There is a general perception amongst academics, government officials, non-governmental organisations (NGOs) and the South African public at large that as a country we have good policies, but that we implement these policies poorly (as reported by the South African Institute of International Affairs in 2011). In fact, one of the fundamental issues that we need to address as a country is to try to understand why, despite good policies, adequate amounts of money and more skilled workers than in most parts of Africa, South Africa performs so badly (especially in health and education) when compared to other African countries. The tendency of policy makers is to blame downstream factors, such as general lack of capacity , “lazy managers” or “obstructive clinicians”, which to some extent is reflected in the research.
But my job today is to describe to you what it is like being at the rural coalface. Though I have loved working in a rural hospital for the past six years, it has also been one of the toughest periods in my life. Working in rural medicine is a bit like sitting on a rollercoaster: a combination of enormous challenge and reward, feeling exhausted and exasperated and then inspired and invigorated, seeing dignity and strength in patients, but also sadness and unnecessary suffering and death. One always feels stretched and one often feels as if one is hanging on by one’s fingertips. The rural idyll is something that might be experienced on weekends off, but the reality of the working week is that on the whole one is extremely busy and constantly rationing care and doing the best one can with the resources available.
It therefore might come as no surprise to the reader that at the coalface “policies” are more often seen as a hindrance than a help to the delivery of health care. Policies or programmes are often imposed from above, with no consultation and with little understanding of realities on the ground. There is usually poor data collection and feedback, lots of time-consuming and unnecessary paperwork and a focus on irrelevant aspects of care with the neglect of critical aspects. I need to make clear that good, realistic and helpful policies are greatly appreciated by most clinicians working at primary care level, as they improve care and the health of our patients (for example the new antiretroviral treatment guidelines).
But there are also many examples of policies and programmes that aim for an unrealistic gold standard (with its unnecessary and unhelpful complexity) and which, as a result, undermine the provision of good healthcare to as large a population as possible.
The first example of this is the new Road to Health Booklet. Although an extremely well-intentioned document, it is completely unrealistic to expect a busy primary care nurse to use this tool properly. It appears as if the designers of the document have never set foot in a packed rural (or township) immunization clinic, or tried to fill in the booklet with 60 screaming babies requiring injections in the waiting room outside. A year after it was introduced in our area, we still find that critical data such as mother’s HIV status and type of prevention-of-mother to child transmission (PMTCT) treatment provided is left out, whilst on the old, much simpler Road to Health Card, this was filled out really well.
Another example of where aiming for gold results in mud delivery is the District Health Information System (DHIS), a tool with so many parameters and different indicators that it is not actually possible to fill it out correctly unless each clinic has several dedicated data capturers with computers and technical support. As a result, much of the data is literally made up (I have seen it happen with my own eyes) and results in very poor quality data. At a recent meeting in my district, for example, several clinics had a higher than 120% coverage for measles vaccination. Yet managers and health planners scratch their heads and wonder why we get such poor quality data and complain that overloaded nurses at the coalface must just fill the data sheets out correctly. The DHIS needs to be simplified drastically, and nurses on the ground must get regular feedback on certain critical indicators that truly reflect improved care.
Many people balk at the idea of not aiming for a “gold standard” at a policy level – surely we must at least aim for the stars even if this isn’t really achievable?
Firstly, I would like to argue that we have ample evidence of how aiming for gold actually undermines the provision of care at grassroots level, and that we instead need to focus on simplicity and doing the basics really well. This would result in the biggest health impact on the greatest number of people.
Secondly, I think that we need to be cognisant of our limitations in terms of both human and financial resources in South Africa and recognise that we do not have the capacity to achieve gold right now, although it may be possible to aim for gold 20-30 years from now.
In the health sector we should be working within a framework of clear, straightforward priorities, aiming for what is achievable (silver?) and doing the basics extremely well, with simple monitoring and clear feedback to all healthcare workers.
I would like to argue that a policy cannot be labelled as “good” unless it is implementable. We need to recognise that putting policy together is the beginning of a long process. Policymakers need to be involved in drawing up implementation strategies, and government must support policy implementation through adequate finances and capacitating and empowering managers to manage the changes that will be required when policy is implemented.
Let me end with a final plea from the coalface that those of you who write policy use the following as your guiding principle: good health policies make things better and easier on the ground and result in improved patient care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This oped was featured in a paper for the Public Health Association of Southern Africa newsletter at le Roux K. How golden policies lead to mud delivery – and how silver should become the new gold. Newsletter of the Public Health Association of South Africa. November 15, 2012. ). The views expressed are those of the author and do not necessarily represent the views of PHASA.
