We have many new case studies, reports and links to videos in the EQUINET updates and useful resources in this issue, and issued a special editorial on protecting health and health services in conflict in February. In this issue we thus use this editorial space briefly to invite you to read these publications. The February editorial responded to the conflict and violence in different global regions, and particularly the violations against the specific protections provided in international conventions of civilian health, health services and health workers in conflict zones. The extreme situation in Gaza, still continuing, prompted the WHO Director General Dr Tedros Adhanom Ghebreyesus to say “Without a ceasefire, there is no peace. And without peace, there is no health.”
At the same time we present in this newsletter many case studies of inspiring action in different urban sites in our region. They address the rising challenges and health risks posed by urbanisation for unmanaged waste and food insecurity, especially for low income communities. They turn challenge to opportunity, such as by linking waste recycling to incomes and to fertiliser for urban agriculture and food security. They change zones of polluting waste dumping and burning into urban green zones through ‘whole of society’ approaches. They show concretely the possibility of and measures for taking on issues such as climate justice and inclusive circular economies. For those affected they show that they can produce change.
These local level initiatives yield optimism, even as frustration and social disempowerment is fostered over global and international level actions on key challenges affecting wellbeing, such as climate, conflict and inequity. As another paper in this issue discussing the Africa Continental Free Trade Agreement asks, can we at national and regional level better protect space and support for such initiatives within our countries, rather than reproducing global trade and economic frameworks that block them? We invite you to contribute evidence and publication to the newsletter, and to explore, debate, analyse and share on these and other health equity issues with us in 2024, and wish you a year of peace, health and progress.
Current Issue
EQUINET NEWSLETTER 238 : 01 March 2024
CONTENTS: 1. Editorial, 2. Latest Equinet Updates, 3. Equity in Health, 4. Values, Policies and Rights, 5. Health equity in economic and trade policies, 6. Poverty and health, 7. Equitable health services, 8. Human Resources, 9. Public-Private Mix, 10. Resource allocation and health financing, 11. Equity and HIV/AIDS, 12. Governance and participation in health, 13. Monitoring equity and research policy, 14. Useful Resources, 15. Jobs and Announcements
1. Editorial
We find ourselves drawing inspiration from the local, and confronting the global.
Editor, EQUINET newsletter
2. Latest Equinet Updates
Addressing health implications of the African Continental Free Trade Agreement in east and southern Africa
Machemedeze R, SEATINI: EQUINET Discussion paper 131, EQUINET, Harare 2023
This desk review on the health implications of the implementation of the AfCFTA within the ESA region implemented by the Southern and Eastern African Trade Information and Negotiations Institute (SEATINI) outlines the health sector and health-related areas directly or indirectly covered by the ACTFA and the relevant subsidiary instruments. It presents information on these and the AfCTA provisions and their implications for trade liberalisation, which are largely consistent with those under World Trade Organization (WTO) agreements. The paper identifies the AfCTA’s positive and negative actual and potential health sector and health- related impacts, including for health equity. It does this in terms of the products that will be subject to liberalisation, including those with potential benefit for health such as local production of health technologies and pharmaceuticals, as well as those that may be harmful to health such as tobacco and genetically modified and ultra-processed foods. It also explores the health implications of the AfCFTA on financial flows and public revenue and on the movement of people, including health personnel. Given this analysis of impacts, measures are proposed that individual countries and the ESA region as a whole may take to protect health equity goals, including monitoring mechanisms to track and report on those impacts.
Climate Change and Health Systems in East and Southern Africa: A Rapid Review
Musuka G, Dzinamarira T: EQUINET, Harare, December 2023
This desk review explored how climate change is affecting health systems in east and southern Africa (ESA); how the region’s health systems are adapting to climate change; and to identify the health system advocacy and policy issues raised in climate change negotiations by ESA countries, including in relation to issues of equity. Climate change was found to be associated with increased demand for health care services and reduced access to them. An increased demand for health services was found to arise from malnutrition caused by drought-related food shortages, an increase in food and water-borne infectious diseases because of drought and floods, especially in low-income settings, as well as heat exhaustion and heat strokes due to heat waves, particularly among people living in informal settlements. Provision of health services was found to be reduced by extreme weather events, with flooding disrupting transport and communication networks, affecting laboratory services, staff and patient travel, supplies of medication and ambulance availability, especially in rural areas. ESA countries have raised a range of advocacy and policy issues related to climate change and health systems in negotiations at the African Ministerial Conference on Environment and the UN Climate Change Conference of Parties (COP).
Communities collaborating in the Kariba Integrated Solid Waste Management Programme: From urban litter-jungles into healthy environments
Municipality of Kariba, TARSC: EQUINET, Harare, 2024
Interventions on urban waste have been integrated into one solid waste management programme in Kariba through multi-actor participation with high literacy, involving existing community structures and different age groups of people, and incorporating their aspirations for a clean town. Different interest groups select their own interventions on urban waste linking to food, energy and other urban needs, and deploy their own innovation, local knowledge systems. These are then integrated into the overall programme. The activities use affordable technologies and locally available materials, creating a demand for local goods. Information and communication technologies used in the programme have been important contributors to successful outcomes. Bringing diverse social groups together contributes to system wide and holistic awareness and links action on urban waste systems to a circular economy and climate justice.
