We welcome your feedback or queries on the issues raised in this oped – please send them to the EQUINET secretariat. For more information read the urban health publications at https://www.equinetafrica.org/bibliography-search.html and watch the climate webinars on the EQUINET website at https://www.equinetafrica.org/content/meetings.html.
1. Editorial
2. Latest Equinet Updates
This brief provides a rapid review of literature and public evidence from various sources on the interface between financing climate justice, tax justice and health equity1. Prior EQUINET webinars on other areas of health equity raised growing concerns on the lack of delivery on commitments made for climate financing in the region. The brief thus complements the work done in previous EQUINET webinars on how climate justice interacts with different facets of health equity, available on the EQUINET website. All briefs from the webinars are being synthesised in a separate discussion document. This brief summarises key issues related to: climate financing in the region and the links to tax and economic justice and health equity; actions proposed to address these issues at local, national and regional level and in international/ global level processes; and issues for further research and discussion.
East and southern African (ESA) countries have achieved many gains in health, but also face many health challenges, including from commercial risks and the challenges of climate change. Poverty and inequality continues to affect opportunities to lead healthy lives. This context, the region’s policy commitment to primary health care and the need for action by many sectors to address the drivers of ill health calls for authorities, approaches and tools that more firmly lever evidence, and multi-sectoral action to protect and improve health. In the same way as environmental impact assessment was institutionalized in the ESA region to play a role in protecting ecosystems, health impact assessment similarly needs to be institutionalized to embed evidence and health promoting changes in wider activities, systems and policies that raise health risks. Policy leaders in Africa recognized this in the WHO AFRO Regional Multi-sectoral Strategy to promote health and well-being, 2023–2030, with a target by 2030 to have institutionalized and integrated health impact assessment .
Assessing the effect of policies, strategies, corporate and economic activities on health is a core capability to protect public health. Health impact assessment (HIA) helps to identify where changes to project design or operation provide health benefits and mitigate health risks, adding economic value and wellbeing. HIA is a structured process that informs decision makers about the potential effects of a project, programme, economic activity or policy on the health and well-being of populations. In 2023, EQUINET and partners initiated work to provide online training and mentored case study work to build HIA capacities in multi-actor teams in ESA countries. The course built understanding of the theoretical basis of HIA, and knowledge of the methods, evidence, analysis in an HIA, of reporting of and engagement on HIA, and implementation and monitoring of proposed actions. It provided mentored guidance of participant HIA practical work, using real HIA case studies. Towards the end of the course there was discussion on issues and strategies for scaling up and integrating HIA in key sectors and in public health law. This report summarises the proceedings and issues raised.
EQUINET has been using participatory action research (PAR) for several decades, reflecting the understanding that the voice, power and self-determination that is inherent for equity should also be integrated in the production of knowledge, and that knowledge and its generation and use is a deeply sociopolitical activity. While some thematic areas of work in EQUINET have applied PAR approaches, not all had, and steering committee (SC) members felt that it would be important to widen understanding of the methods to see how they could be integrated within different areas of work, as a cross cutting process. This online skills session was implemented in June 2024 to give colleagues involved in EQUINET work a brief introduction to PAR and how it can be used in EQUINET’s various thematic areas. The session aimed stimulate interest in and understanding of how PAR can deepen the different areas of research work on health equity. A video of presentations in the session is available at https://youtu.be/OR_lhxoSQuQ
This EQUINET regional meeting gathered people from institutions involved in the work on urban health and health impact assessment (HIA) and related expertise in May 2024 in Nairobi, Kenya, to address issues relating to scaling up promising, climate responsive practice to promote healthy urban food, waste and ecosystems in ESA. It built on work implemented in the region on urban health from 2020 and used a mix of presentation, discussion and participatory processes. The meeting reports on information shared on experience and evidence from both urban health work and HIA in ESA on the laws, policies, systems, features, measures and tools that positively impact on and make linkages across economic, social, health and ecosystem wellbeing, including to respond to climate change. Delegates identified implications for policy and practice at national, regional and global level and a theory of change, strategies and recommendations to advance, support and scale-up the promising policies, practices and tools identified in the meeting.
3. Equity in Health
When global outbreaks of disease are declared ‘over’, what, when and for whom is an end ‘the end’ and what happens after? How do declarations of ends shape personal experiences of crises, ongoing access to care, health and obligations? Global health is defined by narratives of a clearly discernible and singular end. Official announcements of ‘the end’, however, are often arbitrary and unstable. Furthermore, they can distract from important counter-narratives and undermine social, environmental, political and epistemic justice when those ‘left behind’ are excluded from discussions of whether the end has been achieved, or is achievable, and if so when and how. Today, uncertain trajectories, the ‘slow violence’ of environmental degradation, passive attrition of many diseases, and drug resistances question ideas of a singular extinction event and finality. Drawing on an interdisciplinary approach involving historians, sociologists, epidemiologists, psychologists, bioethicists, literary and legal scholars, philosophers and policymakers, this research has two synergistic empirical and normative aims: 1. to explore lived experiences of time and temporality of endings of crises, to capture counter-narratives and their implications for future practices, responses and policies, and 2. to provide an account of the moral and ethical obligations and responsibilities of global health institutions in the aftermaths of crises to health. From detailed comparative research in three countries, including ethnographic, cognitive time-perception and archival methodologies, the authors foreground the people, places, processes and policies to capture everyday experiences of endings and aftermaths in context.
