Health systems throughout sub-Saharan Africa have been in a state of decline since the debt crisis of the 1980s and the subsequent effects of structural adjustment, chronic public under-investment and health sector reform. In this context, with the fragile health systems resulting, the proliferation of global health actors and initiatives (GHIs), that we have witnessed over the past decade, presents a risky strategy for catalyzing sustained and equitable improvements in health.
Vertical, selective GHIs could either establish a ‘virtuous cycle’ of positive synergies with health systems strengthening, or enter a ‘vicious cycle’, where they perpetuate or accentuate existing health system deficiencies, creating a greater dependence on vertical programmes for the rapid delivery of life-saving interventions. The publication in the Lancet this year (2009; (Vol 373 pages 2137 – 2169) of a review of the impact of GHIs on health systems by the World Health Organization’s Maximizing Positive Synergies (WHO MPS) initiative has therefore attracted attention and controversy.
The review noted the positive association between GHIs and improved outcomes, particularly in terms of HIV/AIDS, TB, Malaria and vaccine-preventable child deaths. However, it did not adequately answer the question of whether vertical and selective disease-based GHIs have had a positive or negative effect on health systems more broadly, nor whether they could have been better designed or implemented to optimize across-the-board health improvements.
This is because the review faced many methodological limitations. The first was a lack of good quality studies and evidence on the issue. This is a consequence of the minimal resources invested in establishing the monitoring systems needed to assess the effects of GHIs on health systems. Further, there is limited appreciation in the health community of the kinds of methods needed to study complex and large socially-mediated systems.
A second limitation was the lack of quality control of the data used by the WHO MPS collaborative group. Good, moderate and poor quality data appear to have been treated equally, including potentially biased information provided by GHIs themselves. On top of this, most members of the writing group had a direct conflict of interest with the subject matter, so the conclusions and recommendations read as a result of political negotiation, rather than an independent synthesis of the available evidence.
As a third limitation, the review only examined four actors: the Global Fund to Fight Against AIDS, TB and Malaria, GAVI, the World Bank’s Multi-Country AIDS Programme (MAP), and the US President’s Emergency Plan for AIDS Relief (PEPFAR). It therefore didn’t capture the effects of more than a hundred other global health actors and initiatives, despite the fact that one of the biggest problems for countries is the cumulative effect of numerous GHIs.
Finally, the conceptual framework of the review was designed to examine the effect of GHIs on health systems, but the conclusions of the review muddled the assessment of the impact of GHIs on health systems with impacts on health outcomes and outputs. Clearly, the Global Fund, GAVI, PEPFAR and MAP have had a positive impact on health outputs and outcomes. It would have been hard to avoid doing so considering the billions of dollars spent by these four GHIs, and the general four-fold increase in development assistance witnessed since 1990, described by Ravishankar and others in the same issue of the Lancet (2009, Vol 373, pages 2113 – 2124).
The question of whether vertical and selective disease and vaccine-based GHIs have had a positive or negative effect on health systems is perhaps academic. What is more important is that GHIs are henceforth able to maximize their positive synergies with broader health systems needs.
In this regard, in spite of its limitations, the WHO MPS initiative has been an important and valuable exercise. It has drawn attention to the need for further monitoring and assessment of the relationship between GHIs and health systems strengthening. This should include paying greater attention to the global health architecture as a whole, and efforts such as the International Health Partnership launched by some bilateral and multilateral health funding agencies to reduce the wasteful fragmentation, duplication, competition and conflicts amongst different actors and initiatives. Secondly, it has highlighted the need for GHIs to ensure that external development assistance for health is invested in a more coherent, equitable and comprehensive manner.
However, for GHIs, health sector and civil society actors, including those in east and southern Africa, the challenge is in knowing how to move forward. For example, if GHIs are to pay more attention to health systems strengthening, who will coordinate this? As a follow-up to the work and deliberations of the High Level Taskforce on Innovative Financing for Health, the World Bank, the Global Fund and GAVI are now discussing how they can create a shared platform for financing and supporting health systems strengthening.
But what will this mean? Will the World Bank take the lead in defining the policy agenda, and if so, will it promote a conservative and neoliberal policy agenda? Or will an expanded and modified version of the Global Fund and GAVI take charge? What of the role of the WHO, the International Health Partnership and countries themselves? With a global health architecture that remains over-populated, disorganized and competitive, there is a danger that countries may experience a series of uncoordinated and selective health systems strengthening initiatives. Agreeing to the fact that GHIs must pay more attention to health systems strengthening is only the start of a process.
While there is welcome attention to how official aid can be better managed to support health systems strengthening, there has been little discussion about how private finance will be harnessed to support equitable health systems development. The Gates Foundation, working with the International Finance Corporation, the African Development Bank and a German development finance institution have recently created a new private equity fund that will invest in small- and medium-sized private health companies in sub-Saharan Africa. Such an initiative runs contrary to the evidence that expanding commercialized health care will be harmful to equity and health systems strengthening.
Furthermore, the attention placed on health systems strengthening does nothing to plug the existing resource gaps of many countries. How do we campaign for a comprehensive Primary Health Care agenda when there is are still too few health workers, or inadequate funds for medicines? With the economic recession and signs of some donors cutting back on development aid, the competition for scarce resources may get worse.
This situation calls for the global health community to develop a set of positions and campaign on three distinct, but inter-related issues: The first is the architecture of development assistance for health, to work towards a coherent system for funding equitable health systems development and on-going improvements in access to effective health care. The second is that of health systems policy itself, particularly in relation to the appropriateness and fairness of different health financing strategies, as well as the role of markets and the private sector. Finally, the third, resonating with the call to meet the full content of the 2001 Abuja commitment at national and international level, is that of expanding both domestic and international resources for health in Africa.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For papers on health systems (fair financing, health worker retention) effects of GHIs visit the EQUINET website and the Economic Governance for Health network website at www.eg4health.org
Editorial
A concern for health equity is not new in global health. Equity was central to the World Health Organization (WHO) 1946 constitution, and to the work that culminated in the Declaration of Alma Ata in 1978. Despite this, the health agenda has mostly focused on securing progress on priority challenges. This has contributed to substantial advances in average life expectancy in most parts of the world. Yet the global health community has often seemed unable to counter the widening inequities brought by uneven progress.
