Understanding the interplay of occupational, public health, and climate-related risks for informal workers: A new framework with findings from Zimbabwe and India.

Globally, there are 2 billion 'informal' workers, who lack access to social protection while facing profound health risks and socioeconomic exclusions. The informal economy has generated most jobs in Low and Middle-Income Countries (LMICs), but few studies have explored informal workers' complex health vulnerabilities, including in the face of climate change. This paper will discuss recent action-research in Indore (India), Harare, and Masvingo (Zimbabwe) with informal workers like vendors, waste-pickers, and urban farmers. We conducted qualitative interviews (N = 110 in India), focus group discussions (N = 207 in Zimbabwe), and a quantitative survey (N = 418 in Zimbabwe). Many informal workers live in informal settlements ('slums'), and we highlight the interrelated health risks at their homes and workplaces. We explore how climate-related threats-including heatwaves, drought, and floods-negatively affect informal workers' health and livelihoods. These challenges often have gender-inequitable impacts. We also analyse workers' individual and collective responses. We propose a comprehensive framework to reveal the drivers of health in the informal economy, and we complement this holistic approach with a new research agenda. Our framework highlights the socioeconomic, environmental, and political determinants of informal workers' health. We argue that informal workers may face difficult trade-offs, due to competing priorities in the face of climate change and other risks. Future interventions will need to recognise informal workers' array of risks and co-develop multifaceted solutions, thereby helping to avoid such impossible choices. We recommend holistic initiatives to foster health and climate resilience, as well as participatory action-research partnerships and qualitative, intersectional data-collection with informal workers.

Challenges in international health financing and implications for the new pandemic fund.

BACKGROUND: The failures of the international COVID-19 response highlighted key gaps in pandemic preparedness and response (PPR). The G20 and WHO have called for additional funding of $10.5 billion per year to adequately strengthen the global PPR architecture. In response to these calls, in 2022 the World Bank announced the launch of a new Financial Intermediary Fund (The Pandemic Fund) to catalyse this additional funding. However, there is considerable unclarity regarding the governance makeup and financial modalities of the Pandemic Fund, and divergence of opinion about whether the Fund has been successfully designed to respond to key challenges in global health financing. METHODS/RESULTS: The article outlines eight challenges associated with global health financing instruments and development aid for health within the global health literature. These include misaligned aid allocation; accountability; multistakeholder representation and participation; country ownership; donor coherency and fragmentation; transparency; power dynamics, and; anti-corruption. Using available information about the Pandemic Fund, the article positions the Pandemic Fund against these challenges to determine in what ways the financing instrument recognizes, addresses, partially addresses, or ignores them. The assessment argues that although the Pandemic Fund has adopted a few measures to recognise and address some of the challenges, overall, the Pandemic Fund has unclear policies in response to most of the challenges while leaving many unaddressed. CONCLUSION: It remains unclear how the Pandemic Fund is explicitly addressing challenges widely recognized in the global health financing literature. Moreover, there is evidence that the Pandemic Fund might be exacerbating these global financing challenges, thus raising questions about its potential efficacy, suitability, and chances of success. In response, this article offers four sets of policy recommendations for how the Pandemic Fund and the PPR financing architecture might respond more effectively to the identified challenges.

Recovering lost tax to meet the health financing gap for universal public sector health systems in East and Southern Africa.