This community-based case-control study identified determinants of teenage pregnancy in Malawi. It used secondary data from the 2015-16 Malawi Demographic and Health Survey from all 28 districts of Malawi. Data on 3435 participants 20-24 years old were analysed. In multivariable analyses: no teenage marriage; secondary education; higher education; richest category of wealth index, use of contraception, domestic violence by father or mother were found to be significant factors in teenage pregnancy. The authors recommend that the government sustain and expand initiatives that increase protection from teenage pregnancy, reinforce the implementation of amended marriage legislation, introduce policies to improve the socioeconomic status of vulnerable girls and increase contraceptive use among adolescent girls before their first pregnancy.
Equity is at the core and a fundamental principle of achieving the family planning (FP) 2030 Agenda. However, the conceptualization, definition, and measurement of equity remain inconsistent and unclear in many FP programs and policies. This paper documents the conceptualization, dimensions and implementation constraints of equity in FP policies and programs in Uganda, through. a review of literature and key informant interviews with 25 key stakeholders in 2020. A limited number of documents had an explicit definition of equity, which varied across documents and stakeholders. The definitions revolved around universal access to FP information and services, with limited focus on equity. The dimensions most commonly used to assess equity were either geographical location, or socio-demographics, or wealth quintile. Almost all the key informants noted that equity is a very important element, which needs to be part of FP programming. However, implementation, client and policy constraints were observed to continue to hinder its implementation in FP programs in Uganda.
4. Values, Policies and Rights
The advancement of digital technologies has stimulated immense excitement about the possibilities of transforming healthcare, especially in resource-constrained contexts. For many, this rapid growth presents a ‘digital health revolution’. While this is true, the authors note that there are also dangers that the proliferation of digital health in the global south reinforces existing colonialities. Underpinned by the rhetoric of modernity, rationality and progress, many countries in the global south are pushing for digital health transformation in ways that ignore robust regulation, increase commercialisation and disregard local contexts, which risks heightened inequalities. The authors propose a decolonial agenda for digital health which shifts the liner and simplistic understanding of digital innovation as the magic wand for health justice. In the proposed approach, they argue for both conceptual and empirical reimagination of digital health agendas in ways that centre indigenous and intersectional theories. This enables the prioritisation of local contexts and foregrounds digital health regulatory infrastructures as a possible site of both struggle and resistance. Their decolonial digital health agenda critically reflects on who is benefitting from digital health systems, centres communities and those with lived experiences and finally introduces robust regulation to counter the social harms of digitisation.
After negotiations spanning over 2 years, International Health Regulations (IHR) 2005 was amended by consensus during the 77th Session of World Health Assembly (WHA77) in the first week of June 2024 (WHO, 2024). The amendments set out the legal framework for delivery of equity in health emergency preparedness and response. One of the drawbacks of the IHR adopted in 2005 was the lack of explicit legal provisions requiring WHO and States Parties to ensure equitable access to health products to prevent disease outbreaks from becoming public health emergencies of international concern (PHEIC). The amendments adopted by WHA77 address this gap. Around 24 Articles out of 66 Articles, and 6 Annexes out of 9 Annexes were amended substantively and 2 new Articles were added. Amendments in Articles 1, 3, 13, 15-18, 44, and Annex 1 and the two new Articles, 44 bis and 54 bis, help in particular addressing the gaps relating to equitable access to health products. Article 3 now recognises equity and solidarity as principles of IHR implementation. The Amended Article 3 now mandates that the implementation of the IHRs needs to “promote” equity and solidarity. It means there should be demonstrated enhancement in the delivery of equity, in the implementation of IHR.
The East, Central and Southern Africa Health Community 73rd Health Ministers Conference was held in Arusha in the United Republic of Tanzania from June 20 -21, 2024. The Conference was attended by Honourable Ministers, Heads of Delegations, senior officials from ECSA Health Community Member States, partner organizations, research institutions, civil society organizations and other key stakeholders. The Conference was organized under the theme: 50 Years of Leadership and Excellence in Regional Health Collaboration. Deliberations at the Conference proceeded under the following sub-themes: 1. Human Resources for Health 2. Health Financing 3. Emerging and Re-emerging infectious diseases and health emergencies 4. Reproductive, Maternal, Neonatal, Child and Adolescent Health and Nutrition 5. Non-communicable, mental health and Substance use 6. Mitigating the effects of climate change on health 7. Technology and Innovations in health At the end of the conference, the Ministers considered and passed the resolutions presented in each of these areas in this document.
Food fraud (often called fake food in South Africa) or the deliberate misrepresentation or adulteration of food products for financial gain, is a growing problem in South Africa, with severe public health and financial consequences for consumers and businesses. It has generated a public outcry against food fraud practices especially in communities and reputational damage to food manufacturers. Despite the risks, food fraud often goes undetected, as perpetrators are argued to be becoming increasingly sophisticated. The precise magnitude of food fraud remains obscure, as incidents that do not cause consumer illnesses are frequently unreported and, as a result, are not investigated. Food fraud can occur at any stage of the food supply chain, from production to processing to retailing or distribution. This is due in part to the limitations of current analytical methods, which are not always able to detect food fraud. This review of food fraud in South Africa looks at several factors that may be contributing to epidemic of food fraud, including inadequate penalties, inadequate government commitment, a complex labelling regulation, emerging threats such as e-commerce, and shortage of inspectors and laboratories. The review recommends establishing a single food control/safety authority, developing more food safety laboratories, and adopting innovative technologies to detect and prevent food fraud. South Africa faces a serious food fraud crises unless decisive action is taken.