The recently completed World Health Assembly has the potential to be a turning point in addressing health inequities. Two resolutions were passed, fundamentally grounded in a concern for equity and social justice - one on 'primary health care, including health systems strengthening' (available at http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R12-en.pdf) , and another on 'reducing health inequities through action on the social determinants of health' (available at http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R14-en.pdf).
Around 50 countries spoke in strong support of the resolution on primary health care, and almost 40 countries intervened in support of acting on the social determinants. There was a constructive consensus in favour of both texts, with discussion centred on the strength and tone of the resolutions. Throughout the Assembly, multiple references were made to the importance of social justice and fairness in the plenary and across the agenda items.
The events that sparked these resolutions from WHO - the convening of the Commission on Social Determinants of Health in 2005 and the groundswell of support from countries for the renewal of primary health care, leading to the 2008 World Health Report - reflect an increasing understanding and intolerance for widening health inequities in the modern era. There is increasing support for the idea that health equity should be seen as a key development goal and as a measure of the progress of the global community.
Such consensual support would have been unthinkable until relatively recently and has strongly built on the explosion in knowledge of health inequities, both within and between countries, in the last twenty years. The broad range of civil society and academia have made important contributions in terms of advocacy, the generation of knowledge and the demonstration of innovative strategies to address the social determinants. The Commission's damning diagnosis - 'social injustice is killing people on a grand scale' - owes much to this work.
So what now? The twin resolutions call for a broad range of actions based on the values of Alma Ata from the international community, member states and the WHO secretariat. The Assembly's understanding of both primary health care and addressing the social determinants of health emphasises the key role of multi-sectoral action, beyond the necessary but insufficient functioning of health systems, if health inequities are to be reduced. Achieving such action issues a difficult challenge to health leaders at global, national and local levels.
Anyone who believes in health equity should be encouraged by these developments. Of course, the resolutions by themselves will not achieve health for all. But they provide a powerful endorsement of the report of the Commission and of the need for renewal of primary health care. The challenge in implementing these resolutions, to contribute towards improved health equity, is one to which civil society can continue to make a vital and essential contribution.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit http://www.who.int/topics/primary_health_care/en/ for PHC and http://www.who.int/social_determinants/en/index.html for SDH.
For the health sector, finding new ways of thinking about strategies to address health inequities is critical if achievement of the Millennium Development Goals is to be remotely possible. Over the past few years, the notion that a Framework Convention on Global Health could help to address some of the most fundamental inequities in health at global level, has been gaining ground. First proposed by Larry Gostin, a leading scholar in the field of health and human rights in 2007, the idea that a new model of global health governance could succeed where ethical exhortations and/or appeals to international legal norms have failed, is very attractive. Indeed, it is not only in health that increasing attention is being turned to these 'Framework Conventions'. The Internet Governance Project (IGP), an alliance of academics that focuses on Internet policy and how information and communication technology affects the interests of civil society, also proposed in 2004 the idea of a Framework Convention as an institutional option for internet governance globally.
Is a Framework Convention on Global Health the missing spark in our efforts to address the yawning and seemingly growing health inequalities around the world? Is it possible that such a Framework Convention will provide answers hitherto lacking in the debates and strategies to strengthen equitable people-oriented health systems? To do so, it is first necessary to understand what is meant by a Framework Convention.
To date, there are approximately four existing framework conventions, two better known conventions under the UN machinery, namely, the UN Framework Convention on Climate Change and the WHO Framework Convention on Tobacco Control, and a convention on the Protection of the Ozone Layer, as well as a Council of Europe Framework Convention for the Protection of National Minorities. A framework convention provides a mechanism for international consensus that avoids focus on details that may be contentious and contested and which may bog down negotiations. It rather establishes principles and norms for international action, setting up a procedure for later negotiation of more detailed arrangements. This was evident in the early agreements needed to set up the Global Convention on Climate Change, which is now overseen by the Conference of States Parties to the convention, with subsequent rounds to establish targets globally.
Gostin argued in 2008 that a Framework Convention on Global Health could significantly improve global health governance and would, amongst other goals, “...commit States to a set of targets, both economic and logistic, ...set achievable goals for global health spending as a proportion of Gross National Product,...build sustainable health systems; and create incentives for scientific innovation for affordable vaccines and essential medicines.” However, central to the purported benefits of the Framework Convention is the notion that “governments should care about serious health threats outside their borders” in that such threats pose direct health, economic and security risks.
Is this likely to offer us more leverage than other forms of policy engagement, particularly those using existing international human rights mechanisms related to the right to health, such as, for example, holding governments accountable for core obligations regarding the right to health? The experience in relation to other Framework Agreements is perhaps salutary. Firstly, negotiations to provide teeth to the Framework Convention on Climate Change through the Kyoto protocol remain locked in dispute, despite the agreement on the basic principles in the Framework Convention. Indeed, the huge quantum of effort invested in lobbying, advocacy, research and policy work since adoption of the Convention to support stricter controls of greenhouse gas emissions has remarkably little to show for the years of investment. Secondly, the ability to strike a deal within the UN system relies on careful diplomacy usually guided by the lowest common denominator acceptable to a wide range of national players and networks, usually dominated by rich and powerful nations. The likelihood of the outcome of such a set of circumstances generating a Framework Convention that fundamentally challenges global power relations therefore seems low. Thirdly, whereas the Climate Change and Tobacco Control Framework Conventions challenged interests that were fundamentally corporate-driven, a Framework Convention on Global Health would be essentially directed at nation states. Such states may either be those actors who need to be convinced that their own interests lie in improving the health of populations outside their border, or states whose weak economies and subservient trade relationships undermine the extent of their sovereignty and ability to regulate independently to realise the right to health of their own peoples. In the latter case, the value of such a Framework Convention, which is likely to be replete with general provisions and non-binding targets, appears singularly weak.
