Editorial

Be part of the exchanges at #EQUINETConf22 on Catalysing Change for Health and Social Justice!
EQUINET steering committee

The EQUINET Conference 2022 “Catalysing change for health and social justice” welcomes community members, workers, state personnel at all levels, civil society, parliamentarians, academics, trade unions, diverse professionals, innovators, producers and others to present ideas and hear experience from the east and southern Africa region. We will also learn how other regions are confronting equity challenges and discuss and propose key areas of action and policy to promote health equity and social justice. We need your input so please don't get left behind! Find out more in the EQUINET update section of the newsletter, follow @EQUINETConf22 on twitter or visit the conference website at https://www.equinetafrica.org/conference/home.html.

Confronting inequities in the ‘donor’-‘recipient’ relationship in health in Uganda
Danny Gotto, Innovations for Development, Uganda

Like many other countries in East and Southern Africa, Uganda’s health sector is highly dependent on overseas development aid (ODA). The country receives considerable sums from external funders through grants, loans, and other forms. As initially conceived of, ODA intended to reduce poverty, and to support socio-economic development. Although initially conceived to be a form of temporary assistance, Uganda, like many other countries in the east and southern Africa, has continued to face financing gaps for these development aspirations. ‘Short-term’ foreign funding has become ‘long-term’ and Uganda, like others, has become increasingly dependent on aid to meet key health service obligations.

The COVID-19 pandemic threatens to turn this dependency into debt. In a 2021 analysis of aid flows to Uganda before and during COVID-19, Owori (https://devinit.org/resources/aid-uganda-covid-19/) reported bilateral grants to be the largest source of ODA to Uganda in 2020. The United States was noted to be the largest external funder, followed by the European Commission. However, Owori also found that the profile of official development assistance had switched in 2020 from grants to increased proportions of concessional loans from international financial institutions. At a time when the country faces significant liabilities from the pandemic, and a rise in the debt to GDP ratio from 48% before COVID-19 to 52% in 2022, the shift from grants to loans adds further pressures to the public purse. The ‘East African’ reported in February 2021 that the National Budget Framework Paper 2021/2022, approved by parliament, projected that Uganda will spend 97% of its total domestic revenue on debt servicing, with the US$231 million for this six times the health sector budget. Efforts to re-negotiate or restructure loans have not yet yielded meaningful progress. Uganda is yet to benefit from G20 Debt Service Suspension Initiative (DSSI) and China, the largest creditors is not part of the DSSI. This means that Uganda has to borrow to pay.

The level of global inequality between countries and between elites and many in society clearly calls for redistributive financing within and between countries. Foreign funding to the health sector has led to impressive areas of progress in Uganda, such as in relation to reducing HIV and responding to treatment and care needs for AIDS.

However, concerns have been raised in the past over the way ODA from high to low and middle income countries can encourage corruption, distort priorities, mask inefficiencies and shift attention away from domestic budget commitments, and from deeper international economic and investment issues. Despite long-standing and significant levels of external aid, Uganda’s health sector still suffers from inadequate funding and infrastructure, wider health system deficits and weaknesses in governance. The provision of foreign assistance appears to have generated a culture of dependency from recipients and paternalism from funders. A ‘donor’ - ‘recipient’ relationship risks local expertise, knowledge and capacities being ignored, and can encourage neo-colonial and racist assumptions and attitudes. A northern aid industry has often placed itself in the position of managers, intermediaries, implementers, and monitors of ODA. On the other side, it also leads to an unhealthy reliance on foreign funding to meet state and sector obligations in health, such as immunizing children that should be funded by the Uganda government.

Whatever the well-meaning intentions, a mix of dependency and paternalism carries the risk of infantilizing leaders, and of absolving states of their responsibilities to their populations through domestic resources. It would be naïve to ignore that ODA carries with it interests of both funder and recipient. This calls for transparency in and negotiation of these interests. Commitments have been stated to increase transparency in this relationship, but these commitments are not always delivered on, and still far too little information is shared with local actors. ODA financing of a large share of health expenditure comes with conditions for close monitoring and reporting by states to external funders, sometimes with stronger state accountability to high income country funders and tax payers that to the citizens and parliaments of recipient countries, marginalizing mechanisms for domestic accountability. While such accountability needs to be demanded within our countries and there have been improvements in aid accountability, Wild and Domingo have observed in the past that what is written on paper is often different from what is practiced (https://tinyurl.com/57jap9jn). A preference for vertical funding of health sector programmes, not all through state systems, and off-budget funding with parallel reporting mechanisms means that evidence is not always shared with domestic actors. It is not easy to access information on external funding when off budget, such as in various forms of private- public partnerships or parallel institutions. Demands for domestic accountability also face power imbalances between funders and communities, and between high and low income countries.

