Comrades, colleagues, citizens
As we prepare to host the UN Habitat 4 it is timely to reflect on the declarations made and the journey we've taken since the last conference in Quito, Ecuador in October 2016. (Is really it only the fourth conference - many of us weren't even born when the first was held in 1976!) We are fortunate here in Harare to be part of a regional movement, together with our strategic partner cities, towards more equitable and inclusive urban environments. Habitat 3 gave early voice to many of the changes that were nascent in our cities at the time: greater networking between cities, space for people to influence urban design in their cities, a consciousness of climate challenges and an awareness of the intertwined fortunes between urban and rural areas. Our cities today are not isolated. Whilst retaining their unique qualities and idiosyncrasies, they are part of highly globalised, networked ecosystems where our futures are deeply connected.
Our archives reveal that the atmosphere in Quito was aspirational. From the records excavated after the Great Data Crash of 2025, we reconstructed video footage of Habitat 3. The voice in it of the then Secretary-General of United Cities and Local Governments Africa, Jean Pierre Elong Mbassi still rings clear: “Local authorities are now on the map, what we want next is to be around the table…we hope that people will realise that without local authorities, there’s no way we can implement the global agendas adopted in 2015 and 2016”. This was echoed by the World Mayor’s Assembly who asserted two key demands: The first that city, metropolitan and regional governments be involved in UN negotiations, with powers to make decisions independent of national government; and the second that mayors have access to international finance and that instruments such as a Green Climate Fund also be allocated to and handled directly by cities.
In 2036, with collective, participatory urban budgeting now commonplace and seamless networks between cities, it is easy to forget that only a few decades ago cities were primarily considered national hubs, managed by nation states. We in East and Southern Africa have especially benefited from the Ore to Information Fund through which finance raised from the last mining operations was invested in open access technology infrastructure. This has allowed us to have the fastest data connectivity in the world, bringing huge benefits for technological innovation and education, access to health information, for the reach of health and economic services and capacities and new resources for community dialogue and action.
This month we celebrate 68 years since the principle of the ‘right to the city’ was first proposed by Henri Lefebvre. UN Habitat 3 was a critical marker for those campaigning for this right. We take it as commonplace today, but respect that those early struggles were not easily won.
Championed by Brazil and Ecuador, the ratification at Habitat3 of a New Urban Agenda (NUA) made this the first internationally negotiated document to reference the right to the city and encourage nation states to enshrine it in their laws. Under the slogan “Cities for people, not for profit!” civil society from various campaigns against gentrification, privatisation of public space and criminalisation of homeless and vulnerable citizens lobbied for the inclusion of the right. They called for governments to put citizens before private sector interests in the city, building on the 2004 World Charter on the Right to the City and the 2010 UN World “Right to the City” Urban Forum in Brazil.
At that time, Brazil and Ecuador were the only two countries to have this right enshrined in law. Still the Habitat3 negotiations saw large parts of the right to the city excluded from the final document. It did not mention the ‘social function of land’ or ‘participatory approaches at all stages of the urban policy and planning processes’. These clauses were struck off during the drafting. The NUA was also non-binding. As we look back in 2036, we owe a debt to the global Right to the City movement that brought together civil society, local government and other actors around the world, including from health, who picked up the baton after Quito, to implement the principles of equity and inclusivity in the 2016 NUA. Women in Informal Employment Globalizing and Organizing had already by 2016 publicised the economic, social and environmental contribution to cities of women informal sector workers and Colombia’s waste pickers had already won a court ruling to block a waste management contract that did not provide opportunities for informal recyclers. We have seen others follow suit, including those living in slums, health activists from communities affected by pollution and urban waste, increasingly bringing previously excluded groups to the policy making and planning table, affirming their rights to a city that ensures wellbeing for all. This has not been easy, especially given the legacies we inherited from the early years of the 21st century of unpredictable weather, rising sea levels, pollution and waste threatening the ecosystems of all in our cities, of massive socio-economic inequalities, of destructive wars and of big population movements across countries. However we now fully understand that inclusion and investment in wellbeing is not only as a matter of rights and justice, but is vital for our collective survival.
