Raising and empowering demand from communities: The missing link in Primary Health Care in Uganda
Rosette Mutambi, Coalition for Health Promotion and Social Development, Uganda

Stifled by perennial under-funding, inadequate health care workers and a critical shortage of infrastructure, Uganda’s modest primary health care system has a more significant challenge to contend with – building effective demand among poor and vulnerable people. The Alma Ata declaration on Primary Health Care (PHC) declared health to be a fundamental right, but also observed that this called for full participation of communities in their health services.

Official statistics show, however, that only a third of the population uses the government-supported health system in Uganda – both public and private-not-for-profit. This means that a large share of poor and vulnerable people, including disabled people, families led by single mothers, orphans and internally displaced people, are not reached by public investments in health. They may seek services in private clinics, or buy medication from pharmacies or herbalists, but many poor people are likely to self-medicate at home, or hope for a natural healing process.

This still limited uptake of public sector health services obviously has many roots. The Coalition for Health Promotion and Social Development (HEPS-Uganda), a local health rights civil society organisation, advocates for access to affordable health care and essential medicines, especially for disadvantaged people. The evidence HEPS-Uganda has gathered from the eight of the eighty five districts of the country where it operates suggests that both service providers and users lack awareness of their rights and responsibilities in health. The Uganda Human Rights Commission confirmed this picture in 2007, observing that health rights of many Ugandans are being violated, especially the right to information, dignity and access to essential medicines. This is surely one contributor to the poor use of services, and a barrier to effective organisation of the health system around PHC.

Through its Community Outreach and Health Complaints and Counselling (C&C) programmes, HEPS-Uganda has worked with communities and health providers in eight districts of Uganda to implement initiatives aimed at increasing public and community participation in planning and implementing primary health care, including in the rational use of medicines.

The results have been telling. When expectant mothers in Kamwenge District in western Uganda, in Kawempe Division of the capital Kampala, in the districts of Pallisa and Budaka in eastern Uganda, and in the Lira District in the North of the country have increased their understanding of their health rights and the services that meet them, their uptake of antenatal services and their delivery at health centres under professional supervision has in some cases doubled over a year to eighteen months.

Through the C&C programme, HEPS-Uganda has established an independent feedback mechanism that receives complaints of health rights violations from health consumers, which it then tries to resolve through mediation with health providers and counselling. The process creates awareness of health rights and responsibilities in both sides, and has proved an effective way to identify and improve the whole system, within the community and within the local level health services.

The Uganda Human Rights Commission has observed that the violation of health rights has not been given adequate attention in Uganda. But programmes like HEPS-Uganda’s C&C programme create confidence and hope: Community members can approach health providers in an informed manner and demand the services they are entitled to. On the other side, health providers also recognize their duties and play their roles more effectively. The benefits are tangible for poor communities. In Pallisa and Budaka districts, community representation on health centre management committees is now more effective in the programme areas, and decisions are more responsive to community needs and preferences. Health centres have scrapped illegal charges that consumers have continued to incur across the country, despite government abolishing cost-sharing as far back as 2001. The end result is a more people centred, friendlier health care environment for communities as well as health workers, and the initiative is successfully demonstrating the people’s power in improving their health.

It is not that the country’s policy makers do not appreciate the value of community empowerment in the effort to achieve “Health for All”. Uganda is among the countries that adopted the Alma-Ata Declaration 30 years ago, committing itself among other things to a human rights approach to health in which “the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.”

At the country level, the national health policy commits the Government “to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.”

With ill-health identified in official surveys as the leading cause of high levels of poverty, national development plans, including the Health Sector Strategic Plan and the Poverty Eradication Action Plan, contain planned activities aimed at empowering communities for health.

There are numerous examples of how communities are playing a role in efforts to create a community-based primary health care system. Community drug distributors dispense anti-malarial medicines door-to-door; village health teams mobilise communities for sanitation and HIV prevention and treatment and community members are involved in implementing the “directly-observed treatment” strategy to manage tuberculosis (TB). There have also been policies to entrust management of lower level health units to local governments and to management committees with community representatives.

However, with the exception of the TB management strategy, the performance of the rest of the initiatives still leaves alot to be desired. Other planned activities that would have empowered communities and consolidated the success of those already underway remain at the planning level, nearly a decade since the policy and other development plans were published. For example, there has not been any national programme of community capacity building “for effective participation of health problems, planning of health services, in resource mobilization and in the monitoring of health activities”.

Uganda has made the important step of guaranteeing a minimum health care package, but with minimal resources. It is trying to attain universal access to primary health care, but with US$8 per person, instead of the estimate of $34 made by the Macroeconomic Commission on Health. Without effective and collective demand from community level people will carry on ‘making do’ with poorly resourced health systems, and under-using the resources that are applied.

Effective and collective demand calls, however, for a system that involves the intended beneficiaries in planning and implementation, and for an informed and empowered community, able to demand and use the services it needs. In a resource poor setting like Uganda, the case for community empowerment for health is even stronger. It is needed in setting priorities, deciding on resource allocation, monitoring the performance of service providers and in building health care seeking behaviours. Government will have to live to its commitment to empower communities health if it is to guarantee their right to quality health care.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.

Change agents, substitutes or scapegoats for crumbling health services – What roles can communities health workers play?
Uta Lehmann, School of Public Health, University of the Western Cape

“I started volunteering [as a community health worker] in 1996. During that time, the most common disease in my village was tuberculosis (TB). We worked together and visited those who were infected with TB. We also went to fetch their pills from hospital and distributed them accordingly. We were to ask the sick people to cough out the sputum and save it inside specimen bottles that we took to a certain sister at the hospital.” (Eastern Cape community health worker)

Community members have been rendering certain basic health services to their communities for at least 50 years. All over the world, but particularly in countries in Asia, Africa, and Latin America community or village health workers (CHWs) have been providing health education to their communities, helping pregnant mothers and new-born babies and treating basic illnesses. They are often mature women, with little formal education. The quotes from CHWs in Eastern Cape South Africa highlight this experience.

“My first encounter with the health programmes was in 1986. Our training was to help people who had been swept by the river waters and nearly drowned. ….We went to all the homes teaching people about TB and how to avoid it. To those who had it already we continued to train them on how to take care of themselves and prevent further spreading of the disease. We encouraged people to have toilets, to build chicken runs and pig sties and avoid animals running loose all over the place to keep ourselves in good health.” (Eastern Cape community health worker)

Since the arrival of HIV, community health workers have also been counselling community members, providing peer support and home-based care and ensuring that people on antiretroviral therapy take their treatment. In some countries they have also been involved with HIV testing.

