At the just ended World Health Assembly (WHA 66) member states reviewed progress in implementing the WHO Global Code of Practice on International Recruitment of Health Personnel. This was the first review report since the adoption of the Code three years ago. The Secretariat report tabled at the WHA showed that few African countries had designated authorities for monitoring and reporting on the Code, and that only one African country had submitted a report on implementation. This low response has been commented on in April 2013 EQUINET newsletter (http://www.equinetafrica.org/newsletter/index.php?issue=146)
When the report on the health workforce, which included progress on the Code, was discussed at the WHA, the discussion was somewhat muted. Only fourteen member states commented on the report, and only eleven made reference to the Code. African countries speak as a group on issues through a nominated delegate. Burkina Faso spoke for the 46 WHO-AFRO member states, and Ethiopia spoke in support of Burkina Faso. Those that attended the WHA in 2010 when the Code was adopted observed the contrast to the exciting atmosphere of intense debates and the large number of voices that were heard at that stage.
So what has happened over the last few years? At a side event at the WHA, participants took stock of the progress, or lack thereof, in the implementation of the Code. The side event was organised by Medicus Mundi Internationales together with the Governments of Malawi and Belgium, EQUINET and AMREF. Participants raised various challenges that member states faced in getting the implementation of the code off the ground, including their lack of preparedness, the poor mobilisation of national level stakeholders and limited engagement of civil society since the Code was adopted. Ministries of Health were also reported to be overwhelmed with other issues. WHO and some countries reassured that despite low reporting, work was underway. The fact that many countries had reported was seen as a positive sign, given the voluntary nature of the code, as was the commitment of Northern countries, (USA, EU) and WHO Secretariat to support its implementation.
The muted African member state reaction to the report at the WHA by the Secretariat may, as raised above, be explained by the diplomacy process of the Africa Group, where African ministers reach agreed positions, as they did on this issue, giving little added value in countries making further individual statements. While shared position and voice is an important feature and strength of African diplomacy, it is also common practice for countries to state/restate their position as they “align themselves with the statement made by the delegate for...... region”. This allows countries to give force behind specific areas and for country experiences to add weight to positions raised. African countries may also have been reluctant to raise their voice in the WHA process given lack of input to the Secretariat report, as raised earlier.
Whatever the reason, and this needs to be further explored, the low profile adopted by African member states on this occasion may have sent a message that the Code is not perceived to be a key policy instrument for the region to address its continuing challenges over the production, retention and migration of health workers. If so, then given the energy that went into its adoption, where are the shortfalls?
There are lessons from other processes at the WHA. Voluntary codes may fall out of attention as other issues demand more urgent government attention. If this is the case then the implementation of the only other WHO Code - on breast milk substitutes – provides a lesson on the role of civil society to galvanise countries into action, particularly with technical support of WHO. Civil society has kept the code on breast milk substitutes alive and current and generated pressure within countries to ensure that it is implemented. Is this possible for the Code of Practice on International Recruitment of Health Personnel? In theory it is achievable. The loss of health workers in countries of highest health need is still a concern, and communities and health workers have an interest in the issue, as it affects their rights and services.
Civil society organisation on health worker issues has partly been through the Global Health Worker Alliance (GHWA). The fact that the GHWA currently has no executive director weakens its support for civil society input, and creates uncertainty about its future. The third global forum on health workers organised by WHO and the GHWA will be held in Recife, Brazil in November 2013. It should provide an opportunity to review and give profile to the role of the Code in addressing health worker issues, and give new momentum to the role of civil society in its implementation. This however does need civil society, health worker organisations and academics within countries to ask questions on the implementation of the Code, to ask delegations for feedback from the discussions held at the WHA, and to know, share information on and support implementation of the Code.
It is also a matter of concern that reforms at the WHO Secretariat have diminished the capacity of the unit dealing with health worker issues. Fewer people are now contending with an increasing workload, weakening the capacity of that unit to play a leading role in support of member states and the wider community.
A number of civil society organisations, including MMI/Peoples Health Movement, and the International Federation of Medical Students Associations (IFMSA) spoke as observers at the WHA deliberations on the Code. Most of the presentations raised the weakening of these institutional capacities for supporting its implementation and called for a stronger Health Systems Policies and Workforce unit at WHO Secretariat and a stronger GHWA.