INTRODUCTION: Universal healthcare services funded through taxation and free at point-of-access are the most equitable ways of funding healthcare rights. This paper examines key public sector health financing measures in 17 East and Southern African (ESA) countries, estimates the funding gap for basic and comprehensive services and relates this to sources of lost tax revenue. METHODS: Health financing and tax data for 2018 (the most recent year available) were extracted from international databases for each ESA country, and analysed collectively for the region, comparing against intergovernmental estimates of optimal funding and tax capacity. Despite limitations noted, the scale of the health financing gap and tax losses informed policy recommendations. RESULTS: The annual average per capita financing gap ranged from $28 to $84 for basic to comprehensive services, respectively, applying estimates of funding needs. Many innovative financing measures being explored do not meet this scale of deficit. Annual ESA per capita tax losses were estimated as: US$34.20 from shortfalls in domestic tax capacity and US$13.80 from illicit financial flows largely due to commercial practices. A proposed 25% minimum effective tax rate on multinationals in a fairer global tax system would yield an additional annual collection US$26.20 in the region. CONCLUSIONS: Addressing a total annual tax loss of US$34 billion from these three sources alone would almost completely finance the region's US$36 billion financing gap for a comprehensive public sector health system. The COVID-19 pandemic's exposure of the need for investment in public sector services suggests an opportunity for an alliance between health and finance sectors to ensure progressive taxation as the core funding for an equitable, universal health system. This implies costing the health funding demands and gap in ESA countries; strengthening domestic tax capacity, expanding wealth taxes, curbing illicit outflows and providing health evidence to ongoing African diplomacy for a fairer global tax system.

Equity dimensions in initiatives promoting urban health and wellbeing in east and southern Africa.

Urbanisation in east and southern Africa (ESA) has brought opportunity and wealth together with multiple dimensions of deprivation. Less well documented in published literature on the ESA region are features of urban practice that promote health equity. This work thus aimed to explore features of urban initiatives aimed at improving health and wellbeing in ESA countries and their contribution to different dimensions of health equity. A thematic analysis was implemented on evidence gathered from 52 documents from online searches and 10 case studies from Harare, Kampala, Lusaka, and Nairobi. Most of the initiatives found focused on social determinants affecting low income communities, particularly water, sanitation, waste management, food security and working and environmental conditions, arising from longstanding urban inequalities and from recent climate and economic challenges. The interventions contributed to changes in social and material conditions and system outcomes. Fewer reported on health status, nutrition, and distributional outcomes. The interventions reported facing contextual, socio-political, institutional, and resource challenges. Various enablers contributed to positive outcomes and helped to address challenges. They included investments in leadership and collective organisation; bringing multiple forms of evidence to planning, including from participatory assessment; building co-design and collaboration across multiple sectors, actors and disciplines; and having credible brokers and processes to catalyse and sustain change. Various forms of mapping and participatory assessment exposed often undocumented shortfalls in conditions affecting health, raising attention to related rights and duties to promote recognitional equity. Investment in social participation, organisation and capacities across the initiatives showed participatory equity to be a consistent feature of promising practice, with both participatory and recognitional equity acting as levers for other dimensions of equity. There was less evidence of distributional, structural and intergenerational equity. However, a focus on low income communities, links made between social, economic and ecological benefit, and investment in women and young people and in urban biodiversity indicated a potential for gains in these areas. The paper discusses learning on local process and design features to strengthen to promote these different dimensions of equity, and issues to address beyond the local level to support such equity-oriented urban initiatives.

Asserting public health interest in acting on commercial determinants of health in sub-Saharan Africa: insights from a discourse analysis.

The actors influencing the commercial determinants of health (CDOH) in sub-Saharan Africa (SSA) have different interests and lenses around the costs and benefits of market influences in health. We analysed the views and priorities on CDOH in the discourse of global and regional agencies, SSA governments, private investors and companies, civil society and academia through a desk review of online publications post-2010, validated by purposively selected key informant interviews.The most polarised views were between civil society and academia on one hand, focused more on harms, and private business/investors on the other, almost exclusively focused on benefits. Others had mixed messaging, encouraging partnerships with commercial actors for health benefits and also voicing cautions over negative health impacts. Views also differed between transnational and domestic business and investors.Three areas of discourse stood out, demonstrating also tensions between commercial and public health objectives. These were the role of human rights as fundamental for or obstacle to engaging commercial practice in health; the development paradigm and role of a neoliberal political economy generating harms or opportunities for health; and the implications of commercial activity in health services. COVID-19 has amplified debate, generating demand for public sectors to incentivise commercial activity to 'modernise' and digitise health services and meet funding gaps and generating new thinking and engagement on domestic production of key health inputs.Power plays a critical role in CDOH. Commercial actors in SSA increase their influence through discursive and agential forms of power and take advantage of the structural power gained from a dominant view of free markets and for-profit commerce as essential for well-being. As a counterfactual, we found and present options for using these same three forms of narrative, agential and structural power to proactively advance public health objectives and leadership on CDOH in SSA.

