tag:theconversation.com,2011:/global/topics/health-systems-21855/articleshealth systems – The Conversation2023-11-14T14:12:25Ztag:theconversation.com,2011:article/2161892023-11-14T14:12:25Z2023-11-14T14:12:25ZHealth professionals need to collaborate. Changing how they’re taught helps build that skill<figure><img src="https://images.theconversation.com/files/557971/original/file-20231107-17-khqow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's crucial that medical professionals learn to collaborate.</span> <span class="attribution"><span class="source">Katleho Seisa</span></span></figcaption></figure><p>When health professionals collaborate rather than operating in silos, everyone benefits – patients, families and the health system at large. This is a fact supported by ample <a href="https://www.mdpi.com/2227-9032/7/4/117">research</a> <a href="https://www.sciencedirect.com/science/article/abs/pii/S1939865416301175">evidence</a>. The professionals reap the benefits, too: staff satisfaction and retention are <a href="https://www.sciencedirect.com/science/article/abs/pii/S1939865416301175">improved</a> through collaboration.</p>
<p>But in the real world, health professionals and departments often slip into <a href="https://strategica-conference.ro/wp-content/uploads/2022/04/68.pdf">silo mentalities</a>. And silos in healthcare, as US cardiologist Laurence Sparling <a href="https://www.weforum.org/agenda/2020/11/healthcare-silos-are-bad-for-us-heres-the-cure/">writes</a>, are bad for healthcare. The “cure”, Sparling argues, is integrated healthcare with “cross-silo dialogue” – collaborative healthcare.</p>
<p>But collaboration is a skill that has to be taught. People don’t automatically know how to work in teams. Instead, they have to develop the competencies to do so. Where better to start than in the professional training they receive?</p>
<p>We are lecturers in the <a href="https://www.uwc.ac.za/study/all-areas-of-study/units/interprofessional-education-unit/overview">Interprofessional Education Unit</a> at the University of the Western Cape in South Africa. For two years, we tracked the development of students doing the first-year interprofessional theoretical module called Primary Health Care. </p>
<p>As we explain in <a href="https://pubmed.ncbi.nlm.nih.gov/36308973/">a recent paper</a>, we tweaked the material dimension (the physical and virtual spaces in which learning and teaching occurs) to help students develop some of the <a href="https://www.ipecollaborative.org/2021-2023-core-competencies-revision">core competencies needed for interprofessional work</a>. These include communication with patients, families, community members and health team members; as well as teamwork competencies with all their complexities and demands. </p>
<p>There were immediate and marked improvements in students’ results. We also saw that students became better at giving each other constructive feedback and working together when needed. These are important skills to harness as they work towards becoming health professionals.</p>
<h2>Changing things up</h2>
<p>Information is available to modern students with the flick of a finger on the screen. This means the curriculum needs to be constantly evaluated to develop an appropriate learning environment.</p>
<p>One model of education <a href="https://pubmed.ncbi.nlm.nih.gov/30870148/">shows</a> that learning environments in the health professions are made up of two parts. There’s the psychosocial dimension, itself made up of three components: the personal, social, and organisational. </p>
<p>The material dimension is the second part and was the major focus of our changes. Starting in 2019, we introduced a few substantial changes to the way we taught and evaluated students. (Not knowing, of course, that in 2020 these sorts of adaptations would become necessary in a pandemic.)</p>
<p>Firstly, we converted the course’s traditional classroom test into an online test. Secondly, we introduced changes to the blog in which students had to post responses to a lecture. Students had previously reported that the topics were too rigid and that they therefore simply regurgitated what lecturers had presented.</p>
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Read more:
<a href="https://theconversation.com/health-professionals-work-in-teams-their-training-should-prepare-them-163586">Health professionals work in teams: their training should prepare them</a>
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<p>Another change was to an assignment on how social issues are addressed by organisations in nearby communities. Usually, students had to visit those communities. But many had in the past expressed concern about the costs of travelling to communities – most relied on public transport – and their safety. They also struggled with the logistics of coordinating with team members from various departments. </p>
<p>So we instead invited community members into the classroom to share experiences and stories of their communities. Students were, of course, allowed and encouraged to pose questions to these community members. Students interacted with community members to gain insights into the local indigenous knowledge systems, which represent the unique knowledge passed down through generations within a society. This strengthened their use of polite language and clear communication in important interactions, both important for interprofessional communication.</p>
<h2>Marked improvements</h2>
<p>These innovations brought about immediate improvements in students’ results. At the end of 2019, following the changes from an in-classroom to an online test, the grade point average improved from 49.94% to 81.54%. While a more modest improvement, the average score for the blog went up by 4.53 percentage points. And finally, in the community assignment, the average grade point improved by nearly 12 percentage points.</p>
<p>A number of factors can be credited for these improvements. For instance, the use of <a href="https://books.google.co.za/books?hl=en&lr=&id=gVr0dVVLfeIC&oi=fnd&pg=PT7&dq=storytelling+as+a+learning+tool&ots=6Ql5_Qqpth&sig=35Y9FhA6NlOj1DyeW_WLxXGWLOk#v=onepage&q=storytelling%20as%20a%20learning%20tool&f=false">storytelling</a>, as in the meetings with community members, has long been thought to aid learning. </p>
<p>We received positive feedback from students. One said:</p>
<blockquote>
<p>(This) is a very interesting module because you get to meet other students doing different courses and learn more about their courses, our lecturer made it fun and interesting too.</p>
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<p>Another commented:</p>
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<p>The course was interesting and it showed how the inter-sectoral collaboration helps society and the health of many patients.</p>
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<h2>Applying our lessons</h2>
<p>Our advice to others lecturing in this field includes these points:</p>
<ul>
<li><p>Help students to get comfortable with online environments. Incorporate technology into the first-year curriculum. </p></li>
<li><p>To enhance teamwork, give students the chance to critically and productively confront and reflect on their perspectives from early on in a health professions education programme. </p></li>
</ul>
<p>Health professional educators must recognise the emergence of a new, digital paradigm in higher education. A comprehensive and integrated approach to education, research and community engagement is required as the healthcare industry transitions to an interprofessional model, pushing us to dismantle barriers and promote teamwork. Continually evaluating programmes to stay ahead of technological advancements helps prepare them for success.</p><img src="https://counter.theconversation.com/content/216189/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gérard Charl Filies works for UWC. </span></em></p><p class="fine-print"><em><span>Luzaan Africa works for UWC</span></em></p>It’s all too common for health professionals and departments to slip into silo mentalities.Gérard Charl Filies, Senior Lecturer: Interprofessional Education Unit, University of the Western CapeLuzaan Africa, Lecturer in the Interprofessional Education Unit , University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2141932023-10-06T12:30:23Z2023-10-06T12:30:23ZHealth on the ballot as Argentina poised to elect ‘anarcho-capitalist’ bent on slashing social protections<figure><img src="https://images.theconversation.com/files/551487/original/file-20231002-25-wdcz31.jpg?ixlib=rb-1.1.0&rect=0%2C20%2C3384%2C2228&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The hand that wields the chain saw looks set to carry the crown.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/presidential-candidate-javier-milei-of-la-libertad-avanza-news-photo/1701087602?adppopup=true">Tomas Cuesta/Getty Images</a></span></figcaption></figure><p>The front-runner heading into <a href="https://www.as-coa.org/articles/poll-tracker-argentinas-2023-presidential-election">Argentina’s presidential vote on Oct. 22</a> is prone to wielding a chain saw – both physically and metaphorically.</p>
<p><a href="https://www.economist.com/the-americas/2023/09/07/meet-javier-milei-the-frontrunner-to-be-argentinas-next-president">Javier Milei</a>, a right-wing libertarian whose brash demagoguery has <a href="https://www.washingtonpost.com/world/2023/08/16/javier-milei-donald-trump-argentina/">drawn comparisons to Donald Trump</a> and <a href="https://worldcrunch.com/world-affairs/javier-milei-bolsonaro">Brazil’s former President Jair Bolsonaro</a>, likes to <a href="https://www.cnn.com/2023/10/01/americas/chainsaw-candidate-argentina-javier-milei-hnk-intl/index.html">brandish the power tool at campaign events</a> as a symbol of what he intends to do if elected: cut back on government.</p>
<p>Milei has promised to take his chain saw to the ministries of <a href="https://cnnespanol.cnn.com/2023/08/30/milei-ministerios-eliminar-por-que-de-que-se-encargan-orix-arg/">education, environment and women’s rights</a>, to name but a few, and to <a href="https://english.elpais.com/international/2023-08-18/far-right-candidate-javier-milei-launches-attack-on-argentinas-scientific-community.html">ax funding for scientific research</a>. The country’s central bank would also <a href="https://www.economist.com/by-invitation/2023/09/29/javier-milei-argues-that-argentinas-central-bank-should-not-exist">cease to exist</a>, if Milei fulfills his <a href="https://www.americasquarterly.org/article/mileis-path-to-dollarization-riddled-with-doubts/">pledge to “dollarize</a>” Argentina’s economy – that is, to scrap the country’s peso and replace it with the U.S. currency.</p>
<p>Milei promises a radical change to Argentina’s current trajectory. And his <a href="https://www.msn.com/en-us/news/world/far-right-candidate-javier-milei-launches-attack-on-argentinas-scientific-community/ar-AA1frQ9N">attacks on science and education</a> form part of a troubling <a href="https://www.dissentmagazine.org/article/is-anti-intellectualism-ever-good-for-democracy/">anti-intellectual, right-wing populism</a> that threatens liberal democracies worldwide.</p>
<p>However, as an <a href="https://www.macalester.edu/geography/facultystaff/ericcarter/">expert on the history of public health in Argentina</a>, I believe Milei could face stiff resistance if he tries to undo a long-standing consensus on the need for the government to provide universal health care and other social services.</p>
<h2>A shock to the political system</h2>
<p>A <a href="https://www.weforum.org/people/javier-gerardo-milei">former economics professor</a>, Milei is a relative political newcomer, having served just one term in the national congress. As with other right-wing populists, he casts himself as a political outsider.</p>
<p>When it comes to public spending, Milei <a href="https://english.elpais.com/international/2023-08-14/javier-milei-the-ultra-right-libertarian-and-anarcho-capitalist-who-represents-angry-argentina.html">styles himself as an “anarcho-capitalist</a>.” His plans include eliminating both the Ministry of Health and <a href="https://www.conicet.gov.ar/?lan=en">Conicet</a>, the agency that funds most academic research in Argentina, and folding them into a new <a href="https://www.pagina12.com.ar/582281-como-se-hace-el-ajuste-que-propone-milei">Ministry of Human Capital</a>, with a fraction of their current budget and personnel. </p>
<p>Milei’s rhetoric taps into a <a href="https://www.statista.com/statistics/1367447/public-opinion-president-alberto-fernandez-argetina/">deep well of discontent</a> among Argentinians with the current government led by Alberto Fernandez, a member of the <a href="https://www.oxfordreference.com/display/10.1093/oi/authority.20110803100318435">Peronist party</a>, which has held power for most of the past three decades. </p>
<p>Since assuming power in 2019, Fernandez has presided over <a href="https://www.reuters.com/markets/argentine-shoppers-face-daily-race-deals-inflation-soars-above-100-2023-09-13/">runaway inflation</a>, <a href="https://apnews.com/article/argentina-poverty-inflation-massa-milei-d515d077f61147b203149d9e2a6a164c#">rising poverty</a> and <a href="https://apnews.com/article/caribbean-buenos-aires-argentina-3aa151384f591b367865dd8faa418007">accusations of official corruption</a>.</p>
<p>The government’s handling of the COVID-19 pandemic saw an <a href="https://www.scielo.br/j/hcsm/a/YpyrzqkvHZBVBhVTYzjxsHc/?lang=en">initial boost in public support for Fernandez</a>. But by the middle of 2021, frustration with the government was starting to boil over – due in part to <a href="https://www.aljazeera.com/news/2021/2/20/argentina-health-chief-asked-to-resign-after-vip-vaccine-access#:%7E:text=The%20government%20has%20been%20rocked,getting%20vaccinations%20before%20their%20turn.">accusations of preferential priority</a> for COVID-19 vaccinations for Peronist officials and their friends and families. </p>
<p>Meanwhile, for Milei, the pandemic proved to be a <a href="https://foreignpolicy.com/2023/08/23/milei-argentina-presidential-election-politics-economy-villarruel/">catalyst for his rise to political fame</a>. Fanning the flames of public discontent, he appeared frequently on television and in social media to call out a “political caste” for imposing what he deemed unnecessary and economically damaging pandemic restrictions. His popularity <a href="https://elpais.com/argentina/2023-08-20/jovenes-hartos-de-los-politicos-y-sin-futuro-la-tierra-fertil-en-la-que-enraizo-milei.html">has since skyrocketed among young people in Argentina</a>, attuned to “anti-progressive” messaging online and exhausted by economic crisis and political corruption. Milei <a href="https://www.iprofesional.com/politica/389621-quienes-son-los-votantes-de-javier-milei">polls much better among men</a>, in part because many women are alarmed by <a href="https://www.nbcnews.com/news/latino/thousands-women-march-latin-america-abortion-rights-rcna118147">his intention to reverse the country’s 2021 legalization of abortion</a>.</p>
<h2>Health as a social right</h2>
<p>Evidently, Milei has tapped into a <a href="https://www.aljazeera.com/news/2023/8/15/argentina-primary-results-reflect-frustrations-desire-for-change-experts">thirst for sweeping political change</a>. </p>
<p>But there is reason to believe that his proposals to reduce the government’s role in the health sector would run into strong headwinds, given the longer-term pattern in Argentina and across the Latin America region.</p>
<p>Today, there is a <a href="https://www.statista.com/statistics/914586/general-opinion-healthcare-system-argentina/#statisticContainer">broad public acceptance</a> of a strong role for government in guaranteeing and protecting the right to health care, along with other “social rights” like education and gender equality.</p>
<p>As I explain in my new book, “<a href="https://uncpress.org/book/9781469674452/in-pursuit-of-health-equity/">In Pursuit of Health Equity</a>,” a hemispheric “social medicine” movement has, over the past century, played a key role in the construction of welfare state institutions in many Latin American countries. Led by progressive doctors, left-wing academics and health activists, social medicine – which sees health as being intrinsically tied to socio-economic factors – has sought to build robust health systems as part of a <a href="https://social.desa.un.org/sites/default/files/migrated/22/2021/04/Argentina_SP-Governance.pdf">strong social safety net</a>. Social medicine advocates see health as a right rather than a commodity.</p>
<p>In Argentina, <a href="https://www.aljazeera.com/news/2023/6/20/a-divided-legacy-marks-50-years-since-perons-return-to-argentina">Juan Domingo Perón</a>, the founder of the populist Peronist movement that Milei now hopes to dislodge from power, understood social medicine. To make Argentina’s population healthier and more productive, in the 1940s Perón expanded the government’s role in health care while advancing policies to <a href="http://www.columbia.edu/%7Elnp3/mydocs/state_and_revolution/Juan_Peron.htm">improve labor conditions, nutrition and housing</a></p>
<figure class="align-center ">
<img alt="A crowd of people stand around a large figure with 'PERON' written at the top." src="https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=478&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=478&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=478&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=601&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=601&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=601&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A huge 1948 rally in support of Juan Peron.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/buenos-aires-argentina-shown-is-the-tremendous-throng-news-photo/514876518?adppopup=true">Bettmann/Getty Images</a></span>
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</figure>
<p>Later, politically active academics took on prominent roles in health planning in the leftist governments of Brazil, Argentina and Bolivia in the late 1990s and early 2000s, <a href="https://uncpress.org/book/9781469674452/in-pursuit-of-health-equity/">opposing market-based reforms and the incursion</a> of a U.S. health care model that critics say puts profit over people.</p>
<h2>Healthy approval ratings</h2>
<p>Milei’s popularity suggests another swing in the pendulum of Latin American politics, which has tended to oscillate between state-centered and free-market-oriented models.</p>
<p>Clearly, a large contingent of Argentine voters agree with his basic contention that the current government has provoked an <a href="https://foreignpolicy.com/2022/08/15/argentina-imf-debt-massa-fernandez/">economic crisis</a> with <a href="https://brownpoliticalreview.org/2023/03/peso-problem-argentinas-economic-crisis/">overly generous spending</a>.</p>
<p>Yet his more extreme proposals are likely to meet resistance. </p>
<p>As Argentinian scholar <a href="https://scholar.google.es/citations?user=6lMifj8AAAAJ&hl=es">Maria Laura Cordero</a> and I found in <a href="https://doi.org/10.1016/j.healthplace.2022.102870">our survey during the pandemic</a>, Argentinians have mostly positive feelings toward public health institutions and the people who work in them, coupled with intense disdain for the political class. Around 67% of those we surveyed approved of the performance of the health sector, compared with 22% approval of political leadership during the pandemic.</p>
<p>Dismantling the public health sector in favor of market mechanisms like a <a href="https://infonews.com/javier-milei-la-libertad-avanza-elecciones-presidenciales-sistema-de-salud-educacion-recorte.html">voucher system to pay for health care</a> or <a href="https://enys.conicet.gov.ar/la-salud-publica-en-guardia/">putting public hospitals in competition with one another</a>, as Milei has suggested, may prove to be unpopular. </p>
<p>There is broad consensus about a fundamental right to health care in Argentina, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9973504/">as elsewhere in Latin America</a>. And the public, by and large, understands that government intervention is necessary to make health care accessible to the poor and to respond to public health emergencies like the recent pandemic.</p>
<p>Health workers, deeply invested in the precepts of social medicine, are sure to resist Milei’s attempts at health reform. In response to Milei’s plans, the president of the Argentine Public Health Association stated that “<a href="https://enys.conicet.gov.ar/la-salud-publica-en-guardia/">solidarity and the building of the common good are present in the DNA</a>” of health personnel in Argentina. The public is also likely to worry at the prospect of increased fees and the lack of coverage for basic health care needs.</p>
<h2>Research under attack</h2>
<p>Milei hasn’t won anything yet, nor is there a clear rightward tilt in Latin American politics – in the past two years, leftist presidential candidates have prevailed in countries as varied as Brazil, Chile, Colombia and Guatemala. But even if he fails to push through his radical agenda, the rhetoric of his campaign could serve to undermine confidence in Argentina’s health and science institutions.</p>
<p>Milei capitalizes on the politics of resentment, <a href="https://www.revistahcsm.coc.fiocruz.br/english/la-ciencia-en-argentina-y-sus-demonios">vilifying “unproductive” researchers who receive support from Conicet</a>, especially social science and humanities scholars.</p>
<p>Such attacks on government support for scientific research, health care and education are consistent with a global right-wing ideology, typified by the likes of Viktor Orban of Hungary or <a href="https://floridapolitics.com/archives/618813-gov-ron-desantis-vetoes-14-5-million-in-health-care-spending/">Ron DeSantis</a>, a Republican presidential candidate in the U.S.</p>
<p>Within the bottom-line mentality of neoliberalism – a political ideology that preaches free-market reforms over state involvement – such research is seldom viewed as profitable, nor does it tend to offer the possibility of new therapies or technologies produced by “hard” sciences and modern biomedicine. </p>
<p>But as the history of Latin American social medicine shows, social scientists can counter that, with time, their approach has helped build more just, free and healthy societies. And that legacy is now at stake as Argentinians head toward the polls.</p><img src="https://counter.theconversation.com/content/214193/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eric D. Carter does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Argentinians will vote in a new president on Oct. 22, 2023. But the front-runner’s plans to slash health funding might find resistance.Eric D. Carter, Professor of Geography and Global Health, Macalester CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2131412023-09-10T15:08:42Z2023-09-10T15:08:42ZHeat waves have a cost. Here’s why it’s important to quantify it<figure><img src="https://images.theconversation.com/files/547065/original/file-20230811-19-98uwkx.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C983%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The health and economic impacts of heat are often invisible and silent.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Among the extreme weather events we are now experiencing, including floods, severe storms and wildfires, heat waves are having the greatest impact on human health.</p>
<p>Indeed, the deadliest weather event in Canadian history was the heat dome (abnormally hot temperatures that lasted several days) that hit British Columbia in 2021, causing <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/heat_related_deaths_in_bc_knowledge_update.pdf">at least 600 deaths</a>. In addition to increased mortality, extreme heat is responsible for more emergency room visits, ambulance transports, hospitalizations, calls to health information lines, work-related accidents and greater mobilization of emergency response teams. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/541747/original/file-20230808-15-vi1j62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541747/original/file-20230808-15-vi1j62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541747/original/file-20230808-15-vi1j62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541747/original/file-20230808-15-vi1j62.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541747/original/file-20230808-15-vi1j62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=547&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541747/original/file-20230808-15-vi1j62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=547&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541747/original/file-20230808-15-vi1j62.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=547&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Temperature anomalies during the heat dome in British Columbia in 2021.</span>
<span class="attribution"><span class="source">(NASA)</span></span>
</figcaption>
</figure>
<p>Climate change will make heat waves <a href="https://doi.org/10.1126/science.1098704">longer and more intense</a>. Their future impact will be exacerbated by an <a href="https://doi.org/10.1016/j.amepre.2008.08.021">aging population and increased urbanization</a>. </p>
<p>In this context, it is vital to be able to assess the health and economic burden of heat waves now and in the future. Yet, very little is known about the economic impact of extreme heat.</p>
<h2>Why do we know so little?</h2>
<p>Natural disasters such as floods, hurricanes or wildfires cause material damage to homes, businesses and agricultural crops. Since these losses are often reimbursed by insurers or governments, in the event of a catastrophe, the financial data associated with these events is readily available and known. </p>
<p>On the other hand, extreme heat tends to affect more people’s health. As a result, these costs are buried in health-care system expenditures or borne by society as a whole, making them much harder to quantify. Extreme heat is often reported as <a href="https://doi.org/10.1289%2Fehp.1206025">a “silent killer”</a> because its impacts are much more invisible and silent compared to other natural disasters.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="flooding in the street" src="https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542372/original/file-20230811-29-ltbvjq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The material damage caused by other natural disasters, such as floods, is more easily quantifiable.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>In recent years, a few studies have attempted to estimate the costs associated with extreme heat in Canada and elsewhere in the world. For example, forecasts of the annual costs of premature heat-related deaths in Canada have been estimated at <a href="https://climatechoices.ca/wp-content/uploads/2021/06/ClimateChoices_Health-report_Final_June2021.pdf">$3 billion to 3.9 billion per year by 2050, and $5.2 billion to 8.5 billion by 2080</a>. </p>
<p>Although important and relevant, the existing research on the economic impact of heat often focuses on only one effect, for example mortality. But the impacts of extreme heat are much broader. In addition, the spatial scale of the analysis is often large (covering a whole country or province). That limits the possibility of carrying out cost-benefit analyses on a more local scale. Finally, there is room for improvement in the methodological approaches used in existing studies. </p>
<p>With multidisciplinary expertise (data science, hydrometeorology, public health and actuarial science), we seek to use innovative approaches to assess the health costs of heat in Québec and Canada. For example, we recently used artificial intelligence (AI) to process large meteorological and medical-administrative databases <a href="https://www.sciencedirect.com/science/article/abs/pii/S0048969723032837">to better model the health impacts of heat</a>. We will continue this work and built on it in order to quantify the economic burden of heat.</p>
<h2>Why is this so important?</h2>
<p>We need to be able to estimate the historical and future health costs of extreme heat in order to put in place efficient and coherent measures to fight climate change. </p>
<p>On the mitigation side, that is the reduction of greenhouse gas (GHG) emissions. Reliable projections of the health costs of extreme heat would reveal what health authorities or society can expect to pay if GHG emissions continue to rise. In this way, the reduction in GHG emissions could be converted into avoided health costs, and thus into potential savings for governments and society. This represents another argument in favour of reducing GHG emissions.</p>