We were fascinated to find in our excavated websites an account by Barcelona's first female Mayor (to think - that city is now on its fifth female mayor!). Writing after Quito, Ms Colau said that Habitat 3 saw women coming to the forefront of political change. She noted that “the 21st Century is the century of cities - in part because this is a moment of great political uncertainty at many levels. But within that uncertainty, we see empowered citizens asking to be protagonists, and the city is the place to do this.”
We are looking forward to hosting Habitat 4 this year here in our region in real and virtual space. We welcome all joining us in our increasingly inclusive understanding of ‘the city’ with all the people and connected spaces that are critical to healthy urban life. As we gather to debate new challenges, we are fortunate to reflect on the debates, advances and still unresolved issues from Habitat 3 that we have found, to reflect on where we reached in 2030 with our sustainable development goals, and to bring in the voice of all to craft our Agenda for Habitat 4.
This oped was sent in response to our invitation for reflections post Habitat III. This issue provides a range of resources and publications related to urban health. Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org.
Editorial
The concept of global health security underpins the current framework for global preparedness and response to emerging infectious diseases. The Global Health Security Agenda –a collaboration between governments– was launched in 2014, aiming to make our interconnected world safe from infectious disease threats. The governments involved in the Global Health Security Agenda focus on strengthening their countries’ capacities for detection, response and prevention.
In the context of public health emergencies, the Agenda has received financial and political support from international organizations and almost 50 countries. However, there is tension between the aims of global health security and governments’ mandate to ensure national security. The 1994 United Nations Development Programme’s Human Development Report first introduced the concept of human security, referring to security of citizens as individuals rather than that of the states in which they live. We posit that the use of the term global health security can have a negative unintended effect on the ultimate goal of improving health for all. There are three reasons why this term potentially privileges the security of the state rather than the security of individuals.
First, global health security, in its current use, is largely focused on protecting high-income countries against public health threats coming from low- and middle-income countries. Ebola virus, Marburg, Zika virus, dengue, chikungunya, Rift Valley and Lassa fevers, originated in low- and middle-income countries. If the Agenda is used to prioritize global health risk depending on the origin of infections, resource allocation may become even more skewed towards high-income settings. To ensure that a health security agenda is an integral part of national and foreign policy of each country, political attention and coordination between national ministries is needed as well as support from the national security budget.
Second, global health security tends to emphasize disease containment to protect national security rather than the prevention of future local outbreaks. Disease containment is common practice in the control of emerging infectious diseases. A national security perspective often results in unilateral, neo-colonial and/or short-term solutions designed to protect national borders. For example, many countries and airline companies imposed travel restrictions during the 2013–2016 Ebola virus disease outbreak in western Africa, contrary to World Health Organization recommendations.
Third, we argue that respect for human rights and values such as equity and solidarity should underlie each national security agenda. Such values are consistent with the motives of many people who provide health services in public health emergencies. Health security agendas should aim to build resilience to future outbreaks of infectious diseases, and require a long-term systems approach based on surveillance and national health system strengthening.
Protecting the world from infectious disease threats requires that national governments share the responsibility of serving those most in need, wherever they live. We believe that the concept of global health security should be expanded to include solidarity and sustainability. In this way, we will be able to develop a long-term approach and overcome the limitations of current responses to global health emergencies.
This editorial appeared first as an open access editorial in the WHO Bulletin in December 2016 at n/volumes/94/12/16-171488/en/.
As usual this is a short newsletter, given the time of year. Our newsletter is now on its 190th issue and we appreciate the range of creative work reported in all the 16 years of its existence. The 245 editorials written by a range of people from community, civil society, parliament, government, technical and research institutions provide comment and reflection on a diversity of health issues and debates. The over 11000 entries in the 190 newsletters all available in a searchable database on the EQUINET website carry a wide range of ideas, experiences, evidence, analysis and voice from and on east and southern Africa. The newsletter database is a rich searchable resource of how policy and publication focus has shifted over nearly two decades and of whether writing on the region is increasingly being led from the region.
