Impact of Coronavirus on developing countries

UNISON’s submission to the International Development Select Committee Inquiry

May 2020

UNISON is the largest trade union in the UK, representing 1.3 million members working in public services. We have established links with trade unions globally, including in Africa, Asia and Latin America. UNISON plays a leading role in the global union federation Public Services International (PSI), which represents over 30 million public service workers worldwide. Through our international partnerships and projects we work to defend workers rights and quality public services globally.

UNISON’s support and involvement in PSI’s extensive work on a trade union response to the Ebola Virus Disease has enabled us to develop strong links with public service unions in West Africa and gain an understanding of the lessons from the crisis.

Public service unions are at the forefront of the global response to the Covid-19 pandemic, representing millions of workers in health, social care, WASH, education, local government and other public services. Through our partnerships with unions around the world and the experience of our own members we are uniquely placed to respond to this inquiry.

1.0                The emergence, incidence and spread of coronavirus virus infections and the Covid-19 disease in developing countries

1.1               The World Health Organisation has stressed that “The best defence against any outbreak is a strong health system”. However, the spread of the pandemic has rapidly exposed the fragility of health systems, in particular in the global south.

1.2               The preliminary results of a PSI survey of public service unions on Covid-19 emphasises how weak health systems are hindering the response to the pandemic, with 60 percent citing insufficient trained staff, 64 percent a shortage of beds in appropriate wards in public hospitals and 51.4 percent not enough medicines/pharmaceuticals. Whilst these results provide a global picture, we recognise the situation is significantly worse in many countries in the global south.

1.3               Health workers are disproportionately affected by the pandemic. UNISON is receiving consistent messages that severe shortages of Personal Protective Equipment (PPE) and testing are having a significant impact on the safety of health workers globally. The International Trade Union Confederation (ITUC) is conducting regular surveys of trade union national centres to assess the international response to the pandemic. Its third survey, conducted in 107 countries between 20-23 April, found that less than half (49 percent) said they always or very often have access to adequate PPE. Of these just 16 percent said that supplies were always adequate, whereas 16 percent said that supplies were rarely or never adequate[i]. Unsurprisingly, the survey shows that the availability of PPE varies significantly according to region, with 36 percent of respondents in Africa and 28 percent of respondents in the Americas saying that adequate supplies of PPE were rarely or never available.

1.4               The preliminary results of the PSI survey provide an even more concerning picture. Just 23 percent of unions surveyed responded that health-workers have been provided with full and replenished PPE including masks, gloves, goggles, gowns, hand sanitizer, soap and water, cleaning supplies, and 55 percent saying that they have not. In response to the question “have all workers delivering public services who could come into contact with infected people been issued with adequate PPE?” only 13 percent answered positively.

1.5              The World Health Organisation (WHO) have emphasised the importance of testing to track and reduce the spread of the pandemic and allow public service workers to return to work. In PSI’s survey of public service unions 77.9 percent of respondents have highlighted a shortage of testing kits.

1.6              Aid and loan conditionalities, austerity measures and tax evasion and avoidance have contributed to decades of underfunding of public health systems. Governments have sought to make cost savings through a variety of measures including freezing salaries, reducing the workforce, privatisation and the introduction or increase of user fees. As well as weakening health systems, these measures inevitably lead to lower health outcomes and increased inequality, as they disproportionately affect women and poorest in society.

1.7              The promotion of privatisation in many countries has also contributed to the weakening of public health systems. Decades of evidence has demonstrated that quality public health systems are far more efficient and effective at meeting the health needs of populations, particularly the poorest and most vulnerable. Where healthcare provision is motivated by profit, services are inevitably focused on more affluent and urban areas, and service quality and standards and workers’ rights are diminished, whilst information is rarely shared between providers. Whilst some countries have compelled private providers to support the response, the pandemic has highlighted the need for development agencies including DFID to revisit its policy of promoting and supporting the privatisation of healthcare, particularly Public Private Partnerships (PPPs) in the global south.

1.8              The economic impact of the pandemic has exposed the fundamental flaws in international policies which have far too often assumed that quality public healthcare is a financial burden rather than a creator of wealth and essential and affordable, even for the poorest countries.