<p>On the adaptation side, meaning actions to be taken to limit the consequences of climate change, estimates of the health costs of heat could serve as inputs for cost-benefit analyses of adaptation measures, such as greening or fighting urban heat islands. In such analyses, the benefits would be quantified as the heat-related health costs that would be avoided by these measures. Moreover, as these actions are often implemented at the neighbourhood or municipal scale, it will be necessary to have cost estimates that are as local as possible. Adaptation will reduce costs now, but also in the future.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/541995/original/file-20230809-15-6g0v7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541995/original/file-20230809-15-6g0v7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541995/original/file-20230809-15-6g0v7m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541995/original/file-20230809-15-6g0v7m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541995/original/file-20230809-15-6g0v7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541995/original/file-20230809-15-6g0v7m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541995/original/file-20230809-15-6g0v7m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A park laid out in the city as a measure to combat urban heat.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
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<p>Estimating the health costs of heat waves is of great importance, but has been often neglected in the past in comparison to other natural disasters. New multidisciplinary research, based on advanced methodological approaches, will provide more comprehensive and accurate data on the economic impacts of extreme heat. </p>
<p>This evidence represents an effective tool for convincing decision-makers. Since our governments generally understand economic language very well, we need to adapt our discourse to be able to influence public policy.</p><img src="https://counter.theconversation.com/content/213141/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremie Boudreault received funding from the Natural Sciences and Engineering Research Council of Canada (NSERC), the Canadian Institutes of Health Research (CIHR), the Regional Climatology Consortium (Ouranos) and the Institut national de santé publique du Québec (INSPQ).</span></em></p><p class="fine-print"><em><span>Celine Campagna et Fateh Chebana ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur poste universitaire.</span></em></p>Further research is needed in order to quantify the costs of extreme heat so we can reduce its damaging effects now and in the future.Jérémie Boudreault, Étudiant-chercheur au doctorat en science des données et santé environnementale, Institut national de la recherche scientifique (INRS)Celine Campagna, Adjunct professor, Institut national de santé publique du Québec, Université LavalFateh Chebana, Professor in Data Science applied to the Environment and Environmental Health, Institut national de la recherche scientifique (INRS)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2067832023-06-25T11:09:53Z2023-06-25T11:09:53ZFive questions for African countries that want to build climate-resilient health systems<figure><img src="https://images.theconversation.com/files/531313/original/file-20230612-23-rcpr42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Sudan has been beset by floods for the past four years. Its health system, like those in other African countries, will have to adapt to climate change.</span> <span class="attribution"><span class="source">SIMON MAINA/AFP via Getty Images</span></span></figcaption></figure><p>Every day seems to bring a new headline about a devastating climate event. African countries aren’t spared. A “<a href="https://mg.co.za/thoughtleader/opinion/2022-04-19-flood-prone-durban-ill-equipped-to-weather-the-climate-crisis/">rain bomb</a>” in South Africa. <a href="https://www.scientificamerican.com/article/warming-worsened-west-africa-floods-that-killed-800-people/#">Flooding</a> in Nigeria. <a href="https://theconversation.com/cyclones-in-southern-africa-five-essential-reads-200371">Cyclones</a> battering Mozambique, Malawi, Zimbabwe and Madagascar. <a href="https://theconversation.com/kenyas-seasonal-rains-keep-failing-what-needs-to-be-done-115635">Drought</a> in Kenya.</p>
<p>These events have enormous <a href="https://www.amazon.com/Planetary-Health-Protecting-Protect-Ourselves/dp/1610919661">health and social effects</a>, among them death, injuries, malnutrition and diseases (infectious and non-communicable). This all puts tremendous pressure on countries’ health systems, both in terms of caring for those affected and because facilities like hospitals and clinics are vulnerable to damage and destruction.</p>
<p>Extreme weather events, for example in South Africa’s <a href="https://doi.org/10.4102/phcfm.v14i1.3778">KwaZulu-Natal</a> and <a href="https://www.medicalbrief.co.za/floods-destroy-generators-at-two-eastern-cape-hospitals/">Eastern Cape</a> provinces, also disrupt energy supplies, communications, supply chains, the workforce and provision of essential services such as maternity and chronic care. </p>
<p>How, then, can African countries build more resilient primary healthcare systems as the effects of climate change worsen? We recently conducted a <a href="https://www.sciencedirect.com/science/article/pii/S2667278223000299?via%3Dihub">scoping review</a> on primary healthcare and climate change in Africa and found very little evidence to guide health systems in answering this question. </p>
<p>We looked for any studies in the African context that investigated primary healthcare and climate change. The review mapped the available evidence onto the World Health Organisation’s (WHO’s) <a href="https://www.who.int/publications-detail-redirect/9789241565073">health system building blocks</a>: leadership and governance; the health workforce; the health information system; infrastructure and technology; service delivery; and health financing. </p>
<p>We identified five key questions that health systems must answer to build more resilient primary healthcare.</p>
<h2>1. What training do medical professionals need?</h2>
<p>Health professionals in most African countries receive barely any training related to the health and social effects of dramatic changes in weather patterns.</p>
<p>There are some moves to change this. The Southern African Association of Health Educationalists recently published a <a href="https://doi.org/10.4102/phcfm.v15i1.3925">position paper</a> calling for the integration of planetary health and environmental sustainability into health professions curricula in Africa. The World Organisation of Family Doctors has also launched a <a href="https://www.globalfamilydoctor.com/News/WONCAEnvironmentlaunchesplanetaryhealthcourse.aspx">global online training programme</a> on planetary health. </p>
<p>This kind of training should focus on how different health services – for instance nutrition, HIV, TB, malaria, immunisations, maternity – should adapt to the effects of climate change. It should also offer insights into how facilities can be better prepared for emergencies and extreme events.</p>
<p>But training new health professionals isn’t enough. Continuing professional development and in-service training is key too.</p>
<h2>2. What are the community’s key vulnerabilities?</h2>
<p>The primary healthcare system in Africa should be <a href="https://gh.bmj.com/content/4/Suppl_8/e001489">community-orientated</a>, focusing on the health needs of the whole community, not just those who use a particular facility. This kind of primary care has become policy in some health systems, <a href="https://doi.org/10.4102/phcfm.v12i1.2632">for instance</a> in South Africa’s Western Cape province. </p>
<p>The community-orientated approach has usually focused on addressing the <a href="https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1">social determinants</a> of ill health such as early childhood development or education. Now, environmental determinants of health and key climate-related vulnerabilities must also be considered.</p>
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Read more:
<a href="https://theconversation.com/africas-first-heat-officer-is-based-in-freetown-5-things-that-should-be-on-her-agenda-199274">Africa's first heat officer is based in Freetown – 5 things that should be on her agenda</a>
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<p>For example, <a href="https://cer.org.za/wp-content/uploads/2023/02/Health-impacts-of-Eskoms-non-compliance-with-minimum-emissions-standards-Google-Docs.pdf">air pollution from coal-fired power stations</a> is a major cause of non-communicable diseases such as ischaemic heart disease, stroke, asthma, chronic obstructive pulmonary disease and lung cancer. </p>
<p>Building informal settlements in flood plains or having no trees in urban slums can increase vulnerability to floods and high temperatures. Floods can displace people and cause injuries as well as water-borne diseases such as <a href="https://health-e.org.za/2023/02/08/cholera-third-case-confirmed-in-gauteng/">cholera</a>. High temperatures can lead to dehydration, heat exhaustion and even <a href="https://www.medicalbrief.co.za/change-in-work-hours-suggested-after-heat-stroke-deaths/">death from heat stroke</a>.</p>
<h2>3. How can the health system track environmental changes?</h2>
<p>Health information systems traditionally collect data on health services and a population’s health needs. For instance, such systems can identify outbreaks of notifiable infectious conditions to support rapid responses.</p>
<p>But they rarely include indicators that warn of environmental challenges. </p>
<p>Primary health care facilities and services need to identify the particular climatic events that they are likely to face. For some this may be extreme temperatures or drought. For others it may be severe storms or cyclones, or sea level rise and storm surges. </p>
<p>They should also identify the most likely changes in the burden of disease linked to such events. For example, will they face an increase in climate migrants, heat-related conditions, water or vector borne infectious diseases, mental health problems or malnutrition? </p>
<p>Our <a href="https://doi.org/10.1016/j.joclim.2023.100229">scoping review</a> did not find any African examples of health information systems tracking the changes or providing early warning of climate-related events.</p>
<h2>4. How can health systems build climate resilience?</h2>
<p>Primary healthcare facilities and services need to continue functioning in the face of environmental challenges, such as cyclones, and provide safe healthcare, for example with extreme heat. Facilities need robust infrastructure, lighting, water, heating and cooling, and energy supply. Services need healthcare workers, equipment, medication and supplies, and communications. </p>
<p>For example, a <a href="https://doi.org/10.1016/j.seta.2017.02.022">hybrid energy system</a> may improve resilience and mitigate the health system’s carbon footprint. Such systems may also provide resilience against power cuts. Health systems need to consider how they can design facilities and systems to withstand environmental challenges, respond to emergencies and continue offering essential services.</p>
<h2>5. What are the next steps?</h2>
<p>The scoping review reveals a widespread absence of evidence on how to address the issue of climate change in African primary healthcare. There’s a need for more research. </p>
<p>South Africa’s Stellenbosch University and the primary care and family medicine (<a href="https://primafamed.sun.ac.za/">PRIMAFAMED</a>) network in sub-Saharan Africa are studying the impact of climate change on primary healthcare, developing tools for facilities to identify their risks and vulnerabilities, and identifying the learning needs of primary care providers. </p>
<p>Health systems also need to explicitly address the risks of climate change. There are examples that others can learn from: for instance, the Department of Health and Wellness in South Africa’s Western Cape province has established a Climate Change Forum to develop policy on both mitigation (becoming carbon neutral by 2030) and adaptation (preparing for climate related events and challenges).</p><img src="https://counter.theconversation.com/content/206783/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bob Mash receives funding from the Flemish Interuniversity Council (VLIR), the SA Medical Research Council, the National Research Foundation, and World Diabetes Foundation. He is the President of the SA Academy of Family Physicians and coordinates the Primary Care and Family Medicine (PRIMAFAMED) network in Sub-Saharan Africa.</span></em></p><p class="fine-print"><em><span>Christian Lueme Lokotola receives funding from the Flemish Interuniversity Council (VLIR). He is coordinating the African Hub of climate change, migration and health network research (under the Flemish Interuniversity Council grant). He is an active associate member of Wonca Environment Group, Global Family Doctors Association, Primafamed (Primary Health Care and Family Medicine Association in Africa), Southern African Association of Health Educationalist (SAAHE) and Public Health Association of South Africa (PHASA).
</span></em></p>Primary health care systems must become more resilient as the effects of climate change worsen.Bob Mash, Distinguished Professor, Division of Family Medicine and Primary Care, Stellenbosch UniversityChristian Lueme Lokotola, Lecturer in Planetary Health, Division of Family Medicine and Primary Care, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2054992023-06-12T09:56:25Z2023-06-12T09:56:25ZHIV care for migrant women in South Africa: the gaps and 5 steps towards offering better services<figure><img src="https://images.theconversation.com/files/529106/original/file-20230530-19-44pgfi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa's healthcare system has gaps in providing HIV treatment to highly mobile women.
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Around <a href="https://www.statssa.gov.za/publications/P0302/P03022022.pdf#page=24">8.45 million</a> people in South Africa live with HIV – an estimated 13.9% of the population. Of South African women aged 15-49, approximately <a href="https://www.statssa.gov.za/publications/P0302/P03022022.pdf#page=25">24%</a> are HIV positive.</p>
<p>The roll-out of services to prevent mother-to-child transmission of HIV has been notably successful in <a href="https://www.hst.org.za/publications/District%20Health%20Barometers/DHB+2017-18+Web+8+Apr+2019.pdf#page=105">reducing</a> the rate of transmission. </p>
<p>But there are still gaps in the delivery of HIV treatment and prevention. A case in point is migrant women. <a href="https://theconversation.com/south-africas-healthcare-system-cant-afford-to-ignore-migration-120797">People who move</a> across national borders or between regions and provinces are particularly easy for healthcare systems to miss. And there’s no integrated system of tracking them. Nor is there any robust national data on how many migrant women, specifically pregnant migrant women, are on treatment and virally suppressed. </p>
<p>In 2020, it was <a href="https://www.statssa.gov.za/?p=14569">estimated</a> that there were 4 million migrants in South Africa, some of whom were women living with HIV. The public health system has <a href="http://www.samj.org.za/index.php/samj/article/view/8569">struggled to respond</a> yet alone integrate this mobile population.</p>
<p>The vulnerability of migrants was <a href="https://theconversation.com/covid-affected-access-to-hiv-treatment-the-stories-of-migrant-women-in-south-africa-show-how-195214">highlighted</a> during the COVID-19 pandemic when restrictions affected people’s ability to travel to access treatment as well as the delivery of healthcare.</p>
<p>In a recent <a href="https://journals.sagepub.com/doi/full/10.1177/11786329211073386">paper</a> we explored the challenges of the COVID-19 pandemic for HIV prevention services in Johannesburg, South Africa’s economic hub. We interviewed healthcare providers and stakeholders in policy and programming. The aim was to understand the gaps in ensuring adherence to lifelong antiretroviral therapy for mobile populations. </p>
<p>The information we gathered shone a light on the country’s overburdened healthcare facilities and the shortcomings in the network of referral clinics in Johannesburg and across Gauteng province. We went on to draw from these insights to understand the systemic gaps in the delivery of antiretroviral treatment (ART) to migrant women. We identified five in particular. And we then identified possible solutions, including how technology could improve access to healthcare.</p>
<h2>The gaps</h2>
<p>The pandemic created new problems in healthcare delivery and exposed existing shortcomings. Five main themes emerged from our qualitative study. </p>
<p>First, women living with HIV and who were highly mobile feared going to healthcare facilities because they were scared of getting COVID. This interrupted their treatment and increased their risk of falling ill. </p>
<p>Second, some healthcare workers told us they felt overwhelmed by the added burden of the pandemic on providing HIV prevention services to pregnant women. For example, many reported that there was a lack of infrastructural resources to follow social distancing protocols. This disrupted their provision of care. </p>
<p>Third, migrant women faced a number of logistical barriers:</p>
<ul>
<li><p>some who left Gauteng province and then tried to return to collect their medication couldn’t do so due to border and lockdown restrictions</p></li>
<li><p>some lost their jobs and income, and were unable to afford travel to collect their ART</p></li>
<li><p>some were denied care because they didn’t have documentation (though this <a href="https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/what-does-the-law-say-about-migrants-and-refugees-accessing-healthcare-in-south-africa/">should not have been a barrier</a>). </p></li>
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<p>These factors resulted in patients interrupting treatment. </p>
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Read more:
<a href="https://theconversation.com/5-essential-reads-on-migrant-access-to-healthcare-in-south-africa-190257">5 essential reads on migrant access to healthcare in South Africa</a>
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<p>Fourth, some individuals who sought treatment reported mistreatment and xenophobic <a href="https://theconversation.com/telling-the-complex-story-of-medical-xenophobia-in-south-africa-127040">attitudes</a> from healthcare providers. Even some healthcare providers reported that their colleagues behaved negatively towards <a href="https://theconversation.com/southern-africa-needs-better-health-care-for-women-and-girls-on-the-move-121151">migrant women</a>. </p>
<p>Time pressures were the fifth theme. Health workers said they needed more time to counsel patients. This helps build a rapport and strengthens the ability of patients to manage their health. </p>
<p>From these insights we drew up a list of interventions we think would improve antiretroviral services to migrant women in South Africa. </p>
<h2>What can be done?</h2>
<p>The first step is to dispense antiretrovirals for a longer duration of time to alleviate stress for individuals on the move and encourage retention in the ART programme.</p>
<p>Secondly, decentralise services and bring care to the community with pop-up delivery that can help remove logistical barriers like transport to clinics that are far away. </p>
<p>Thirdly, introduce virtual care platforms – like online HIV prevention of mother to child transmission services. It could help highly mobile individuals to interact with healthcare providers. This could help to improve the referral system between clinics and counsellors could follow up patients who had moved. The system could keep better patient records and send reminders for medicine collections. In addition, it should include translation services to help remove communication barriers between service providers and users. And it could better integrate communication of healthcare facilities – even those in other countries – so as to track patients.</p>
<p>Fourthly, healthcare providers need better opportunities to build closer relations with each other. This could create a better understanding of the changes in their work and the underlying issues that affect them. Greater understanding could help get to the root of where <a href="https://theconversation.com/migrants-in-south-africa-have-access-to-healthcare-why-its-kicking-up-a-storm-189574">negative attitudes</a> towards migrants stem from to improve behaviours towards patients. </p>
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Read more:
<a href="https://theconversation.com/the-social-management-of-hiv-african-migrants-in-south-africa-127955">The social management of HIV: African migrants in South Africa</a>
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<p>In addition, healthcare facilities often improvise to come up with strategies and solutions that meet the requirements and changes to programmes. If these were better documented they could then provide knowledge translation and learning opportunities on a larger scale for other healthcare providers, facilities and programmes.</p>
<p>Fifth, government should evaluate healthcare environments before changing policies and programmes. Platforms such as working groups should be provided for collaboration with researchers, service providers and mobile patients to help direct policy and practices. </p>
<p>South Africa needs to take a more pragmatic approach to the delivery of antiretroviral treatment. It needs a healthcare system that is migration-aware and offers a service that recognises mobility – one that speaks to the realities of migrant women living with HIV in South Africa.</p><img src="https://counter.theconversation.com/content/205499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melanie Bisnauth holds a PhD in Public Health at the University of Witwatersrand, South Africa and received funding from the Life in the City, School of Governance. Some of the work discussed in this article was funded through this grant.
</span></em></p>The vulnerability of migrants was highlighted during the COVID-19 pandemic when restrictions affected people’s ability to travel to access treatment.Melanie Bisnauth, Doctoral Researcher, School of Public Health and Public Health Technical Advisor, Anova Health Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2036082023-04-30T09:07:59Z2023-04-30T09:07:59ZHealth workers cope with a huge amount of stress - how to build a resilient health system in South Africa<figure><img src="https://images.theconversation.com/files/521573/original/file-20230418-24-zznukr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Brenton Geach/Gallo Images via Getty Images</span></span></figcaption></figure><p>Popular and academic literature is replete with examples of how to cope with daily stresses. Mental health professions have also long researched and implemented strategies to deal with <a href="https://theconversation.com/what-is-burnout-and-how-to-prevent-it-in-the-workplace-insights-from-a-clinical-psychologist-196578">burnout</a> from workplace stressors.</p>
<p>Coping with stress is not a new phenomenon. But COVID-19 and the responses to the pandemic have increased our attention on how people and systems cope with stress-inducing shocks. </p>
<p>This should not surprise us given the impact of COVID-19 on almost every aspect of our lives. There are indications that many people and countries are still struggling to emerge from its shadow.</p>
<p>Resilience is a relatively new area of study in the health sector and is explained as the ability of an individual to withstand and recover from adversity using their inner strength, optimism, and being flexible and competent.</p>
<p>Everyday resilience is important to ensure health workers can cope with daily stressors, and take action to change their circumstances when they are confronted with challenges. At a health system level, everyday resilience means that health workers can deal with the systemic challenges in their work environment. </p>
<p>We argue that everyday resilience is needed at two levels: healthcare workers – who mostly bore the brunt of the pandemic in their working and personal lives – as well as the health system. </p>
<p>We draw on <a href="https://pubmed.ncbi.nlm.nih.gov/29081995/">research</a> around resilience in the health sector to highlight why it’s important to focus on it for health workers and for <a href="https://healthsystemsglobal.org/news/a-new-era-for-the-who-health-system-building-blocks/">the health system</a> as a whole. </p>
<h2>Health workers</h2>
<p>Health workers face trauma daily. Their line of work often requires them to make life-saving decisions in the face of significant resource limitations as well as high expectations of patients, families, communities and their managers. </p>
<p>The rate of burnout in health workers is high throughout the world. This was exacerbated by the COVID-19 <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2021.758849/full">pandemic</a> which contributed to alarming levels of anxiety, depression and traumatic stress among <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266008">South African health workers</a>. </p>
<p>There have been suggestions about how to build <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-023-09223-y">resilience</a> in health workers, including <a href="https://pubmed.ncbi.nlm.nih.gov/33511272/">medical students</a>, against daily workplace stresses. </p>
<p>There’s an example of how COVID-19 had an impact on the health workforce from clinical associates at the University of Pretoria’s Health Sciences Faculty who supported mining companies. About 100 clinical associates conducted COVID-19 screening, testing, follow up and vaccinations. They performed quarantine or isolation ward duties and provided general healthcare services to miners. </p>
<p>During the peak COVID infections periods the clinical associates worked an average of 18 hours per day. They took huge physical and emotional strain. Many of them also had to deal with severely ill relatives and deaths. They met every evening via a virtual call to discuss their experiences and complex cases. This provided an outlet for their emotional strain and an opportunity to improve their clinical understanding. </p>
<p>Because of the direct access to the emotional support provided by the university staff, these health professionals could readily find support when they felt overwhelmed. Halfway through the pandemic, a team of private occupational therapists conducted an eight-week online group therapy programme with the clinical associates, called the <a href="https://otgrow.co.za/">Unsung Heroes</a> programme. Conducting this form of therapy online was unheard of before the pandemic, and included both group therapy sessions as well as individual consultations. Clinical associates afterwards reported how much these sessions helped them to cope with the burden of COVID. </p>
<p>But the focus on building resilience at the individual level has been criticised as focusing on the symptoms rather than the root causes. For example, studies have argued that building resilience in frontline health workers may hide the <a href="https://gh.bmj.com/content/2/2/e000224">systemic challenges</a>. </p>
<p>These might include a shortage of personnel, inadequate equipment and medicines, and organisational cultures that limit innovation and adaptation. A more comprehensive approach to building resilience would, instead, focus on what some have called everyday <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538378/">resilience</a>, based on <a href="https://academic.oup.com/heapol/article/38/2/192/6759214">everyday capabilities</a>.</p>
<h2>What does such a focus offer the health system?</h2>
<p>Borrowing from the ideas of colleagues working with the <a href="https://resyst.lshtm.ac.uk/everyday-resilience#:%7E:text=Everyday%20resilience%20is%20the%20ability,of%20constant%20challenge%20and%20strain">London School of Tropical Medicine and Hygiene</a>, everyday resilience is founded on </p>
<blockquote>
<p>the combination of absorptive, adaptive and transformative strategies that actors in systems adopt in responding to strain. </p>
</blockquote>
<p>Transformative <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5553211/">resilience</a> ultimately implies changing the system so that it can continue to change in the face of multiple, future, unpredictable challenges.</p>
<p>The literature suggests the need for further research into the notion of transformative resilience. But we already know a lot about what can be implemented even as the world focuses on the structures, practices and routines needed for pandemic preparedness and control.</p>
<p>There are many <a href="https://gh.bmj.com/content/2/2/e000224">proactive (adaptive) examples</a> from South Africa and Kenya of how primary healthcare workers coped before the COVID-19 pandemic. These examples illustrated personal agency as well as system changes initiated at local level.