Editorial
Hermann Biggs, a pioneering public health practitioner, said in 1894 that countries get the public health outcomes they invest in. “Within natural limitations, every community can determine its own death rate”. In this newsletter there are many facets of the choices made around this. The papers in all sections reveal a tension between the possibilities for significantly improved health, through new technologies and examples of promising practice, and of the resource and other barriers to their application. At national level, Charlotte Muheki Zikusooka questions in her editorial whether, for example, Ugandans are making adequate investment in “health for all” to get to “prosperity for all”. Other inputs focus on how the limited resources available are being allocated and spent. In 1894, when Hermann Biggs made his comment, global policies and practices had a less significant influence on health. Today their influence is growing. Various contributions in this newsletter recognise this, for example in the country call for WHO leadership in ensuring coherence in global health and for predictable innovative and mandatory international financing for health. The recently passed UN Resolution on the right to water and sanitation recognises both national and international roles in progressively realising the right to these profoundly important determinants of health. So if today we are adding to Biggs’ comment “… and we can globally determine the death rates of us all”, what rights and duties towards meeting public health costs does that imply?
As we turn the corner of 2010 and make our personal plans for 2011, it’s also appropriate to think about the plans and actions we will take to improve our lives as a nation. With election fever raging in my country, Uganda, there are more than enough promises on how to make Uganda a better country. However, some questions remain unanswered. For me, and possibly for many others, one area we need to give more attention to is the current and future health of our population. The question I pose is: are we heading towards “health for all”? Are we taking steps to achieve health care for all, more recently referred to as “universal health coverage”?
The World Health Organisation defines universal health coverage as “securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost”. In 2005, the World Health Assembly adopted a resolution urging its member states to work towards universal coverage and to ensure that their populations have access to the health interventions they need without the risk of financial calamity. This means that people should be protected from the costs of health care when they fall ill, that all people should access the services that are available to meet their health needs, and that services should meet conditions of quality and dignity, regardless of people’s ability to pay.
The goal for universal health coverage is; ‘No one should die because they cannot afford health care, and no one should be made poorer because they get sick.’ The questions we should grapple with are: how far has Uganda moved towards achieving this? And what specific plans are being laid for gradual movements towards achieving this?
It’s surprising to find that preventive and public health and health care were conspicuously missing from the principles and pillars of Uganda’s poverty reduction strategy of “Prosperity for All” (Bonna Bagagawale). For a long time, wealth creation and health have been considered to be inextricably inter-linked. People with ill-health cannot produce at their most desirable abilities, and poor people face many threats to their health. It can be a vicious cycle. Health or lack of health can be the difference between wealth and bankruptcy, especially when we consider the fact that one of the most common causes of poverty can be health care costs. In Uganda, households contribute about 49% of total health expenditure. We need to better understand the impact our health systems are having on people's health and wealth, and therefore on our economic growth as a nation.
In pursuing the goal of universal coverage for health, we should also look at how our health services are financed. In 2001, government officially abolished fee payment at public health facilities. This is one of the most commendable steps in moving towards achieving universal coverage. However, such an action would have been even more beneficial if was followed by additional actions that enhance faster movement towards “health for all”. Uganda spends about $27 per person on health per year, which is below the $40 per person recommended by the World Health Organisation for provision of a basic package. A significant proportion of the $27 spent on each person comes from external sources that are sometimes unsustainable. Sadly, even though fees have been lifted, about half of our total health funding still comes from direct cash spending by households at private health providers whose services are usually viewed to be a relatively better quality than those provided in government facilities.
This financing situation poses two problems. The first is obvious; our health sector is severely under-funded. Ministry of Health estimates current expenditure per person on essential medicines as only US$ 0.87 against an estimated requirement of US$ 10 per person. It is therefore not surprising that only 35% of the health facilities have six tracer medicines and supplies. The second is less obvious: financing a health system from people’s cash payments (out-of-pocket) is the most unfair, fragmented and least likely approach to take us towards “health for all”. Experts in health financing, in Uganda and the world over, acknowledge that universal health coverage cannot be achieved in contexts were countries have not effectively addressed the issue of equitable health financing.
So what do we need to do? Equitable financing is based on set of principles, namely: financial protection (no one in need of health services should be denied access due to inability to pay and households’ livelihoods should not be threatened by the costs of health care); progressive financing (contributions should be distributed according to ability-to-pay, and those with greater ability-to-pay should contribute a higher proportion of their income than those with lower incomes); and cross-subsidies (from the healthy to the ill and from the wealthy to the poor). Uganda’s current financing systems may still be far from what we need to achieve “health for all”, but it is also possible for us to take the necessary steps to achieve it.
As Uganda turns a new corner into 2011, hopefully we can start building the road map and taking these steps to move towards “health for all”.
This editorial first appeared in New Vision Uganda on 4th Jan 2011. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org.