In the past CHWs have been seen as advocates for health in their communities and agents for social change. This made them central to comprehensive primary health care. In recent years a much more technical understanding has taken hold, which views CHW programmes as a strategy to address health worker shortages in most countries. This view is reflected in the 2006 World Health Report which advocates the delegation of tasks to lay health workers.

The renewed enthusiasm for community health workers presents great opportunities to seriously review how community health is organized and rendered and to empower communities. However, questions have to be asked about the rationale and intention of this enthusiasm:
• Is it realistic to expect commununity members from invariably impoverished communities to take responsibility for what in effect are essential health services, often with very little training and hardly any supervision?
• Are governments in fact not abdicating their responsibility for ensuring appropriate health care for their citizens, in particular the most vulnerable ones?
• Under what circumstances are CHW programmes empowering communities and under what circumstances are they shifting the burden of health care to those most vulnerable in society?
• What roles can CHWs realistically play?

There is ample rigorous evidence from different parts of the world that CHWs can play a crucial role in broadening access and coverage of health services in remote areas and can undertake actions that lead to improved health outcomes in a range of areas, including child health, TB and HIV/AIDS care. CHW programmes hold the potential of enabling countries to build sustainable, cost-effective and equitable health care systems, thus contributing towards moving closer to achieving the Millennium Development Goals. However, the challenge of achieving success cannot be underestimated. Programmes need careful planning, secure funding and active government leadership and community support. To render their tasks successfully, CHWs need regular training and supervision and reliable logistical support. Importantly, governments have to retain their responsibility for essential health services at all levels, including for CHWs programmes. It is their responsibility to ensure that CHWs are, in fact, appropriately and adequately trained and supported by health service staff and communities and that their roles are clearly understood by all role players. This requires political leadership and substantial and consistent resourcing.

Given present pressures on health systems and their proven inability to respond adequately, the existing evidence strongly suggests that, particularly in poor countries, while CHW programmes are not easy, they are a good investment. This is particularly true given that the alternative in reality is NO care for the poor living in geographically peripheral areas.
They represent far more than improved service provision and access, however.

The continued testimony from the community health worker in South Africa’s rural Eastern Cape province demonstrates the personal and social dimensions of health actions that CHWs bring:
“Then the disease called HIV/AIDS started attacking people till it came to my house and attacked my own son. I could not understand this disease which he came with from Cape Town, but I took him to hospital. I was very hurt and heartbroken to see how his whole body was covered with sores, from head to toe, even the softest parts. I took him to hospital. At the hospital I was not told that it was HIV/AIDS, I was told he had TB. After reading his forms carefully, because I could read a little, I discovered that they had diagnosed him with thing [HIV/AIDS]. My frustration worsened, and that is when I decided to give myself to the whole of the village to help other people, especially that I had this bad experience firsthand. I went up and down the ravines of the village working. Many more people were discovered to be infected till this day. I worked harder and harder though, unfortunately, some of those I tried to help could not make it, they died. Some had very bad sores and we frequently washed them. I would take a flask from home and boil water for my patients to keep in it so I could prepare something to eat for them before taking their medication. For some, I would get there and start making fire with wood as we normally do in the rural areas, and warm water to use for his bath. They looked very bad during those days but today you wouldn’t think it’s the same person that I had nursed to recovery” (Eastern Cape community health worker).

Village health workers: Essential for health, under-valued by planners
Rusike I and Chigariro T: Community Working Group on Health, Zimbabwe

Village health workers (VHWs) were key to Zimbabwe`s successful expansion of primary health care (PHC) in the early 1980s. They played a central role in closing the gap between public health services and communities at local levels, bringing health services outreach to communities, and facilitating community roles in the health delivery system. For example, village health workers and community based distributors were instrumental in implementing the successful Zimbabwe Family Planning Programme, as they helped raise awareness on family planning methods such as condoms and combined oral contraceptives (commonly known as ‘the Pill’), as well as the advantages of child spacing. These efforts are reflected in the expansion of coverage of contraception and reported decrease in fertility rates in the country from 6.5 children per woman in the early 1980s to 4.3 children per woman in 2001.

VHWs continue up to today to augment the work being done by the mainstream health sector: raising awareness, giving health advice, monitoring growth of children under five years, and mobilising communities during out-reach programmes and for immunisation. Mrs. Kaseke a VHW in Mwanza ward (Goromonzi district) echoes these sentiments. One of her roles as a VHW is to mobilise food for chronically ill and home based patients in her area. She also runs community-based growth monitoring clinics on Saturdays. ‘I have a scale that was allocated to me by the clinic when I started as a VHW. Women from my area bring their babies to my homestead. I weigh the babies and record their weight on cards, as it is done at the clinic. I then use the weight records to check if the child is growing well; otherwise I refer the child to the clinic for further assessment’.

VHWs see an important role for themselves in bridging the gap between the community and the health services, as explained by another VHW from Gokwe South District, Musatyanika Wushe: ‘We are the link between the community and the health department. We advise and refer the community to seek medical attention early, care for home-based ridden patients, and chronic and TB patients on DOTS’.

Despite these vital functions, the numbers of VHWs and the role played by VHWs has diminished over the past two decades in Zimbabwe. While communities cite low morale due to lack of incentives as the major setback, the VHWs and other health staff point to lack of incentives and supporting resources and protective equipment as a major barrier to their performance.

In their early years, VHWs benefited from incentives such as uniforms, bicycles and allowances, which were meant to enhance their work and motivate them. Bicycles were both a token of appreciation and a tool to enable these volunteers to take their services to a wider population. The allowances they received helped them to buy basic necessities such as soap, so that they could look presentable while they carried out their duties. These incentives are now a thing of the past; and the remaining cadres are at times compelled to use their own resources to ensure that they can continue to serve their communities.

Highlighting the plight of VHWs, Mr. Wushe said, ‘We, as village health workers, are surprised about how we are handled. The problem is, out of all these duties, our allowances are still as low as ZW$20,000 (about US$0.01) per month, which is received after 12 months. One may be surprised to hear that allowances for December 2006 were received on the 26 of November 2007! We are very much exposed to the world of infection because we do not have protective clothing to put on when attending to home-based patients, most of which may have open wounds. From 2002 up to now ,we have tried in vain to request this protective clothing from our district hospital but the response is disheartening’.