Which UHC? Features for Equity and Universalism Comment on "Universal Health Coverage for Non-Communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare".

Equity and universality are implicit in universal health coverage (UHC), although ambiguity has led to differing interpretations and policy emphases that limit their achievement. Diverse country experiences indicate a policy focus on differences in service availability and costs of care, and neoliberal policies that have focused UHC on segmented financing and disease-focused benefit packages, ignoring evidence on financing, service, rights-based and social features that enable equity, continuity of care and improved population health. Public policies that do not confront these neoliberal pressures limit equity-promoting features in UHC. In raising the impetus for UHC and widening public awareness of the need for public health systems, coronavirus disease 2019 (COVID-19) presents an opportunity for challenging market driven approaches to UHC, but also a need to make clear the features that are essential for ensuring equity in the progression towards universal health systems.

Rethinking the Paradigm and Practice of Occupational Health in a World Without Decent Work: A Perspective From East and Southern Africa.

The global political economy is generating new forms and growing shares of informal, insecure, and precarious labor, adding to histories of insecure work and an externalization of social costs. The COVID-19 pandemic has highlighted the consequences of ignoring such signals in terms of the increased risk and vulnerability of insecure labor. This paper explores how such trends are generating intersecting adverse health outcomes for workers, communities, and environments and the implications for breaking siloes and building links between the paradigms, science, practice, and tools for occupational health, public health, and eco-health. Applying the principle of controlling hazards at the source is argued in this context to call for an understanding of the upstream production and socio-political factors that are jointly affecting the nature of work and employment and their impact on the health of workers, the public, and the planet.

Engaging globally with how to achieve healthy societies: insights from India, Latin America and East and Southern Africa.

The way healthy societies are conceptualised shapes efforts to achieve them. This paper explores the features and drivers of frameworks for healthy societies that had wide or sustained policy influence post-1978 at global level and as purposively selected southern regions, in India, Latin America and East and Southern Africa. A thematic analysis of 150 online documents identified paradigms and themes. The findings were discussed with expertise from the regions covered to review and validate the findings.Globally, comprehensive primary healthcare, whole-of-government and rights-based approaches have focused on social determinants and social agency to improve health as a basis for development. Biomedical, selective and disease-focused technology-driven approaches have, however, generally dominated, positioning health improvements as a result of macroeconomic growth. Traditional approaches in the three southern regions previously mentioned integrated reciprocity and harmony with nature. They were suppressed by biomedical, allopathic models during colonialism and by postcolonial neoliberal economic reforms promoting selective, biomedical interventions for highest-burden diseases, with weak investment in public health. In all three regions, holistic, sociocultural models and claims over natural resources re-emerged. In the 2000s, economic, ecological, pandemic crises and social inequality have intensified alliances and demand to address global, commercial processes undermining healthy societies, with widening differences between 'planetary health', integrating ecosystems and collective interests, and the coercive controls and protectionism in technology-driven and biosecurity-driven approaches.The trajectories point to a need for ideas and practice on healthy societies to tackle systemic determinants of inequities within and across countries, including to reclaim suppressed cultures; to build transdisciplinary, reflexive and participatory forms of knowledge that are embedded in and learn from action; and to invest in a more equitable circulation of ideas between regions in framing global ideas. Today's threats raise a critical moment of choice on which ideas dominate, not only for health but also for survival.

Beyond command and control: A rapid review of meaningful community-engaged responses to COVID-19.