In this issue we provide in full the communique of the Second BRICS Health Ministers’ Meeting held in January 2013. How far does this emerging concerted voice provide new impetus for the social justice needed for equity in health? While the familiar commitments are included to reducing major disease burdens, there are also welcome signs in the communique of attention to dealing upstream with the "risk" environments for health, of assessing the impact on health "of all public policies at national and international levels" and of commitment to "community empowerment". Equally the communique refers to a commitment to implementing measures for technology transfer and co-operation across low and middle income countries, such as for ensuring production and access to generic medicines as part of realising the right to health. The communique was less clear on two aspects: the active role of the 43% of the world’s population living in BRICS countries in realising these commitments, and the regional solidarity and integration needed in each of their regions to ensure to benefit to the weaker economies of their regions.
The BRICS countries, represented by the Ministers of Health of the Federative Republic of Brazil, the Russian Federation, India, People’s Republic of China and Republic of South Africa, met in New Delhi on 11 January 2013 at the Second BRICS Health Ministers’ Meeting.
The meeting recalled the Delhi Declaration of 29 March 2012 during the BRICS leaders summit and the Joint Communiqué of the BRICS Health Ministers at Geneva of 22 May 2012 including specific areas of work under the BRICS Health Platform for each Member State, focussed on the theme “BRICS Partnership for Global Stability, Security and Prosperity” to address emerging health threats.
The Ministers recalled that BRICS is a platform for dialogue and cooperation amongst countries representing 43% of the world’s population. The Ministers reiterated their commitment to the Beijing Declaration of July 2011 for strengthened collaboration in the area of access to public health and services in BRICS States including implementation of affordable, equitable and sustainable solutions for common health challenges. The Ministers committed to strengthen intra-BRICS cooperation for promoting health of the BRICS population. The BRICS Health Ministers resolved to continue cooperation in the sphere of health through the Technical Working Group.
The Ministers drew attention to the current global threat of non-communicable diseases and noted that in 2008, around 80% of all NCD deaths occurred in low and middle income countries. The Ministers recognized the significant role of BRICS countries in the global process of prevention and control of NCDs including the Moscow Declaration of April 2011, the WHA Resolution 64.11 of May 2011 and the Political Declaration of the UN General Assembly of September 2011.The Ministers recognized the need for more research into the social and economic determinants leading to occurrence of non-communicable diseases, amongst the BRICS countries. They resolved to collaborate and cooperate to promote access to comprehensive and cost-effective prevention, treatment and care for the integrated management of non-communicable diseases, including access to medicines and diagnostics and other technologies.
The Ministers also recognized the need to combat mental disorders through a multi-pronged approach including the World Health Assembly Resolution 65.4, consideration of a Comprehensive Mental Health Action Plan through sharing of innovations in the field of Mental Health Promotion, diagnosis and management, exchange of best practices and experiences amongst BRICS countries.
The Ministers renewed their commitment to the WHO Framework Convention on Tobacco Control and stressed the importance of research and study by WHO and other stakeholders into the social and economic determinants of tobacco use and its control.
The Ministers recognized that multi-drug resistant tuberculosis is a major public health problem for the BRICS countries due to its high prevalence and incidence mostly on the marginalized and vulnerable sections of society. They resolved to collaborate and cooperate for development of capacity and infrastructure to reduce the prevalence and incidence of tuberculosis through innovation for new drugs/vaccines, diagnostics and promotion of consortia of tuberculosis researchers to collaborate on clinical trials of drugs and vaccines, strengthening access to affordable medicines and delivery of quality care. The Ministers also recognized the need to cooperate for adopting and improving systems for notification of tuberculosis patients, availability of anti-tuberculosis drugs at facilities by improving supplier performance, procurement systems and logistics and management of HIV-associated tuberculosis in the primary health care system.
The Ministers called for renewed efforts to face the continued challenge posed by HIV. They committed to focus on cooperation in combating HIV/AIDS through approaches such as innovative ways to reach out with prevention services, efficacious drugs and diagnostics, exchange of information on newer treatment regimens, determination of recent infections and HIV-TB co-infections. The Ministers agreed to share experience and expertise in the areas of surveillance, existing and new strategies to prevent the spread of HIV, and in rapid scale up of affordable treatment. They reiterated their commitment to ensure that bilateral and regional trade agreements do not undermine TRIPS flexibilities so as to assure availability of affordable generic ARV drugs to developing countries.
The Ministers committed to strengthen cooperation to combat malaria through enhanced diagnostics, research and development and committed to facilitate common access to the technologies developed or under development in the BRICS countries.
The Ministers renewed their commitment for effective control of both communicable and non-communicable diseases through cooperation in sharing of existing resource information, development of risk assessment tools, risk mitigation methods, referral systems, life course approaches, community empowerment, monitoring health impact assessments of all public policies at national and international levels.
Recognizing that an effective health surveillance, including injury surveillance, is the key strategy for controlling both communicable and non-communicable diseases, that surveillance is also the cornerstone around which the implementation of the International Health Regulations (2005) is based and further recognizing that the countries may be using different models for surveillance based on different realities and best practices, the Ministers committed to strengthen cooperation in the mechanisms for planning, monitoring and evaluating disease prevention and control activities and capacity-building for effective health surveillance systems.