Don’t waste the waste! A case study of promising approaches in managing organic solid waste in Manandriana Municipality, Antananarivo Avaradrano, Madagascar
FARM Madagascar, TARSC: EQUINET, Harare, 2024
Understanding how waste management systems are linked to and interact with other sub- systems and the influence and moderation effects of contextual factors including climate change is important in informing actions and approaches that promote health and wellbeing. Waste management systems provide a potential entry point for fostering innovations, collaborations and system-wide changes for healthy communities and ecosystems, such as through strengthening their linkages with food systems and promotion of circular economies. This case study showcases experiences from the municipality of Manadriana in Antananarivo, Madagascar. It has been produced within a series on integrated urban health in EQUINET to foster learning on these promising approaches within east and southern Africa.
From a Waste Dumpsite into a Food Basket in Bembeke, Dedza, Malawi
Country Minders for Peoples Development, TARSC: EQUINET, Harare 2024
Bembeke, Dedza has been transformed from one of the worst dumping sites to one of the cleanest urban sites in Malawi. CMPD, in partnership with the Environmental Affairs Department (EAD), and stakeholders in Bembeke Dedza, devised and implemented a waste management initiative to turn waste into manure, reducing waste and improving food security in Bembeke. Bembeke farmers were trained to produce manure from waste and theatre campaigns were held in eight zones to sensitise communities on ‘waste to wealth’. Urban waste and food security interventions succeed when all key stakeholders, including community members participate from conception to completion. Turning waste into fertiliser for food production contributes to food security, environmental protection, circular urban economies and mitigates the effects of climate change.
Health-promoting food and waste management systems in Kwekwe City: Turning waste into assets
City of Kwekwe, TARSC: EQUINET, Harare, 2024
Waste pickers, mostly women collect aluminium cans from shopping centres and homes and sell them to small-scale smelters based in home industries in Mbizo, Amaveni and other suburbs in Kwekwe. The aluminium scrap sells for between 45-50c (US$) per kilogram. The aluminium is moulded into useful traditional pots for local sale. Depending on their sizes, the pots sell for between US$10 to US$90. This is one of the ‘waste-to-asset’ recycling activities in Kwekwe City described in this brief. Harnessing treated wastewater for crop irrigation recycles nutrients and protects the environment. The food produced, sold and consumed locally in urban agriculture alleviates poverty, and promotes food security and health. Community participation, partnerships and collective decision-making in waste management applies local knowledge and assets for environmental protection and climate justice. Using solar energy protects urban environments, reducing dependence on polluting fossil fuels, and reducing the greenhouse gases that contribute to climate change and its negative impacts. Circular economic activities promote climate-proofing and inclusive economic development
Promoting comprehensive primary health care mental health interventions for young people: A Malawi case study
Chikaphupha K, Nanji N, Muhia J: REACH Trust, IWGHSS EQUINET, Harare, 2024
This study in Malawi aimed to assess the experiences of 15–24-year-old youth with regard to mental health problems, to evaluate the management of mental health issues and the responses to the issues they face, as well as to recommend interventions to address young people’s mental health challenges. The study employed a mixed methods approach. The 7% prevalence of depression identified in the study seems low compared to the 11–14% in youth in several other studies in Africa. Challenges identified relating to access to mental health services indicate the need for improved availability and accessibility of mental health services for young people faced with mental health problems. The COVID-19 pandemic further impacted youth by increased losses in education, income, employment and food security, as well as increased gender-based violence and sexual abuse. Based on the findings, recommendations are made on areas of primary health care, community, multisectoral, and youth interventions to better support mental health promotion, mental illness prevention, detection, counselling, care and wider responses for young people in Malawi. Although the sample size was small, these may also be relevant across other countries in sub-Saharan Africa.
Promoting the Three R’s -Reduce, Recycle and Reuse- in waste Management in Kadoma, Zimbabwe
Abdullah Dzinamarira Foundation Trust, Young Men Christian Association, TARSC: EQUINET, Harare, 2024
Waste management is a critical issue facing cities globally, particularly in low-income countries with limited resources. Responding to this challenge, the Abdullah Dzinamarira Foundation (ADF) and Young Men’s Christian Association (YMCA) implemented a comprehensive waste management programme promoting the promote the three Rs - Reduce, Reuse, and Recycle- in Rimuka, a densely populated low-income suburb in Kadoma, Zimbabwe. Waste reduction strategies can be low-cost and high-impact. They call for increased education and awareness on how waste management can create new industries and jobs. This work in Kadoma set up forums and interventions to involve local people and involved stakeholders to build awareness of the opportunities that waste reuse and recycling provides for jobs and inputs to local food and product. The programme generated interventions linking waste recycling to food production, plastic waste collection to incomes and renewal energy to improved urban conditions. Climate change affects health and is creating health inequalities. City efforts to reuse, recycle and reduce contribute to improved health climate change mitigation and adaptation.
