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News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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Toto Care Box: Enhancing Maternal and Newborn Health in Kenya

In Kenya, maternal deaths account for 14% of all deaths to women aged between 15-49 years according to the Kenya Demographic and Health Survey (KDHS, 2014). Neonatal mortality rate stands at 22 deaths per 1000 live births, a proportion calling for urgent action. The number of children dying in the country is used as a marker of social well-being and national development. It is a reflection of the country’s healthcare system and can be used to evaluate the health policies. Like many other health indicators, the burden of maternal and newborn mortality is heaviest among the poor. In the context of urban informal settlements, indicators such as low use of health services and increasing child mortality suggest that the urban poor are a highly vulnerable and marginalized group. Also, with 17 women dying daily in the country during childbirth, all efforts should be directed towards targeted solution finding and implementation of a sound maternal health system. Toto Care Box Africa Trust is a non-profit organization making great strides in bettering maternal health outcomes for poor and underserved women in the Kenyan informal settlement areas since 2016. To date the organization has been able to secure the lives of more than 5000 women and newborns including the poor, those living with HIV/AIDS and the homeless. Additionally the organization has stimulated partnerships in the healthcare system by incorporating the work of various health facilities and corporates in the fight against maternal and newborn deaths. Every mother matters and each newborn deserves a dignified and equal start to life

By Reagun Andera Odhiambo

M & E and Grants Officer at Toto Care Box Africa Trust


 Toto Care Box: Enhancing Maternal and Newborn Health in Kenya




The state of maternal and newborn health in the Kenyan context

Kenya, just as other low-and-middle income countries of the Sub-Saharan Africa continues to realize modest maternal and newborn health outcomes. Sub-Saharan Africa had the highest Neonatal Mortality Rate (NMR) globally in 2018 at 28 deaths per 1000 live births according to the World Health Organization (WHO). A number of factors can be directly linked to these outcomes which are often marked with loss of lives, high maternal and neonatal morbidities and other life-long consequences on the lives of the affected.

In Kenya, the recommended and ideal maternal and newborn care remains only available for the elites and those in the high socio-economic class; those who can pay for health services. The remaining majorities only seek basic care in order to survive and are thus predisposed to poor maternal and newborn health outcomes which may lead to preventable deaths and morbidities. Worse even, some shun from seeking basic healthcare for reasons of poverty and stigmatization; they depend on fate for survival. In Kenya 39,000 newborns die annually due to preventable causes. Also, 17 women die daily during childbirth due to lack of lifesaving education. There is urgent need for all efforts to be directed towards curbing this preventable problem endemic in our country.


The unacceptably high maternal and newborn mortality rates in Kenya relate to a number of factors which should form the basic action points for preventive solutions by key stakeholders in the health sector. Many gaps can be identified through an exploration of the state of maternal and newborn health in Kenya:

Health-service delivery gaps

According to the 2014 Kenya Demographic and Health Survey (KDHS), only 61% live births occurring in Kenya are delivered in a health facility. 62% are assisted by a skilled provider and 53% of women receive a postnatal care checkup. Also, one in three newborns receives postnatal care from a doctor, nurse or midwife. With regards to vaccination coverage, only 79% of children (12-23 months) receive all basic vaccines. These statistics reveal the underlying gaps in access and utilization of essential maternity services by the public.

Many health facilities charge highly for various maternity services including emergency obstetric care. This makes the services less affordable and inconvenient resulting in an overall low uptake. Poor health infrastructural development marked by fewer health facilities in highly populated regions also causes accessibility problems which translate to poor maternal and child health outcomes. A number of facilities have few qualified staff with many unskilled attendants who put women and newborns at risk. All these service delivery factors collectively derail the efforts towards curbing maternal and newborn deaths in the country.

Environmental gaps

Expectant women and infants suffer the greatest brunt of ill-health in Kenya as a result of unfavourable environmental factors. The harsh environmental conditions in which infants are born make them vulnerable to malaria, diarrheal diseases, neonatal sepsis and respiratory infections. Informal settlement areas for instance are overcrowded with poor air quality as a result of poor waste disposal, scarcity in clean water supply and poor drainage. All these contribute to unhygienic conditions which make it hard to care adequately for newborns.

The situation is worsened by negative cultural beliefs and practices such as early marriages, emphasis on home deliveries and traditional cures. Data shows that some expectant women living around health facilities do not utilize Maternal and Newborn Health (MNH) services because of misleading cultural beliefs advocating for home-based care by elders; who in most cases are untrained.

Knowledge/Awareness gap

Despite the fact that majority of Kenyan women at least attain secondary education, most of them have little knowledge and awareness on many aspects of maternal and newborn health and overall reproductive health. This predisposes them to the risk of pregnancy-related complications and other sexual and reproductive health issues. The women may prove clueless when it comes to issues of family planning, breastfeeding, hygiene, proper nutrition, antenatal care, postnatal care, immunization among others. Knowledge plays a critical role in the maternal and newborn health outcomes of individuals and thus it remains a key factor at play amid the high mortality rates being witnessed.


