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
Editorial
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
The World Health Organization (WHO) states in its constitution that it aims to achieve "the attainment by all people of the highest possible level of health.” The World Health Assemblies (WHAs) provide a key opportunity to engage on the achievement of this aim. Yet in an interesting study by Kitamura et al. in May 2013 in Health Policy reviewing the agendas of the WHAs between 1970 and 2012, the authors concluded that “agenda items of the WHA do not always reflect international health issues in terms of burdens of mortality and illness.”
So how are countries and stakeholders shaping the WHA agenda?
One way is through the WHO Executive Board (EB), particularly as it plays a role in setting the provisional agenda for the WHA. EB members are individuals nominated by countries with technical expertise in health. Of the 34 members of the Executive Board, seven are from the African region. Currently these are from Cameroon (2011-2014), Chad (2012-2015), Namibia (2013-2016), Nigeria (2011-2014), Senegal (2011-2014), Sierra Leone (2011-2014) and South Africa (2013-2016). As EB members, they are well-positioned to be heard and to bring concerns from their regions to the table. They can also block issues being discussed. The WHO secretariat also plays a role in agenda setting. Procedurally, the provisional EB agenda is proposed by the WHO Director-General. Getting issues on the agenda for the WHA is, however, not difficult. According to the rules of procedure, every proposal brought by a member state and any proposals submitted by the DG should be included in the provisional WHA agenda. So how are these policy levers being used?
Take the 2014 EB agenda for example. Many agenda items were not controversial as they are carried over from previous years, after broad agreement around their importance. This included non-communicable diseases (NCDs), neglected tropical diseases and reform of the WHO. Other agenda items may be more controversial. For example, when in 2012 the United States of America and Thailand successfully petitioned to include lesbian, gay, bisexual and transgender (LGBT) access to health in the WHO EB agenda for consideration it provoked debate, with Egypt and Nigeria, on behalf of their regions, asking for the item to be deleted.
This issue exemplified how health concerns can reflect and raise political division. Bringing health into diplomacy platforms, including that of the WHO, poses a challenge for how to avoid foreign policy concerns overshadowing health issues. The US delegate, Nils Daulaire, speaking about the demands for deletion of the LGBT item in 2012 said that it was “unprecedented for WHO member states to come together to attempt to remove an item legitimately placed on the Executive Board agenda by another member state. We believe it is important to afford each other the courtesy to discuss these important health items, even those with which not everyone agrees. Changing this deeply-established precedent risks politicizing all EB agenda items moving forward.” At the same time, countries are sensitive about health platforms being used to advance wider foreign policy agendas.
On the specific agenda item, a compromise position was reached to delete it and to ask the DG to consult with members on how to address the public health issues for future discussion. African diplomats in Geneva noted that the issue could continue to cause a stalemate unless the DG brings compromise solutions from her consultations within the regions. In the 2014 EB the item thus appeared as ‘[deleted]’ on the final agenda, and there was no discussion of it, as Member States had not agreed on a title or content of accompanying documentation for it. Until they do, the item will not be discussed.
Agenda setting can and does thus fall victim to politics and requires diplomacy to reach solutions that are acceptable to the membership. However African countries have successfully brought items to the WHA agenda, such as that of ethical recruitment of health workers. What may restrict both the inclusion and action on agenda item may be the limits set by the General Program of Work (GPW). The GPW is set for the organization every 5 years. Unless a suggested item falls within the GPW and has funding allocated to it, it is unlikely to make it onto the formal agenda. The Organization is currently working on its 2014-2019 GPW and bases its’ plans on a set of distinct categories in the GPW that have been agreed to by Member States - that is communicable diseases, non-communicable diseases, promoting health through the life course, health systems, and preparedness, surveillance and response. One reform of the WHO underway, according to the WHO website, is to “allow greater flexibility in allocating resources to priorities within these categories”, which may then give flexibility for new agenda items not yet covered in the GPW.
Even when issues make it to the WHA agenda, will they receive adequate attention?
