Narrowing the urban-rural electricity gap in Sub-Saharan Africa: Does equal distribution of political power matter?

Why Digital Health Literacy Matters in Rural Sub-Saharan Africa:How Bridging the Digital Health Literacy Gap Could Improve Access to Health Services and Social Equality Ismaila Ouedraogo, Roland Benedikter, Borlli Michel Jonas Some, and Gayo Diallo Digital Health Literacy Matters Around the world, mobile phones have been used for quite some years now to put healthcare systems into interactive action through various mobile health applications. The results regarding efficiency, access, greater social equality, and interconnectivity are proven, and they promise to mitigate economic and educational gaps. All this is increasingly the case in sub-Saharan Africa (SSA), where the technological prerequisites are quickly evolving. About 500 million people in SSA—more than 46 percent of the region's population—were subscribing to mobile services in 2020, and their numbers are forecast to reach 615 million in 2025 (GSMA 2022). In the meantime, coverage works also in the structurally poorest areas. In 2020, 2G mobile network coverage in Burkina Faso was 81 percent for the territory and 92.4 percent for the population (ARCEP 2020). The high penetration rate of mobile phones and the increasing coverage of the mobile network has created a vast variety of opportunities for health provision. Mobile devices can no longer be ignored in practical health delivery and disease prevention workflows. The positive potential of the application of digital health tools is obvious, and it is often said that mobile devices will be a key vehicle on the road to achieving universal health coverage in the Global South. Despite this promise, the deployment of digital health tools in SSA faces many challenges, such as an urban-rural gap, a gender divide, low digital literacy, and a shortage of electricity and interconnectivity [End Page 134] (Holst et al. 2020). Poorly designed, unsustainable, unsafe, and irresponsible digital health products circulate that waste time, energy, and physical and financial resources. Digital health literacy increasingly correlates with digital inclusion—a situation where people can access and use information and communication technologies to take charge of and improve their health. Inversely, digital health technologies become useless when users do not have the skills, connectivity, mutual exchange, or understanding to use them, or do not have access when they need them. Designing digital health solutions that fit with the digital literacy prerequisites and skills of low-qualified users matters crucially in SSA for sustainably sufficient coverage. The ability to find, understand, and use e-health resources is critical for consumers to be able to use current and future health services. Digital health literacy is therefore no longer an option but has become a fundamental requirement in SSA in the design of inclusive solutions. Innovative Mobile Health Initiatives in SSA during the COVID-19 Pandemic The advent of the global COVID-19 pandemic, which began in 2020, has accelerated the pace at which mobile technology is becoming commonplace in people's healthcare. In many countries, healthcare systems rapidly shifted to enabling medical consultations digitally. The increase in mobile phone usage was correlated with an increase in access to information, with phones acting as information relays. Cell phones were used to disseminate pandemic-related information to disadvantaged communities in SSA. Several examples catch the eye. In Burkina Faso, Viamo is a social enterprise that understood this paradigm shift early. It attempted to connect disadvantaged individuals and organizations with appropriate information via mobile devices to enable them to make better decisions (Sandwidi 2020). Through its mobile services, it had played an integral role in bridging the information gap among communities in rural areas long before the advent of the pandemic (UNDP, n.d.). Among other initiatives, it partnered in 2010 with Orange Burkina, a primarily national telecommunication company, to launch a mobile service that allows underserved communities to have free access to information in four of Burkina Faso's most spoken local languages: Mooré, Dioula, Fulfulde, and Gourmanché. Viamo instructions are provided mainly orally, in the same four languages, to include those who cannot read. These approaches, hailed by many customers, have evolved over time. Since 2017, Viamo's platform has covered many themes, including COVID-19 orientation, family planning, health, agriculture, early childhood development, weather forecasts, news, and entertainment. Each theme is usually subdivided...

