The Trade Related Aspects of Intellectual Property Rights (TRIPs) Agreement of the World Trade Organisation came into effect on 1 January 1995 and set standards for intellectual property systems. Least Developed Countries (LDCs) have until 2016 to bring their systems into line with TRIPS for pharmaceutical patents. Five years may seem a long time. But how far have we come in the 15 years since the agreement was passed?
One of the most important steps taken after the agreement was the successful advocacy at the WTO Ministerial conference in Doha in 2001 to include flexibilities in the TRIPs agreement so poorer countries could address their public health crises, especially given the AIDS epidemic. Paragraph 17 of the Doha Declaration provided that the TRIPS Agreement be interpreted in a manner supportive of public health by promoting access to existing medicines. The flexibilities provided for compulsory licensing or the right to grant a license, without permission from the license holder; for parallel importation or the right to import products patented in one country from another country where the price is less; for exceptions from patentability and limits on data protection and for early working, known as the Bolar Provision, allowing generic producers to conduct tests and obtain health authority approvals before a patent expires, making cheaper generic drugs available more quickly at that time. The World Health Organisation (WHO) in its 2008 Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, urged for these flexibilities to be implemented in national laws and international agreements, including facilitating, through export, access to pharmaceutical products in countries with insufficient or no manufacturing capacity.
Nine years after Doha, a review of legislation shows that the intellectual property regimes in place in many east and southern African (ESA) countries have not been significantly changed. Patenting laws in many countries (eg Botswana and DRC) were passed before the TRIPS agreement or Doha round. Some (such as Zimbabwe and Zambia) already provided for the flexibilities, but some still have gaps, such as in South Africa, where flexibilities enabling production and export of medicines to the region are still to be enacted. Some countries, such as Kenya, have enacted new laws providing for flexibilities, while in others (such as Uganda and Namibia), these proposals still remain in draft form. While WTO provides for countries to provide the TRIPS Council with "as much information as possible on their individual priority needs for technical and financial cooperation in order to assist them in taking steps necessary to implement the TRIPS Agreement, " so far in ESA only Uganda has taken this step. LDCs in ESA do not have to give exclusive marketing rights to pharmaceuticals that are subject of a patent application until 1 January 2016, but it is unclear how many countries have yet conducted self-assessments to prepare negotiating positions for possible extension of this waiver.
Even those ESA countries that have the flexibilities in their laws are not fully implementing them. They face a number of constraints. Most ESA countries lack domestic pharmaceutical research and manufacturing capacities and have insufficient technical and infrastructural capacities to effectively regulate medicines. Countries have weaknesses in their pharmaceutical management and procurement systems, and in accessing pricing and patent status information. Countries also face economic and political pressures. Stronger property rights (including of intellectual property) is urged as necessary for foreign direct investment and countries face trade and investment pressures not to use the TRIPS flexibilities.
African configurations are at various stages of negotiating comprehensive Economic Partnership Agreements with the European Union, for example. While the underlying 2000 Cotonou Agreement does not oblige ESA countries to negotiate IPR rules and aims for “co-operation” in the field of IPRs, the overall intention of the agreement is to protect intellectual property rights. EU business seeks to open new markets for its exports and this includes protecting intellectual property, given the heavy involvement of EU companies in research and development. The African Growth and Opportunities Act (AGOA (2000) has unilaterally extended market access to ESA countries, with one of the requirements for eligibility being that the country should commit itself to eliminating barriers to US trade and investment by “protecting intellectual property rights,” and desist from interfering in the economy through measures such as price controls, subsidies and government ownership of economic assets. Most recently, anti-counterfeit laws, such as those passed in Kenya, under debate in Uganda and effected through amendments to existing law in Tanzania, while seeking to prevent the damage caused by fake medicines, have the potential to limit the legal production and distribution of generic medicines. When Anti-Counterfeit Laws define a counterfeit as a good that is identical or substantially similar to a good protected under an intellectual property right, they appear in effect to include legal generic products. It seems these states have not designed their anti-counterfeit laws to adequately take into account the protection of TRIPS flexibilities.
A lack of vigilance to protecting the ground won at Doha is now apparent in a new problem. The 2001 public health related aspects of the TRIPS flexibilities now have to be formally adopted at the World Trade Organisation. For this two thirds of countries need to propose the formal adoption. By December 2009, according to the WTO (http://www.wto.org/english/tratop_e/trips_e/amendment_e.htm), only Mauritius and Zambia in ESA had added their names to this proposal. In other words the ESA countries have not added their names to the critical mass needed to enable a formal adoption of the protocol amending the TRIPS agreement at the WTO. This formal adoption should have been implemented by December 2007. The deadline was extended to December 2009, and on 17th December 2009, WTO members agreed to a second extension to December 2011. It is important for ESA countries to now formally propose adoption to avoid the unnecessary renegotiation of these critical amendments to the TRIPs agreement.