The agenda of both the EB and the WHA have become longer and longer over the years. In May 2013, for example, the WHA agenda included numerous weighty issues, including health post 2015, NCDs, communicable diseases (including malaria and neglected tropical diseases), WHO reform, substandard/spurious/falsely-labelled/falsified/counterfeit medical products and a range of other issues. With such packed agendas, smaller delegations to the WHA face challenges in participating when equally important issues are being discussed at the same time. Dr. Emmanuel Makasa, health attache at the Zambia high commission in Geneva noted in one 2013 meeting in the region that African delegations have responded to this by working as a group: “We work together as the African Group of Health Experts in Geneva to tackle issues and engage as a group, which helps with our individual member state staff shortages and different professionals present at the meetings.”
A lengthening agenda may also reflect the widening reach of global factors and policies in health, or the widening range of concerns claiming for attention. Either way, countries need proactive strategies to get their health concerns onto the global agenda, to ensure that they obtain attention and are addressed. It implies long term thinking, preparing and collaborating with partners in advance to develop positions and organizing the evidence, expertise and alliances to raise and advance agenda items. As Chigas et al. highlighted in 2007 those who can early on “frame the definition of the problem and the terms of the collective debate, can have enormous influence on the subsequent negotiations and their outcomes.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The Centre for Trade Policy and Law is working with EQUINET on a research programme on GHD in association with the ECSA HC Strategic Initiative on Global Health Diplomacy. For more information on the issues raised please visit www.equinetafrica.org
It is time to raise critical questions around the wide and growing enthusiasm for Universal Health Coverage (UHC), which is increasingly seen as a silver-bullet solution to health care needs in low- and middle-income countries. Although confusion still exists as to what UHC actually means, international development agencies typically define it as a health financing system based on pooling of funds to provide health coverage for a country’s entire population, often in the form of a ‘basic package’ of services made available through health insurance and provided by a growing private sector.
Global health agencies such as the World Health Organization, and international financial institutions such as the World Bank, are promoting this approach in response to the rise in catastrophic out-of-pocket expenditure for health services, and in the face of crumbling public health systems in the global South (both of which were precipitated by the fiscal austerity imposed by organizations such as the World Bank and the International Monetary Fund in the 1980s and early 1990s). In this new model, UHC prescribes a clear split between health financing and health provision, allowing for the entry of private insurance companies, private health providers and private health management organizations. The logic is that health care challenges require an immediate remedy, and since the public system is too weak to respond, it is strategic to turn to the private sector.
In short, the UHC model is built on, and lends itself to, standard neoliberal policies, steering policy makers away from universal health options based on public systems. Building and improving the public healthcare system is not part of this mainstream narrative, with the state generally confined to managing the system.
Although these programs are now zealously promoted by global health agencies, the evidence to support their implementation remains extremely thin. Giedion, Alfonso and Díaz in a review of existing evidence for the World Bank published in 2013 observed that reliable data upon which to evaluate their performance are hard to come by and methodologies designed to collect good evidence are singularly lacking, illustrated by the highly contested data of some early health reforms based on universal insurance in the South (e.g. Chile, Colombia and Mexico), which have nonetheless been used to legitimize the current UHC agenda.
In a paper recently published by the Municipal Services Project, we argue that secure finances for health care are a necessary but insufficient condition for systems that are equitable and provide good quality care. We analyze the reasons why finances need to be channeled through well-designed public systems if they are to be spent efficiently. We further argue that, in glossing over the importance of public provisioning of services, many proponents of UHC are actually interested in the creation of health markets that can be exploited by capital.
In Europe, 20th-century reforms have intensified health being delivered as a market commodity. The more recent experiences of Brazil’s SUS, India’s Arogyasri and Thailand’s Universal Health Care Coverage scheme all show features of this neoliberal model, within very diverse settings and reforms. They all show a persistence or expansion of private sector participation in provision of care, despite the fact that all are tax-funded health systems. In all cases, public funding does not match needs and this opens space for the progressive creep of the private sector into the larger health system. In Brazil, while the SUS has expanded public primary care services, hospital care remained largely publicly paid and privately provided. Despite a strong policy commitment to universal public sector health systems in Brazil and Thailand, the neoliberal ethos and its promotion of private provisioning appears too strong to shake off. Consequently all three countries have a powerful private for profit sector in health. This influences the functioning of the system as a whole, ratcheting up costs, jeopardizing the integrity of the public sector and drawing away resources, both financial and human, from resource-starved public facilities.