In a world of rapidly shifting policy attention, it seems to be important to organise and secure the resources, institutional roles and capacities for implementation when negotiating new instruments, particularly if they are voluntary as the Code is. The next few years will be a test of whether the slow implementation is a feature of countries preparing for a marathon rather than a sprint, or whether it is a feature of diminishing interest in the race. Issues are also sustained when they have a place in the current focus of policy attention. The focus of this year’s WHA and of much current global engagement in heath was on universal health coverage (UHC). It was thus important that health workers were identified as a central element of that policy.
This then may be the important message that we need to send. Delivering on UHC is not possible without health workers, and one sign of that delivery at global level is the extent to which countries are operationalizing the Code and implementing its intentions. The international agreements negotiated by member states at the WHO are instruments for achieving UHC, whether voluntary or not, as are the global and national capacities in governmental and non-state institutions for leading and being accountable on their implementation.
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
Editorial
When I joined the Global Fund in 2003, my main responsibility, as the Manager of Online Communications, was to help the organisation deliver on its commitment to transparency. One of the conditions set forth by donors was the ability to trace every granted dollar to make aid recipients accountable for how it would be spent. This meant, among other things, developing and maintaining a website that quickly became a central repository of all Global Fund data and information. We were praised for the unprecedented level of openness that this made possible. But over time, I realised that something was (and still is) missing.
If you Google “Global Fund” + AIDSfor news stories, the overwhelming majority of results are articles that are reactive (i.e. based on official announcements, press releases and conferences) or that make reference to the Fund only indirectly or anecdotally.
Apart from experts in donor governments and a handful of technical partners, Aidspan and the likes, very few local organisations or people take advantage of Global Fund transparency to trigger open and well-informed discussions on aid effectiveness. How can this be when all the data and documents are “just a mouse click away”? Close to $20 billion were disbursed in a few years. Where did it all go? Who got it? To do what? With what success?
The Fund’s website should be an extraordinary tool to get the facts right on those questions. It should be a gold mine of stories for local journalists, civil society organisations (CSOs), activists and parliamentarians in recipient countries. But, for the most part, they aren’t panning for this gold. What is transparency all about if it doesn’t translate into increased accountability at country level, and if people and communities for whom the Global Fund was created don’t use it to keep pressure on grantees, to voice their concerns and claim their rights?
The reality is that using Global Fund data to make recipients accountable is out of reach to most concerned people because they lack access to the Internet, because they don’t have enough time or the technical skills – and because there are obstacles to freedom of information and speech.
Global Fund transparency, as it is practised today, is more of a barrier to journalists and in-country activists than anything else: intimidating piles of reports filled with obscure language, countless files and downloadable materials that reassure technocrats in donor capitals but that don’t say much about the reality of what happens to the funds when they hit the ground. Understanding, processing and making use of this information requires learning about technical jargon, Global Fund internal processes, and the roles and responsibilities of different local partners. One needs to be familiar with web searching techniques and data processing methods, and to have some basic communication skills to translate often indigestible data into a plain, common language that non-technical audiences can understand.
Last, but not least, trying to make the powerful accountable in countries with no such tradition is a risky game for the few activists and concerned citizens who dare to do so. With the rise of the “Open Government” and “Open Data” movements in Africa and elsewhere, people may fear less for their lives than they used to, but threats and intimidation are still very much a daily reality for local watchdogs.
This leads to a strange paradox. As I heard recently: “That is almost the flip side of transparency. It’s very easy to use transparency if actually you want to drown people in information. I know it’s a tactic for lawyers: just give too much information to people, and it will be difficult for them to really figure out what is important.” Certainly, the Global Fund did not create this complexity consciously and voluntarily, but the result is the same: mountains of data and files that have the effect of shielding grantees and the Fund’s bureaucracy from too much scrutiny.
Today, in the wake of the Global Fund, a growing number of international organizations have committed to making their information on aid spending easier to find, use and compare. More than 120 UN agencies, multilateral banks, bilateral donors and NGOs have already endorsed the IATI (the International Aid Transparency Initiative) and have agreed to convert their data into a common standard. While this is a major step in the right direction, a simple lesson should be drawn from the Global Fund’s experience: Opening up databases is not enough for change to occur in the way local accountability happens. Rather, change requires a real commitment to accompany those for whom this data is made available as they make their first steps in the maze of aid transparency.