For example the temporary reintroduction of user-fees in Kenya, agreed with local communities, until government funding was again transferred to ensure that primary healthcare services were not disrupted. </p>
<p>In South Africa there are examples of new forms of collaborating across organisations to work towards shared goals. There are also new ways of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538378/">managing and organising meetings</a> to support learning and enable mutual accountability among colleagues in primary care settings. </p>
<p>Across countries, respectful leadership practices that empowered frontline workers and strengthened relationships were also found to be very important to everyday resilience.</p>
<p>Similarly, during the COVID-19 pandemic, the Western Cape Department of Health in South Africa introduced the concept of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250842/">daily huddles</a>. These daily hour-long meetings allowed for key issues to be presented and discussed. They included managers from all levels of the health system – including the private health sector – as well as managers from other sectors of government. As the pandemic receded, they happened less frequently.</p>
<p>The meetings enabled managers to work across silos in the health system across administration and health programmes, for example. Everyone that participated in the huddle could do so freely without sanction. This reduced the hierarchy within the health system. </p>
<p>The presentations in these huddles were evidence-based. They illustrated the importance of real-time information as well as use of evidence for decision making. </p>
<p>Our colleagues who were part of these huddles <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250842/">reported</a> that they used these to build on long-standing initiatives in the province to strengthen the health system.</p>
<h2>Organic learning systems</h2>
<p>The COVID-19 pandemic highlighted various challenges to health workers and health systems. These are foremost in our minds. But the sector has faced similar challenges over many decades. </p>
<p>There are many examples of how to strengthen resilience that we can learn from, and scale. What is clear is that unless health systems are organic learning systems and continuously focus on building systems for resilience, we may run the risk of learning anew each time health workers and health systems face a catastrophic event. </p>
<p>Building a strong health system that focuses on everyday resilience may be the best way to deal with everyday challenges as well as pandemics.</p><img src="https://counter.theconversation.com/content/203608/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>COVID-19 and responses to the pandemic have increased our attention on how individuals and systems cope with stress-inducing shocks.Yogan Pillay, Extraordinary Professor in the Division of Health Systems and Public Health, Stellenbosch UniversityFlavia Senkubuge, Deputy Dean: Health Stakeholder Relations in the Faculty of Health Sciences, University of PretoriaLucy Gilson, Professor and Head, Health Policy and Systems Division, School of Public Health, University of Cape TownSaiendhra Moodley, Public Health Medicine Specialist and Senior Lecturer, University of PretoriaSuzi Malan, Manager: Partnerships and Projects at Department of Family Medicine, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2021202023-04-11T20:08:39Z2023-04-11T20:08:39ZTracking health care’s global environmental impact is a step toward more sustainable health systems<figure><img src="https://images.theconversation.com/files/518949/original/file-20230403-24-q6w329.jpg?ixlib=rb-1.1.0&rect=99%2C18%2C4039%2C2404&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Researchers around the world are working to assess the environmental impacts of health care.</span> <span class="attribution"><span class="source">(AP Photo/Vadim Ghirda)</span></span></figcaption></figure><p>The health-care sector is <a href="https://doi.org/10.1016/S2542-5196(23)00022-0">threatened by the increasing impacts of global environmental change, but is also a significant contributor to the problem</a>. Recent estimates suggest health care is responsible for between <a href="https://doi.org/10.1016/S2542-5196(20)30121-2">two and five per cent of global greenhouse gas, sulphur dioxide, nitrogen oxide and particulate matter emissions</a>.</p>
<p>In 2020, <a href="https://www.england.nhs.uk/greenernhs/2020/10/nhs-becomes-the-worlds-first-national-health-system-to-commit-to-become-carbon-net-zero-backed-by-clear-deliverables-and-milestones/">England’s National Health Service</a> became the first health system in the world to set a target of achieving net zero carbon dioxide emissions. Since then, a further <a href="https://www.who.int/initiatives/alliance-for-transformative-action-on-climate-and-health/country-commitments">21 countries have committed to achieving net-zero health system emissions, and 58 nations have pledged to make their health systems sustainable and low-carbon</a>.</p>
<p>Progress on this front will ultimately depend on two things:</p>
<ul>
<li> the rapid quantification of health care’s environmental impacts at all levels of service provision and across all geographic regions, and </li>
<li> promptly providing this data to relevant stakeholders, including health care policymakers, managers, procurement teams, administrators, and health care workers themselves.</li>
</ul>
<p>In an effort to aid this latter step, we recently launched <a href="http://www.healthcarelca.com">HealthcareLCA</a>: the first global living database of health care-related environmental impact assessments.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1600638452378533888"}"></div></p>
<h2>An innovative open-access platform</h2>
<p>While researchers around the world are working hard to assess the environmental impacts of different aspects of health care, the HealthcareLCA database serves as an up-to-date repository for this work, bringing together new and existing assessments into one centralized location. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="map showing geographical distribution of research on health care's environmental impact" src="https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=466&fit=crop&dpr=1 754w, https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=466&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/516820/original/file-20230321-22-tyfpuj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=466&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Collectively, the studies included within the HealthcareLCA database to date have been authored by more than 850 authors from over 350 institutions. This chart shows the geographical distribution of these institutions, with the size of each dot corresponding to the number of included studies published by each institution.</span>
<span class="attribution"><span class="source">HealthcareLCA</span></span>
</figcaption>
</figure>
<p>The database currently houses more than 4,500 environmental impact values (including, for example, contributions to global warming, ozone depletion, smog formation, and acidification) for nearly 1,500 health care products and activities. These include equipment, pharmaceuticals, investigations, procedures, treatments, services and entire health systems.</p>
<p>Importantly, HealthcareLCA is open-access and “living” in nature, meaning that our online database is freely accessible and continuously updated as new research becomes available.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="graph showing growing number of data sources on the environmental impact of different aspects of health care" src="https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=363&fit=crop&dpr=1 600w, https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=363&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=363&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=456&fit=crop&dpr=1 754w, https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=456&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/516819/original/file-20230321-18-86v8ia.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=456&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Accumulation of health care-related environmental impact assessments over time with studies broken down into different categories based on their scale of analysis.</span>
<span class="attribution"><span class="source">HealthcareLCA</span></span>
</figcaption>
</figure>
<p>When HealthcareLCA was launched in December 2022, <a href="https://doi.org/10.1016/S2542-5196(22)00257-1">in conjunction with a Personal View article in <em>The Lancet Planetary Health</em></a>, it included 152 studies published between 2000 and 2021. Since then, our research team has added a further 43 studies, indicating rapid growth within this important research field. </p>
<h2>Interacting with the data</h2>
<p>The HealthcareLCA platform is designed to be highly interactive, allowing users to sort, search and filter data according to their individual needs and interests. </p>
<p>Data can be readily organized by world region, country, institution, health care field, discipline, scale of analysis and environmental impact category assessed, among other parameters.</p>
<p>For instance, those interested in dentistry could quickly find studies relevant to their practice, including dental floss and toothbrushes, personal protective equipment, examination kits, materials used for fillings, and a range of procedures such as extractions, crowns and root canals.</p>
<p>More specifically, a surgical team in the United Kingdom that is interested in reducing the carbon footprint of its operating rooms could combine filter conditions to show only U.K.-based studies that have estimated the global warming potential of surgical equipment or procedures.</p>
<p>In this way, users can quickly appraise what has been studied within their field of interest, get a sense of the associated environmental impacts, and consider mitigation strategies they might wish to implement.</p>
<p>Our tutorial video provides an overview of how users can navigate and interact with the database, including several step-by-step examples of how to organize the data with different questions in mind.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/UXtHt6UyP5o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Watch this tutorial video to learn how to navigate and interact with the HealthcareLCA database.</span></figcaption>
</figure>
<h2>A central access point to data</h2>
<p>The HealthcareLCA database is designed to expedite knowledge translation in support of moving towards more sustainable health systems globally. We hope to provide relevant data to help inform and guide changes in health policy and practice, as well as to identify areas for future research. The database is intended to provide a central access point to that data for health care providers, policymakers and administrators.</p>
<p>For the first time, anyone with an interest in health care sustainability can easily find out what health care products and activities have been studied and begin learning about their associated environmental impacts.</p>
<p>We encourage readers to <a href="https://healthcarelca.com/database">explore the online database</a>, <a href="https://doi.org/10.1016/S2542-5196(22)00257-1">read about its role in supporting efforts to make health care more sustainable</a> and engage in discussions about how we can work together to achieve sustainable health care provision globally.</p><img src="https://counter.theconversation.com/content/202120/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>HealthcareLCA is supported by CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis), which is a Canadian capacity-building initiative to address health care’s contribution to the climate crisis that is itself funded by Environment and Climate Change Canada’s Climate Action and Awareness Fund for Community-Based Climate Action Projects. HealthcareLCA is also supported by the Creating Sustainable Health Systems in a Climate Crisis flagship project at Dalhousie University’s Healthy Populations Institute and Brighton and Sussex Medical School (BSMS).</span></em></p>The HealthcareLCA database is an interactive tool for exploring health care’s significant environmental impact. It can inform changes in health policy and practice, and identify areas for research.Jono Drew, Adjunct Faculty, Department of Surgery (Neurosurgery), Faculty of Medicine, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1942532022-11-16T19:04:18Z2022-11-16T19:04:18ZOur health system is like a ‘worn pair of shorts’. This latest COVID wave will stretch it even thinner<figure><img src="https://images.theconversation.com/files/495526/original/file-20221116-23-7wz962.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C998%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-having-headache-tired-work-while-1715051302">Shutterstock</a></span></figcaption></figure><p>The <a href="https://www.health.gov.au/news/new-covid-19-variant-leads-to-increase-in-cases">latest COVID wave</a> is with us, with its <a href="https://theconversation.com/from-centaurus-to-xbb-your-handy-guide-to-the-latest-covid-subvariants-and-why-some-are-more-worrying-than-others-192945">viral subvariants</a> <a href="https://www1.racgp.org.au/newsgp/clinical/new-variants-expected-to-supplant-ba-5-in-australi">BQ.1 and XBB</a>. Once again, our health system will be stretched.</p>
<p>That’s not just hospitals. A stretched health system affects the interaction between you and your GP, the availability of medicines, the policies of the aged care home your mother is in, the research that brought you vaccines, the mental health-care provider, Medicare and more.</p>
<p>The situation is very different to earlier COVID waves. Now, we have fewer public health measures in place. Health staff <a href="https://theconversation.com/health-worker-burnout-and-compassion-fatigue-put-patients-at-risk-how-can-we-help-them-help-us-191429">are also exhausted</a> from almost three years of the pandemic.</p>
<p>Here’s what needs to happen next for our health systems to cope with the latest COVID wave.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-can-we-expect-from-this-latest-covid-wave-and-how-long-is-it-likely-to-last-194444">What can we expect from this latest COVID wave? And how long is it likely to last?</a>
</strong>
</em>
</p>
<hr>
<h2>First, the good news</h2>
<p>The <a href="https://www.health.gov.au/news/new-covid-19-variant-leads-to-increase-in-cases">current COVID wave</a> (Australia’s fourth) is being fuelled by ever-more “pushy” Omicron subvariants <a href="https://theconversation.com/from-centaurus-to-xbb-your-handy-guide-to-the-latest-covid-subvariants-and-why-some-are-more-worrying-than-others-192945">such as BQ.1 and XBB</a>, waning immunity from <a href="https://kirby.unsw.edu.au/news/least-two-thirds-australians-including-children-and-adolescents-have-had-covid-19-two-national">past infection</a> and vaccination, and fewer public health measures. Luckily it appears the new subvariants <a href="https://www.health.gov.au/news/new-covid-19-variant-leads-to-increase-in-cases">don’t cause</a> more severe disease.</p>
<p>What we’ve learned from past waves, plus widespread availability of <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines?gclid=EAIaIQobChMImdXB6b6v-wIVVhwrCh3FQgcVEAAYASAAEgJZXfD_BwE&gclsrc=aw.ds">vaccines</a> and <a href="https://www.health.gov.au/health-alerts/covid-19/treatments/eligibility?gclid=EAIaIQobChMIp7Wr2r6v-wIVgINLBR2GGAbIEAAYASAAEgJTH_D_BwE&gclsrc=aw.ds">treatments</a>, should keep more people from getting severely ill and needing to go to hospital.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/previous-covid-infection-may-not-protect-you-from-the-new-subvariant-wave-are-you-due-for-a-booster-193292">Previous COVID infection may not protect you from the new subvariant wave. Are you due for a booster?</a>
</strong>
</em>
</p>
<hr>
<h2>But health workers are burnt out</h2>
<p>However, health professionals are <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2021.750529/full">burnt out</a>.</p>
<p>Globally, health-care systems are seeing more-complex cases compared with before the pandemic, for a number of reasons. This includes increased complexity of conditions due to our ageing population, delayed care over the pandemic and because COVID is complicating existing conditions and care processes.</p>
<p>Globally, health systems have also had to deal with surges in other viruses – such as influenza and, especially in children, <a href="https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html">respiratory syncytial virus</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1574315232926711808"}"></div></p>
<p>During this latest COVID wave, more health staff will likely become infected. This will result in workforce absences, which will be difficult to fill over the coming summer period. <a href="https://www.anmf.org.au/media-campaigns/news/australia-facing-nursing-shortage-as-more-than-two-years-of-covid-takes-its-toll">Nursing shortages</a> continue.</p>
<p>Health-care staff feel isolated, and <a href="https://www.sciencedirect.com/science/article/pii/S2772598722000319">lonely</a>. Some feel the care they provide <a href="https://insightplus.mja.com.au/2022/11/health-workforce-not-normal-not-safe-but-it-can-be-fixed/">is not safe</a>. <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-022-00764-7">Some</a> are <a href="https://www.apna.asn.au/about/media/one-in-four-primary-health-care-nurses-plans-to-quit">leaving</a> their professions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-worker-burnout-and-compassion-fatigue-put-patients-at-risk-how-can-we-help-them-help-us-191429">Health worker burnout and 'compassion fatigue' put patients at risk. How can we help them help us?</a>
</strong>
</em>
</p>
<hr>
<h2>We know what works</h2>
<p>Health systems will revisit what we know has worked during past COVID waves.</p>
<p>As case numbers climb, hospitals may need to cancel elective surgeries. They may need to boost their intensive care unit (ICU) capacity, by redeploying staff and facilities. They can assess COVID patients outside to minimise the risk of viral transmission, as they’ve done before. </p>
<p>Telehealth services could be expanded, we could see more use of existing community fever and respiratory clinics.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/omicron-is-overwhelming-australias-hospital-system-3-emergency-measures-aim-to-ease-the-burden-175233">Omicron is overwhelming Australia's hospital system. 3 emergency measures aim to ease the burden</a>
</strong>
</em>
</p>
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<p>But these old measures may not be enough. The health system is bursting at the seams in multiple places simultaneously. It’s like we had an old pair of shorts, COVID came along, and is causing holes in multiple places where things were already worn. </p>
<p>That includes <a href="https://www.theguardian.com/australia-news/2022/aug/10/not-honest-new-health-minister-dismisses-coalition-election-claim-that-bulk-billing-had-hit-88">primary care</a> (patients’ first contact with the health system, such as general practice), <a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">the ambulance system</a> and <a href="https://acem.org.au/News/August-2022/ACEM-statement-on-primary-care-and-emergency-depar">hospitals</a>.</p>
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Read more:
<a href="https://theconversation.com/ambulance-ramping-is-a-signal-the-health-system-is-floundering-solutions-need-to-extend-beyond-eds-187270">Ambulance ramping is a signal the health system is floundering. Solutions need to extend beyond EDs</a>
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<h2>Here’s what we need to do next</h2>
<p>Here are three things <a href="https://www.nature.com/articles/s41586-022-05398-2">that would</a> <a href="https://www.who.int/publications/m/item/covid-19-strategic-preparedness-and-response-plan-2022--global-monitoring-and-evaluation-framework">help</a> an already stretched health system during this current wave and beyond.</p>
<p><strong>1. Reduce COVID transmission</strong></p>
<p>The <a href="https://www.who.int/publications/i/item/WHO-WHE-SPP-2022.1">World Health Organization</a> and Australian <a href="https://www.mja.com.au/journal/2021/215/4/we-are-not-doing-enough-prevent-spread-covid-19-and-other-respiratory-viruses">experts agree</a>, a clear priority is to reduce transmission of SARS-CoV-2, the virus that causes COVID.</p>
<p>We also need infection control <a href="https://www.nejm.org/doi/full/10.1056/NEJMra1510059">trials that mimic the real world</a> and <a href="https://www.mja.com.au/journal/2021/215/4/we-are-not-doing-enough-prevent-spread-covid-19-and-other-respiratory-viruses">new approaches to infection control</a> not only in the health system but in education and in workplaces too. </p>
<p>As policies about wearing masks, testing or isolating after testing positive have been diluted, improvements such as <a href="https://www.mja.com.au/podcast/217/10/mja-podcasts-2022-episode-42-healthy-indoor-air-quality-why-its-important-prof-lidia">improving indoor air quality</a>, take on increased importance.</p>
<p><strong>2. Strengthen primary care</strong></p>
<p>World leaders <a href="https://apps.who.int/iris/bitstream/handle/10665/328123/WHO-HIS-SDS-2018.61-eng.pdf?sequence=1&isAllowed=y">have agreed</a> the bedrock of resilient and cost-effective health systems is a <a href="https://blogs.bmj.com/bmj/2020/10/26/a-safer-world-starts-with-strong-primary-healthcare/">strong primary health care</a> base.</p>
<p>So we need to bolster existing services, and to continue to address the aged care, disability and mental health care sectors to help with timely support of patients through the hospital system and out into other types of care. </p>
<p><strong>3. Gather and share information for decision making</strong></p>
<p>We should strive for better national data on health and the health system, building on existing valuable information held nationally and by state and territory health departments. </p>
<p>We could access and analyse data on individuals from across primary care and hospitals, public and private – <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4050016/">other countries do</a>. </p>
<p>This would allow us to better and more efficiently understand resource strengths and gaps across the health system (for instance improving wait-times for surgery). It would also help us to better understand needs (for instance, workforce needs) and to respond quicker, to ultimately improve people’s health.</p>
<h2>We all play a role</h2>
<p>COVID is <a href="https://www.mja.com.au/podcast/217/10/mja-podcasts-2022-episode-41-politics-pandemics-and-origins-omicron-prof-eddie">here to stay</a>. So we all play a role in reducing the impact on our health systems. Reduce the number of times you are infected. Get vaccinated. Wear a <a href="https://www.mhlw.go.jp/content/3CS.pdf">good quality mask</a> in crowded, closed, close-contact settings.</p>
<p><a href="https://www.health.gov.au/health-alerts/covid-19/testing">Test</a> often and stay home when unwell. Find out if you are eligible for <a href="https://www.health.gov.au/health-alerts/covid-19/treatments/eligibility">antiviral medications</a> and plan how you would get them if COVID positive.</p>
<p>Vote well. Politics are playing a <a href="https://www.nature.com/articles/s41586-022-05398-2">hefty hand</a> in our response to COVID locally and globally.</p>
<p>There will be more COVID waves. We need to focus on equity and social determinants of health, reducing the need for people to access the health system in the first place.</p>
<p>Health care is the pointy end of COVID. We need to aim to <a href="https://www.health.org.uk/publications/build-back-fairer-the-covid-19-marmot-review">build stronger and fairer</a> systems for the years ahead. </p>
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Read more:
<a href="https://theconversation.com/first-covid-hit-disadvantaged-communities-harder-now-long-covid-delivers-them-a-further-blow-183908">First, COVID hit disadvantaged communities harder. Now, long COVID delivers them a further blow</a>
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<img src="https://counter.theconversation.com/content/194253/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Martiniuk receives funding from the National Health and Medical Research Council (NHMRC). </span></em></p>Here’s what needs to happen next for our health systems to cope with the latest COVID wave.Alexandra Martiniuk, Professor of Epidemiology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1923442022-10-13T14:22:00Z2022-10-13T14:22:00ZTigray’s healthcare workers haven’t been paid in over a year – and bear the brunt of the war<figure><img src="https://images.theconversation.com/files/489388/original/file-20221012-5607-61pmb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The unfolding crisis will only worsen the situation in Tigray.</span> <span class="attribution"><span class="source">Eduardo Soteras/AFP via Getty Images</span></span></figcaption></figure><p>Tragic stories of suffering and death have emerged from Tigray since 2020, when civil war erupted between the central Ethiopian government and the regional Tigrayan government.</p>
<p>In just one example, a professor who headed Ayder Hospital’s oncology department in Mekelle, the capital city of Tigray, <a href="https://www.theguardian.com/global-development/2022/may/25/i-saw-an-oncologist-cry-tigray-cancer-patients-sent-home-to-die-for-lack-of-drugs">spoke</a> of women’s malnutrition and resulting childbirth complications and deaths.</p>
<p>It’s not only the patients who are suffering. Despite being <a href="https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/INTRO/365?OpenDocument">protected</a> by <a href="https://www.icrc.org/en/doc/assets/files/publications/icrc-002-0173.pdf">international laws</a>, healthcare workers and health facilities in the region are extremely vulnerable. Since the war broke out, healthcare workers have <a href="https://pubmed.ncbi.nlm.nih.gov/34815244/">lost their jobs</a>, been <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00115-8/fulltext">displaced</a>, and been wounded, threatened or <a href="https://tigrayeao.info/tigray-health-bureau-tigray-health-sector-annual-bulletin-2021-january-2022/">killed</a>.</p>
<p>There have been <a href="https://www.state.gov/air-strike-on-village-market-in-tigray/">reports</a> of ambulances being obstructed and health workers being <a href="https://www.doctorswithoutborders.org/latest/widespread-destruction-health-facilities-ethiopias-tigray-region">prevented</a> from treating civilians. </p>
<p>There’s a lack of <a href="https://www.theguardian.com/global-development/2022/may/25/i-saw-an-oncologist-cry-tigray-cancer-patients-sent-home-to-die-for-lack-of-drugs">medical supplies</a>. Patients and healthcare workers have resorted to unusual measures. At one hospital, healthcare workers were <a href="https://apnews.com/article/health-ethiopia-africa-united-nations-dialysis-f9c2c16ba1ee9704fa3799d1846d7ee5">reusing gloves</a> and asking patients to bring white clothes that could be repurposed as gauze.</p>
<p>Tigray’s healthcare systems were already <a href="https://ligsuniversity.com/blog/assessment-of-hr-standards-in-private-and-public-hospitals-in-tigray-region-ethiopia">under pressure</a> before the war. The unfolding crisis will only worsen the situation. Action is crucial: the international community must recognise and acknowledge that accepted global norms related to healthcare workers’ safety are being violated. They must condemn the situation in the strongest terms. Tigray’s health sector needs support – both now and when the war ends.</p>
<h2>Trying circumstances</h2>
<p>Healthcare workers in Tigray were last paid in <a href="https://www.devex.com/news/opinion-in-tigray-we-are-demanding-food-and-medicine-not-bombs-102621">May 2021</a>. In July 2021, <a href="https://pubmed.ncbi.nlm.nih.gov/34815244/">50%</a> of the region’s roughly 20,000 healthcare workers did not report for normal duty. This figure includes all 741 <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-12-352">health extension workers</a> employed in posts across Tigray to provide primary healthcare services, including crucial maternal and child health services.</p>
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Read more:
<a href="https://theconversation.com/what-people-from-war-torn-tigray-told-us-about-the-state-of-their-lives-amid-the-war-180594">What people from war-torn Tigray told us about the state of their lives amid the war</a>
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<p>The economic meltdown and the ongoing violence have prompted many healthcare workers to flee. Some have remained in the area, seeking refuge in camps for internally displaced people. Researchers found about <a href="https://pubmed.ncbi.nlm.nih.gov/34815244/">2,000 healthcare workers</a> living in one such camp in Mekelle. Others <a href="https://www.unhcr.org/news/stories/2021/2/6033e61d4/working-commitment.html">have fled</a> to neighbouring countries like Sudan.</p>
<p>During an interview with the BBC on 3 October 2021, the head of the Tigray region Health Bureau, Dr Hagos Godefay, reported that <a href="https://gh.bmj.com/content/7/4/e008475">22,000</a> health workers were displaced. </p>
<p>Those who have continued to work, along with international aid workers providing healthcare support, are extremely vulnerable. The regional Health Bureau reports that <a href="https://www.devex.com/news/opinion-in-tigray-we-are-demanding-food-and-medicine-not-bombs-102621">37 healthcare workers have been killed and 78 wounded</a> since the start of the war. The UN says <a href="https://reliefweb.int/report/ethiopia/hc-ai-statement-killing-23-aid-workers-tigray-region-start-crisis">23 aid workers</a> have died. </p>
<h2>Fears for the future</h2>
<p>Healthcare infrastructure has not been spared in this conflict. Seventy-eight percent of health posts (primary healthcare structures), 72% of health centres, and 80% of hospitals have been <a href="https://www.ethiopia-insight.com/2022/01/26/data-shows-siege-and-destruction-of-health-system-are-causing-preventable-deaths-in-tigray/">destroyed</a>. </p>
<p><a href="https://www.researchgate.net/publication/349750000_Status_of_the_Tigray_universities_Ethiopia_after_nine_months_of_war">Educational facilities</a>, including medical colleges, have also repeatedly come under attack. The resulting disruptions bode ill for the future – Tigray may experience a significant gap in the supply of skilled health professionals in the coming years.</p>
<p>Some students from the medical colleges have stepped up to provide services, despite not yet being qualified. This unfortunate situation imposes a responsibility beyond their capacity. It’s also likely to cause extreme stress in their lives and may drive them out of the profession after the war.</p>
<p>The extreme and blatant disregard of healthcare
workers’ neutrality (which is guaranteed in numerous international agreements), the <a href="https://globalhealthnow.org/2022-04/tigray-and-its-health-care-system-under-siege">denial</a> of access to basic services for civilians and wounded combatants, and the destruction of healthcare infrastructure in the Tigray war cannot be justified. </p>
<h2>Looking ahead</h2>
<p>It is a painful paradox. At a time when Tigray’s citizens need it most, they cannot access good, reliable, safe healthcare. We fear that the situation won’t improve.</p>
<p>We expect that Tigray’s post-conflict period will be characterised by poor health outcomes due to the limited availability of healthcare workers and complete collapse of its healthcare system. The brain drain of health workers and collapse of the healthcare system, and sustained negative health outcomes in the population after the conflict, have been seen in several conflict areas such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947047/">Sierra Leone</a> and <a href="https://www.sciencedirect.com/science/article/pii/S0277953621000836">Yemen</a>. </p>