The three countries typify the challenges that LMICs face while attempting to construct universal systems that borrow from the internal logic of a UHC that is not based on public systems, where ideological pressures prevent the adoption of an entirely public system of care provision. The challenges of providing high quality and equitable health care are most acute in low and middle-income countries because of faster growing populations, higher prevalence of infectious diseases, and growing burdens of non-communicable illnesses. We would argue that re-imagining public health care – rather than the private sellout of health systems via a neoliberal agenda in UHC – is the only way forward in building truly universal health outcomes.
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 see the Municipal Services Project website at www.municipalservicesproject.org and the MSP Occasional Paper, ‘Universal Health Coverage: Beyond Rhetoric’ at: http://www.municipalservicesproject.org/publication/universal-health-coverage-beyond-rhetoric.
When the news came of Nelson Mandela’s death messages came spontaneously on our list from colleagues from across the 16 countries in EQUINET. We can’t include them all but some are below. They signal the pride that Mandela gave to all in being African, the many facets of justice and wisdom he symbolized for people in the continent, his respect for power being located within the people and the inspiration that people drew and will continue to draw from his life. Hamba Kahle Madiba.
From Amuda Baba in Democratic Republic of Congo: It is a big loss for Africa. We have lost a symbol of peace, unity and humility. May his soul rest in peace.
From Severina Lemachokoti in Kenya: His wisdom was unique and his wise words will forever remain to build people of all races in the years to come.
From Moses Lungu in Zambia: We will draw lessons from him on equity, equal and social justice for all. Bless his family and nation
From Sam Wamani in Uganda: Mandela was and will remain a true love for all people of all colours. Africa and the world will always remember Madiba.
From Isabella Matambanadzo in Zimbabwe: He gave us an unmatchable sense of the dignity in being black Africans and of our humanness. ..May we always carry the best of you with us.
From Elisha Sibale in Tanzania: His lifelong commitment to social justice for all was a beacon to the world.
From Dennis Chibuye in Zambia: The world has lost of a true patriot and visionary leader. …Long Live Mandela Spirit.
From: Kingsley Chikaphupha in Malawi: An icon, statesman and a true son of Africa!!
From Wilson Asibu in Malawi: May his life inspire us all, especially the youth who have a great opportunity to sculpture their lives into greatness.
From Jacob Ongala Owiti in Kenya: Mandela had the unique ability to take power to the people - So, who will take up the Mandela's spear and move it forward?
From Fortunate Machingura in Zimbabwe: He said: “To be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others” he said…enhancing the freedom of others implies our joint action as a collective.…it’s now up to us Comrades… the struggle continues!
We wish all a 2014 in which our struggles for health and justice flourish.
If our health systems ‘listen’ better to people’s input, will this make them more responsive to people’s needs? Will strengthening people’s voice and role in decisions in health systems help overcome the significant inequalities that exist in east and southern Africa - and more widely - in access to and use of health services? What do we need to do to ensure that the substantial resources that flow to and in health systems reach the primary care and community level?
These were questions that we tackled at a recent regional joint workshop of the Community of Practitioners in Accountability and Social Action in Health (COPASAH) and the Regional Network for Equity in Health in East and Southern Africa (EQUINET) hosted by TARSC in Zimbabwe. Thirty people attended this workshop, including community health activists, civil society organisations, health workers, academics and researchers from Kenya, South Africa, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe. As a group, they came from a wide range of contexts and experiences, working with or representing people living with HIV and AIDS, elderly people, women and children, health workers and people whose health rights had been violated. Participants came from organisations whose goals included supporting and strengthening community roles in monitoring health service delivery, and advocating for equity and quality of health services and increased resources for health.
Given the wide social inequalities in our societies, all who attended the meeting are working in some way to invest in and support community capacities to articulate their needs, present their conditions, negotiate for resources that improve their lives, and monitor the delivery on state commitments towards improving health. We agreed that, in order for this to happen and for it to have an impact upstream, beyond the more common ways that people support health services - such as caring for people who are ill or contributing their own resources or time to improve services - people also need to have a greater role in the planning, delivery and monitoring of their health services.
We brought our own stories of how greater citizen engagement with service providers, especially around social action on health and social accountability in services, makes for more effective and acceptable health services. For example, participants from South Africa, Kenya and Zambia noted that setting up community-health worker committees had helped to improve dialogue and collective action. Uganda CSOs reported on a randomized field experiment of community-based monitoring of public primary health care providers in Uganda by Björkman and Svensson in 2007 that showed how social accountability mechanisms led to large increases in utilization of services and improved health outcomes.