The Ministers urged focus on the unique strength of BRICS countries such as capacity for R & D and manufacturing of affordable health products, and capability to conduct clinical trials. The Ministers called for strengthened cooperation in application of bio-technology for health benefits for the population of BRICS countries.
The Ministers emphasized the importance of child survival through progressive reduction in the maternal mortality, infant mortality, neo-natal mortality and under-5 mortality, with the aim of achieving the Millennium Development Goals. They confirmed their commitment to a renewed effort in this area and to enhance collaboration through exchange of best practices.
The Ministers discussed the recommendations of the Consultative Expert Working Group on Health on coordination and financing of R & D for medical products and welcomed the proposal to establish a Global Health R&D observatory as well as the move on holding regional consultations to set up R&D demonstration projects. The Ministers urged that the entire process, including priority setting, should be driven by WHO Member States and should be based on public health needs, in particular those of developing countries, with the cost of R & D delinked from the final products.
The Ministers reiterated their support to the continued discussions on the process of reform of WHO, to better respond to global challenges in programmatic, organizational and operational terms, including the future financing of WHO, and welcomed the proposal to establish a financing dialogue based on priorities collectively set by WHO Member States in a structured and transparent process.
The Ministers acknowledged the value and importance of traditional medicine and need of experience and knowledge-sharing for securing public health needs. They urged for cooperation amongst the BRICS countries through visits of experts, organization of symposia to encourage the use of traditional medicine, in all spheres of health.
The Ministers confirmed their support for the United Nations General Assembly Resolution on universal health coverage and committed to work nationally, regionally and globally to ensure that universal health coverage is achieved.
The Ministers recalled the Beijing Declaration of the 1st BRICS Health Ministers’ Meeting in 2011, emphasizing the importance and need of technology transfer as a means to empower developing countries. In this context, they underlined the important role of generic medicines in the realization of the right to health. The Ministers renewed their commitment to strengthening international cooperation in health, in particular South-South cooperation, with a view to supporting efforts in developing countries to promote health for all and resolve to establish the BRICS network of technological cooperation. The Ministers acknowledged the need of use of ICT in Health services to promote cost-effective treatment in remote areas. They encouraged strengthened cooperation amongst the BRICS countries to share their experiences in e-Health including tele-medicine. The Ministers agreed to cooperate in all international fora regarding matters relating to TRIPS flexibilities with a public health perspective.
The Ministers agreed to establish platforms for collaboration within BRICS framework and with other countries with a view to realizing the goals and objectives outlined in this Declaration.
This statement is drawn from the Government of India communique on the BRICS Health Ministers meeting at http://pib.nic.in/newsite/erelease.aspx?relid=91533. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
There is consensus that states have an obligation to ensure Universal coverage (UC), through creating and realising an entitlement for everyone to be protected against the costs of health services and to have access to the effective, quality services they need. From an equity perspective, social solidarity is essential to achieve UC, through income cross-subsidies (from the rich to the poor) so that payments are based on the ability to pay, and risk cross-subsidies (from the healthy to the ill) so that people access health services based on need and not ability to pay.
So what options do east and southern African (ESA) countries have to reach this goal? While there may be some distance before reaching UC, the choices made at this stage are critical for ensuring steady progress towards it.
The 2010 World Health Organisation’s World Health Report unequivocally states that it is not feasible to achieve UC through voluntary enrolment in health insurance schemes. A number of ESA countries are introducing community-based health insurance (CBHI) as one means of pre-payment. These schemes will not move a country towards UC, although they may temporarily assist vulnerable households until mandatory pre-payment funding increases considerably and user fees are removed. However there is a potential danger that their existence may allow governments to abrogate their responsibility to promote mandatory pre-payment funding mechanisms.
Voluntary schemes can only be complementary or supplementary to mandatory pre-payment financing mechanisms, including tax and mandatory insurance. From international experience, mandatory pre-payment funding is well over 60% (and often over 70%) of all health service expenditure in countries that have health systems that are regarded as universal.
Many African countries are now discussing or introducing mandatory health insurance (MHI) schemes. However, caution should be exercised. If MHI contributions are placed in a separate pool to benefit the contributors only (which often is the case) this creates a tiered and inequitable system that does not ensure that all have the same service benefit entitlements. If the goal is to achieve universal coverage, then it is critical to minimise fragmentation in funding pools to achieve cross-subsidies. This means that if MHI is introduced, the funds collected from it should be pooled with those from government revenue to fund benefits for the whole population.
There has also been some investigation into introducing MHI contributions by those outside the formal employment sector. This should receive more critical assessment than there has been to date, especially as such contributions are strongly regressive and generate little revenue. If there is political insistence on generating funding from those outside the formal employment sector, indirect taxes, such as VAT, are a more equitable and efficient mechanism for achieving this goal, particularly in low-income countries. However, in the context of the large income inequalities present in many east and southern African countries, efforts to improve the collection of taxes from high net-worth individuals and multinational corporations may be more appropriate. Further, some countries are generating revenue for health from royalties on natural resources such as gold, copper and oil, and not only from taxes.