We continue to encourage you to document your work and to send us send your blogs, and links to your reports, papers, news, conference announcements, videos or other forms of information so the newsletter can assist to share experience, evidence and learning from work on health equity in the region. As we said last year, 'Until the lions write their story, tales of the hunt will always glorify the hunter'. We encourage you to roar even louder in 2017!
Please send your blogs, and links to your reports, papers, news, conference announcements, videos or other forms of information from your work on health in the region, and we will be happy to share it.
We look forward to working with you in the coming year and wish you a healthy 2017, and a thoughtful, steady and exuberant progress in our struggles for health equity. .
Fidel Castro, leader of the Cuban revolution, passed away on Friday 25 November. He was a towering figure and one of the defining leaders of the 20th century. Leaders across Latin America sent tribute. Chile's Michelle Bachelet called him a 'leader for dignity and social justice in Cuba and Latin America", while El Salvador's president, Salvador Sánchez Cerén, said “Fidel will live forever in the hearts of those of us who fight for justice, dignity and fraternity.” As China’s official news agency Xinhua noted, he was “a pioneer in battling ... neoliberal globalisation, foreign debt and exploitation of natural resources.” CLASCO in Argentina pointed to his role, together with the Cuban people, of pointing to an alternative of a world "without injustices, without exclusions, without exploitation" ("Fidel era un hombre, como tantos otros. Pero Fidel se transformó, y lo hizo junto a las luchas del inmenso pueblo cubano, en un horizonte, en una promesa, en un destino utópico: el de construir un mundo sin injusticias, sin exclusiones, sin explotación; un mundo emancipado, liberado, solidario").
The transformation in Cuba was profound. Manuel Garcia Jr reflected the day after Fidel's death on the transformation he experienced first hand in 1959 Havana: "Every person, every place, every moment exuded the same sense of uplift. I was immersed in a national sense of freedom, and it soaked into my psyche and bones. This experience permanently magnetized my political compass, so that regardless of verbal arguments and logical constructs in later years, my compass always points my sympathies toward freedom for any people". The nearly 60 years since of struggle in Cuba, a small island of 11 million people, often battling powerful global forces, unquestionably generated some contradictions. Ahmed Kathrada in the Mail and Guardian notes that "history will always judge people differently based on who is writing it".
He also notes, however, together with many other voices from Africa, that Fidel Castro came from "a generation of leaders, who envisioned a more equitable society, based on mutual cooperation, especially between developing nations" and that he was one of the foremost supporters of Africa's liberation movements and anti-colonial struggles. The internationalism of Cuban people in Africa has been sustained to today: whether in the support by Cuban troops of Angola's resistance to an apartheid military attack in the 1970s, whether through providing medical education in Cuba for thousands of African doctors over many years, or sending many Cuban doctors to African countries, including the many who came to West Africa to help in the efforts to control Ebola in 2014/5. At the same time, Castro also pointed to the rift between rich and poor in African countries, as he did at the speech to the South African parliament in 1998.
Whatever the context and debates, Fidel was an unwavering champion of health justice, of the right to health and of progress in social determinants like literacy and food security. He was a driving force of a universal health care system in Cuba that is a responsible for making Cubans some of the healthiest people in the world. As the journal MEDICC noted in a tribute the day after his death: "Over the years, President Castro took an abiding interest in health and was at the forefront of promoting advances in health care, research and medical education: establishing rural hospitals and a national network of hundreds of community-based clinics, making prevention a cornerstone of training and service; generating extraordinary investments in biotechnology to develop novel vaccines and cancer therapies, and specialized services for Cuban newborns with heart disease. Finally, he considered the most significant “revolution within the revolution” to be the creation in the 1980s of the family doctor-and-nurse program, posting their offices on every block and farmland in Cuba. The outcomes of these efforts were not achieved by one man, but by 500,000 Cuban health workers, who were able to count on health as a government priority. Together, they faced dengue and neuropathy epidemics; and the scarcity of medicines, including for HIV-AIDS patients, after the collapse of the socialist bloc and tightening of the US embargo on Cuba in the 1990s. Their dedication has won a healthier nation".