Advances can never be taken for granted in a rapidly changing world, and neither can the five year period we have left before TRIPS is fully enforced, for us to put in place a self determined legal, institutional and investment environment for drug manufacture and procurement in ESA countries. For now there is an urgent need for all ESA countries to endorse the protocol on the TRIPS amendments that the flexibilities are entrenched. In the next five years we still appear to have much to do to take advantage of the flexibilities through our laws, policies and capacities, including with respect to the production and export of medicines within the region, and to set the terms for discussions on intellectual property regimes (IPRs) with trade and development partners in a manner that puts us in a stronger position to produce and procure medicines and to protect public health. Our national health strategic plans in ESA should all include clear roadmaps of how we will effectively use the next five years to achieve this.
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 SEATINI website at http://seatini.org/ and the EQUINET website at www.equinetafrica.org.
Editorial
Since the 2005 World Health Assembly resolution calling for member states to pursue universal health systems, there has been growing interest in how this can be achieved in low- and middle-income countries.
The promotion of universal coverage means that health systems should seek to ensure that all citizens have access to adequate health care (adequately staffed with skilled and motivated health workers) and financial protection from the cost of using health care. Universal coverage requires both income cross-subsidies (from the rich to the poor) and risk cross-subsidies (from the healthy to the ill) in the overall health system. This stems from our understanding of equity, which requires that people should contribute to the funding of health services according to their ability to pay and benefit from health services according to their need for care. Prior work in the fair financing theme in EQUINET indicates that there is still a heavy dependence on external funding in some east and southern African (ESA) countries and heavy burdens on poor people through high levels of out of pocket financing.
A key impetus for the World Health Assembly resolution was the growing evidence on the extent to which households in many countries were being impoverished by having to pay for health care on an out-of-pocket (OOP) basis. This has led to an international consensus that prepayment health care financing mechanisms (tax funding and health insurance) should be the preferred sources of funds and that reliance on OOP payments should be reduced, if not completely eliminated. A number of ESA countries have removed user fees at some or all public sector facilities (e.g. South Africa, Uganda and Zambia). While there have been positive effects, such as dramatic increases in the use of public facilities particularly by poorer groups, this has been hard to sustain where there is inadequate funding of public facilities from tax revenue and/or grants from overseas development aid. This has meant that some facilities do not have medicines available and have too few staff to cope with the increased number of patients. Where this has occurred, patients have had to increasingly rely on private health services, paid for on an OOP basis and again face the possibility of impoverishment if costs were high relative to their income levels.
This experience has demonstrated that while it is critical to reduce out-of-pocket payments for health care, it is equally important to improve public funding of health services. This is particularly so, if we are to progress toward universal health systems that provide financial protection and access to needed health care for all. Although private health insurance is a form of prepayment financing, it does little to contribute to universal coverage in low- and middle-income countries. This is because very few people can afford the premiums for such insurance and only those who contribute benefit from the services funded by private insurance schemes. Instead, what is required is the creation of as large a pool of funds as possible that can be used to fund health services that will benefit the entire population. This can be achieved through allocations to the health sector from tax funds, which can be supplemented by mandatory (i.e. compulsory) health insurance contributions by those with the financial means to contribute in this way. Development aid funds can also contribute to this integrated pool of funds, but given the unreliability of external funding and that this source is unlikely to be sustainable in the long term, it is critical that the emphasis increasingly is placed on domestic public funding for health services.
For many years, we have been told that this is simply not possible. The reality is that unless we take steps to make increased domestic public funding of health care possible, we will never achieve universal health systems in Africa. What steps are required? There is a need to increase tax revenue. A number of African countries (including Kenya, South Africa and Uganda) have managed to dramatically increase tax revenue without increasing tax rates, through improved tax collection. Consideration is also being given by some countries to introduce new taxes whose burden falls on the wealthy (such as levies on foreign exchange transactions). Equally importantly, the allocations from tax revenue to the health sector should be increased. Most ESA countries are very far from the Abuja target of devoting 15% of government funds to the health sector. The ability of governments to allocate more funds to the health sector is enhanced greatly by debt relief. Malawi is one country that has made progress towards the Abuja target. This has occurred due to active lobbying by parliamentarians, who put forward a private members bill to secure a government commitment to move towards this target. From the Malawian experience, it is clear that it is important to emphasise that it was the Heads of State that signed the Abuja Declaration (rather than simply Ministers of Health). Many parliamentarians and government officials are unaware or ill-informed about the Abuja target. In addition to improved general tax funding of health services, mandatory health insurance contributions (which are often very similar to a dedicated health tax) could be introduced. The key lesson from other low- and middle-income countries, particularly in Latin America, is that it is critical to integrate general tax allocations for health and mandatory insurance contributions in a single pool of funds to be used for the benefit of the entire population if universal coverage is to be achieved.
