The African Union (AU) African Mining Vision envisages a mining sector on the continent that contributes to the continent’s development, not only in terms of its economic growth, but also through mining processes that are “safe, healthy, gender and ethnically inclusive, environmentally friendly, socially responsible and appreciated by surrounding communities.” An increasing number of multinational companies from all regions globally are extracting mineral resources in east and southern Africa (ESA), but how far are these extractive industries (EIs) delivering on this vision of flourishing, healthy communities in their vicinity?
Notwithstanding the price fluctuations in the sector, EI exports have yielded significant returns, with oil, gas and mineral exports from the continent estimated in 2009 to be worth roughly five times the value of international aid inflows. They have, however, been associated with rapid but unsustainable growth and high levels of inequality, especially where they have limited forward or backward linkages into the national economy, and where they do not adequately invest in or protect the social and economic development of local communities.
A demand for socially responsible EI practice has already led to over 25 international standards, codes, performance standards and guidance documents from United Nations (UN) institutions, international agencies, including the International Finance Corporation, civil society and from business itself. The standards relate to business and human rights, to labour, health, environmental and social obligations, to socially responsible investment and practice and to transparency in governance of the sector. The international standards relating to health in EIs are detailed in a recent EQUINET report (Discussion paper 108) and policy brief available on the EQUINET website. As a condition for granting mining or prospecting rights, they cover duties to assess and prevent health, social and environmental risks and to ensure fair process and health, social and livelihood protections for communities that are relocated due to mining. During the mining processes, they include prevention of harm to the health of workers and surrounding communities, making fair fiscal contributions to health care and ensuring fair benefit and transparency in their operations. They also include post closure obligations in relation to any longer term health and social harm.
Recognising regional need and benefits, African states have resolved to harmonise standards and laws for the sector at sub-regional level, in west Africa, through ECOWAS, and southern Africa, through SADC. A number of ESA countries, such as South Africa, Mozambique, Zambia and Kenya, have also set in place initiatives to bring local standards and practice for EIs in line with global best practices.
The rapid expansion of the sector into new areas, the legislative gaps in countries with newer sectors, the differences in power between multinational actors and under-resourced states and communities, amongst other factors, have led to various areas of harm and conflict that call for such rights and duties to be made clear. Notwithstanding the employment, income and fiscal contributions they bring, EIs have been reported to bring health risks for workers and surrounding communities. These risks arise from hazardous working conditions and degraded or polluted environments, from the displacement of local people, several thousand in some cases, without adequate replacement of living conditions, resources, services and livelihoods, and from generous tax exemptions that limit EI contributions to social services. The EQUINET discussion paper summarises some of this published evidence. It also reports evidence of discontent or protest from local communities, who feel excluded from decisions and frustrated by grievance handling mechanisms. Indeed, the African Commission on Human and People’s Rights has established a Working Group on Extractive Industries, Environment and Human Rights Violations in Africa to examine and propose measures to prevent and provide reparation for such negative impacts, while civil society campaigns, like ‘Publish what you pay’ have sought greater transparency in EI operations. These conditions suggest that it would be timely to give more attention to realising the intentions to harmonise regional standards on EIs and to ensure that health is included within this.
An analysis of the laws on EIs and health in the ESA region in Discussion paper 108 indicates some general findings across the region: There is generally protection in current ESA laws of occupational health for workers employed by EIs, of duties to the environment, and of fiscal and post mine closure duties. There is, however, weaker protection in current ESA laws of the health and social wellbeing of communities displaced by mines, of families living around mines and of health duties post-closure, such as in relation to chronic diseases. In the laws analysed, fewer countries included duties on forward and backward links with local sectors, communities and services.
It was however a positive finding that where there are gaps in the law, there are also clauses in the law of one or more individual ESA countries that are aligned to international standards that may guide what may be included in the laws of others.
Such ‘good practice’ clauses could inform the content of harmonised regional standards. Their origin from ESA countries of different size and income also suggests that it would be feasible to apply them more widely across the region. The EQUINET discussion paper and policy brief at http://tinyurl.com/gr6yyza present suggested clauses for regional guidance on health in EIs (and the laws they derive from), in line with international and continental standards.
Implementing the vision of a socially responsible, healthy and inclusive mining sector clearly calls for more than law. In relation to health, there is evidence of the need for strengthened enforcement and practice, such as to revisit over-generous fiscal exemptions, to integrate health more centrally in tools for and approvals from impact assessment, to strengthen public sector co-ordination and capacities to monitor and prevent health risks, and to provide public information and meaningful mechanisms for community voice and agency in measures to protect their health. However, having harmonised regional standards may help to raise awareness and understanding amongst the different public sectors, private actors and communities of their roles, rights and duties in relation to health in EIs, and give support to the social and institutional processes and measures needed to promote healthy practice.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. You can read further evidence in EQUINET Discussion paper 108 Corporate responsibility for health in the extractive sector in East and Southern Africa at http://tinyurl.com/zm7afbk and Policy brief 42 at http://tinyurl.com/gr6yyza
Editorial
While economics is not World Health Organisation (WHO)’s core expertise, the impact of poverty and income maldistribution on population health clearly justifies the organisation working with other agencies within or outside the UN system to focus much more attention on questions of disparity. Things being the way they are right now, it is thus difficult to make sense of the shrinking scope of WHO’s role in global health governance.