Various categories of vulnerable women respond differently to their maternal and newborn health needs in Kenya. This is dependent on the prevailing conditions and the resilience of the affected individuals in coping with unforeseen events. A number of vulnerable groups and their typical responses in the utilization of maternal and newborn health is discussed below:

The poor and underprivileged

Poverty remains a great hindrance to good health and well-being particularly maternal and newborn health. Lack of finances to pay for vital health services leaves many women helpless when it comes to access and utilization of emergency obstetric care. For reasons of poverty and lack of essential newborn care commodities (baby clothes, soap, diapers etc.), majority of women forego hospital-based care. They feel stigmatized for showing up in health facilities with no basic newborn care items at the time of delivery. Also, poor women find it hard to access highly nutritive foodstuff during the pregnancy and postnatal period. This leaves them at risk of nutritional disorders and deficiencies which might have a reflection on the health and well-being of their newborns. There is an overall increased likelihood of low uptake of facility-based care among poor women in comparison to rich women.

Teenage mothers

Teenage mothers are made vulnerable by the event of childbirth at a very young age which research confirms can be lethal and with lifelong consequences. In most cases, teens are clueless on almost all aspects of maternal and newborn health owing to their low literacy levels. They have limited knowledge and are just in the discovery face of life where sexual and reproductive health issues can be overwhelming to them. Typically, such young and vulnerable mothers shun from seeking medical care for reasons of fear of judgement and stigmatization. Some develop suicidal feelings especially those who become pregnant as a result of sexual abuse and molestation. They often miss their antenatal care appointments some even delivering their babies at home. The fear of bringing up a child single-handedly and possible termination of their education also causes anxiety for most of them. This reduces their morale and consistency in seeking maternal and newborn care in health facilities.

Slum dwellers

Informal settlement areas otherwise referred to as slums remain high risk areas when it comes to maternal and newborn health. These areas are characterized primarily by overcrowding, poor sanitation, poor housing conditions, inadequate fresh water supplies and high rates of social crimes all of which make it hard to offer or practice ideal maternal and newborn care. Slum dwellers due to congestion are mostly unemployed hence high dependency ratios remain endemic in such areas. That means that majorities cannot pay for essential maternal and newborn health services leave alone putting food on their tables.  The areas have poor infrastructural statuses which make it hard, even impossible to access emergency obstetric care and other vital health services.

Typically, slum dwellers give preference to their survival (food and shelter) with little or no concern for their maternal and newborn well-being which is viewed as a secondary need and less important. They should however not be faulted for this because they are often left with no other options but to survive. It is because of this reason that health facilities continue to report few antenatal care contacts and hospital deliveries in such areas. Consequently, preventable maternal and newborn conditions such as pre-eclampsia, gestational diabetes, malaria, pneumonia and diarrhea remain endemic in the areas resulting in high mortality rates.

Mothers living with HIV/AIDS

HIV/AIDS has a great bearing on the maternal and newborn health statuses of women and children. The affected women need specialized care during pregnancy. This helps secure their newborns while at the same time safeguarding the health of the mother from opportunistic infections and childbirth-related complications. Prevention of mother to child transmission of the virus should be prioritized at all times. Women living with HIV/AIDS may fear to seek facility-based obstetric care for reasons of stigmatization or mistreatment. They may feel overwhelmed with the whole idea of prevention of mother to child transmission of the virus and thus need counselling and personalized user-friendly care. They may find it hard to consistently attend their antenatal care appointments, for this reason they need to be encouraged to adhere to ANC attendance recommendations. This can be achieved through incentivization and adoption of user friendly maternal health services.

Refugees and the homeless

Being homeless or in a refugee setting leaves many expectant women and newborns at risk for many preventable infections and possible death. Such individuals may lack almost all basic necessities including food, shelter, clothing and even security and are thus vulnerable. Refugees often have no access to quality maternal care and they may end up delivering their newborns without the assistance of health professionals. Antenatal care is absent for most of them. For the homeless, sleeping outside in the cold affects their health drastically resulting in infections which affect their pregnancy outcomes and the overall health of their newborns. Such individuals need assistance in seeking maternal care and finding comfortable housing facilities.


Toto Care Box history

The Toto Care Box story began in 2012 in a little village called Marich in West Pokot, when Lucy Wambui Kaigutha (the founder) was working as a Public Health researcher collecting data on Integrated Management of Childhood Illnesses (IMCI). She had to conduct focus groups amongst women from this village. One mother stood out to her, she had five children, her fifth barely two weeks old and she had nothing. This woman stayed in Lucy’s mind long after she came back from West Pokot. She knew she needed to do something for the mother and her baby. One day she stumbled upon an article, “Why Finnish babies sleep in cardboard boxes” as she was browsing the internet and that was the inspiration for the Toto Care Box. In Finland, babies have been sleeping in cardboard boxes since 1939 after the Second World War as a government initiative to reduce maternal and infant mortality. Currently, Finland has the lowest maternal and infant mortality in the world. Lucy then decided to create the Toto Care Box tailored to suit the Kenyan needs and bring about similar outcomes. This would later be adopted for other high need African countries the aim being to save at least one million maternal and newborn lives in Africa by 2022.