<p>Here’s what’s needed to address the situation:</p>
<ul>
<li><p>global advocacy and a show of solidarity from the international community</p></li>
<li><p>mobilisation and financial commitment to rebuild the health workforce </p></li>
<li><p>demanding accountability from those who have flagrantly violated international law and ignored global norms around protecting healthcare workers even in times of conflict.</p></li>
</ul><img src="https://counter.theconversation.com/content/192344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fisaha Tesfay works as humanitarian coordinator for Tigrean diasporas living in Australia, New Zealand and East Asia to ease the humanitarian crisis in Tigray </span></em></p><p class="fine-print"><em><span>Fasika Amdesellassie and Hailay Gesesew do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Since the war broke out, some healthcare workers have lost their jobs, others have been displaced, wounded, threatened or killed.Hailay Gesesew, NHMRC Research Fellow (Public Health), Flinders UniversityFasika Amdesellassie, Surgeon, Ayder Hospital, Mekelle UniversityFisaha Tesfay, Postdoctoral Research Fellow, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1735092022-01-19T13:26:47Z2022-01-19T13:26:47ZThree pillars to strengthening health systems in African countries<figure><img src="https://images.theconversation.com/files/441035/original/file-20220117-17-ztsb1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Africa has a growing promising cadre of smart and skilled health experts.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Africa needs, and is ready for, nothing short of a new public health order, with systems better able to prepare for and respond to the next health threat. Having engaged in outbreak response, research, and capacity development in Africa for decades, it is all too clear to us how weak health systems provide fertile ground for the growth and spread of dangerous pathogens. </p>
<p>But also growing during this time is a promising cadre of smart and skilled African health experts. </p>
<p>Now a new health order is required to provide the networking and infrastructure for them to apply their talents for maximum impact. </p>
<p>To attain a new health order, African governments need to bolster investment in research and development, innovation and manufacturing of health tools. This would underpin a strong pharmaceutical industry, which, in our view, is fundamental to creating resilient health systems.</p>
<p>The COVID-19 pandemic has laid bare many of Africa’s challenges in accessing health care. Despite the best intentions, Africa lags far behind the world in COVID-19 testing, vaccination, and therapeutics. The testing rate across Africa is over <a href="https://www.finddx.org/covid-19/test-tracker/">40 times lower</a> than in Europe. Less than <a href="https://ourworldindata.org/covid-vaccinations">10%</a> of the continent’s 1.2 billion people are vaccinated, compared with at least <a href="https://ourworldindata.org/covid-vaccinations">50% of the rest of the world</a>. </p>
<p>This situation has brought home to African countries the need to take matters into their own hands by developing local manufacturing capacity for diagnostics, vaccines, and therapeutics to guide them through the COVID-19 pandemic and beyond. And governments need to work more closely with scientists.</p>
<h2>Manufacturing capacity</h2>
<p>There is a critical need to increase Africa’s capacity to produce vaccines. </p>
<p>There are pharmaceutical companies in 40 of Africa’s 54 countries. But there are <a href="https://carnegieendowment.org/2021/09/13/is-there-any-covid-19-vaccine-production-in-africa-pub-85320">only six production facilities</a> set up or in the pipeline. </p>
<p>According to the World Health Organisation (WHO) only <a href="https://www.afro.who.int/news/what-africas-vaccine-production-capacity">five African countries</a> have full vaccine manufacturing capabilities, all with modest production. For the rest, their contribution is largely limited to “fill and finish” work – formulating active pharmaceutical ingredients and filling and packaging vials.</p>
<p>Virtually all countries producing vaccines depend on external funding to enhance their capacity. South Africa, for example, through the African Union (AU), <a href="https://www.dfc.gov/media/press-releases/dfc-ifc-proparco-and-deg-support-south-african-covid-19-vaccine-maker-aspen">received funding from the US International Development Finance Corporation</a>, and its European partners, to boost its manufacturing capacity.</p>
<p>In 2021 the AU and Africa Centres for Disease Control and Prevention announced the launch of the <a href="https://africacdc.org/news-item/african-union-and-africa-cdc-launches-partnerships-for-african-vaccine-manufacturing-pavm-framework-to-achieve-it-and-signs-2-mous/">Partnerships for African Vaccine Manufacturing</a>. The aim is to use pan-African and global partnerships to scale-up vaccine manufacturing in Africa. The plan is that 60% of African routine immunisation needs will be met on the continent by 2040. </p>
<h2>Partnership between government and scientists</h2>
<p>Governments must work more closely with scientists who have better knowledge and understanding of highly infectious diseases and viruses; and can provide sound advice to guide policy action.</p>
<p>In addition, governments must reduce barriers to health innovation and actively support African researchers and centres involved in the sciences.</p>
<p>One way of ensuring this happens is putting greater energy and resources into public health institutions. An example of such an institution is the <a href="https://pubmed.ncbi.nlm.nih.gov/11116997/">Brazilian Oswaldo Cruz Institute</a>. It was established in 1900 as an immediate response to address Brazil’s greatest health threats at the time. These included the bubonic plague, yellow fever, and smallpox.</p>
<p>These diseases were decimating the population, hindering the economic and social development of the country. The situation was similar to the threat posed by COVID-19 today.</p>
<p>The institution has a remarkably broad range of public health responsibilities. These include:</p>
<ul>
<li><p>hospital and ambulatory care health-related research </p></li>
<li><p>production of vaccines, drugs, reagents, and diagnostic kits</p></li>
<li><p>training health workers and </p></li>
<li><p>providing information and communications related to health, science, and technology.</p></li>
</ul>
<p>The institute offers valuable lessons on how national public health institutions can be strengthened on the African continent. </p>
<h2>Toward short- and long-term solutions</h2>
<p>There is unprecedented momentum to strengthen the public health response in Africa. This includes prioritising vaccine manufacturing, which can further serve as the foundation for the manufacturing of diagnostics and therapeutics. </p>
<p>Prioritising sustainable investments in line with WHO’s <a href="https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf">Health System Pillars </a> offers the potential to reorganise health systems in a way that maximises impact across the entire health landscape in support of addressing COVID-19 and other health issues.</p>
<p>There is no better time than now for Africa to implement a new public health order with strengthened national public health institutions and the Africa Centres for Disease Control and Prevention (Africa CDC) to fight infectious diseases and continue to build towards achieving <a href="https://au.int/en/agenda2063/overview">Agenda 2063</a>. </p>
<p><em>This article is part of a media partnership between the Africa Centres for Disease Control and The Conversation Africa for the first <a href="https://cphia2021.com/">Conference on Public Health in Africa</a>.</em></p><img src="https://counter.theconversation.com/content/173509/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To attain a new health order, African governments need to bolster investment in research and development, innovation and manufacturing of health tools.Charles Shey Wiysonge, Director, Cochrane South Africa, South African Medical Research CouncilDaniel Bausch, Senior Director, Emerging Threats and Global Health Security, FIND, Geneva, Switzerland and Professor, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1733352022-01-19T13:26:33Z2022-01-19T13:26:33ZHow COVID gave African countries the opportunity to improve public health<figure><img src="https://images.theconversation.com/files/441455/original/file-20220119-27-194sbvn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pandemic has engaged ordinary citizens in a way that can only be positive for the future of healthcare.</span> <span class="attribution"><span class="source"> Tshekiso Tebalo/Xinhua via Getty Images</span></span></figcaption></figure><p>The COVID-19 pandemic has tested Africa’s public healthcare systems. It exposed weaknesses, gaps and inequalities – but also some potential solutions.</p>
<p>The challenges presented by the pandemic are an opportunity for African health systems to move beyond their current limitations. Many have been pushed to develop innovative approaches. </p>
<p>Countries rapidly expanded diagnostic capacity and genomics and increased the use of electronic health records. Nations and sectors (public and private) pooled resources in response to the logistical challenges of delivering an adult vaccination programme at pace. Scientific capacity across the continent, while limited, pooled together in effective partnerships.</p>
<p>These experiences, lessons and solutions – if supported by political leadership and long-term financial investment – can be used to develop health systems suited for the 21st century and beyond. African public health and political leaders should be identifying and investing in what works. </p>
<p>As a public health professional working to strengthen health systems across the African continent for many years, I would like to offer some reflections on these emerging opportunities. </p>
<p>A useful framework for these reflections comes from the director of Africa Centres for Disease Control and Prevention (CDC), Dr John Nkengasong. He described <a href="https://www.sciencedirect.com/science/article/pii/S0092867420312381">four essentials</a> for a new public health order for Africa. These are: stronger institutions; local manufacturing; the public health workforce; and respectful partnerships. I would add a fifth: empowered citizens. </p>
<h2>Strengthened public health institutions</h2>
<p>Sharing knowledge and skills has proved to be an effective way to use scarce resources across the continent during the pandemic. Africa CDC has taken the lead as a coordinating institution for the continent in promoting a “do once and share” approach. </p>
<p>The strengths of African scientific and health institutions have been pooled to build up others. For example, Institute Pasteur Dakar Senegal provided training across the continent on PCR testing for COVID-19. This raised <a href="https://africacdc.org/download/quarterly-newsletter-of-the-africa-centres-for-disease-control-and-prevention-december-2020/">capacity for diagnostics</a> from two countries (Senegal and South Africa) in January 2020 to 48 African Union member states by the end of April 2020. </p>
<p>The African Centre of Excellence for Genomics of Infectious Diseases, based in Nigeria, has worked with the Africa CDC’s Africa Pathogen Genomics Initiative to extend the <a href="https://africacdc.org/news-item/africa-cdc-ramps-up-training-on-sars-cov-2-genomics-and-bioinformatics/">skills across the continent</a>.</p>
<p>National public health institutes have grown their capacity to monitor and respond to situations. They’ve built on experience from past epidemics and adopted new technology for faster electronic, event-based information management systems. </p>
<p>The scarcity of supplies during the COVID pandemic has led to the emergence of African solutions to procure resources, from medical equipment to vaccines. </p>
<p>The <a href="https://www.thepresidency.gov.za/newsletters/africa-centres-disease-control-and-prevention-secures-first-tranche-covid-vaccines">Africa Vaccine Acquisition Task Team</a> could be a game changer by improving value for money through pooled procurement and supporting a domestic manufacturing market. </p>
<h2>Local production</h2>
<p>Africa has the <a href="https://www.unaids.org/en/resources/fact-sheet">highest burden</a> of HIV in the world and yet relies on other regions to produce diagnostic tests. Just <a href="https://gh.bmj.com/content/bmjgh/6/6/e006108.full.pdf">1% of Africa’s vaccine needs</a> are domestically produced. It’s similar for drugs to treat African high burden diseases. The lack of diagnostic capacity persists and the story of vaccine inequity is well described.</p>
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Read more:
<a href="https://theconversation.com/new-donation-pledges-wont-fill-global-covid-19-vaccine-shortfalls-heres-why-168789">New donation pledges won't fill global COVID-19 vaccine shortfalls. Here's why</a>
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<p>African leaders have recognised the importance of a health sector manufacturing ecosystem. There is renewed commitment to develop a system to deliver 60% of the continent’s vaccine needs <a href="https://africacdc.org/news-item/african-union-and-africa-cdc-launches-partnerships-for-african-vaccine-manufacturing-pavm-framework-to-achieve-it-and-signs-2-mous/">by 2040</a>. This ambition has stimulated support for the <a href="https://au.int/en/pressreleases/20211109/treaty-establishment-african-medicines-agency-ama-enters-force">Africa Medicines Agency</a>, a body to regulate the manufacture of pharmaceutical products. </p>
<p>A pharmaceutical manufacturing ecosystem on the continent will drive research and development focusing on African health needs. </p>
<h2>Stronger health workforce</h2>
<p>Africa has <a href="https://gh.bmj.com/content/4/Suppl_9/e001115">far fewer</a> health professionals than it needs. The pandemic has shone a light not just on the numbers and cadres of health workforce required, but also on the quality. </p>
<p>At the beginning of the pandemic when the only control measures relied on community engagement - isolation, personal hygiene and contact tracing – community health workers were essential. They now support the COVID-19 vaccination programme. The opportunity exists for them to be absorbed into health systems to support the wider health service. </p>
<p>Pooled training enabled the development of standardised quality healthcare for COVID-19 patients. This approach lends itself to the development of quality guidelines for other priority diseases across the continent.</p>
<h2>Trusted partnerships</h2>
<p>The COVID-19 pandemic has driven unprecedented collaboration between the public and private sectors. The growth in private sector <a href="https://africacdc.org/news-item/us100-million-africa-pathogen-genomics-initiative-to-boost-disease-surveillance-and-emergency-response-capacity-in-africa/">laboratory diagnostic</a> capacity is of note. The COVID-19 response is the first time that private sector capacity has contributed so much to a public health response.</p>
<p>The development of the African Vaccine Acquisition Trust as a centralised purchasing agent on behalf of the African Union <a href="https://africacdc.org/news-item/african-vaccine-acquisition-trust-avat-announces-108000-doses-of-vaccines-arriving-in-mauritius-as-part-of-the-first-monthly-shipment-of-johnson-johnson-vaccines/">member states</a> and the <a href="https://amsp.africa/">Africa Medical Supplies Platform</a> are continental firsts. They show what is possible through strong trusted partnerships. </p>
<p>Collaborations like these can be applied to other challenges in the drive towards universal health coverage. </p>
<h2>Advocacy and empowered citizens</h2>
<p>The COVID-19 pandemic has engaged ordinary citizens in a way that can only be positive for the future of healthcare on the continent. The entire globe and the continent have focused on the same questions. The weak and under-resourced state of African health systems – and the dependence on aid for health services – have been laid bare. </p>
<p>Citizens are <a href="https://theconversation.com/what-sets-good-and-bad-leaders-apart-in-the-coronavirus-era-140013">beginning to challenge</a> their political leadership. The opportunity exists now for their demands to be harnessed to a wider debate about healthcare investment. As electoral cycles come along, health system investment needs to be on the agenda. African heads of state must be challenged to meet the commitments of the <a href="https://au.int/sites/default/files/pages/32894-file-2001-abuja-declaration.pdf">Abuja declaration</a> of April 2001 – to commit at least 15% of annual national budgets to improving the health sector. </p>
<p>The pandemic has demonstrated that improvement is possible even with limited resources. Leaders must build on this momentum to establish a new public health order for Africa. </p>
<p><em>This article is part of a media partnership between the Africa Centres for Disease Control and The Conversation Africa for the first <a href="https://cphia2021.com/">Conference on Public Health in Africa</a>.</em></p><img src="https://counter.theconversation.com/content/173335/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ebere Okereke does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The challenges presented by the pandemic are an opportunity for African health systems to move beyond their current limitations.Ebere Okereke, Senior Technical Adviser, Tony BIair Institute; Honorary Senior Public Health Adviser to the Director Africa CDC and Associate Fellow, Global Health Programme, Chatham HouseLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1686622021-12-15T19:09:35Z2021-12-15T19:09:35ZWe calculated the impact of ‘long COVID’ as Australia opens up. Even without Omicron, we’re worried<figure><img src="https://images.theconversation.com/files/436515/original/file-20211209-25-1xvwosg.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tired-student-doing-homework-home-sitting-1895928658">Shutterstock</a></span></figcaption></figure><p>Over the past two years, we’ve learned COVID-19 survivors can develop a range of longer-term symptoms we now call “<a href="https://theconversation.com/long-covid-a-public-health-experts-campaign-to-understand-the-disease-152212">long COVID</a>”. This includes people who did not have severe illness initially.</p>
<p>Such <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1">longer-term symptoms</a> can affect multiple systems in the body. This can result in ongoing, severe fatigue plus a wide range of other symptoms, including pain, as well as breathing, neurological, sleep and mental health problems.</p>
<p>So far, Australia has had far fewer COVID-19 cases than many other nations. But as we <a href="https://www.australia.gov.au/framework-national-reopening">re-open</a>, this situation may change. So we will likely see more long COVID in the months and years ahead.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-mystery-of-long-covid-up-to-1-in-3-people-who-catch-the-virus-suffer-for-months-heres-what-we-know-so-far-161174">The mystery of 'long COVID': up to 1 in 3 people who catch the virus suffer for months. Here's what we know so far</a>
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<p>Our research, which we posted <a href="https://www.researchsquare.com/article/rs-1066181/v1">online as a pre-print</a> and so has yet to be independently verified, examined the shifting burden of disease of COVID-19 as Australia re-opens and as high vaccination rates reduce mortality and severe illness. </p>
<p>We show how long COVID will increasingly drive the burden of COVID illness, even as death rates decline.</p>
<p>We <a href="https://iht.deakin.edu.au/wp-content/uploads/sites/153/2021/12/Briefing-Paper_Long-Covid_Final.pdf">also estimate</a> the likely numbers of long COVID cases we can expect in Australia over the two years following reopening.</p>
<p>We wrote this <a href="https://iht.deakin.edu.au/wp-content/uploads/sites/153/2021/12/Briefing-Paper_Long-Covid_Final.pdf">briefing paper</a> before the rise of Omicron, the impact of which we’re yet to fully understand. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/will-omicron-the-new-coronavirus-variant-of-concern-be-more-contagious-than-delta-a-virus-evolution-expert-explains-what-researchers-know-and-what-they-dont-169020">Will omicron – the new coronavirus variant of concern – be more contagious than delta? A virus evolution expert explains what researchers know and what they don't</a>
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<h2>Here’s what we did and what we found</h2>
<p>We examined the 2021 Delta outbreaks in <a href="https://www.coronavirus.vic.gov.au/victorian-coronavirus-covid-19-data">Victoria</a> and <a href="https://www.health.nsw.gov.au/Infectious/covid-19/Documents/covid-19-surveillance-report-20211111.pdf">New South Wales</a> in which nearly 140,000 people had been infected by the end of October.</p>
<p>We estimated long COVID prevalence using two sources. A large dataset <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/1april2021">from the UK</a> found more than 13% of people had symptoms after 12 weeks. A much smaller study <a href="https://www.sciencedirect.com/science/article/pii/S2666606521001024?via%3Dihub">conducted in NSW</a> found about 5% had symptoms over roughly the same period.</p>
<p>Our modelling suggests, by the end of October, the combined Victoria and NSW outbreaks may <a href="https://iht.deakin.edu.au/wp-content/uploads/sites/153/2021/12/Briefing-Paper_Long-Covid_Final.pdf">have already led to</a> 9,450–19,800 people having developed long COVID that could last 12 weeks after their COVID infection.</p>
<p>Even more will have experienced long COVID symptoms for a shorter time: 34,000-44,500 people will likely have symptoms for at least three weeks after first becoming ill, but our model indicates more than half will then recover over the following nine weeks.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/will-australia-follow-europe-into-a-fourth-covid-wave-boosters-vaccinating-kids-ventilation-and-masks-may-help-us-avoid-it-172296">Will Australia follow Europe into a fourth COVID wave? Boosters, vaccinating kids, ventilation and masks may help us avoid it</a>
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<p>We also estimated the likely consequences for long COVID if we follow
Australia’s national re-opening plan, based on interim modelling from the <a href="https://www.doherty.edu.au/uploads/content_doc/DOHERTY_MODELLING_INTERIM_REPORT_TO_NATIONAL_CABINET_17TH_SEPTEMBER_2021.pdf">Doherty Institute</a>, which has since been updated.</p>
<p>The Doherty Institute modelled various scenarios with different vaccination rates and public health measures in place. These gave different estimates of COVID-19 cases. We combined these with our upper and lower estimates for long COVID prevalence. </p>
<p>We calculated that more limited relaxation of public health measures could generate 10,000-34,000 long COVID cases (people with symptoms lasting at least 12 weeks). More complete relaxation of public health measures could lead to 60,000-133,000 long COVID cases.</p>
<p>Based on the longer-term UK data for long COVID prevalence, we calculated 2,000-11,000 people might still be sick a year after their initial infection.</p>
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<p>What we cannot be absolutely certain about is the impact of vaccination on the expected number of long COVID cases. Some studies suggest that if vaccinated people become infected, this reduces their chance of developing long COVID, but <a href="https://www.nature.com/articles/d41586-021-03495-2">the evidence remains uncertain</a>. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/we-shouldnt-lift-all-covid-public-health-measures-until-kids-are-vaccinated-heres-why-172625">We shouldn't lift all COVID public health measures until kids are vaccinated. Here's why</a>
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<h2>Many impacts, beyond health</h2>
<p>Long COVID can be a debilitating and distressing health condition. It also has a number of economic impacts, for the health system and people’s ability to work.</p>
<p>For instance, people with long COVID require <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-issues-brief-no-40-managing-long-term-health">coordinated care</a> across a range of different health services and specialties.</p>
<p>Recent data from the UK’s <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/2december2021">Office for National Statistics</a> indicate that around 1.2 million people reported long COVID symptoms in the four weeks to the end of October. The UK health secretary <a href="https://www.independent.co.uk/news/health/sajid-javid-long-covid-nhs-b1934861.html">said he was alarmed</a> at the growing scale of this problem for the National Health Service.</p>
<p>Indeed, attempts to provide long COVID care through specialised hospital-based clinics in the UK and elsewhere have led to <a href="https://www.thetimes.co.uk/article/long-queues-for-long-covid-clinics-jk8jr7tt6">long waiting times and uneven access</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Exhausted health worker leaning on hospital wall holding cup of coffee" src="https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=251&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=251&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=251&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=315&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=315&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436524/original/file-20211209-23-1lleiea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=315&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Health systems will be under strain, particularly if health workers are struggling with long COVID.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-tired-exhausted-nurse-doctor-having-1698233623">Shutterstock</a></span>
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<p>By contrast, Australia needs to <a href="https://ahha.asn.au/publication/health-policy-issue-briefs/deeble-issues-brief-no-40-managing-long-term-health">focus urgently on</a> identifying and counting long COVID. It also needs to establish mechanisms to coordinate care for long COVID by mobilising resources across the community and private sectors, not just public hospitals. </p>
<p>Meeting the emerging needs of people with long COVID represents an additional burden on health-care systems <a href="https://www.mja.com.au/journal/2021/215/11/entering-australias-third-year-covid-19">already battered</a> by COVID and rapidly rising backlogs of care for other conditions.</p>
<p>If health-care workers are <a href="https://pubmed.ncbi.nlm.nih.gov/33830208/">particularly at risk</a> of long COVID as some people claim, this will further stretch health systems as they take time out to recover or leave the workforce.</p>
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<strong>
Read more:
<a href="https://theconversation.com/6-ways-to-prevent-a-mass-exodus-of-health-workers-172509">6 ways to prevent a mass exodus of health workers</a>
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<p>Beyond health care, long COVID again highlights weaknesses which were made clear early in the COVID-19 pandemic, but which have not yet been remedied. </p>
<p>COVID-19 has <a href="https://www.theguardian.com/australia-news/datablog/2021/oct/12/delta-deaths-expose-australias-great-disadvantage-divide">more severely affected</a> those who are socially and economically disadvantaged, and who rely on insecure employment. We expect long COVID to continue to be over-represented in this already disadvantaged population.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/social-media-activism-trucker-caps-the-fascinating-story-behind-long-covid-168465">Social media, activism, trucker caps: the fascinating story behind long COVID</a>
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<h2>Avoiding COVID-19 in the first place</h2>
<p>While societies around the world grapple with addressing the types of disadvantage the pandemic has exposed, there are several steps individual people can take to minimise their risk of long COVID.</p>
<p>Obviously, this means minimising your risk of COVID-19 in the first place. This means vaccination, mask wearing where appropriate, and complying with other public health measures.</p>
<p>Meanwhile, if you test positive for COVID-19, isolate early, rest and do not return to work until you have fully recovered.</p><img src="https://counter.theconversation.com/content/168662/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>We refer in this piece to earlier work we (MH and MRA) undertook to produce an Issues Brief commissioned by the Deeble Institute for Health Policy Research, the research arm of the Australian Healthcare and Hospitals Association. No funding or remuneration was provided by the Deeble Institute or AHHA for that work.</span></em></p><p class="fine-print"><em><span>We refer in this piece to earlier work we (MH and MRA) undertook to produce an Issues Brief commissioned by the Deeble Institute for Health Policy Research, the research arm of the Australian Healthcare and Hospitals Association. No funding or remuneration was provided by the Deeble Institute or AHHA for that work.</span></em></p>More cases of long COVID can put strain on our health system. So we need to think about where and how we offer care.Martin Hensher, Associate Professor of Health Systems Financing & Organisation, Deakin UniversityMary Rose Angeles, Associate Research Fellow, Health System Financing and Sustainability, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1717472021-11-12T13:24:16Z2021-11-12T13:24:16ZSouth Africa’s health system is on its knees: the budget offers no relief<figure><img src="https://images.theconversation.com/files/431645/original/file-20211112-27-tzmyp6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The COVID pandemic highlighted the gaps in South Africa's health system. </span> <span class="attribution"><span class="source">Guillem Sartorio / AFP via Getty Images</span></span></figcaption></figure><p>South Africa’s 2021 <a href="http://www.treasury.gov.za/documents/mtbps/2021/speech/speech.pdf">medium-term budget policy statement</a> was more of the same old narrative. It didn’t speak to the high expectations that the impact of poverty and inequality would feature strongly.</p>
<p>Instead South Africans got: </p>
<blockquote>
<p>be patient, let’s stick to the dream of a primary account surplus, then maybe then we can make the investments needed to implement expanded social security, invest in strengthening the health system and so on. Until then let’s just do more with less. </p>
</blockquote>
<p>Budgets on their own don’t solve structural issues such as the effectiveness of the state. Reducing the wage bill doesn’t address the poor management or budget execution. Instead it increases the execution risk. But they do provide some insight into government plans for addressing its broader developmental priorities.</p>
<p>In South Africa’s case, addressing the impact of poverty and inequality on broader development is and should be our priority. For example, the youth unemployment rate <a href="http://www.statssa.gov.za/?p=14415">is at 60%</a>. This is structural as many of the discouraged job seekers have neither the skills nor the required retraining to access opportunities. The government’s plans will not address this. If a very big growth does arrive it will not benefit these groups, particularly those in rural areas where work opportunities are few.</p>
<p>Given the toll COVID has had on the country’s socio-economic life, including health, there were high expectations that Enoch Godongwana, the Minister of Finance, would signal in the medium term budget policy statement how government planned to mitigate the impact of COVID on the health system.</p>