During the late 1970s and early 1980s, many African countries experienced a profound slowdown in economic growth. The growth rate of real per capita GDP fell from 0.4% per year during the 1973-80 period to 1.2% per year during the 1980-89 period.' The causes-internal and external-of Africa's economic decline and the strategies for restoring economic growth are much debated. Nevertheless, broad consensus has emerged on the importance of (i) increasing total investment and (ii) promoting private-sector development and increasing its share of total investment for long-term growth.2 It is widely recognized that gross domestic investment fell substantially in Africa during the 1980s and remains severely depressed across the region. The proportion of total domestic investment in GDP fell from 20.8% per year during 1973-80 to 16.1% per year during 1980-89. In some countries, investment has fallen to less than 10% of GDP-a level that is insufficient even to replace depreciated capital. In Africa, the minimum investment needed to replace depreciated capital is estimated at 13% of GDP.3 In recent years, there has also been a growing recognition among many African leaders, faced with new realism and pragmatism, that the private sector could play a significant role in economic development. The focus in the longer term of structural adjustment programs and sectoral reforms adopted by these countries is on creating more appropriate incentives and a framework for private-sector development as the basis for achieving sustainable economic growth. In addition, multilateral and bilateral institutions have developed new initiatives with priorities for private-sector development. In 1989, the International Finance Corporation, an affiliate of the World Bank, es-

BackgroundUnderstanding urban-rural gap in childhood survival is essential for health care interventions and to explain disparities in the determinants of Under-5 mortality. There is dearth of information about the factors explaining differentials in urban-rural Under-5 mortality especially in sub-Saharan Africa (SSA). In this study, we sought to quantify the contributions of bio-demographic, socioeconomic and proximate factors in explaining the urban-rural gap in Under-5 mortality in SSA.MethodsThis study utilized secondary data from Demographic and Health Survey (DHS) in 35 sub-Saharan countries conducted between 2006 and 2016. Child (aged 0 and 59 months) death was the outcome variable in this study. Oaxaca-Blinder decomposition was used to decipher urban-rural gap in the factors of Under-5 mortality.ResultsSignificant urban-rural differentials were observed in Under-5 mortality across bio-demographic, socioeconomic and proximate factors. In the decomposition model, about 44.27% of urban group and 74.71% of rural group had Under-5 mortality in sub-Saharan countries. Maternal age, education, use of newspaper, TV, wealth index, total children ever born, size of baby and age at first birth contributed towards explaining urban-rural gap inUnder-5 mortality.ConclusionThese findings could be contributory to health care system improvement and socioeconomic developmental plans to address under-5 mortality in SSA. Strengthening maternal and child health (MCH) programmes, specifically in rural areas and improving health care services would help to ensure overall child survival.

BackgroundAbout 31 million children in sub-Saharan Africa (SSA) suffer from immunisation preventable diseases yearly and more than half a million children die because of lack of access to immunisation. Immunisation...

Open defecation remains a major public health and equity challenge in Sub-Saharan Africa, where national averages often mask profound subnational disparities. Progress toward Sustainable Development Goal (SDG) 6.2 depends not only on increasing coverage but on closing persistent rural-urban gaps. This study quantified the magnitude and national consequences of these inequities using harmonized 2022 data. We analyzed WHO/UNICEF Joint Monitoring Programme (JMP) 2022 estimates for 20 low- and lower-middle-income countries using four standard inequality metrics: the absolute difference (D), rate ratio (R), population attributable risk (PAR), and population attributable fraction (PAF). These indicators quantify both the scale of rural-urban gaps and the portion of the national burden attributable to rural disadvantage. Countries were grouped into a three-tier equity typology based on national prevalence and the size of the rural-urban gap. National open-defecation prevalence ranged from 0.1% (Gambia) to 67.0% (Eritrea), with rural rates consistently and substantially higher than urban rates. In most countries, rural residents were three to ten times more likely to practise open defecation than urban residents. PAR and PAF results showed that eliminating rural disadvantage would reduce national prevalence by up to 40-60% points in the most unequal settings. Countries clustered into three profiles: high burden with extreme inequity (n = 6), moderate burden with persistent inequity (n = 10), and low burden with residual inequity (n = 4). We found that eliminating the rural disadvantage could reduce the national prevalence of open defecation by up to 40% points in the most unequal settings, demonstrating that equity is central to achieving SDG 6.2. Open defecation in Sub-Saharan Africa is overwhelmingly concentrated in rural populations, making inequity, not simply low coverage, the central barrier to achieving SDG 6.2. Integrating simple equity metrics such as D, R, PAR, and PAF into national monitoring systems can help governments identify priority populations, estimate potential gains from reducing disparities, and target investments more efficiently and fairly. Equity-focused sanitation strategies are therefore essential to ensuring that no community is left behind.