There is often an almost automatic assumption that there is no ‘fiscal space’ to increase funding of health services from government revenue. It is important to critically examine this assumption.
Government revenues in ESA countries range widely from about 12% of GDP in Madagascar to 33% in the DRC, while government expenditure ranges from less than 13% of GDP in Madagascar to 33% in Mozambique. These ranges are considerably lower than the levels in advanced economies for both government revenue (36%) and expenditure (44%). Government debt levels are considerably lower in ESA countries, ranging from less than 26% of GDP in Zambia to 64% in Madagascar, than the average for advanced economies of over 100%. Given that all of these measures are expressed relative to GDP and that some lower-income countries are able to attain higher levels of revenue and expenditure, there does appear to be scope to explore increasing the fiscal space within the so-called emerging markets and low-income countries.
Health financing policy choices not only relate to how revenue is mobilised for UC. Purchasing involves determining service benefit entitlements (what services are purchased with the pooled funds and how people will be able to access these services) and how service providers will be paid. Attention should be given to more active purchasing. This requires identifying the health service needs of the population, aligning services to these needs, paying providers in a way that creates incentives for the efficient provision of quality services, monitoring the performance of providers and taking action against poor performance. Active purchasing is critical for ensuring that available funds translate into effective health services accessible to all.
Moving towards universal coverage also requires improvements in service delivery and management. In particular, emphasis should be placed on improving services at the primary health service level, which are effective in reaching the poor and which are able to address most of the health service needs of the population in ESA countries. Improving primary health services offers the greatest potential for increasing population coverage affordably. In addition, it is important to broaden the decision-space of managers at facility and district level, so that they can be more responsive to patients’ and staff needs and to the incentives created through active purchasing. Equally decentralisation of management responsibility should be accompanied by development of governance structures that allow for accountability to the local community.
East and southern African countries have some way to go in moving toward UC. The choices made at various points in the journey will be important for achieving that goal. While the detail of those choices will depend on the context in each country, international experience and regional evidence suggest that far more emphasis should be placed on government revenue funding for health services and that funds from mandatory health insurance schemes should be pooled with funds from government revenue. We also need a richer body of evidence, including from research, to support active purchasing of services and measures for addressing service delivery and management challenges, as these are essential if universal access to services of appropriate quality is to be achieved.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org and read EQUINET Discussion paper 95: McIntyre D (2012) ‘Health service financing for universal coverage in east and southern Africa’
Over the last eight years there has been an increased interest in the use of performance based funding to ‘strengthen’ African health systems. Performance based funding has been used in different ways in the past within countries. With its growing popularity at global level, we need to be clearer about how these funding models work in practice and how far the performance based agenda being advanced at global level integrates meaningful participation and partnership in building health systems in Africa. How much are African actors setting and shaping this emerging global agenda?
Performance based funding refers to the idea of transferring resources (money, material goods) for health on condition that measurable action will be taken to achieve predefined health system performance targets. These performance targets may relate to particular health outcomes, to indicators of delivery of effective interventions (such as immunization coverage), to the utilization of certain services (like HIV counseling and testing), or to meeting targets in relation to quality of care. Because performance based financing offers incentives for positive action, many global institutions promote it as a way to efficiently and effectively reform the way that health systems are planned, financed, coordinated and steered. This is particularly true of external funding in many low and middle-income African countries, where there is growing evidence to suggest that performance based funding is being championed by global and bilateral funders as a key innovation in health financing. Funding agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank claim that performance based funding promotes reform in a way that can also be locally owned and accountable. This argument is based on a claim that performance targets and indicators will be developed through the active participation of local actors from within various African states, rather than being set by global agencies from the top-down.
Despite increasing use of these arguments for performance based funding within global health policy, there is still a lack of consensus about what performance based funding actually means, and little evidence to support the assumed causal pathways through which diverse African health systems theoretically achieve the governance outcomes claimed. There is also limited evidence about the extent of local participation in the design of performance based initiatives, and particularly in how far African actors – governments, civil society, health services, individuals and the private sector – have participated in the design, implementation and delivery of performance based funding initiatives. It is thus not clear who is participating in shaping, deciding and adopting performance based funding agendas and goals and how these decision-making processes work. There are questions about how targets are set, who sets these targets, as well as about how ‘performance’ is measured, and what exactly constitutes ‘good’ performance.