Here is what I think needs to happen.
Build capacity to use Global Fund data. Local watchdogs need help to stay afloat in the aid data deluge, to learn how to use the tools of transparency to have impact. While their work may not require the same level of technical sophistication as global watchdogs, they need training. They need to be able to understand who does what and where to find the information. They need to acquire watchdogging skills, using real-life case studies and guidance based on local needs. Watchdogs usually don’t focus on one single aid provider; no organisation would be justified in developing such a programme in isolation. Therefore, the capacity building should be a shared responsibility, and a combined and coordinated effort, by all concerned parties, such as the IATI signatories and some global or regional players in the field of transparency. The Global Fund has the credibility to take the lead on this. It should sit down with IATI partners to explore how a step-by-step, scalable, replicable and carefully targeted capacity-building programme could be implemented. As a critical side effect, such an initiative could provide some recognition to participating local aid monitors, thus breaking their isolation and protecting them in the exercise of their democratic rights.
Declare war on gobbledygook. Besides data, transparency is first and foremost about communicating in plain language. How much sense does it make for thousands of people, including the Secretariat’s own staff, to have to turn to a newsletter like the GFO to understand the rules of the game of a multi-billion dollar transparent organisation? The Global Fund should elevate proper communications with implementers (and others) to a top priority. The Fund should stop relying on technical staff to draft documents that are meant for wide distribution. It should reinforce the capacity of its Communication Department by adding writers who can translate complex policies and procedures into plain language.
If the Global Fund were to support and encourage local watchdogs, this would constitute a valuable early warning system for the Fund – one that complements the work of the local fund agents and the Office of the Inspector General. Building the capacity of local watchdogs to use transparency could greatly reinforce the Fund’s own risk management and fraud prevention efforts, at little cost. The Global Fund should also tackle its poor communications with implementing countries by addressing the Secretariat’s capacity issues in this field. With the 2015 MDG deadline on the horizon and the development community bracing for what comes next, with pressure on the Fund to improve its oversight mechanisms, and with the need for the Fund to position itself for a possible redefinition of its mandate, these measures could reassure donors about its capacity to be a truly different business model in international development.
The Global Fund should renew its commitment to transparency and take bold steps to promote wide use of its transparency in recipient countries. Information is power. It’s time to give power to those for whom the Global Fund was created so that transparency can fully achieve what it is meant for.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Robert Bourgoing joined the Global Fund in its early days, in 2003, and was a senior member of its communications team until last year. He is a trained lawyer and an experienced journalist, and currently works as an independent consultant. This commentary was originally published in Global Fund Observer (GFO) Issue No. 215 on 23 April 2013, produced by Aidspan.
Diplomats, officials, civil society and private actors converging in May at the World Health Assembly bring to the spotlight the increasing extent to which decisions on policies and resources for health systems are taking place at global level. Beyond the health sector, global level negotiations on trade, investment, migration and climate have significant impacts on health. Foreign policy has traditionally concerned itself with economic and security issues. Health has been brought to foreign policy when epidemics have threatened trade or economic expansion, or as a way to generate positive relations between countries. Health diplomacy in colonial Africa did both, preventing disease from affecting colonial economic interests and providing medical services to legitimize colonial expansion.
Health has in recent decades assumed a higher profile as a goal of foreign policy at the global level, such as in the negotiation of global responses to treatment rights for people living with HIV, or the negotiation of competing interests around recruitment and migration of health workers. Political attention to health in global policy became more intense and sustained after 2000, with many new global conventions, funds and institutions. This raises twin challenges for African actors in global health diplomacy (GHD), to ensure that the norms and goals of public health are not lost in the differing norms and goals of foreign policy, and to ensure that African interests are advanced and protected within global processes.