The learning gap between urban and rural areas is a persistent problem in many sub-Saharan African countries. Previous studies have found that the urban-rural learning gap is attributed to the fact that student characteristics and school resources are different in urban and rural areas. Our study updates this finding by using the latest dataset and further examines the changes in the attributed sources over time. Using 15 educational systems in sub-Saharan Africa, we examined 4 potential sources of the gap: student, family, teacher, and school characteristics. Our results reveal that the urban-rural learning gap in recent years is attributed mostly to differences in school and family characteristics. We also found that the attribution remains the same over time from 2004 to 2011 and that the attribution to family characteristics’ differences became slightly greater than the one to school characteristics’ differences.

Sub-Saharan Africa (SSA) has the highest maternal and under-5 mortality rates as well as low facility births, with a high percentage of births occurring in the absence of skilled personnel. We examine trends in health facility births in SSA by geographic areas (urban-rural) and regions; and also the correlation between health facility birth and neonatal mortality rate (NMR). Data come from Demographic and Health Surveys (27 countries), conducted between 1990 and 2014. Median health facility births, urban-rural gaps, and regional variations in health facility births between initial (1990) and latest (2014) surveys were calculated. The median health facility birth increased from 44% at initial survey to 57% at the latest survey. Rural areas had a higher percentage increase in health facility births between initial and latest surveys (16%) than urban areas (6%) with a 2% overall gap reduction between initial and latest surveys. Health facility births were inversely associated with NMR at initial (R2=0.20, p=0.019) and latest (R2=0.26, p=0.007) surveys. To achieve the Sustainable Development Goal target of reducing neonatal mortality, policies should particularly focus on bringing rural areas on par with urban areas.

As a continent with 54 independent states Africa’s diversity is often highlighted but frequently forgotten when fertility is discussed. Fifty and more years ago to consider that all African countries and societies had a single fertility pattern (large numbers of children) and single trend (unchanging over time) was a valid characterization. Since the 1960s however that uniformity has disappeared replaced by substantial inter- and intra-country differences in fertility patterns and trends that render previous perceptions of continent-wide homogeneity obsolete. In this chapter we consider two African countries—Ghana and Kenya—whose fertility patterns and trends and their determinants have been well documented (Bongaarts 2008; Garenne 2008; Machiyama 2010; Shapiro and Gebreselassie 2008; Sneeringer 2009). Both countries have benefited from regularWorld Fertility Surveys (WFS) and Demographic and Health Surveys (DHS) that record trends in fertility family planning (FP) and other relevant indicators. The recently introduced Performance Monitoring and Accountability 2020 (PMA2020) surveys monitor progress since 2012 for the FP2020 initiative and occasional Situation Analysis and Service Provision Assessment surveys have also detailed the readiness of the health system in both countries to make quality FP services available. Ghana and Kenya share some common history: both have relatively strong health system legacies from the period of British colonialization; both were among the earliest countries to achieve independence; they were the first two African countries that developed policies to address population growth in the 1960s; and both have received substantial and sustained resources over several decades from many external donors and technical assistance organizations explicitly intended to increase the availability and quality of family planning services. However they are composed of cultures that are both diverse within each country and markedly different in many ways between the two countries. The two countries demonstrate remarkably different pathways in fertility and family planning patterns and trends from the 1970s to the present. We highlight some of the key differences and similarities explain why they have occurred and identify insights that could inform a wider understanding of fertility transitions and the role of family planning in other African countries. (excerpt)

Urban–rural differentials in child malnutrition: Trends and socioeconomic correlates in sub-Saharan Africa