It falls to us to continue the struggle for health justice with the same compass, solidarity and tenacity.
From 14-18 November 2016, 2,062 delegates from 101 countries assembled in Vancouver, Canada, for the Fourth Global Symposium on Health Systems Research on the theme of ‘Resilient and responsive health systems for a changing world’. This year’s Symposium consisted of five days of 53 organised sessions, 248 oral presentations, 74 satellite and skills building sessions, 385 posters, and 155 e-posters. Social media played a great part in whipping up the spirit of engagement, before and during the Symposium. Blogs also played a role in generating energy before the Symposium; the most popular of these was a blog from the SHAPES thematic working group challenging the concept of resilience in health systems.
Since Cape Town, the world has shifted from efforts to achieve the MDGs to the launch of the SDGs, which maintain a focus on UHC, but call more strongly for a systems-orientated approach by embedding health in broader social and environmental perspectives. In support of these goals, there is even greater focus on research to reduce inequities in relation to marginalised and vulnerable groups. On the policy and implementation front, there has been a transition in the funding landscape from donor funding for interventions, towards emphasis on locally generated funds. In this context, the local production of health policy and systems research is also increasingly valued.
Several themes emerged from the discussion and debate during this Symposium. First, it is important to recognise the many meanings of resilience. Health system resilience and responsiveness is anchored in people living and working within their communities. But, we need to be cautious not to romanticise communities as resilient, when what they are doing is coping in difficult situations. Systems need to be resilient precisely so that the burden of such resilience does not fall on the most vulnerable in our societies. Health systems resilience needs to be qualified by an explicit focus on equity and social justice, and support the empowerment of the most vulnerable. Second, discussions amongst participants highlighted the importance of resilient and responsive health systems as ones which provide integrated, people-centred services, with a focus on primary health care as the frontline of routine services and outbreak response. Subnational actors, including communities, are reservoirs of resilience for health systems. Resilient health systems are those which operate from the “end-user back”, and not from the organisation forward. Nevertheless, governments have the responsibility for steering all actors – public and private – in the interests of the broader community.
Third, while some discourse on resilience emphasises health security, such a perspective can sometimes be counter-productive, and should be balanced with the protection of health rights and health system strengthening. Health security should be an inclusive concern of the entire global community, and never a reason to exclude or marginalize. Fourth, the resilience discourse should be positioned within achieving the SDGs and mobilising collaboration and leadership across sectors. This together with integration and a move away from vertical approaches will help achieve the sustainable management of health systems. Symposium delegates repeatedly stressed the importance of people and relationships, flexibility and the capacity to mobilize new resources. Fifth, the Symposium gave occasion to highlight the struggles of indigenous peoples against historic privileges, including in high income countries. This has received insufficient attention in the Symposia to date. People in high income countries have much to learn from the experiences of low and middle income countries as well as from their own indigenous or marginalized populations.
The Symposium identified several areas for action for HSG, for researchers, funders and policy makers.
The Fourth Global Symposium has allowed our community to hold a light to the concept of resilient and responsive health systems, recognising their importance for achieving UHC and the SDGs, while acknowledging the potential shortcomings. Resilience adds a useful lens to our existing concepts and approaches, but it does not replace or supersede them. The world is changing, and resilience and responsiveness are needed now more than ever. The accumulated knowledge we have as a community builds on the continuing Symposia agenda of improving the science needed to accelerate Universal Health Coverage; to be more inclusive and innovative towards achieving UHC; and to make health systems more people-centred. For the next two years, Health Systems Global as a community of practitioners and researchers will look to remain at the vanguard of defining the field of health policy and health systems, while impacting our broader communities, and improving our global society.