However, the most important consideration is really the extent to which a Framework Convention on Global Health is able to strengthen opportunities for civil society engagement and building agency on the part of those most adversely affected by global health inequalities. Inasmuch as Gostin suggests that a Framework Convention on Global Health “would stimulate creative public/private partnerships and actively engage civil society stakeholders,” it is the extent to which such engagement offers meaningful mechanisms for preferentially strengthening the collective agency of the most marginalised groups, within and between countries that will be the test of whether the Framework Convention on Global Health really promotes equity and the right to health, or whether, like much other international policy-making, it proves a nice-sounding but ineffectual sump into which health equity activists invest endless amounts of energy, with not much to show for it.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit the EQUINET website- www.equinetafrica.org.
The way we finance health and health care makes a significant difference to the coverage and accessibility of our health care systems. It has thus been an issue capturing increasing attention from the international community, including from United Nations Children’s Fund (UNICEF), the European Union, the High Level Taskforce on International Innovative Financing for Health Systems who have all held consultations on this in the first quarter of 2009. The UNICEF meeting reviewed the evidence base on the imposition of a ‘price’ for use of health care services - user fees – and considered options and support for feasible health financing mechanisms. UNICEF itself was questioning the necessity and value of user fees in resource constrained settings, particularly given the opportunity costs, transaction costs and barriers posed to utilisation. The EU meeting sought input to its policy on health care financing for developing countries. The meeting reviewed a draft policy that was oriented towards support for general tax financing for public health care systems augmented by Social Health Insurance as a feasible next best alternative modality for long term sustainable health care financing.
There seems to be wide agreement on the question of maintaining tax revenue as the core of health financing, and on the introduction of SHI as the major source of additional domestic funds for health. The debates are more about how to implement these mechanisms in low resource settings.
The simplest mechanism is that of financing through tax revenue. There is evidence that systems that are more dependant on tax revenue have less inequality (measured through the Gini co-efficient) with regard to resource distribution and therefore a higher level of equity within the system. Recognition was made of the need to have with this a systematic resource allocation mechanism as well as a package of care that general tax revenue will purchase, to support a rationale priority setting process and to ensure fairness. It was noted that tax funded systems are more suited to achieving this. Yet increasing these tax revenues cannot simply depend on overall economic growth, as there appears to be little evidence so far that economic growth has translated into immediate gains for resourcing the health sector. There is thus need for evidence and dialogue on the options for strengthening tax revenue sources, including the role of sector wide approaches, of budget support to the health sector and of overall budget support.
Although Social Health Insurance (SHI) is often raised as an equitable option for financing universal coverage, there is limited or zero revenue generation from social security schemes in the African region. In countries such as Ghana, Tanzania and Rwanda, SHI schemes are substantially financed through taxation or support from external resources (such as the Global Fund). They therefore appear to be more hybrid tax based systems with additional transaction costs that may be generating inefficiencies in resource use and allocation. In the same countries coverage of social and private health insurance schemes is extremely limited, raising serious concerns about equity in revenue generation and in service provision and consumption. In other countries, such as South Africa, where private health insurance exists along side some social security mechanisms, the private insurance is limited in terms of coverage and yet consumes a relatively high share of total health expenditures – demonstrating again potential inefficiencies and inequality. We thus need to further analyse and evaluate equity issues in the implementation of social health insurance to inform whether and how to implement these schemes.
So there are clear areas for further work to advance progressive, equitable health financing in Africa.
It is therefore worrying that we are still locked into endless debates on user fees. These debates generate diverse opinion. In health systems in which user fees have been removed at a broad level (South Africa, Uganda, Zambia) as well as those where the user fee exemptions have been targeted at specific vulnerable groups such as child and pregnant women (in support of child, maternal and reproductive health) the evidence of increased utilisation is clear. The evidence also shows that the transaction costs of user fee administration negates any positive contribution of user fees themselves in additional revenue or value terms. The contribution of user fees to health revenues remains low. Some institutions and country representatives strongly support community financing, such as through mutual funds, as well as user fees in public sector facilities. Yet some institutions and country representatives strongly support community financing, such as through mutual funds, and user fees in public sector facilities.
This draws attention from more substantial issues, such as the fact that government commitments to improved health sector funding remains low. Countries have been slow to increase their health sector budgets, let alone reach the 15% of government budget for health set in the 2001 Abuja heads of state commitment and the Southern African Development Community commitments for the Maputo targets. Making these promised increases to the health sector budget would exceed any resources that could be raised through user fees.
One problem is that the debate on health financing is fed by a mix of evidence, values and anecdotes. Relevant evidence is not always available for health sector financing decisions, and ethical and value considerations affect the design of and preferences in health care financing. The case for user fees (alongside community financing initiatives) is often made without evidence and based on institutional interests, rather than on the basis of health system development and improvement of population health. Disappointingly at the UNICEF meeting earlier this year, no consensus was reached and further consultative processes were proposed.
Given the weight of evidence showing the negative balance in the impact of user fees on health systems and population health, I would argue that there is, however, sufficient evidence to put this issue to rest. Rather than continuing the debate on user fees, we should shift to debates on more substantive approaches to resource mobilisation, including:
* How to achieve increased health sector budgets
* How to strengthen tax revenue sources and funding for sector wide and budget support
* How to assess the equity issues in the implementation of social health insurance to inform policy decisions whether and how to introduce SHI
* How to promote accountability and transparency in the way health systems use their funds
Meanwhile as we need to move on in Africa to focus debates and build coherence on these wider financing policies, we also note the proliferation of different donor meetings on this issue. The situation is calling for a harmonised approach among donors and international agencies, if not in terms of harmonised funding, at least in terms of a common position that external funders can adopt on financing options that strengthen the health system. This would be in line with the Paris Declaration on Aid Effectiveness and Harmonisation, so perhaps the World Health Organisation should take some leadership in co-ordinating this?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on health financing issues please visit the EQUINET website- www.equinetafrica.org.