One factor could be the wide and ambiguous use of slogans about ‘stakeholders’ and the fait-accompli of ‘multi-stakeholder platforms’ and ‘public-private partnerships’. The term ‘stakeholders’, bundling together public interest civil society organizations with international NGOs, private sector enterprises and philanthropies under the term ‘non-state actors’, appears to endow all of these private ‘stakeholders’ with the right to a ‘seat at the table’, with only the tobacco and arms industries declared off limits. Such ‘sitting rights’ jeopardize people’s human rights as enshrined in various instruments, including the right to health.
‘Donor’ countries (the US in particular) continue to push the WHO towards working with industry through such ‘multi‐stakeholder partnerships’, rather than giving it the chance to implement regulatory and fiscal strategies that could make a real difference. Bilateral funders and big philanthropies demand that WHO provide data according to their particular interests, beyond the compilation of country-reported statistics. They focus on providing technical interventions, and introduce a bias away from interventions on the right to health or social determinants.
This treatment of WHO is part of a wider onslaught on the UN system generally. The whole UN system is held hostage to short-term, unpredictable, funding. The freezing and periodic withholding of countries’ assessed contributions and tightly earmarked voluntary contributions creates dependence on private philanthropy. It applies a sustained pressure to adopt the multi‐stakeholder partnership model of program design and implementation that gives global corporations an undeserved ‘seat at the table’.
If the WHO reform is to realise the vision of its Constitution, it will require a global mobilization around the democratization of global health governance, within the wider global mobilization for human rights and equity in global economic and political governance. Globalization has created new collective health needs that cross old spatial, temporal and political boundaries. In response, we need global health governance institutions that represent the many, not the few; and that are sufficiently agile to act effectively in a fast-paced world and capable of bringing together the best ideas and boundary-shattering knowledge available.
Yet the WHO seems strangely detached from the broader political turmoil and changes unfolding around the world. WHO may point to its 193 member states and claim to be universally representative, but it is far from politically inclusive. Like the alienation felt by millions around the world, many members of the global health community have turned elsewhere to move issues forward and get things done. We thus see a steady decline of WHO, clinging to obsolete political institutions and bureaucratic models, yet kept alive by member states as an essential public institution. This decline is not because WHO is not needed, but because it has not adapted to and is not publicly financed for a changing world. It is not the WHO that we need today.
Political innovation must thus become a fundamental part of the process of WHO reform. We need to think: How might virtual and interactive town halls improve communication between global health policy-makers and the constituencies they serve? How might the closed world of global policy-making be opened up and strengthened through virtual public consultations, feedback and monitoring systems? How might the concept of global citizenship become institutionalized within our global health institutions, especially WHO?
We also need to challenge the re-legitimation of the ‘free trade agenda’ in health that has strengthened intellectual property (patent) protection regimes despite their well-known negative consequences for public health. We need to question the mantra of the ‘realistic costing of outputs’ that prescribe programme implementation models where programmes comprise a set of planned outputs from prescribed activities with known costs. This approach leaves little, if any, room for flexibly managing complexity in planning and implementing systems. It makes health actors, including WHO, wary of the longer term implementation processes needed in health systems, partly because they disrupt ‘production schedules’ demanded by funders.
These models also contradict our understanding that health care is just one of the factors influencing health and can only be considered part of the solution. As the 2008 WHO Commission on the Social Determinants of Health stated, “Social injustice is killing people on a grand scale and constitutes a greater threat to public health than a lack of doctors, medicines or health care services”. The conditions under which people live and work, their socioeconomic development, education, housing and other conditions have a major impact on health behaviours and outcomes. A robust analysis of the root causes of the preventable global disease burden is thus essential to understand which ‘stakeholders’, or duty bearers, are part of the problem and which are part of the solution. Consistent with human rights principles and the findings of the 2008 Commission report, such analysis enables us to identify which can be trusted to have a seat at the policy table.
This influence of social injustice on health and the analysis of root causes of preventable disease appears most obscured in the influence of external funders over health ministries in the global south. It keeps them focused slogans such as ‘development assistance’ and ‘public-private partnerships’ that in their design serve the agenda of the richest 1%. In so doing it sustains a world view of the beneficence of private enterprise and that accepts as natural and unchanging conditions of global inequality and environmental degradation.
This editorial draws on points raised in the work of PHM and other colleagues, including K Detavernier, M Kok, K Lee, D Legge and E Pisani. For further information visit the PHM website at http://www.phmovement.org/ . Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
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.
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.