The Nairobi Urban Health and Demographic Surveillance System: Bringing community voice and evidence to urban health in slum communities
AB[M]R, TARSC: EQUINET, Harare, 2024
The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was the first African urban health and demographic site surveillance (HDSS) based in a slum. It seeks to address the health and social needs of urban slum dwellers. NUHDSS has generated the information and evidence needed, to strengthen and inform action and change on healthy food systems and green spaces, promoting equity, poverty reduction and climate justice; facilitating the circular economy through reduced use, reuse, and recycling of waste. The NUHDSS data and nested studies were used to assess the impacts of interventions, to inform local and national policy-making and programmes to improve community health locally, in Kenya and in other African countries. As a tool for community voice and to support governance approaches and collective learning, the NUHDSS platform and process has strengthened the voice and involvement of residents of Viwandhani and Korogocho slums in their health and socioeconomic development bringing community voice in a ‘whole of society’ approach that recognizes and engages all stakeholders.
Transforming Mbale City’s urban food system in the Good Food for Cities Programme
Food Rights Alliance, Rikolto, Global Consumer Centre, TARSC: EQUINET, Harare 2024
Rapid urbanisation in Uganda especially in cities like Kampala and Mbale is reshaping the urban food systems, altering demand and introducing food related challenges. Despite the positive aspects of urban development, there is an increase in unregulated activities that lead to unsafe food practices. The Good Food for Cities programme recognizes these challenges as opportunities to establish more sustainable, fair and healthy food systems in Mbale and Kampala. The programme aims to forge coalitions involving businesses, consumers, local authorities and other food system actors to ensure inclusive, resilient and healthy food environments for all citizens. Two crucial mechanisms of the Good Food Council and the Good Food Parliament serve as platforms for consultation, dialogue, accountability and collective decision making. The programme adopts a three-tier intervention strategy of promoting sustainable production, inclusive urban food markets and an enabling environment. These areas give emphasis to regenerative agriculture, and multi stakeholder participation, addressing climate change, and urban inequalities and food insecurity.
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3. Equity in Health
Climate risks in urban areas
Humphreys G: Bulletin of the World Health Organisation 1:102(2), 90-91, 2024
Engaging with communities in informal settlements presents opportunities to mitigate the health impacts of climate change, but government investment is also needed. Around one third of the estimated 4.5 billion urban dwellers worldwide use pit toilets or septic tanks, which are normally the first to be overwhelmed in floods, spreading excrement and the pathogens it carries into the environment. Climate change is likely to exacerbate the challenges faced in cities. According to UN-Habitat, “cities are growing faster than governments can build the necessary institutional capacity to better plan and manage urban growth." in the absence of progress on urban investment, planning and management, one suggested way of addressing inequitable exposure to climate risk is to engage with the communities most affected. Not only are community members motivated to initiate risk mitigation measures, they also typically have the best understanding of their surroundings, including the makeup of the local population, and areas most likely to flood.
Global health inequities: more challenges, some solutions
Tangcharoensathien V, Lekagul A, Teo Y-Y: Bulletin of the World Health Organisation 102, 86–86A, 2024
This theme issue of the Bulletin of the World Health Organization shows how health inequities affect many areas, both at national and global scale. The papers discuss health inequity and its root causes, and offer promising solutions. Challenges include national statistics not capturing health inequity among vulnerable populations such as Indigenous people, refugees and migrant workers, including migrant health workforce. However, good practices exist. For example on paper reports on local Indigenous communities successfully managing primary health-care clinics, that can be scaled up and replicated. Overall, the issue editors observe that rectifying global health inequity requires multidimensional interventions and decisive government leadership at the macro-policy level, collaboration with affected populations at the micro-operational level and accelerating progress towards UHC.
The role of the social sciences and humanities in pandemic preparedness responses: insights gained from COVID-19, HIV and AIDS and related epidemics
Govender K, King J, Nyamaruze P, et al: African Journal of AIDS Research, 22(4), 269–27, 2023
The COVID-19 pandemic, particularly from 2020 to mid-2022, debilitated the management of the HIV epidemic in Africa. The multiple effects included well-documented HIV service interruptions, curtailment of HIV prevention programmes, the associated marked increase in both the risk for HIV infection among key populations and vulnerability of sub-populations. As importantly but less well documented were the diverse negative socio-economic effects that accentuate HIV risk and vulnerability generally (e.g. loss of earnings, gender-based violence, stigma, police harassment of people during lockdowns. The global biomedical response to COVID-19 was necessary and remarkable for mitigating the bio-physical impacts of the pandemic. However, this article suggests that key lessons learnt during the HIV and AIDS and other pandemics were ignored, at least during the early stages of COVID-19. The authors critique is that better integration of the social sciences and humanities in responses to pandemics can counter the reflex tendency to uncritically adopt a biomedical paradigm and, more importantly, to enable consideration of the social determinants of health in pandemic responses.