She has walked for 10 kilometers now. She can hear the child on her back, the harsh crying of an hour ago fading to exhausted whimpering. Her local clinic has not had a qualified nurse for some months, so she is walking the 20 kilometers to the nearest district hospital, hoping that by the time she gets there, the child will not have succumbed to the fever that she could not dampen with home treatment.
For this woman, as for many others in the region, the long walk to care is a consequence of inadequate numbers of critical and skilled health personnel, high levels of external and internal migration and poor distribution of staff in areas of high health need. Even where health workers are in place there is report of low staff morale. In 2005 health ministers in the Southern African Development Community (SADC) identified the non availability of skilled health professionals as a key factor undermining achievement of health Millennium Development Goals.
With the reality of poor communities bearing the brunt of a yawning gap between need and supply of health workers, health ministers in the East, Central and Southern African Health Community (ECSA-HC) resolved in 2007 to have in place by 2008 national strategies to recruit, motivate and retain health workers, using both financial and non-financial incentives. Since then both ECSA-HC and SADC have developed strategies for responding to the health worker crisis. A number of countries in the region have also developed and began to implement strategies, adding new measures to existing incentives. In March 2009, the ECSA-HC Ministers met again in Swaziland to review how far these commitments had been addressed.
Towards this, in February 2009, EQUINET and the ECSA-HC held a regional meeting, hosted by University of Namibia, to review evidence gathered from countries on how well incentives for health worker retention were working. These incentives are not always cash payments. The studies showed that dealing with poor working conditions, poor communication, unsupportive management and inadequate recognition is also important to attract health workers and to motivate them to stay.
As Hon Petrina Haingura, Deputy Minister of Health and Social Services in Namibia noted in opening the meeting, “We all know and understand that our governments are not in positions to provide huge salaries to our health workers but much more can be done within working environments. Health workers frequently complain and express dissatisfaction with management, poor leadership, lack of support and recognition; supervisors do not even know the word ‘thank you’ for good performance.”
The studies carried out in Kenya, Tanzania, Uganda, Swaziland and Zimbabwe gave evidence that the incentives most valued by workers were training and support for their career paths; improvements in services and working environments; housing mortgages / loans; recognition and reward for performance and accessible health care. Delegates at the meeting suggested that these be planned for and costed as a core set of strategies in health worker retention strategies in all countries in the region, even while further locally relevant strategies are considered.
Some of these strategies are being applied, but on a targeted or piecemeal basis, for selected health workers, or in specific programmes. Leaving it to individual facilities to set and apply these incentives seemed to lead to a vicious cycle of poorly resourced facilities, with weak management, having the least ability to attract staff, despite greater need. The evidence suggested that retention packages should preferably be health sector wide, with career path and training support based on analysis of responsibilities and tasks.
Prof Yoswa Dambisya of University of Limpopo summarised the learning from the region: “Non-financial incentives have been successful when they have been deliberately planned, with consultation across the board, as in Uganda; when they meet immediate needs through top-ups and allowances as in Malawi; when a combination of financial and non-financial incentives is used as in Zambia and Uganda; when incentives are used to attract health workers from private to public sector as in Uganda; when incentive programmes are integrated with SWAP or budgets as in Uganda and Malawi; and when national and donor funding were mobilised for an emergency human resource programmes in Malawi and Zambia”.
Moving from cash top-ups for selected personnel as an emergency response, to supporting career paths, health services and long term housing as an investment for retention moves us, therefore, from the realm of quick fixes to longer term change. It calls for long term planning of needs and services, and the information to support this. It demands management capacities, tools and guidelines, delivered through procedures and processes that build trust and participation. These features are often under-developed in health systems in the region, yet without them, even the best designed incentives remain largely on paper. Indeed one of the findings of the studies was that while many of the countries had made progress in setting policy measures for dealing with incentives for retention, delivery on the ground was still limited, in part due to gaps in these capacities. One sign of weak support for these capacities is the ironic exclusion from incentives schemes, training and professional exchanges of the very personnel who manage human resources for health.
These deeper, system wide changes are not just good for health worker retention, but for the quality and performance of services as a whole. But they do demand more than short term, ad hoc injections of project funds. One requirement is that governments in the region should increase the budgets for health to meet the Abuja commitment of 15% government spending on health. Analysis of experience with international and global funding suggests also that these funds are best pooled into sector wide funds, if they are to support system wide incentive schemes for health workers, with plans for their use harmonized with national plans.
This raises issues of sustainability and of shared international and national responsibility that need to be addressed. When a draft code of practice on the International Recruitment of health personnel was tabled at the January World Health Organisation Executive Board, however, the debate reported on it suggested that there is some way to go in reaching a shared understanding of how international responsibilities should be managed. In 2007, African countries, many of whom are source countries for migrating health workers, had requested a code that was more than voluntary. The WHO secretariat chose instead to stick to international practice of a non-binding agreement and presented a voluntary draft code, with some high income countries receiving health workers echoing this choice. African countries at the 2008 Executive Board thus again raised the need for an enforceable code, for the rights of communities in source countries to be considered and for a compensation mechanism to address losses. So the code was referred for more consultation.
As we follow the woman and her baby into the district hospital from the long walk, her hope is focused on the fact that she has come in time to save her baby. Our hope is that she will not need to make this walk again, and that African health systems provide the environments, task alignment, career paths and long term security to ensure that their health workers are found in the services where they are needed, backed by the wider economic improvements and political stability needed to keep them there.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on the health worker retention issues please visit the EQUINET website- www.equinetafrica.org. Information on the ECSA-HC resolutions and programme on health workers can be found at http://www.ecsahc.org/
It is increasingly clear that without accessible, equitable, quality health services we will continue to fall short on delivering on the health Millennium Development Goals or commitments made on access to treatment for AIDS and other major diseases. So the negotiations currently underway on services under the Economic Partnership Agreements (EPAs) between the European Union (EU) and East and Southern African (ESA) countries are a matter for wide public interest. In August last year we pointed to issues for concern in these negotiations. With the negotiations underway, these issues become an even greater matter for public and parliamentary concern: Will they bring new resources and partnerships in building our health services, or will they blow new holes in already fragile systems?