In addition to the resource gaps for VHWs, there have also been some changes in roles and responsibilities that have affected their work on health. During the period 1988-1999, the government introduced a multi-purpose cadre, the ‘village community worker’ (VCW). They were introduced under the Ministry of Political Affairs to take up a number of roles, including taking over some roles previously implemented by VHWs. However, unlike the VHWs, VCWs were political appointees, appointed by the ruling party leadership and then employed and trained by the Ministry of Political Affairs. This reporting and accountability structure weakened the link between the community and the health authorities. After calls by communities for the re-introduction of VHWs, the Community Working Group on Health (CWGH), among other civil society groups, lobbied government through the Ministry of Health and Child Welfare to re-introduce this cadre. VHWs were subsequently re-introduced in Zimbabwe in 2001 and over 2,000 VHWs were trained across the nation. While this has been welcome, there is still need to address the barriers to their morale and functioning.

VHWs have been proposed as one measure to deal with a gap in health worker numbers. While they cannot replace adequately trained staff at primary and district levels of health systems, they are a key cadre in the health system because they are aware of the health needs and aspirations of their communities. This makes them an invaluable asset in advancing community-orientated health delivery and they should be supported. Although the 2008 national health budget in Zimbabwe had a sizable allocation towards VHWs, meetings held in 25 districts where CWGH is operating suggested that this budget is yet to reach the cadres on the ground. The CWGH has thus urged government to work with other stakeholders to create a plan to fully revive the VHW programme, support their work and ensure that resources allocated in the budget for VHWs reach them.

This is not just a matter for government. As part of civil society, we see that the presence of VHWs in our communities is essential in our quest for equity in health and accessibility of health services. We too need to be part of this support. Towards this end, CWGH will be documenting the roles and impacts of VHWs in our communities to engage government and other stakeholders to value and resource these roles in the spirit of health for all.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. The CWGH is a network of membership based civic organisations focusing on advocacy, action and networking around health issues in Zimbabwe. www.cwgh.co.zw

Health services in the Market Place: What will we get from negotiations on service agreements in the EU Economic Partnership Agreements?
Aulline Mabika, SEATINI

In the next six months countries in the east and southern African region will be negotiating the agreements on services in the European Union (EU) – East and Southern Africa (ESA) Economic Partnership Agreements. These services negotiations are already halfway through and are expected to be complete by the end of 2008. The negotiations currently cover mainly financial and telecommunications services, and say little about protecting social services. Yet many countries in the region are facing pressures to privatise health services, even though the growth of a private sector in health services withdraws resource and staff to service a wealthier minority at the cost of universal access to health care services for the majority.

Protecting the health of the populations in the sixteen eastern and southern Africa in the region is a development priority. Twelve of them are least developed countries (LDCs) with the lowest human development indicators in the world. Almost all these countries experience negative economic growth and falling disposable incomes, one in six children dies before their fifth birthday and more than half the population is still living on less than US$1 a day. The EU on the other hand, with whom the agreements are being negotiated, consists mainly of developed economies, five of which are among the ten largest economies in the world and most of their people enjoy high standards of living. These negotiations are clearly taking place between unequal partners.

Countries in ESA experienced a wave of liberalisation of health services under the Structural Adjustment Programmes (SAPs), with a fall in funding of and access to services by the poorest communities. Further liberalisation is opening up services to commercial players whose aim is to generate profit. Trade in health services is argued to increase access to health care in remote and under-serviced areas; to generate foreign exchange; to provide new employment, give access to new technologies; and to reap economic gains from remittances of health workers who migrate. However, these benefits are often only obtained in the private for profit health care sector, promoting internal migration from the public health sector to private health care, with unaffordable costs of care for poor and vulnerable members of society, whose needs must be assured by governments.

Governments in the region have recognised the need for public sector led services for access to health care in poor populations, even while some have permitted the growth of private services. Universal access to basic health services is a stated development goal in many ESA countries. Health is a human right enshrined in many national constitutions and various signed and ratified international legal instruments.

Yet there is little protection of the right to health or to health care in the interim EPA agreements initialled in 2007. When these were concluded, despite significant opposition from the region, their sections on development cooperation should have provided for protection of public health, but no such protection was included.

The SADC-EU EPA Article 3 (2) provided that ‘The Parties understand this objective to apply in the case of the present Economic Partnership Agreement as a commitment that:(a)the application of this Agreement shall fully take into account the human, cultural, economic, social, health and environmental best interests of their respective population and of future generations (my emphasis)’ This gives some basis for ensuring that the rest of the EPA negotiations protect health rights, and it will be important to keenly follow the SADC EPA negotiations to hold negotiators to the commitment to protect their people’s best interests in health. Despite lobbying from civil society, the ESA-EU EPA on the other hand does not contain any mention of protecting health except reaffirming the parties’ commitments to the realisation of the millennium development goals in the preamble to the agreement.

Both interim EPAs however included a clause opening the way for further negotiations in areas relevant to health, such as services, intellectual property rights, and investment. These further negotiations appear likely to motivate liberalisation of services. This is promoted in the guidelines set out in the General Agreement on Trade in Services (GATS) of the World Trade Organisation (WTO) and the EPA is modelled along GATS. It is likely to cover similar areas, including health and health related services, migration of health professionals, and health care financing.

How can ESA countries protect their health services in the negotiations?

Firstly, as a minimum, it is important that the EPA negotiations do not go beyond the framework agreed at the WTO in the GATS and do not include GATS-plus obligations. Negotiators should live up to the commitment of the 4th Ordinary Session of the AU Conference of Ministers of Trade in April 2006: ‘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.’

However countries can go further. Under the terms of the interim EPAs, countries are free to exclude a wide range of sensitive goods and sectors from liberalisation. Our governments should take advantage of this flexibility to exclude health and related social services from liberalisation. For governments like Zambia and Malawi whose health service sectors are already open under GATS, they should not further entrench liberalisation under EPAs.

Negotiators must protect government policy space to remain key providers of health services in the EPA negotiations. Negotiators need to ensure that governments have full authority to regulate and control private for profit provision and financing of health services. Governments should also do formal health impact assessments in any health-related sector where liberalisation is being proposed, whether under GATS or the EPA. Commitments should be explicitly made in the EPAs on ethical recruitment and treatment of health workers and on EU investment in public budgets to produce and retain health workers in source countries.