For this to happen, however, we see that the health system needs to change. When the health system itself does not give any authority to frontline workers, it is difficult for the same workers to respond to communities. Decentralisation of power and resources within the system to local levels, together with the capacities for it, is thus necessary if people at community level are to be effective in providing input to the organisation of services. The health system needs to make clear what entitlements people have, and what obligations service providers have, and to communicate this widely to health workers and the public as a prerequisite for delivering health rights and building social accountability. If our health systems are to become more people-centred, they need to not only develop skills, knowledge and procedures around technical issues, but they also need the skills, knowledge and procedures for health workers and managers to facilitate meaningful community engagement and involvement, including in decision making. And these are most needed where the communities enter the system, that is, at the primary care level. To build ‘people centred’ health systems it is essential that resources, including medicines and skilled health workers, reach the primary care level.
This touches on the power dynamics within health systems. The inequalities in health systems are not just inequalities in relation to resources, or to access to services. There are also inequalities in power: between service providers and communities, between different kinds of health personnel and between different levels of the health system. This is an issue that is largely invisible but that has impact on the participation in and use of health systems by more marginalised groups. So a great part of our meeting tackled the sort of mechanisms and processes that can address this power imbalance. For example, mechanisms such as community prioritising of health needs, monitoring service delivery using community score cards, community- health centre meetings and community action planning, can help to make service providers more accountable to communities, and can potentially support and improve interactions between communities and frontline service providers. This strengthened interaction can then, if based on a mutual listening and understanding, lead to alliances between local health workers, managers and communities in negotiating with higher level authorities for improvements in services.
One of the ways of embedding a shift in power relations and to strengthen that alliance and interaction between communities and primary health care actors, is through using participatory reflection and action (PRA) approaches. PRA uses a variety of visual and verbal methods to provoke discussion, analysis and planning for action in such a way that it can strengthen the power that people have to change their own lives, their communities and the institutions that affect them. For the last 10 years, the pra4equity network in EQUINET has been exploring how this approach can support the strengthening of a people-centred health system. At our meeting we built on this to examine how PRA can be used to shift attention and resources towards the primary care level of the health system, to make those at higher level more accountable to the needs of communities, and to ensure the capacities of frontline services to deliver on those needs. In reviewing some of the blocks and deficits raised in our current health systems, we concluded that PRA does have a role to play in improving transparency, improving dialogue between rights holders and duty bearers, and establishing platforms for feedback and consultation.
This was a unique opportunity to bring together and build synergies between two bodies of work, on PRA approaches and on social accountability. It also raised the potential for PRA approaches to position our engagement on accountability within a dialogue between communities and their frontline health workers, for both to listen to and engage with the realities and experience of the other. We already have evidence, in the work of the pra4equity network published on the EQUINET site, that this improves local service quality for both health workers and communities. The question we are yet to test, and will be exploring in our follow up work, is whether this shared power is able to address imbalances in institutional resources and power within the health system, so that the resources, skills, commodities and authorities reach the primary and community level services, where they are most needed.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Further information on the issues raised in the oped can be found in the report of the meeting and other publications on the EQUINET website at www.equinetafrica.org and in the COPASAH website at www.copasah.net
At the 3rd Global Forum on Human Resources for Health, Recife, Brazil, November 2013 a group of civil society organisations and regional networks produced a statement of commitment on the key role of health workers in universal systems. The statement from EQUINET, European Public Health Alliance, Health Poverty Action, Health Workers for All and All for Health Workers, Latin-America Association of Social Medicine ALAMES , Medicus Mundi International Network MMI, People’s Health Movement PHM, Public Services International PSI, The Centre for Health Sciences Training, Research and Development CHESTRAD and WEMOS is shown below.
The health workforce crisis remains a core barrier to achieving the Millennium Development Goals (MDGs) for health with only 31% and 12% respectively of 75 Countdown countries likely to attain MDGs 4 and 5. Despite donor and country commitments at the 1st and 2nd Global Forums on Human Resources for Health, the global health workers’ shortage persists. Of the 57 countries identified as falling below the WHO target only 19 have seen an improvement in their aggregate health worker density. Earlier commitments to increase domestic resources or external aid, as well as implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, remain largely unfulfilled.