How Toto Care Box promotes maternal and newborn health

Toto Care Box provides a simple but unified solution to the maternal and newborn mortality problem among vulnerable and underserved community members. This is achieved through a community-based integrated model bringing together health facilities, Community Health Volunteers (CHVs) and the target women. The main goal of the program is to increase access and uptake of quality life-saving maternal and newborn health services. The program is therefore important for a number of reasons; it provides a framework for achieving both the sustainable development goal and the Big 4 agenda related to maternal and newborn health. It is also critical in strengthening the health system through stimulating partnerships among the stakeholders in health. The program’s nature of working at the grassroots helps find more sustainable solutions which can be replicated in other high need areas in the country.

Toto Care Box addresses community maternal and newborn health needs in three major ways:

PROVISION – 18 maternal and newborn essentials are given to vulnerable women and newborns in order to prevent maternal and newborn deaths.

INCENTIVIZATION – women receive a Toto Care Box after attending at least four antenatal care visits and delivering in a health facility.

EDUCATION – women are educated on fundamentals of maternal and newborn care including danger signs during pregnancy and for the newborn, exclusive breastfeeding, proper hygiene, cord care and prevention of common newborn illnesses.

The program is guided by four core objectives all of which aim at reducing maternal and newborn deaths:

To incentivize women to attend at least four antenatal care visits.

These help in early detection and prevention of pregnancy-related complications such as hypertension and pregnancy diabetes both of which can dramatically affect the fetus. Early detection means regular monitoring and treatment.

To incentivize women to deliver in health facilities.

Facility deliveries by qualified birth attendants help reduce the chances of childbirth complications which often result in the death of a mother, her newborn or both.

To reduce the four major causes of newborn deaths (malaria, neo-natal sepsis, pneumonia and diarrheal diseases).

This is achieved by providing 18 low-cost, high-impact maternal and newborn essentials for the optimum survival of newborns.

To provide up-to-date maternal and neonatal information to women to ensure birth preparedness and effective childbearing.

This is done through mass education, Toto Care Box maternal and newborn care training as well as childbirth classes by Lamaze certified facilitators.

Solution targets

The Toto Care Box program prioritizes informal settlement areas of Kenya as well as other disaster prone and high need areas for its intervention. This is mainly because such areas are faced with serious problems when it comes to accessibility, affordability and acceptability of maternal and child health services and essentials. The areas are often characterized by poor living conditions and residents have high illiteracy levels and a diminished ability to make healthy choices. The primary beneficiaries are poor and underserved women and newborns but the program impact is generated at both household and community levels.


Currently, the Toto Care Box program works in 9 high need areas in Kenya and serves over 5000 underprivileged women and newborns. Through the program, a number of partnerships both local and global have been made aiming the betterment of maternal and newborn health outcomes for the poor. Also, the program has made great strides in impacting the lives of teen mothers and their newborns as well as mothers living with HIV/AIDS. Our hope is to give every newborn an equal and dignified start to life.

Call for support

We appeal to every interested persons, groups and organizations to support our highly potential cause (Toto Care Box) to reach out to other needy women. Support can be in form of financial assistance, donation of individual items (baby clothes, soap, diapers etc.), partnering in what we do, purchasing Toto Care Boxes for women or sharing our work with potential funders and donors. Feel free to reach out to us through the below contacts:



Phone +254701945110/ +254719313712



Evidence generated from the impact of the Toto Care Box program in Kenya reveals that maternal and newborn deaths can be prevented, reduced and even eradicated through simple but targeted interventions. Multi-factored and unified approaches need to be implemented especially in high need areas through synergistic partnerships by all the stakeholders in health. It is only through such client-centered methods that we will be able to secure our maternal and newborn health individually, communally, regionally, nationally and even continentally. Let us all strive to give each newborn a dignified and equal start to life.


PEAH News Flash 391

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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Contribution of the COVID-19 Crisis to Teenage Pregnancy Upsurge: a Case of Mukuru Kayaba Slums, Nairobi Kenya

According to the 2014 Kenya Demographic and Health Survey (KDHS), 1 in 5 Kenyan teenage girls is a mother. Also, statistics by the United Nations Population Fund (UNFPA) indicated that between June 2016 and July 2017, 378,397 girls got pregnant before their twentieth birthday in Kenya. Similarly, 379,573 teenage girls were made pregnant by the end of last year as reported by the National Council on Population and development (NCPD). These huge numbers cause devastation bearing in mind that they were reported during normal times. What then are we to expect with the new normal where essential functions and healthcare services have been greatly compromised by the Covid-19 pandemic?

By Reagun Andera Odhiambo

M & E and Grants Officer at Toto Care Box Africa Trust

Contribution of the COVID-19 Crisis to Teenage Pregnancy Upsurge

A Case of Mukuru Kayaba Slums, Nairobi Kenya


Early estimates by a number of local and global health organizations point towards a potential increase in indirect mortalities caused by the Covid-19 pandemic. Among the areas that are expected to be greatly affected in this regard are Sexual and Reproductive Health (SRH) as well as maternal and newborn health. Disruption of essential health services and the subsequent inaccessibility by those in need is a direct effect of the Covid-19 pandemic which seemingly generates lethal outcomes.

To explore Covid-19 outcomes on the health of adolescents and young people, my attention has been drawn to teenage pregnancy. This is an endemic problem greatly rooted in our country just as in other middle and low income countries which is bound to escalate with the current crisis.