ESA negotiators cannot treat health and health care services as a market matter, divorced from social issues. What is discussed in these negotiations are not just a matter of people’s survival, but also affect the cohesiveness and solidarity of societies and the support ESA countries are able to give to vulnerable communities. The negotiations on health services are thus a matter of public interest, and civil society should be involved. Public consultation on negotiations will surely strengthen the hand of negotiators by ensuring there is a strong public mandate to take firm positions on these vital health issues. Civil society should track the services negotiations, parliaments should ask questions about them, and we should continue to lobby for an EPA that respects the rights of the African people, especially the right to health. This means continuing to demand that ESA governments and the EU member states respect their obligations to international human rights instruments as they negotiate EPAs and that the people’s welfare takes priority.

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 or the full please visit SEATINI (www.seatini.org) or EQUINET www.equinetafrica.org.

The AIDS road to Comprehensive Primary Health Care for all?
Gorik Ooms, Wim Van Damme, Marie Laga, Institute of Tropical Medicine, Antwerp and Nathan Ford, University of Cape Town, South Africa

On 28 May 2008, the Institute of Tropical Medicine (ITM, Antwerp) hosted a workshop at the World Health Organization (WHO, Geneva) to review the evidence on positive and negative impacts of the global AIDS response in low-income countries in sub-Saharan Africa on general health systems and services. The workshop involved people working in AIDS and health services, in civil society and in academia with and from Sub-Saharan Africa.

The original question was simple and straightforward: what is the evidence to support or refute recent claims that global resources allocated to fight AIDS are over inflated and do little to support, and may even undermine, health systems?

Discussions quickly moved beyond this original question. The Alma Ata concept of Primary Health Care (PHC) – comprehensive PHC rather than selective PHC – proved to be a uniting concept. The real question became: how can the global AIDS response best contribute to the realisation of Comprehensive PHC? Most participants agreed that there are lessons to be learned – good and bad – from the global AIDS response, that will help us move closer towards Comprehensive PHC for all.

There is evidence of the global AIDS response strengthening general health systems and services, and there is also evidence of the global AIDS response weakening general health systems and services.

The most important point of stress identified related to the overall shortage of health workers. In some countries, the AIDS response was reported to have led to an ‘internal brain drain’, with health workers abandoning their previous occupations to work on AIDS programmes. In other countries, the AIDS response enabled improved working conditions of health workers across the board, helping to attract and or retain more health workers.

Without systematic reviews, or an agreed score card allowing us to add up the strengthening effects and to subtract the weakening, we cannot conclude if the overall result is predominantly negative or positive. However, the positive effects of strengthening general health systems and services seem be more likely where national public sector led strategies explicitly aimed for these positive synergies. This finding suggests that if recipient countries want AIDS funding to strengthen general health systems and services, they need to negotiate the needed flexibility from donors for this.

Therefore, we felt it would be more productive to focus on what measures promote positive synergies and avoid negative synergies - to support this, rather than trying to make a conclusive statement on whether the balance is currently positive or negative.

One key issue is the under-funding of health care in developing countries. Whether the objective is Comprehensive PHC for all, fulfilling the Right to Health obligation, or achieving the health-related Millennium Development Goals (MDGs), neither national nor international funding of health care measures up.

Scarcity of human and financial resources was observed to drive competition and rivalry. At the same time, health funding should not only increase, but also become more reliable in the long run. For ministries of health to embark to an ambitious health workforce programme, for example, a long term financing perspective is needed. It doesn’t make sense to increase training capacity today, if 10 years from now the additional health workers’ salaries cannot be secured to employ trained personnel. A new concept of sustainability adopted for AIDS treatment – where sustainability is based on domestic resources and sustained international funding – should be expanded to health systems and services, including salaries of health workers.

Most participants to the meeting acknowledged that AIDS activists have been more successful than the proponents of PHC at getting their priority high on the political and funding agendas. However, within the spirit of Comprehensive PHC, they saw this could be an opportunity rather than a threat, if this is used to equally raise the profile on general health systems and services, not to depress the profile given to AIDS responses.

Delegates felt the means to this was through renewed impetus for what is fundamentally a shared and uniting paradigm of Comprehensive PHC, including AIDS prevention and treatment, where:
• Health (and health care) is a human right, and an entitlement
• Programming and financing is adapted to needs and not to scarcity of human and financial resources
• Macroeconomic policies are adjusted to vital needs and not the other way around
• Concerns about the sustainability of health care is addressed as a shared global responsibility, depending as much on sustained national funding as on sustained international funding
• The people whose health is at stake are involved in the decision-making process
Where the global AIDS response has made significant progress on these issues, the benefits of this progress must be extended to general health systems and services.

• Governments must live up to their promises: governments of low-income countries must allocate 15% of their domestic government revenue to health while governments of high-income countries must allocate the equivalent of 0.7% of their Gross Domestic Product (GDP) to global solidarity, and 15% of that (0.1% of GDP) to health.
• These commitments should be open-ended (as long as needed), without aiming for national financial resources to replace international financial resources as soon as possible, as this would undermine the crafting of ambitious health plans, including workforce plans.
• Ceilings on health expenditure (included in policies imposed by the International Monetary Fund) must not hamper the realisation of the right to health or Comprehensive PHC for all.
• The people whose right to Comprehensive PHC is at stake have the right and the duty to be involved in critical decisions that affect their health.
• The global aid architecture must be reorganised in such a manner that it supports Comprehensive PHC for all, not one part of Comprehensive PHC at the expense of another; andGeneral health systems and services not only need strengthening, but also transforming: involving and working with communities as participants of health systems and services, rather than merely ‘clients’ or passive recipients of health services.

We found that the global AIDS response created real challenges for health systems and services, but also that there are ways to tackle and minimise them. The global AIDS response also created real opportunities, which should be maximized.

Comprehensive PHC is a uniting goal for all constituencies. It demands a significant mobilisation of knowledge, experience and additional funding. We cannot afford to repeat the mistake of three decades ago, when the ideal of Comprehensive PHC was abandoned as unaffordable, leaving us with the present health and health systems deficit.

This oped is not intended to be an accurate record of the meeting referred to which can be obtained from the authors located at Institute of Tropical Medicine, Antwerp [http://www.itg.be/itg/GeneralSite/Generalpage.asp]. EQUINET welcomes further opeds on the issues raised in this oped and on Comprehensive PHC, particularly from an equity perspective. Please send debate, comment or queries on the issues raised, or communications for oped authors to the EQUINET secretariat, email admin@equinetafrica.org.