2.0              The direct and indirect impacts of the outbreak on developing countries, and specific risks and threats

2.1              Zimbabwe

Zimbabwe’s health service has been at breaking point for years. The working conditions for health care workers were already dire as was the shortage of resources and medicinal supplies. Health facilities are understaffed, have low standards of occupational health and safety, and do not all have constant access to water. Furthermore, health workers are paid shockingly low wages. The Zimbabwe Nurses Association (ZINA) has gone on strike, along with doctors and customs officials, demanding:

1. PPE: Health workers have no personal protective equipment, and without it they have a greatly increased risk of infection;

2. Access to constant water supply - In some hospitals the water supply is erratic. Without access to water, health workers face a higher risk of infection;

3. Risk allowances – given the increased risk to workers’ lives and the conditions in which they work, health workers are demanding a risk allowance, in a time where many will be overworked and may pose a risk to their families;

4. Access to training and information on COVID-19[ii].

The Zimbabwe Congress of Trade Unions (ZCTU) also called for the country to lock down, for PPE supplies to health workers and for targeted testing[iii] and is raising awareness of the pandemic amongst its members, despite the challenges of communicating under lock-down in Zimbabwe. As is the case in most countries, the pandemic poses enormous barriers to organising, representing workers and collective bargaining. The recently re-established National Tripartite Forum consisting of the Government, ZCTU and MCOZ, the employers’ organisation, has met virtually since lockdown. However, the lack of national data collection and statistical analysis makes it very difficult to respond the crisis and the government continues to be unwilling to share information or listen to the concerns of social partners.

2.2              Swaziland/Eswatini

UNISON has been approached by public service unions in Swaziland/Eswatini about severe shortages of PPE. A significant proportion of the population have underlying health issues as the kingdom has both the highest HIV and TB rates in the world. Health systems are extremely weak and essential medicines are regularly in short supply. At the beginning of April UNISON was approached by the National Public Service and Allied Workers’ Union with concerns that first line responders including paramedics were being forced to work without access to adequate PPE. On 17 March the Swaziland Democratic Nurses Union held a march with many hospitals holding sit ins to demand PPE. Although the government has responded with some PPE, there continue to be severe shortages.

2.3              Turkey

The Trade Union of Employees in Public Health and Social Services (SES) has been collecting data on the impact of Covid-19 from health facilities across Turkey, due to concerns that the Ministry of Health does not provide data in a transparent manner and the indicators used, the capacity of hospitals to deal with the pandemic, and the failure to include SES and the Turkish Medical Association in the monitoring and response to the pandemic. The SES survey of 294 health facilities from 52 provinces, conducted between 15 to 18 April, identified at least 1,833 health workers with confirmed COVID-19 from 301 health facilities. Based on these figures SES estimates that there were at least 8,000 health workers with confirmed cases of Covid-19 in Turkey at the time. SES has highlighted shortages and discrepancies in the distribution of PPE for health workers as a significant contributing factor.

2.4              Malaysia

Workers producing PPE are also facing risks as manufacturers fail to provide them with adequate protection as they respond to the unprecedented global demand. Malaysia exports 60 percent of the world’s rubber gloves. Many factories, including those renowned for migrant labour linked to modern slavery practices, continue to operate at full capacity. These workers are forced to work in close proximity without the PPE they need, for extremely long hours and low pay. Where it has been possible to interview workers in factories, they have reported that despite the exploitation, they are relieved to have any income at all and they share everything amongst friends and families who have lost their jobs without any pay. Our partner in Malaysia, Tenaganita, one of Malaysia’s oldest labour rights NGOs, is supporting migrant workers, refugees and abused women through a 24-hour hotline, advice in multiple languages and the provision of masks, sanitisers and food parcels.

2.5              Migrant workers

Some measures taken to reduce the spread of the pandemic, in countries where social protection systems are weak, are exacerbating poverty and inequality. In several Gulf states, whose economies are largely reliant on low paid migrant labourers, thousands of workers have been left jobless due to the lockdown, without the means to return home[iv]. In Qatar, which has one of the highest infection rates in the world, disproportionately affecting migrant workers, many have been dismissed or placed on unpaid leave, some without access to food or accommodation. Families in the global south who are dependent on remittances from migrant workers are also significantly affected by the measures.

2.6              As governments seek to reorganise their health priorities to respond to the pandemic, unions have highlighted concerns that other essential health services are being deprioritised, particularly where health systems are weak. In many countries women’s access to reproductive health services has decreased, as have other essential services including management of diseases, vaccinations, care of infants and older people etc. This will inevitably lead to significant additional health challenges and pressure on health systems both in the short and longer term.

3.0              The UK’s response, bilaterally and with the international community, to the spread of coronavirus to developing countries

3.1              DFID and the UK government should support global efforts to provide PPE to all

workers exposed to high risk of contagion. Steps should be taken to ensure and

protect decent work in supply chains. The pandemic has exposed weaknesses

in global supply chains with countries competing with each other to access

limited supplies, highlighting the need for consideration of domestic production,

and support for the development of domestic production in poorer countries.