<p>Indeed, government has invested heavily in mitigating COVID-related risks. Examples include the introduction of a social distress grant, reduced interest rates, and tax incentives to businesses most affected by the lockdown. The investments in vaccine procurement have also been significant. </p>
<p>Government also implemented a number of other public policy measures. These included several regulations to limit the spread of the virus, imposed alcohol bans to reduce the impact of trauma related injuries on the health system, and made significant allocations for vaccines. </p>
<p>But all of this wasn’t enough as <a href="https://www.samrc.ac.za/reports/report-weekly-deaths-south-africa">265,000</a> more people died between March 2020 and November 2021 when compared to deaths from natural causes in previous years. This is almost <a href="https://sacoronavirus.co.za/">three times</a> more that the official number of reported COVID deaths. It will take some time to fully unpack this anecdotal evidence from district health managers who investigated unexplained deaths in facilities. But these figures demonstrated the disruption to services and the need for strategies to address this going forward. </p>
<p>The COVID-related restrictions had some <a href="https://resep.sun.ac.za/examining-the-unintended-consequences-of-the-covid-19-pandemic-on-public-sector-health-facility-visits-the-first-150-days/">unintended consequences</a>. These included restrictions on access to routine health services. A <a href="https://resep.sun.ac.za/examining-the-unintended-consequences-of-the-covid-19-pandemic-on-public-sector-health-facility-visits-the-first-150-days/">survey</a> done in the first 150 days of South Africa’s lockdown in 2020 showed a sharp drop in access to health services. Particularly, access to HIV and tuberculosis testing saw declines of <a href="https://resep.sun.ac.za/examining-the-unintended-consequences-of-the-covid-19-pandemic-on-public-sector-health-facility-visits-the-first-150-days/">up to 50%</a>. </p>
<p>In addition, COVID exposed the inefficiency of South Africa’s parallel health system. Over 50% <a href="https://www.nicd.ac.za/wp-content/uploads/2021/07/COVID-19-Testing-Summary-Week-26-2021.pdf">COVID tests</a> were done in the private sector, despite only <a href="https://www.equinetafrica.org/sites/default/files/uploads/documents/DIS84privfin%20mcintyre.pdf">15% of the population</a> enjoying private medical scheme coverage. More than 40% of <a href="https://www.nicd.ac.za/wp-content/uploads/2021/07/NICD-COVID-19-Weekly-Sentinel-Hospital-Surveillnace-update-Week-24-2021.pdf">COVID-related hospital admissions</a> were in private admissions. Official COVID deaths were also higher in public facilities – often as a result of delayed seeking of care. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/healthcare-in-south-africa-how-inequity-is-contributing-to-inefficiency-163753">Healthcare in South Africa: how inequity is contributing to inefficiency</a>
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<p>Considering all of this, there was an expectation that government would seize the moment and make the necessary investments to improve access to and the responsiveness of the health system. Instead, the budget framework proposed further cuts to an already collapsing public health system.</p>
<p>The <a href="https://www.gov.za/documents/national-health-act">National Health Act</a> defines the governance of the South Africa’s health system, assigning to the three spheres of government - national, provincial and municipal.</p>
<p>The national Department of Health provides a framework for a structured and uniform health system. Provincial departments are responsible for the delivery of healthcare services. They employ most healthcare workers and are dependent on the provincial equitable share of national revenue for the funding of healthcare. The cuts to the provincial equitable share will place further pressure on struggling rural provinces like the Eastern Cape, Limpopo, Northwest, Free State to make the necessary investments to address health inequities. </p>
<h2>Impact of budget cuts on publicly funded healthcare</h2>
<p>The effective governance of health systems depends on good quality data on a number of indicators. These include burden of disease, delivery of health services, outcomes of interventions and advances on equity particularly the limiting of out-of-pocket expenditures.</p>
<p>A <a href="http://www.treasury.gov.za/documents/mtbps/2021/aene/FullAENE.pdf#page=190">National Health Insurance (NHI)</a> indirect grant was introduced to strengthen health management information systems to improve decision making and prioritisation. Cuts to this grant set back this crucial investment in strengthening health system responsiveness. The NHI grant has a history of poor spending. But the grant has been redesigned to support the development of the required infrastructure for the establishment of the NHI Fund.</p>
<p>A <a href="https://academic.oup.com/heapol/article/36/5/639/6209444">recent report</a> by the Medical Research Council looked at the readiness of public hospitals to use <a href="https://hmsa.com/portal/provider/zav_pel.fh.DIA.650.htm">diagnostic related groups</a> - a patient classification system that helps standardise the cost of care. The report highlighted the woeful state of hospital administrative systems. About 40% of hospitals assessed were unable to produce discharge records - among other challenges. Cuts to this NHI indirect grant will compromise efforts to address this. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/water-power-cuts-and-neglect-are-taking-their-toll-on-south-africas-top-hospitals-163897">Water, power cuts and neglect are taking their toll on South Africa's top hospitals</a>
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<p>Then there’s the health revitalisation grant which is meant to support the building of new facilities and refurbishment of existing ones. Its share of the budget remains static over the next three years. Considering the significant overruns in the management of these projects, this may have been an opportunity to reduce expenditure while prioritising the strengthening of organisational systems which the grant also accommodates. Infrastructure investments are essential to improving the health system. But closer consideration should be given to how projects are identified, evaluated and approved. With limited fiscal space, greater priority should be given to revitalising existing infrastructure. </p>
<p>Allocations to the HIV and TB and community outreach grant remain static. But given the need to respond to COVID-related disruptions it is essentially a cut. Furthermore, some consideration should have been given to effectiveness of the current grant. To end HIV as a public health threat the UN had <a href="https://www.unaids.org/en/resources/909090">set targets</a> that by 2020: 90% of people living with HIV must know their status; 90% of people with HIV who know their status must be initiated into treatment and lastly 90% of those initiated into treatment must be virally suppressed. Currently, South Africa scores poorly across the cascade. It needs closer interrogation of what is constraining the response. Continuing to do more of the same is clearly not the way. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/hiv-aids-and-90-90-90-what-is-it-and-why-does-it-matter-62136">HIV, AIDS and 90-90-90: what is it and why does it matter?</a>
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<h2>Abdication of constitutionally mandated obligations</h2>
<p><a href="https://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf">Section 27</a> of the Constitution guarantees everyone the right to healthcare services and commits the government to progressive realisation of this right.</p>
<p>And the budget – the vehicle for making this constitutional guarantee a reality – should be prioritising the interests of the most vulnerable. Instead, it places the interests of the elites ahead of the needs of the majority. </p>
<p>Elites are not reliant on public provision of basic services like education and health care. Private health expenditure matches government health expenditure despite only covering 15 % of the population. Similarly the expansion of low fee private schools will erode the capability of publicly funded education. And the cuts to teacher numbers will not be felt by the elites.</p><img src="https://counter.theconversation.com/content/171747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Russell Rensburg does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Budgets on their own don’t solve structural issues. But they do provide some insight into government plans for addressing its broader developmental priorities.Russell Rensburg, Director Rural Health Advocacy Project, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1706242021-11-03T19:07:22Z2021-11-03T19:07:22ZHealth care contributes 7% to Australia’s carbon emissions – but health is missing from our COP26 plan<figure><img src="https://images.theconversation.com/files/429839/original/file-20211102-13-1qx97py.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C8000%2C5329&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Australia finally has a net zero plan at the Commonwealth level. But so far, health hasn’t been factored into Australia’s national climate response. The federal government has yet to announce plans specific to the sector or, more broadly, the health of Australians.</p>
<p>This is despite <a href="https://www.mja.com.au/journal/2018/209/11/mja-lancet-countdown-health-and-climate-change-australian-policy-inaction">experts</a> warning climate inaction is putting lives at risk and could overwhelm our health system, and Australia’s health sector <a href="https://www.mja.com.au/journal/2021/high-value-health-care-low-carbon-health-care">accounting for 7% of the country’s carbon emissions</a>.</p>
<p>Countries are expected to arrive in Glasgow for the 2021 United Nations Climate Change Conference, known as COP26, with dramatically scaled up commitments to those they pledged in Paris in 2015.</p>
<p>And health is clearly on the agenda. The UK government has announced a <a href="https://cdn.who.int/media/docs/default-source/climate-change/cop26-health-programme.pdf?sfvrsn=cde1b578_10">COP26 Health Programme</a>, calling on governments to commit to climate resilience and low-carbon health systems.</p>
<p>But when it comes to how the health sector is affected by, and contributes to, emissions, Australia’s response is missing in action.</p>
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<h2>Australia’s report card</h2>
<p>The COP26 Health Programme’s rationale is that climate change is driving <a href="https://theconversation.com/climate-change-is-resulting-in-profound-immediate-and-worsening-health-impacts-over-120-researchers-say-151027">poorer health outcomes</a>, increasing <a href="https://theconversation.com/one-in-three-heat-deaths-since-1991-linked-to-climate-change-heres-how-else-warming-affects-our-health-161761">deaths</a>, and health inequities. </p>
<p>But health systems are well placed to be a significant part of the solution and can:</p>
<ul>
<li><p>motivate stronger global ambition to reduce emissions</p></li>
<li><p>help protect people from negative impacts of climate change</p></li>
<li><p>and make a substantial contribution to reducing national and global emissions.</p></li>
</ul>
<p>Australia is one of the most climate-vulnerable places on Earth. A hotter and more hostile climate spells dangers for the human population as well as the natural world. Extreme heat is <a href="https://www.mja.com.au/system/files/issues/215_09/mja251302.pdf">impacting worker productivity, affecting outdoor community and sporting activities</a>, and driving critical workforces, like <a href="https://theconversation.com/too-hot-heading-south-how-climate-change-may-drive-one-third-of-doctors-out-of-the-nt-156959">doctors</a>, away from the Northern Territory.</p>
<p>Health impacts of bushfires and smoke pollution and other extreme weather <a href="https://www.mja.com.au/journal/2020/213/6/unprecedented-smoke-related-health-burden-associated-2019-20-bushfires-eastern">drives up demand for urgent health care</a>. And as we have seen, infectious diseases like COVID <a href="https://theconversation.com/coronavirus-is-a-wake-up-call-our-war-with-the-environment-is-leading-to-pandemics-135023">can render our societies inoperable</a>. </p>
<p>Novel viruses and infectious diseases like COVID are expected to increase in a warming world, and made even more likely <a href="https://theconversation.com/coronavirus-is-a-wake-up-call-our-war-with-the-environment-is-leading-to-pandemics-135023">due to human-caused destruction of natural environments</a> (to feed our unsustainable appetite for “growth”) that otherwise provide a buffer against disease.</p>
<p>And as we now know, when health-care systems are struggling to manage a crisis like COVID, many <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274978/">other health problems get ignored</a>, leading to worsening health outcomes from other causes. </p>
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Read more:
<a href="https://theconversation.com/coronavirus-is-a-wake-up-call-our-war-with-the-environment-is-leading-to-pandemics-135023">Coronavirus is a wake-up call: our war with the environment is leading to pandemics</a>
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<p>A recent <a href="https://d3n8a8pro7vhmx.cloudfront.net/caha/pages/1947/attachments/original/1635387507/CAHA_Framework_2.0__v10__-_DL_28.10.pdf?1635387507">analysis</a> of Australian policy reveals little recognition at the Commonwealth level of the health impacts of climate change. Policy action is only just getting under way at state and territory level.</p>
<p>The federal government’s net zero by 2050 pamphlet, <a href="https://www.industry.gov.au/sites/default/files/October%202021/document/the-plan-to-deliver-net-zero-the-australian-way.pdf">The Australian Way</a>, doesn’t address the risks and opportunities for the health sector, despite its significant <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-51961730180-8/fulltext">contribution to national emissions</a>. This emission contribution is largely from public and private hospitals, which have huge energy demands, largely met by coal-powered electricity. Also, the production of pharmaceuticals is extremely energy intensive.</p>
<p>Australia’s failure to address the health impacts of climate change in its <a href="https://www4.unfccc.int/sites/ndcstaging/PublishedDocuments/Australia%20First/Australia%20NDC%20recommunication%20FINAL.PDF">climate plan</a> recently scored it <a href="https://climateandhealthalliance.org/initiatives/healthy-ndcs/ndc-scorecards/">0/15 compared to other countries</a> by the Global Climate and Health Alliance ahead of COP26. </p>
<p>The Australian government had not integrated health into its climate policies on any of the five measures: health impacts, health in adaptation measures, health co-benefits, economics and finance, or overall.</p>
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<p>Australia’s update to the <a href="https://www.awe.gov.au/sites/default/files/documents/national-climate-resilience-and-adaptation-strategy.pdf">National Climate Resilience and Climate Adaptation Strategy</a> (released quietly, ahead of COP26) mentions health and well-being. But it firmly hands responsibility to state, territory and local governments. </p>
<p>So far, the Queensland government has led the way. It developed a <a href="https://d3n8a8pro7vhmx.cloudfront.net/caha/pages/1573/attachments/original/1536565697/H-CAP_Final.pdf?1536565697">Human Health and Wellbeing Climate Adaptation Plan</a> in 2018, offering high level guidance for managing the health risks of climate change and realising the benefits of climate action.</p>
<p>Victoria recently released a <a href="https://engage.vic.gov.au/aaps-healthandhumanservices">draft Health and Human Services Adaptation Action Plan</a>, as part of its commitments under the state’s <a href="https://www.climatechange.vic.gov.au/victorian-government-action-on-climate-change">Climate Change Act</a>. </p>
<p>In Western Australia, a year-long Climate and Health Inquiry led to a <a href="https://www.mediastatements.wa.gov.au/Pages/McGowan/2020/12/New-health-and-climate-change-framework-for-WA.aspx">comprehensive 2020 report</a>. Climate action is necessary, <a href="https://www.mediastatements.wa.gov.au/Pages/McGowan/2020/12/New-health-and-climate-change-framework-for-WA.aspx">the McGowan government said</a>, “for health system sustainability and [because] the benefits of change far outweigh costs when health is factored in”. Implementation is yet to commence.</p>
<p>New South Wales supports <a href="https://www.sydney.edu.au/medicine-health/our-research/research-centres/climate-change-human-health-and-social-impacts-node.html">human health and social impact research at the University of Sydney</a>, but is yet to release an adaptation plan or strategy.</p>
<p>Other states have announced initiatives but no state-wide plans, yet.</p>
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Read more:
<a href="https://theconversation.com/australia-needs-a-national-approach-to-combat-the-health-effects-of-climate-change-151380">Australia needs a national approach to combat the health effects of climate change</a>
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<h2>Change from the ground up</h2>
<p>Despite an absence of guiding policy, the vast majority of public hospitals and health services in Australia have joined <a href="https://www.greenhospitals.net/">Global Green and Healthy Hospitals</a>. This is an international network of health institutions working to reduce their carbon and environmental footprint. Queensland Health, Victorian Department of Health and the ACT Health Directorate are also members.</p>
<p>Without the national coordination <a href="https://www.caha.org.au/mr2710">called for by health groups</a>, this could lead to a fragmented approach, limit effective adaptation and likely drive up costs.</p>
<p>Last week, over 50 health groups offered <a href="https://www.caha.org.au/mr2710">over 175 recommendations</a> to reduce greenhouse gas emissions in ways that protect and promote health and well-being. They include legislating a 75% cut in emissions by 2030, rapidly phasing out fossil fuels and transport, and decarbonising health care by 2035.</p>
<p>While federal Health Minister Greg Hunt said the federal government’s plan is “<a href="https://www.news.com.au/technology/environment/climate-change/health-medical-groups-say-more-action-needed-to-mitigate-health-risks-of-climate-change/news-story/e9d1c771a1f55c27ac253aca80b451fd">good for health</a>”, health stakeholders are less convinced.</p>
<p>Most countries <a href="https://www.who.int/publications/i/item/who-health-and-climate-change-survey-report-tracking-global-progress">now have national climate and health plans</a>.</p>
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<h2>A leadership vacuum</h2>
<p>The <a href="https://www.croakey.org/cop26-putting-health-on-the-agenda/">recent COP26 Health Roundtable</a> for Australian, New Zealand and Fiji health ministries was attended by seven of the eight states and territories – Tasmania and the federal government didn’t attend.</p>
<p>The roundtable aimed to encourage national and subnational governments to make commitments to developing climate-health adaptation plans and <a href="https://cdn.who.int/media/docs/default-source/climate-change/cop26-health-programme.pdf?sfvrsn=cde1b578_10">low carbon and sustainable health care</a>.</p>
<p>Fiji has made such commitments, which will be announced in Glasgow by World Health Organization (WHO) Director General Dr Tedros Ghebreyesus <a href="https://climateandhealthalliance.org/press-releases/global-climate-and-health-event-to-put-health-and-equity-at-center-of-ambitious-climate-action/">on November 9</a>. But none of Australia’s state, territory or national representatives have yet made the pledge. </p>
<p>The global health community is watching closely. Some 450 organisations, representing 45 million health workers in 102 countries, signed a letter <a href="https://healthyclimateletter.net">sent to all national leaders attending COP26</a> calling for health to be included in all national climate plans.</p>
<p>The WHO has released a report, <a href="https://www.who.int/publications/i/item/cop26-special-report">The Health Argument for Climate Action</a>, with a set of ten priority actions for governments.</p>
<p>These include:</p>
<ul>
<li><p>aligning climate and public health commitments in their COVID recovery plans</p></li>
<li><p>putting health at the centre of the global climate talks</p></li>
<li><p>and prioritising climate interventions that deliver the largest health, social and economic gains.</p></li>
</ul>
<p>We hope the Australian government, and all leaders in Glasgow, are listening.</p><img src="https://counter.theconversation.com/content/170624/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fiona Armstrong is the Executive Director of the Climate and Health Alliance. Climate and Health Alliance receives funding from Lord Mayors Charitable Foundation and Health Care Without Harm, and has previously had grants from Australian Communities Foundation and Community Impact Foundation.</span></em></p>The Australian government may have announced its net zero plan, but it has yet to factor in the health sector or the health of its people.Fiona Armstrong, Executive Director, Climate and Health Alliance; Honorary Associate, Department of Public Health, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1634412021-07-01T15:12:51Z2021-07-01T15:12:51ZCOVID-19 shows why Africa’s reliance on outsiders for health services is a problem<figure><img src="https://images.theconversation.com/files/409084/original/file-20210630-25-1mg1z1w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source"> Gecko Studio/Shutterstock</span></span></figcaption></figure><p>The COVID-19 pandemic has reinforced several truths about the detrimental effects of Africa being over reliant on western and international stakeholders to solve its health challenges and using western solutions to Africa’s health problems.</p>
<p>The continent has suffered heavily from the global COVID-19 supply chain <a href="https://hub.jhu.edu/2020/03/06/covid-19-coronavirus-impacts-global-supply-chain/">crisis</a>. Competitive procurement by governments with deeper pockets has hiked prices of vaccines while national export controls on essential commodities and raw materials have blocked access. These effects were recently <a href="https://www.news24.com/fin24/companies/health/rich-countries-deliberately-kept-vaccines-from-africa-says-telecoms-billionaire-strive-masiyiwa-20210623">highlighted</a> by the African Union special envoy, Strive Masiyiwa.</p>
<p>This is a manifestation of a much larger systemic problem. African countries rely heavily on western funding, products and approaches within their health systems. This includes preventative and diagnostic measures developed for western societies and cultures as well as interventions developed and optimised in the west. One example is the international criteria for the autoimmune disease lupus. My colleagues and I <a href="https://pubmed.ncbi.nlm.nih.gov/30245865/">recently</a> showed that these were set using predominantly white patients and did not capture the unique characteristics of the disease in black Africans. </p>
<p>Another problem is that relying on donor funding means that the funder ultimately determines the health priorities. This is one reason why many programmes in Africa focus on a single disease such as HIV. This approach allows impact evaluating and <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)90079-9.pdf">accountability</a>. But it leads to health workers and services specialised in managing a single disease.</p>
<p>Africa countries need integrated health systems in which priorities and services are decided on, led and owned locally. This is the approach being advocated for by the World Health Organisation for <a href="https://www.who.int/news-room/events/detail/2021/01/28/default-calendar/eliminating-ntds-together-towards-2030-formal-launch-of-the-new-road-map-for-neglected-tropical-diseases">neglected tropical diseases</a>. </p>
<p>Country leadership and ownership of health systems will only come if African governments step up to the plate. And if there’s private investment. Most African countries have pledged to set a target of allocating at least 15% of their annual budget to improve their <a href="https://africanarguments.org/2020/04/19-years-africa-15-health-abuja-declaration/">health sector</a>. <a href="https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?end=2018&locations=ZG&start=2018">None has achieved this</a>. </p>
<p>With the additional COVID-19 damage to health services in <a href="https://www.who.int/news/item/23-04-2021-covid-19-continues-to-disrupt-essential-health-services-in-90-of-countries">90%</a> of African countries, the need to prioritise health in government budget allocations has never been more urgent. </p>
<h2>Unique health needs</h2>
<p>The COVID-19 pandemic has illustrated how African countries have unique health needs. The continent’s population is younger, it has more infectious diseases, a larger rural population, uses both western and traditional medicine, and has cultural practices that affect disease risk.</p>
<p>African countries need a systemic approach targeting training, research, infrastructure, implementation and awareness programmes through the following three ways. </p>
<p>First, countries need to invest in training and retaining health personnel and services appropriate for their needs. Europe has about 40 doctors and 75 nurses per 10,000 people. <a href="https://www.who.int/data/gho/data/themes/topics/health-workforce">Africa has</a> about five doctors and 10 nurses per 10,000 people. This has meant that countries can’t rely on clinical staff for universal health coverage such as COVID-19 testing and screening. </p>
<p>Community health workers have become a critical part of the African health system delivering universal health coverage. They have played an important role in the <a href="https://gh.bmj.com/content/5/6/e002550">COVID-19 pandemic</a>. For example, South Africa drew on its <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284159/">community-orientated primary care</a> staffed by community health workers for disease surveillance and testing.</p>
<p>They should be trained and rewarded appropriately to deliver other forms of interventions such as treatments for neglected tropical diseases and maternal health services. </p>
<p>Second, invest in and promote world class research on African health interventions including herbal medicines and traditional healers to solve African health problems. In Zimbabwe a novel way of providing mental health therapy is a good case in point. The country only has 17 registered psychiatrists for a population of <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30166-8/fulltext">15 million people</a>. A team drew on the African tradition of talking therapy that can be delivered by community health workers as an intervention for mental illness. This therapy, formalised through the <a href="https://www.centreforglobalmentalhealth.org/the-friendship-bench">Friendship Bench</a>, was used to deliver therapy to <a href="https://www.centreforglobalmentalhealth.org/the-friendship-bench">30,000 people in 2017</a>. </p>
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Read more:
<a href="https://theconversation.com/how-a-community-based-approach-to-mental-health-is-making-strides-in-zimbabwe-79312">How a community-based approach to mental health is making strides in Zimbabwe</a>
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<p>One reason the Friendship Bench has been successful is that its effectiveness has been evaluated <a href="https://jamanetwork.com/journals/jama/fullarticle/2594719">in clinical trials</a>. </p>
<p>A significant amount of research has been conducted on <a href="https://www.hindawi.com/journals/ecam/2013/617459/">herbal medicines</a> to identify active ingredients and mechanisms of action. But most have not undergone international standard clinical trials. As a result they are treated with suspicion and inferiority. This is a gap that needs to be filled.</p>
<p>But these trials should be conducted in Africa. This is because genetic, comorbidity and cultural disease risk factors in Africans differ from elsewhere.</p>
<p>For example, Africans are more likely to carry concurrent infectious diseases such as parasitic worms and malaria, possibly with HIV as an underlying condition. An example of different practices is that many women still prefer to deliver their babies with the help of <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1691-7">traditional birth attendants</a>. </p>
<p>In addition, the African Union should insist that drug and vaccine trials carried out in Africa meet international standards to avoid repeating historical <a href="http://news.bbc.co.uk/2/hi/africa/6719141.stm">ethical concerns</a>. This will build trust which underlies willingness to participate in trials. </p>
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Read more:
<a href="https://theconversation.com/africa-must-make-sure-its-part-of-the-search-for-a-coronavirus-vaccine-136531">Africa must make sure it's part of the search for a coronavirus vaccine</a>
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<p>The African Union should also ensure Africans receive the full benefit from clinical trials conducted on the continent by negotiating access to the interventions before granting trial permissions. </p>
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Read more:
<a href="https://theconversation.com/south-african-covid-19-vaccine-trials-hold-key-lessons-for-future-partnerships-154676">South African COVID-19 vaccine trials hold key lessons for future partnerships</a>
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<p>Third, countries must create a permissive environment to support research and innovation. This includes intellectual property and medicines controls policies and competitive markets. Researchers in Africa have <a href="https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-020-04620-8">indicated</a> several barriers to running clinical trials including human capacity, delays in regulatory and ethical reviews, complex logistical and financial systems, bureaucracy and opaque procedures. </p>
<p>The continent already has frameworks for health innovations and most countries have medicines control authorities. These should now be harmonised at continental level through the <a href="https://joppp.biomedcentral.com/articles/10.1186/s40545-020-00281-9">Africa Medicines Agency</a> to facilitate sharing of best practices and transparency. <a href="https://www.nepad.org/news/pharmaceutical-manufacturing-plan-africa">The Pharmaceutical Manufacturing Plan for Africa</a> provides a vehicle for local pharmaceutical production, while the <a href="https://www.un.org/africarenewal/magazine/january-2021/afcfta-africa-now-open-business">African Continental Free Trade Area</a> agreement aims to make African industries more competitive on the global stage. Their implementation needs to be accelerated.</p>
<p>It is clear that as long as African countries don’t produce the health personnel and products Africa’s health system needs, they will be at the <a href="https://gh.bmj.com/content/6/6/e006362">back of the global queue</a> for resources produced abroad.</p><img src="https://counter.theconversation.com/content/163441/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francisca Mutapi receives research funding from National Institute for Health Research (NIHR) through the (NIHR) Global Health Unit ‘Tackling Infectious Diseases to Benefit Africa' at the university of Edinburgh and The Royal Society through a International Collaborative Grant.