4. Values, Policies and Rights
Outer packaging labelling of medicines in Southern African Development Community countries: comparative analysis of requirements and transition terms for harmonisation
Narsai K, Masekela F, Leufkens H, et al: BMC Health Services Research 24:111, 1-7, 2024
The COVID-19 pandemic highlighted an urgent need for harmonised requirements for the regulation of medicines. The authors compared outer packaging labelling requirements and transition terms for harmonization for countries in the Southern African Development Community (SADC) region. Data on legislation and/or regulatory guidelines for medicine outer packaging labelling from National Medicines Regulatory Authorities were obtained for countries in the SADC region by February 2023. A detailed comparative content analysis was conducted to determine alignment with the requirements of the SADC harmonised labelling guidelines to assess readiness levels of each country to transition to the SADC harmonised labelling guideline for outer packaging of medicines. Content analysis showed at least 11 out of 16 countries require national legal reform to transition to the SADC harmonised labelling guideline. In all cases where countries specified labelling requirements for outer packaging of medicines, these were stipulated in national medicines legislation. Even though there is a high level of alignment across the countries in terms of national labelling requirements, most countries in the SADC region would still require national legislative reform to transition to regional harmonised labelling requirements and then ultimately to continental requirements of the African Medicines Agency.
The Kampala Declaration on Health, Human Rights and Development
The Republic of Uganda Ministry of Health, CEHURD, September 2023, Uganda
This declaration was made by the delegates at the Inaugural Uganda National Conference on Health, Human Rights and Development held in Kampala in September 2023. The declaration makes several commitments, including that the Ministry of Health provide leadership for an integrated and multi-sectoral approach which recognises the intersectionality between SDG 3, human rights and other SDGs. It also commits to strengthen collaboration across all sectors in advancing the right to health; fast-track Government’s process of passing and implementing the National Health Insurance scheme in order to realise Universal Health Coverage; and urges Government through the Parliament to progressively increase financing for health in order to realise the Abuja Declaration of allocating 15% of national budget towards health. The declaration proposes to increase the generation and use of evidence in planning and implementing health interventions, including on social determinants of health; to make more progress on the Right to health in Uganda to realise Sustainable Development Goals.
WHO Asks Member States: Join Talks on Global Plastics Treaty, and Climate Action for Health
Fletcher E: Health Policy Watch, January 2024
A first-ever WHO initiative to join the global negotiations on a plastics treaty, as well as the first WHO decision on climate and health since 2008, are set to come before the World Health Assembly in May 2024. The draft decision on climate change and health, led by eight member states, including Peru, Kenya, the United Arab Emirates and the United Kingdom, reflects new evidence on the linkages between climate and health. The WHO propose to make health-related inputs into the new treaty instrument on plastics, including about particularly hazardous plastics or polymers that should be phased out, and play an active role in a UN science-policy panel on plastics pollution. A range of non-state actors criticised the absence of reference to “fossil fuels” as a driver of climate change in the draft climate and health decision, with one suggesting that WHO should treat fossil fuels like tobacco. The draft document calls upon WHO to clean up its own house by “firmly integrating climate across the technical work of the WHO at all three levels” and develop a “Roadmap to Net Zero by 2030 for the WHO Secretariat, in line with the UN Global Roadmap.”
5. Health equity in economic and trade policies
Developing an agenda for the decolonization of global health
McCoy D, Kapilashrami A, Kumar R, et al: Bulletin of the World Health Organization 102:2, 130–136, 2024
Colonialism, which involves the systemic domination of lands, markets, peoples, assets, cultures or political institutions to exploit, misappropriate and extract wealth and resources, affects health in many ways. In recent years, interest has grown in the decolonization of global health with a focus on correcting power imbalances between high-income and low-income countries and on challenging ideas and values of some wealthy countries that shape the practice of global health. The authors argue that decolonization of global health must also address the relationship between global health actors and contemporary forms of colonialism, in particular the current forms of corporate and financialized colonialism that operate through globalized systems of wealth extraction and profiteering. They present a three-part agenda for action that can be taken to decolonize global health. The first part relates to the power asymmetries that exist between global health actors from high-income and historically privileged countries and their counterparts in low-income and marginalized settings. The second part concerns the colonization of the structures and systems of global health governance itself. The third part addresses how colonialism occurs through the global health system. Addressing all forms of colonialism is argued to call for a political and economic anticolonialism as well as social decolonization aimed at ensuring greater national, racial, cultural and knowledge diversity within the structures of global health.
Mining-Affected Communities: The Elephant Not in the Room
Bailey L: Natural Resource Governance Institute, Blog post: 9 February 2024
At the Mining Indaba in Cape Town in the week of February 5-9 countless references were made to mining-affected citizens of African countries. However, the author of this blog notes that absent from almost all of the rooms where this word was repeatedly invoked were…members of mining-affected communities. Tengi George-Ikoli shared an African adage: “A man’s head should not be shaved in his absence.” Community voices are observed to be essential in spaces like Indaba to ensure that decision makers account for the social, economic and environmental impacts of mining and minimize them. One place that was replete with community stakeholders was Alternative Mining Indaba, which has operated in distant parallel to the main Indaba for 15 years. However the author argues in this blog that until communities and civil society have a more fixed and prominent seat at the table, and agendas reflect the importance of their voices, progress on challenges such as adding value to raw commodities will be difficult.