Alma-Ata in 1978: Whither the Health for All Vision and Primary Health Care Strategy?
Dr Halfdan Mahler, Former Director-General of WHO: Recirculation of address to the 61st World Health Assembly

This editorial is drawn from a speech by Dr Halfdan Mahler to the World Health Assembly in May 2008. Dr Mahler was the Director General of WHO at the time of the 1978 Alma Ata declaration on Primary Health Care. He stated at the 2008 WHA:

Milan Kundera wrote in one of his books: "The struggle against human oppression is the struggle between memory and forgetfulness." So allow me to remind all of us today, of the transcendental beauty and significance of the definition of health in WHO's Constitution: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

This definition is immediately followed by: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Most importantly, the very first constitutional function of WHO reads: "To act as the directing and coordinating authority on international health work." Please do note that the Constitution says "the" and not "a" directing and coordinating authority.

So please, allow this old man in front of you to insist that unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.

My memory tells me that the World Health Assembly had this in mind when, in 1977, it decided that the main social target for governments and WHO in the coming decades should be the attainment of what is known as "Health for All".

And, the Health Assembly described that as a level of health that will permit all the people of the world to lead socially and economically productive lives. The Health Assembly did not consider health as an end in itself, but rather as a means to an end.

That is, I believe as it should be.

When people are mere pawns in an economic and profit growth game, that game is mostly lost for the underprivileged.

Let me postulate that if we could imagine a tabula rasa in health without having to deal with the constraints - tyranny if you wish - of the existing medical consumer industry, we would hardly go about dealing with health as we do now in the beginning of the 21st century.

To make real progress we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactoral causation of disease, have for a long time, called attention to the association between health problems of great importance to man and social, economic and other environmental factors. Yet, considering the tremendous political, social, technical and economic implications of such a multidimensional awareness of health problems I still find most of today's so-called health professions very conventional, indeed.

It is, therefore, high time that we realize, in concept and in practice, that a knowledge of a strategy of initiating social change is as potent a tool in promoting health, as knowledge of medical technology.

Primary health care is indeed conditioned by its holistic framework and as such, may use different expressions. For example, in some countries health management has to be considered along with such things as producing more or better food, improving irrigation, marketing products, etc. It is not that people consider health services as unimportant, but there are things like getting food, or a piece of land, or house or an accessible source of water which are more of a life and death nature and must, in the wisdom of the people, come first to make other things meaningful. We have rarely considered these needs as falling within our expressed policies for health development and therefore, we risk being restricted, unilateral and ineffective in our action.

Again, I am afraid that conventional or medical wisdom has done very little to provide scientific and political credibility to the alleged importance of individual, family and community participation in health promotion.

These concerns, to which I have just alluded prompted an organizational study on "Methods of promoting the development of basic health services" by WHO's Executive Board in 1973 in which it is bluntly stated that:

"There appears to be widespread dissatisfaction of population about their health services for varying reasons. Such dissatisfaction occurs in the developed as well as in the Third World. The causes can be summarized as a failure to meet the expectations of the populations; an inability of the health services to deliver a level of national coverage adequate to meet the stated demands and the changing needs of different societies; a wide gap (which is not closing) in health status between countries, and between different groups within countries; rapidly rising costs without a visible and meaningful improvement in service; and a feeling of helplessness on the part of the consumer who feels (rightly or wrongly) that the health services and the personnel within them are progressing along an uncontrollable path of their own which may be satisfying to the health professionals but which is not what is most wanted by the consumer".

It was this organizational study by WHO's Executive Board that led to the decision by WHO in co-sponsorship with UNICEF to convene "The International Conference on Primary Health Care" in the city of Alma-Ata in 1978.

Let me then repeat with awe and admiration, the consensus concept of primary health care as contained in the Declaration of Alma-Ata 1978:

"Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part, both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community.

"It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process."

Let me also quote from the Declaration of Alma-Ata, that primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. In my opinion, an admirable summation of key priorities.

Are you ready to address yourselves seriously to the existing gap between the health "haves" and the health "have-nots" and to adopt concrete measures to reduce it?

Are you ready to ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors, in order to promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development?

Are you ready to make preferential allocations of health resources to the social periphery as an absolute priority?

Are you ready to mobilize and enlighten individuals, families and communities in order to ensure their full identification with primary health care, their participation in its planning and management and their contribution to its application?

Are you ready to introduce the reforms required to ensure the availability of relevant human resources and technology, sufficient to cover the whole country with primary health care within the next two decades at a cost you can afford?

Are you ready to introduce, if necessary, radical changes in the existing health delivery system so that it properly supports primary health care as the overriding health priority?

Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care?

Are you ready to make unequivocal commitments to adopt primary health care and to mobilize international solidarity to attain the objective of health for all by the year 2000?

Alma-Ata was, in my biased opinion, one of the rare occasions where a sublime consensus between the haves and the have-nots in local and global health emerged in the spirit of a famous definition of consensus: "I am not trying to convince my adversaries that they are wrong, quite to the contrary, I am trying to unite with them, but at a higher level of insight."

The Alma-Ata primary health care consensus also reflects a famous truism: "The Health Universe is only complete for those who see it in a complete light, it remains fragmented for those who see it in fragmented light!"

In conclusion, my personal view is that the Alma-Ata primary health care consensus has had major inspirational and operational impacts in many countries having a critical mass of political and professional leadership combined with adequate human and financial resources to test its adaptability and applicability within the local realities through a heavy dose of systems and operations research.

Mind you, it is much easier to be rational, audacious and innovative when your are rich! But, please, let us not forget that the inspirational energies and the evidence base came from the developing countries themselves, be they governmental or non-governmental sources.

For a majority of these countries, financial support from so-called donors was essential to carry out a broad array of studies, in appropriate technology, human resources development, infrastructure development, social participation, financing etc. in order to integrate the Alma-Ata vision into heavily constrained local contexts.

Most donors, after an initial outburst of enthusiasm quickly lost interest or distorted the very essence of the Alma-Ata Health for All Vision and Primary Health Care Strategy under the ominous name of selective primary health care which broadly reflected the biases of national and international donors and not the needs and demands of developing countries.

But in spite of these brutal impediments many developing countries have shown, before and after the Alma-Ata happening, courageous adhesion to its health message of equity in local and global health. Civil society movements have also been prime shakers and movers in these admirable efforts.

And so, being an inveterate optimist I do believe that the struggle between memory and forgetfulness can be won in favour of the Alma-Ata Health for All Vision and its related Primary Health Care Strategy. Let us not forget that visionaries have been the realists in human progression.

And so, distinguished audience, let us use the complete light generated by WHO's Constitution and the Alma-Ata Health for All Vision and Primary Health Care Strategy to guide us along the bumpy, local and global health development road.
Thank you.