Current Board Memberships
Board Member – Uniting to Combat Neglected Tropical Diseases.
Current Membership of international expert/independent advisory committees
1. Sub-Committee for the Hideyo Noguchi Africa Prize, Japanese Government and WHO AFRO.
2. Scientific Advisory Board of the Else-Kröner-Center, Mwanza, Catholic University of Health and Allied Sciences, Tanzania
3. Royal Society of Edinburgh, Member, RSE Post-Covid Futures Commission - Building National Resilience.
4. UK Foreign, Commonwealth & Development Office (Formerly DFID) Science Advisory Group
5. UK Research and Innovation (UKRI) Global Challenges Research Fund Strategic Advisory Group
</span></em></p>Relying on donor funding means that the funder ultimately determines the health priorities. This is one reason why many programmes in Africa focus on a single disease such as HIV.Francisca Mutapi, Professor in Global Health Infection and Immunity. and co-Director of the Global Health Academy, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1386502020-06-28T08:23:28Z2020-06-28T08:23:28ZWhy managing blood pressure matters during COVID-19 pandemic<figure><img src="https://images.theconversation.com/files/343777/original/file-20200624-132972-1n7ou9d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A member of the nursing staff at Chandaria Health Centre in Nairobi, Kenya, measures the temperatures of visiting patients. </span> <span class="attribution"><span class="source">Tony Karumba/AFP via Getty Images</span></span></figcaption></figure><p>Hypertension, or high blood pressure, is a leading cause of <a href="https://www.who.int/news-room/fact-sheets/detail/hypertension">death</a> around the world. It’s also one of the top risk factors causing in premature <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156511/">death</a> and disability. And it’s more common in sub-Saharan Africa than anywhere else in the world: <a href="https://apps.who.int/iris/bitstream/handle/10665/79059/WHO_DCO_WHD_2013.2_eng.pdf;jsessionid=A6FE3BEFC68CE82550A2874026C49272?sequence=1">46%</a> of the region’s adults over the age of 25 have hypertension. </p>
<p>Unfortunately the region also has a high burden of communicable diseases, such as HIV, tuberculosis, cholera and measles. These often get the most urgent attention from health authorities, instead of hypertension. </p>
<p>Healthcare systems across the region are short of <a href="https://www.afro.who.int/news/what-needs-be-done-solve-shortage-health-workers-african-region">health workers</a>. They have unreliable medical supply systems, and wide variance in quality and safety of care being provided. The result is that for many people, hypertension care is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2615747/">sub-standard</a>. And the challenges have only gotten greater because of the need to divert healthcare efforts towards the <a href="https://theconversation.com/africa/covid-19">COVID-19 pandemic</a>. </p>
<p>Health facilities have been tested in ways they did not anticipate. The growing <a href="https://africacdc.org/covid-19/">number</a> of cases of the new disease threatens the capacity to provide adequate care for patients with <a href="https://theconversation.com/coronavirus-risks-forcing-south-africa-to-make-health-trade-offs-it-can-ill-afford-136301">other medical conditions</a>. </p>
<p>The COVID-19 impact on hypertension care is already being felt in Kenya as non-communicable disease <a href="https://www.youtube.com/watch?v=_XabzLvxop8">clinics have been closed</a> in some areas since the beginning of the outbreak. These clinics provide care to people with hypertension, diabetes and other noncommunicable diseases. Their closure threatens to curtail the gains made against these conditions. It’s now difficult for patients to get treatment and routine check-ups. It means that they could miss early detection and management of <a href="https://theconversation.com/chronic-conditions-worsen-coronavirus-risk-heres-how-to-manage-them-amid-the-pandemic-136037">health problems</a>.</p>
<p>Managing hypertension matters in the fight against COVID-19 too. What’s known about COVID-19 so far suggests that people with <a href="https://jamanetwork.com/journals/jama/fullarticle/2765184">pre-existing</a> conditions such as hypertension, diabetes and heart disease can experience severe complications when infected with SARS-CoV-2, the virus that causes COVID-19. </p>
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<a href="https://theconversation.com/kenya-cant-afford-to-neglect-people-with-underlying-conditions-during-covid-19-137095">Kenya can't afford to neglect people with underlying conditions during COVID-19</a>
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<h2>Addressing the problem</h2>
<p>Uncontrolled hypertension is known to put people at risk of life-threatening cardiovascular <a href="https://apps.who.int/iris/bitstream/handle/10665/79059/WHO_DCO_WHD_2013.2_eng.pdf;jsessionid=A6FE3BEFC68CE82550A2874026C49272?sequence=1">complications</a> such as stroke and heart disease. Taking anti-hypertensive <a href="https://www.ncbi.nlm.nih.gov/pubmed/9042847">treatment</a> substantially <a href="https://www.ncbi.nlm.nih.gov/pubmed/8884546">reduces</a> the risk of <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1511939">illness</a> and death related to uncontrolled hypertension.</p>
<p>In 2015, Kenya conducted the STEPwise survey, which brought together a lot of information about non-communicable disease risk factors. It provided the first nationally representative picture of hypertension in the country, including its prevalence, awareness, treatment and control. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219055/">study</a> found that about a quarter of Kenyan adults between the ages of 18 and 69 had hypertension.</p>
<p>Since the release of the report, the government of Kenya has developed a set of <a href="https://www.health.go.ke/wp-content/uploads/2018/06/Cardiovascular-guidelines-2018_A4_Final.pdf">guidelines</a> and <a href="https://www.sciencedirect.com/science/article/pii/S2211816019300122">interventions</a> have been carried out. </p>
<p>Recently, however, most facilities have shifted their priorities to COVID-19 cases. The curfews that are still in effect in Kenya also affect the working hours of clinics. This has an impact on hypertension care services. </p>
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Read more:
<a href="https://theconversation.com/chronic-conditions-worsen-coronavirus-risk-heres-how-to-manage-them-amid-the-pandemic-136037">Chronic conditions worsen coronavirus risk – here's how to manage them amid the pandemic</a>
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<h2>What needs to be done</h2>
<p>The government must establish guidelines on the management of hypertensive patients during the COVID-19 pandemic. These should provide alternatives to hospital and community based care, such as mobile phone consultations, mobile clinics or telemedicine. </p>
<p>Patients should have access to routine follow-up and people at risk of developing it must have options for screening. Access to emergency care must be available at any time considering lockdowns and curfews put in place.</p>
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Read more:
<a href="https://theconversation.com/ready-to-see-your-doctor-but-scared-to-go-here-are-some-guidelines-140291">Ready to see your doctor but scared to go? Here are some guidelines</a>
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<p>Mechanisms should be put in place to ensure patients can still get their anti-hypertensive medication and supplies, especially if they are poor and vulnerable. This should include strengthening supply chains and allowing pharmacists to extend ordinary prescriptions. The result will be fewer emergencies and less need for patients to interact with care providers.</p>
<p>Health education must continue to improve awareness about prevention and management of hypertension. This can be done by the community based and other non-governmental organisations currently delivering social care services to vulnerable populations. Messages can also be sent via phones through collaboration between mobile service and healthcare providers.</p>
<p>In these unprecedented times many people are <a href="https://theconversation.com/how-to-manage-your-blood-pressure-in-isolation-135958">confined</a> in their homes. It is now more important than ever for people with hypertension to maintain a healthy lifestyle, reduce stress levels and, more importantly, continue taking their prescribed medications.</p>
<p>Even in countries with weak health systems, a lot can be done to keep essential services going. Strategic coordination and management will go a long way towards keeping people well during the response and recovery phases of the pandemic.</p><img src="https://counter.theconversation.com/content/138650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shukri F. Mohamed does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most facilities prioritize COVID-19 cases. In addition, curfews are still in effect in Kenya, which affects the working hours of clinics providing hypertension care services.Shukri F. Mohamed, Research officer, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1358622020-04-16T14:20:00Z2020-04-16T14:20:00ZAfrica’s health systems should use AI technology in their fight against COVID-19<figure><img src="https://images.theconversation.com/files/327630/original/file-20200414-117583-17rfil9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A doctor measures a worker's temperature in Kitui, Kenya. With technology, AI and human resources, Africa's health systems can take on COVID-19.</span> <span class="attribution"><span class="source">Photo by LUIS TATO/AFP via Getty Images</span></span></figcaption></figure><p>COVID-19 and its <a href="https://theconversation.com/africa/covid-19">grave impact</a> worldwide has emphasised just how critical it is for African countries to develop their healthcare systems. For the most part, these systems are <a href="https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS">woefully underfunded</a> and <a href="https://worldpopulationreview.com/countries/best-healthcare-in-the-world/">understaffed</a>.</p>
<p>It will take many different approaches to repair these systems. Given my area of expertise and <a href="https://scholar.google.com/citations?hl=en&user=B2uyXAUAAAAJ&view_op=list_works&sortby=pubdate">my research focus</a>, I am interested in the role that Artificial Intelligence (AI) might play in bolstering the continent’s health systems.</p>
<p>AI embodies the field of knowledge that seeks to create machines (computers) that can emulate human cognitive functions such as learning, reasoning, understanding, vision, perception, recognition, and problem solving to a reasonable level. Computers that have AI capabilities are currently being used in several <a href="https://www.forbes.com/sites/bernardmarr/2019/12/16/the-10-best-examples-of-how-ai-is-already-used-in-our-everyday-life/#3cacbb8f1171">real-world</a> domains to solve problems. </p>
<p>We know that AI can be used effectively in healthcare. Since 1972, when the first AI system for medicine, known as <a href="https://www.britannica.com/technology/MYCIN">MYCIN</a>, was created, more sophisticated systems <a href="https://builtin.com/artificial-intelligence/artificial-intelligence-healthcare">have evolved</a>. Today AI technologies are used to help detect and treat diseases; predict the growth of the disease, and help doctors to <a href="http://sitn.hms.harvard.edu/flash/2019/artificial-intelligence-in-medicine-applications-implications-and-limitations/">make better decisions</a>. With <a href="https://www.geopoll.com/blog/mobile-phone-penetration-africa/">the rise</a> of mobile technologies like phones and tablets, even in rural areas, AI’s potential for use in rural healthcare is growing.</p>
<p>In previous studies I conducted with some of my colleagues, we explored how to apply this potential while considering ethical and practical issues. Two of the studies <a href="http://eprints.covenantuniversity.edu.ng/12722/1/Binder1.pdf">focused on</a> <a href="http://dx.doi.org/10.33965/eh2019_201910l006">disease diagnosis and treatment</a>. Two others <a href="https://ieeexplore.ieee.org/abstract/document/8908213">considered</a> how AI <a href="https://link.springer.com/content/pdf/10.1007%2F978-3-030-45002-1_35.pdf">might be used</a> to monitor and improve people’s adherence to medication regimens.</p>
<p>So, how could the lessons from my research and from existing AI healthcare initiatives be applied during the current fight against COVID-19?</p>
<h2>Some AI applications</h2>
<p>For starters, I must make clear that I’m not suggesting AI is the silver bullet that will solve all of the continent’s healthcare issues. Instead, AI initiatives should be developed in conjunction with spending on infrastructure and training. AI can supplement the efforts of available medical personnel – and help keep them safe.</p>
<p>AI has already played a significant role in each stage of fighting the COVID-19 pandemic. Some areas where we saw immediate applications include the processing of large amounts of data to find patterns that could lead to the discovery of potential treatment drugs; as well as <a href="https://www.geekwire.com/2020/ai-helping-scientists-fight-covid-19-robots-predicting-future">treating infected people</a>. </p>
<p>In China, <a href="https://www.telegraph.co.uk/global-health/science-and-disease/engineers-develop-robots-treat-test-covid-19-patients-bid-protect/">robots were used</a> to test and treat COVID-19 patients while healthcare workers stood at a safe distance to minimise the risk of infection. The analysis of large volumes of medical records data using AI <a href="https://jamanetwork.com/journals/jama/fullarticle/2762689">allowed Taiwan</a> to identify people at a high risk of COVID-19 infection; they were then contacted and advised about how to lower that risk.</p>
<p>In the US, <a href="https://newatlas.com/automotive/autonomous-shuttles-covid-19-test-mayo-clinic/">self-driving bus shuttles</a> have been used to transport COVID-19 tests from one point to another to protect healthcare workers from infection and to enable them to use more of their time to attend to patients’ direct treatment needs. </p>
<p>Some other types of AI technologies have already been deployed as part of the global response to COVID-19. These range from <a href="https://www.channelnewsasia.com/news/singapore/covid19-trace-together-mobile-app-contact-tracing-coronavirus-12560616">tracking</a> the movement of people to curb transmission through contact by seeking to know who they have been with, and not just where they have been, to the development of an <a href="https://www.geekwire.com/2020/ai2-microsoft-team-tech-leaders-use-ai-war-coronavirus/">AI-powered database</a> that will help enable researchers to quickly discover literature resources that are related to coronavirus and its cure.</p>
<p>As shown in the Chinese example, computer systems or robots can be used to screen people for COVID-19. This will reduce the risk of medical professionals being infected, which is important given that they are at high risk of infection. In rural contexts, this is especially key: these areas are already battling with <a href="http://www.chwcentral.org/sites/default/files/People%20First-%20African%20solutions%20to%20the%20health%20worker%20crisis.pdf">staff shortages</a> and having medical staff fall ill leaves the areas more vulnerable.</p>
<p>Other options that could be considered for rural African contexts include simple AI systems that can respond when a sick person sends a text message or a voice note from a mobile phone describing their symptoms. The response might be what kind of drugs to take, or where to find help in their area.</p>
<h2>Ethical considerations</h2>
<p>There are ethical concerns when using any AI technology. Issues of accountability (who takes the liability/credit), privacy and protection of personal information, informed consent, trust, and social implications <a href="https://www.oatext.com/some-ethical-and-legal-consequences-of-the-application-of-artificial-intelligence-in-the-field-of-medicine.php">are important</a> when using AI for healthcare.</p>
<p>It will not be enough for African countries to merely roll out AI systems. They must also each develop an ethical framework that will guide the use of these systems, both as they relate to COVID-19 and more broadly.</p>
<p>The framework must be contextual and should stipulate when, where, and how AI systems should be deployed for healthcare to ensure ethical and responsible usage.</p>
<p>Also, there must be new laws and policies to regulate the use of AI in healthcare, similar to those that are already in place or in development in <a href="https://www.lexology.com/library/detail.aspx?g=0eb1137d-b52c-445e-aade-2d1c49701453">the EU</a>, US, and Singapore. This will provide the legal backing and framework that is needed to cater for lawsuits that may arise from the use of AI systems. </p>
<p>All of this will lay the much-needed foundation for the adoption of AI for healthcare in Africa, and particularly for rural healthcare. It will also help prepare for future exigencies in the mode of COVID-19.</p><img src="https://counter.theconversation.com/content/135862/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine Olawande Daramola receives funding from the Cape Peninsula University of Technology (CPUT), National Research Foundation (NRF), and International Grant Donor agencies such as the National Institute of Health (NIH), and the Bill Gates Foundation. </span></em></p>AI can supplement the efforts of available medical personnel - and help keep them safe.Olawande Daramola, Prof, Cape Peninsula University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1324482020-02-27T18:58:18Z2020-02-27T18:58:18ZIt’s now a matter of when, not if, for Australia. This is how we’re preparing for a jump in coronavirus cases<figure><img src="https://images.theconversation.com/files/317488/original/file-20200227-24651-og4taa.jpg?ixlib=rb-1.1.0&rect=18%2C0%2C6221%2C4154&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/coronavirus-china-novel-2019ncov-people-white-1629512083">Shutterstock</a></span></figcaption></figure><p>While countries around the globe have been taking precautions to prevent the spread of COVID-19, the disease caused by the novel coronavirus, it has now been reported in <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200226-sitrep-37-covid-19.pdf?sfvrsn=6126c0a4_2">37 countries</a> outside China. </p>
<p>As of February 26, close to <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports">3,000 cases and 43 deaths</a> had been recorded outside China. In Australia, we’ve so far seen <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert">23 cases</a> across five states.</p>
<p>The good news is currently there’s no evidence of “community transmission” of the virus in Australia. This means it’s not spreading locally. All cases have had travel connections to China or the Diamond Princess cruise ship, or very close contact with a confirmed case in Australia (being in the same family or tour group).</p>
<p>But as the list of countries with community transmission increases – it’s happening in <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200226-sitrep-37-covid-19.pdf?sfvrsn=6126c0a4_2">South Korea</a>, which has more than 1,200 cases, and <a href="http://www.salute.gov.it/portale/nuovocoronavirus/dettaglioNotizieNuovoCoronavirus.jsp?lingua=italiano&menu=notizie&p=dalministero&id=4112">Italy</a>, which has 400 – so too does the risk of an escalation in Australia. It’s now a matter of “when” local transmission occurs, not “if”.</p>
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Read more:
<a href="https://theconversation.com/is-the-coronavirus-a-pandemic-and-does-that-matter-4-questions-answered-131128">Is the coronavirus a pandemic, and does that matter? 4 questions answered</a>
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<p>In this climate, the Australian government has developed a national <a href="https://www.health.gov.au/resources/publications/australian-health-sector-emergency-response-plan-for-novel-coronavirus-covid-19">emergency response plan</a>, which takes us through three phases. Prime Minister Scott Morrison <a href="https://www.abc.net.au/news/2020-02-27/federal-government-coronavirus-pandemic-emergency-plan/12005734">yesterday announced</a> we are activating this plan.</p>
<h2>Phase 1</h2>
<p>The current “Initial Action” stage of the COVID-19 plan focuses on preventing introduction and establishment of the disease in Australia through border measures and social distancing. These are measures designed to keep infected (or potentially infected) people away from healthy people.</p>
<p>In an effort to contain COVID-19 and delay it becoming established in Australia, the Australian government banned the entry of foreign nationals (excluding permanent residents) who had been in mainland China in the last 14 days. This ban has now been <a href="https://www.abc.net.au/news/2020-02-27/federal-government-coronavirus-pandemic-emergency-plan/12005734">extended</a> to March 7.</p>
<p>The return of Australian residents from China, and more recently <a href="https://www.abc.net.au/news/2020-02-22/coronavirus-ban-lifted-students-travel-china-to-australia/11991292">year 11 and 12 students</a> studying in Australia, has been strictly controlled. </p>
<p>People returning are required to go into home quarantine for 14 days after they leave China.</p>
<p>And at this stage, university students from China must spend 14 days in <a href="https://www.abc.net.au/news/2020-02-24/coronavirus-travel-ban-students-relieved-to-be-back-in-australia/11993586">a third country</a> before arriving in Australia.</p>
<p>Other countries have imposed their own border restrictions, as well as <a href="https://www.who.int/ith/2019-nCoV_advice_for_international_traffic/en/">screening people for illness</a> before they enter. These measures have undoubtedly slowed the spread of COVID-19 throughout the world and delayed its progression to a pandemic.</p>
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<img alt="" src="https://images.theconversation.com/files/317494/original/file-20200227-24659-1rcsfl7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317494/original/file-20200227-24659-1rcsfl7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317494/original/file-20200227-24659-1rcsfl7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317494/original/file-20200227-24659-1rcsfl7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317494/original/file-20200227-24659-1rcsfl7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317494/original/file-20200227-24659-1rcsfl7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317494/original/file-20200227-24659-1rcsfl7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The first stage of Australia’s emergency plan aims to keep coronavirus out of the country as much as possible.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<h2>Phase 2</h2>
<p>The true clinical severity of this disease remains highly uncertain, but overall it appears <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12034">less severe</a> than the 1918–19 influenza pandemic or SARS and more severe than the pandemic flu in 2009.</p>
<p>Importantly though, compared to other epidemic and pandemic diseases, COVID-19 is considered <a href="https://www.health.gov.au/resources/publications/australian-health-sector-emergency-response-plan-for-novel-coronavirus-covid-19">highly transmissible</a>, so a large number of cases is likely.</p>
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Read more:
<a href="https://theconversation.com/yes-australians-on-board-the-diamond-princess-need-to-go-into-quarantine-again-its-time-to-reset-the-clock-131906">Yes, Australians on board the Diamond Princess need to go into quarantine again. It's time to reset the clock</a>
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<p>Given ongoing uncertainties, the plan doesn’t articulate the number of cases that would need to be diagnosed for the second phase, “Targeted Action”, to be enacted. The plan simply stipulates public health activities need to be balanced (or “proportionate”) to the magnitude and severity of the pandemic.</p>
<p>We would expect phase two to be put into place when we’re seeing community transmission occurring in Australia.</p>
<p>In this second phase, the current strict border measures and quarantine for arrivals will likely be relaxed as “keeping it out” becomes futile. The focus will shift to minimising spread within Australia and limiting the health, social and economic impact of the disease.</p>
<p>Australians might see a public health response like we’ve seen in Italy. This could include cancellation of large local gatherings (sporting matches and festivals), closure of schools, universities and some workplaces, and strict local travel restrictions.</p>
<p>Community members will be asked to take responsibility for their own “social distancing” if they have mild disease or have been in close contact with someone with the virus (by self-isolating or self-quarantining at home). </p>
<p>These measures, while disruptive to individuals and households, have been highly effective to date in preventing community transmission of COVID-19 in Australia and will remain very important throughout the response to this disease.</p>
<p>As case numbers rise, case management will need to be streamlined to make best use of finite resources within the health system, including personnel, primary care and hospital capacity and personal protective equipment. Options include greater use of fever assessment clinics, caring for COVID-19 patients together on wards, and keeping people out of hospitals and emergency departments if they don’t require that level of care.</p>
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Read more:
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<p>The government, public health experts and clinicians will actively review and be guided by new information to determine exactly which of these clinical and public health measures to put in place.</p>
<p>While many mild cases have been admitted to hospital during the containment phase, community-based care will be the reality for most people as we become more familiar with this disease and its usual course. This approach will allow us to provide higher levels of clinical care for those at greatest risk of poor outcomes, such as older people.</p>
<h2>Phase 3</h2>
<p>It’s likely, but not certain, that COVID-19 will remain in circulation beyond 2020 and become “endemic” in Australia – that is, here for good. But once the peak has passed (that’s when there’s a declining number of new infections and less demand on hospitals), the COVID-19 plan will move into the “Standdown” phase, which is essentially a return to “business as usual”. </p>
<p>We have a huge challenge ahead of us, but the measures we all take can make a big difference to how this plays out. Whether it’s isolation and quarantine or simply frequent handwashing and good cough etiquette, we can all help protect ourselves, our families, and the most vulnerable in society.</p>
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Read more:
<a href="https://theconversation.com/heres-why-the-who-says-a-coronavirus-vaccine-is-18-months-away-131213">Here's why the WHO says a coronavirus vaccine is 18 months away</a>
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<img src="https://counter.theconversation.com/content/132448/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine Gibney receives funding from the Australian Government National Health and Medical Research Council (Early Career Fellowship) and the Royal Australasian College of Physicians (RACP GSK Research Establishment Fellowship). </span></em></p><p class="fine-print"><em><span>Jodie McVernon receives funding from the Australian Government National Health and Medical Research Council, and the Australian Government Departments of Health and Foreign Affairs and Trade. </span></em></p><p class="fine-print"><em><span>Brett Sutton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are three phases to Australia’s response plan. The ‘Initial Action’ stage, the ‘Targeted Action’ stage, and finally, the ‘Standdown’ stage. Right now, we’re in the first.Katherine Gibney, NHMRC early career fellow, The Peter Doherty Institute for Infection and ImmunityBrett Sutton, Adjunct Clinical Professor, Monash UniversityJodie McVernon, Professor and Director of Doherty Epidemiology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1249572019-10-21T15:13:25Z2019-10-21T15:13:25ZInvesting in health systems is the only way to stop the next Ebola outbreak<figure><img src="https://images.theconversation.com/files/297649/original/file-20191018-56220-yk8az0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">UNICEF carers at a creche for children whose parents are being treated for Ebola. Building health infrastructure is crucial to stopping the next outbreak.</span> <span class="attribution"><span class="source">Epa/ Hugh Kinsella Cunningham</span></span></figcaption></figure><p>The ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC) recently surpassed <a href="https://www.who.int/csr/don/10-october-2019-ebola-drc/en/">3,000 infections</a>. The outbreak had been <a href="https://www.who.int/csr/don/4-august-2018-ebola-drc/en/">raging for nearly a year</a> by the time it was declared a <a href="https://www.nytimes.com/2019/07/17/health/ebola-outbreak.html">“public health emergency of international concern”</a> in July. </p>