The EPAs were supposed to have been concluded in 2008, but when none of the African negotiating groups was able to reach a final agreement, most initialled Interim EPAs (IEPAs) with the EU to avoid trade disruption. Many countries, the African Union and the Economic Commission for Africa observed that the EPAs needed to more explicitly put development at the centre, and civil society called for more explicit protection of public health. The IEPA with SADC explicitly protected health by providing, in Article 3, that the application of the agreement should take into account the human, cultural, economic, social, health and environmental interests of the population and of future generations. The IEPA with other ESA countries did not. So countries are going into negotiations on specific trade issues, including trade in services, with different levels of protection in their framework agreement.
ESA countries have already been very cautious about liberalising trade in health services, given the need for public sector health services to be delivered outside the market to populations living below the poverty line and the need for additional government measures and subsidies to staff, and provide these services. Few ESA countries have thus committed their health services to liberalisation in the World Trade Organisation (WTO) GATS agreement, preferring to determine the pace and nature of any market opening within reversible domestic policies. In ESA, only Malawi and Zambia have made GATS level commitments in the health sector.
Meanwhile the EPA services negotiations are going on largely below the radar. While the umbrella Cotonou Agreement of June 2000 explicitly commits EU and ACP states to the development of the social sector, there are also strong signals that the liberalisation of all services will be actively promoted.
So it depends largely on what the negotiators agree in the coming months. ESA countries have no obligation to trade in health services and may elect, without prejudice, to explicitly exclude trade in health services. Under conditions of unequal access and differentials in coverage, ESA governments may justly feel that they cannot reduce government authorities to regulate providers, to compel cross subsidies, increase risk pools, manage health worker migration and other measures needed to ensure universal health care coverage. Hence the 2006 AU Conference of Ministers of Trade stated: “We shall not make services commitments in the EPAs that go beyond our WTO commitments and we urge our EU partners not to push our countries to do so.”
There are numerous arguments negotiators should be raising for excluding health services from EPA compelled trade liberalisation.
Both ESA and EU countries are signatory to international treaties, conventions and constitutional obligations to health and health care that create obligations to be discharged by the State Parties. Negotiators should be cautious about clauses in the services negotiations appear to undermine these commitments. Using the precautionary principle that applies in public health, those promoting clauses that appear to undermine these commitments should be asked to prove why they do not do so.
As raised in previous debates on trade and health, ESA countries need to protect the flexibilities already won under WTO agreements. the TRIPS agreement allows for government authorities to compulsory licensing and parallel importation. The GATS agreement provides for flexbility for governments to follow “a reasonable time-frame”, to bar foreign services suppliers from operating at the same conditions with local providers where this is necessary to protect health, or to grant more favourable treatment to service suppliers from regional bodies of only developing countries like SADC. ESA negotiators should resist any liberalisation process which forces them to take on obligations or a faster pace of liberalisation than that which obtains currently under the WTO process.
However we could go further. Protecting public health and access to health services demands more than a defensive posture in the negotiations. ESA countries could use the services negotiations to more explicitly protect public health and recognize state obligations to protect universal and equitable access to health services. For example, negotiators could include clauses that
 Recognize the priority for protection of public health as a guiding principle, as provided for in the EU-SADC IEPA.
 Commit parties to allowing government authorities and availing specific resources to the public health sectors of the ESA countries as part of the development dimension of the EPA.
 Commit the parties as in Article 25 of the Cotonou Agreement to make available adequate funds for improving health systems and primary health care, including for regulating the operations of the private health sector.
 Commit the parties to co-operation on ensuring ethical practice on the migration of health workers, including in terms of making technical and resource investments to address the costs to ESA countries of permanent health worker migration to the EU;
 Commit the parties to provide overseas development aid for health programmes in a manner that integrates with national financing arrangements and that avoid outflows of critical health personnel from public health services, in line with the principles of the Paris Declaration on Aid Effectiveness.
The services negotiations are an opportunity to raise again that the health sector should be part of the development chapter of a comprehensive EPA, as envisaged under article 34 of the Cotonou Agreement, and not simply a matter for market trading. Concluding the services negotiations before this is clarified would seem to be a case of the cart pulling the horse. Even more importantly, the cart should not be pulled in the dead of night. Given the significant ‘life or death’ impact for millions of people in the region of any discussions that affect health services, the negotiators should bring such issues to public and parliamentary forums for debate and feedback, before they conclude.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on the health issues in the EPA negotiations please visit the EQUINET website- www.equinetafrica.org. or SEATINI website (www.seatini.org)
There is no question that a large-scale global expansion of health services is needed to reach the internationally agreed Millennium Development Goals for health. But how this massive scale up is to be achieved is the subject of considerable debate.
What exactly is the best way to reduce the number of women dying in pregnancy and childbirth and the number of children killed everyday by pneumonia and diarrhoea? How can we best ensure that, for those living with HIV and AIDS, anti-retroviral medicines are widely available?
For many international organisations and donors, an expansion of private sector health care delivery is considered the key to scaling up health care systems in poor countries. As a result, a growing number of influential organisations are pushing for increased funding of private sector health care, fostering the idea that those who can afford it should pay for their own private health care, and that governments should contract private providers to serve those who cannot.
The World Bank is one such body, advocating private sector involvement in health care while decrying the failure of public health systems in poor countries.
But are institutions that promote the increased role of the private sector in health using reliable evidence to inform their policy decisions? What does the evidence of other countries tell us; countries that have successfully managed to achieve universal access to health care?
Recent research has found that worldwide, publicly financed and delivered services continue to dominate in higher performing and more redistributive health care systems. Studies suggest that no low or middle-income country in Asia has achieved universal or near-universal access to health care without relying solely or predominantly on tax-funded public delivery.
The country level evidence speaks for itself: in just ten years, Botswana, Sri Lanka, South Korea, Malaysia, Barbados, Costa Rica, Cuba and the India State of Kerala were all able to cut child deaths by between 40 and 70 per cent – thanks to committed action by governments in organising and providing health services.