According to the 2014 Kenya Demographic and Health Survey (KDHS), 1 in 5 Kenyan teenage girls is a mother. Also, statistics by the United Nations Population Fund (UNFPA) indicated that between June 2016 and July 2017, 378,397 girls got pregnant before their twentieth birthday in Kenya. Similarly, 379,573 teenage girls were made pregnant by the end of last year as reported by the National Council on Population and development (NCPD). These huge numbers cause devastation bearing in mind that they were reported during normal times. What then are we to expect with the new normal where essential functions and healthcare services have been greatly compromised by the Covid-19 pandemic?

The Covid-19 pandemic brings with it massive consequences directly, indirectly and in multi-factored ways. The indirect consequences are mainly triggered by the breakdown of essential health services including SRH services such as family planning and maternal and newborn health. With the current lockdown, curfew and cessation of movement directives by the government, access to and provision of essential reproductive health services is interfered with and somehow compromised for both users and providers. Teenage girls and young women are part of those affected because they need these services.

According to Plan International, Covid-19 related school closures hit girls the hardest. This is because being out of school increases teenage girls’ vulnerabilities to not just early and unwanted pregnancies but also to early marriages or contraction of Sexually Transmitted Infections (STIs) including HIV/AIDS. Also, with schools closed, young girls are shut up at homes where they are faced with an increased risk of sexual exploitation and gender-based violence all of which may result in unwanted pregnancies.

With the current emphasis on “staying at home”, teenage girls and their male counterparts find themselves with plenty of uninterrupted time where they get to engage in experimental sexual activities in a curious exploration of their sexuality and the fulfilment of the demanding needs of their fast growing bodies. All these fun-filled explorations may go unnoticed only to be revealed a while later by “missing periods” or “a growing bump” otherwise said to be an unwanted pregnancy.

Teenage pregnancies have been proven to cause serious negative impacts on the lives and future of the affected girls especially with regards to their overall health as well as mental and social well-being. Teen mothers less likely continue with their pursuit of education and thus end up in poverty which comes with both depression and rejection. Some teens decide to terminate their pregnancies not looking at the numerous risks they present themselves to by choosing the risky procedure. Abortions are the second leading cause of death for girls 15-19 years of age and leave the victims who survive with lifelong complications including fistula. Worse even, some take their lives for fear of judgement and feelings of guilt.

Mukuru Kayaba, an informal settlement forming part of the larger Mukuru slums extending through Kwa Ruben and Kwa Njenga areas is one area that has been hard hit by the teenage pregnancy crisis over time.

The area just like other slum areas is faced with numerous problems relating to poverty and over congestion such as poor housing, high unemployment and dependency ratios, strain on available resources including essential healthcare, insecurity and high disease burden and prevalence.

Barely four months of the Covid-19 pandemic seems to produce an alarming upsurge in the number of teenage pregnancy cases being reported both to the local authorities in the area and to the health facilities offering maternity and other reproductive health services. Toto Care Box, an NGO working with women and newborns in the area reports an overwhelming demand for their services and products at this critical time and this is attributable to the rising number of cases of teenage pregnancy. At this point am tempted to imagine about the real iceberg lying in the unreported cases as well as those attempting to or already successful in termination of these unwanted and unplanned for pregnancies. Is there need for alarm?

Almost all the forty seven Counties in Kenya have been hard hit by the teenage pregnancy crisis. Latest statistics reveal that Nairobi County tops the list with 11,795 girls aged between 10-19 years reporting to be pregnant between the months of January and May this year. Here is the distribution for top ten counties as per the June Report on the state of teenage pregnancy in the country:

Direct causes of this sudden upsurge in the number of teenage pregnancy cases being reported can be explained using Covid-19 pandemic as the core trigger.

Depressing economic times such as the one presented by the Covid-19 pandemic are known to push teenage girls from poor families into sexual activities in exchange for food and other forms of necessities including protection from suffering. Most often, this type of vulnerability is hard to prevent because the victims are pushed to the limits and have no other options left. A number of studies point out to the fact that sexual exploitation in the context of sex in exchange for food and other essentials is widely reported as vulnerable girls and their families struggle to meet basic needs especially in times of crisis. This could be a perfect reality of what is being experienced by the suffering Kayaba residents.

Findings by the National Council for Population and Development (NCPD) support my hypothesis by confirming that approximately 26% of teen girls from poor households experience teenage pregnancy in comparison to 10% belonging to wealthier households. Poverty is actually a factor at play in Mukuru.

Also, as earlier mentioned in the article, the Covid-19 containment measures currently in place constrain teenage girls at home presenting them with enough free time to find innovative ways to experiment sex unnoticed. The “stay at home” directive therefore greatly helps flatten the Covid-19 curve while exponentially increasing the teenage pregnancy curve. Is the directive to be blamed in any way?

Teenage pregnancies have the cumulative effect of perpetuating the cycle of poverty which consequently lowers individual, social and economic development.

Toto Care Box is an organization working with poor women including girls in the Kenyan slums to better their reproductive health outcomes. The organization provides support to teenage girls undergoing the teenage pregnancy crisis by encouraging them to carry their pregnancies to term, to attend antenatal clinics, to deliver in health facilities and to care adequately for their teens despite the stigma, negative judgement and rejection.

This is done through a community-based approach involving education and incentivization. The organization does not however support the idea of young girls engaging in risky sexual behaviors that predispose them to early unwanted pregnancies. Visit for details.