BackgroundImproving maternal and reproductive health still remains a major challenge in most low-income countries especially in sub-Saharan Africa. The growing inequality in access to maternal health interventions is an issue of great concern. In Ghana, inadequate attention has been given to the inequality gap that exists amongst women when accessing antenatal care during pregnancy and skilled attendance at birth. This study therefore aimed at investigating the magnitude and trends in income-, education-, residence-, and parity-related inequalities in access to antenatal care and skilled attendance at birth.MethodsA database was constructed using data from the Ghana Demographic and Health Surveys (DHS) 1988, 1993, 1998, 2003, and 2008. The surveys employed standard DHS questionnaires and techniques for data collection. We applied regression-based Total Attributable Fraction (TAF) as an index for measuring socioeconomic inequalities in antenatal care and skilled birth attendance utilization.ResultsThe rural–urban gap and education-related inequalities in the utilization of antenatal care and skilled birth attendants seem to be closing over time, while income- and parity-related inequalities in the use of antenatal care are on a sharp rise. Income inequality regarding the utilization of skilled birth attendance was rather low and stable from 1988 to 1998, increased sharply to a peak between 1998 and 2003, and then leveled-off after 2003.ConclusionsThe increased income-related inequalities seen in the use of antenatal care and skilled birth attendance should be addressed through appropriate strategies. Intensifying community-based health education through media and door-to-door campaigns could further reduce the mentioned education- and parity-related inequalities. Women should be highly motivated and incentivized to attend school up to secondary level or higher. Education on the use of maternal health services should be integrated into basic schools so that women at the lowest level would be inoculated with the appropriate health messages.

In the newly independent states of southern Africa, many women have taken advantage of the political opportunities granted them in just a little more than the last decade and are now exercising political responsibilities equiva lent to those of women in the developed nations. The United Nations has contributed to this process by its impact on the constitutions of these countries and by its assistance to women through its various agencies. In twenty-nine nations south of the Sahara, women exercise their constitutional rights of suffrage. In many of these countries, women are playing a responsible role in government, judicial, and diplomatic af fairs. In Liberia, for example, where women first received suffrage and the right to hold political office in the 1940's, they are active in all branches and levels of government and in the diplomatic service. Women in southern Africa exhibit great interest in political matters, and their increasing abilities contribute much to the development of their nations.—Ed.

Reviewed by: Education Marginalization in Sub-Saharan Africa: Policies, Politics, and Marginality by Obed Mfum-Mensah Jamaine Abidogun Education Marginalization in Sub-Saharan Africa: Policies, Politics, and Marginality OBED MFUM-MENSAH Lexington Books, 2018, 240 pages. Obed Mfum-Mensah brings a wealth of knowledge, experience, and insight to his book, Education Marginalization in Sub-Saharan Africa: Policies, Politics, and Marginality. The book is organized in two parts: theory on marginality and education; and education policy and practice regarding marginality. He provides a synopsis of human capital (education for production) and human rights (education for all) theoretical and philosophical arguments. His work falls squarely within a human rights framework as he defines the need for an education structure that advocates equity and provides the structures and policy to ensure equity in education to everyone in the wider society. The chapters are designed to defend and promote the argument of education for all to fulfill what has been touted as a global education mandate. This noble mandate resonates in most teacher education programs today as the accepted or expected goal for national education programs. Mfum-Mensah positions this mandate against the historical and contemporary realities of national education systems across sub-Saharan Africa that simultaneously seek to educate all students as they also supply trained labor for the nation-state. These two theories, human capital and human rights, represent a global struggle within education. His specific mission in this work is to demonstrate the need to better identify how to engage marginal groups across sub-Saharan Africa in national education. His work contributes to the development and restructuring of sub-Saharan African education systems to ensure full participation of presently marginal groups. Chapters 1 to 3 describe the historical and contemporary (colonial and postcolonial) common structures of national education programs found across sub-Saharan Africa. In this work, Mfum-Mensah provides a generalized account of colonial and postcolonial education structures. He posits that colonial policy and later postcolonial policy purposefully favored some African groups, i.e., those who serve the colonial or later postcolonial political and economic agenda, to the disadvantage of other African groups. He identifies the benefited groups as male, able-bodied, urban, and primarily Christian as the educated elite, who historically benefited from colonial education and later, postcolonial education policy and practice. The colony and later the nation-state maintained an education system that was top-down in nature with a [End Page 149] curriculum designed to benefit those in power. He does make the distinction between colonial and postcolonial periods, to note that one’s ethnic identity fluctuates as favored or marginalized based over time and political context. From this simplified, but generally accurate historical context, Mfum-Mensah effectively draws from a range of sub-Saharan African countries to identify marginalized groups and documents the disparities in their education access and participation. These groups include disproportionately female students; Muslim students (especially Muslim students residing in Christian or Christian-dominated localities); students with disabilities; rural students; nomadic students; and refugee students. He also includes marginalized ethnonational groups, who are most often, but not always, the minority in the nation-state population. Notably they are always the ethnic or racial group not in political or economic power. He demonstrates through intersectional analysis (which includes students who belong to more than one marginalized group) the extraordinary impact marginalization can have on a student to effectively block them from access and participation in schools that do not consider their structural or curricular needs to support their success. Within Mfum-Mensah’s work is consistent emphasis on the role of religious identity that in most areas historically marginalized access for Muslim students. Historically, some of this, at least in the Anglophone regions, was explained by British indirect rule, which left Islamic education systems intact in return for non-interference with the British colonial economic mission. Mfum-Mensah describes this as neglect of their education. It is agreed that Muslim students rarely participated in colonial education outside of the urban center. Still, based on his argument where he cites the imposition of European culture as a major disadvantage of colonial and later postcolonial education, Islamic groups may have fared better across sub-Saharan Africa...