6. Poverty and health
Associations between child marriage and food insecurity in Zimbabwe: a participatory mixed methods study
Gambir K, Matsika A, Panagiotou A, et al: BMC Public Health 24:13, 1-14, 2024
This study explored how food insecurity influences child marriage practices in Chiredzi, Zimbabwe. It used mixed methods, including participant-led storytelling and key informant interviews. A total of 1,668 community members participated in the story-telling, while 22 staff participated in interviews. The authors found that food insecurity was a primary concern among community members and was among the contextual factors of deprivation that influenced parents’ and adolescent girls’ decisions around child marriage. Parents often forced their daughters into marriage to relieve the household economic burden. At the same time, adolescents were found to be initiating their own marriages due to limited alternative survival opportunities and within the restraints imposed by food insecurity, poverty, abuse in the home, and parental migration. COVID-19 and climate hazards exacerbated food insecurity and child marriage, while education was assessed to be a modifier that reduces girls’ risk of marriage. The authors suggest that child marriage programming in humanitarian settings should be community-led and address the gender inequality that underpins child marriage. They argues that programming must be responsive to the diverse risks and realities that adolescents face to address intersecting levels of deprivation.
Perceived barriers of access to health and nutrition services under drought and food insecurity emergency in north-east Uganda: a qualitative study
Njuguna C, Tola H, Maina B N, et al: BMC Public Health 24:390, 1-9, 2024
This study explored barriers to access health and nutrition services in drought and food insecurity emergency affected districts in north-east Uganda. The authors interviewed 30 patients and 20 Village Health Teams from 15 districts and used thematic data analysis on the findings. The majority of respondents reported that difficulties in access to health and nutrition services, with various sociocultural, economic, environmental, health system, and individual barriers. The study identified several modifiable barriers that are addressed in proposals for comprehensive interventions in the paper.
7. Equitable health services
Self-reported cardiovascular disease risk factor screening among people living with HIV vs. members of the general population in Botswana: a community-based study
Molefe-Baikai O, Kebotsamang K, Modisawakgomo P, et al: BMC Public Health 24:198, 1-8, 2024
This paper aimed to assess whether people living with HIV (PLWH) were more likely to have previously been screened for cardiovascular disease risk factors (CVDRFs) than people without HIV. A population-based, cross-sectional study was conducted among individuals aged 16 to 68 years across 22 communities in Botswana. Of the 3981 participants enrolled, 2547 were female, and 1196 were PLWH. PLWH were more likely to report previous screening for diabetes, elevated cholesterol and to have had their weight checked than HIV-uninfected participants. PLWH were also more likely to have received counselling on salt intake, smoking cessation, weight control, physical activity and alcohol consumption than their HIV-uninfected counterparts. PLWH were almost two times more likely to have been previously screened for CVDRFs than those without HIV, indicating a need for universal scale-up of integrated management and prevention of CVDs in the HIV-uninfected population.
“It's about our health and our future”: Ensuring sexual and reproductive health support in northern Mozambique
UNFPA Press Release: Reliefweb, January 2024
Since 2017, Niassa and the neighbouring provinces of Cabo Delgado and Nampula in Mozambique have faced mounting attacks by non-state armed groups, with millions of people fleeing their homes in search of safety. This has come alongside repeated climate shocks – from flooding to drought and powerful cyclones – and ensuing public health emergencies such as malaria and cholera outbreaks. The ongoing instability and decimated health facilities have rendered pregnancy and childbirth increasingly life threatening, while conflict and displacement are also putting women and girls at greater risk of gender-based violence and trafficking. UNFPA is distributing contraceptives and raising awareness through mobile teams and clinics across northern Mozambique. In Niassa, health providers from all 16 districts have received training on long-term family planning methods, such as the Pill, implants and intrauterine devices. Through the Lichinga centre, community leaders and volunteers have also spoken to around 2,500 adolescents and young people from the region, discussing cultural barriers to sexual health and the stigma surrounding HIV and AIDS. A collaboration with Rádio Moçambique and Radio Comunitária de Cuamba also produced over 360 broadcasts that discuss sexual and reproductive health services and gender-based violence. Presented in local languages such as Ciyao and Cinyanja and Emakhuwa, the outreach efforts reached around 1.6 million people in Niassa province alone.