In conclusion, successful efforts to curb teenage pregnancy must address underlying drivers through programs such as behavior change, sex education, social and economic development, reproductive rights advocacy and health systems strengthening. With all that in mind I still remain with a number of unanswered questions; Who is to be blamed for the teenage pregnancy problem? Who are the male perpetrators and what consequences do they face for their actions? What role do parents play in solving the crisis? How many teens will be affected by the end of the Covid-19 pandemic?

PEAH News Flash 390

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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Substantial Aspects of Health Equity During and After COVID-19 Pandemic

Health equity as a concept of minimizing health disparities among people, could be of utmost importance during the COVID-19 pandemic. Providing equity in health and participating in the acts of providing equitable healthcare have different aspects. Although this pandemic is not the first global-scale biological threat that humankind has faced, there is still some points to be further addressed. Deeming health as a public good, inevitably necessitates taking responsibilities for its fair provision. The aim of this study is to notify the public (policy makers, medical staff, and other individuals interested in the topic of health equity) about some strategies to consider the tenets of equity in health while managing the COVID-19 pandemic

By Erfan Shamsoddin

DDS, National Institute for Medical Research Development, Tehran, Iran

Substantial Aspects of Health Equity During and After COVID-19 Pandemic

A Critical Review 




When emergencies occur, even principal ethos and tenets of any context might seem vulnerable to change under the imposed pressures. This has been the case for 2019 novel coronavirus disease (COVID-19) regarding different aspects of health equity till today. Humankind has already dealt with contagious outbreaks and plagues, which have caused significant changes in the trajectory of scientific, political, and social sentiments regarding the disasters alike (1,2). Spanish flu (1918-1920), Smallpox outbreak (1972), human immunodeficiency virus (HIV) pandemic (originated from 1980s), severe acute respiratory syndrome (SARS) (2002-2003), swine flu pandemic (2009-2010), and Ebola outbreak (2014-2016) are all some instances of such disasters (2). Appreciating all the efforts of healthcare systems around the world, there were also some major shortcomings and mistakes in response to these upsurges (1,3–5). Delayed provision of effective treatments, unclear and inefficient communication between the governments and their people, not providing enough education and awareness sources and even funds resources (previous to the occurrence of illnesses), are all among these wrongdoings (5,6). All these conditions seem to be partially or completely repeated for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) related disease. A highly contagious illness representing a basic reproduction number between 2 and 2.5, a crude mortality ratio between 3% to 4%, and an infectiousness phase starting at 2.3 days before the symptoms onset (7–9). Though substantial measures and means have been enhanced since the earlier crises (i.e. more technological advancements, swift communications, better healthcare resources and management, higher drug production figures, etc.), there still exists some discernible inconsistencies and differences within the management protocols among various countries and regions worldwide (6). Looked at from a health policy and management perspective, lowering the variations and increasing the commitment to certain cornerstones, which have been established and reinforced formerly, could ultimately lead to better results and more controllable political environments for populations and even governments (10). All in all, despite noticing the temporary nature of this issue, the provision of health in an equitable way seems to be rattling and reshaping over the period of COVID-19 outbreak. Such a claim could further be described in four separate domains: political position, development status, cultural tendencies, and baseline health status. Figure 1 depicts a schematic view of these components.


Figure 1


Political position

Political compass can greatly influence the initiation, implementation, and outcomes of the national and regional announced policies in response to plagues (11). Overall, this can be dissected into two major levels: national and international policies. Though the evidence could usually help in directing public policies, it is inevitably less effective when the event is unprecedented, at least in some aspects. Accordingly, although some official pandemic preparedness guidelines were available for Middle East respiratory syndrome-related coronavirus (MERS-CoV), the birth of imminent COVID-19 has shown some different characteristics (12). Management strategies obeyed by the initially-virus-acquainted governments show variations from the past as well. Hong Kong, as an instance, have gone through quite similar conditions at 1997, during the H5N1 influenza outbreak. Total judgements on the performance of Margaret Chan, minister of health in Hong Kong at that time, are usually regarded as positive, well-led, and justifiable (13). Decimating domestic poultry seemed and still seems the best choice to prevent a pandemic (13–15). On the other hand, during the initiation of COVID-19, despite all the effective efforts and interventions implemented by the Chinese government after the spread of COVID-19 (16), lack of transparency _since announcing an outbreak as soon as possible, greatly impacts on the extent of public engagement_ and not following the WHO protocols about conducting full surveillance and control of avian outbreaks, was undeniable during the beginning of the crisis (17–19). Several explanations could be given as the cause of these shortcomings, namely, avoiding evidence-based decisions in favor of political biases, experimenting new solutions in response to an unknown biothreat (hoping to control the threat locally), and lazy governance (18,20). Healthcare is not a private commodity and every government should seek its provision as a public good (21). Consistently, multilateral efforts to address an outbreak or disaster could usually be considered as a critical step toward the resolution of a healthcare crisis in the least time possible (22–24). This will be eventually in favor of public health promotion. Instructions introduced by WHO are mainly in accord with the same principle, mainly emphasizing on travelling regulations, high-capacity surveillance measures and rapid reporting of positive cases to the international health organizations (25).