To address this question this study undertook a 4-step approach, including (i) a compilation of international policy recommendations, (ii) an online survey, (iii) four regional workshops with international experts and (iv) a ranking for prioritisation. Policies were identified and prioritised based on their double- or triple-duty potential, synergies and trade-offs. Using participatory and transdisciplinary approaches, policies were identified to have potential if they were effective in tackling two or three of the primary outcomes of interest: (1) undernutrition, (2) obesity/NCDs and (3) environmental degradation. A final list of 44 proposed policies for healthier and more environmentally sustainable food systems created was divided into two main policy domains: ‘food supply chains’ and ‘food environments’. Of the top five expert-ranked food supply chain policies, two were perceived to have high potential: (a) incentives for crop diversification; (b) support for start-ups, and small- and medium-sized enterprises. For food environments, three of the top five ranked policies had perceived high potential: (a) affordability of healthier and more sustainable diets; (b) subsidies for healthier and more sustainable foods; (c) restrictions on children's exposure to marketing through all media.
5. Health equity in economic and trade policies
The COVID-19 pandemic has forced a reflection on the origins of supplies in African healthcare market and underscored the need for an increase in local manufacturing of medical supplies. Several African countries’ health markets have been heavily reliant on imports. This article demonstrates how the African healthcare market has had a high import dependency and the role that the African Continental Free Trade Area (AfCFTA) could play to reverse this. It is estimated that African countries import between 80% and 94% of medical supplies, 75% of testing kits, between 70% and 95% of pharmaceuticals, and 99% of vaccines. During the COVID-19 pandemic, countries imposed export restrictions which impacted the flow of medical supplies to African countries. This finding highlighted the limited production capabilities on the African continent and reiterated the need to strengthen continental value chains and local manufacturing capacity for public health on the continent. Local innovations sought to minimize the impact of these supply chain disruptions. Using case studies on the local production of COVID-19 testing kits and personal protective equipment, the article highlights progress made toward health market reform. It calls attention to the implementation of the AfCFTA to strengthen the supply, manufacturing, and trade of medical resources. The article highlights countries that have African-made pharmaceuticals and vaccinations and the importance of regional hubs to expand these products in African healthcare markets. The author concludes by discussing investments made to expand local manufacturing of health products.
This paper aimed to assess community members’ perceptions regarding health risks associated with potentially toxic elements and cyanide pollution in Kwekwe City. An explorative cross-sectional study was conducted with key stakeholders and industrial settlements’ residents. Face-to-face interviews with key informants and focus group discussions with residents and workers were used to gather data. A thematic approach was utilised in data analysis. Study participants, who played a crucial role in the research process, perceived that industrial pollution principally linked to cyanide, mercury and chromium posed significant environmental and health risks. This participatory approach in risk perception assessment is critical in providing insight into the scope of the problem and formulating intervention strategies. However, given that qualitative study results lack generalisability and replicability, quantitative studies need to be undertaken to determine environmental levels of toxic chemical pollutants as a complementary measure.
The World Bank’s 2024 Global Economic Prospects report, indicates that global economic growth will stabilize in 2024 at a pace that is insufficient for progress on development goals.The needs for adaptation, Africa’s priority, remain underestimated, particularly for universal access to energy. To address these daunting challenges, the report asks where is the money? External resources are substantial, but with problematic accessibility, conditionalities and ineffective utilisation. Debt has become an impossible option, as Africa’s external debt has already tripled since 2009, and is compounded by a complex structure that renders traditional relief mechanisms obsolete. Foreign Direct Investment (FDI) and participation in global financial markets remain disproportionately low. To move forward, the foundation calls for a radical reboot of the current multilateral financial system and more effective organisation and use of domestic resources. According to the African Union, the mobilisation of the continent’s domestic resources is expected to cover up to 90% of the financing required for Agenda 2063. This means drying up illicit financial flows, strengthening tax systems- African states cannot afford tax holidays for foreign companies-, leveraging remittances, sovereign funds, pension funds and private wealth, monetising Africa’s green assets – biodiversity, critical minerals, carbon-sinking potential. This is argued to demand a paradigm shift that avoids any trade-off between climate and development, that moves beyond the aid and charity model to a cooperative, deal- making one, and that puts ownership in Africa.
Researchers have argued that wealthy nations rely on a large net appropriation of labour and resources from the rest of the world through unequal exchange in international trade and global commodity chains. The authors assess this empirically by measuring flows of embodied labour in the world economy from 1995–2021, accounting for skill levels, sectors and wages. They find that, in 2021, the economies of the global North net-appropriated 826 billion hours of embodied labour from the global South, across all skill levels and sectors. The wage value of this net-appropriated labour was equivalent to about USd18 trillion in Northern prices, accounting for skill level. This appropriation roughly doubles the labour that is available for Northern consumption but drains the South of productive capacity that could be used instead for local social needs and development. Unequal exchange is understood to be driven in part by systematic wage inequalities. The authors find that Southern wages are 87–95% lower than Northern wages for work of equal skill. The authors argue that this means that while Southern workers contribute 90% of the labour that powers the world economy, they receive only 21% of global income.