The full statement is found at http://healthsystemsresearch.org/hsr2016/wp-content/uploads/Vancouver-Statement-FINAL.pdf and further information on Health Systems Global and the conference can be found on the HSG website at http://healthsystemsresearch.org/hsr2016/
In this issue we have a numerous papers and videos reporting the discussions, debates and policy proposals at Habitat III in Quito, Ecuador in October. They provide evidence of the challenges for and visions of life in today's and tommorrow's cities, including in relation to improvements in health for all in the city. We will keep an eye on these debates from Habitat III that affect urban health equity and invite you to send us your views for the next newsletter. What do you see as the major urban health challenges in our region? What success stories do we have? And how has Habitat III has contributed to meeting challenges for and nourishing success towards meeting the right to health in our cities?
When the Global Symposium on Health Systems Research (GSHR) gathers health systems researchers in November 2016 to explore ‘resilience’ in health systems in a context of inequality and economic, social, environmental and health challenges, what learning and insights will we bring to the table?
Between August and October this year we carried out two rounds of discussion drawing in diverse voices from amongst the over 300 people globally in our pra4equity list, hosted by the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The first was to discuss our experiences in learning from action in participatory action research (PAR) and the second on what that implies for how we understand the concept of resilience.
The PAR process involves gathering and systematising lived experience to collectively analyse and validate the underlying causes, set, take and reflect on actions on these causes and draw knowledge from it. In earlier meetings we realised that people are less confident of this phase of learning from action. There was a demand to discuss further the processes for building the understanding, power and self-confidence to produce and evaluate change.
In the discussions, people drew attention to various methods they used to facilitate learning from action, including through the ‘but why’ method, progress markers and wheel charts, and mapping or taking photographs of change from initial findings as a means to reflect on the change and what has enabled or blocked it. These processes and tools have not only been used to review how far we have achieved intended actions and outcomes, but also to reflect on the thinking and hypotheses on what produces change. The collaborative development of hypotheses for change by those involved in the PAR (as a form of critical theory or using PAR forecasts, like weather forecasts) was seen to be integral to learning from action. So too was helping people to document their ongoing learning.
In our learning network we’ve also used the reflections across countries on actions on the same problem area as a form of ‘meta-analysis’, to share insights on what facilitates the implementation of change, what blocks it and why, drawing learning also from what is similar and different across countries.
The steps of action and learning often take several PAR cycles to address deeper determinants and build meaningful change. This is especially relevant when people are engaging on deeply rooted power relations or determinants that are beyond local control, such as addressing gender in South Sudan or commercial sex work in Malawi. While not always the case, some noted that this can take more than a decade of work in both high and low income settings, calling for sustained processes.
This raises challenges in some settings. Tracking of change may stop too early, those working in communities may lack the time or resources to record and report the change and the resources and attention to do this may not last for the time needed. Researchers or facilitators may not always be included in or able to stay with change processes that take place over years. PAR processes may also differ from the institutional cultures or priorities of universities or of the trade unions, social movements and other organisations that represent or work with the social groups involved.
The power imbalances involved are often protected by strong interests. We reflected that before applying any method, including PAR, we need to be clearer on its strategic possibilities, given the contexts and social actors. While this may lead to choices within range of approaches and forms of activism, it was asserted that a self-determined understanding of the symbolic and material dimensions of inequalities remains a powerful starting point for any approach.
Notwithstanding the difficulties, numerous examples of positive experience were shared! In Monrovia, for example, PAR implemented after the Ebola epidemic led to a shared, more comprehensive understanding of maternal health amongst the health workers and community members involved, pointing to actions to strengthen the continuity and interaction of the different services and roles needed to improve maternal health care.
In our discussions it was also suggested that the action and change in PAR should not only be seen in terms of material changes in conditions, although this is important. It can in addition be seen in the change in the people involved. As one participant noted in the discussion, “we pay too much attention to the actions and not enough to the actors.” For those often excluded from formal planning and decision making, it is important to appreciate how far they themselves are transformed in the process, in terms of their consciousness and self- confidence to produce change. This can start early in the PAR process, even from the first step of recognising and listening to shared experience.