8. Human Resources
How Functional Reviews in the Health Sector Exacerbated Occupational Stress and Burnout Among Clinical Officers at Public Hospitals in Malawi
Chinguwo P: Clinical Sociology Review 18(2), 1-37, 2023
The authors present how the implementation of some functional reviews in the health sector exacerbated occupational stress (OS) and burnout among clinical officers at public hospitals in Malawi through a qualitative case study at four district hospitals and one central hospital, all state-owned. The functional reviews are found to have aggravated occupational stress and burnout among clinical officers at public hospitals, and perpetuated interprofessional conflicts between clinical officers and medical doctors. The authors recommend that a psychosocial risk assessment should be conducted to avoid or minimise the risks of occupational stress and burnout among clinical officers posed by the implementation of functional reviews in the health sector.
Implementation framework for income generating activities identified by community health volunteers (CHVs): a strategy to reduce attrition rate in Kilifi County, Kenya
Riang’a R, Nyanja N, Lusambili A, et al: BMC Health Services Research 24:132, 1-17, 2024
This study sought to identify strategies for implementing Income-Generating Activities (IGAs) for Community Health Volunteers (CHVs) in Kilifi County in Kenya to improve their livelihoods, increase motivation, and reduce attrition. Focus group discussions were carried out with CHVs and in-depth interviews among local stakeholder representatives and Ministry of Health officials. A need for stable income was identified as the driving factor for CHVs seeking IGAs, as their health volunteer work does not provide remuneration. Individual savings through table-banking, seeking funding support through loans from government funding agencies, and grants from corporate organizations, politicians, and other donors were proposed as viable options for raising capital for IGAs. Empowering CHVs with entrepreneurial and leadership skills, and connecting them to support agencies were proposed to support implementation and the sustainability of IGAs. Group-owned and managed IGAs were preferred over individual IGAs. The authors propose that agencies seeking to support CHVs’ livelihoods should engage with and be guided by the input from CHVs and local stakeholders.
9. Public-Private Mix
Malaria vaccine shortfall, heavy cost of Africa’s child deaths all thanks to global complacency
Kafuko Z: Daily Maverick, South Africa, 2024
The RTS,S/AS01 malaria vaccine produced by GSK was recommended by the World Health Organization in 2021. In October 2023, WHO recommended the second malaria vaccine, R21/Matrix-M, developed by Oxford’s Jenner Institute and manufactured by the Serum Institute of India. Both the RTS,S and R21 vaccines have been shown to be effective and safe. Yet for months it was unclear how many doses of R21 would be ordered and delivered; and only recently just 10 million were reported as ordered and delivered at a time when the number of doses available stood at 25 million. The solution to this shortfall is argued to require African action, to prioritise these lifesaving vaccines and push Unicef and GAVI to procure supply. Respective countries aiming to roll out the vaccines also need to authorise R21 through their regulatory authorities, a process that can take about 6 months. So far, only Nigeria, Ghana and Burkina Faso have done so. Applications to GAVI go through the ministries of health and finance and can be submitted only once every three months. The authors propose allowing a rolling window for applications to be submitted as soon as they are ready to save time, but also see the situation as .a wake-up call to Africa to build its own capacity for pioneering research and development of countermeasures against endemic diseases.
10. Resource allocation and health financing
Costing of HIV services, Uganda and United Republic of Tanzania
McBain R, Jordan M, Kapologwe N, et al: Bulletin of the World Health Organisation 101(10), 626–636, 2023
This study evaluated resource allocation and costs associated with delivery of HIV services in Uganda and the United Republic of Tanzania. Time-driven activity-based costing was used to determine the resources consumed and costs of providing five HIV services: antiretroviral therapy (ART); HIV testing and counseling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. In Uganda, service delivery costs ranged from US$8.18 per visit for HIV testing and counseling to US$43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$3.67 per visit for HIV testing and counseling to US$28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. The authors state that establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden.
Health expenditure: how much is spent on health and care worker remuneration? An analysis of 33 low- and middle-income African countries
Toure H, Garcia M, Izquierdo J, et al: Human Resources for Health 21:96, 1-14, 2023
This paper assessed the amount spent on health and care workforce remuneration in the African countries, its importance as a proportion of country expenditure on health, and government involvement as a funding source. Calculations are based on country-produced disaggregated health accounts data from 33 low- and middle-income African countries, disaggregated wherever possible by income and subregional economic group. Per capita expenditure health and care workforce remuneration averaged US$38, or 29% of country health expenditure, mainly coming from domestic public sources. The contributions from domestic private sources and external aid both measured around one-fifth each—23% and 17%, respectively. Spending on health and care workforce remuneration was uneven across the 33 countries, spanning from US$3 per capita in Burundi to US$295 in South Africa. West African countries, particularly members of the West African Economic and Monetary Union, were lower spenders than countries in the Southern African Development Community, both in terms of the share of country health expenditure and in terms of government efforts/participation. By income group, health and care workforce remuneration accounted for a quarter of country health expenditure in low-income countries, compared to a third in middle-income countries. An average 55% of government health expenditure is spent on health and care workforce remuneration, across all countries. The results clearly show that the remuneration of the health and care workforce is an important part of government health spending, with half of government health spending on average devoted to it. Comparing health and care workforce expenditure components allows for identifying stable and volatile sources, and their effects on health and care workforce investments over time.