6. Poverty and health
While recent evidence established a positive causal relationship between some social protection programmes and food security there is little evidence on the extent to which these initiatives are associated with better educational and sexual and reproductive health outcomes among vulnerable adolescents in Lesotho. This study used cross-sectional, nationally representative data from the 2018 Lesotho Violence Against Children and Youth Survey to examine the association between social protection receipt and educational and sexual and reproductive health outcomes among adolescents and young people living in poverty. Social protection receipt was defined as household receipt of financial support from a governmental, non-governmental, or community-based program that provides income. Among the 3 506 adolescent females and males living in the two lowest poverty quintiles, receipt of social protection was associated with improvements in multiple adolescent outcomes: higher odds of consistent condom use, educational attainment, and school enrolment. Stratified analyses by sex showed that social protection receipt was also associated with reduced likelihood of child marriage among females and higher odds of educational attainment and school enrolment among males. The study provides evidence that social protection programs are associated with improved educational, sexual and reproductive health and child marriage prevention outcomes among adolescents living in poverty. The author recommends implementing and expanding such social protection initiatives to improve the well-being of vulnerable adolescents.
This paper documented the contexts in which women selling sex in Kampala Uganda meet and provide services to their clients, using qualitative data from semi-structured interviews with 20 women 18 years or older, who were self-identified as sex workers. Women met clients in physical and virtual spaces. Physical spaces included venues and outdoor locations, and virtual spaces were online platforms like social media applications and websites. Of the 20 women included, 12 used online platforms to meet clients. Generally, women from a clinic sample were less educated and predominantly unmarried, while those from a snowball sample had more education, had professional jobs, or were university students. Women from both samples reported experiences of stigma, violence from clients and authorities, and challenges accessing health care services due to the illegality of sex work. Even though all participants worked in settings where sex work was illegal and consequently endured harsh treatment, those from the snowball sample faced additional threats of cybersecurity attacks, extortion and high levels of violence from clients. To reduce risk of HIV acquisition among women who sell sex, the authors suggest that researchers and implementers consider these differences in contexts, challenges, and risks to design innovative interventions and programs that reach and include all women.
7. Equitable health services
This paper aimed to update a woman hand-held case notes tool reflecting WHO 2016 antenatal care (ANC) guidelines in Malawi. In 2022, the authors applied a co-creative participatory approach in 3 workshops with key stakeholders to compare the current ANC tool contents to the WHO 2016 ANC guidelines, decide on key elements to be changed to improve adherence and change in practice, and to redesign the woman’s health passport tool to reflect the changes. The developed tool was endorsed for implementation within Malawi’s healthcare system by the national safe motherhood technical working group in July 2023. Five themes were identified in the analysis that were missed in the previous tool. Participants further recommended strengthening of already existing policies and investments in health, strengthening public private partnerships, and continued capacity building of healthcare providers to ensure that their skill sets are up to date. The authors' efforts reflect a pioneering attempt in Malawi to improve women’s hand-held case notes to enhance quality of care and improve women’s satisfaction with their healthcare system.
A Case for Integration: A Collection of Lived Experiences of People Living with NCDs and HIV has been published as part of the Non Communicable Disease (NCD) Alliance’s “Our Views, Our Voices” initiative, dedicated to promoting the meaningful involvement of people living with NCDs in the NCD response. Many people living with HIV struggle with mental health, yet most are unaware that their HIV status makes them more vulnerable. A number of people with HIV also reported that their other conditions were not promptly diagnosed by healthcare workers at HIV clinics. The NCD Alliance has developed 15 Transformative Solutions, which are recommendations for contextually appropriate, person-centred information about NCDs and their risk factors for people living with HIV. These include overarching recommendations: that governments – with the support of WHO, UNAIDS, global health donors, and key constituencies, including civil society, communities and people living with HIV and NCDs, and the private sector – must coordinate, fund and drive local context- responsive agendas for HIV-NCD integration to achieve the 90% integrated care target, which emphasises person-centred care and considers the whole care cascade (prevent-find-link-treat- retain). The document proposes that government strategies, national policies, and strategic plans for HIV-NCD integration must: take a phased and context-specific approach to linkages and integration of services and systems; promote the transition to UHC; consider the state of development of different national and local systems for health; and include essential HIV and NCD prevention and care services as key priorities in COVID-19 recovery plans and the ‘building back better’ agenda.
This paper explored the experiences and perceptions of women receiving post-abortal care services in Zambia, within a human-rights framework. A qualitative case study was conducted between August and September 2021 in Lusaka and Copperbelt provinces of Zambia. Fifteen women seeking post-abortion care services were` interviewed using audio recorders; transcribed data was analyzed using thematic analysis. Women who experienced spontaneous abortions delayed seeking health care by viewing symptoms as ‘normal pregnancy symptoms’ and not dangerous. Women also delayed seeking care because they feared the negative attitudes from their communities and the health care providers towards abortion in general, despite it being legal in Zambia. Some services were considered costly, impeding their right to access quality care. Women delayed seeking care compounded by fear of negative attitudes from the community and healthcare providers. To ensure the provision and utilization of quality all abortion-related healthcare services, the authors argue that there is a need to increase awareness of the availability and legality of safe abortion services, the importance of seeking healthcare early for any abortion-related discomfort, and the provision and availability of free services at all levels of care should be emphasized.
