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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As 2022 ends, thanks for joint actions and wishing you a heathy start to 2023
EQUINET Steering Committee

We appreciate the ideas, actions, initiatives on health equity we've shared in 2022. The context is challenging, but our conference in 2022, profiled in this issue, showed the rich perspectives, evidence, experiences and creativity people in the region bring to our struggles for social justice in health. We wish you wellbeing and progress in 2023! In 2022 our EQUINET Conference and various steering committee meetings identified key areas of work on health equity within our three strategic directions - Reclaiming the resources; Reclaiming the state; Reclaiming collective agency and solidarity. We are building on past work and alliances, renewing network leadership and developing a programe of research, work, dialogue, and engagement to put the resolutions of our Conference into action. To give time for this we will not have the quarterly newsletter in March 1 2023. Watch out for our next newsletter on June 1 2023- it will be a bumper issue!

Catalysing change for equity and social justice in health: Resolutions for action
EQUINET Conference 2022: Headline resolutions, November 2022

Delegates at the EQUINET Conference 2022 comprised representatives of civil society organisations, community members, parliament, central and local government leaders and officials, trade unions, media, academia, researchers, and personnel from regional and international organisations. We came together virtually under the umbrella of the Regional Network for Equity in Health in East and Southern Africa (EQUINET) to deliberate the actions needed to Catalyse change for health and social justice in this region.

Our deliberations took place at a time of deep-seated and multiple crises that have decimated the basic foundations for provision of public goods (the state, resources and collective agency) in our region, with the poor and marginalised communities left behind to shoulder the burden.
• Are alarmed by the: deepening resource extraction from our region that harms our environment and depletes resources for current and future generations; by inequalities in health, wellbeing and access to services, especially in urban areas and with particular consequences for young people, that are exacerbated by harmful commercial practices; underfunding, privatisation and commodification of public sector services; and by local to global political and economic systems that promote profit over people, disempower people and disrupt collective agency, dignity and social solidarity.
• Are greatly concerned with the limit and slow pace of action to address these challenges and make the change needed to promote equity in health and wellbeing at local, national and regional levels.
• Recognise that public sector-led health systems and comprehensive primary health care are central elements of the robust, redistributive and participatory states that are essential to meet our challenges, including from pandemic, conflict and climate injustice and address global drivers of injustice and inequity.
• Unequivocally identify the pivotal contribution that human rights, solidarity values, collective organisation and social power make in supporting self-determined action towards social, economic and ecological justice.

Committing to reclaim our resources, our states and our collective agency and solidarity for health and social justice, and as a catalyst for a political economy and systems that are rooted in values of equity, social justice, collective wellbeing and protection of nature, we propose a set of inter-linked areas of action to address our most critical challenges and tap our assets for health.

Building on our past 25 years, we understand that equity demands sustained, longer-term action. Over the next five years, we will:

1. Take action to:
a. Build and amplify a clear and affirmative pro-equity, pro-public discourse to affirm values, claim rights, resist inequity and demand action.
b. Track, generate evidence and knowledge on inequities and rights violations in health and wellbeing, and on the opportunities for and feasibility of social justice change that promotes both sustained human and ecosystem wellbeing.
c. Promote, demonstrate, advocate for and contribute to the implementation of specific equity-promoting laws, policies, practices and reforms for equity in health and wellbeing.
d. Build the capacities, leadership and activism needed to promote active participation and communities as agents of change; and to engage in participatory democracy around the policies, laws and systems that are critical in catalysing equity-oriented change.
e. Develop, sustain and work with pro-equity networks and alliances for action within and across countries in the east and southern Africa (ESA) region, in exchanges and engagement with other regions, with global actors and in global processes.

2. With a particular focus on the following issues:
• Development and implementation of constitutional and legal provisions that protect the right to health and enable action on equity in health and wellbeing.
• Healthy living, working and ecological conditions and food sovereignty, including specific concern on the extractive sectors, corporate practices, climate and eco-social justice, and for youth health and urban wellbeing.
• Adequate and progressive public sector resourcing (financial, health worker, commodities, infrastructures) and fair allocation for comprehensive primary health care oriented, universal, equitable, socially accountable public sector health, social and essential services, including in pandemics, and on disaggregated and publicly accessible information, monitoring and public health surveillance systems that integrate community evidence.
• Investment in local production of essential health products and tax justice, and the rule systems, measures and institutional reforms for this within the region and at global level.
• Regional counterproposals to paradigms, narratives, and local to global economic, political and procedural drivers of policies and practices that harm equity health and wellbeing and participatory democracy in health systems and services.

These headline resolutions were adopted by the conference on its final day. Further detail on the issues and areas of action is shown at https://www.equinetafrica.org/conference/resolutions.html.