National and international funds have been channelled to strengthen health workforce programs, like task shifting and the scaling-up of community health worker’s programmes. However, too little investment has been targeted at the recurrent costs of health workforce development, for instance on salaries, education and social protection measures for health workers. The inequitable distribution of health workers through increased mobility and migration within and between countries adversely affects access to health.
Health workers and a robust health system are essential for universal health coverage (UHC), and realizing the right to health through universal health systems.
Therefore at the 3rd Global Forum on Human Resources for Health in Recife, Brazil, we, the undersigned representatives of civil society organizations hereby commit that we will:
• Help amplify the voices of health workers, especially those at the lower levels of care and support their work to influence national and global health policies and plans.
• Assist local civil society organizations to ensure their voices are heard in global and national health workforce policy discussions.
• Assist in strengthening the capacity of patient groups to advocate for equitable and quality services staffed by sufficient, competent and equipped health workers at all levels of care.
• Recognise the gender dimensions of the health workforce and champion the rights of women health workers, and
To catalyse a strong movement for health workers, we will:
• Advocate for governments at all levels to institute plans and allocate adequate resources for human resources for health (HRH) to ensure that every person has access to a trained, supported and equipped health worker.
• Press bilateral and multilateral organizations and civil society actors to increase health workforce development efforts and financing, including of national training institutions, in alignment with government plans.
• Work with training institutions, professional and regulatory bodies to achieve quality in health worker education, including on the social determinants, so that every health worker is competent to provide quality care and accountable to the populations they serve.
Strengthen the advocacy of health workers and civil society for improved infrastructure, support and working conditions
• Support the development of a strong, motivated, public workforce to counter some of the ill- effects of an increasingly globalised, inequitable and unstable economy and rapidly changing health and demographic patterns.
• Commit our own resources and expertise to assist in converting HRH policy and plans into action.
To ensure accountable HRH systems at national and global levels, we will:
• Work with governments, the Global Health Workforce Alliance, the World Health Organization, and other stakeholders to develop mechanisms to measure progress towards improved and equitable access to competent health workers
• Monitor and report on progress of public HRH commitments made by global actors and governments.
• Assist citizens and health workers in developing strategies to enhance accountability of national and global actors and challenge inequitable policies that impact on HRH development.
• Increase transparency of our programmatic and technical contributions to national HRH strategies and attempt to reduce onerous reporting requirements placed on countries. We will commit ourselves to supporting a strong public sector for health workforce development and be accountable in our own funding and technical programs to mitigate the ‘internal brain drain’ from the public to the private sector.
We will hold donors, government and multilateral actors accountable to:
• Ensure that economic governance arrangements and fiscal space enables the development of a strong national health workforce as a long-term investment in the wellbeing of the people and the economy of a country. The return on investment to employ a health worker is many times higher than to bail out a bank.
• Provide the leadership, resources and stewardship needed to fulfil commitments made to urgently and effectively address the health workforce crisis and ensure improved and equitable access for every person to competent health services.
• By 2015, develop, finance, and implement HRH action plans, including strengthening national training institutions, with concrete targets and integrate them into national health plans.
• Ensure that health workers and civil society organizations are active partners in the health workforce policies, planning and development.
• Promote equitable access to health care by investing especially in health workers at primary and community levels and in community structures to facilitate citizens’ voices.
• Improve investment in health workforce development, including salaries and social protection, and in national training institutions in order to rapidly increase numbers of HRH.
• Assist in development of robust HRH information systems to facilitate improved planning and management and
• Respect and implement the Global Code of Practice on the International Recruitment of Health Personnel including additional enforceable legislation and redistribution mechanisms to compensate for the international ‘brain drain’ that exacerbates global health inequalities.
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
Google the words “universal health” and in under 3 seconds you’ll get 165 million results. There is a crescendo of talk on universal health coverage. But has it been translated into terms that can engage social debate? The two editorials in this month’s newsletter and several of the papers suggest that such debate across all of society is critical, given how deep the consequences for society of the choices made. In the first editorial, Latin American social medicine and health scientists warn of the negative impacts of segmented insurance options. The second editorial, drawn more from African experience, argues a similar case. Both urge for exploration of tax funding, particularly given that universal systems are a right of all citizens not a benefit of particular employees or contributors. There are clearly debates and choices- are they reaching the people who will be most affected by them?