8. Human Resources
When caring for critically ill patients, health workers often need to ‘call-for-help’ to get assistance from colleagues in the hospital. This study aims to describe health workers’ experiences about calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya. Ten hospitals across Kenya and Tanzania were visited and in-depth interviews conducted with 30 health workers who had experience of caring for critically ill patients. The study identified three thematic areas concerning the systems for calling-for-help when taking care of critically ill patients: i. Calling-for-help structures: with a lack of functioning structures for calling-for-help; ii. Calling-for-help processes: with calling-for-help processes noted to be innovative and improvised; and iii. Calling-for-help outcomes: with the help provided not that which was requested. Calling-for-help when taking care of a critically ill patient is a necessary life-saving part of care, but health workers in Tanzanian and Kenyan hospitals experience a range of significant challenges. Hospitals lack functioning structures, processes for calling-for-help are improvised and help that is provided is not as requested. These challenges are observed to be likely to cause delays and to decrease the quality of care, potentially resulting in unnecessary mortality and morbidity.
This paper examined the health workforce governance strategies applied by 15 countries in the WHO Africa Region in responding to the COVID-19 pandemic. The authors extracted data from country case studies developed from national policy documents, reports and grey literature obtained from the Ministries of Health and other service delivery agencies. This study was conducted from October 2020 to January 2021 in 15 countries - Angola, Burkina Faso, Chad, Eswatini, Ghana, Guinea, Guinea Bissau, Ivory Coast, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal and Togo. All 15 countries had national multi-sectoral bodies to manage the COVID-19 response and a costed national COVID-19 response plan. All the countries also reflected human resources for health activities along the different response pillars. These activities included training for health workers, and budget for the recruitment or mobilization of additional health workers to support the response, and for provision of financial and non-financial incentives for health workers. Nine countries recruited an additional 35 812 health workers either on a permanent or temporary basis to respond to the COVID-19 with an abridged process of recruitment implemented to ensure needed health workers are in place on time. Six countries redeployed 3671 health workers to respond to the COVID-19. The redeployment of existing health workers was reported to have impacted negatively on essential health service provision. The paper raises strengthening multi-sector engagement in the development of public health emergency plans as critical to promote the development of the holistic interventions needed to improve health workforce availability, retention, incentivization, and coordination and to ensure optimized utilization based on competencies, especially for the existing health workers.
This paper aimed to assess the knowledge and practice of health workers (HWs) towards maternal and child health (MCH) in Kasai and Maniema, two Democratic Republic of the Congo provinces with very high maternal mortality ratios and under-5 mortality rates. This cross-sectional study was conducted with all HWs in charge of MCH in 96 health facilities of Kasai and Maniema provinces in 2019. Among participating HWs, 43% were A2 nurses, 82% had no up-to-date training in MCH, and 48% had only 1-5 years of experience in MCH. In the two provinces combined, about half of HWs had poor knowledge and poor practice of MCH. Good knowledge and practice scores were significantly associated with high qualification, continuing up-to-date training in MCH, and 6 years of experience or more in MCH. The authors argue that conversion of A1 nurses into midwives as well as the provision of up-to-date training in MCH, supervision, and mentorship could improve the skill level of HWs and could thus reduce the burden of MCH in the DRC.
9. Public-Private Mix
The current Kenyan cigarette tax regime is reported to fail to control cigarette consumption efficiently, especially among young people. Kenya decentralized the implementation of the Tobacco Control Act to 47 county governments in 2010. However, this decentralization has created a need for more institutional coherence in implementing the act. The tobacco industry exploits these fragmented counties by targeting the young people with tobacco products, particularly in the eastern, central and coast counties, where less resources are available for governance and control of substance use. The central government is thus recommended to enforce measures that ensure homogeneous implementation of tobacco control in all counties. The lobbying power of the tobacco industry blunts the effectiveness of the cigarette excise tax policy. In 2017, the industry lobbied the Kenyan government to adopt a two-tier tax system, which caused differential taxes between cheap and premium cigarettes. Unfortunately, the current Kenyan tax does not help to reduce nicotine pouch consumption and fails to prevent young people from starting. Therefore, a case for reforming the excise tax policy on cigarettes and nicotine products is argued to exist: the government needs to coordinate robust and comprehensive operations to regulate the entire supply chain of the e-liquid market. These measures should be combined with targeted cessation support and awareness campaigns focusing on vulnerable young people. The authors propose that Kenya can do better by replicating Uganda’s approach, which taxes tobacco progressively, as well as to implement aggressive tobacco taxation in line with the WHO FCTC; introduce high taxation of or ban nicotine pouches and regulate e-liquids.
The Amandla! Radio Podcast presents a deep dive into public-private partnerships and the corporate takeover of development. This is the inaugural episode of the new podcast series hosted on CKUT McGill Radio and is the successor to a long-running radio show that broadcast for over three decades. The podcast documents discussions held earlier this year with several authors of the book Corporate Capture of Development. The authors discuss the disruptive and negative impacts of public private partnership development models in Kenya, Ghana, Sierra Leone and Mexico. The rich insights cover issues ranging from the role of the state, how to build resistance and what kind of alternatives could be considered. The accounts describe the learning and tell a story that demands action.
