The final session of what was without a doubt one of the best symposiums in health lent itself to reflection on four days of sessions that sparked debate and hopefully action on people centred health systems. As a funder of health systems research in low and middle income countries for over a decade, International Development Research Centre has supported the Health Systems Research Symposium from its birth, with an aspiration that be one of the processes that contribute to access to health and health care for all.
So what were the key messages that I heard and have taken home.
Professor Thandika Mkandawire began by articulating that we need health systems to be democratic, social, inclusive and to contribute to development. At the same time Prof Irene Agyepong reminded us of a Nigerian proverb that a “goat that belongs to the whole village belongs to nobody - this is how health systems can be described, but we must not let it go that way.”
So as a funder I ask myself whether I will stick to, as one panelist said “the politics of the achievable”? My answer is no, as it would not do justice to the energy, excellence and commitment that I witnessed from participants over the course of the last three days and more importantly it would not do justice to the people who have no access to health or do not have a voice.
I’ve organised what I have heard into: the “not to dos”, the “must dos”, and the “how to do”.
As a ‘not to do’ Rene Loewenson reminded us that by simply putting people in the middle does not make it a people centred health system.
So what must we do? In terms of how we do people centred health system research, the knowledge that matters is the knowledge that facilitates change, as we were reminded by Kumanan Rasanathan. As Nancy Edwards suggested we must move from gold standards to platinum standards of methods. In practice this means, quoting several people from the conference:
• Firstly, that people’s knowledge and role in the production, analysis and interpretation is a critical driver of people centred health systems. It means that people are in control and researchers are the facilitators of the process.
• Secondly, making data work for people rather than have people work for data. In one session someone spoke about “chasing data to fit with multiple donors’ agendas”. We need to incorporate multiple types of evidence and to bring in other practices and methods.
• Thirdly, while strengthening capacities are key, we cannot assume that none exist. We should recognise that capacity strengthening goes beyond training to actually shifting power, as noted by Aku Kwamie.
As a further ‘not to do’ Gita Sen reminded us that we cannot confuse the PC of People Centred with the PC of Political Correctness. We must break divides of race, gender, class, caste, culture or language and come together. This was illustrated eloquently despite the English language barrier by Lina Roso Polomo, a researcher from Mexico, as she explained how international guidelines do not always recognise the cultural diversity of our countries.
So if accountability is brought in by people, then as Kausar Khan eloquently relayed, the ‘must do’s’ include duties for us to reduce ethnic and racial divides as we facilitate, mobilise, fund, engage and catalyse people-centred health systems. It cannot be ‘us’ and ‘them’ as Martin McKee reminded us. At the conference I saw reflected in the program the silos being reduced as ‘systems’ sessions starting to integrate with ‘disease’ sessions, and discussions moved to bridge social movements with think tanks. Inclusion and integration are key. After all, as Lucy Gilson said on the first day of the symposium, the challenge that we must squarely address is governance.
Throughout the conference there was concern about the double-edged sword of Ebola, that has served this community with deep and significant challenges. The West African Health Organisation is demonstrating commitment to work with all of us to address Ebola and the system failures that it has starkly uncovered. WHO, UNICEF and European funders are advancing initiatives that address both basic science and health systems but as a global community we must do more and USAID and the World Bank called a number of meetings throughout the symposium to discuss this.
Moving from the ‘not to dos’ and the ‘must dos’ to the ‘how to do’, the wisdom of the Emerging Leaders (young researchers) is the take home lesson for all of us here. They said that to change mindsets we need to see, talk about and deal with the gorilla in the room. To make an impact we need to take the time to stop and reflect, with others that are like minded and also with those who are not. Lastly they told us that in each of us we have the capacity to lead as we bridge divides to build collective ownership of health systems that - quoting Sheik, Ranson and Gilson from the Health Policy and Planning Supplement on the Science and Practice of People-Centred Health Systems - truly “serve people and society”.
These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the global symposium visit http://hsr2014.healthsystemsresearch.org/
Editorial
Seven out of ten Tanzanians think that have no say in what Government does. Yet seven out of ten Tanzanians also think that voting is their only means of influence over Government. This may sound contradictory, but at core, they both reflect the same sentiment. Aside from the choices they make during elections, citizens do not feel that they influence government decision-making or activity. They appear to have little trust that formal institutions or local government officials will address their issues, and formal political institutions seem to play minimal roles in people’s lives. Nine out of ten people report that they have not interacted with their member of parliament in the last year, half have not interacted with their street or village chairman to raise issues and only one in seven citizens are members of any political party.
These findings were released by Twaweza in a research brief titled Citizens making things happen: are citizens active and can they hold government to account? The brief is based on data from Twaweza’s Sauti za Wananchi, Africa’s first nationally representative mobile phone survey that interviews households across Mainland Tanzania.
Sauti za Wananchi, (http://www.twaweza.org/uploads/files/Sauti-za-Wananchi-English.pdf) was initiated by Twaweza as a response to the concern that policy makers make decisions for the whole country, but with poor information on the experiences and realities of a large majority of citizens and on whether their policies are working on the ground across different places. It provides timely, low cost and reliable data and is a nationally representative barometer of the reality reported by Tanzanians. In 2014, together with our partners, we expect to conduct 20 survey rounds, and use widespread dissemination and intensive media outreach to share the findings, especially with policy actors, to shine a light on citizens’ experiences and views.
So how are people taking up their concerns? Despite the apparently low levels of interaction with formal channels uncovered by Sauti za Wananchi, 6 out of 10 citizens report that they made joint or collective complaints to officials in their community in the last 12 months, sometimes repeating the same complaint. Common complaints ranged from seeking improvements in local public services, to teacher absenteeism and access to clean and safe water. Just over a quarter of people reported raising complaints about the absence of drugs at local facilities, generally complaining several times in the past year.