11. Equity and HIV/AIDS
Socioeconomic inequalities in uptake of HIV testing during antenatal care: evidence from Sub-Saharan Africa
Dadzie L, Gebremedhin A, Salihu T, et al: International Journal for Equity in Health 23:4; 1-12, 2024
This paper assessed the socioeconomic inequalities in HIV testing during antenatal care in sub-Saharan Africa, using Demographic and Health Surveys data spanning from 2015 to 2022. Overall, 73.9% of women in sub-Saharan Africa tested for HIV during antenatal care. Being among the richer and richest wealth quintiles increased the odds of HIV testing during antenatal care. The authors emphasize the necessity for sub-Saharan Africa public health programs to think about concentrating their limited resources on focused initiatives to reach poorer women and should provide women with comprehensive HIV knowledge and decrease the number of lost opportunities for women to get tested for HIV.
12. Governance and participation in health
I still don’t know how someone gets pregnant: determinants of poor reproductive health among young female refugees in South Africa
Crankshaw T, Freedman J, Mutambara V, et al: BMC Women's Health 24:10, 1-11, 2024
This study explored the reproductive health and rights’ needs and challenges amongst young refugee women in South Africa. It was carried out in eThekwini in South Africa in 2021 and 2022 through 35 semi-structured, in person interviews with young refugee women 18 and 24 years old living in the city centre. Eleven of these women had experienced one or more pregnancies while living in South Africa and all of these women had experienced at least one unintended pregnancy. Participants had poor reproductive health knowledge of the role of menstruation and how conception occurs. Economic, social, and legal insecurities intersected in complex ways as determinants of poor reproductive health outcomes. Despite availability, contraceptive use was poor and linked to lack of knowledge, myths and unwanted side effects. There were negative economic and social impacts for young refugee women experiencing early pregnancies irrespective of whether they were intended or not. Desire for confidentiality shaped lack of access to legal termination of pregnancy in the public health sector. Participants experienced specific vulnerabilities resulting from their position as refugees despite length of stay in South Africa. It is important to better understand these specificities in the design of programmes and policies aimed at ensuring positive health outcomes for these young women.
Misinformation, knowledge and COVID-19 vaccine acceptance: a cross-sectional study among health care workers and the general population in Kampala, Uganda
Atuheirwe M, Otim R, Male K, et al: BMC Public Health 24:203, 1-10, 2024
This study assessed people’s knowledge of the COVID-19 vaccine and the effect of misinformation on vaccine uptake among healthcare workers (HCWs) and the general population in Uganda. This was a cross-sectional quantitative study conducted in 2022, including 311 HCWs and 253 from the general population. The study revealed that the proportion of vaccinated HCWs (77.4%) was significantly higher than that of the vaccinated general population (64.4%). The research revealed that a large proportion of the participants (89.7%) encountered rumours regarding unverified adverse effects of the COVID-19 vaccine that significantly contributed to vaccine hesitancy,. The study showed a negative impact of misinformation on vaccine uptake and could be the most significant contributor to vaccine hesitancy in future vaccine programs.
13. Monitoring equity and research policy
Challenges for research uptake for health policymaking and practice in low- and middle-income countries: a scoping review
Semahegn A, Manyazewal T, Hanlon C, et al: Health Research Policy and Systems 21:131, 1-16, 2023
This paper compiles current evidence on barriers to uptake of research in health policy and practice in low- and middle-income countries using scoping review. A total of 4291 publications were retrieved in the initial search, of which 142 were included as meeting the eligibility criteria. Overall, research uptake for policy-making and practice in low- and middle-income countries was very low. The challenges to research uptake were related to lack of understanding of the local contexts, low political priority, poor stakeholder engagement and partnership, resource and capacity constraints, low system response for accountability and lack of communication and dissemination platforms. Important barriers to research uptake were identified, particularly limited contextual understanding and low participation of key stakeholders and ownership. The authors suggest improved understanding of the local research and policy context and participatory evidence production and dissemination to promote research uptake for policy and practice. Institutions that bridge the chasm between knowledge formation, evidence synthesis and translation are noted to potentially play critical role in this translation process.
Reflections on the process, challenges, and lessons learned conducting remote qualitative research on Violence Against Women during COVID-19 pandemic lockdown in South Africa
Mahlangu P, Machisa M, Jewkes R, et al: BMC Public Health 24:33, 1-9, 2024
The COVID-19 pandemic lockdown and restrictions on movement presented an opportunity to conduct Violence Against Women (VAW) research using remote methods. The authors discuss how they adapted methods, reflect on lessons learned, and make recommendations highlighting key considerations when conducting remote research on a sensitive topic of VAW. An exploratory qualitative study was designed using remote methods with 18 men and 19 women, aged 18 years and older, who lived with their partner or spouse during lockdown in South Africa. Data presented in this paper draws from researchers’ reflections drawn from debriefing sessions during the research process, and from participants’ interview transcripts. Remote recruitment of participants took longer than anticipated, and the authors had to re-advertise the study. The authors could not ensure safety and privacy during interviews. Regardless of all the safety and privacy measures the authors put in place during the research process, some participants had an adult person present in the room during interviews, and the researchers had no control over interruptions. Rapport was difficult to establish without an in-person connection, which limited disclosure about violence experience and perpetration. Given the methodological and ethical challenges which limited disclosure of violence against women remotely, the authors conclude that telephone interviews used in this study impacted on the quality of study data. Therefore, the authors do not recommend violence against women research to be conducted remotely, unless it is essential and participants are already known to the interviewer and trust has been established.
