Towards a socially just model: balancing hunger and response to the COVID-19 pandemic in Bangladesh

Summary box Responsive and timely research is needed to better understand the challenges faced by poor and vulnerable populations to inform immediate interventions and policies to address this unprecedented COVID-19 modern-day pandemic. There is a need to research changes through time to understand and address the continuous and long-term economic, mental and emotional impact of lockdown on the most marginalised. Many of the Bangladeshi population are vulnerable, yet the COVID-19 response focuses on individual behaviour with limited attention to the social, economic and contextual factors that prevent the most marginalised from following national recommendations. In the context of structural constraints, continuation of the lockdown has to be accompanied by strong political resolve to ensure that people do not go without basic meals and have basic health information and support. The experiences of people living and working in slums in Bangladesh needs to be captured and translated to context specific strategies for lockdown, as current measures risk starvation for many. In the context of COVID-19, the lockdown model is being imported from a different context (western or developed economies) with stronger economic bases and better social safety nets for those in need, but is there a better way forward for low resource contexts? Economic mortalities may overtake health mortalities for the poorest who survive on daily wage labour

Stronger together: evidence for collaborative action on neglected tropical diseases

This editorial has been written by programme leads at the Liverpool School of Tropical Medicine in the UK to condense the learning shared across articles. Articles within this supplement have been written and led by authors in Nigeria and Liberia, and informed by learnings from across the partnership including from our partners in Ghana and Cameroon and articles previously published. Early career researchers were supported throughout the COUNTDOWN programme to publish evidence and lead the production of impactful papers. Decision makers and local implementers from each context are also authors on the papers within the supplement and were supported to engage with the writing process

Co-creation and self-evaluation: An accountability mechanism process in water, sanitation and hygiene services delivery in childcare centres in Nairobi's informal settlements

Background: Accountability strategies are expected to enhance access to water, sanitation and hygiene (WASH) service delivery in low-and middle-income countries (LMIC). Conventional formal social accountability mechanisms (SAMs) for WASH service delivery have been inadequate to meet the needs of residents in informal settlements in LMICs. This has prompted growing interest in alternative informal SAMs (iSAMs) in Nairobi's informal settlements. To date, iSAMs have shown a limited effect, often due to implementation failures and poor contextual fit. In childcare centers in Nairobi's informal settlements, co-creation of the iSAMs process, where parents, childcare managers, researchers and other WASH stakeholders, contribute to the design and implementation of iSAMs, is an approach with the potential to meet urgent WASH needs. However, to our knowledge, no study has documented (1) co-creating iSAMs processes for WASH service delivery in childcare centers and (2) self-evaluation of the co-creation process in the informal settlements. Methods: We used a qualitative approach where we collected data through workshops and focus group discussions to document and inform (a) co-creation processes of SAMs for WASH service delivery in childcare centers and (b) self-evaluation of the co-creation process. We used a framework approach for data analysis informed by Coleman's framework. Results: Study participants co-created an iSAM process that entailed: definition; action and sharing information; judging and assessing; and learning and adapting iSAMs. The four steps were considered to increase the capability to meet WASH needs in childcare centers. We also documented a self-evaluation appraisal of the iSAM process. Study participants described that the co-creation process could improve understanding, inclusion, ownership and performance in WASH service delivery. Negative appraisals described included financial, structural, social and time constraints. Conclusion: We conclude that the co-creation process could address contextual barriers which are often overlooked, as it allows understanding of issues through the ‘eyes' of people who experience service delivery issues. Further, we conclude that sustainable and equitable WASH service delivery in childcare centers in informal settlements needs research that goes beyond raising awareness to fully engage and co-create to ensure that novel solutions are developed at an appropriate scale to meet specific needs. We recommend that actors should incorporate co-creation in identification of feasible structures for WASH service delivery in childcare centers and other contexts

Does inter-border conflict influence the views of task sharing among community health volunteers in Nigeria? A qualitative study

Background: Volunteer community health workers are increasingly being engaged in Nigeria, through the World Health Organization’s task sharing strategy. This strategy aims to address gaps in human resources for health, including inequitable distribution of health workers. Recent conflicts in rural and fragile border communities in northcentral Nigeria create challenges for volunteer community health workers to meet their community's increasing health needs. This study aimed to explore the perception of volunteers involved in task sharing to understand factors affecting performance and delivery in such contexts. Methods: This was a qualitative study conducted in fragile border communities in north central Nigeria. Eighteen audio recorded, semi-structured interviews with volunteers and supervisors were performed. Their perceptions on how task sharing and allocation of tasks affect performance and delivery were elucidated. The transactional social framework was applied during the thematic analysis process to generate an explanatory account of the research data, which was analysed using NVivo software. Results: Promotive and preventive tasks were shared among the predominantly agrarian respondents. There was a structured task allocation process that linked the community with the health system and mainly cordial relationships were in place. However, there were barriers related to ethnoreligious crises and current conflict, timing of task allocations, gender inequities in volunteerism, shortage of commodities, inadequate incentives, dwindling community support and negative attitudes of some volunteers. Conclusion: The perception of task sharing was mainly positive, despite the challenges, especially the current conflict. In this fragile context, reconsideration of non-seasonal task allocations within improved community-driven selection and security systems should be encouraged. Supportive supervision and providing adequate and timely renumeration will also be beneficial in this fragile setting

Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health

Background A cohesive and strategic governance approach is needed to improve the health workforce (HW). To achieve this, the WHO Global Strategy on Human Resources for Health (HRH) promotes mechanisms to coordinate HRH stakeholders, HRH structures and capacity within the health sector to support the development and implementation of a comprehensive HW agenda and regular reporting through WHO’s National Health Workforce Accounts (NHWA). Methods Using an adapted HRH governance framework for guidance and analysis, we explored the existence and operation of HRH coordination mechanisms and HRH structures in Malawi, Nepal, Sudan and additionally from a global perspective through 28 key informant interviews and a review of 165 documents. Results A unified approach is needed for the coordination of stakeholders who support the timely development and oversight of an appropriate costed HRH strategy subsequently implemented and monitored by an HRH unit. Multiple HRH stakeholder coordination mechanisms co-exist, but the broader, embedded mechanisms seemed more likely to support and sustain a comprehensive intersectoral HW agenda. Including all stakeholders is challenging and the private sector and civil society were noted for their absence. The credibility of coordination mechanisms increases participation. Factors contributing to credibility included: high-level leadership, organisational support and the generation and availability of timely HRH data and clear ownership by the ministry of health. HRH units were identified in two study countries and were reported to exist in many countries, but were not necessarily functional. There is a lack of specialist knowledge needed for the planning and management of the HW amongst staff in HRH units or equivalent structures, coupled with high turnover in many countries. Donor support has helped with provision of technical expertise and HRH data systems, though the benefits may not be sustained. Conclusion While is it important to monitor the existence of HRH coordination mechanisms and HRH structure through the NHWA, improved ‘health workforce literacy’ for both stakeholders and operational HRH staff and a deeper understanding of the operation of these functions is needed to strengthen their contribution to HW governance and ultimately, wider health goals

A call to action for Universal Health Coverage – Why we need to address gender inequities in the Neglected Tropical Diseases community

The UN’s Sustainable Development Goals (SDGs) and pledge to leave no one behind have raised the importance of ensuring equitable health outcomes and healthcare delivery. Multisectoral approaches to tackling neglected tropical diseases (NTDs), including prevention, diagnosis, treatment, and healthcare, have had a limited focus on gender. Yet, gender roles and relations shape vulnerability to NTDs, access to prevention and treatment, and experience of living with NTDs [1]. Understanding the similarities and differences of disease vulnerability and experience between genders can support NTD actors to deliver equitable prevention, diagnosis, and treatment services. The NTD community, including researchers and practitioners, needs to better understand these dynamics and take action to advance gender equality, meet the NTD roadmap 2020 goals, and contribute towards the SDGs and universal health coverage (UHC). The UHC movement is advocating for clear action to address the gender determinants of health. This viewpoint synthesizes evidence from a discussion paper [2] developed by the UN Development Programme (UNDP) and TDR (Special Programme for Research and Training in Tropical Diseases sponsored by UNICEF, UNDP, World Bank, and WHO) in partnership with the Liverpool School of Tropical Medicine to support governments and nongovernment organizations to understand how to recognize and address gender inequities within NTD programs and improve delivery through gender analysis

Eliminating onchocerciasis within the Meme River Basin of Cameroon: A social-ecological approach to understanding everyday realities and health systems

Background Onchocerciasis affects some of the world’s most marginalized people, perpetuating poverty and inequalities. Mass Drug Administration (MDA) with Ivermectin has taken place within the Meme River basin region in Cameroon for over 15 years. Despite this, onchocerciasis is still prevalent in the region due to existing and emerging contextual challenges. Using a social-ecological approach we explore the everyday realities of communities, highlighting the challenges and potential solutions that could support Neglected Tropical Disease (NTD) programmes when transitioning from control to elimination of onchocerciasis in this highly endemic area and other similar communities. Methodology/Principal finding In-depth interviews (71) with community members and Community Drug Distributors (CDDs) were conducted to understand current knowledge, attitudes, and behaviours in relation to transmission, prevention and treatment of onchocerciasis. Through application of the social-ecological model, four key themes were identified: 1. Contextual factors on health promotion interventions (Onchocerciasis history and understanding of the disease, prevention and mitigation strategies and MDA experience); 2. Social determinants (poverty and livelihoods, economic and social impacts on CDD volunteers and stigma); 3. Environmental determinants (exposure, housing, occupation and poverty); and 4. health seeking pathways and decision making for treatment (access, cost and preferable treatment routes). We discuss these core and cross cutting themes (gender differences and community participation/ownership) in relation to intersectoral collaboration, gender equity and health systems support, making recommendations for NTD programmes within the context of integrated and interdisciplinary approaches. These include the need for; intersectional and gender analysis at the local level, addressing environmental dimensions of onchocerciasis through integrated and regular health promotion, vector control strategies and access to safe water sources; reflection and action that embeds responses to social and economic barriers to MDA; integrated case detection and management that is responsive to onchocerciasis symptoms and related stigma and a fair and just support network for CDDs. Conclusion/Significance NTD programmes need to respond to diverse community circumstances and behaviours. Communities are not a homogeneous risk group and treating them in this way will delay elimination. A deeper understanding of individual needs and their capacity to seek prevention and treatment must be considered if onchocerciasis is to be eliminated and the remaining impacts managed