When it comes to raising issues within the community, Sauti za Wananchi found that people are fairly vocal about problems they face. Eight out of ten citizens raise their issues in the groups they belong to, and three out of ten have called in to a radio station or complained to a friend. In contrast, people are much less likely to walk out of a discussion, attend a demonstration or protest or to refuse to pay tax, and far less report that they would or use force to achieve a political cause.
Community groups thus play a more significant role in people’s lives. Seven out of ten Tanzanians belong to one, often religious groups, but also savings and loans groups. Community solidarity appears to be high: almost all citizens believe that if an unforeseen incident, such as house fire, occurred, their community would get together to help. The same confidence doesn’t extend beyond immediate communities, and when asked whether they trust people generally, nine out of ten people felt that you had to be very careful with others. Citizens also strongly feel that they can rely on themselves to get things done. Seven out of ten citizens respond positively to statements about their own ability to overcome challenges, find solutions to their problems and accomplish their own goals.
People also contribute collectively to their services: Seven out of ten citizens directly contribute to constructing or maintaining public facilities, most giving money and the rest contributing time. While the level of tax collection is low, people are in one way or another contributing to the running of government. However these collections are not well regulated. The lack of transparency and checks and balances mean that contributions may not be collected fairly or used productively. In fact, four out of ten of those who contributed to local facilities say they were forced to do so, eroding public trust.
Sauti za Wananchi paints an interesting picture of the experience of Tanzanians. Rakesh Rajani, Head of Twaweza at the time, summed it up: “Tanzanians are active members of community groups and undertake collective action to complain to officials in their community. They also feel that they are able to tackle obstacles and make things happen in their own lives but express feelings of powerlessness when it comes to their influence over government. Thus far citizens have shied away from the more emphatic and vocal forms of citizen agency such as tax refusal, protests or walk outs. However significant service delivery challenges remain in all major sectors. If the Government does not become more responsive to this softer engagement, we may see citizens become more aggressive in the future.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the evidence, issues and processes raised in this op-ed please visit Twaweza at www.twaweza.org and read the full report at http://www.twaweza.org/uploads/files/CitizenAgency-EN-FINAL.pdf
Thomas Deve, a member of the EQUINET steering committee, passed away on Sunday 7th September. The diversity of people who have written tributes show how widely he connected from local to global level. He brought a personal connect to people and struggles across the continent and critical analysis and debate to our network. He was a researcher, a policy analyst, a band manager, a teacher, a thinker, an activist and much more. We bid him a reluctant farewell and Thomas, our struggle to reclaim the resources for health will continue.
At the recent 2014 International AIDS Conference we heard that 35 million people are living with HIV, but 55% haven’t been tested. Under the 2013 WHO guidelines, UNAIDS reported in 2013 that the HIV treatment coverage in low and middle-income countries represented only 34% of the 28.6 million people eligible in 2013. Medicines for malaria, pneumonia and other common conditions don’t reach many low income communities and there are new challenges in ensuring the long term treatment for chronic conditions.
Access to medicines continues to be a major preoccupation in African health systems. Beyond the unequal distribution of access to essential medicines globally and within countries, resistance to anti-malarials, antibiotics, and treatments for TB and other conditions can worsen the problem. The new medicines developed are frequently more expensive and may also require more stringent supervision to ensure they are properly used. For example in the 2014 AIDS Conference it was noted that there is a 10 fold price increase from first to second line treatment, and the World Health Organization (WHO) reported in 2012 that the 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB) longer and more expensive treatment. These medicines are often imported, at a cost that consume a large share of health budgets. Countries in east and southern Africa (ESA) often draw on support from external funders to meet these costs.
This rising challenge, coupled with high levels of dependency on external producers and funders makes ESA countries very externally dependent when it comes to medicines. This, and the potential contribution that pharmaceutical manufacture could make to economies and trade within the continent, especially given the rich natural resources for medicines, prompted the African Union and its sub regions in east and southern Africa to come up with plans to enhance local pharmaceutical production. African Ministers of Finance, Planning and Economic Development in Nigeria in March 2014 noted: “There is growing consensus that strengthening the local production of essential medicines is a priority, along with advancing industrial development and moving the continent towards sustainability of treatment programmes for HIV, tuberculosis and malaria, and improving access to safe and effective medicines to treat a broad range of communicable and non-communicable diseases.”
The Pharmaceutical Manufacturing Plan for Africa (PMPA), the Southern Africa Development Community (SADC) Pharmaceutical Business Plan 2007-2013 and the East African Community (EAC) Regional Pharmaceutical Manufacturing Plan of Action 2012-2016 all propose policy measures to create the conditions for and support local production, as one, albeit not the only way to strengthen access to medicines.
The same plans are also rather clear about the obstacles that have to be overcome to achieve this, including in terms of ensuring adequate legal provisions, improved and reliable energy, transport and other infrastructure, technology, skills and research and development capacities to enable and sustain production and finance capital. The same 2014 conference of African Ministers of Finance, Planning and Economic Development cited above noted in its statement: “The challenges the pharmaceutical industry faces in upgrading facilities and production practices in Africa include the requirement for large capital investments and the need for experts, specially trained workers, increased regulatory oversight and regulatory harmonisation at the regional and continental levels in order to create bigger markets.”