These shortfalls and concerns are being voiced in many countries in the region, and by some stakeholders in high income countries, including those seeking to ‘decolonise’ ODA while still meeting obligations to global public goods and solidarity. This raises questions about how ODA is directed, given and used now and in the longer term, especially if the ‘giving’ creates repayment liabilities that the public will be paying for well into the future.

These issues need to be debated. In writing this oped with the intention to contribute to this dialogue, including on the actions to address the issues raised. For example, I suggest some areas of action.

Transparency and access to information should be at the heart of the negotiation of and accountability on interests in ODA relationships, not only between states, but also to the public on both sides. The lack of transparency and blockages in information flow noted earlier, including between states and citizens need to be addressed. This includes bringing ODA ‘on-budget’ in the health sector to capture and align the resources towards national health priorities and systems, and to enable and improve the mechanisms for and practice of public domain reporting and oversight.

The priorities brought by ODA need to be aligned to national health system priorities. The upward accountability to funders and high income source countries and power imbalances between low- and high-income countries can be argued to generate a reliance on solidarity and inadequate incentives for ODA funders to make good on their commitments under the Paris Declaration and other global commitments. ODA funders need to understand, engage with and align to the contexts, priorities and cultures of countries they engage with, and to invest time and resources upfront to engage to a greater degree in designing their investments and projects with local actors. This is important to avoid overlooking and under-investing in local health problems and priorities, and in the institutional and system needs to implement them. It can be argued that the shift noted earlier in Uganda from grant to loan funding, for example, reflects more the interests of high income country funders than the post-pandemic realities faced by the country and its communities.

This places a demand on states to build strategic capacities and alliances to negotiate domestic interests, to look beyond immediate sums to their implications and future burdens. However, there is also an obligation on ODA funders to not exploit or exacerbate weaknesses in recipient capacities and accountability mechanisms, but reinforce or support their strengths. For both sides this is a business of ‘relationships’ and diplomacy, and one in which power inequities and the institutional barriers on both sides of the relationship need to be more explicitly addressed, to achieve outcomes that matter for sustained population health equity.

We welcome your feedback or queries on the issues raised in this editorial. Please send them to the EQUINET secretariat. You can read more from I4DEV at http://www.i4dev.or.ug/

Meet commitments to public sector financing of public health to walk the talk of’ ‘pandemic preparedness’
Bona Chitah, University of Zambia


After a long period of domestic underfunding of public health services, particularly prevention and promotion services, the COVID-19 pandemic generated massive immediate demand to fund these same services. It arrived at a time when many public health systems in east and southern Africa (ESA) were fragmented, with challenges in service quality and provision and unmet need in the population. An analysis of health financing in ESA countries included in this newsletter showed that the pandemic called for a massive scale up of investment in testing; surveillance; infection prevention; waste management and health promotion. These were all areas that had seen declining investment in most ESA countries in the decade before the pandemic.

The regional analysis reviewed selected indicators available from the WHO Global Health Expenditure database for 2000–2019 of the extent to which governments prioritise health in domestic budget spending; provide financial protection; and spend on primary health care. A country case study then gave a deeper look at the health financing demand for the response to the pandemic, using national ministry of health data for 2020–2021 and projections for 2023.

Between 2000 and 2019, less than half of ESA countries included progressively increased their share of health spending in the budget and by 2019, only two met the Abuja Declaration commitment of 15% of government budget spending on the health sector. By 2019, seven ESA countries had out-of-pocket spending (OOPS) above the upper limit of 20% suggested by WHO to avoid catastrophic expenditures and impoverishment, four of them considerably so. For nine of the 16 ESA countries (including Zambia) in 2019, less than 50% of spending on primary health care (PHC) came from government spending, suggesting a high degree of reliance on external funders for this key area of pro-poor spending.

It can be argued that those countries that gave less priority to public sector health in government spending and that provided less financial protection against impoverishment for users through OOPS could have been in a weaker position at the onset of the COVID-19 pandemic in relation to provide public health sector leadership, protect wider services and protect households during the pandemic. Adequate domestic spending on PHC is necessary to resource the public and community health and primary care levels of health systems that are key in pandemic responses.