Evidence-based/-oriented policy making is another component which is highly under the impression of political stances in each country. More developed countries have already established and paved the evidence-assisted policy making pathways to follow. Nevertheless, developing countries have been getting more and more involved in this discipline in the last few years (26,27). Practicing this type of policies, might probably require training more specialists, more interactive international relations, and as a result, more interim costs. To take or not to take this road is basically determined by the authorities in force in developing countries _who mostly have been under long-term effects of narrative and rhetoric evidence in their decision makings. More developed countries on the other hand, can scrutinize and introduce modern patterns of the process. These new governance patterns usually get distributed via different medias (e.g. publications, news, professional events, international organization reports, etc.) which could serve as “scientific advice” for developing countries (28,29). The resiliency, nature, and ethos of healthcare systems, are therefore greatly maneuvered by the political position of the leaderships (30).

It is worth mentioning degree of autonomy and emancipation for trade markets and originator companies for they are regarded as gamechangers, hugely depending on each country’s political perspectives (31). The lucrative market of non-pharmaceutical and pharmaceutical products (including personal protection equipment, therapeutic/palliative drugs, and therapeutic/preventive vaccines) can be a tempting target for brand industries seeking out for-profit policies in the region during and after the occurrence of a plague (32). The final pathway of local and international economic investments and interventions is mainly determined and assessed during and in response to mishaps like COVID-19 (33).

Overall, the extent to which every nation will follow these rules and reach the goal of better health status, significantly depends on the principles on which their political compass is built upon.


Development status

The more industrialized and affluent a country/region is, the more capable it gets to resolve the financial issues during counteracting infectious outbreaks (34). Healthcare systems get established by developing critical care-provision infrastructures, gaining experiences (healthcare stewardship), providing and implementing technological advancements, building reliable international collaborations and coalitions, and scientific progression. Lack of such infrastructures in less-developed regions, could additionally exacerbate the issues imposed by a pandemic like COVID-19 (35,36). Since health is an integrated, intertwined matter worldwide, such disasters will inevitably exert their afflictions globally.

History is always repeating itself. After occurring an imminent pandemic like COVID-19, it is most likely that the first therapeutic/preventive treatment will get produced in an industrialized country, which would then support the mass production and lead the huge pharmaceutical markets in the near future. This was the case for 1918 influenza pandemic, H1N1 Influenza pandemic, and H5N1 avian Influenza (37,38). The request for compulsory benefit sharing (for pharmaceutical interventions) from developed countries led to constant rejections. Standard Material Transfer Agreement in 2009 _when negotiating for equitable access to influenza vaccines_ went through the same pathway and reached an evident destination, failure (37). Conceiving equity in health as a “charity” or “help” flowing from industrialized regions toward the less well-off, would probably result in similar outcomes in the future. Therefore, there need to be more accurate and comprehensive covenants between international parties aiming for equity in health throughout the world (39).

Another necessary fundament in healthcare systems, is the delivery. Provision of treatments in an effective and efficient way is of critical importance during infectious spreads, mostly affecting more susceptible patients (40). Individuals with special needs, systemic conditions, life-threatening and/or incurable diseases, women during the pregnancy period, older adults, and people under conditional restrictions (e.g. individuals restricted in jails) are all considered as susceptible people whom need to be specially treated by the governments during pandemics (41).  Other than the pharmaceutical pools, constructive care delivery needs sufficient assets of human resources and healthcare facilities (36). Care providing centers with limited hospital beds, have already been facing an overflow of COVID-19 patients in several countries and districts (e.g. China, EU, USA, Middle East) (42–45).  It can be said that the pandemic has damaged less-developed countries more severely in terms of value of fiscal crisis management costs as a share of country’s gross domestic product (GDP) (46). For example, defining fiscal stimulus packages and supportive funds to provide people with financial aids during the COVID-19 pandemic, has been of very different amounts among various countries (47).

All in all, the economic status and available resources of any country count as critical determinants of the COVID-19 management protocol.


Cultural norms

When enforcing local and domestic policies, the trail which the interventions will follow, and accordingly the empirical outcomes, are substantially affected by public opinion (48,49). The responsiveness of healthcare policies is perpetually being amended and directed by citizens’ predilections. Many current healthcare plans shift control and decision-making to the governments, whilst the final beneficiaries from these would be the citizens. The vast majority of people always care about the quality of care as the first aspect of healthcare provision in their regions. Increasing access, lowering the costs, and improving the choices are other considered variables for the quality of care (49). Nevertheless, the circumstances substantially differ in the case of a pandemic like COVID-19.

Public acceptance rate of the local and global policies concerning the health status is crucially affected by people’s personal beliefs (religion, etc.), ethnic prejudice, and culture (50). Inhabitants and citizens are actually the “performers” of the announced policies in each area, making them the most critical elements in directing the implementation of each intervention. For example, insisting on not obeying the curfews and not following the social distancing program (SDP) have been seen in various locations during the COVID-19 outbreak (51–54). Other countries, have redefined and reshaped some of the SDPs in order to be able to adjust the measures in accord with general people’s beliefs (55,56). These contextual policies have not shown promising results so far, as they fundamentally differ from the basic non-pharmaceutical interventions defined to cut the transmission routes of the virus (57). Epidemiologic advices relating to SDPs usually consider the following as critical tips: possibility of aerosol transmission, contact time necessary for contracting the COVID-19 during exposures, the minimum infectious dose, the degree of infectivity prior to onset of symptoms and its duration after recovery, seasonality effect, and immune responses in human beings (58). Looking at these factors, it seems challenging to gain people’s compliance after announcing new policies in a region to be obeyed, especially if the number of cases had been low (insignificant for the public) before the announcement date (59).