10. Resource allocation and health financing
Kenya aims to apply the National Health Insurance Fund (NHIF) as the ‘vehicle’ to drive universal health coverage (UHC). While there is some progress in moving the country towards UHC, the availability and accessibility to NHIF-contracted facilities may be a barrier to equitable access to care. The authors estimated the spatial access to 3858 NHIF-contracted facilities, with data on road network, elevation, land use, and travel barriers. Nationally, 81.4% and 89.6% of the population lived within 60- and 120-minute travel time to an NHIF-contracted facility respectively. At the county level, the proportion of the population living within 1-hour of travel time to an NHIF-contracted facility ranged from as low as 28.1% in Wajir county to 100% in Nyamira and Kisii counties. Overall, only four counties had met the target of having 100% of their population living within 1-hour (60 min) travel time to an NHIF-contracted facility. The author argues that this evidence of the spatial access estimates to NHIF-contracted facilities can inform contracting decisions by the social health insurer, especially focussing on marginalised counties where more facilities need to be contracted. particularly if accelerating progress towards achieving UHC uses social health insurance as a key strategy in Kenya.
Zimbabwe has received substantial external assistance for health since the early 2000s, including funding earmarked for, or framed as, health systems strengthening (HSS). This study sought to examine whether external assistance has strengthened the health system (i.e. enabled comprehensive changes to health system performance drivers) or has just supported the health system (by increasing inputs and improving service coverage in the short term). Between August and October 2022, the authors conducted in-depth key informant interviews with 18 individuals and reviewed documents to understand: (1) whether external funding has supported or strengthened Zimbabwe’s health system since the 2000s; (2) whether the experience of COVID-19 fosters a re-examination of what had been considered as HSS during the pre-pandemic era; and (3) areas to be reconsidered for HSS post COVID-19. The findings suggest that external funders have supported Zimbabwe to control major epidemics and avert health system collapse. However, the COVID-19 pandemic showed that supporting the health system is not the same as strengthening it, as it became apparent at that time that the health sector is plagued with several system-wide bottlenecks. The authors analyse external funding to be fragile and highly unsustainable, reinforcing the oft-ignored reality that HSS is a sovereign mandate of country-level authorities, and one that falls outside the core interests of external funders. The key positive lesson from the pandemic was that Zimbabwe is capable of raising domestic resources to fund HSS. However, they note that there is no guarantee that such funding will be maintained, calling for attention to government’s stewardship for HSS, and for external funders to re-examine whether their funding really strengthens the national health system.
11. Equity and HIV/AIDS
This study aimed to identify women’s HIV Self-Testing (HIVST) knowledge, utilization, and its associated factors in Sub-Saharan Africa (SSA). The data used were gathered from the most recent demographic and health surveys conducted in 21 SSA nations between 2015 and 2022. The level of knowledge and utilization of HIVST among women in SSA was very low. To improve this situation, the authors suggest facilitating institutional delivery, promoting access to modern contraception, increasing ANC coverage, empowering women’s associations, creating culturally respectful mass media content, and involving rural and economically disadvantaged women.
This study conducted in 2022 aimed to elucidate the experiences of these in a small group of young, HIV + men who have sex with men and transgender women in Zambia through in-depth interviews and a questionnaire. The authors recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants’ mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of transgender women had moderate to significant symptoms of depression or major depression compared to men who have sex with men, at 33% and 6%, respectively. Similarly, more transgender women had contemplated suicide than MSM peers. Overall, having to hide both one’s sexuality and HIV status had a compounding effect and was described as living a private lie. The authors argue that effectively addressing stigma and poor mental health outcomes among young HIV-positive MSM and transgender women requires a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening community-informed public health efforts.
12. Governance and participation in health
Mozambique launched a peer-support program in 2018, in which HIV-positive mothers provide adherence support as mentor mothers (MMs) for HIV-positive pregnant and lactating women and HIV-exposed and infected children. A descriptive qualitative evaluation was conducted in 2020 across nine facilities in Gaza Province to assess the acceptability and barriers to implementation of the mentor mother program (MMP) among those receiving services and providing services. There were initial challenges with acceptability of the MMP, especially regarding confidentiality concerns and MM roles. Sharing additional information about MMs and making small changes during the beginning of the MMP resulted in generally high acceptance of the programme. HIV-positive mothers reported that counseling from MMs improved their understanding of the importance of and how to take the anti-retroviral treatment. HIV-positive mothers reported having reduced guilt and shame about their HIV-status, feeling less alone, and having more control over their health. MMs shared that their work made them feel valued and decreased their self-stigmatization. However, MMs also reported feeling that they had inadequate resources to perform optimal job functions; they listed inadequate transportation, insufficient stipends, and false addresses of clients among their constraints. Overall, health care workers felt that their workload was significantly reduced with MM support and wanted more MMs in the community and health facility. This study found that the MMP was considered a substantive and highly valued support to HIV-positive mothers, resulting in increased anti-retroviral treatment literacy among patients, improved self-reported well-being and sense of community and reduced feelings of isolation.
The advent of global health initiatives (GHIs) has changed the landscape and architecture of health financing in low and middle income countries, particularly in Africa. Alignment and harmonisation of partnerships and GHIs are still difficult in the African countries with inadequate capacity for their effective coordination. Both published and grey literature was reviewed to understand the governance, priorities, harmonisation and alignment of GHIs in the African Region; to synthesise the knowledge and highlight the persistent challenges; and to identify gaps for future research. GHI governance structures are often separate from those of the countries in which they operate. Their divergent funding channels and modalities may have contributed to the failure of governments to track their resources. There is also evidence that GHI earmarking and conditions drive funding allocations regardless of countries’ priorities. GHIs have used several strategies and mechanisms to involve the private sector. These have widened the pool of health service policy-makers and providers with both positive and negative implications. To maximise returns on GHI support, the authors suggest that there is need to ensure that their approaches are comprehensive as opposed to being selective; to improve GHI country level governance and alignment with countries’ changing epidemiologic profiles; and to strengthen their involvement of civil society.