These ambiguities raise concern about how performance based funding complements other key processes that aim to broaden participation within ‘global health partnerships.’ Partnership has, for example, become a key concept within the Global Fund, World Bank and WHO processes. Millennium Development Goal 8 refers to developing a partnership for development, and the Paris Declaration aims to increase the ability of national and local governments and stakeholders to engage with and shape health policy at national, regional and global levels. However, if we don’t know how far African actors do actually participate in the formulation, implementation and evaluation of initiatives such as performance base funding, it is unclear how far they meet these commitments towards more cooperative processes, where all stakeholders engage with and shape health policy. Given that participation is a key normative aim in debates about furthering more equitable health diplomacy, it is important to know whether and how far performance based funding, as it is currently being practiced, fulfills these normative aims and is (or is not) an effective strategy for reforming health system governance in a participatory and equitable manner.
These questions are being explored in collaborative research currently underway in EQUINET, through the University of Sheffield, Queen Mary University, the University of Zambia, the University of Dar es Salaam, the Ministry of Health Zambia and the University of Kwazulu-Natal, as one input to regional dialogue on global health partnership and equitable health system strengthening.
Performance based financing initiatives have potentially powerful effects on health systems. Their agendas and preferred performance targets become embedded in, and potentially shape, local and national forms of state governance, participation and authority. The current context of global actors devising and advancing such models makes it is critical for African actors to proactively and effectively access and engage in the processes that shape these emerging global health policies: from design (agenda setting) through to implementation and delivery. It is equally critical to know the possibilities and limits of the spaces and places for such participation, especially those provided for by global actors such as the WHO, World Bank and Global Fund .
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
A growing number of the world’s workers are invisible to mainstream occupational health and safety (OHS): The vendor in Maputo or Nairobi trading on a city pavement, the person sorting waste on Durban’s municipal garbage dump, or the garment worker using her own home to make clothes for the local or international market.
These ‘atypical’ places of work have existed for many years, especially in developing countries. But OHS generally deals with formal workers in formal workplaces such as shops, factories, offices and mines. It does not accommodate much understanding of the social determinants of health, that is the relationship between risk, poverty and informal work, or how community health is affected by the conditions people work in.
Some risks are general to all forms of informal work, such as the low and unreliable incomes earmed, and the lack of cover by work-related health insurance. In addition, the different places of work present different types of specific risk: for example, street vendors are exposed to the sun and to vehicle fumes; stall holders in built markets face fire hazards; and those sorting waste are exposed to broken glass, putrid meat and discarded batteries on waste dumps. The different employment relationships, including self-employment, disguised waged work and informal waged work, also influence the risks that workers and their families face.
These employment patterns present challenges to the discipline and the practice of OHS. Profound institutional disconnects are becoming more apparent because of the numbers of workers involved, in the global north and south, and because of the growing public awareness of the informal economy.
OHS policies, norms and standards are usually set nationally, but it is local government that has most control over day-to-day working conditions. For example, street vendors’ conditions of work are vitally affected by the presence or absence of local government provision of public toilets, shelters for trading, lighting and refuse removal. Industrial out-workers who use their homes as places of production are affected by zoning and planning regulations, housing density and roads (including for access to health services and to markets). While calls are being made nationally for job creation through support to informal enterprises, local governments have in contrast smashed people’s livelihoods through evictions and confiscation of assets, undermining workers incomes and health. Better vertical institutional coherence between local and national levels could enhance opportunities for informal workers to earn better and more reliable incomes.
There are also horizontal institutional tensions and gaps. At national level, macro-economic policies lead to increased poverty and inequality that cannot easily be redressed by social policies. At local government level, informal workers engage with local government officials from departments such as sanitation, public health and environmental health that may have different policies and practices for regulating informal work, and that have limited understanding of the positive economic role played by the informal workers.
Is a reformed and more inclusive occupational health and safety possible, not only conceptually, but also in terms of enabling realistic compliance, with shared responsibilities between the state, informal workers, and employers (where these exist)?
Innovative work done by the ILO and others have tended to allocate most of the responsibility for ensuring health and safety to the informal workers themselves. But it is known that poorer informal workers do not easily prioritise their own health above their need to earn better incomes and thus may not invest in improving the safety of their working conditions. For example, industrial outworkers earning piece rates for stitching garments may not take regular breaks; waste pickers may not use personal protective equipment if it slows their work down; or headload porters may not carry lighter loads when they earn according to loadweight.
New evidence of opportunities for informal workers to engage constructively with local government over improved OHS is emerging from a five-country research and advocacy study in Brazil, Ghana, India, Peru and Tanzania, being done by Women in Informal Employment: Globalizing and Organizing (WIEGO). WIEGO is a network that seeks to improve the status of the working poor in the informal economy, especially women, through support for increased organization and representation; improved statistics and research; more inclusive policy processes; and more equitable trade, labour, urban planning, and social protection policies. The network implemented participatory research with worker groups, many of whom are affiliates of WIEGO, followed by institutional mapping of OHS in each country and in selected major cities. The studies highlighted that new worker movements – organizations and associations, often structured along sectoral lines – are critical for effective engagement over recognition and improved conditions. These movements emphasise the right to work, advocate for recognition of informal work and many are collecting rigorous data about the contribution of informal work to the local and national economy, in order to strengthen their position. Their highest expressed priority, after higher and more reliable returns to their labour, is for access to health services.