In research that we carried out in 2013 and 2014, we found signs of progress in overcoming these obstacles, but also many challenges. Kenya, Uganda and Zimbabwe, for example, produce medicines that are not only consumed in their own countries, but are exported to other countries in the region. Some of the factors that appear to support this include the presence of a sound regulatory framework for the pharmaceutical sector, partnerships with other countries bringing investments in manufacturing and in capacities for it (such as in Uganda), local skills and research and development institutions that can support the technology for local production. Further, existing practice points to the critical importance of regional trade as a way of ensuring adequately sized markets to provide a return on investments. These are examples in practice of measures that are articulated in the regional plans.
However, we also found that while many countries have national pharmaceutical policies that articulate such goals, they also depend on policy in other areas, such as energy and infrastructure, and that there is a gap between policies and their implementation.
The implementation gap is evident in a number of areas. One is in the extent to which governments are supporting local production with tax and other incentives to create a conducive investment, business and trade environment. For example there could be stronger measures to exempt duty and value added tax (VAT) on imported pharmaceutical raw materials and packaging materials to stimulate local production and reduced corporate tax rates, investment tax credits and other incentives for companies to set up production. Yet sometimes we find that the opposite is in place. For example in Zimbabwe imported drugs were in 2000 exempted from duty and VAT, while the raw materials and packaging needed for local manufacturing attracted duties of up to 40% and VAT of 15%. This increases the cost of locally produced drugs, especially when other countries are not placing these high charges on their producers, making imports cheaper than locally produced medicines. This doesn’t make sense given the policy intentions and we should at least level the playing field and avoid tariff structures that promote de-industrialisation!
There is also a gap in the dialogue that should be going on between governments, pharmaceutical companies and training institutions on what capacities, skills and personnel are needed for the pharmaceutical industry and how these can be attracted and developed, including through schemes to attract and retain appropriate personnel in the public service and in countries.
While there is an emerging interest in south-south partnership agreements on some of these areas, it is equally important that attention be given to implementing the regional plans, to use memberships of Common Market for Eastern and Southern Africa, the Southern African Development and the East African Community to negotiate for a tripartite Free Trade Area between the three blocs to widen markets for medicines and to strengthen regional interactions on the technology, infrastructure, capacities, research and development and capital needed for pharmaceutical production.
In a continent with such high health need and demand for treatment, surely we need to not only be asking when we will get better access to medicines, but when we will get better control over access to medicines?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
Our health systems are sites of constant change and struggle. In east and southern Africa national health services centred on comprehensive primary health care (PHC) have been ‘reorganised’ through waves of liberalisation, privatisation, disease focused verticalisation, performance based financing and many other reforms. People have come to services to find new rules for what is free and what is charged, for what medicines and supplies are present and what is not, and community health activities and workers have appeared, disappeared and appeared again.
The drive for a universal national health service was embedded in national liberation struggles. The PHC approach was a global concept that resonated strongly with popular expectations of what post independent health systems should look like. Many of the subsequent changes have emerged as waves of international reform, increasingly influenced by global level actors. When we ask people in participatory sessions to form a human sculpture of how their health systems are organised around a patient visiting for care, the sculpture most commonly has health workers, managers and others looking upwards to the next level to get the resources and attention they need to solve problems, (most looking away from the patient), usually with the person representing a powerful but distant global funder elevated in both power and stature on a chair in a far corner of the room.
While these may be caricatures, they raise the question- when it comes to changes in health systems, who counts? Whose views, expectations, ideas, evidence, numbers, analysis and knowledge is used to generate change?
This matters because health is ‘a state of mental, physical and social wellbeing and not just the absence of disease’, because health outcomes reflect conditions that are socially created, and health systems are thus social institutions, built out of and influencing society. The explosion of knowledge on the biomedical basis of disease and on risk factors in public health has informed massive advances in survival. It has, however, weakly addressed and often ignored the social context and determinants of health and the social nature of health systems. As a consequence we face persistent and sometimes widening inequality in health and in access to services, rising levels of multiple morbidity and chronic conditions, epidemic resurgence and antibiotic resistance, amongst other challenges.
The problem does not lie in the extraordinary scientific innovation and creativity that lay behind these medical advances. The problem lies in one form of knowledge subjugating others, excluding and disempowering others from the creative processes that transform society, a mistake akin to suggesting that the trunk of the elephant is the whole elephant.
That knowledge as socially constructed is not a new concept. This understanding has been central to social sciences and to cultural, anticolonial, gender and indigenous struggles. With the failure to implement what is known, in health sciences it has led to increased attention to fields such as health systems and policy research, where rather than absolute prescriptions, there is a quest to better understand ‘what works where and for whom’.
This wider lens will generate a better understanding of context in health sciences. Will it also overcome a tendency for ordinary people to be the last to know the waves of reforms transforming their health systems? Freire argued decades ago that meaningful social transformation, including of health systems, can only occur with the deep involvement of the people affected. The incubation of the PHC approach, the efforts to build national health services across diverse countries, the refusal to allow health care to be commodified, the gains in access to improved living and working conditions have all been a product of social and political action.
This type of action does not grow out of knowledge and perspective built in distant corridors. In the last century activist scientists such as Orlando Fals Borda in Latin America pointed to a different understanding of science, one that seeks to not only understand the world but to transform it, and, as importantly, one in which knowledge is built from lived experience and from the learning and self-awareness that grows from action. Participatory action research (PAR) has developed in different forms as a method for such science. It overcomes the separation between subject and object. Those affected by the problem are the primary source of information and the primary actors in generating, validating and using the knowledge for action, and using action and change as a means to new knowledge. A new methods reader on ‘Participatory action research in health systems’ produced by EQUINET and TARSC with Alliance for Health Policy and Systems Research and IDRC Canada that can be obtained on the EQUINET website in end September details the principles and methods of PAR, its challenges and the many ways and levels at which it is being used.