How can women in vulnerable circumstances move beyond hopelessness, extreme poverty, and the health and livelihood challenges of a global pandemic? What are the best research approaches to make their experiences count in post-pandemic recovery efforts and future preparedness? Ask them. Two research projects in the provinces of Eastern Cape and KwaZulu-Natal, South Africa, are using experiential methodologies to reveal women’s stories, ideas and solutions to their post-pandemic recovery. By taking two different approaches — one ethnographic and the other a workshop series combined with trial cash transfers —, these two projects aimed to understand the multidimensionality of the lives and circumstances of economically disadvantaged women and investigated different ways to amplify their voices using inclusive approaches. Common themes have emerged from the oral histories collected to date. Researchers report that the pandemic disproportionately affected women, many of whom lost their jobs. Workplaces, health centres and other services closed, leaving women disconnected from their social networks. Adult children and spouses moved home, causing even greater strain and leading to increases in domestic violence. Greater numbers of youth pregnancies added to women’s already difficult care burden. Many women reported that debt closed in. High inflation further compounded the problem, leaving women’s households in a continuous cycle of economic deficit. They continue to struggle with food insecurity and an almost universal dependence on social grants for survival. Women reported a new normal: living with stress, mental illness, isolation and substance use.
13. Monitoring equity and research policy
The world faces global health risks that need to be effectively addressed in integrated, participatory efforts. However, risk analysis frameworks do not account for the complex nature of systems that span multiple sectors or disciplines. The authors propose the participatory and interdisciplinary concept of risk negotiation to transform the way global health challenges such as pandemics, physical and mental health inequities, environmental problems and food security are tackled. To allow such risk analysis, there is a need to recognize the value of risks and trade-offs and negotiate them with stakeholder groups representing different disciplines and sectors. This approach becomes feasible through recent technological breakthroughs such as artificial intelligence-assisted multi-agent negotiations or large language models. These models are accessible, hold promise in negotiating agreements and can be used to accommodate the complexity of real-world decision-making.
Sub-Saharan Africa has the highest under-five mortality rate globally and child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step, described in this paper, identifies national priorities for newborn and child health guideline development. This followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. The authors established national Steering Groups, comprising 10–13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with Steering Groups where final priority topics were agreed. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In South Africa, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and low birth weight babies. In Malawi, they focused on nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and nutrition for low both weight and preterm infants.
14. Useful Resources
This resource provides updated information on Mpox, on its mode of spread, who it infects, how it is treated, and vaccine options and vaccine inequality related to Mpox. It also provides information on how to prevent the spread of mpox.
Routine health facility data helps decision-makers better understand facilities’ service readiness, utilization, and quality, enabling evidence-based policy and resource decisions. MOMENTUM’s “Strengthening Analysis and Use of Routine Facility Data for Maternal, Newborn, Child and Adolescent Health” webinar series is a “training of trainers” for monitoring, evaluation, and learning professionals. The series covers WHO’s Analysis and Use of Health Facility Data: Guidance for Maternal, Newborn, Child, and Adolescent Health (MNCAH) Program Managers toolkit, which introduces a catalog of indicators for MNCAH that can be monitored through routine health facility data and offers guidance on data quality, analysis, and use. The series will feature real-world examples of how to improve analysis and use of routine health facility data. French interpretation will be available at all sessions.
The Health Emergency Preparedness Response and Resilience (HEPRR) programme for Eastern and Southern Africa was officially launched in May 2024. Through the ECSA-HC in collaboration with the Intergovernmental Authority on Development (IGAD), the programme aims to fortify the region’s health systems to ensure robust preparedness and effective responses to health emergencies, including from climate change. The programme adopts a Multi-Phase Programmatic Approach (MPA), starting with Kenya, Ethiopia, and Sao Tome and Principe, with subsequent phases incorporating additional countries. This phased approach allows for flexibility and adaptability, leveraging insights from earlier phases to enhance the programme’s impact.
This televised discussion about the debt crisis in Kenya comprises a conversation with Kwame Owino of The Institute of Economic Affairs (IEA Kenya), Professor Attiya Waris, the UN Independent Expert on Foreign Debt and Human Rights and Jason Braganza, Executive Director of the Africa Forum on Debt and Development. The discussion touches on budget deficit, whether or not to mobilize domestic revenue or borrow, the operation of the Kenyan Debt Management Office, and structure and transformation of the Kenyan economy. The speakers critique the deference of the global economy to creditors over debtors, and call for debt reorganisation.
15. Jobs and Announcements
This call is for vibrant individuals from Anglophone and Francophone Africa to join the next fellowship cohort under the Litigating Reproductive Justice in Africa (LIRA) Programme. The Programme aims to foster an environment where Africa embraces Reproductive Justice through progressive, evidence-based, and collaborative litigation for access to Sexual and Reproductive Health Rights (SRHR). The programme particularly targets building the capacities of African individuals through our renowned fellowship programme. This round of call for fellows will commence in October 2024 and it is a full-time in-person engagement for a period of 6-12 months at Ahaki. The fellowship is designed to support Ahaki’s programmes and provide opportunities for career development in research, litigation and capacity enhancement in reproductive justice. Ahaki encourages researchers, scholars, litigants, activists, and practitioners from across Africa to apply for the fellowship programme.