Two other important aspects of cultural beliefs during this pandemic, are the stigma about people who contracted the virus and have been cured (and the ones in contact with them, either directly or indirectly), and the origins of COVID-19 (60–62). Educating the citizens of any country is an utmost imperative to be addressed by their government. Accusing the Chinese residents of “unhealthy” eating habits or simply blaming the Wuhan virology lab as the causes and origins of SARS-CoV-2, would be superficial and not backed up by robust evidence till today.


Public health status

When a pandemic happens, regardless of what infrastructures are available, previous state of public health plays a critical role in the management phase (64). This refers to the therapeutic service-provision phase. In the case of COVID-19 pandemic, no definitive treatment is obtained yet (July 7th, 2020). This has led to a widespread human infection status (phase 5-6 of pandemic according to WHO’s classification of Influenza pandemic) and it is currently proceeding as the medical scientific teams seek highly effective treatment lines and possible candidates as preventive/therapeutic vaccines (65,66). This makes it indispensable for the medical staff to provide their patients with the best possible supportive and palliative treatments.

Generally, the presence of comorbidities can impose higher risks of exacerbation for the secondary illnesses or conditions. Results of a nationwide cross-sectional study conducted on 1590 Chinese patients, shows the same trend. Patients with any type of comorbidity have shown poorer clinical prognoses and resulted in less-favorable clinical outcomes. A greater number of comorbidities also correlated with poorer clinical outcomes and the most prevalent comorbidities were hypertension (16.9%) and diabetes (8.2%) (67). Taking these two systemic conditions as the cornerstones for further inferences, data shows that the prevalence, and consequently the burden imposed by them differs throughout the world. Data from the year 2010 shows that 28.5% (95% confidence interval (CI), 27.3-29.7%) of the world’s adults had hypertension in high-income countries. This figure was 31.5% (95% CI, 30.2-32.9%) in low- and middle-income countries (68). Another study evaluating the burden of type 2 diabetes in 2011, stated that Asia accounted for 60% of the world’s diabetic population with India placing as the second epicenter of diabetes pandemic (69). More studies concerning COVID-19 have represented the following results:  Portion of population at increased risk of contraction with SARS-CoV-2 virus was the highest in countries with older populations, African countries with high HIV/AIDS prevalence, and small island nations with high diabetes prevalence. Table 1 shows the results of regional names ordered by the number of individuals at increased risk of severe COVID-19 illness (units are measured in million(s) of people).

Table 1


These numbers can implicitly show the disparities among countries facing a global challenge like COVID-19. Although a lower share of population was displayed to be at risk for COVID-19 in African countries (3.1%) (compared to Europe with 6.5%), this simply implies the existence of much younger populations in African region. It was also mentioned that age-specific risks in African countries tend to be similar or higher than age-specific risks in European countries (70). Given that the opportunities and necessary basics to manage the disease are not similar worldwide, reporting the mortality occurrences could not simply be considered as the best choice to assess countries’ performances regarding the pandemic. Correspondingly, countries have been using some other measures to report their performance and productivity loss. Excess mortality (the number of deaths above and beyond what we would have expected to see under ‘normal’ conditions) or disability-adjusted life years (DALY) _which is usually adjusted by age, sex, and region (burden of COVID-19) are two examples of such measures (71,72).

Overall, when assessing the performance of each country against COVID-19 pandemic, everybody should first notice the baseline health status, initially available infrastructures, and the imperative costs of management for each country.



Health equity is defined by the international society for equity in health (ISEqH) as: “the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically”. This definition implies the existence of systematic (rather than random or haphazard) differences pertaining to health equity. This allows for comparisons regarding health status alterations due to a specific disease/condition/illness, between the residents of geographically distinct (but socially alike) areas (73). However, as stated by P. Braveman and S. Gruskin in 2006, “a health disparity/inequality is a particular type of potentially avoidable difference in health or in important influences on health that can be shaped by policies; it is a difference in which a disadvantaged social group or groups … systematically experience worse health or greater health risks than the most advantaged social groups” (73). In consequence of accepting both these interpretations, we should continuously and perpetually seek for a reduction in health disparities/inequalities in the context of public health assessments. Health policies can actively change the values of health-related indices within populations, making them as the first-line actors responsible for creating/deteriorating health disparities. In a time of economic downturn due to the COVID-19 pandemic, which is forecasted to lower the global economic growth by 0.5% in 2020 (from 2.9% in 2019 to 2.4% in 2020) (74), one might consider the issue of health equity as “unnecessary” or “unsuitable”. However, health equity is a universal term, highly intertwined with basic human rights and political justice. This would additionally stress the exigency of health equity during the COVID-19 outbreak, when underserved people around the world would probably need it the most. Some suggestions for not ignoring health equity amidst and after the pandemic are going to be introduced in this section.