<p>Why, after all the lessons learnt in the DRC as well as earlier in West Africa, does it remain so difficult to prevent a small outbreak from becoming an emergency?</p>
<p>Since the West African epidemic, which <a href="https://apps.who.int/iris/bitstream/handle/10665/208883/ebolasitrep_10Jun2016_eng.pdf?sequence=1">killed more than 11,000 people</a> between 2014 and 2016, governments and philanthropists have invested in tools to respond to Ebola-like outbreaks. Health authorities have refined their protocols and practices. And in the intervening years Ebola vaccines and treatments have become more readily available for outbreak response. </p>
<p>The emergency in the DRC demonstrates that despite all these positive changes, the global response to containing Ebola outbreaks is undermined by the lack of health care and public health infrastructure. </p>
<p>The DRC has <a href="http://apps.who.int/gho/portal/uhc-country.jsp">among the weakest basic health infrastructure in the world</a>, with only about one doctor per 10,000 people and 55-65% access to essential medicines like antibiotics and insulin. Health facilities themselves have <a href="http://apps.who.int/healthinfo/systems/datacatalog/index.php/ddibrowser/54/download/165">limited resources for controlling infection</a>: 20% of health facilities lack latex gloves, and only half stock disinfectants.</p>
<p>Public health capacity is just as poorly equipped to handle an outbreak. As of 2016, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5711307/">only three of the DRC’s 517 districts</a> had a qualified field epidemiologist. Such front-line personnel are critical to detect and contain outbreaks.</p>
<p>Without developing the stability and capacity of these systems in the DRC – and other countries at risk – more outbreaks are inevitable. And without infrastructural investments, we are likely to continue to detect outbreaks too late to contain easily. </p>
<p>But it needn’t be this way. We can prevent new outbreaks of Ebola the same way we’ve prevented cholera, plague, measles, and the other infectious diseases that only persist under poverty and neglect. It requires building the capacity of health systems on the ground.</p>
<h2>Time is of the essence</h2>
<p>The outbreak that was announced in the DRC last August had likely been <a href="https://apps.who.int/iris/bitstream/handle/10665/325883/SITREP_EVD_DRC_20190714-eng.pdf?ua=1">ongoing for at least four months</a>. This meant that by the time international authorities could react, cases were already scattered and difficult-to-track, and the growth of the epidemic was already out of control.</p>
<p><a href="https://www.who.int/csr/don/4-august-2018-ebola-drc/en/">Many of the first few dozen infected people,</a> who fell ill between about April and August last year, must have demonstrated classic Ebola symptoms such as high fever, bleeding, and multiple organ failure. But these extreme symptoms went undetected and uncontrolled because the people didn’t have access to basic health services.</p>
<p>This illustrates the problem: that few early Ebola cases in the DRC are likely to have access to a facility with the tools for accurate diagnosis of a rare disease. And even where there are health facilities, they are unlikely to have the resources to protect their workers against infection or to properly sanitise surfaces. </p>
<p>Just as critically, once the disease has started to spread, there are not enough local public health officials around to quickly raise the alarm and implement effective interventions such as quarantines, safe burials, and community engagement. </p>
<p>The failure to detect early cases isn’t once-off oversight. It’s a systemic problem. </p>
<p>A <a href="https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0007428">study we published this summer</a> with colleagues at the University of Cambridge suggested that most outbreaks are never detected or reported as Ebola. We also estimated that, on average, the first case of any outbreak has less than a 10% chance of being detected. Without diagnostics, most of these cases are likely treated as other more common fevers, such as malaria or typhoid.</p>
<p>An example of the difference basic infrastructure and health services can make can be found across the border in Uganda. It has <a href="https://www.who.int/healthinfo/systems/SARA_H_UGA_Results_2014.pdf?ua=1">a much greater ability</a> to prevent infections from spreading. Almost all facilities have access to gloves and disinfectant. They also have more consistent access to essential medicines, diagnostic tools, and public health workers trained in hemorrhagic fever response. </p>
<p>These very basic resources have dramatic affect. Uganda is <a href="https://www.cdc.gov/vhf/ebola/history/chronology.html#anchor_1526565114626">one of the only countries</a> in West and Central Africa to report isolated cases of Ebola. And its responses to contain cases from the DRC have been <a href="https://www.who.int/csr/don/11-july-2019-ebola-drc/en/">swift and effective</a>.</p>
<p>But investment in health infrastructure remains difficult to sell to decision makers. </p>
<h2>What’s needed</h2>
<p>Attitudes are <a href="https://science.sciencemag.org/content/361/6404/eaat9644">slowly changing</a>. But the global health community has a history of obsession with <a href="http://dx.doi.org/10.1056/NEJMp1014255">“vertical” interventions</a>. These, like mosquito nets and other strategies to control a single problem cheaply, are easy to measure and economically efficient.</p>
<p>By contrast, lifting basic public health infrastructure to the level necessary to control disease outbreaks, can seem like an impossible and immeasurable goal. Nevertheless, it still may be more affordable in the long run than the status quo. </p>
<p>The <a href="https://www.bloomberg.com/news/articles/2019-07-23/ebola-budget-set-to-triple-as-international-risk-grows-who-says">$324 million the World Bank committed</a> to fighting the DRC outbreak <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5711307/">could fund training</a> and <a href="https://academic.oup.com/heapol/article/31/9/1143/2452978">20 years of salary</a> for specialised epidemiologists in each district of the DRC. The <a href="https://www.bmj.com/content/350/bmj.h376.full">billions of dollars</a> spent fighting the 2014-2016 epidemic could be transformative.</p>
<p>Basic health infrastructure is the only way to consistently prevent Ebola. It’s important for other reasons too. </p>
<p>Measles – a disease easily prevented by a cheap vaccine – has <a href="https://theconversation.com/outbreaks-of-measles-compounding-challenges-in-the-drc-124660">killed more people in the DRC this year</a> than Ebola has. <a href="https://newrepublic.com/article/154708/ebola-outbreaks-inequality">Residents of Ebola-affected regions often wonder</a> why Ebola gets so much more attention than measles, conflict, or poverty. All of these take more lives, more consistently. </p>
<p>All could be improved by more consistent international support, not just when an outbreak catches our imaginations.</p>
<p>Ebola epidemics aren’t inevitable. To prevent Ebola, we must invest in health systems, not just reactive Ebola responses.</p><img src="https://counter.theconversation.com/content/124957/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emma Glennon receives funding from the Gates-Cambridge Trust and owns shares in a start-up (Univursa) that builds tools for outbreak responses.</span></em></p><p class="fine-print"><em><span>Freya Jephcott receives funding from Queens' College and the University of Cambridge and owns shares in a start-up (Univursa ) that builds tools for outbreak responses.</span></em></p>The emergency in the DRC shows that despite all these positive changes, the global response to containing Ebola outbreaks is undermined by the lack of health care and public health infrastructure.Emma Glennon, PhD candidate, University of CambridgeFreya Jephcott, Research fellow, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1241832019-09-30T13:40:13Z2019-09-30T13:40:13ZLessons from Rwanda on how trust can help repair a broken health system<figure><img src="https://images.theconversation.com/files/294043/original/file-20190925-51405-nrqs3d.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C895%2C1000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Niyazz/Shutterstock</span></span></figcaption></figure><p>Seven countries around the world – three of them in Africa – have made faster than expected progress over the past 15 years in reducing <a href="https://data.unicef.org/topic/child-survival/under-five-mortality/">deaths among children younger than five</a>. These seven countries, Bangladesh, Cambodia, Ethiopia, Nepal, Peru, Rwanda and Senegal, were selected because they have all performed unexpectedly well in improving childhood health relative to their <a href="https://data.worldbank.org/indicator/NY.GDP.PCAP.KD.ZG">economic growth</a>. </p>
<p>There are many factors at the root of their achievements, most notably, a strong integrated and coordinated health system built on primary health care. However, one cross-cutting factor stands out that we believe allowed them all to achieve significant health gains but which, so far, tends to be always overlooked: trust.</p>
<p>This is clear from a <a href="https://wellcome.ac.uk/sites/default/files/wellcome-global-monitor-2018.pdf">report</a>, published by the Wellcome Trust and the Gallup Institute earlier this year. It surveyed 140,000 people in 140 countries to find out how they felt about science and health. </p>
<p>A study on public attitudes to science and health on a global scale, the survey covered topics such as whether people
trust science, scientists, and information about health; the levels of understanding and interest in science and health; the benefits of science;
the compatibility of religion and science; and attitudes to vaccines. </p>
<p>There’s a remarkable overlap between countries that have achieved progress in health goals such as reducing under-5 mortality, and those that ranked high in the trust survey. All seven were among the highest ranked globally when it came to their populations’ belief in the importance of vaccines while six out of the seven ranked highly in their trust in hospitals and health clinics. </p>
<p>There’s logic in this. With greater population trust in health systems, health uptake and health outcomes improve. People are more likely to understand the benefits of health services and place a high value in receiving these services. This includes trusting in vaccinations which would lead people to placing a high value on vaccinating their children.</p>
<p>Rwanda in particular has done well in building population trust. According to the survey, the country reports the highest levels of confidence in hospitals and health clinics in the world, and the largest proportion of the population who agree that vaccines are effective. Rwanda also comes out on top in the world in terms of how much of its population believes that vaccines are important for children and in <a href="https://data.unicef.org/resources/immunization-coverage-estimates-data-visualization/">the percentage of children who are vaccinated.</a></p>
<p>This is the result of the work the Rwandan government has done over the past 25 years to build a strong health system and foster an inclusive approach to health coverage, starting at a community level. These actions can serve as a model for other countries to replicate.</p>
<h2>Crucial steps</h2>
<p>It is 25 years since Rwanda was destroyed by the <a href="https://www.un.org/en/ga/search/view_doc.asp?symbol=S/1999/1257">1994 genocide</a> against the Tutsi. Since then, the country of more than <a href="http://www.statistics.gov.rw/statistical-publications/subject/population-size-and-population-characteristics">12 million</a> people has developed a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60574-2/fulltext?rss=yes">strong, decentralised health system</a> and addressed many of the major financial and geographic barriers that vulnerable populations face in accessing healthcare services. </p>
<p>Some of the steps have included:</p>
<p><strong>Prioritising programmes that leave no one out</strong></p>
<p><strong>Building a decentralised health system:</strong> There are 15,000 villages in Rwanda. By 2018, each one had <a href="http://www.rbc.gov.rw/index.php?id=19&tx_ttnews%5Btt_news%5D=447&cHash=c95bbbc0655d12b71c9ccdc675ab2313">four community health workers</a>. These community health workers are elected by their peers and are highly respected, trusted members of their communities who are spending sleepless night to keep their peers healthy. </p>
<p>The trust that’s been built between community health workers and the people they represent has provided a strong foundation in developing broader trust in health systems and in the government that created the system.</p>
<p><strong>Promoting the uptake of health services and vaccination service delivery</strong>: Community health workers, among other tasks, ensure that all pregnant women in their village attend antenatal clinics and deliver in a health facility, that every child gets vaccinated, and that community members are educated about the importance of vaccines and other preventive and curative treatments.</p>
<p><strong>Offering universal access to a range of treatments:</strong> For example, HIV prevention care and treatment services, including the use of antiretroviral treatment.</p>
<p>All these measures contributed to growing population trust in the health system. People feel more comfortable in seeking out healthcare at health facilities and trusting the advice given to them by health professionals. </p>
<h2>More work remains</h2>
<p>There have been <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60574-2/fulltext?rss=yes">tangible benefits</a> to this rebuilding. Life expectancy has doubled. Immunisation coverage rates also increased from less than 30% in 1995 (with five kinds of vaccines administered) to 94% in 2015, with <a href="http://www.nitag-resource.org/uploads/media/default/0001/03/ff28cb2c2cb72344d4d7416d8178b25407d57cbb.pdf">10 vaccines administered to boys and 11 administered to girls, including the HPV vaccine</a>.</p>
<p>This is not to say that Rwanda doesn’t have more work to do. That’s also true of that the other six countries that performed well in the Wellcome Global Monitor.</p>
<p>Education remains a critical gap. The Wellcome Global Monitor <a href="https://wellcome.ac.uk/sites/default/files/wellcome-global-monitor-2018.pdf">reported</a> that the seven countries had some of the highest population proportions with little to no knowledge of science, especially among older people.</p>
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Read more:
<a href="https://theconversation.com/rwanda-university-sets-out-to-teach-doctors-medicine-and-management-110527">Rwanda university sets out to teach doctors medicine and management</a>
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<p>A lack of science education is a major barrier to improving health outcomes and achieving and sustaining <a href="https://www.who.int/health_financing/universal_coverage_definition/en/">universal health coverage</a>. Strong education systems that are training our scientists, clinicians and health professionals are crucial to ensuring countries have enough skilled professionals to provide high quality care to everyone. </p>
<p>This is a gap we are trying to fill at the <a href="https://ughe.org/">University of Global Health Equity</a> in the rural north of Rwanda: to train future clinicians to have the tools to effectively address inequities in healthcare and to build and maintain health systems that leave no one out.</p><img src="https://counter.theconversation.com/content/124183/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Professor Agnes Binagwaho is the vice-chancellor of the University of Global Health Equity</span></em></p><p class="fine-print"><em><span>Miriam Frisch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rwanda’s government has taken concerted, deliberate steps over the past 25 years to build a strong health system.Agnes Binagwaho, Vice Chancellor, University of Global Health EquityMiriam Frisch, Research Associate to the Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1228062019-09-11T13:41:52Z2019-09-11T13:41:52ZRebuilding health systems from the bottom up: a South African case study<figure><img src="https://images.theconversation.com/files/291505/original/file-20190909-109962-1hazous.jpg?ixlib=rb-1.1.0&rect=15%2C26%2C2533%2C1594&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A community care worker providing treatment to a TB patient at her home. </span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:DOT_administering_treatment.jpg">Wikkicommons/Stherere23</a></span></figcaption></figure><p>The recent publication of the <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">National Health Insurance Bill</a> in South Africa has provoked <a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">vigorous debate</a>. Many question whether the proposed reforms contained in the Bill offer meaningful solutions to the <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-signing-presidential-health-compact-25-jul-2019-0000">well-documented</a> <a href="https://www.hqsscommission.org/">crisis</a> in South Africa’s health system. </p>
<p>This crisis is two-fold. On the one hand is the lack of access and poor quality in the public health system which serves around <a href="https://www.dailymaverick.co.za/article/2019-08-20-is-the-national-health-insurance-bill-open-to-a-constitutional-challenge/">85%</a> of the population. On the other hand is an expensive and inefficient private health sector for the remaining minority. There are massive inequities in the distribution of resources between the two sectors. </p>
<p>There is widespread recognition that health system legislation alone will not address the deep seated problems in both sectors. Top-down reforms like those proposed in the NHI Bill need to be complemented by a bottom-up process of strengthening health systems. This must be focused on the most decentralised level of the health system, the district health system. South Africa’s public health system is organised into 52 health districts. </p>
<p>My colleagues and I at the University of the Western Cape believe that this sort of strengthening is not only possible – it’s already happening in pockets. We have <a href="https://doi.org/10.1093/heapol/czz060">engaged</a> with district, provincial and national government players to document the potential of such bottom-up initiatives. </p>
<p>Our recently published <a href="https://doi.org/10.1093/heapol/czz060">research</a> showed how coordinated action by local, provincial and national government players, working with existing resources, can create a fairly rapid turn-around in the performance of health districts. The case study we focused on could provide valuable lessons as South Africa prepares to introduce the NHI. </p>
<h2>Gert Sibande District</h2>
<p>Gert Sibande is a health district in the largely rural province of Mpumalanga. In 2014, this district had the highest death rate from severe acute malnutrition in the country: <a href="https://doi.org/10.1093/heapol/czz060">28%</a> of children younger than five who were admitted to hospital with the condition died during their stay. </p>
<p>But there was a dramatic decline in deaths in Gert Sibande over the three years that followed. The number of children who died from severe acute malnutrition dropped to one-third of the previous levels <a href="https://doi.org/10.1093/heapol/czz060">9%</a>. This decline in deaths was associated with a <a href="https://doi.org/10.1093/heapol/czz060">59%</a> drop in admissions. </p>
<p>In other words, children with severe acute malnutrition weren’t only receiving more effective treatment, cases were being prevented from occurring in the first place. </p>
<p>Severe malnutrition has been a major contributor to child deaths in South Africa, along with causes such as pneumonia and <a href="http://www.samj.org.za/index.php/samj/article/view/12238">diarrhoea</a>. Despite South Africa’s wealth, child malnutrition remains unacceptably <a href="https://foodsecurity.ac.za/wp-content/uploads/2018/04/Final_Devereux-Waidler-2017-Social-grants-and-food-security-in-SA-25-Jan-17.pdf">high</a>. Addressing this is a national priority. </p>
<p>Our research team conducted in-depth interviews with healthcare providers and their managers, to identify how the rapid improvements in acute malnutrition outcomes in Gert Sibande District were made possible. </p>
<p>Interviewees reported widespread shifts in mindsets and practices over the three years. These included improved quality of hospital care for children with severe acute malnutrition and more rigorous identification of children at risk of malnutrition in primary health care facilities. Better referral systems and household follow-up of children by community health workers were also key. </p>
<p>We were particularly interested in understanding how these shifts were triggered in a public health system that is frequently regarded as being trapped in a culture of poor <a href="https://www.hqsscommission.org/">performance</a> and low accountability. </p>
<h2>Key health system interventions</h2>
<p>Changes were initially prompted by consensus in Gert Sibande District that there was a problem to be addressed. This was followed by a series of health system strengthening interventions. These included:</p>
<ul>
<li><p>the appointment of a recently retired, senior public sector manager from another province to visit the district once a month; </p></li>
<li><p>a system of reporting deaths to senior district clinicians and programme managers within 24-hours; </p></li>
<li><p>regular processes of problem analysis and response in district and sub-district structures involving managers, clinicians and information officers;</p></li>
<li><p>empowering dietitians, who were previously marginal actors, to play a central role in steering the response; </p></li>
<li><p>a system of reciprocal accountability where expectations of performance were matched by the provision of support and resources; </p></li>
<li><p>improved supply chains through the provincial office; and,</p></li>
<li><p>building capacity for connected systems thinking. </p></li>
</ul>
<p>Apart from the appointment of the part-time facilitator, no external donor resources were sourced or deployed to the district.</p>
<p>We characterised these interventions as producing three kinds of system-level change. One was “ways of thinking” (knowledge and the use of evidence). The second was “ways of governing” (leadership, participation and coordination). The third was “ways of resourcing” (inputs and capacity). </p>
<h2>Way forward</h2>
<p>The experience of Gert Sibande District is not unusual. There are several “pockets of effectiveness” in South Africa’s public health <a href="https://www.spotlightnsp.co.za/2018/09/21/building-public-health-system-capacity-for-nhi-learning-from-disease-specific-successes-for-system-development/">system</a>. This points to the latent capabilities available in this system. </p>
<p>We believe that unlocking this latent capability needs the kind of deliberate actions seen in Gert Sibande. The system-level changes and health outcomes achieved through such actions will, in turn, only be sustainable in the long run if they are enabled by higher levels of the system. </p>
<p>This entails, firstly, a recognition that change at the frontline won’t be engineered by a stroke of the legislative pen. Meaningful change requires systematic approaches to strengthening, working directly at base of the health system. Gert Sibande’s experience suggests that this does not necessarily have to cost more. </p>
<p>Secondly, national leaders are the best placed to steer a wider consensus on the need to separate political from administrative decision-making in the health system, especially at provincial level. Meritocratic appointment of district and provincial managers, accompanied by more decentralised decision-making on appointments of staff and use of funds, would be an important first step. </p>
<p>A third supportive action would be to invest heavily in developing distributed leadership and management capacity, oriented to public value, as part of a reinvigorated focus on human resources for health.</p>
<p>These approaches could lay the groundwork for a successful NHI that genuinely addresses systemic problems from the bottom up rather than imposing solutions from the top down. </p>
<p><em>Maria van der Merwe and Beauty Marutla from the Mpumalanga department of health, and Joey Cupido and Shuaib Kauchali from the National department of health contributed to this article.</em></p><img src="https://counter.theconversation.com/content/122806/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Schneider is a professor in the School of Public Health, at the University of the Western Cape. She holds a South African Research Chair in Health Systems Governance and receives funding from the South African Medical Research Council and the South African National Research Foundation. </span></em></p>Top-down reforms like those proposed in the NHI Bill need to be complemented by a bottom-up process of health system strengthening.Helen Schneider, Professor, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1003432018-07-24T14:20:04Z2018-07-24T14:20:04ZMen aren’t being tested for HIV. How health services can plug the gap<figure><img src="https://images.theconversation.com/files/229044/original/file-20180724-194131-to6c93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A community health worker conducting a HIV test in a mobile clinic in a remote part of KwaZulu-Natal. </span> <span class="attribution"><span class="source">Greg Lomas / Médecins Sans Frontières</span></span></figcaption></figure><p>Men make up slightly less than half of the adults living with HIV across the world. Yet they account for nearly 60% of the AIDS related deaths. </p>
<p>This is one of the observations from the <a href="https://www.thelancet.com/commissions/global-health-HIV">The Lancet Commission on HIV</a>, which looked at the global response to the pandemic. According to the <a href="https://www.thelancet.com/commissions/global-health-HIV">report</a>, the key driver of this gender difference in health outcomes between men and women is that men use health care services less than women. </p>
<p>This isn’t a new observation: for more than 10 years antiretroviral therapy (ART) programmes in sub-Saharan Africa have been reporting that a <a href="https://www.ncbi.nlm.nih.gov/pubmed/17459154">disproportionately higher</a> number of women are on treatment compared to men. </p>
<p>There’s a simple reason for this, which my work in the last decade highlights: men’s health is generally overlooked in HIV care. My studies show that women remain the focus of HIV testing and ART programmes, while men are disadvantaged in access to these. </p>
<p>In a <a href="http://journals.sfu.ca/jias/index.php/jias/article/view/21902/html">recent analysis</a> of long-term mortality in five large antiretroviral programmes in South Africa, I found that that over the last 12 years the proportion of men starting ART remained the same: between 2004 and 2006 only 31% of those enrolling in treatment programmes were men; by 2015, the figure was unchanged. </p>
<p>What this shows is that there needs to be a real mind shift towards men’s health issues. This, in turn, should lead to health care being provided in ways that encourage men to be tested so that they can get treatment earlier than is often currently the case. For example, <a href="https://www.ncbi.nlm.nih.gov/pubmed/25062091">research</a> shows that providing mobile clinics, or testing people at home, can make a difference.</p>
<p>So what are the obstacles to increasing men’s access to ART?</p>
<h2>Opportunities to access</h2>
<p>The largest obstacle is access to HIV testing. Most testing is done through health facilities, often with a strong focus on testing pregnant women. </p>
<p>The average woman will have a number of encounters with the health system in her lifetime. As a young girl, she will probably go to the local clinic for family planning. When she is pregnant she will go for antenatal care. When her child is small she will go to the local clinic for vaccinations. As mothers are generally still the main caregivers, she will take her child to the clinic when the child is ill. And if she has an elderly relative, there’s a chance she will accompany them to the clinic. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229062/original/file-20180724-194143-1cazopv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Community caregiver Nonhlanhla Ngema passes a long queue of patients at Eshowe Gateway Clinic to collect ARVs as part of a Medecins Sans Frontieres (MSF) to keep people on treatment.</span>
<span class="attribution"><span class="source">Greg Lomas / Médecins Sans Frontières</span></span>
</figcaption>
</figure>
<p>This means that there are several opportunities to be offered an HIV test and to start treatment. And if she starts treatment at a young age, she is likely to be healthy and have good survival prospects. So the health system seems to be doing well at engaging young women in HIV services. </p>
<p>In contrast there has been very little concerted effort from health services to go out and find the men. </p>
<p>The pattern of men’s engagement with the health system is totally different. There is no easy entry point into the health system for healthy young men. Primary health care clinics offer few services targeting men. This is generally limited to treating TB and sexually transmitted infections.</p>