We are now exploring pathways of policy influence, engaging in international and national OHS platforms and dialogues, and encouraging a change in the curriculum for OHS training. Powerful vested interests are obviously stacked against such reforms, including from within mainstream OHS disciplines, and from global owners of capital who are presently ‘off the hook’ in terms of their responsibility for the health and safety of the millions of workers who produce for them. However the research in each of the countries has identified encouraging points of entry and increasingly organized advocacy for a more inclusive OHS.
For more information on the issues raised in this op-ed please visit www.wiego.org and the OHS newsletter at http://wiego.org/ohs/newsletter , or write to Francie Lund lundf@ukzn.ac.za or Laura Alfers Laura.Alfers@wiego.org
There is longstanding stated policy support for health equity in East and Southern Africa. Social protest over inequality and pressure around delivery on these policies is equally longstanding, from struggles for political and economic rights to recent struggles over constitutional rights to food, water, shelter, healthy environments and health care, to hold the state and corporates accountable in relation to these entitlements, or to negotiate fairer benefit for Africa from use of its resources in the global economy.
So it confronts widely held social values when inequalities in health persist or widen, notwithstanding aggregate progress and economic growth. Why should women in Africa have 39 times the risk of dying in pregnancy and childbirth than those in high-income countries? Why, across the countries of East and Southern Africa should there be seven-fold differences in under five year mortality and 22-fold differences in the rate of women dying due to pregnancy and childbirth? Within some countries of the region nearly one in five children under five years die in the poorest households. Children of mothers with lowest education are five times more likely to be under-nourished than those with highest education.
People ask: Why shouldn’t all children, adolescents, mothers or households expect the nutrition, health and mortality outcomes of the most educated, wealthiest households or best performing geographical region of their country?
We live in an integrated regional community and global economy. Money, trade, raw materials and goods cross porous national borders. How then can such enormous differences between communities and countries be acceptable, particularly for conditions that can be prevented through technologies that have been known for over a century, including safe water, toilets, adequate food, decent shelter, access to midwives and so on? Why should huge numbers of people continue to suffer diseases of injustice?
In a 2007 Regional Equity analysis (http://tinyurl.com/9lrpl4e) , the EQUINET steering committee analysed the inequalities in health in East and Southern Africa and identified the policies and measures that could close them. The steering committee resolved to track what progress was being made in these areas, in a process called the Equity Watch. In 2012, EQUINET has produced a Regional Equity Watch that updates the 2007 analysis, drawing on a framework developed with review input from the East, Central and Southern African Health Community, WHO and UNICEF. The book is now available on the EQUINET website (www.equinetafrica.org) and acknowledges the many people and institutional contributors and processes that made input to it.
The 2012 Regional Equity Watch is essentially a watch on progress of what we know works to close gaps in health. It provides evidence on numerous policies and interventions that are being applied in health systems, agriculture, safe water and sanitation, in relation to employment and urbanisation and other areas that have closed gaps in inequality within the region. For example, investments in smallholder food production, especially for women farmers, have reduced inequalities in nutrition. Many countries have successfully implemented measures to encourage female children to enrol and stay in primary education. There are examples of activities that reduce urban poverty by enhancing employment, improving living conditions and investing in participatory planning, particularly in unplanned urban settlements. There are initiatives that have aligned national and international resources to support community management of safe water or to fund and support primary health care services and community health. There is promising practice in overcoming geographical differentials in access to health care through investments at primary care and community level, including through community health workers, community outreach, social organisation and participation, moving away from fee payments at point of care and integrating specific programmes within comprehensive primary care services. These practices underway repeatedly point to the possible.
However the 2012 Regional Equity Watch also asks why we are not making more progress in implementing the possible. It highlights that while there has been positive economic growth across most countries of the region in the whole of the 2000s, in many countries growth is occurring with increasing poverty and inequality, generating social disadvantage. Rapid, unserviced urbanisation, inadequate investment of profits and surpluses in new jobs, and significant disparities in access to agricultural resources, are common pathways found for growth with inequity. The Regional Equity Watch reports unacceptably slow progress in improving coverage of safe water and sanitation, low and unequal coverage of early childhood education and care and secondary education; inadequate public investment in improving access to land and other inputs for female smallholder food producers and inadequate resources - people, medicines and money- reaching and being absorbed by the community and primary care level of health systems. It raises concern about inadequate progress in formalising and resourcing mechanisms and capacities for participatory democracy and social power in health systems, particularly when observing the growing power that transnational corporates have in areas fundamental to health, such as in social determinants like food security or health service inputs like medicines.