Data gathering transparency is a key determinant in obtaining the best health-related outcomes. Reporting the true figures obtained from diagnostic tests gives the policy makers a correct insight about the situation in their sectors. This can later direct their decisions in shortcut ways to manage the outbreak promptly. Government-level transparency is also of utmost importance when it comes to reaching the best outcomes in the least possible time. Presenting the risks and hazards existing in the environment (without prioritizing politically-oriented aims over the health status of the nation) will attract public attention. This is going to be followed by more public engagement regarding the SPDs and participating to curb the viral transmission.

Another matter being suggested here is to provide open access to COVID-19 related topics for medical research teams around the world. There have already been some valuable efforts to gather and publish medical results free of fees worldwide. This is more necessitated when a plague threats the lives of humankind globally. Also, it is mutually accepted for all the physicians that providing their patients with the best possible treatment options, is a moral obligation. Following the same trend in other disciplines (technological advancement, political strategies, etc.) would definitely assist in resolving the troubles.

Two years after the Ebola outbreak (in 2014), the world bank announced the creation of the pandemic emergency funding facility (PEF) which is described as “a health insurance scheme for the world’s poorest countries and for qualified international responding agencies” (21). Although the coverage may seem low ($500m fund compared to the estimated 8.8 trillion dollars cost of COVID-19), the act itself lays a reliable pattern to scale up the response to such outbreaks in the world. Another example of introducing such acts is designing patent pools for pharmaceutical products. When settled as effective treatments against COVID-19, the demand for some limited types of drugs (antimalarial, anti-inflammatory, or anti-viral) will be soaring in the medical market. Suggesting effective ways to reach sustainable agreements between the brand industry and the generic competitors will increase the accessibility and affordability of the therapeutic/preventive agents in the near future. Patent pooling was suggested as one strategy to address the same issue for antiretroviral drugs (potential treatments for acquired immunodeficiency syndrome (AIDS) (75). Designing similar interventions and not-for-profit-policies could immensely affect the fair availability of vaccines and drugs in the near future.

Lastly, educating residents about possible risks in nutrition patterns could be critical to halt the occurrence of other imminent outbreaks. A meeting report published by WHO in 2008 clearly claims the possibility of viral transmission via non-typical routes. Foodborne infection is introduced as a “frequent” viral transmission route. SARS-CoV and highly pathogenic avian influenza (HPAI) are described as resistant to (mild) food production processes routinely used to inactivate or control bacterial pathogens in contaminated foods (76). Regardless of literacy rate in a country, specific education in certain fields seems to be necessary to promote and reinforce the public engagement for some policies. Whenever there would be sufficient and robust evidence to claim a scientific critique about the origins of SARS-CoV-2, modifying Chinese residents’ nutrition patterns, which are engraved in them during several generations, might only be possible by extensive and persistent long-term education to achieve significant results. This claim is not limited to the Chinese nation and would be applicable to all kinds of risky dietary patterns around the globe.



Perceiving health as a public good obliges all governments to participate in the act of providing equity in health globally. Given that the favors will eventually return to their own nations, these acts should be done by any means available to the healthcare systems. Governments should refrain from political biases and cultural prejudices and reinforce the healthcare infrastructures as they are all necessary steps for achieving health equity.



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PEAH News Flash 389

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 389


Police Transparency Is A Public Health Issue, Too 

Taking Back Our Voices — #HumanityIsOurLane 

Education: a neglected social determinant of health 

The effect of food taxes and subsidies on population health and health costs: a modelling study 

Q&A: Women Workers in Fast Fashion Demand Justice 

DNDi Financial and Performance Report 2019 

Fostering local production of essential medicines in Nigeria  

Next Kampala Initiative webinars: Thursday, 9 and 16 July 2020 Health aid in the time of COVID-19. Exploring how to move from aid to global solidarity 

Q&A: An opportunity to change the world with science 

Tackling antimicrobial resistance in the COVID-19 pandemic 

Will COVID-19 be evidence-based medicine’s nemesis? 

Timeline of WHO’s response to COVID-19 

Coronavirus disease (COVID-2019) situation reports 

Latest COVID-19 Statistics from African Countries 

World Surpasses 500,000 COVID-19 Deaths; Medicines Access Experts Challenge US $2340 Per Remdesivir Treatment Course Price Set By Gilead For Developed Countries 

Remdesivir developed country price announced 

COVID-19 vaccines: EU prioritises preferential access, paying lip-service to global solidarity 

Intellectual Property, Innovation and Access to Health Products for COVID-19: A Review of Measures Taken by Different Countries 

COVID-19: Countries race to strengthen compulsory licensing legislation 

How Orphan Drug Policy Could Impede Access To COVID-19 Treatments 

Mental health, COVID-19 and primary healthcare in Guinea : a tale of stigma and solidarity 

Q&A: Want to know about COVID-19 in Haiti? Ask a nurse 

Can future pandemics be prevented? 

The Future Path of U.S. Clinical Research: Bridging Geographic Diversity by Nicole Jarosinski

Put Climate at the Heart of COVID-19 Economic Recovery Plans 

Climate fund targets $2.5 billion in clean energy investment for SE Asia 

EU climate transition needs mineral miners, not coal miners 

US to join summit on global green recovery from Covid-19 crisis 

Judy Asks: Are Citizens’ Assemblies the Answer to the Climate Crisis? 

Swelling Indian National Opposition As Modi Plans To Expand Coal Mining