With its high share of global mortality and illness, the stakes are high for Africa. Hence, for example, in the context of an HIV pandemic that was ravaging the continent, African countries played a lead role in negotiating the 2001 Doha declaration on the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) and Public Health, which provided for WTO Members’ right to protect public health and access to medicines for all. Africans also provoked the global negotiation on the recruitment of health workers, given that African health systems were losing millions of dollars invested in training of health workers and losing key people for service delivery. Raising such issues at the global level takes diplomacy beyond negotiating economic self-interest, and raises shared risk, and shared responsibility as a basis for collaboration across borders. While this presents new opportunities for addressing Africa’s health challenges, global solidarity is not a dominant feature of diplomacy, and health demands may be diluted or overshadowed in foreign policy processes as states secure their interests in response to financial, climate, resource, food and other threats to security. The transborder nature of GHD also raises caution in the public health community as it may disguise a more direct and influential hand of private interests, including in global health institutions.
New actors are also becoming increasingly influential in global diplomacy. Brazil, China and India, each facing their own health challenges, have become more engaged and influential in GHD, and south-south cooperation has opened up new avenues of influence, including for African countries. Countries in the ‘global south’ bring new perspective to global health: For example China’s principles of peaceful coexistence avoids interference or conditionality in the relations between states, with foreign policy used to widen its access to resources and markets and to speed up its own modernisation. Brazil’s pursuit of ‘structural cooperation in health’ in contrast brings a rights based approach to health, raising the precedence of health in global economic and trade platforms, such as in its negotiations on patents, counterfeits and technology transfer. We discuss other examples of approaches to diplomacy in EQUINET discussion paper 96 ‘Concepts in and perspectives on global health diplomacy’.
This raises the question: Are there uniquely African perspectives or approaches in GHD? This is not easy to answer by reading published materials- much diplomacy on health in Africa appears to be unrecorded in the public domain, or documented by northern or global actors. Across African countries, there is evidence of some principles more commonly informing foreign policy. Reciprocity and interdependence is rooted in traditional norms that give more weight to the interests of the community than those of the individual (‘I am because we are’). These principles informed the unity around struggles for national independence and Africans have continued to build unity in global engagement through alliances across sovereign states, such as in the Africa Group at the World Health Assembly. Liberation and nation building have also been central to recent African history. This ‘liberation ethic’ has continued to inform diplomacy post-independence, from the shared stance against apartheid South Africa to a foreign policy engagement on economic decolonization. As a form of public diplomacy, this foreign policy image has also been used to bolster domestic legitimacy. Many African countries are also explicitly pursuing developmental foreign policies, raising economic justice and seeking to protect the authorities needed for developmental states within international policy, albeit with some diversity of view on what a developmental foreign policy means.
How far have these approaches influenced global diplomacy on health, a sphere that has been more commonly associated with emergency relief and development aid? Africans are increasingly involved in GHD, and initiatives such as the ECSA Health Community Strategic Initiative on GHD seek to strengthen African engagement and influence in global health platforms. There is evidence from examples such as the 2001 Doha declaration, the claims on health worker migration or recent negotiations on technology transfer or on research and development that the liberation ethic, unity and developmental foreign policy are informing diplomacy on health. It is however difficult to read how far these principles are being actively crafted for the 21st century and used for health. For example, how do principles of sovereignty, non-interference and self determination that have been central to nation building accommodate the human rights approaches or concepts of shared risk and shared responsibility that are being used to raise health as a goal of global diplomacy? How effectively are newly emergent south-south alliances, such as BRICS, strengthening the unity (and regional integration) within African countries that is seen to be key to global engagement? What co-ordination across sectors and institutional changes need to take place within African countries to strengthen their hand in advancing a liberation ethic and developmental foreign policy in health negotiations at global level?
Further information on the issues raised in this editorial can be found in EQUINET Discussion paper 96 at http://www.equinetafrica.org/bibl/docs/GHD%20concept%20paper%20Jan2013.pdf. The discussion paper is an interim working paper to draw feedback and EQUINET invites you to send your comments on African approaches to health diplomacy to include in the next edition. Please email your comments and inputs on the questions raised to admin@equinetafrica.org.
The two editorials in this months newsletter address issues that have significance to African health systems - medicines access and health worker migration. In the first, Germán Velásquez raises concern that the latest joint WHO, WTO and WIPO in its silence about health and access to medicines in the publication effectively subordinates the right to health to international trade rules. A more direct challenge to patent systems is argued for, and a further article in the newsletter from the Federal Reserve Bank of St Louis goes further to argue that the patent system suppresses innovation and should be abolished. In the second editorial, Yoswa Dambisya and colleagues raise concern about a different silence: They ask why African countries have become so silent on implementing the Code on International Recruitment of Health Workers, given their prolonged struggle to obtain it. Both raise questions about the effectiveness of global level diplomacy as a platform for addressing key issues affecting public health in Africa. A new working paper on the EQUINET website ("Concepts in and perspectives on global health diplomacy") explores this further, and invites views and perspectives on the questions raised.