New health equity network in Uganda to address disparities in health
Mulumba Moses, HEPS Uganda

Uganda has implemented a number of reforms to its health sector to make services more accessible to poor communities, including abolishing user fees, introducing public-private partnerships in service delivery, and decentralizing the management of health services to district and lower local government levels. Yet poor people continue to face barriers to use of health services. Costs of health services are still cited by poor people as being a barrier to using services, as are long distances to health centers, particularly for rural residents. Access to health care is thus an important equity issue in Uganda: Poor and disadvantaged people experience a greater burden of disease - but have poorer access to health care than those who have higher incomes.

These were the challenges discussed at a recent national meeting on health equity in Uganda hosted by HEPS Uganda, Makerere University School of Public Health and EQUINET. The meeting included presentations of work on disparities in health and access to health care, from researchers from academic, government and non government organisations. While the presentations reported on a range of initiatives to improve health in the poorest communities, they also gave evidence of the continuing challenges the country faces.

For instance, one study reported by the Institute of Public Health at Makerere University found in three districts of Uganda that the poorest households were 2.4 times more likely to suffer ill health than the richest. Infant and child mortality among the poorest Ugandans are reported to be double that in the richest group. Such inequities are also common in vulnerable groups that have greater need for health care. Addressing the needs of the poorest communities can be overshadowed by deficits in access to care for a much wider group of people. For example, the meeting was informed that despite a significant improvement in access to antiretroviral therapy (ART), demand for ART has continued to outstrip supply, and only about 60% of people who need ART can access it. Older persons were also described as having high health needs that may not be met due to wider poverty and isolation.

Not surprisingly a number of papers in the meeting thus explored the way resources are allocated to address these challenges. The first issue that arose was the overall shortfalls in health financing. The US$14 per capita reported to be spent on health was noted to be about a third of the resources needed for minimum health care services. While new resources have been mobilised nationally and internationally for AIDS, presenters reported that there is still a significant shortfall in funding for AIDS, especially at the district level. It was reported that out-of-pocket payments continue to exceed public sector spending, even though most poor people use public services and through fees have been abolished in the public sector. This is a barrier to health care for poor communities, and the source of these charges needs to be better understood to address them. The continued shortfall in overall financing also draws attention to whether budgets give special consideration to vulnerable groups. Concern was expressed in one presentation that district councils set budget priorities using a narrow definition of gender health needs within the community. Women have weak control over productive resources and household finances, and unless services give additional attention to this situation they will also lack command over the resources they need to protect their health.

Such disparities remain an issue to be addressed to promote health and access to health care in Uganda. There was wide agreement that such inequalities were avoidable and thus merited attention and action. Some actions were presented and discussed: The experience of community health insurance schemes was reviewed as one option for supplementing health resources. A study was presented showing that 81% of households surveyed in one rural district expressed willingness to enroll in Community Heath Insurance schemes and were willing to contribute on average Ushs.5,977 (US$3.4) per person per year. Further work needs to be done on how equitable and sustainable these schemes are, especially for the poorest. It was argued that strengthening decentralisation, through resource allocation that prioritises districts and community level, could also go a long way to strengthening the health care system used by low income groups, and thus addressing inequity. Various examples were presented of strategies to empower and mobilise communities to engage with their health services, including the Village Health Team Strategy and the use of media, drama and of participatory reflection and action methodologies.

Across these options it was agreed that ensuring fair opportunities for health should not be left only to the Ministry of Health, but should be a matter for all sectors. According to the Ministry of Health in Uganda, over the past fourteen years, considerable effort has been made to restore the functional capacity of the health sector, through increasing public health spending, reactivating disease control programmes and re-orienting services to primary health care in Uganda. However, the ministry observed in a 2007 report that there still remain significant challenges in matching need for health services with available resources, making equity or fairness an important issue for advancing national policies for the population as a whole (http://www.health.go.ug/policies.htm).

The people and organisations at the national meeting agreed to continue networking to advance health equity work, and formed a new Ugandan health equity network. This will create a platform and ignite further action for health equity at national level. With leadership from different institutions working in these areas the network will share evidence, knowledge and strengthen advocacy on areas of health equity that include: resource mobilisation and allocation to the health sector; addressing health needs of vulnerable groups; protecting health in trade policies and agreements; and advancing health rights, community empowerment and effective governance in health. While it was evident in the meeting that a lot of work is underway, it is not always shared and communicated within Uganda and in the East and Southern Africa region. The delegates thus agreed to strengthen and widen links between people and institutions working on equity in health, to promote research and practice in this vital area of national health policy.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. For more information on the health equity network in Uganda, contact HEPS Uganda at heps@utlonline.co.ug, working with Makerere University School of Public Health. Further information on the issues raised and the report of the Uganda national meeting is also available at the EQUINET website at www.equinetafrica.org.

A tale of two voices: Avoiding mixed messages on commitments to health
Rene Loewenson, TARSC/EQUINET and Di McIntyre, UCT/ EQUINET

Two meetings took place in the last month.

On 18-20 April, the Southern Africa Development Community (SADC) held an international conference on poverty and development in Pailles, Mauritius. Background material for the conference prepared by SADC showed the threat posed by critical levels of HIV and AIDS, TB and Malaria to achievement of the Millennium Development Goals (MDGs). Countries were recommended to reprioritise their spending to curb the spread of diseases and other health problems impacting on development, including by meeting commitments to the 2001 Abuja Declaration commitment of 15% of national budgets on public health.

The AU Ministers of Finance and Planning and Economic Development meeting held in Addis Ababa- Ethiopia from 26 March to 2 April also noted with concern the necessity for long-term sustainable financing of and investment in health created by AIDS and other diseases. However, they were publicly silent on the commitment made by African heads of state in 2001 to allocate 15% of their annual national budget to health as a means towards this. Indeed, there are unconfirmed reports from people attending the meeting that some Ministers of Finance argued for the Abuja target adopted by their heads of state in 2001 to be abandoned.

That the region needs to increase its public sector investment in health is not in dispute. Poorer groups continue to have considerably worse health than the better off; economic growth and achieving the Millennium Development Goals (MDGs) in the region is seriously undermined by the prevalence of HIV and AIDS, TB, Malaria and other diseases. Eleven of the sixteen countries in east and southern Africa spend less in their public sectors than the US$34 needed for the most basic interventions for these conditions, let alone the US$60 or more needed for more comprehensive health services. So far, only three countries in the SADC Region have reached the Abuja target, although more are moving in a positive direction. Ten of the sixteen countries in the region would, if they met the Abuja target, increase their public financing to health above the basic level of US$34/capita needed for these basic health programmes.

