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A client gets his hands sanitised outside a fruit and vegetable wholesale. Bulawayo, 27 April 2020.beeld:

People centrered approach to COVID-19

On the 11th March 2020, the World Health Organization (WHO) declared the Coronavirus, largely referred to as COVID-19 a pandemic. The first COVID-19 case in Africa was reported in Egypt in February 2020. South Africa reported the first case in southern Africa in March 2020.

Introduction – Regional situation overview

Today cases in the region stand at over 500 000 with more than a thousand deaths, and still counting. More than anything else, the pandemic brings to the core three critical areas; regional health systems/models and the resulting entrenched structural inequalities health gap disparities; (see also related article in flemish), the role of Civil Society Organisations (CSOs) – and response thereof. This raises critical questions around organising as well as their watchdog role. The pandemic also brings forward historical and contemporary labour patterns which are important in informing current responses as well as in the formulation of sustainable and inclusive health systems in the region.

Other critical COVID-19 questions

Several interventions have already noted the gender disproportionate effects of the pandemic; for example demographics speak to the over representation of women in primary health care throughout the region, a resulting effect of historical labour patterns that relegated women to care work. Outside of formal labour arrangements women carry the unpaid role as care givers bearing the burden of caring for the sick thus putting them on the frontlines of the pandemic.

Two tier health systems and COVID-19 policy response

South Africa and Zimbabwe’s major policy responses were to enforce shutdowns, restricting cross border movements as well as placing conditions on local travel in a bid to contain the virus. The conditions are periodically reviewed in response to changes in infection rates and other socio-economic issues. Mozambique on the other instituted a state of emergency which banned international travel but still allowed inter-provincial. In the beginning, Mozambique only had one testing centre in Maputo, not only putting pressure on the system but excluding people from other areas who could not afford travel costs. Testing centres have since been established in other parts of the country. While policy review in response to the pandemic is a step towards the right direction, they are largely on the surface and for the most part do not address underlying structural issues within the health care system including other governance and socio-economic issues needed for a people centered human rights based approach to quality health provision.

Brecht De Vleeschauwer – FOS36 (9)
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All three countries, Mozambique, South Africa and Zimbabwe are characterised by two tier parallel health care systems – public and the private. South Africa and Mozambique offer free public health care, while in Zimbabwe  it is relatively less expensive than private health care (though still out of reach for many); are often under resourced and as a result do not provide quality dignified health care often due to the pressure on the system. Needless to say, the pressure has been heightened by COVID-19. In South Africa and Zimbabwe front line workers have continuously raised the appalling conditions in which they work. They have highlighted the lack of even the most basic of tools such as Personal Protective Equipment (PPE), disproportionately exposing them to the virus.

In Zimbabwe health practitioners recently went on strike action over poor working conditions. Key to demands is particular lack of PPE, but true to the Zimbabwean culture of violence they were beaten, by security officers back into the workplace. In that night alone Harare Central Hospital recorded seven stillborn babies due to staffing challenges. In other words, deaths that could have been prevented.

Mozambique has relatively less pressure on the health system in comparison with South Africa and Zimbabwe and there are no reports of major PPE shortages for the health sector, however this does not necessarily mean there are no shortages. In May 2020, the Confederation of Economic Associations of Mozambique (CTA) reported there were 76 companies in the country with the capacity to produce masks and visors. These companies have since received $50m USD in government support to do so.

Private health care on the other hand which provide quality health care is out of reach of many working class communities due associated costs, widening the health gap. While in South Africa and Zimbabwe solidarity funding initiatives to have been put as a measure to alleviate the effects of the pandemic, they are threatened by corruption and maladministration. South Africans recently learnt with great shock of the extent to which those close to the ruling elite allegedly pocketed COVID-19 funding, in what is now largely known as the PPE scandal. Not much decisive action has come from the government. Abuse of COVID-19 relief funds is not unique to South Africa. Reports from Zimbabwe speak to allegations of abuse of funds too. Relief funds are allegedly being used as political weaponry. Concerns have been raised over people escaping from quarantine centres because of alleged poor conditions that do not meet health and dignity standards. Zimbabwe has taken the abuse a notch further and is allegedly using the COVID-19 cover to clamp down on civil liberties, deploying the military against civilians. Those exposing the government are meet with severe consequences. Handling of the COVID-19 virus demands responsible political leadership not abuse of office.

COVID-19 has forced a change in behaviour with heightened awareness of the need to do basic things to prevent the spread of communicable diseases including hand washing and social distancing, and the wearing of masks, which is mandatory across all three countries. While most of the initial cases were imported, the majority of active cases are now local transmissions.  Instead of engaging a simplistic approach to this, accusing citizens of not adhering to regulations as has is largely portrayed in main domain, this cannot be looked at in isolation of historical and contemporary policy formulation and implementation. The assumed behavioural patterns hinge on colonial spatial development in health, transport and urban housing systems in the region which sought to promote residential segregation along racial lines as a tool of power, political and social control. A key marker of this is the clustering of housing in urban areas, thus undermining social distancing and hand washing due to the communal nature of water sources. For example a site visit organised by one of FOS’s partners in South Africa, Women on Farms Project (WFP) showed how a community of over 200 people in Wellington share one communal water source. And the water is not even free, it costs R 5 for 4 x 5 litre cans (see image below). It may seemingly look like a low amount but put in perspective it is out of reach for 56% working class communities who survive on  R561 per person per month (in April 2019) This is also commonly referred to as the “extreme” poverty line. With the impact of COVID-19 and the resulting disruption in livelihoods the impact may have been exacerbated. Infection control needs to take into cognisance policy vis-a vis lived realities and respect for human rights and human dignity.