In different parts of the world, PAR has built a more direct link between theory building and practice in health systems. Workers and unions have used PAR to expose and organise for change in working conditions that are harmful to their health. Young people in high and low income countries have used it to raise visibility of and engage with authorities on harmful community environments. Indigenous communities have used it to negotiate the organisation of their health care. It has been used in continuous processes in local authorities in shaping PHC, learning from cycles of transformation.
The practice of PAR flags that change is not itself a problem in health systems in east and southern Africa. It is rather a problem when the knowledge used to guide this change does not draw on the experience, knowledge and wisdom of those directly involved, through methods that build their power to inform, learn from and shape that change.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read Participatory action research in health systems: a methods reader, available on the EQUINET website www.equinetafrica.org from end September 2014
The roll out of Performance-based financing (PBF) in east and southern Africa is now widespread. Yet a recent study found cause for concern with this often ‘taken-for granted’ financing mechanism. As a result, there is a need to better understand and debate how PBF reinforces or contradicts other measures being used to build and strengthen universal health systems.
Performance-based financing has become increasingly popular in global health financing. It involves the transfer of money or goods based on implementation of a measurable action or achievement of a predetermined performance target. It is seen to increase accountability to both external funders and national stakeholders, by tracking of how money is spent. Having clear targets is argued to strengthen health systems by providing a way of assessing what programs are efficiently delivering ‘value for money’ and by rewarding good practice. Its proponents argue that external funders, generally large contributors to African heath systems, should transfer funds based on performance to achieve these gains.
In the past year we carried out research examining PBF in South Africa, Tanzania and Zambia, and with regional and global institutions (more fully reported in EQUINET discussion paper 102 at http://tinyurl.com/nudgky3). This work raised questions about how PBF affects the strength and equity of health systems, and what latitude African actors have to ‘reframe’ PBF mechanisms to address their concerns.
Certainly a majority of the African actors had a positive perception of PBF and its ability to strengthen health systems, a perception also evident in the general literature pertaining to PBF. In particular, evidence suggests that Africa actors believe that PBF is useful in curbing corruption, in incentivizing targeted health outputs, and in increasing accountability mechanisms. These benefits, where they have occurred, have generated support for and ownership of the approach.
Nevertheless, at the same time there were many concerns regarding the practice of PBF. Questions were raised about how performance criteria are selected and how far national input was factored into the design of PBF, a key principle in the Paris Declaration. We found that the space for genuine participation in the design of PBF was narrow, usually limited to high level personnel in national systems, and that it was affected by factors such as how much of the public budget is externally funded. Lower dependency on external funding appeared to give countries greater possibilities of setting their own targets and resisting funding conditions that potentially conflict with national strategic plans. We found, for example, that South Africa, with less than 10% of its health budget externally funded, had greater latitude to negotiate and resist unfavourable conditions. We also found that this ability to ‘push-back’ was less available in Tanzania and Zambia, where external funding contributes up to half of the health budget. Some African actors in health ministries and in service provision expressed weariness about the external conditions demanded by funders, and called for a more decisive national voice. As one senior African health official suggested, ‘when PBF is the result of national ownership then it has excellent potential to be a mechanism for change… however, if it is not, then it will certainly be doomed to…not deliver on its promises.’
We found that while there is great enthusiasm for monitoring and rewarding outcomes, in practice this needs substantive investment in health information systems. We found, as others have, that information systems lack the reliability, capacities and support to analyse and use evidence to evaluate performance. Unless this is recognized and addressed, use of performance indicators can cause weaker services (with poorer capacities to manage information) to do worse, reducing their PBF ‘score’ rating and thus restricting their funding. This causes considerable concern, since these services are usually the ones that are in more marginalized areas of highest need. In addition, many of the African actors we interviewed complained that the reporting systems required by funders are cumbersome, time-consuming and add considerable overhead costs. External funders, particularly the Global Fund, were reported to change reporting requirements and ‘goal posts’ mid-stream, without sufficient notification or technical assistance, leading to confusion and delays in programme reporting and roll out.
Furthermore, external auditing mechanisms were often found to be ‘not fit-for-purpose’, implemented by auditors with little health knowledge or understanding of the recipient country, with inadequate communication between auditors and recipients.. Audit processes were found to be inflexible on target satisfaction. For example, Local Fund Agents (LFA) of the Global Fund were reported to often refuse to answer recipient’s questions during report writing, to refuse to discuss reporting problems during the audit, or to allow the final LFA evaluations to be seen by recipients. This was argued to damage partnership and national input to PBF conditionalities.
Moreover, many African actors that we interviewed assumed the merits of PBF, without being able to refer to strong evidence to support this view. There is also a growing weariness about PBFs ability to ‘be all things to all people’ and an urge to have a more realistic national assessment of PBF as being one of many financing measures available.
Where PBF is seemingly most successful is in cases where there is a strong sense of national ownership and multi-sectoral partnership. PBF has had positive impacts where robust information systems exist, so that future targets can be based on valid data, where performance monitoring is possible, and where evaluations can be made reliably. It is seemingly most successful when targeted on tightly focused health interventions, like payment per patient seen, and not on broad whole-of-system targets, where it is difficult to isolate and track individual variables. A better understanding of the positive features can contribute to health system strengthening.
However our study also found evidence of negative consequences that can weaken national health systems. Reaching PBF targets can sometimes compromise quality of care, vertical PBF schemes can create ‘health silos’ that are not always fully integrated into comprehensive primary health care, and PBF schemes are often not well embedded into a sustainable long-term health strategy.