There is significant potential gain when such increased spending is directed towards primary health care and district services, providing improvements in early detection, access and treatment for disadvantaged groups and in under-served areas. Many of the actions that improve health in poor communities are indeed taken outside the health sector, to improve physical, economic and social environments. However, evidence and experience shows that levering such actions for health across a range of sectors still calls for strong public health leadership, with adequate resources and political support to encourage shared mandates and co-ordinated action for health across all sectors.

The SADC meeting documents made it clear that a public sector led response is vital: Governments have the primary and most important role, responsibility and means for implementing systemic changes and sustaining them in the long run. Government action to reprioritise spending on health and develop sustainable, progressive strategies for financing health care is thus essential to create a basis for complementary strategies and inputs from other sources.

In contrast, diluting or failing to meet commitments to public funding for health undermines the necessary response to a major development challenge with greatest cost to poor households. As the SADC conference on poverty and development was informed, SADC Member States account for 35% of the people living with HIV globally and there are over 5.2 million orphans in the region. The region has the world’s worst TB infection rate and the rate has increased in the last 15 years, while the resources needed to cope with the epidemic have dwindled. New epidemics of multi-drug resistant tuberculosis (MDR-TB) and extreme drug-resistant tuberculosis (XDR-TB) pose grave and rising public health threats, particularly where health resources are limited. There are an estimated 30 million cases of malaria and 400 000 deaths from malaria in the region, with particular risk for children and pregnant women.

Such illness impacts on household income, diverting time and money for caring - sometimes at the expense of food consumption or school enrolment in children - with longer term consequences for poverty and production, especially for agricultural production and food security. Ill health places particular demands on women and children to provide or pay for care. As public funding for health has fallen, the region has also experienced rising charges and out-of-pocket payments for health care. When public services are under-funded or inaccessible and out-of-pocket payments for health increase, this has a particularly impoverishing effect on women, lower income and socially marginalised groups.

So meeting the heads of state commitment in Abuja is important to directly address significant and rising disease burdens; provide the necessary public and health sector leadership to lever other contributions to health; and protect against rising impoverishment and inequality resulting from unaffordable levels of household spending on health care in the lowest income households.

This is clearly not only a matter of increasing resources for health, but of redirecting resources towards greatest health needs. However review of experience in African countries shows that equitable allocation of public sector health care resources is more likely in a situation of increasing resources to health, backed by a policy commitment to equity and explicit mechanisms for achieving reasonable allocation targets.

Not surprisingly therefore, the paper produced by the SADC secretariat for the conference on responses to the economic impact of the three communicable diseases was clear and unequivocal: ‘SADC Member States and governments have committed themselves to many declarations including Abuja 2001 on the three communicable diseases, the Maputo Declaration of 2005 on declaring TB an emergency and UNGASS to name a few. They need to fulfill these obligations and put a mechanism in place to monitor and evaluate them.’

The commitment made by the heads of state in Abuja 2001 towards allocating 15% of their national budgets for health was an important contribution to poverty reduction and equity, and a challenge to international partners to eliminate debt and meet their own commitments to overseas development aid. We would expect a similar level of explicit commitment to the goal from the Ministers of Finance in the region, and more than that delivery on the 15% government funding to health.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET calls for “Abuja plus” i.e. 15% government spending to health, increased local and international per capita funding, debt cancellation, abolishing user fees, increasing the share of progressive tax funding, and 50% of government spending to district levels and primary health care. EQUINET work on fair financing in health is available at www.equinetafrica.org.

Fair allocation of government health resources in east and southern Africa - signs of progress
Di McIntyre, Bona Chitah, Lovemore Mabandi , Felix Masiye, Tomas Mbeeli, Shepherd Shamu, EQUINET Fair Financing Theme and University of Cape Town Health Economics Unit

Beyond the call for governments to meet their commitment to spend 15% of their budgets on health, we are concerned to see that government spending reaches those with greatest health needs. So how well do governments perform in equitable allocation of their health spending?

In many African countries, health care spending levels are very different between different provinces, regions and districts. This is largely a historical inheritance. Health services, particularly hospitals which consume the major share of health care resources, are heavily concentrated in the largest urban areas, and rural areas are relatively under-resourced. Yet almost all countries in east and southern Africa have policy goals to provide equitable access to health care for their citizens. This implies that health care resources (financial, human and facilities) should be fairly distributed between geographic areas on the basis of health needs.

Internationally, it has been found that using a needs-based resource allocation formula is a helpful strategy for breaking the historical inertia in resource allocation patterns. Such formulae are used to distribute public sector health care resources between geographic areas (such as provinces or regions and districts) according to the relative need for health services in each area.

The indicators commonly used to identify relative levels of need for health services, and thus applied in these resource allocation formulae internationally are:
• population size;
• composition of the population, as young children, elderly people and women of childbearing age tend to have a greater need for health services;
• levels of ill-health, with mortality rates usually being used as a proxy for illness levels; and
• socio-economic status, given that there is a strong correlation between ill-health and low socio-economic status and that poor people rely most on publicly funded services.

A growing number of African countries have also adopted such needs-based formulae to guide the allocation of health care resources, using a mix of these indicators. How well then are we doing in the region in matching government spending on health to health needs?

A questionnaire survey of researchers and senior government officials in selected countries in the region (Namibia, South Africa, Zambia and Zimbabwe) carried out in the EQUINET work on fair financing showed that there has been progress in the equitable allocation of public sector health care resources over the past few years in the region. However, the extent of progress and pace of change varies between countries.

In both Zambia and Namibia, the most under-resourced provinces and regions have seen increased allocations, while allocations to provinces whose share of resources is proportionately greater than their share of health needs have been gradually reduced. Although South Africa has a different system where it allocates domestic public sector resources for health and other services as a ‘block grant’ to provinces, there has also been considerable progress towards equity in the distribution of health care resources in the past few years. In Zimbabwe, progress towards equity targets has been constrained by significant absolute shortfalls in health care resources, due to wider economic difficulties. In the main, however, the countries surveyed were generally making progress applying some form of needs based formulae in the region, with positive gains for districts with greater health needs.

Achieving this progress is underpinned by an explicit policy commitment to equity and to redistribution of resources. For example, the Namibian 1998 health policy states that “Particular emphasis shall be paid to resource distribution patterns in Namibia to identify and accelerate the correction of disparities”. South Africa, Zambia and Zimbabwe have made similar declarations.