14. Useful Resources
Brief and video from EQUINET Webinar 3:Climate justice and primary health care systems
EQUINET, REACH Trust, IWGHSS, TARSC: EQUINET, Harare, November 2023
This brief reports on the issues raised in the third webinar in the EQUINET series on climate justice and health, with this webinar on health systems and climate. It was convened by the Research for Equity and Community Health (REACH) Trust, and the International Working Group for Health Systems Strengthening (IWGHSS). This brief summarises key points raised by speakers and participants on how climate features are impacting on PHC-oriented health systems; the actions that need to be taken to address these issues at local, national and regional level and in international/ global level processes and forums from a regional lens; issues raised to be further discussed in the other thematic webinars. The brief is shared to draw further comment and input on the issue. The video of the full webinar is also available on the EQUINET website.
Brief and video from EQUINET Webinar 4: Climate Justice and Trade Systems
EQUINET, SEATINI, TARSC: December 2023, EQUINET, Harare
In 2023 – 24 EQUINET is organising a series of online dialogues to share knowledge and perspectives from community/local, national and international level on the impact of climate trends, the intersect with the other drivers/ determinants of inequity, the implications for policy and action that links climate to health equity and vice versa, and the . proposals for policy, practice, research, and action. This brief reports on the issues raised in the fourth webinar in the series on climate justice and trade systems, convened by SEATINI-Southern Africa in the EQUINET steering committee. This brief summarises key points raised by speakers and participants on how climate features are impacting on trade and health systems; the actions that need to be taken to address these issues at local, national and regional level and in international/ global level processes and forums from a regional lens; and issues raised to be further discussed in the other thematic webinars. The brief is shared to draw further comment and input on the issue.The video of the full webinar is available on the EQUINET website.
15. Jobs and Announcements
50th Anniversary Celebration of ECSA-HC: A Milestone of Regional Health and Cooperation
ECSA Health Community: Arusha, 2024
As we step into 2024, the East Central and Southern Africa Health Community (ECSA-HC) is celebrating its 50th anniversary. This milestone not only symbolizes a half-century of collaboration with our core member states – Kenya, Lesotho, Eswatini, Malawi, Mauritius, the United Republic of Tanzania, Uganda, Zambia, and Zimbabwe – but also reflects our expansive efforts in health advocacy and service beyond these borders. Over the years, ECSA-HC’s endeavors have reached various other African nations, contributing significantly to the advancement of health care standards and services across a wider region. ECSA HC will be sharing details of the anniversary events and activities on the website, in a year of reflection, celebration, and renewed commitment to advancing health care in our region.
A call for proposals for community actions that promote social justice and solidarity
Deadline for applications: 3 April 2023
ACT Ubumbano invites proposals from community and activist organisations, and organisations of faith, for support for social justice action. These actions may be responses to the impact of environmental, gender and economic injustice on communities, or they may be campaigns to change particular situations that communities are struggling with. The action must be implemented and completed by 30 November 2024. Proposals may be for a maximum of ZAR30,000 (South African Rands). Amounts allocated are likely to be less than this to reach as many applicants as possible.
SOLVE Open Call For Solutions
Submissions open until April 18
Solve’s Global Challenges seek exceptional innovators who are using technology to solve today’s most pressing problems. Those selected become a Solver team and join this nine-month support program, receive access to funding in grants and investments, join a powerful network of impact-minded leaders, receive coaching and strategic advice from experts, and gain exposure in the media, among many other benefits. Since 2016, over 20,000 solutions headquartered in over 180 countries have been submitted in response to Solve’s Global Challenges. The resource supports a diverse group of 299 Solver teams, who have collectively impacted over 190 million lives worldwide. These teams are 62% women-led and headquartered in 59 different countries.
World Congress of Epidemiology 2024
24-27 September 2024, Cape Town, South Africa
The theme of World Congress of Epidemiology 2024 is “Epidemiology and complexity: challenges and responses” which will engage the depth and breadth of methods and practice in contemporary epidemiology. The meeting will feature top-calibre invited speakers presenting plenary lectures, workshops and interactive sessions. The abstract-driven programme will include oral and poster presentations including theory and application from every sub-discipline of epidemiology. With more than 2000 delegates expected, WCE2024 promises to be a unique opportunity to share experiences and expertise – the opportunities to learn, grow and network within the field will be phenomenal. This is the first time the congress will be hosted on the African continent.
EQUINET News
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