On 5 February 2013, in a ceremony at the WTO, the three Director Generals of WTO, WIPO and the WHO launched the trilateral publication titled:
“Promoting Access to Medical Technologies and Innovation”, the fact that a publication regarding public health was launched at the headquarters of the WTO is a reflection of the increasing importance of public health issues in the context of WTO and WIPO, an issue on which the WHO has been the leader.
The study shows progress on the part of the WTO and WIPO since they talk about these issues without “taboo”, however it does not give a complete picture of the extent to which WHO has lead this issue over the past decade. 17 resolutions by the World Health Assembly adopted between 1996 and 2012 are cited in the report in a table on page 44 concerning intellectual property and health. These resolutions are of highly prescriptive character, for the secretariat and for countries on how to protect public health from the possible negative impact of new international trade rules. Despite numerous resolutions and publications in the last 15 years by the WHO on this issue, many of which are not mentioned in the report, the disclaimer of the document says that “(…) the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the WHO, WIPO and the WTO be liable for any consequences whatsoever arising from its use.”
This could give the wrong impression to the reader of this report that the WHO has no opinion on whether a compulsory license may, in special circumstances, facilitate access to drugs, or if an international exhaustion regime, that allows parallel imports from any country can reduce the cost of drugs and therefore contribute to access. The 17 WHA resolutions give a mandate to the WHO to engage, promote and defend mechanisms and policies in favour of access. Thus, it is important to ensure that the Trilateral Cooperation with WTO and WIPO do not lead the WHO to share a “neutral” vision, totally disengaged from its mandate of protection of health. This would be contrary to the exemplary leadership from the WHO on “The Revised Drug Strategy”, WHA 52.19 in 1999 or the “WHO Policy Perspectives on Medicines” published in 2001 that says: “National patent and related legislation should:
• Promote standards of patentability that take health into account. (…)
• Incorporate exceptions, trademark provisions, data exclusivity and other measures to support generic competition.
• Permit compulsory licensing, parallel importation and other measures to promote availability and ensure fair competition.
• Permit requests for extension of transitional period for TRIPS implementation, if needed and if eligible.
• Carefully consider national public health interests before instituting TRIPS-plus provisions
As expressed by the three NGOs that addressed the Executive Board in January this year, on the issue of IP and public health, the Trilateral Report is a weak and unambitious document in which the WHO does not fully reflect the work it has done on these issues in accordance with its mandate.
The question that we as member states of the WHO, international organisations with a clear vision regarding the priority of health such as UNDP or UNAIDS, or UNICEF, non-profit NGO’s working on public health, the academia and all the sectors concerned with the promotion of health and access to medicines should ask is what is the relevance and status of this report in the face of the 17 resolutions by the WHA giving a clear mandate that is not reflected in this document.
It would seem that we have overcome the debate that began in the early 2000’s about which one was first, the right to health or international trade rules, but in this trilateral publication, the mandate of the WHO to promote public health seems to have been subordinated to accommodate IP and trade interests that WIPO and WTO promote.
Therefore, the Trilateral Report is in the nature of a “Wikipedic” report that describes what others have said on the issue, without any of the three organisations saying what they think. The 251 page document contains no recommendations, not even a conclusion, or any guidance. In comparison, the 2006 WHO report on Public Health, Innovation and Intellectual Property rights (CIPIH report), led by the former president of Switzerland, Ruth Dreifuss, contained 60 recommendations.
A Japanese saying goes: “what a man does not say is the salt of a conversation”. We can say that this report…is an insipid report…
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This oped was first featured in a 2013 mailing of the South Centre, Geneva
In May the World Health Assembly (WHA) will review progress on the implementation of its 2010 Resolution WHA 63.16 passing the WHO Global Code of Practice on the International Recruitment of Health. This was only the second non-binding code passed by WHO, after the 1981 Code on Breast Milk Substitutes, and its adoption was greeted with relief and optimism given the effort that went into it. Much of that pressure and momentum came from African regional bodies like the African Union, Southern African Development Community and ECSA Health Community and from their member states.