Given these reflections, we had a second, equally challenging discussion on the concept of resilience from a PAR lens. In part this was due to its adoption as a theme by the GSHSR and in part its increasing use in global discourse. Resilience has been used in environmental and physical sciences to describe the stability of a system against interference from external disturbances, but has migrated to the social sciences. The GSHR website says: “Resilience: absorbing shocks and sustaining gains…. Health systems must be resilient – able to absorb the shocks and sustain the gains already made….”
As was raised in June by Topp, Flores, Sriram and Scott, our network also challenged use of a term that implies ‘absorbing shocks’ and ‘stability’ when the system is an outcome of unjust and structural inequalities that undermine health. PAR has developed in many settings as a direct confrontation with these inequities, seeing their disruption as necessary for health. It would thus not comfortably be applied in the science of ‘absorbing shocks’, when these derive from such injustice.
At the same time some noted that there appears to be a second set of meanings to the term. Resilience has also been used in some contexts to refer to the capability to sustain a positive change or to resist negative change, to transform and move from a harmful equilibrium to new more positive one and the ability to self-organise into a healthier state. This appears to have greater resonance with the process in PAR, given that it draws in the learning from action on a system and intends to raise the direct power and capability of those directly affected.
Given how different these ‘meanings’ are, we noted that we need to understand explicitly and not assume how people are using the term resilience, including at GSHSR. It has often been applied in relation to shocks and emergencies, for example. However participants raised that ‘emergency’ responses commonly use command and control styles that do not strengthen the capacity of or build co-determination with the affected community. If resilience refers to the ability to move to a healthier state, then systems need to transform the conditions producing shocks to prevent them, and not merely to absorb them, and to do so in ways that are defined with and build the capabilities, voice and power of those directly affected.
Please send feedback or queries on the issues raised in this oped or interest in the pra4equity list to the EQUINET secretariat at admin@equinetafrica.org.
In 2008 parliamentarians from Parliamentary Committees on Health in East and Southern Africa committed to raising the profile of health in all parliaments in the region, to strengthen their leadership, roles, capacities in and evidence for promoting, monitoring and advancing equity in health and health care. In this issue we have given attention to the role and work of African parliaments in health, both in the editorial and in various recently published items. Parliaments play a critical role in health, promoting public information and dialogue, scrutinising and reviewing laws, reviewing budget proposals and overseeing the implementation of policy and the functioning of the executive. There are numerous documents on the EQUINET site that report this parliamentary work in health since 2008, including on raising accountability on the Abuja commitment on domestic financing for health. This issue gives a glimpse into the more recent work and debates on health underway in African parliaments.
One reason why many of our health policies fail to be fully implemented in our region is that we lack a robust mechanism to make sure of this. Parliaments play a key role in this. They provide a link between government and citizens on laws and treaties, budgets and in overseeing in implementation of national programmes. In the early 1990s, most African countries initiated reforms for their parliaments to play a more effective and visible role in these functions.
The idea to bring the Portfolio Committees on health in the region together was first mooted in 2003, in part due to falling budget allocations to health, to the devastating impact of AIDS and to evident inequalities in access to funds and services. We recognized that as members of parliament (MPs) we needed to use our representative mandate to communicate social expectations and strengthen social voice and power in health. A core group of MP used our own resources to visit other parliaments in the region to share the idea and listen to the feedback. The network was finally launched in 2005 as the Southern and East Africa Parliamentary Committees on Health (SEAPACOH). Today we have widened to all of Africa and are the Network of African Parliamentary Committees on Health (NEAPACOH). So far we have active participation from Angola, Botswana, Benin, Burkina Faso, Burundi, Ethiopia, Ivory Coast, Gambia, Ghana, Kenya, Kingdom of Lesotho, Malawi, Mali, Morocco, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe and we welcome other parliamentary committees on health in the continent.