Responses to COVID-19 have included top-down, command-and-control measures, laissez-faire approaches, and bottom-up, community-driven solidarity and support, reflecting long-standing contradictions around how people and populations are imagined in public health-as a 'problem' to be managed, as 'free agents' who make their own choices, or as a potential 'solution' to be engaged and empowered for comprehensive public health. In this rapid review, we examine community-engaged responses that move beyond risk communication and instead meaningfully integrate communities into decision-making and multi-sectoral action on various dimensions of the response to COVID-19. Based on a rapid, global review of 42 case studies of diverse forms of substantive community engagement in response to COVID-19, this paper identifies promising models of effective community-engaged responses and highlights the factors enabling or disabling these responses. The paper reflects on the ways in which these community-engaged responses contribute to comprehensive approaches and address social determinants and rights, within dynamics of relational power and inequality, and how they are sometimes able to take advantage of the ruptures and uncertainties of a new pandemic to refashion some of these dynamics.

COVID-19 in East and Southern Africa: Rebuilding Differently and Better Must Start Now.

By June 2020, the cumulative cases and deaths related to COVID-19 in 16 East and Southern African (ESA) countries were still rising, with an average case fatality rate of 1.46%.[1] From its initial presence in cities and regional transport hubs, cases are spreading, including to rural areas, among health workers and as migrants cross borders to return home.[2].

Rebuilding people-centred maternal health services in post-Ebola Liberia through participatory action research.

During the March 2014-January 2016 Ebola crisis in Liberia, Redemption Hospital lost 12 staff and became a holding facility for suspected cases, prompting violent hostility from the surrounding New Kru Town community, in the capital city Monrovia. Inpatient services were closed for 6 months, leaving the population without maternity care. In January 2015, Redemption reopened, but utilization was low, especially for deliveries. A key barrier was community trust in health workers which worsened during the epidemic. The New Kru Town council, Redemption Hospital, the International Rescue Committee, and Training and Research Support Centre initiated participatory action research (PAR) in July 2015 to build communication between stakeholder groups, and to identify impacts of the epidemic and shared actions to improve the system. The PAR involved pregnant women, community-based trained traditional midwives (TTMs) and traditional birth attendants (TBAs), and community leaders, as well as health workers. Qualitative data and a pre-post survey of PAR participants and community members assessed changes in relationships and maternal health services. The results indicated that Ebola worsened community-hospital relations and pre-existing weaknesses in services, but also provided an opportunity to address these when rebuilding the system through shared action. Findings suggest that PAR generated evidence and improved communication and community and health worker interaction.

Strengthening Integrated Care Through Population-Focused Primary Care Services: International Experiences Outside the United States.

Many high- and middle-income countries (HMICs) are experiencing a burden of comorbidity and chronic diseases. Together with increasing patient expectations, this burden is raising demand for population health-oriented innovation in health care. Using desk review and country case studies, we examine strategies applied in HMICs outside the United States to address these challenges, with a focus on and use of a new framework for analyzing primary care (PC). The article outlines how a population health approach has been supported by focusing assessment on and clustering services around social groups and multimorbidity, with support for community roles. It presents ways in which early first contact and continuity of PC, PC coordination of referral, multidisciplinary team approaches, investment in PC competencies, and specific payment and incentive models have all supported comprehensive approaches. These experiences locate PC as a site of innovation, where information technology and peer-to-peer learning networks support learning from practice.

Raising the profile of participatory action research at the 2010 Global Symposium on Health Systems Research.

By involving citizens and health workers in producing evidence and learning, participatory action research has potential to organize community evidence, stimulate action, and challenge the marginalization that undermines achievement of universal health coverage. This paper summarizes and analyzes results of two sessions on this research model convened by the authors at the First Global Symposium on Health Systems Research in Montreux Switzerland, November 16-19, 2010. In so doing, it reviews case studies and experiences discussed, particularly their contribution to universal health coverage in different settings. The paper also reflects on challenges faced by participatory action research, and outlines recommendations from the two sessions, including creation of a learning network for participatory action research.