<p>The fact that men are falling outside the net of health care systems is well illustrated in data on people knowing their HIV status. In 2012 nearly a third (31.9%) of men didn’t know their status compared with only 19% in the case of women. The greater proportion of men not knowing their status was particularly worrying given that the percentage of all adults with HIV who didn’t know their status <a href="https://www.ncbi.nlm.nih.gov/pubmed/26091299">dropped dramatically between 2000 and 2012</a> – from over 80% in the early 2000s to 23.7%. </p>
<p>This has important implications for men as well as their sexual partners. People with HIV who are undiagnosed are likely to have high viral loads. This means they have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/22313960">high risk</a> of sickness and death, and also that they are more likely to transmit HIV. </p>
<h2>Reaching men</h2>
<p>So how do we reach more men earlier?</p>
<p>Finding ways of testing men as early as possible will mean changes in the way our health system delivers services. </p>
<p>Preliminary findings show that there is higher testing uptake among men in services that fall outside the traditional facilities. For example, research shows that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25062091">providing mobile clinics</a>, testing people at home, self-testing and offering male-only or <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.12593">male-friendly services</a> can increase men’s uptake of HIV testing. </p>
<p>These and other strategies need to be tried in different settings, and where successful, rolled out across the sub-continent.</p>
<p>The good news is that a change in mindset seems to be happening. After years when it seemed that they were blind to the mounting evidence, international agencies and big donors are starting to discuss the absence of men from HIV programmes. At the end of 2017, UNAIDS produced a report on this blind spot in the response to HIV.</p>
<p>The World Health Organisation has recently established a working group on engaging men into HIV care. And most recently, at the 2018 International AIDS Conference, PEPFAR, the US President’s Emergency Plan for AIDS Relief, launched a global coalition <a href="https://www.pepfar.gov/press/releases/284176.htm">to increase testing and access for men</a>. </p>
<p>Given the huge influence that international agencies and donors have on the priorities of national programmes in sub-Saharan Africa, these are long overdue but extremely welcome new initiatives which could substantially increase access to testing and ART for men.</p><img src="https://counter.theconversation.com/content/100343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Morna Cornell receives salary funding from the National Institutes for Health, USA, under award number U01AI069924.</span></em></p>Women and children remain the focus of HIV while men are disadvantaged in accessing testing and treatment in Africa.Dr Morna Cornell, Senior Researcher, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/946662018-05-08T13:55:27Z2018-05-08T13:55:27ZPrivate lab tests in Uganda are costly. But price doesn’t equal quality<figure><img src="https://images.theconversation.com/files/217945/original/file-20180507-46356-fy1v70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Very few laboratories in Uganda are accredited. </span> <span class="attribution"><span class="source">Arne Hoel / World Bank</span></span></figcaption></figure><p>Laboratory tests are the <a href="https://scholar.google.com/scholar_lookup?author=Ngo%2C+et+al&title=Frequency+that+laboratory+tests+influence+medical+decisions&publication_year=2016&journal=J+Appl+Lab+Med&volume=1%3B4&pages=410-4">backbone of clinical care</a>. They are used to screen patients, to diagnose diseases and to manage conditions ranging from anaemia and diabetes to HIV and malaria. </p>
<p>Considerable effort has gone into improving laboratory services in many African countries. But, as many <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064661">previous studies</a> have shown, the quality of laboratory tests in much of sub-Saharan Africa is poor. </p>
<p>This is because most of these <a href="http://www.afro.who.int/sites/default/files/2017-06/afro-guidance-lab-systems-final_dec2014.pdf">laboratories don’t have</a> the necessary infrastructure nor enough competent staff who are adequately trained or the adequate management systems in place.</p>
<p>In many African countries laboratory testing is provided both as a free service in the public health sector and for a fee <a href="https://www.mm3admin.co.za/documents/docmanager/f447b607-3c8f-4eb7-8da4-11bca747079f/00060290.pdf">by private companies</a>. In some countries the majority of lab tests are done in the private sector; for instance, <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064661">more than 90%</a> of the laboratories in Uganda’s capital city Kampala are privately owned.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/26226183">Research shows</a> that these services, for which patients pay out of their own pockets, tend to be costlier than those offered in the public sector. But there’s been no evaluation of whether the more expensive tests provide better, more accurate results. </p>
<p>We tried to answer this question in <a href="https://doi.org/10.1093/ajcp/aqy017">our study</a> which looked at the costs and accuracy of tests at laboratories in Kampala. We randomly selected close to 80 laboratories and ordered 13 of the most commonly ordered laboratory tests – among them tests for malaria, pregnancy, HIV, syphilis, glucose; complete blood counts, and liver and kidney function tests.</p>
<p>We found that people are paying up to 36 times more for private laboratory tests than they do in the public sector. And, most importantly, test prices do not predict their quality. Higher costs don’t mean more accurate or clinically useful results. </p>
<p>The findings suggest that Uganda should put an external system in place to ensure that the public gets what they pay for.</p>
<h2>Global standards</h2>
<p>There are two broad sets of measures where the quality of laboratories can be checked against. </p>
<p>Firstly, countries are obliged to set up guidelines for both public sector and private laboratories. </p>
<p>But many countries around the world failed to follow these prescriptions, leading to the World Health Organisation also creating <a href="http://www.afro.who.int/sites/default/files/2017-06/afro-guidance-lab-systems-final_dec2014.pdf">guidelines</a> to help them set up their laboratory systems.</p>
<p>Although this has improved the quality of a few laboratories, the challenge is that the vast majority of laboratories are still not meeting the lowest bar of the guidelines. </p>
<p>The second set of measures are international accreditation standards that monitor laboratory quality. There are two. One is <a href="http://www.cms.gov/clia/">US-based</a> and the other are standards created by the International Organisation for Standardisation <a href="http://www.iso.org/iso/home/standards.htm">based in Europe</a>. Laboratories that meet these standards are considered accredited and recognised as meeting international performance standards. But laboratories are not obliged to go through this accreditation. </p>
<p>There are thousands of laboratories across Africa. Ideally, each of these should be accredited. But a 2014 study shows that in <a href="https://doi.org/10.1309/AJCPQ5KTKAGSSCFN">37 of 49 sub-Saharan African countries</a> there was not a single accredited clinical laboratory. Only 380 laboratories accredited to international standards in the region – and 91% of these were in South Africa, Namibia and Botswana.</p>
<p>Uganda has both accredited and non-accredited laboratories. We included both in our study to try and gauge whether the relevant “stamp of approval” affected the tests’ accuracy.</p>
<p>To establish how accurate and expensive the tests were we sent real, but unknown samples, to all the laboratories in our study. And we then also recorded how much they charged us for performing the tests. To establish accuracy, we used results on the same samples from specialised laboratories both in Uganda and Australia to determine the correct results. </p>
<p>We made three important observations. </p>
<h2>Our findings</h2>
<p>Firstly, accuracy varied widely. About 98% of the samples from accredited laboratories were correct while only 66% of the samples from the unaccredited laboratories were correct. </p>
<p>Secondly, accuracy depended on the type of test that was being done. For example, about 90% of test results for HIV, malaria, and syphilis were correct. But only 38% of the tests for urine pregnancy screenings, blood counts, and liver and kidney function tests were accurate.</p>
<p>And test prices ranged widely for an individual test performed in different laboratories. Some labs in the private sector were charging 36 times more than others. Yet we found no relationship between price and quality. </p>
<p>Our findings show that both accreditation and the test being done matters. Tests done by an accredited laboratory is likely to produce correct results 98% of the time. The figure plummets in unaccredited labs.</p>
<p>The quality is likely to be acceptable at all the laboratories for common tests such as HIV and malaria. But for people who had kidney or liver disease, the quality of test is generally not good. These problems stem from a lack of clear and enforced laboratory quality requirements. They have real impact on what diagnoses and treatments patients receive, and must be fixed. </p>
<h2>The way forward</h2>
<p>The way to address this problem is to make the market more transparent by making quality measurable and obvious to the public. </p>
<p>Based on our study, there are two practical approaches that could work. The first is ensuring that laboratories in Africa have international accreditation. The second involves doing quality checks such as those used in this study. </p>
<p>Some countries –like South Africa and Namibia – have bodies that monitor the quality of the laboratories but this is not a uniform practise across the continent. The responsibility to enforce such a practice could emerge from bodies like the World Health Organisation or the <a href="http://www.aslm.org/">African Society for Laboratory Medicine</a> which aims to strengthen laboratories.</p>
<p>Achieving international accreditation should be the goal for every laboratory. </p>
<p>But accreditation is an expensive and challenging task in the short term, especially for small private laboratories. In the meanwhile countries that still have challenges with the quality of their laboratories could use the testing of unknown samples as an achievable, affordable, and effective way to monitor their laboratories and reestablish the public’s trust.</p><img src="https://counter.theconversation.com/content/94666/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy Amukele does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Considerable effort has gone into improving laboratory services in many African countries. But the quality of tests is questionable.Timothy Amukele, Assistant Professor Johns Hopkins University, and Director of the Hopkins Bayview Medical Center Clinical Laboratories, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/838472017-09-21T17:26:09Z2017-09-21T17:26:09ZLassa fever will keep ravaging Nigeria unless better surveillance is put in place<figure><img src="https://images.theconversation.com/files/185759/original/file-20170913-3750-10rbx61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lassa fever in several Nigerian states is being spread by rats. </span> <span class="attribution"><span class="source">World Health Organisation</span></span></figcaption></figure><p><em>Lassa fever was first discovered nearly 50 years ago <a href="https://www.cdc.gov/vhf/lassa/index.html">in Nigeria</a>. Since then, it has been reported in other West African countries including Sierra Leone, Liberia and Guinea. There is also evidence of Lassa fever presence in southern Mali, Burkina Faso, Côte d’Ivoire and Ghana, all of which share a <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1863-2378.2012.01469.x/full">similar tropical wooded savanna ecological zone</a>. But there is still no vaccine against the disease. A new outbreak in 19 Nigerian states and in Lagos city – the most populated city on the continent – has sparked fears that the disease will get out of control and result in a public health event of international concern. Conversation Africa editor at large Declan Okpalaeke spoke to Oyewale Tomori about the outbreak.</em> </p>
<p><strong>What is Lassa fever and how prevalent is it?</strong></p>
<p>It is a fatal viral haemorrhagic disease caused by the <a href="http://vhfc.org/lassa_fever">Lassa virus</a>, a member of the Arenaviridae family of viruses, which naturally infects the widely distributed house rat. </p>
<p>The disease is transmitted through the urine and droppings of an infected species of the rat – the Mastomys natalensis or multimammate – found in most tropical and subtropical countries in Africa. They are able to contaminate anything they come in contact with: surfaces, food and water. And they are prolific breeders. A female Mastomys rat can produce between 98 and 156 <a href="https://www.academia.edu/8112091/Reproductive_characteristics_of_three_sympatric_species_of_Mastomys_in_Senegal_as_observed_in_the_field_and_in_captivity">babies in one year</a>.</p>
<p>The Lassa virus spreads through human to human contact with tissue, blood, body fluids, secretions or excretions. This includes coughing, sneezing, kissing, sexual intercourse and breastfeeding. In hospitals the disease is spread through contaminated equipment. </p>
<p>Each year, the number of Lassa virus infections in west Africa is estimated at 100,000 to 300,000, and between 5000 and 10 000 people die each year. About 80% of those infected do not show any symptoms, the remaining 20% suffer <a href="http://www.who.int/mediacentre/factsheets/fs179/en/">severe multi-organ damage</a>. However, such estimates are crude, because there isn’t uniform surveillance of cases. In some areas of Sierra Leone and Liberia about 10%-16% of people admitted to hospitals every year have Lassa fever, which indicates the serious impact of the disease on the <a href="https://www.cdc.gov/vhf/lassa/index.html">population of this region</a>. </p>
<p>People become ill six to 21 days after they are infected. A fever is usually the first symptom followed by headaches and coughing, nausea and vomiting, diarrhoea, mouth ulcers and swollen lymph glands. Some patients also complain of muscle, abdomen and chest pains. And later, patients’ necks and faces swell and they bleed from their orifices and into their internal organs.</p>
<p>Lassa fever is endemic in Benin, Ghana, Guinea, Liberia, Mali, Sierra Leone, and Nigeria. But in the last six years Nigeria has carried the <a href="http://apps.who.int/iris/bitstream/10665/258535/2/9789290233657-eng.pdf?ua=1">bulk of the caseload</a>.</p>
<p><strong>What is the reason for the latest outbreak?</strong> </p>
<p>There are several possible reasons: an increase and spread of rodents through the country; unplanned urbanisation; and sanitation and garbage disposal problems.</p>
<p>It is clear that outbreaks are becoming more widespread in Nigeria. Between 1969 and 2008, Lassa fever cases were reported in only six to seven of Nigeria’s 36 states. But between 2009 and 2015 this doubled to between 10 and 14 states reporting outbreaks. </p>
<p>In 2016 at least 26 states reported cases and at least 18 states have reported outbreaks so far this year. </p>
<p>And although outbreaks previously only occurred during the dry season, the disease is now found throughout the year. </p>
<p>Despite these increases, the outbreaks have been accepted as “normal” and not elevated to a national emergency status. As a result Nigerian authorities have been caught unprepared with each outbreak.</p>
<p>There is also a technical challenge. Diagnosing Lassa fever is difficult because the early symptoms are similar to other endemic diseases in the region like malaria, typhoid, influenza, <a href="https://www.cdc.gov/leptospirosis/index.html">leptospirosis</a> and <a href="http://www.who.int/mediacentre/factsheets/fs259/en/">trypanosomiasis</a>. </p>
<p>The biggest issue is that Nigeria has failed to sustain any reliable disease surveillance system. </p>
<p>In 2015 Nigeria set up an emergency operation centre to monitor and control the spread of the Ebola virus which resulted in the country <a href="http://www.who.int/csr/disease/ebola/one-year-report/nigeria/en/">containing the disease in three months</a>. But it’s since been dismantled.</p>
<p><strong>Why is there an Ebola vaccine but not one for Lassa fever?</strong> </p>
<p>Lassa fever – like Ebola – is a fatal haemorrhagic disease. The difference is that the severity of Ebola in the region in 2015/2016 and the fear of its spread beyond the borders of West Africa led to unprecedented efforts to license a vaccine against the disease. Lassa fever, on the other hand, has not spread beyond the region since it was first described in 1969. It is therefore unlikely that it will be treated in the same way. </p>
<p>There are several experimental vaccines that have been developed and are being tested on animals. Only one vaccine (VSVΔG/LASVGPC) has protected monkeys against the disease. Others in development have demonstrated an immune response in laboratory animals so offer some protection. But all have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4401668/">failed to offer full protection</a>.</p>
<p>The drug Ribavirin can be used to treat cases, but it’s more successful if treatment is started early. This means that an early and reliable laboratory diagnosis is vital for the proper management of cases. </p>
<p>The challenge in developing a vaccine is that so long as the category of Lassa Fever threat is lower than that of Ebola virus disease, foreign donors and agencies won’t be focused on the issue. </p>
<p>Governments and scientists in countries where Lassa fever is endemic should spearhead the development of a vaccine against the virus. They must re-order their priorities and putt funds into vaccine trials as a service for public good.</p>
<p><strong>In the meantime, what needs to be done to contain and control Lassa fever?</strong></p>
<p>There are three areas that need attention. </p>
<p>Firstly, Nigeria needs to develop disease control and surveillance strategies. Central to this is rodent control. This should include environmental health authorities establishing a regular surveillance strategy for rats. </p>
<p>Secondly, community and environmental hygiene needs to be improved. Houses need to be kept clean and garbage should be disposed far from residential areas. And special care needs to be taken in storing and preparing food.</p>
<p>Thirdly, hospitals must follow strict standard infection control practices. Corpses of people who have died must be treated with care to avoid transmitting the infection. Health workers and laboratory personnel must get the necessary specialised training in handling infectious cases. And the traditional washing of bodies after death should be avoided. </p>
<p>Lastly, infection control practices must be followed, such as restricting access to laboratories and decontaminating material before it leaves the laboratory.</p><img src="https://counter.theconversation.com/content/83847/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oyewale Tomori does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Lassa outbreaks are becoming more widespread in Nigeria but have not been given national emergency status like Ebola.Oyewale Tomori, Fellow, Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/827712017-08-24T19:29:16Z2017-08-24T19:29:16ZAfrican politicians seeking medical help abroad is shameful, and harms health care<figure><img src="https://images.theconversation.com/files/183316/original/file-20170824-18746-orpi5c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nigerian President Muhammadu Buhari is one of many African leaders to have gone abroad for medical treatment.</span> <span class="attribution"><span class="source">Reuters/Afolabi Sotunde</span></span></figcaption></figure><p>There is an African idiom that if a man does not eat at home, he may never give his wife enough money to cook a good pot of soup. This might just be true when applied to politicians on the continent seeking medical help anywhere but home.</p>
<p>Africa’s public health systems are in a depressing condition. Preventable diseases <a href="http://www.un.org/africarenewal/magazine/special-edition-women-2012/investing-health-africa%E2%80%99s-mothers">still kill a large number of women and children</a>, people <a href="https://www.aho.afro.who.int/en/ahm/issue/14/editorial/health-systems-and-primary-health-care-african-region">travel long distances</a> to receive health care, and across the continent <a href="https://www.iol.co.za/news/south-africa/western-cape/where-patients-sleep-on-the-floor-1268243">patients sleep on hospital floors</a>. On top of this, Africa’s health professionals emigrate in droves to search for <a href="http://www.un.org/africarenewal/magazine/december-2016-march-2017/diagnosing-africa%E2%80%99s-medical-brain-drain">greener pastures</a>.</p>
<p>It’s therefore not surprising that people from Africa travel abroad – mainly to Europe, North America and Asia – for their medical needs. In 2016, Africans spent over <a href="http://uncova.com/african-leaders-and-medical-tourism">USD$6 billion</a> on outbound treatment. Nigeria is a major contributor. Its citizens spend over <a href="https://www.imtj.com/news/nigeria-spends-1-billion-outbound-medical-tourism/">USD$1 billion annually</a> on what’s become known as <a href="https://www.cdc.gov/features/medicaltourism/index.html">medical tourism</a>.</p>
<p>It can be argued that private citizens opting to seek medical help in other countries don’t owe the public any explanation, because it’s their own affair. But medical tourism among Africa’s political elite is a completely different kettle of fish and a big cause for concern, because they are responsible for the development of proper health care for the citizens of their countries. </p>
<h2>The shame</h2>
<p>It’s well documented that politicians from across the continent go abroad for <a href="http://uncova.com/african-leaders-and-medical-tourism">medical treatment</a>. The reasons for exercising this choice are obvious: <a href="http://www.bbc.co.uk/news/world-africa-40685040">they lack confidence</a> in the health systems they oversee, and they can <a href="https://www.voanews.com/a/nigerian-health-care/3726922.html">afford</a> the trips given that the expenses are paid for by taxpayers. </p>
<p>The result is that they have little motivation <a href="http://www.bbc.co.uk/news/world-africa-40685040">to change the status quo</a>. Medical tourism by African leaders and politicians could therefore be one of the salient but overlooked causes of Africa’s poor health systems and infrastructure.</p>
<p>Since the beginning of 2017, President Muhammadu Buhari of Nigeria has spent more time in the UK for <a href="https://citifmonline.com/2017/08/14/buhari-feels-ready-to-go-home-after-treatment-in-uk/">medical treatment</a> than he has in his own country. By seeking treatment abroad, Buhari broke one of his own electoral promises – to <a href="http://www.bbc.co.uk/news/business-36468154">end medical tourism</a>. </p>
<p>Buhari is just one of many heads of state to find help elsewhere. Patrice Talon, the President of the Republic of Benin, underwent <a href="http://www.africanews.com/2017/06/19/benin-president-patrice-talon-underwent-surgery-while-in-paris/">surgery in France</a> a few months ago.</p>
<p>The cases of Buhari and Talon, however, aren’t as bad as other presidents who have had decades to fix their countries’ health care systems, but haven’t. Robert Mugabe, President of Zimbabwe for the past 37 years, frequently seeks <a href="http://www.reuters.com/article/us-zimbabwe-mugabe-idUSKBN18711B">eye-related treatment</a> 8,240 kilometres away in Singapore. Jose Eduardo dos Santos who has just stepped down as Angola’s leader after 38 years, also <a href="https://www.reuters.com/article/us-angola-president-spain-idUSKBN19O1SK">travels to Spain for treatment</a>.</p>
<p>In the recent past, some African leaders died abroad while seeking treatment. Zambia’s <a href="https://www.theguardian.com/world/2008/aug/19/zambia">Levy Mwanawasa</a> died in France while the country’s <a href="http://www.bbc.co.uk/news/world-africa-29813612">Michael Sata</a> passed away in the UK. Then there was Guinea Bissau’s <a href="http://www.bbc.co.uk/news/world-africa-16473457">Malam Bacai Sanha</a> who died in France, Ethiopia’s Meles Zenawi who <a href="http://www.bbc.co.uk/news/world-africa-19328356">died in Belgium</a>, and Gabon’s Omar Bongo who <a href="https://www.theguardian.com/world/2009/jun/08/gabon-omar-bongo-death-reports">died in Spain</a>.</p>
<p>A few fortunate ones made it home, but died shortly afterwards. They include Nigeria’s Musa Yar’Adua who died in Abuja after returning from <a href="http://www.telegraph.co.uk/news/worldnews/africaandindianocean/nigeria/7683904/Nigerian-president-Umaru-YarAdua-dies-after-months-of-illness.html">treatment in Saudi Arabia</a>, and Ghana’s Atta Mills who died in Accra after returning from a <a href="http://www.bbc.co.uk/news/world-africa-18972107">brief medical spell in the US</a></p>
<p>The picture painted above is shameful. As long as Africa’s leaders keep going abroad for medical reasons, the ambition for better health infrastructure will remain an <a href="http://www.bbc.co.uk/news/world-africa-40685040">illusion</a>.</p>
<h2>Costs and risks</h2>
<p>Countries pay a heavy cost for this behaviour. It’s estimated that in Uganda, the funds spent to treat top government officials abroad every year could <a href="http://www.monitor.co.ug/News/National/688334-1394344-9hmafbz/index.html">build 10 hospitals</a>.</p>
<p>Not only do the leaders travel with elaborate entourages, but they also travel in expensive chartered or presidential jets. For example, the <a href="http://sunnewsonline.com/nigeria-not-paying-4000-daily-for-presidential-jet-in-london-presidency/">cost of parking</a> Buhari’s plane during his three month spell in London is estimated at £360,000. That’s equivalent to about 0.07% of Nigeria’s <a href="http://www.financialnigeria.com/nigeria-s-health-budget-grossly-inadequate-feature-121.html">N304 billion budget allocation for health</a> this year. And there would have been many other heavier costs incurred during his stay.</p>
<p>The failure of leaders to improve health care and stem <a href="http://www.bbc.co.uk/news/health-11327505">brain drain</a> also carries a heavy price. A 2011 report estimated that nine African countries – including Nigeria and Kenya - had lost <a href="http://www.bmj.com/content/343/bmj.d7031">USD$2.17 billion</a> of their investment in health care professionals. This figure might be higher now.</p>
<p>On top of this, African hospitals that were previously world class have been reduced to symbolic edifices due to political negligence. For example, Lagos University Teaching Hospital was once deemed to be one of the <a href="https://guardian.ng/opinion/african-leaders-and-medical-tourism/">best on the continent</a>. Recently, it was criticised for <a href="http://saharareporters.com/2017/04/11/jaf-condemns-lagos-university-teaching-hospital-decadence">decadence</a>. Not far away, Ghana’s flagship national health insurance scheme is <a href="http://www.myjoyonline.com/news/2017/April-13th/ghanas-health-insurance-on-the-brink-over-12-billion-debt.php">ailing</a>.</p>
<p>Essentially, when people charged with responsibility feel they have no need for public health systems because they can afford private health care at home or abroad, ordinary citizens bear the brunt. </p>
<h2>The way forward</h2>
<p>The effective health systems in western and Asian countries that are being patronised by African leaders only exist because they were developed, and are consistently maintained, through political commitment and visionary leadership, qualities that are clearly <a href="https://theconversation.com/african-citizens-have-good-reasons-to-be-fed-up-with-their-politicians-81053">lacking in Africa</a>.</p>
<p>To bring change, African citizens must start condemning political medical tourism. They must also push for regulations to curb the shameful practice. Taxpayer funded medical trips should be banned and criteria set detailing what sicknesses that can be covered by the public purse. Though a <a href="http://nigeriahealthwatch.com/wp-content/uploads/bsk-pdf-manager/1189__2014_Official-Gazette-of-the-National-Health-Act-,_FGN_1272.pdf">law</a> to this effect exists in Nigeria, it appears to be <a href="https://www.imtj.com/news/missing-healthcare-law-nigeria/">ineffective</a>. It must, and should work.</p>
<p>Essentially, if the leaders do not experience the poor state of health care, they might never strive for any positive changes to it.</p><img src="https://counter.theconversation.com/content/82771/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tahiru Azaaviele Liedong does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health care systems in many African countries are very poor. Instead of fixing them, many African leaders seek medical attention abroad incurring huge bills which are ultimately paid by taxpayers.Tahiru Azaaviele Liedong, Assistant Professor of Strategy, University of BathLicensed as Creative Commons – attribution, no derivatives.