While Zambia had low OOPS, its share of government spending on health had also been falling prior to 2020, and, with a low share of government spending in total PHC expenditures, was dependent on external funds for these services. As overall health spending fell in real terms in the years immediately before the pandemic, the budget increasingly focused on curative care, with a falling share of spending on health promotion and prevention.

Hence, while Zambia implemented features of a robust preventive, health promotion and care response, the prior financing trends and a wide reported gap between needs versus resources mobilised suggests funding constraints to achieving the full scope of what intended in policy. The financial plans for the health sector response to the pandemic showed that, contrary to prior spending patterns, the greater share of resources were needed for prevention-related activities including testing, infection prevention and control, including for the health workforce, for health products and waste management systems. These are also areas where the funding gap was noted to be highest. It appeared (excluding vaccination donations) that external funder committed support was more focused on treatment and care, rather than for the wider range of prevention services. This funding gap thus placed high demand for domestic resource mobilisation, at a time when the pandemic also led to economic disruption, recession and increased debt, intensifying resource scarcity, for both households and for health sector spending.

The Zambian health ministry COVID-19 budget showed a sudden, urgent and costly increase imposed by the need to mitigate COVID, with some reports of reversals in gains made in areas such as maternal and child health programmes as resources were redirected to address emergent pandemic needs and health workers were over-stretched.

Estimates of the funding needed for the pandemic response indicate budget needs that are nearly 60 times higher than the last recorded government health spending in the 2016 national health accounts. While the response to an emergency inevitably demands new resources, there is a question of how far a sustained period of under-financing of critical prevention infrastructure, supplies and services over many years contributed to this gap. Conversely, the benefit of areas of previous investment is apparent in Zambia’s ability to make use of existing HIV, malaria and TB related laboratory services to rapidly decentralise laboratory capacity for COVID-19.

As the evidence focused on broad trends in the region and a focus on only one country on pandemic budgets, it would be useful to explore further the experience across other ESA countries. However, for health financing in the region, the evidence suggests that pandemic preparedness is not an acute event, but rather a sustained process of investment in public health services and personnel that may be more likely to enable rapid repurposing and switching to address new pandemic needs. This implies governments meeting the Abuja commitment, not letting the public sector share of financing fall to levels that undermine domestic public sector leadership of the multiple actors in preparing for and responding to public health priorities, and more consistently prioritising prevention and promotion and PHC services in domestic health financing.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information can be found in EQUINET Discussion paper 124 on the EQUINET website.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

COVID: Using the rupture for change
Editor, EQUINET newsletter

Our editorials usually provide a lens on a perspective and issue occurring within east and southern Africa. But what we currently see in different parts of the world are a call to solidarity and people's connection across regions, including to ensure that what is happening locally is not rendered invisible in global policy and accountability. We have seen scenes of human tragedy unfolding in Gaza and India and military violence faced by people protesting against the privatisation of health care in Colombia. In region to region solidarity this newsletter includes a message from the People's Health Movement in our region protesting those facing injury and threats to health in Colombia.

Connecting across regions and peoples seems critical at this moment for what sort of world we will create. Arundhati Roy in 'The pandemic is a portal' (open access) wrote "Whatever it is, coronavirus has made the mighty kneel and brought the world to a halt like nothing else could. Our minds are still racing back and forth, longing for a return to “normality”, trying to stitch our future to our past and refusing to acknowledge the rupture. But the rupture exists. And in the midst of this terrible despair, it offers us a chance to rethink the doomsday machine we have built for ourselves. Nothing could be worse than a return to normality. Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it".

Our two editorials both point to global processes that demand engagement, vigilance, support and sustained activism across regions and peoples if we are to use this rupture for change.

The COVID-19 TRIPS Waiver: What happens after grabbing the tail of the tiger?
Riaz Tayob, SEATINI, South Africa

Without any doubt, it is a success for South Africa, India and other co-sponsors of the TRIPS Waiver proposal, along with progressive political, professional and civil society voices, that the United States of America changed its position on the TRIPS Waiver. The waiver proposes a time-limited waive of patents and other rights related to essential health products for COVID-19 in the World Trade Organisation (WTO) TRIPS agreement.

The TRIPS Waiver proposals are now moving to text-based negotiations. If historical experience on access to medicines and the current power relations are anything to go by, the waiver proposers have grabbed the tail of the proverbial tiger in pushing for more distributed production of vaccines, diagnostics and therapeutics. What is to be done now that the US has agreed to talks?