While improved domestic public funding of health services will not happen overnight, we need to start moving in this direction as a matter of urgency. We need to understand better how countries have managed to improve their tax collection and how some have managed to successfully motivate for increased allocations to the health sector. We need to continue to mobilise for debt cancellation to free up limited domestic resources for funding social services. We need to protect our health systems from interventions promoted by international organisations that will take us further from achieving universal coverage (such as efforts to commercialise health care delivery and funding). We need to convince our policy-makers that universal health systems can only be achieved through improved domestic public funding of health services.
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 Health Economics Unit website at http://heu-uct.org.za/ and the EQUINET website at www.equinetafrica.org.
Worldwide, according to World Health Organisation (WHO) in 2001, mental and behavioural disorders affect 450 million people and account for 15% of the overall burden of diseases from all causes. Yet, nearly two-thirds of those affected do not receive adequate care due to stigma, discrimination, neglect and poverty. Mental health is an integral part of the whole health of a person. Even when physical illness predominates, the mental health status of the person can influence the course and outcome of physical illness. While the prevalence and pattern of mental health disorders are similar in high and low income countries, for low income countries the challenges of providing mental health services are myriad. They range from mental health being given low priority by policy makers, to poor or unavailable services in terms of infrastructure and services, to inadequate health workers oriented to mental health care needs.
Health worker shortages have received increasing attention of late as one of the most critical gaps in the provision of services. Too often, however, the critical gap in mental health personnel is overlooked. There is a particular shortage of mental health workers in low income countries. Estimates show that there is an average of one psychiatrist for two million people in low-income countries compared to one for every 10,000 people in the high-income countries. In Kenya for example, there is one psychiatrist per four million people and mental health services at the primary level are largely left to general nurses and clinical officers. Kiima and colleagues in 2004 found that these personnel readily recognise psychosis, but are less able to recognise learning disorders, emotional disorders and conduct disorders in children and adolescents. Primary care staff who feel uncertain of their skills in this area may not adequately diagnose mental health problems, or may refer cases to higher level facilities. Besides being expensive, this leaves a large number of mentally ill patients untreated. The social and economic cost, as with other areas of unmet need, then falls on the individual, family and community.
It seems unlikely, in the foreseeable future, that we will achieve the psychiatrist: population ratio levels in developing countries that compare to what has been attained in developed countries. This is especially so as internal and external migration draw specialized personnel out of our health systems and out of services in poorest communities where health needs are high. How then can we meet the significant deficit in addressing a public health burden like mental health, at a time of major shortfalls in our health systems?
WHO has in recent years proposed task-shifting as one way of filling the gap in availability of health workers. This implies transferring skills to less academically qualified but more available personnel to provide key services. There are some emergent efforts in Kenya to replicate this for mental health services. The various mental health issues and service roles in different stages of the cycle of prevention, treatment and care are explored to assess where task-shifting provides a feasible possibility to reach the community and improve service provision. These efforts must still be shown to make a real difference in effective services for communities. They need to link skilled health personnel with those in frontline care through supervision and support so still demand these high skill personnel for leadership, and in research and higher training. So task shifting makes it even more important to find effective options for retaining these high skill personnel in their own countries and to link their own desired career paths to the needs of the health system. Kenya has been notable in the region for its production and retention of psychiatrists and could make a very interesting case study on the success of national retention psychiatrists, even though these personnel may not be equitably distributed in the country.
The task shifting debate also draws attention to wider, primary health care (PHC) oriented and innovative options that integrate mental health into other promotive, preventive and curative services at community level. A holistic approach is in accordance with the WHO definition of health, that encompasses physical, social and mental wellbeing. Wiley-Exley in 2007 in a 10-year review of community mental health care in low- and middle-income countries showed that community based care can provide improvements in mental health, even though more work is needed in specific areas such as services for children and adolescents. Preliminary work by Jenkins in Kenya shows that retraining of primary health workers in mental health can have an impact in the number of correctly diagnosed mental health cases and the quality of referrals. Othieno and colleagues, with Department of psychiatry, University of Nairobi and with EQUINET support, have worked with community members in Kariobangi in the suburbs of Nairobi using participatory methods to recognize and find ways of dealing with cases of mental illness in their community. A similar approach has been used to encourage compliance among those with HIV infection who engage in harmful alcohol use. These case reports, both found in more detail on the EQUINET website, suggest that participatory action research methods could be effective in detection and management of mental health issues at primary care services and in the community. More work is needed in this area and if replication in other parts of the country proves its efficacy, it could be included in the curriculum for the health workers at all levels. As noted with the task shifting discussion, however these approaches should be complemented by developing referral and tertiary services, and skilled personnel. This is not only needed to support the implementation and supervision of PHC approaches to mental health, but also because as the needs are recognized, referrals from the primary care facilities are bound to increase.