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Furthermore, while measures such as travel restrictions do make sense in terms of infection control, they are not without challenges and the impact is felt by the most vulnerable groups. In a webnair hosted by ILRIG a Community Health Care Worker (CHW) from Zimbabwe shared the impact on women in farming communities; ‘women can no longer access contraceptives due to local clinics running out of stock, donor agencies are cut off from accessing the areas while women themselves cannot get to better resourced health centres due to restrictions in place’. Access contraception is not only a basic feminist right but has huge sexual and reproductive health implications.

Vulnerable groups such as women, precarious workers, and migrant populations are particularly vulnerable to health shocks and economic shocks and they are a group most likely to face structural barriers to accessing other fundamental human rights and freedoms. In South Africa for example Black African migrants have generally faced barriers in accessing health amongst other socio-economic rights (See related article).

FOS partner responses

The epidemic is multifaceted. It transcends the health/medical scope. It is also economic and political, requiring a multi sectoral approach. Civil society response is imperative. The critical question is – how do CSOs enable productive livelihoods, tap into community activism, protect rights and human dignity and build on historical and contemporary expressions of solidarity for all people while demanding transformation in health provision?

To ensure sustainable, dignified public health for all during and post COVID-19 period, a human rights based approaches founded on multi sectoral and interdisciplinary approach including political leadership is imperative. FOS partners are engaged in various approaches towards equitable health models and mitigating the virus including adding their voice to calls for accountability and transparency of COVID-19 funds. Partners across the region have adopted a robust approach to COVID-19 education and awareness. Solidarity based approaches and popular education/creative art platforms are some of partner strategies. CSAAWU, ILRIG and WFP are in partnership on solidarity forums with a strong focus on women on farms. ILRIG is working on a comic book with linkages between COVID-19 and the environment, highlighting the multifaceted nature of the virus. WFP is amongst other interventions engaged in popularising information around COVID-19 and its various implications through short courses on health rights.

Across the region FOS partners are engaged in supporting and strengthening the voice of the CHCWs, who give their labour for next to nothing. Partners are in solidarity with CHWs in their fight for recognition by respective government health structures. The plight of CHCWs include emotional lack of PPE and other material support, struggles for financial support in the form of decent living wages as well as emotional wellness support. Across the region CHCW stipends are the poverty line of the respective countries. In Mozambique. Stipends are generally pegged at minimum wage. There is however a high number of Health Activists who work on a voluntary basis. In Zimbabwe particular their stipends are not regular as they are donor funded. Most donors have scalling down in activities due to COVID-19.

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Rachel Ncube (64) says she has been a vendor since 1987 and has no idea how she will provide for her family after the Covid19 lockdown since the Bulawayo City Council has banned all vending in the CBD. Bulawayo, 27 April 2020.beeld:

Across the region, partners are also involved in coordinating with relevant actors and other key stakeholders such as the media in the prioritisation of most urgent actions. This includes mainstreaming good hygiene practices through the development and dissemination of fit-for-purpose information, education communication (IEC) materials tailored to the needs of the population, for example SINTAF in Mozambique. For partners in Zimbabwe and Mozambique are largely engage national radio to popularise information and make it accessible. In Zimbabwe, LEDRIZ and the ZCTU now standing radio slots while some South African partners have also engaged community radio stations and online creative activities and other forms of popular education awareness.

Partners are also involved in the provision of basic health material support such as hand sanitizers and face masks to vulnerable groups. This form of support is however linked to broader program activities, it is not provided on a humanitarian basis. Mozambican partners are also involved in a cooperative at making face masks augmenting income, at a time where livelihoods are disrupted.

Partners are working on other broader human rights and social justice issues. SINED in Mozambique supports domestic workers to register for social security. COMUTRA is working closely with government to raise awareness on the way women are impacted by the outbreak and lack of social protection particularly where reproductive health and sexual rights are concerned. UPCG continues to closely with local health facilities and CHWs at in its efforts to ensure a high standard of service is rural communities.

Dialogue is one other channel. The ZCTU is involved in social dialogue in Tripartite Negotiating Forum (TNF), a forum which brings together labour, government and business on consultation, cooperation and negotiation on social and economic issues. The principles of solidarity, support, human rights, dignity and building critical awareness must underline partner programming at national and regional levels.

Addressing COVID-19 and beyond

  • Mapping, monitoring, and analysing the impact of COVID-19 on vulnerable groups. This must involve a critical analysis of the virus and contextual environment to inform the medium and longer-term response to the broader socio-economic dimensions of the COVID-19 crisis affecting vulnerable populations even post COVID-19. This approach is also recommended by IOM (International Organisation for Migration).
  • Enhancing the capacity of FOS partners to protect vulnerable groups during and post COVID-19 by identifying and disseminating good practices, strengthening dialogue and coordination between and across multilateral stakeholders.
  • Reinforcing public health preparedness measures from grassroots/community level to CSO and national health care systems.
  • Building of stronger national and regional alliance amongst FOS partners across FOS thematic areas given the COVID-19 multi layers.
  • Undertaking joint lobbying and advocacy across the spectrum involving greater, robust and sustained approach compelling regional and African leadership to implement the various health and human rights mechanisms they have committed to, such as the Abuja Declaration, Protocol to the African Charter on Human and Peoples Rights, Sustainable Development Goals 2030, and Agenda 2063 amongst others.
  • Mainstreaming Strategic Preparedness and Response Plans in partner programming.

Systematic collection and utilisation of data to ensure evidence-based programmatic responses vis-a-vis the fast-changing health, environmental and political and socio-economic dynamics.