The World Health Organization has noted much progress towards the realisation of Millennium Development Goals related to maternal and child health. Eighty percent of women in many developing economies now receive at least one visit during pregnancy by a skilled birth attendant (although only 52% had the recommended four visits), and 68% of women across developing regions receive skilled health attendant care (up from 56% in 1990). However, disparities follow regional and urban-rural gaps. Sub-Saharan Africa and Southern Asia lag behind other regions in the provision of antenatal care and skilled attendance at birth (although typically attended by a family member or villager) and over 32 million of the 40 million births not attended by skilled health personnel in 2012 occurred in rural areas. Overall, one-quarter of women in developing nations still birth alone or with a relative to assist them. While increased numbers of medically-trained midwives and health workers or midwife assistants would increase coverage by up to 40%, these are longer-term solutions. In the short term, gross disparities in services in some resource-poor areas have been alleviated by recruiting Traditional Birth Attendants (TBAs) re-trained in emergency obstetric skills to deal with emergency situations and to refer women onto health facilities when necessary. Samoa and Bangladesh are examples. For many women for a range of reasons TBAs are preferable to hospital care. It therefore makes sense to recognise their place within maternity care, to offer basic and ongoing training and to set up registration procedures thus better ensuring the monitoring of outcomes. Incorporating TBAs into the formal healthcare system would meet both physiological and relational components of birth. In terms of the latter, TBAs would act as cultural brokers between Western and traditional cosmologies and provide women with continuity of care from a known carer; in the West a demonstrably simple but effective intervention promoting physiological safety and reducing the need for higher level medical interventions.

The aim of this paper is to try to explain governance failures in Sub-Saharan Africa and to identify reforms which can lead to good governance. The failures are mainly due to institutions that do not work properly, corruption, and lack of real democracy. Governance reforms can be both institutional and political. The political reforms should promote and reinforce democratic practices. Institutions should guarantee the rule of law and limit the elite’s economic and political power. Keywords: Governance – Development – Sub-Saharan Africa – Reforms DOI: 10.7176/EJBM/12-24-05 Publication date: August 31 st 2020

This chapter analyses political power in electoral authoritarian regimes in Sub-Saharan Africa from a collective action perspective. It argues that from the perspective of collective action theory, political power can be understood as the ability to project a credible mobilization threat into the political arena. The analysis shows that authoritarian ruling elites in Sub-Saharan Africa have strong advantages over oppositional elites in both building up and maintaining such a threat. Societal groups therefore represent the most important alternative source of political power in these regimes. Data on social conflicts is used to trace trajectories of political mobilizations of ruling elites, oppositional political elites, and societal groups in Sub-Saharan Africa across countries and over time.