The Code contains some robust provisions for improvements of the health workforce within African countries and for responsibilities across countries, such as through bilateral agreements and leverage of international and national resources for the health workforce. The Code calls for health worker training and management systems within stronger health systems. It calls for coordination mechanisms that involve all players at national level. It sets provisions for information systems and data to monitor this. Article 7.2 of the Code provides for setting up and maintaining a database of laws and regulations on health personnel recruitment and migration. Although non-binding, it promotes accountability between countries as a means to track implementation, with a requirement for information on implementation on provisions of the Code to be reported to the WHO Secretariat every three years, and to the WHA.
So the stage was set for implementation, and the most enthusiastic implementation could have been expected from African countries. However in 2013 the activity, discourse on issues of health worker migration and sense of achievement and optimism that greeted the adoption of the Code are conspicuously absent.
In the report drafted by the Secretariat for presentation at the 2013 WHA only 13 African countries had established designated national authority, and by the end of 2012 only one African country had reported to the Secretariat on Code implementation. In total 81 countries had designated authorities and 48 had reported, but most of these were European countries. It seems thus that the situation has little changes since EQUINET last reported on this in an editorial in March 2012.
So if Africa continues to bear the brunt of the health worker crisis, if African stakeholders and countries have been so vocal and active in pushing for and negotiating for the Code up to its adoption, what is the reason for this lull in activity? Whither Africa?
The same questions asked in March 2012 are still pertinent. Why have African countries been slow to take advantage of the provisions of the Code to leverage benefit from them? Why have so few African countries established designated authorities to drive implementation of the Code or established bilateral agreements drawing on the Code to improve and retain their health workforces? Why has only one African country so far reported on the Code?
It will be important to understand these issues to inform future global health processes. The development process for the Code took nearly a decade since first mooted at WHO level, and longer taking other forums into account. In such a protracted process, the realisation of the Code may be interpreted as an end in itself. The champions for the Code may have changed, with loss of institutional memory, and those active in its negotiations may have moved on to other tasks at hand. Some have argued that the content of the Code does not reflect the original wishes of African countries for compensation or reparations, or for mutual benefits to be spelled out clearly. This may contribute to apathy for its implementation. As a voluntary, non-binding instrument it may be seen to have little effect. It may also be possible that without an active civil society lobby and with limited dissemination of information on the Code to local stakeholders there is weak pressure for its implementation.
The lull in activity since the adoption of the Code could be a lost opportunity to ride the tide of momentum and goodwill that characterised its adoption, a loss that may be difficult to reclaim. However there is still time for the concerted effort of the government and non-government players that played a role in the development of Code to apply their collective effort to ensure its implementation and to realise its benefits. At minimum the Code should be widely disseminated, discussed and follow up areas identified for national policy and diplomacy to support the training, management systems, health systems strengthening, coordination mechanisms, information systems and databases needed to ensure more equitable management across countries of health personnel recruitment and migration. There is need to set up mechanisms for institutional memory and processes that would run regardless of changes in personalities or of individual decision makers.
As a bottom line we are asking for the momentum and vigour that African health ministers, senior officials, professionals and civil society brought to the negotiation of the Code. It is not acceptable for African countries, having worked so hard and done so much to have the Code in place to let it fall at the implementation stage. As we approach the 2013 World Health Assembly we hope that the roaring fire of African voice that led to the Code has not become so hoarse during the negotiation that it is no longer audible!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The authors of this editorial are working on a research programme in EQUINET associated with the ECSA HC Strategic Initiative on Global Health Diplomacy to explore diplomacy on the Code. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
This month's editorial comes from the lens of a health worker at a rural hospital, with an appeal for policy to test itself against whether it supports and has involved those working at the frontline and reflects ground realities. In a few days time a global meeting will be held in Botswana to review the health dimension of global development goals. In the newsletter is a resolution from a meeting of local governments and communities in Guatemala that urges, as we would, for a reminder of the faces, voices, wisdom and importance of the local in that discussion. As evident from the many reports EQUINET has produced, national averages hide significant subnational and within area inequalities, many of which are growing, and social agency, community systems and frontline health services need to be given significantly greater profile in policies and goals seeking to deliver on rights to health.
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.
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.