3.2              Immediately end support for and promotion of the privatisation of healthcare

globally, and instead concentrate on supporting the development of quality

public health services.

3.3              Support countries to recruit and train healthcare workers to alleviate pressure

on existing workers. Support programmes and policies that guarantee decent

work for health workers and other public service workers.

3.4              Support global efforts, coordinated by the WHO, to develop a vaccine for Covid-

19, taking steps to prevent commercial exploitation. Suspend patents on medication necessary for the treatment of the virus.

3.5              Support the development of social protection systems to protect all workers,

including migrant workers, and family income affected by the pandemic.

3.6              Analyse and address the impact of any reductions in the income of migrant

workers on remittances they send back home.

3.7              Encourage Governments not to keep informal traders off the streets once the

emergency is over, without supporting them through decent work or social protection.

3.8              DFID should provide funding to support public service unions to take an active role in the development of policy responses to the pandemic.

3.9              Ensure all PPE and other high demand goods supplied to the public sector are

sourced responsibly. The Government should ensure that public service procurers do not neglect their responsibilities to procure responsibly.

3.10              Ensure that conditionalities are not applied to support for developing countries,

including from IFIs, including for the development of crucial infrastructure, including quality public water and sanitation systems, which will help limit the spread of the pandemic.

3.11              Provide debt relief and debt restructuring for the poorest economies to ensure that debt repayments are not prioritised over public health and the economic crisis.

3.12              Remove conditionalities such as tax breaks for the wealthy, privatisation and other market liberalisations, which will hinder the ability of governments to rebuild economies that work for everyone.

3.13              Take urgent steps to address the crisis for migrants, refugees, asylum seekers,

and particularly those living in camps, at borders and in detention, ensuring their rights are recognised, including the right to quality public health services.

3.14              Develop longer term economic solutions which allow economies to recover,

whilst reducing the inequalities that have exacerbated the pandemic. Global tax

regulations which prevent the use of tax havens, avoidance and evasion, and

ensure governments have the revenue to invest in quality public services should be a priority.

4.0              Lessons identified and learned/applied from previous experience with infectious diseases (for example, Ebola); the implications for DFID’s policy on a global health strategy

4.1              When health workers in Sierra Leone, Guinea and Liberia, the three countries most affected by Ebola, raised concerns with their governments and other authorities at the beginning of the epidemic, their voices were not heard. In Guinea and Sierra Leone, this was primarily due to the lack of a functioning structure for social dialogue, whereas in Liberia health workers faced the additional challenge that public service unions are not recognised by the government. Trade unions in Nigeria on the other hand were able to provide early warnings to the government, and ultimately government and healthcare unions worked closely together to successfully stop the spread of the disease[v].

4.2              Public service unions represent the experts in health and social care who are on the frontline, tackling Covid-19 globally. It is essential that they are included in the development of policy response to the pandemic and the recovery. The preliminary results of a survey by the global union federation Public Services International (PSI) on the Covid-19 response, indicates that the vast majority of governments are not consulting trade unions. Just 23 percent responded that their governments were involving unions in the development of policy responses to COVID-19.

4.3              In the case of Ebola in West Africa, weak health systems from decades of underfunding and a severe lack of resources clearly resulted in a significant loss of life and a failure by governments to respond to the crisis. The International Labour Organisation (ILO) estimates that 41 health workers per 10,000 people are necessary for an adequate healthcare system. In Liberia at the beginning of the Ebola epidemic there were just three health workers per 10,000 people. Thousands were kept on for years as volunteers whilst others were seriously underpaid. Protection for healthcare workers before Ebola was extremely weak with no vaccinations for healthcare workers for a decade and no occupational health and safety provision in workplaces. When the payment of hazard fees to health workers was introduced there were significant challenges in the implementation of the scheme. In Sierra Leone payments were subject to serious delays and irregularities, whilst in Liberia many public sector health workers only received a portion of the amount they are entitled to while few private healthcare worker received hazard pay. The payment of salaries was also subject to long delays.

4.4              Ebola disproportionately affected health workers. In the worst affected countries more than 500 health workers died of Ebola due a lack of personal protective equipment (PPE), unsafe working environments, substandard infrastructure, overexposure to hazardous environments, structural understaffing and a lack of resources to deal with infections. In Liberia this resulted in a 10 percent reduction in the number of doctors and an 8 per cent reduction in nurses and midwives. Sierra Leone saw a 5 percent reduction in doctors and a 7 percent reduction in nurses and midwives. This has further weakened highly fragile health systems and the ability of these countries to respond to the health needs of the population, as well as further health crises.