Share your stories of change in promoting health and social justice in the region
Editor, EQUINET newsletter

In exchanges and work in the region and in the 2022 EQUINET conference 'Catalysing change for health and social justice' we have heard and shared creative, committed and often sustained experiences that promote health equity and social justice at local, national and regional level, and in engaging in global processes. In future newsletters we thus plan to share these stories of change together with our usual editorials. Please contribute and share your work! We invite submissions of about 1000 words that tell the story with links where available to further information that we can feature in future issues. If you need edit support to write it we can assist. Please email your submission to the EQUINET secretariat (email address on the website) with 'Story of Change' in the subject line. If you haven't yet joined the online EQUINET conference you are still in time to register for and join the remaining days. Details are on the EQUINET website.

STORIES OF CHANGE: Opening doors for young people through affordable e-learning in South Africa
Nadine Nanji, Public Health Researcher, University of Cape Town, South Africa

South Africa has high levels of socio-economic inequality and youth unemployment. The COVID-19 pandemic has created many economic challenges, especially for those who are already insecure or who live and work in precarious conditions, many of whom are young people. Poverty and lack of opportunity in a country where there is a visible display of wealth has led to frustration and social unrest. Unemployed youth and those in precarious employment and in lowest income communities are vulnerable to many risks, including mental stress, gender-based violence, sexual abuse, teenage pregnancies, and use of harmful substances.

Digital courses are available, but are often unaffordable for the lowest income youth, as are university courses and other formal training programmes. Digital skills have high value, but how do unemployed, underserved or economically disadvantaged South African youth access these skills? This generates new forms of digital inequity that add to the country’s other dimensions of inequality. While young people have many interests, they want to follow learning tracks that improve their incomes, working lives and wellbeing. They also don’t want to have to high jump over huge demands for formal educational qualifications to have the chance to learn new skills.

In 2021, an initiative was launched to tackle these issues facing the disadvantaged young people, triggered also by the increased demand for online interaction during the COVID-19 pandemic. Afrika Tikkun, a South African non-profit organisation, aims to improve the lives of young people, leveraging solidarity partnerships with other organisations. Afrika Tikkun saw an opportunity to tackle inequities in youth unemployment through education, skills development and placement programmes. They found a partner in Nedbank, who, having done an assessment in 2020 on social issues that could be rectified through financial investment, identified a huge gap in the digital job market in South Africa, with an unmet demand due to a shortfall in skills. Any programme aimed the lowest income young people tapping this opportunity would need to address the multiple barriers they face in access to and the costs of online platforms, to avoid entry barriers from a demand for high formal education levels, and to encourage and guide learning through mentoring and peer support. Afrika Tikkun and Nedbank partnered with Microsoft to draw on their experience in digital skills building, in a collaboration that brought different capacities and roles towards a shared goal.

These partners established an e-learning platform called DigiSkills, with an explicit goal of supporting digital equity for young people. No formal education was needed to join the programme, the program provides in a low bandwidth five free online short courses on professional digital skills with constant support through facilitators, mentors and peer groups to encourage and support participation. The app provides free access to online learning, although data charges to get online still need to be met. The equity test and sustainability of the initiative lies, however, not so much in the resources of the launching partners, but in the reach to and social and economic value it has for the participating young people, particularly those normally excluded from such skills programmes.

By the end of 2021, 1000 students had completed the online digital skills training, with prior screening ensuring that there were drawn from disadvantaged, unemployed or displaced youth. Over 400 of these young people found job opportunities. In 2022, a further 4000 young South Africans are undergoing the training. The DigiSKills program is supporting students to link learning pathways to job creation and entrepreneurial opportunities, and to solidarity with other young people. 26-year-old David, previously unemployed, who took the course and now works as a developer at MLab, commented that the opportunity has given him a power he did not have before to sustain himself and his family. 31-year old Thabani, also a graduate courses, is now assisting other young people to sign up and intends to start his own IT training company to help more youth in South Africa.

There are no magic bullets however. These programmes don’t intend to substitute pathways to higher levels of skills, research and development and on their own don’t stop the brain drain from South Africa. They don’t replace more significant levels of investment in self-determined research and innovation in the country. They don’t yet address the wider cost barriers to internet and data and to capital for young people to create new enterprises. All these areas need state and political attention and a wider level of change on the multiple institutions involved in the systems for skills development, research, innovation and entrepreneurship, including from early child development and in schools.

However, there are some lessons from the story of change on how partnerships can bring together actors with different background and capabilities, based on evidence and embedding clear values, towards a shared vision and implementation. The initiative is perhaps not perfect, not adequate for the significant inequities faced and still to be tested in the longer term. It suggests, however, that individually the young people and each of the institutions involved are not drivers of transformation. It is perhaps in their convergence, and their mindfulness and consistency in addressing an equity goal, that there is a possibility for producing change or shifting power in this key area of inequity for young people in South Africa.

EQUINET, through its Equity Watch Cluster invites your stories of change on any areas that reflect change in health equity and social justice, locally, within countries and regionally in east and southern Africa. In about 1000 words they tell the story of how a change came about, and who made it happen. To send feedback on the issues raised in this oped or to send a story please email the EQUINET secretariat: admin@equinetafrica.org. Further information on Digiskills can be found at the Africa Tikkun website (https://afrikatikkun.org/ ) and at https://www.digiskills.careers/.

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/