These are issues that partners can identify, negotiate on and attempt to resolve. So our findings on the weaknesses of partnerships and genuine national leadership of the PBF agenda – as raised in this editorial and detailed in the full report- are crucial issues to be discussed and debated; to build better partnerships between global and African institutions and to design better systems for strengthening African health systems. As one senior health official commented, ‘we should be accountable for the money we receive and we should try to get as much value for money as possible... this is the non-debated part of PBF and a reason why it is so popular… but exactly how to best generate value for money is still open for discussion and for PBF to work effectively it will be important to get its processes right and to then generate agreement by all those who have to deliver these processes.’
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read the full report on the EQUINET website and visit www.equinetafrica.org
Nurses play an essential role in the post 2015 global agenda of ensuring universal health care. They make up majority of the health workforce. Health systems cannot successfully function without nurses. They influence how systems function, change or are delivered, through the values, knowledge and experience they bring. Their lives and work are affected by the policy decisions and health system roles that are expected to achieve the post 2015 global agenda. So the Southern African Network of Nurses and Midwives (SANNAM) have argued that nurses must be included in the political and policy discussions and health system transformation efforts currently underway.
The Southern African Network of Nurses and Midwives (SANNAM), a network of National Nurses Associations (NNAs) in the 15th Southern African Development Community (SADC) countries met in Pretoria, South Africa in February 2014 to examine the post 2015 proposals for Universal Health Coverage (UHC). The meeting reviewed the proposals from the ongoing global consultations on the focus post- 2015 for ensuring UHC and sustainable development globally.
The report of High Level Panel of eminent persons on the post- 2015 global development agenda and an evaluation of progress on MDGs 2000–2013 have identified a need to secure the planet for all in a sustainable way and to ensure that the global agenda puts people first and at the centre of future development efforts. These reports identify a universal agenda with transformative shifts in five thematic areas:
i. leaving no one behind as a principle of universality in access, sharing resources and assets in all sectors;
ii. putting sustainable development at the centre, including as a means for improving people’s health;
iii. transforming economies and jobs for inclusive growth, with what is drawn from earth’s resources distributed equitably;
iv. building peace and effective, open and accountable institutions that protect human rights; and
v. forging new global partnerships, given that action in one sector, country, and community influences the others.
These proposals obtained broad support from nurses in the SANNAM meeting.
The performance of health systems is necessary to achieve this post 2015 vision. As the 2011 World Health Organisation (WHO) global conference in Brazil on social determinants of health reported, good health requires a universal, comprehensive, equitable, effective, responsive and accessible quality health system. It also depends on the involvement of and dialogue with other sectors and actors, and on effective collaboration in coordinated and inter-sectoral policy actions. The health sector contributes to sustainable development and human rights, and plays a role in ensuring that economic activities do not harm and do benefit social wellbeing. For example South Africa’s extensive ARV programme has contributed widening the benefit from medical technology and raising life expectancy, and the implementation of the National Health Insurance scheme is mobilizing economic resources for universal access to services.
However, SANNAM delegates noted that health systems in many countries fall short of their potential, resulting in a large numbers of preventable deaths and disability, especially for poor people. While UHC means that all people should be able to use the quality health services that they need and do not suffer financial hardship in paying for them, many countries are not achieving this.
So while the goals are noble, a lot more attention needs to be given to how they will be achieved. In the SANNAM meeting, nurse leaders from all countries in the region discussed this further. There are a number of challenges to implementation in our region. There are resource constraints, health professional shortages, migration and distribution of health professionals, household poverty and poor performance of services. Services face challenges in the adequacy of nursing education, with shortages and inadequate skills mix in health workers, loss of a caring ethos and inadequate social participation in services. Shortfalls in leadership, professional competencies and service resources and weak application of governance styles that involve people have led to falling morale. Negative conditions encourage individual practices that further worsen the system, such as moonlighting practices. Unless these and other constraints are addressed, UHC goals may remain aspirations rather than reality.
At the heart of the changes needed, SANNAM members identified the need for a paradigm shift from hospital-centered to community-centered health care. This calls for a rights-based approach to healthcare, where the individual and community are central to the processes for promoting health, preventing and treating disease and care for chronic illness or disability.
Nurses identified that they play a key role in implementing these transformations in health systems. Their competencies, communication and approaches to care can facilitate (or if absent block) peoples uptake of services. They can support (or impede) patient and family-centred care, cultural congruence and team based approaches with other health workers and sectors. They can deliver services in a way that supports people’s role and rights, and that reviews and improves service performance.
Taking goals and policies to implementation thus demands more attention to the people and practice environments of key personnel responsible for delivering on these goals, such as nurses. For example, there is need to promote a positive working environment for nurses and professional associations, to develop creative ways to involve frontline nurses individually and through their associations and networks in policy and practice changes and in evaluation and review, to integrate their proposals and improve responsiveness and feedback. The systems to support this need to be put in place, from Chief Nursing Officers within national ministries of health, and cascading down to provinces and districts to primary care level. The models identified should be backed by adequate resources, management practices and information, and by academic preparation of nurses for their role. Incentives should be oriented to rewarding and supporting implementation of key roles and outcomes, including the communication with and involvement of communities, patients and other sectors.
SANNAM delegates observed that it is therefore critical that nurses, amongst others, understand the health policy issues and the policy-making processes underway and are actively involved in them. The experience nurses bring will help to align the policies and strategies to real conditions and expectations in the system, and contribute to building the post 2015 agenda from the bottom up.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
Antibiotics have been used for over 3,000 years.
Without fully understanding how they worked, many early civilizations used mould and other microbes to treat infected wounds and diseases, attributing their healing power to a magic that drove away the evil spirits that caused disease. In the 20th century advances in science brought new understanding of the role that certain organisms could play in controlling other disease causing organisms. This brought over a century of advances in the use of antibiotics such as penicillin, with significant gains in human survival. Yet today we face a new threat of microbes that are resistant to the array of antibiotics that we have developed in the past century, and our use of antibiotics appears to have made us vulnerable to the onslaught of even more virulent forms of organisms.