Since 2008 and with technical partners like EQUINET and Partners in Population and Development Africa Regional Office, the network has annually brought together the health committee chair, clerk and several other MPs from committees across the continent. This provides a forum for parliamentary committees on health to share concerns, unify voice on common concerns and calls for action, to advocate for health as a fundamental human right and promote democratic principles in health, including in our engagement with global processes. It also allows us to share promising practice and lessons learned. Strategically, we use the annual conference to identify common challenges and resolve on areas for action and on commitments that national health committees/delegations undertake to implement and report progress on at the next conference. We have found that identifying joint areas of action that brings us on the same ‘wave length’ strengthens our effectiveness, individually and collectively. The experiences, views and success stories that we share inspire and inform the individual committees. For example from 2005 we took up a common cause on advocating our Ministries of Finance to meet the Abuja commitment of 15% of the government budget going to health, that raised attention to this issue and contributed to improved allocation in a number of countries. We also raised issues that affect other sectors and committees, such as the positions on intellectual property that are needed to support access to medicines. We produced with EQUINET parliamentary briefs on international treaties affecting health and other health issues that are common for all parliaments in the region. We have in the process built solidarity and collaboration with civil society organisations and regional networks, and with health professionals, academics, non-state actors, research institutes and international agencies. This has enabled us to better understand and synergise our different but complementary roles across all actors to ensure we deliver on social values and policy commitments, such as on health equity.
In our recently held 2016 NEAPACOH conference we have identified some key areas of attention and work for the coming year. Some are platforms we are sustaining from prior years, including to: facilitate greater public participation in health; to pursue and monitor achievement of equity in health; to advocate for improved health budgets and financing (in line with the Abuja commitment); and to promote access to key reproductive health, family planning and HIV/AIDS services. We agreed, further, to evaluate how far our governments have ratified and domesticated health related treaties and to engage on how far actions have been institutionalized and implemented to advance Universal Health Coverage and other Sustainable Development Goals (SDGs) that affect health, including within parliament. We see a need to mainstream the SDGs within the diverse areas of work of parliament, including the public information and consultation for them, and would want to spearhead work on this in health. We also plan to develop a handbook for African parliamentary health committee members as a practical resource to support their role.
The 2016 conference also raised a proposal for NEAPACOH to work with technical partners to evaluate how effectively parliamentary committees are taking forward resolutions, to understand the barriers and support practice. We will do this by visiting a selection of member committees in their countries before the next meeting.
The process of building this network has itself been a learning experience. Indeed we understand that the longevity of this network of parliamentary committees is unique in the continent, outside the formal all parliament unions. We have grown stronger over the years building on our constitution and founding values, and have a board of serving MPs from all five African regions chosen in our annual conference and an office hosted by the Parliament of Uganda. Over the 13 years since we were formed we have benefited from perseverance of leadership and retention of key founding personnel, from sound founding principles, and from a consistent collaboration with key technical partners in the region. At the same time we still have much to do to deliver on our mandate, to be more robust and effective at national, regional and continental level to protect shared health values and to play our role in ensuring that they are delivered on in practice.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. You can find out more on NEAPACOH at www.seapacoh.org
When leaders at the 2015 G7 summit called the 2014 Ebola epidemic ‘a wake-up call for all of us’ they acknowledged that the global response had been too slow, with inadequate health leadership, coordination and emergency funding. At the same time, as argued in the May 2016 editorial in the newsletter, emergency responses cannot be delinked from the strength and authority of health systems to prevent, detect and respond to emerging public health threats, nor to their power to engage sectors on their role in the economic, social, environmental, trade and other determinants of these threats. Shortfalls in public health capacities, including those set in the 2005 International Health Regulations (IHRs) are a warning sign of future outbreaks, often due to neglected diseases or public health risks that get inadequate attention or resources until they trigger large-scale and highly expensive outbreaks.
The two new global financing mechanisms introduced in 2015 to support health emergency responses are thus important additional resources. These are the World Health Organisation (WHO)’s Contingency Fund for Emergencies (CFE) and the World Bank’s Pandemic Emergency Facility (PEF).