Experience from countries in the region point to some of the actions countries need to take to overcome barriers in implementing equitable redistribution of their health care resources.

Countries need to set explicit annual allocation targets to provide clear goals against which progress can be planned and monitored. These targets need to set a reasonable pace of change for the relative redistribution of health care resources to facilitate appropriate planning and avoid unnecessary disruption to services.

Even where these targets exist, countries may need to overcome further difficulties in successfully pursuing these targets. There may be a lack of senior staff at the national level to drive the process. Numerous vertical programs that protect allocations to specific services reduce the pool of general health sector funds available for equitable allocation between geographic areas. It is difficult to translate budget shifts into real changes in expenditure without achieving the more difficult task of also changing the distribution of staff, given their importance in the uptake of resources. Strategies must thus be put in place to facilitate a relative redistribution of staff. This may include negotiations with trade unions and initiatives such as offering additional allowances, preferential training opportunities and other incentives to attract health workers to rural areas.

Resource allocation is a highly politicised process and the resource allocation policy development and implementation process requires careful management in order for it to be successful. The progress reported from the countries surveyed is a sign that these issues can be addressed.

It is politically and technically easier to address these issues and redistribute health care resources when the overall health budget is increasing. Our still limited progress by 2008 towards achieving the Abuja target of devoting 15% of government funds to the health sector thus limits our progress towards more equitable resource allocation. Those countries that are increasing the overall allocations to the health sector have more leeway to effectively redistribute health care resources. All of the additional budget available annually can be allocated to the most under-resourced areas while keeping the budgets of relatively over-resourced areas static in real terms (only allowing a small increase to take account of inflation). It is also an issue for those advocating the Abuja target to monitor that these additional funds are allocated to these areas of greatest health need.

The progress made in the region needs to be protected and advanced: Governments need to engage with and involve key stakeholders, including parliamentarians to ensure their ‘buy in’ to and understanding of the strategies for an equitable sharing of available resources. We have an increasing number of champions for the Abuja commitment. We also need ‘policy champions’ at senior level in Ministries of Health, civil society and parliament to motivate for and monitor progress in making sure that these resources for health are equitably allocated to where they are needed most..

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET work on fair financing in health is available at the EQUINET website at www.equinetafrica.org.

Member states divided on WHO D-G election process and health worker migration
Riaz K. Tayob, Researcher for Third World Network

The World Health Organisation Director General (D-G) Margaret Chan described the recent WHO Executive Board meeting on 21-26 January 2008 as ‘stimulating, constructive and instructive.’ Chan challenged member states’ to provide her with direction regarding the contentious issues facing the WHO but the meeting failed to break the deadlock on issues regarding the selection criteria of the D-G and on how to deal with the International Migration of Health Personnel.

Developed countries opposed the inclusion of regional rotation in the selection criteria for the D-G, alleging that this may undermine the selection of competent candidates. However, many developing countries supported regional rotation as a selection criterion in order to promote balance amongst the regions who have had candidates as Directors-General, while not compromising on competence. The current selection process includes expensive campaign programmes that poor countries cannot afford to mount. Inclusion of the principle of rotation will go a long way to levelling the playing field.

The options presented in the Executive Board report on what the options were for addressing the proposed selection criteria changes were: (1) maintaining the status quo; (2) special consideration to candidates from certain regions; (3) and (4), two related options, considering geographical representation as the criterion for the establishment of the shortlist; (5) considering geographical representation as the criterion for the eligibility of candidates; and (6) using the same system of regional rotation as that applied to candidatures for elective office.
Board members supporting regional rotation of the post of D-G emphasised the need to ensure an equitable selection process and a level playing field among regions. They noted that no D-G had been appointed from three of the six WHO regions, even though qualified candidates from those regions had been proposed in past elections. Board members in favour of maintaining the current system said a pattern of regional rotation would necessarily restrict the choice of candidates, and would not therefore ensure that the most qualified person was elected.

One proposal was that the D-G be elected for 5 years with contribution until all the regions have contributed a D-G. Then it will start again, with the exclusion of the region of the outgoing D-G. While some supported this proposal, others, particularly from high income countries did not. It was proposed that the matter be set aside for two years, to give regions a chance to discuss the issue and the board would decide on it in 2009.

Member states were similarly divided on largely North-South lines on the issue of the international migration of health personal. Issues related to a global strategy, a code of practice, compensation mechanisms, a look into the failing training practices in the developed countries and better data for managing international health worker migration were raised in the discussions.

The developed countries position on WHO’s role on international migration was mainly for collecting information and developing non-binding codes of practice. Many developing countries, on the other hand sought effective actions including a global strategy and compensation. Member states adopted polarised positions and decision making was again deferred, which effectively maintains the existing status quo. Countries in Europe and North America pointed out that migration can have positive effects, such as migrants returning home with useful experience. However it was noted by other states that only 23 percent of the 130,000 health worker personnel abroad came back.

Attention was given to WHO work on the global code of practice, a matter seen to be a high priority for Africa. Without health workers, the Millennium Development Goals in Africa could not be achieved, and it was felt by some that the D-G should work with member states to come up with mechanisms for receiving countries to invest in training health workers in originating countries and assist with incentives.

Particularly raised by low and middle income member states was the observation that developed countries have failed in their own training policies and are now armed with ways of getting health personal from lower income countries, handicapping national health plans and deeply weakening the health systems of these source countries . It was raised that financial, equipment and technical support should be given in compensation, that certain discriminatory policies should come to an end and migrant workers receive the same salaries and benefits as paid to nationals of host countries. Further, headway was urged in developing effective measures to manage migration.

However, it was also noted that migration was a personal choice and that countries dealing with the impact of migration should create ‘task shifting to broaden the types of health workers’ who can provide care. Some members felt that a code of practice would not carry the weight of a ‘soft law’ as it was non-binding and not any kind of law, whether soft or otherwise.

While the WHO Secretariat reported that it was now getting better data and dialogue in place on migration a consultative process should now take place at the Executive Board meeting in 2009.

The debate on these two widely different issues signal that there is yet weak consensus within the WHO Executive Board on key contentious issues facing the WHO. There appears to be agreement on the need to act on such issues, but not yet on the direction of action. A division on “north-south” lines has maintained a deadlock on issues regarding the selection criteria of the D-G and on how to deal with the migration of health personnel. Their deferral for further consultation and review in 2009 contradicts the need for clear leadership on action, with action on health worker migration and retention particularly essential and urgent for developing countries affected.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET work on health worker migration is available at the EQUINET website at www.equinetafrica.org.