For most of the last century, antibiotics were regarded as ‘miracle drugs’. They were used to suppress many life-threatening infections and allowed for advances in other areas, such as surgery, by controlling the risk of infection. Some estimate that they contributed with public health gains to an average of 20 years greater life expectancy in the past century.
However, in this century we appear to be losing the battle against infectious diseases through strategies that rely on antibiotics. It has been more than 20 years since a qualitatively new class of antibacterial medicines have been discovered. More importantly, however, bacteria are fighting back. They have become more virulent in every region of the world and more resistant to the medicines used. The emergence of drug-resistant “super-bugs” has led to diseases that are more difficult and costly to treat, such as in the case of multi drug resistant TB.
How did we get into this position? Many reasons have been given, including poor infection-control practices and the misuse of antimicrobial medicines. Antibiotics were overprescribed without checking whether they were really needed. It was recently estimated that almost half of all current antibiotic prescriptions are unnecessary. Some people stopped taking them when their symptoms disappeared - even if still infected. Antibiotics have been mixed with animal feeds to boost livestock growth, contributing to a build-up of antibiotics and in response leading to more virulent bacteria in the food chain. As we used antibiotics more widely, so bacteria themselves evolved into forms that resisted their effect. Without adequate surveillance to track the impacts of this wide use of antibiotics, resistance silently grew.
According to the World Health Organization (WHO), antibiotic resistance (ABR) has now reached significant levels in all regions of the world. We still lack adequate accurate data on the current global situation. However, a 2014 WHO global report provides a picture from current evidence that is extremely worrying (http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1). The report indicates that in all regions there are high rates of resistance in the bacteria that cause common health problems such as urinary tract infections, pneumonia, diarrhoea and so on. Multi drug-resistant TB is spreading and there are also reports in some countries of resistance to the artemisinin used to treat malaria. In some parts of Africa, as many as 80 percent of the Staphylococcus aureus infections that cause common skin and wound infections are reported to be resistant to methicillin (MRSA).
These trends challenge disease control programmes that rely on treatment. They also challenge health systems. With growing resistance, when treatment with standard first-line antibiotics is no longer effective, more costly stronger second line drugs are used. However, these may not be available in resource-constrained settings. They also have severe side-effects which require monitoring during treatment - further increasing costs to services and communities. ABR adds new pressures on already strained health and development resources. Patients who cannot afford treatment may drop out of healthcare services and the bacteria spread further, especially for poor households, in a vicious cycle of virulent disease, costly care and falling survival.
What then can we do?
The key intervention is to reduce the environments in which infectious organisms breed, through improved living conditions and public health measures. Investing in safe water, improved sanitation, better housing, food preparation and waste management provides a sustainable, pro-poor approach with wider benefits, as do prevention measures such as vaccination.
At the same time WHO also advocates for a comprehensive master plan to combat ABR and to guarantee all - regardless of their economic status - uninterrupted access to antibiotics and other essential medicines of assured quality when needed. On the one hand new affordable medicines, diagnostic and surveillance tools are needed from platforms that foster innovation. However technology is not on its own a solution. We need guidelines and regulations that promote rational use of antibiotics in both human and animal medicine, including when not to use them. Antibiotics should be used only for treatment of diseases and completely banned as growth or food supplements. We need to educate the public to use antibiotics only when prescribed by a doctor, to complete the full prescription - even if people feel better, and to never share antibiotics with others or use leftover prescriptions.
We also need to better understand the scale and spread of the problem to raise awareness and plan for it in our region. In 1998, WHO Member States endorsed the Integrated Disease Surveillance and Response (IDSR) strategy. Yet, surveillance of ABR is still currently inadequate and poorly co-ordinated, and public health laboratories lack full capacities to test for antimicrobial susceptibility. The WHO Regional Office for Africa (AFRO) reports that only a few African countries carry out surveillance of drug resistance for many common and serious conditions. WHO AFRO has in response published a guide to facilitate the establishment of laboratory-based surveillance for priority bacterial diseases and some countries have set up collaborations for national and regional ABR surveillance. There is however no formal regional framework for collaborative surveillance and information sharing, and limited public reporting. This not only hinders efforts to track and control the emergence of drug resistant micro-organisms, but also to assess the effectiveness of policies and activities to manage the problem. We need better standards, capacities, tools and social literacy to determine, monitor and control ABR in humans, animals and in the food chain.
In the face of rising food prices, unemployment, inaccessible services and other problems, ABR can seem a distant problem. But it is not distant, and we can no longer assume the effectiveness of the medicines we have used for treating common microbial diseases. We need to act now to remedy the practices that have led to the emergence of this new threat to human survival.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
Zimbabwe’s media has been awash in 2014 with stories of monthly salaries above $50 000 being taken by the executives across a number of public institutions, in a country where the 2011/12 Poverty Income and Expenditure survey found 77% of those in formal employment to be earning less than US$351 and 63% of all households living below the poverty line. A term has been coined for the scandal - "salary-gate".
One of the worst stories of "salary - gate" was in the voluntary health insurance sector. Zimbabwe has about 30 health insurance companies, termed ‘medical aid’, funding health care for about 10% of the population and providing about 80% of the income to private for profit health services. These medical aid societies are private, voluntary organisations and are deemed to be non-profit.