At the same time, the evidence in favour of private sector solutions is far from strong. On the contrary, there is considerable and increasing evidence that there are serious failings inherent in private provision, which makes it a very risky and costly path to take.
In China the rapid proliferation in number of private health facilities since the 1980s has led to significant declines in productivity, rising prices and reduced utilisation. Lebanon has one of the most privatised health systems in the developing world, it spends more than twice as much as Sri Lanka on health care yet its infant and maternal mortality rates are two and a half and three times higher respectively. And due to wide scale private sector participation in Chile’s health care system it has one of the world’s highest rates of birth by Caesarean section – a more costly and profitable procedure than natural delivery and often unnecessary.
So why do so many influential institutions persist in pushing the role of the private sector?
A major part of the answer lies in a number of common assumptions that are made in favour of for-profit private health-care provision, and which tend to persist unchallenged in the debate.
Firstly many argue that the private sector is already the majority provider in poor countries and it is therefore ‘common sense’ to put it at the heart of scaling up health services. But closer analysis of the data in Africa reveals that nearly 40% of so-called ‘private providers’ are in fact unqualified shopkeepers selling drugs of unknown quality. The same data shows that across 15 sub-Saharan African countries only 3 per cent of the poorest fifth of the population who sought care when sick actually saw a private doctor. And even when the private sector is a significant provider it doesn’t mean overall health care access has improved – over half of the poorest children in Africa have no health care at all. As a Senior Civil Servant from the Ministry of Health in Malawi has stated, ‘When poor people cannot get free services they do not go to private clinics, they go to the bush first and look for herbs.’
Another assumption is that the private sector can provide additional investment to public health systems that need it, but South Africa is one example that demonstrates that to attract private providers to low-income risky health markets significant public subsidy is often required, meaning governments have less money to spend on public health care.
Thirdly it is often claimed that the private sector can achieve better results at lower costs, yet private participation in health care is associated with higher, rather than lower, expenditure. The US commercialised health system costs 15.2 per cent of GDP, while across the border the Canadian national health system costs only 9.7 per cent of GDP. Canada has lower infant and child mortality rates and 46 million Americans have no health care at all.
A fourth claim often made is that the private sector provides superior quality health care, yet the World Bank itself reports that the private sector generally performs worse on technical quality than the public sector. And poor quality in the unregulated informal private health care sector puts millions of lives at risk every day.
A fifth argument made in favour of private sector health care is that it can help reduce inequity and reach the poor, but evidence finds this is not the case. For example market reforms of public health systems in both China and Viet Nam have coincided with a substantial increase in rural people reporting illness but not using any health services.
The last assumption is that the private sector can approve accountability, yet there is no evidence that private health care providers are any more responsive or any less corrupt than the public sector, and when the private sector provides health services on behalf of the state it can make it more difficult for citizens to hold their government to account.
Oxfam’s new briefing paper, ‘Blind Optimism: Challenging the myths about private health care in poor countries,’ released on 11 February, examines these six arguments made in support of the private sector, and looks at the evidence, or lack of it, behind them. It demonstrates that there is an urgent need to reassess the arguments used in favour of scaling up private sector health care provision in poor countries, concluding that prioritising the private sector in health care delivery is extremely unlikely to deliver health for poor people.
Further information on Oxfam and the issues raised in this briefing please visit www.oxfam.org/en/campaigns/health-education/health and email
amarriott@oxfam.org.uk or email the EQUINET secretariat at admin@equinetafrica.org.
The Global Ministerial Forum on Research for Health was held In Bamako, Mali From 17-19 November 2008, significantly the first time in Africa. The 'Bamako Call to Action' declared at the end of the meeting is the outcome of four years of meetings, dialogue and survey of key stakeholders the three days of the conference. As many researchers from the region would not have been present in these processes, this editorial, drawn from various public sources, captures some key features of the Call to Action, and provides a “fly on the wall” snapshot of some of the comments and reflections around it. The call and editorials cited are provided in more detail in this newsletter.
In the opening statement to conference delivered by the WHO Regional Director for Africa, Dr Luis Sambo, WHO Director General Dr Chan underlined the key role of research in keeping health high on the political agenda saying: ”We must have evidence and we need the right kind of evidence … because in most countries, an appeal to health equity will not be sufficient to gain high-level political commitment. It will not be enough to persuade other sectors to take health impacts into account in all policies.”
The Call to Action recognises that “Research and innovation have been and will be increasingly essential to find solutions to health problems, address predictable and unpredictable threats to human security, alleviate poverty, and accelerate development;” As one focus the call proposes establishing November 18 each year as a World Day of Research for Health.
National governments are called on to
• give priority to the development of policies for research and innovation for health, especially related to primary health care, in order to secure ownership and control of their research for health agendas;
• allocate at least 2% of budgets of ministries of health to research;
• improve capacity in institutions, ministries, and throughout systems for the implementation of research policies; and to
• develop, set, and enforce standards, regulations, and best practices for fair, accountable, and transparent research processes.
Further recommendations are made to promote the translation and exchange of knowledge and the build research capacities, including in young researchers.
Institutions at the regional level are encouraged to assist countries through international collaboration, where needed, to build and strengthen research for health capacity and to network researchers to promote the quality, ethics and sustainability of research. Meanwhile all stakeholders are called on to implement the recommendations from the WHO Commission on the Social Determinants of Health, especially those related to health equity, including to promote research on technologies addressing neglected and emerging diseases which disproportionately affect low- and middle-income countries and to ensure civil society and community participation in the entire research process.
To support this, funders and international development agencies are called on to better align and harmonize their funding and programmes to country research and innovation for health plans and strategies, and the global health research architecture and its governance to improve coherence and impact, and to increase efficiencies and equity in research. At least 5% of development assistance funds it was felt should be earmarked for the health sector in research, including for support to knowledge translation and evaluation and for national research institutions, especially in low- and middle-income countries.