BMC Public Health is calling for submissions to a Collection on mental health of adolescents. Adolescence is a critical developmental stage marked by significant physical and emotional changes, with mental health being heavily influenced by societal pressures, academic demands, and technology. Rising rates of anxiety, depression, and other mental health disorders among adolescents pose a global concern, affecting both immediate quality of life and long-term well-being. Addressing these issues is essential for fostering healthy development and preventing future psychosocial challenges. This collection seeks submissions that explore factors influencing adolescent mental health, such as trends in mental health disorders, risk and protective factors, the impact of digital platforms, school environments, family relationships, barriers to accessing mental health services, and effective intervention strategies.
The ICID Ubuntu Community Village (UCV) will be a lively, interesting space that will bring together youth, community members, midwives and other health professionals, Civil Society Organizations, and others working on and impacted by AMR, HIV, TB, or other infectious diseases within a One Health context to interact, learn, share, make new connections, strengthen existing networks and celebrate successes. The UCV will also act as a bridge between the more technical scientific sessions at the ICID 2024 and the community action, by sharing the issues in a manner that is more lucid, relevant, and easily translatable/applicable at the grassroots. There will be a mix of live performances, documentaries/films, music, art, dance, skills building and best practice sharing workshops, speaker sessions/presentations, debates, and other exciting cultural activities, all based on feedback and applications from the diversity of community-connected individuals, groups, and organizations. Key proceedings from the UCV will also be captured and shared on various ISID platforms. Are you a community-connected individual, group, or organization working on and impacted by AMR, HIV, TB, or other infectious diseases within a One Health context? Apply if you would like to participate or present at the ICID Ubuntu Community Village.
The Tshiamiso Trust is on a drive to ensure that all potentially eligible former gold mineworkers and their families, know about their right to lodge a claim for compensation, and are given the opportunity to do so. The Tshiamiso Trust was established in 2020 to give effect to the settlement agreement reached between six mining companies and claimant attorneys in the historic silicosis and TB class action. The companies are African Rainbow Minerals, Anglo American South Africa, AngloGold Ashanti, Harmony Gold, Sibanye Stillwater and Gold Fields. To date, the Trust has compensated over 18,000 beneficiaries, to the value of South African Rand 1.67 billion. The Trust is committed to ensuring that all eligible ex-mineworkers and their families get the compensation they deserve, and appeals your assistance in reaching potential claimants. To lodge a claim: Mineworkers must have carried out risk work at one of the qualifying gold mines during the qualifying periods between 12 March 1965 and 10 December 2019. Living mineworkers must have permanent lung impairment from silicosis or TB that they contracted while doing risk work at these mines. For deceased mineworkers, there must either be evidence that they died from work-related TB within a year of leaving the mine if it's a TB claim, or evidence that they had silicosis or died from silicosis if it's a silicosis claim. For more information and to check eligibility, contact the Trust. Claimants are reminded to be careful of people impersonating the Trust or promising to help speed up their claims. Only the Tshiamiso Trust can process claims in a free service. Claimants must only share their documents with the officials at the lodgement offices and should not pay anyone to help them with their claims.
Nutritional well-being is the product of a complex interplay of factors that directly or indirectly affect what people consume and how their bodies break down and utilize it. Equating malnutrition with hunger changed as evidence grew that underweight and obesity could co-exist in individuals and households and the double burden of malnutrition emerged. This special issue aims to highlight Food, Diet, and Nutrition at the intersection of multiple determinants of health; namely, climate and environmental changes that affect food production and distribution; commercial interests that drive food manufacturing, processing, distribution, and marketing; economic, social, and cultural determinants of households’ and individuals’ consumption choices based on affordability, palatability, and social status perceptions; and the psychosocial realities that influence feeding and dietary habits in the 21st century. It draws contributions and learning from work on how these determinants and environments can be tackled, from interventions on the more immediate conditions that shape food systems to the deeper policy, legal, economic, and other structural interventions that control harmful conditions or that promote healthy food systems. Authors are invited to submit abstracts and full papers as outlined in more detail in the website.
This conference, hosted by CeSHHAR Zimbabwe in collaboration with the Zimbabwean Ministry of Environment, Climate and Wildlife and the Ministry of Health and Childcare, aims to address the detrimental health impacts of climate change on health and wellbeing in Africa and to share research evidence into understanding climate-health mechanisms, the health impacts, effective adaptation and mitigation intervention strategies, equitable climate research, and to discuss how to effectively translate research into policy.
The World Congress of Epidemiology (WCE) will be held in an in-person format for this edition of the triennial congress of the International Epidemiological Association (IEA). WCE is well-known for bringing epidemiologists and public health experts working in different sectors together in an atmosphere designed to promote dialogue, the interchange of ideas, and state-of-the-art scientific research. The theme of WCE2024 is “Epidemiology and complexity: challenges and responses” which will engage the full depth and breadth of methods and practice in contemporary epidemiology. The meeting will feature speakers presenting plenary lectures, workshops and interactive sessions. The abstract-driven programme will include oral and poster presentations including theory and application from every sub-discipline of epidemiology. With more than 2000 delegates expected, WCE2024 promises to be a unique opportunity to share experiences and expertise – the opportunities to learn, grow and network within the field will be phenomenal. This is the first time the congress will be hosted on the African continent.
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