The events of 2014 have shaken these assumptions. The state media, the Herald, on 31st January, 2014 reported that the top fourteen executives of the biggest medial aid society, the Premier Service Medical Aid Society (PSMAS), were getting US$1.1 million monthly in their combined fees and benefits. The chief executive alone was reported in the same media to be paid about a quarter of a million US dollars monthly in direct earnings from PSMAS and from its subsidiary Premier Service Medical Investments (PSMI) and in other benefits and allowances. While the figure remains to be officially verified, other media have made similar report of this figure without it being contested. This is in the context where the majority of PSMAS members- 75% of whom are employed and retired civil servants according to the Civil Service Commission - earn less than US$400 monthly if employed, and significantly less than this if they are pensioners and widows/widowers. While PSMAS paid its managers these huge salaries, they also built up a debt to service providers of US$38 million in unpaid fees. Their failure to pay providers meant that many demanded that PSMAS members pay cash up-front, undermining the financial protection health insurance is supposed to provide.
This was not the first time that PSMAS and some other medical aid societies had come to public attention. PSMAS became the second biggest provider of health services in Zimbabwe after the government in 2003, setting up a subsidiary, PSMI, and using it to acquire and develop private health services. It expanded to accommodate private sector members and became a significant employer of doctors in Zimbabwe. This integration of funder and provider had already raised questions. In 2000 the Competition and Tariff Commission (CTC) raised that such monopolies across all spheres of a sector limited patient choice, and the Medical Aid Societies Statutory Instrument 330 of 2000 regulated such vertical integration. Nevertheless PSMAS and others were given latitude to continue the practice throughout the 2000s, despite beneficiary complaints about restrictions in the providers covered.
The case raises a number of questions, particularly in terms of the effectiveness with which insurers are monitored by their members and regulated by authorities. PSMAS largely covers government as contributors and civil servants members, although it is not a public enterprise. Government as employer nominates four people to the board while six are elected by the members at an annual general meeting, another member is appointed by an affiliated employer organisation and two are nominated by elected members of the board. The chief executive is an ex-officio member. Ironically, civil service members did not elect themselves to the Board. The Board in 2014 included private professionals and heads of several ministries. It was alleged to have been paid US$1million in allowances in 2013 and dissolved itself in February 2014. As na sign of the lack of oversight of the organization the state media citing the Acting Health Minister Dr Mombeshora reported in February that the society’s operating license was not renewed at the end of 2013 for failing to submit audited financial statements. This raises the issue that members of all such insurance schemes should more actively engage with what is happening in their schemes, include through representation on their Boards.
There also seem to be questions about how effectively such schemes are regulated. PSMAS, like other medical aid societies, was regulated as a finance institution by the Ministry of Finance, and as a health institution by the Ministry of Health. Its nature as a society for civil servants additionally brought in the Ministry of Labour and the Public Service Commission. Despite this multitude of regulators, the evidence suggests that there was no effective regulatory control. A number of weaknesses emerge, some of which were pointed out in a 2010 EQUINET Discussion Paper 82 (www.equinetafrica.org/bibl/docs/DIS82zimcapflow.pdf) and at a meeting held on the findings by Training and Research Support Centre (TARSC), SEATINI, in collaboration with Ministry of Health in 2010. The Ministry should play a stewardship and regulatory role given the health insurance and health service role. However regulations were weakly enforced in the 2000s during economic difficulties; and the Ministry oversight role is post hoc, obtaining report of changes to constitutions and practices after they have already been made, without meaningful blocking power to prevent 'bad' behavior. Ironically the Ministry of Health had no representative on the PSMAS board. Regulatory oversight by the Ministry faces challenges in shortages of personnel, ambiguities in the law, lack of reporting from societies and lack of awareness and advocacy by members.
In response to ‘salary-gate’ at PSMAS and a range of public entities Zimbabwe’s Finance minister in March announced that cabinet had set the salary ceiling for chief executive officers of parastatal and public institutions at US$6000. They included PSMAS in this, but there is question over their authority to do so for a private limited company where government has no shareholding.
Do we expect anything to change? The crisis is an opportunity to raise some critical questions about the private health insurance sector. Is this case the tip of the iceberg? Beyond PSMAS, are members of medical aid societies exercising proper oversight of their insurers? Are the resources being effectively used for their purpose? With the majority of people in two medical aid societies in Zimbabwe, CIMAS and PSMAS, how viable are the other 28 insurers? Are their funding pools large enough to protect the membership against risk? With the benefit packages clearly specified but segmented across schemes, what measures are there for the pooling and cross-subsidy among members needed to ensure viability and equity? Are the monopolies of insurers and private providers not blurring the boundaries of what is for profit and what is not, given that medical aid societies are tax exempt as health funders but earning profits in investments in private health services? Why is the law preventing such integration not being enforced? How are societies earning 'surplus funds' in their service investments, even while service providers are not being paid and beneficiaries not covered for their benefits?
The Zimbabwe story may not be unique within the region, and cost escalation and inappropriate spending may be more common than is being publicly reported. The Zimbabwe experience and the questions raised could provoke those in other countries to do a ‘health check’ of their insurance sector, in a manner that leads to action to address weaknesses identified. The biggest weakness appears to be in the absence of accountability and the checks and balances for this. The state should not be allowed to fall short on its obligation to protect members from predatory behavior, and members expect the state to have adequate competencies to regulate the market. The system needs to be more responsive to the community and the community to be more vigilant and demanding of accountability.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised please visit www.equinetafrica.org and see EQUINET discussion paper 82 at www.equinetafrica.org/bibl/docs/DIS82zimcapflow.pdf and EQUINET discussion paper 82, 87 and 99 on private insurance and their regulation.