Inequality within the region is overshadowed and underpinned by the scale of inequality globally. It points to a scale of inequality that needs to be more centrally and explicitly addressed in global dialogue, including on global development goals. At current rates of progress in narrowing the global gap in incomes, it would take more than 800 years for the bottom billion people – many of whom live in east and southern Africa – to achieve even 10 per cent of global income. The Watch points to the continuing net outflow of resources for health from the region, including through debt servicing, skilled worker out-migration, unfavourable terms of trade and extraction of unprocessed minerals and biodiversity. It questions the pro-cyclical, deflationary macroeconomic model that has dominated economic policy globally, given its failure to yield the sustained, inclusive or equitable growth needed to achieve social goals, and the unacceptable depths of deprivation and unacceptably wide and avoidable gaps in health and survival, and in coverage of services in our region. It raises frustration that slow progress in the strength, power and effectiveness of African voice in global decision making is being outstripped by a rapid pace of global extraction of African resources.
Many of the policy choices for a cohesive healthy society in East and Southern Africa raised in the 2012 Watch appear to be a matter of common sense. Beyond technical knowledge, therefore, their implementation depends on leadership and social action. In analysing progress and highlighting both the gaps and the possible, the 2012 Equity Watch aims to nurture and inform both the social intolerance for injustice and the affirmative leadership and demand for just alternatives.
Please send feedback or queries on the issues raised in this briefing or requests and comments in relation to the Regional Equity Watch 2012 to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org or download the 2012 Regional Equity Watch at http://tinyurl.com/8t2fqqf and http://tinyurl.com/8g6obf9.
In a changing global environment, African countries have made clear their intention for the World Health Assembly (WHA) to hold its global leadership in health. At the WHA in 2012, reforms of the World Health Organisation (WHO) were under discussion, with the aims of improving outcomes in agreed global health priorities, ensuring greater coherence in global health, and effective, efficient, responsive, objective, transparent and accountable performance. In a context of a multitude of new global institutions, foundations and alliances involved in health, African countries at the WHA collectively, through Senegal, raised that the WHO provides an organisational means for global processes to value multilateralism, inclusivity and respect for the authority of member states through the WHA. The Africa Group of countries called for the reform process to contribute “to the shaping of a stronger, more effective, more responsive and more responsible WHO.” In the discussion on the reforms, African countries unanimously urged for countries to ensure that whatever the reforms achieve, they must strengthen WHO’s position as the leading global agency for health.
Achieving this calls for more than rhetoric and statements of intent. In the past decades, the World Health Assembly provided a forum for states to review policies and strategies in health and make resolutions that they would implement. In recent years, a host of new players from non health sector agencies, non-governmental organizations, non-state providers of health, industry, faith-based organizations, civil society, foundations and corporates have become involved in decision making on and implementation of health strategies. Over the past decade more than 100 private global foundations have emerged working on different issues related to health. This multiplicity of actors bring multiple visions, mandates and modes of functioning to global policy processes. Alliances such as the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Health Workforce Alliance are now working on issues that the WHO has been working on over the years.
A Ugandan delegate to the 2012 WHA questioned the number of partnerships that WHO was now involved in, arguing that this detracted from its major mandate and role. African countries at the WHA observed that navigating this complex environment calls for WHO to rather strengthen its own intergovernmental nature and particularly the role of countries in its decision making processes. Permanent secretary of the Ministry of Health in Swaziland, Mr. Stephen Shongwe, said for example “As Swaziland we want to reiterate that the WHA is the supreme organ of the WHO and should have the final say in all the decisions. There should be flexibility for the WHA to make decisions. Resolutions should not just be crafted based on the recommendations of the Executive Board. Member states should be able to raise issues that may arise and not just be confined to the defined issues in the agenda.”
African countries’ concerns were addressed in part when the 65th WHA in 2012 resolved that any reform of the organisation be guided by the principle that the intergovernmental nature of WHO’s decision-making be paramount. The Director General was requested to present draft papers on WHO’s engagement with non governmental organisations and with private commercial entities.
However, while this may be a necessary condition for the organisation to claim global leadership in heath, will it be enough? Without the funds coming from the same member states, how will it deliver on its decisions? And will member states use their strengthened and collective decision making to safe guard public health, even in the face of corporates and foundations whose earnings exceed the GDP of many member states?
Global leadership in health demands an organisation that fearlessly and strategically protects public health. At a Special Session of the WHO Executive Board convened in November 2011 to consider the Reform Agenda, the WHO director General Margaret Chan then said that WHO, in "the interest of safeguarding public health", was "not afraid to speak out against entities that are far richer, more powerful, and better connected politically than health will ever be", adding that "we need to maintain vigilance against any real or perceived conflicts of interest."
Civil society actors at the WHA supported this role of public health protector, but questioned whether it is being delivered. They argued that the prospect of money has led the organisation to engage in partnerships that have weakened this leadership role. They held member states liable for this situation, observing that WHO can only become a stronger intergovernmental institution when member states increase their funding support.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org