The CFE emerged from discussions on the IHRs and was adopted at the 2015 World Health Assembly. It aims to fill the gap from the first 72 hours of a declared health emergency until resources from other financing mechanisms begin to flow. It covers all countries regardless of income to prevent events that have substantial public health consequences. As defined in the IHR, these may be due to infectious agents, chemicals, radiation, food safety or other hazards that can escalate into a public health emergency of international concern. The fund is triggered by national request and the level of funding is decided on a case-by-case basis from a $100m fund. It can support personnel; information technology and information systems; medical supplies; and field and local government support. To date, the CFE has disbursed $8.5 million for interventions related to the Zika virus in South America, on yellow fever in central Africa, and drought related food insecurity in Asia.
The 2015 G7, indicating reasons of accountability and effectiveness, located the PEF at the World Bank. It is currently being finalized for launch at the end of 2016, uniquely as an insurance mechanism rather than a grant fund, to support follow up measures in emergencies after initial funding, such as from CFE. It is only focused on infectious disease outbreaks that could become cross border epidemics. Unlike the CFE, only low income countries are eligible for PEF financing. Funds are provided through two delivery windows: an insurance mechanism for up to $500 million per outbreak, and a cash injection between $50 and $100 million. The disbursement criteria are yet to be clarified. The World Bank expresses its anticipation that an insurance model will bring ‘greater discipline and rigor to pandemic preparedness and incentivize better pandemic response planning’, including by building ‘better core public health capabilities for disease surveillance and health systems strengthening, toward universal health coverage’. However it is both ambiguous and problematic that the PEF is yet to state the specific measures for supporting and measuring these aims.
Although born from different governance processes, the two funds do have some links. For example, the CFE intends to be a first response and the PEF a subsequent deeper resource package. They make reference to one another, recognizing the need to interact for coherence of emergency responses.
However, only the CFE has a formal relationship with the IHRs and its core capacities, only the CFE is universal in coverage of all countries, comprehensive in addressing the full spectrum of cross border public health risks enumerated in the IHRs, including radiation, chemical and other risks, and only the CFE is managed under intergovernmental funding rules and institutional frameworks, with explicit support for system functions such as health information, planning and health worker mobilization.
It is not clear why the PEF seemingly circumnavigates the institutional and intergovernmental mechanisms of the IHRs. Two explanations stand out: Firstly, the PEF is a product of G7 processes, which similar to the establishment of the Global Fund in 2000, have supported funds that are independent of WHO governance processes. Secondly the PEF seeks to create an insurance market that will incentivize certain health system conditions to access the funds. The funding mechanism involves reinsurance and proceeds of ‘catastrophe bonds’ (capital-at-risk notes) issued by the International Bank for Reconstruction and Development purchased by insurance-linked securities and catastrophe bond investors, with development partners and international agencies covering the cost of the premiums and bond coupons. As a new financing mechanism drawing in development funds the trigger criteria for funding and reforms to be incentivized, as yet unstated, need to be carefully reviewed.
G7 countries are presently encouraging G20 countries to financially back the PEF and its insurance agenda this September in Hangzhou. But what of the CFE? It covers a wider spectrum of public health risks, fits most comfortably within the IHR framework and aligns more clearly with efforts to strengthen core IHR capacities and national response plans. How far will the PEF, despite its role to fund the ‘deeper’ response, strengthen the health systems to be more effective in detecting and responding to emergencies, and even more importantly in preventing them. How will the PEF explicitly strengthen capacities for the IHR, provide direct funding support for system capacities and align with existing national plans and intergovernmental frameworks? How far will both funds strengthen the community literacy, networks and capacities and the primary health care systems that are needed for effective prevention, preparedness and containment, or link with the rising mobilization of resources and personnel from within Africa, noting the significant role these played in the last major Ebola epidemic.
The addition of new global resources for managing public health are welcome. However, global measures need to reach beyond measures for surveillance and containment if they are to stretch beyond a remedial securitization of global health. Securing health calls for local, national and regional capacities for and global investment in systems that can identify, prepare for, prevent and manage significant public health risks, and for a re-invigorated public health authority and capability to mobilise attention to those communities and action on those key determinants of health that are often ignored, until the onset of such mass scale events.
Please see the full brief at http://tinyurl.com/jsgsgnh and send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.