Post-independent governments in east and Southern African (ESA) countries have all recognised that social participation is central to the success of primary health care (PHC) oriented health systems. There are, however, wide differences in how far they are implementing this policy view. The 2012 EQUINET Equity Watch report found many shortfalls in meaningful levels of social participation in health systems. Health Centre Committees (HCCs) are known by a range of names in different countries but are joint community- health worker structures at primary care level. They offer one way for systems to facilitate social participation and shared decision making between communities and health personnel. There is evidence that they can contribute to quality of and equity in access to health care and improved health outcomes. At a recent EQUINET regional meeting delegates identified ways to better tap into and support this valuable resource for health.
Building on prior work in EQUINET, twenty delegates from seven ESA countries and three international organisations, all working with HCCs, gathered at a regional meeting in February 2014 hosted by Training and Research Support Centre in association with Community Working Group on Health and Medico International in February 2014 to exchange experience on and learning from work to train and strengthen the role of HCCs (The report of the meeting and background paper are available at www.equinetafrica.org).
Dr Portia Manangazira from Zimbabwe’s Ministry of Health and Child Care opening the meeting concurred that HCCs provide a key mechanism for communities to participate in revitalising PHC and for strengthening and monitoring service delivery.
Despite this, while HCCs exist in some form in most countries, they often have no formal legal status or are not trained, resourced or active. In Zambia, the 1995 National Health Services Act provided in law for the District Health Boards and Neighbourhood Health Committees (NHCs). When this was repealed in 2006, it removed the legal mandate for HCCs. Yet in Zimbabwe it has been raised that expecting HCCs to manage public funds from government or external funders without a clear legal mandate is a problem. Even where government guidelines provide for HCCs, they vary in detail. For Zambia, an NHC working group has prepared explicit operational guidelines on establishment, composition, functions and monitoring mechanisms for NHCs. In South Africa, on the other hand, the provisions are more vague and left for the provincial authorities to decide. Generally while guidelines often set HCC composition and duties, they are less clear on how they are funded or on their role in towards social accountability. Despite their role in bringing community voice to service planning and the requirement that they represent communities, HCC members are not always elected by communities, have variable levels of community involvement and influence and may be liable to political control.
To some extent this reflects ambivalence towards whether HCCs are more a voice for the community to influence health services, or an outreach for services to reach and influence communities. Both roles are important, but where do HCCs focus their time and energies? In the Western Cape, South Africa for example, a baseline assessment in two districts found that HCC members spent limited time engaging the community and were spending more time as service volunteers - in security or as queue monitors for example. Similar concerns existed in Uganda. There was concern that in some countries HCC roles have become ‘commodified,’ with the resources available to them based less on community interests or needs than on what is paid for, often by international organisations.
Hence rather than the common practice of a long list of apparently delinked and equally weighted roles, the meeting identified roles of an HCC in a more systemic way, linking these to processes in health systems. The process starts with building an informed health literate community, obtaining community views and drawing on this to bring community voice and experience into the interaction with health service personnel, to jointly design and implement plans and budgets for the health system at primary care and community level. This joint role in governance gives the HCC the information, authority and motivation to go back to communities to facilitate dialogue and social action on health plans; to make sure that the agreed plans have been implemented, and that the duty bearers are capacitated, supported and resourced to deliver on plans and that they do so in a manner that is responsive to the community. HCC members should thus bring the direct experience and views of communities into the system, supporting understanding and reflection within communities on how to improve health, and advocating for improvements, with other sectors or at higher levels of the health system. This means that HCCs are more likely to thrive where health systems are themselves PHC oriented, facilitate action on the social determinants of health and support participatory planning and practice, than where they are organised largely around individual medical care with top down power.
HCC members need to have resources and skills across all these areas of functioning to complement their inherent social capacities and to enable them to overcome power imbalances in the relationships between themselves and health authorities. While there is a lot of training activity taking place, this may be limited to specific disease problems or interventions, may not address the general community health literacy or spectrum of HCC abilities needed and may lack follow up to evaluate its effectiveness or to sustain it. Training may not include some key areas such as budget tracking or assessment of community benefit. Further those providing training for HCCs may themselves lack competencies to build skills in areas such as budget planning or tracking.
Delegates also recognised that for HCCs to be effective in PHC oriented roles, communities themselves need to be health literate and empowered. Social rights to health care, to information and meaningful participation can provide a foundation for this and should be included in all constitutions of the region and in updated national or public health law. Regulations should more clearly define the duties, powers, roles and constitution of HCCs, and guidelines set these in a more systematic manner. However all this is likely to remain on paper unless it is accompanied by processes for capacitating systems and for supporting social activism and information.
The meeting thus proposed a number of areas for follow up attention and action by national authorities and organisations working in health, in relation to legal provisions, guidance, election, composition, functioning and capacity building of HCCs. While the specific cultural contexts differ, it was proposed that the ESA region set minimum guidance for these areas, such as on the core content of and processes for comprehensive HCC training, and that countries budget for the capacity building and functioning of HCCs. As for all other areas of health system performance, it was proposed that the health information system and communities monitor and collect information on the functioning, performance and impact of HCCs. Selected indicators were proposed for this, for further dialogue and development.
The organisations attending the meeting made a commitment as a network of practitioners working with HCCs to continue to link regionally, including to document, to share and make their work more visible. At a time of increasing attention to domestic resources for health, delegates drew attention to the most critical resources in the region- the people. The challenge was raised for policy actors in the region to turn commitments into action and to give systematic attention to the effective functioning of HCCs, as key social assets for health.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised please visit www.equinetafrica.org. The report of the Regional meeting referred to can be found at
http://www.equinetafrica.org/bibl/docs/EQ%20HCC%20Mtg%20Rep%20FEB2014.pdf