From many quarters there has been a positive response to the call as a relevant step forward. The Lancet in its 29 November editorial declares that substantial advances have been made at Bamako on previous discussions, and the journal calls for 2009 to be “the year when the promises of Bamako are acted upon”. According to the Science and Development Network of 20 November 2008, the WHO has said that the Call to Action would be "used as a blueprint for research development approaches, with commitments made to submit the communiqué to the 2009 World Health Assembly and to the UNESCO General Conference. Ok Pannenborg, a senior health advisor at the World Bank, said: "The World Bank Group is extremely happy with the outcome, with its focus on research and innovation and research for health. This call will play a huge role in World Bank workings in the next four years".
The process itself was already reported by some to have had an impact. Aissatou Touré from the Institute Pasteur Dakar in Senegal reported in the conference, for example, that after the Algiers meeting, a decision was made to create a commission for research in the country’s health ministry, incorporating all the different actors involved in research for health to define the national research agenda for years to come.
But others were more critical: On SciDev.Net's blog on the conference one delegate asked ““We’re not saying anything new – what is the progress we’ve made?”
"There are no mechanisms in the call," said Damson Kathyola, director of research at the Malawian Ministry of Health, cited in the Science and Development Network review. "The WHO should [now] create innovation mechanisms for the monitoring and evaluation of the implementation of the strategies in the call. "We know that we need research to improve the health situation of our people in our countries. But there is a disconnect between policy and the implementers. Who's going to implement this?"
The World Bank, WHO, UNESCO, the Council on Health Research for Development (COHRED) and the Global Forum for Health Research have committed to set up a multi-stakeholder governance mechanism for research for health, including civil society, as a platform to take Bamako beyond 2008. The intention is to better network and support existing organisations. Will this work, or will it add another player to the increasingly populated work of initiatives and alliances? And how long will this take to be felt by researchers, health workers and communities in the lowest income countries?
The need to move more rapidly to action was perhaps the most common of the frustrations voiced. On the blog site for “Tropical Diseases Research to foster innovation and knowledge application (TropIKA ) “, Chris Bateman, News Editor of the South African Medical Journal is quoted as saying “Lots of fine words have come out. But, as a wild thought, how would it be if each of the 42 ministers were to tell the conference what they intended to do in the next year in terms of applying research to service delivery and filling the gaps where the needs are? That to me would give the conference real bite.” Dr Lindiwe Makubalo, Ministry of Health, South Africa, added further that “…..it’s really time to look at where the blockages are and try to move them”.
One blockage observed was the relative inequality in power in research– between international funders and countries and between researchers and communities, affecting how time and resources are applied. “Could there have been more representation from the groups we (researchers + communicators about health research) claim to represent? It would have been good to know the views of such groups as well,” asked one delegate.
Unless these blockages to implementing practices that are increasingly called for in documents and conference rooms are honestly identified and addressed, then perhaps BMJ Editor-in-Chief, Fiona Godlee, has basis for her more skeptical fears that in four years time, delegates will be having the same conversations at the next conference. Indeed, perhaps this caution, and concerns that resources now be directed to action, often at more local levels, lay behind the clause in the Bamako call to “evaluate the effectiveness and value of the four-yearly ministerial fora prior to convening a further high-level inter-sectoral forum to discuss global research for health priorities”.
The word “crisis” is becoming more common than water. Multiple crises are converging- economic, climate, energy, food and social. After a long period of speculative financial boom, media in the wealthy countries of North America and Europe are filled with apocalyptic stories of financial crisis, unnerving the people in these countries, who still collectively hold almost 90% of total world wealth. For the half of the world’s adult population who own barely 1% of global wealth, however, the crisis has been going on for decades.
The chronic crisis for this significant majority of the world’s people has been evident in more than a generation of unemployment, landlessness, loss of assets, and deprivation, that has further grown during the financial booms of the last decades. During a period characterised as “economic success” in the highest income countries, malnutrition and food insecurity grew in the poorest countries in Africa, falling international prices reduced returns on production and a food supply chain increasingly controlled by a few transnational corporations was able to further drive down producer prices, especially threatening women smallholder food producers. What was a boom for the import/ export firms, shipping companies, large-scale farm enterprises, financiers and officials who tapped into these commercial and financial circuits, was a deepening economic and social crisis for women and children.
In 2008 attention began to be paid to this food crisis. Like the financial crisis, the food crisis has been growing over decades of aggressive agribusiness. The scale and cost of this liberalized and speculative food production system is now, however, outstripping the possibilities of the usual emergency relief response. The alarming increase in child malnutrition in east and southern Africa post 1990 signals the failure of this model of agriculture for the populations of the region, even while it offered growing profits for largely foreign owned agribusiness.
Repeated outbreaks of disease also signal that people, usually in poor communities, are bearing the brunt of failed policies. Cholera is an avoidable disease that is prevented through safe water and sanitation systems. Zimbabwe has experienced a growing cholera crisis since August. By the first of December the United Nations reported 11,735 confirmed cases of cholera and 484 deaths in Zimbabwe. With the decline in functioning of clean water supplies, people’s mobility and a breakdown of the health sector’s capacity to contain the disease, the cases and fatalities continue to rise. Notwithstanding the economic decline in the country, Zimbabwe has the national wealth to secure basic water supplies and health care. The Zimbabwe Doctors for Human Rights correctly call the failure to do so a violation of human rights.
The globalization of media brings these crises to public attention with increasing speed. But does increasing awareness of such crises bring change?
While change often emerges from crisis, the last three decades suggest that this is not inevitable, particularly if the response fails to challenge the causes of the crisis.
The current financial crisis is possibly the deepest in recent history, but not the first. When the long boom of post-war economic growth ground to a halt in the 1970s, the response to financial decline was an aggressive pursuit of market policies, liberalisation and the opening of countries to transnational corporations. In the 1980s, after a spree of private bank lending, when heavily indebted countries were unable to pay back loans, the International Monetary Fund stepped into the financial crisis to bail out the Northern banks by offering loans to the indebted countries, restructuring their economies towards even greater liberalisation and market reform. These responses have generally served to protect existing wealth and the liberalised and speculative models of economic development that have both deepened inequality and that have been associated with the current crisis.