Review article: Globalisation and women's health in Sub-Saharan Africa: would paying attention to women's occupational roles improve nutritional outcomes?

AIM: This paper explores, through a review of literature, the link between globalisation and nutritional outcomes in Sub-Saharan Africa, focusing on the pathways of women's occupational roles on the food produced, consumed, and secured for households. METHODS: Following a framework linking globalisation and health, we drew evidence from peer reviewed, cross-national or large scale studies, official sources, reviews, online scientific databases, and case studies, published between 1990 and 2009. RESULTS: Publications cite improved technology, information, know how, normative commitments to and resources for human development, returns from access to investment in agriculture for low-income women producers, and urban employment opportunities reducing social discrimination and improving opportunities for household food security, particularly if access to these benefits is reinforced by national policy. However, many more publications cite negative consequences, including in falling national and local food self-sufficiency, livelihood and nutritional losses, widening inequalities, and in declining or insecure access to production inputs, markets, incomes, local foods, and healthcare. These effects are documented to increase time and resource burdens for women, with negative consequences for their own and their families' health and nutrition. CONCLUSIONS: The evidence suggests that globalisation-related economic and trade policies have, on balance, been associated with shifts in women's occupational roles and resources that contribute to documented poor nutritional outcomes in Africa. These trends call for public policies that address such positive and negative effects for women and for improved monitoring of such gender and socio-economic trends, especially at the household and community level, in the tracking of the Millennium Development Goals.

Can the Millennium Development Goals database be used to measure the effects of globalisation on women's health in Sub-Saharan Africa? A critical analysis.

BACKGROUND: Africa has had poor returns from integration with world markets in globalisation, has experienced worsening poverty and malnutrition and has high burdens of HIV and communicable disease, with particular burdens on women. It is therefore essential to describe the impact of globalisation on women's health. Indicators such as the Millennium Development Goals (MDGs) are presented as having a major role in measuring this impact, but an assessment of the adequacy of aggregate national indicators used in monitoring the MDGs for this purpose is lacking. METHODS: The Millennium Development Goals' panel database 2000 to 2006 was used to investigate the association between globalisation and women's health in Sub-Saharan Africa based on various determinants of heath. Out of the 148 countries classified as developing countries, 48 were in Sub-Saharan Africa. RESULTS: Results suggest that developing countries are becoming more integrated with world markets through some lowering of trade barriers. At the same time, women's occupational roles are changing, which could affect their health status. However, it is difficult to measure the impact of globalisation on women's health from the MDG database. First, data on trade liberalization is aggregated at the regional level and does not hold any information on individual countries. Second, too few indicators in the MDG database are disaggregated by sex, making it difficult to separate the effects on women from those on men. CONCLUSIONS: The MDG database is not adequate to assess the effects of globalisation on women's health in Sub-Saharan Africa. We recommend that researchers aim to address this research question to find other data sources or turn to case studies. We hope that results from this study will stimulate research on globalisation and health using reliable sources.

Household impacts of AIDS: using a life course approach to identify effective, poverty-reducing interventions for prevention, treatment and care.

A life course approach was used to assess household level impacts and inform interventions around HIV risk and AIDS vulnerability across seven major age-related stages of life. Our focus was sub-Saharan Africa. We provided a qualitative review of evidence from published literature, particularly multicountry reviews on impacts of AIDS, on determinants of risk and vulnerability, and reports of large surveys. Areas of potential stress from birth to old age in households affected by AIDS, and interventions for dealing with these specific stresses were identified. While specific interventions for HIV are important at different stages, achieving survival and development outcomes demands a wider set of health, social security and development interventions. One way to determine the priorities amongst these actions is to give weighting to interventions that address factors that have latent impacts later in life, which interrupt accumulating risk, or that change pathways to reduce the risk of both immediate and later stress. This qualitative review suggested that interventions, important for life cycle transitions in generalised epidemics where HIV risk and AIDS vulnerability is high, lie within and outside the health sector, and suggested examples of such interventions.