It is important to understand that this stage does not represent agreement on the waiver. It has now merely advanced as an agenda item for discussion. The terms of the waiver have yet to be worked out. Even once agreed, implementation demands rapid support to increase production capacities for the range of products and systems that are able to distribute them, particularly in resource constrained settings. For all products covered, and particularly for vaccines and therapeutics, the waiver time frame and production capacities would need to be able to deal with current and emergent viral mutations and the updates required for a potentially endemic situation of an evolving virus.

Much remains to be done and the convergence of progressive forces that have pushed the waiver to this point need to robustly take on these remaining challenges to realise equitable access to vaccines, diagnostics and therapeutics.

The text-based negotiations and counter-lobbying by big pharma and others pose a risk of the proposals being diluted. As faced by HIV treatment activists in struggles over access to medicines, the proposals will face an incremental detraction from the largely wealthy countries seeking to preserve economic interests. Germany, the influential European power, remains opposed to the waiver, notwithstanding the US change in position. The tables seem to have turned on this. In the HIV-related Doha negotiations in 2001, the US played the ‘bad cop’ and the Europeans the ‘good cop’. While the European Parliament is largely supportive of the waiver it has limited legislative power, as intellectual property is in the European Commission’s domain. Further, the US trade representative to the WTO has said these negotiations will take time, as if they and not they virus are setting the timeline.

Already, the revisions that South Africa and India have made point to some of the areas that may be weakened: The duration of the waiver, with proposals for 3 years subject to renewal, must be adequate for the distributed transfer of capacities in an evolving situation. The necessary scope of technologies -vaccines, diagnostics, medical devices and therapeutics – is in the revised text and should not be whittled down. It is unclear if it will apply to patents only, or as in the current waiver proposal, to other key elements of intellectual property such as trade secrets, industrial designs and copyright.

The struggle for access to HIV-related medicines has much to teach. Two agreements were reached at the WTO, the 2001 Doha Declaration on Public Health, and the 2003 ‘August 30th Decision’. Both were victories to build on, but proved to fall short in meaningfully addressing access. They allowed rich countries that could not be seen to deny access to HIV treatments to virtue signal, but sustained hurdles for countries in applying the flexibilities they provided. This largely sustained dependency on imports for the lower income countries most affected by HIV.

The Doha declaration did establish the important principle of trade agreements being “interpreted and implemented in a manner supportive of WTO members' right to protect public health”, and levered improved, albeit not universal, access to HIV-related medicines. But, as the current pandemic has shown, they do not provide adequate measures for vaccines, diagnostics and other technologies essential for a public health response, and did not adequately shift priorities, power or production capacities to address unfair barriers in global trade rules to meeting public health challenges.

While the World Health Organisation (WHO) Director General has stood fast in articulating support for the waiver and called the inequity in vaccine access ‘vaccine apartheid’, WHO has less power in this debate and lacks the enforcement mechanism that the WTO has for its rules. WHO was out-manoeuvred by the Gates Foundation and rich countries’ preference for the ACT-Accelerator and COVAX at a time when the deeper proposals for patent pooling and technology transfer were made through the COVID-19 Technology Access Pool (C-TAP). The delay in enabling distributed production and weakness of COVAX is already evident in the shortfalls in supplies reaching low and middle income countries through COVAX, more sharply now with the pandemic demand in India restricting vaccine exports. The African Union recently warned African countries that delays in supplies may mean that they will need to restart their two dose vaccine programmes, or complete them with one dose vaccines that may not be distributed until late 2021. This global failure to meet health need makes virtue signalling on solidarity at the same time as self-protecting a profitable system reliant on patents and other monopoly rights particularly hollow. This is especially so in the context of the massive amounts of public funding that enabled innovations and the public support in opposing high income western countries for the waiver.

It can of course be argued that diplomacy involves compromise and that radical change demands sustained struggle. But the process is itself taking place in a space that is biased towards existing wealth. Negotiations at the WTO run on arcane principles and are largely not transparent. The rich countries hold much sway, including through supportive WTO officials. Important negotiations take place in so-called ‘green rooms,’ where experience indicates that consensus is achieved largely by excluding dissenters from the table. A current proposal by some high income countries to prioritise voluntary licensing arrangements as a solution is a symptomatic treatment, still under the control of big pharma, fails to address the causes of import dependency in Africa and other low and middle income countries and should not be used as a lever to delay or focus attention away from the waiver.

Proposers and supporters of the Waiver have grabbed the tail of the tiger. If the proposals are to avoid a death by a thousand cuts, this is the time to intensify focus. The transparency of these negotiations at the WTO and active vigilance, support and sustained activism will be essential to ensure that the outcomes achieved protect the public health rights and aspirations that have been behind the TRIPS Waiver to date.

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