The response to the current financial crisis has starkly demonstrated the choices made over what merits protection. We have for some time known from United Nations data that saving several million lives annually by bringing safe water and sanitation to all would cost $10 billion a year. This money has never been found. Yet in October 2008, in one week, the US government provided a bail out package to the banks of $250 billion, 25 times this amount.
We are also seeing signs in the response of an efficient global machinery shifting the burdens of the financial and food crisis to the most vulnerable. According to the international non government organisation, GRAIN, players in the finance market - investment, equity and other funds – are turning to land as a strategic investment asset and haven for investment funds, even while the food and fuel crisis are driving acquisition of land for wealthy populations food and fuel needs. The organisation’s website lists over 20 such large investments in African countries alone, and notes an escalating trend. This month the South Korean firm Daewoo unveiled plans to lease one million acres of land (a land area the size of Belgium) in Madagascar, to meet Korean food needs. While loss of faith in markets may be triggering business to seek these deals, and deepening financial insecurity may trigger governments in Africa to make such deals, local farmers and communities are least consulted, and from the evidence of trends to date, are most likely to lose control over land, food and economic security.
So while powerful interests are oddly comfortable today talking about financial, energy, food, climate and other crises, there is silence on the crisis of injustice.
The increasing control of the world’s wealth by a diminishing number of players in the face of wide deprivation of the majority of people is a crisis of injustice. The pursuit of private wealth through appropriating collective natural, social and economic resources in a manner that undermines long term survival is a crisis of injustice. The failure of governments, nationally and globally, to meet basic human rights and needs when the resources are there is a crisis of injustice.
The quest for justice thus becomes a focus of ordinary people’s responses. There are many examples of this. In Zimbabwe this week, the Chitungwisa Residents and Rate Payers Association filed a lawsuit this month against the Zimbabwe National Water Authority for the lack of safe drinking water. While overshadowed by the scale of and necessary emergency responses to the cholera crisis, this action is nevertheless one by affected residents to call to account those in authority for how decisions are being made, how resources are being used and for whom power is being exercised. In this newsletter there is similar report of health activists calling leaders of high income countries to account: “For the developed country governments now to use their dominant position in our current system of global economic governance to deal with their own (largely self-inflicted) problems, while ignoring the much greater and longer-standing grievances of the developing world and the profound and urgent global challenges of ill-health, poverty and climate change, would be a betrayal”. As the legitimacy of current policies and institutions are being fundamentally challenged by the multiplicity of crises, more people are beginning to call it what it is- a crisis of injustice.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.
“We demand the inclusion of the Right to Health in the new Zimbabwe constitution!”
This was the slogan at the Community Working Group on Health 15th national conference. The conference was held in October 2008 in Harare and coincided with the organisation’s 10th anniversary celebrations.
The CWGH was born in early 1998, to lead and give visibility to community processes in health. Ten years later over ninety participants attended the conference, including CWGH national members, partners, activists, health cadres and Health Literacy facilitators from 21 of the 25 CWGH districts. The conference reviewed the path that the CWGH has walked through the past ten years. We noted that as much as the CWGH has over the years positioned itself as a voice in the health sector and built community power, still the health sector has continued to deteriorate. The current socio-economic and political environment has not only perpetuated the deterioration, but has also made it increasingly difficult for civil society to offer alternatives for health problems. It was thus noted that the network needed to not only strengthen the existing structures and processes in the network, but also to re-strategise on how best to use these to engage on and advance health under the prevailing harsh environment.
At the conference our health literacy facilitators from 21 districts reviewed the work they were doing to widen social awareness and action on health. Despite the political volatility, we heard from district after district that of actions being taken, including in engaging with the political leadership on health issues. The work of the facilitators has increased the involvement of communities in health actions within communities and around Primary Health care, whether within the community on environmental health, or mobilising resources to support health centres. These are being done through community level initiative with limited external support. It was clear to us that we need to strengthen the programme and these cadres, to cement the work we are doing at community level and translate information into action.
One of the clearest messages was to revive the Primary Health Centre (PHC) concept and comprehensive PHC , if there is hope for change in the health sector. Mary Sandasi, a CWGH national member pointed to the relevance of PHC even 30 years after the Alma Ata declaration to re-build the declining health sector, particularly as it puts the people at the centre of the health system. The CWGH will consistently engage with stakeholders and government to make PHC a more central policy principle, and we will strengthen community structures such as health centre committees and boards and committees at district and national level to organise public efforts to achieve this principle.
As the health sector deteriorates, the gap between rich and poor has continued to widen. Poor people struggle to access health, and higher income groups claim a larger share of public health sector resources. We see EQUINET’s ‘Reclaiming Resources for Health’ book as a resource to inform how we can address unfair, avoidable differences in health. For example, the CWGH has over the past decade taken up equity issues with the Parliamentary Portfolio Committee on Health (PPCH), the Ministry of Health and Child Welfare (MoHCW) and other stakeholders to push for resources to go to services that support poor communities. We have for many years raised attention to the need for more resources to go to disease prevention, for example, and continue to see this as an issue, to ensure that we have safe living environments and communities.
While we commemorated our tenth anniversary, it was difficult to call it a celebration given the collapse of our health care delivery system. What we did celebrate was the dedication and commitment that people have put into the organisation and the struggle for health in the past ten years. The CWGH has grown to be a prominent voice in health, has won the hearts of many to champion peoples health issues and has given greater profile to the positive force that people provide in dealing with health problems. We have grown from strength to strength, but so too have the challenges we face!
To back our efforts to address these, the CWGH membership unanimously endorsed that the network champion the right to health, and push its inclusion in the production of a new Zimbabwe constitution. Taking the theme for the year; ‘CWGH @ 10: In Pursuit of Equity in Health through People Centred Health Systems’ we see that embedding the right to health in our constitution will give us the bottom line we need to make it clear that everyone has a claim to health and health care, no matter what the economic, socio-political, race, creed, gender or other feature. It will be a right that we will fight to include, through social action, and that we will ensure is not left on paper, but protected and promoted, through social action.
Further information on Community Working Group on Health can be found at www.cwgh.org.zw. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.