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 EQUINET: www.equinetafrica.org.
In 2008, Members of Parliament from twelve countries in East and Southern Africa pledged to advance health equity and sexual and reproductive health in the region. How much progress had been made a year later? This was the question that was in focus in a follow up regional meeting in September 2009.
At a meeting in September 2008 hosted by Partners in Population and Development Africa Regional Office (PPD ARO), Regional Network for Equity in Health in East and Southern Africa (EQUINET), African Population Health Research Centre (APHRC) and Southern and East African Parliamentary Alliance of Committees of Health (SEAPACOH) with international partners, the members of parliamentary committees on health made commitments to promote primary health care, health equity and reproductive health.
These reflected the fact that parliaments can and do play a key role in promoting health and health equity through their representative, legislative and oversight roles, including budget oversight. EQUINET reports have documented examples of how these roles have been exercised in East and Southern Africa (ESA) to prioritise health in budgets, to monitor the performance of the executive, to strengthen laws protecting health and to keep the need to redress inequity in health and to promote sexual and reproductive health high on the public agenda.
As a unique measure to consolidate this, members of the health committees came together in the Southern and East African Parliamentary Alliance of Committees of Health (SEAPACOH) in 2005, to build a more consistent collaboration of the committees towards achieving individual and regional goals of health equity and effective responses to HIV and AIDS. The committee members carried out field visits to local governments at districts and lower levels to appraise themselves with the prevailing health needs, and mobilised and sensitised leaders at local government levels, in civil society and in communities on health and reproductive health issues. The parliamentary committees on health have met to review this work on health with EQUINET and various partners in 2003, 2005, 2008, and most recently in September 2009. In April 2009 with PPD support SEAPACOH developed and adopted a Strategic Plan for 2009 – 2013. The three main areas of focus identified include: ensuring needs-based resourcing of the health sector; ensuring effective domestication, implementation and compliance with agreed upon commitments in the health sector by governments; and ensuring sustainability of the alliance.
The follow up meeting in September 2009, hosted by the same organizations provided an opportunity to review progress, share experiences and lessons learnt over the past one year on the implementation of the resolutions of the September 2008 meeting.
Parliamentarians shared information on their progress, challenges, and on how to move commitments further forward. Progress had indeed been made since September 2008. For example:
• The East Africa Legislative Assembly have developed model laws on HIV, AIDS and female genital mutilation and is working to develop pooled procurement of drug, medical supplies and medical equipment; to review health insurance schemes, and to explore options for contracting health workers.
• In Kenya, the Parliament is scrutinizing the government budget through interrogating line ministries’ budgets. They have promoted an economic stimulus package, which provides for model health centers to be set up across the country and for twenty nurses to be hired in each constituency. In Kenya, a parliamentary taskforce has been set up to monitor and oversee action on socio-economic inequalities, including inequality in health and access to health care. The health committee have sensitized fellow MPs and the Ministers of Health and Finance on health issues, leading to legal provisions for Health Committees to be include in the budget process.
• In Malawi, Parliamentarians have moved a motion to persuade government to draft legislation on research activities to prevent abuse of citizens in clinical research trials.
• Namibia’s Committee on Human Resources, Social and Community Development were trained in gender based violence, reproductive health and HIV and AIDS in 2009. They undertook field visits to assess the implementation of government policies and programmes with regard to health and education issues; and revised and costed the national roadmap that outlines strategies and guidelines for improving maternal and child health, as a contribution to reducing illness and mortality in 2009.
• The Parliament of Swaziland reported implementing capacity building work on sexual and reproductive health for members. Members have also moved several motions, including on access to health services, and to promote investigation into the increase in abortions among young people and into the increase in maternal mortality.
• In Uganda, Parliamentarians have engaged Ministries of Health and Finance and the media on the need to fund sexual and reproductive health issues and recommended policy changes in the management and administration of the budget for drugs, including for reproductive health commodities. The committee has with the executive allocated additional government resources for reproductive health and HIV and AIDS. The committee has successfully advocated for a budget line of 200 million Uganda shillings (US$105 000) for activities to address female genital mutilation and prepared and presented a private member’s bill entitled “The Prohibition of Female Genital Mutilation Bill, 2009.
• In Zimbabwe, the Parliament has improved the allocation of resources to health in the budget. The committee on health has tabled a motion on the need to link sexual and reproductive health and HIV in programmes and policies that address vulnerabilities of women and children, has lobbied for the provision of appropriate, affordable, accessible and friendly adolescent and reproductive health services and are currently crafting a policy on male circumcision as one of the added strategies to reduce HIV infection. This was supported by a number of research studies in areas of sexual and reproductive health.
With these areas of progress taking place, the need to network regionally to share progress and experience was evident. In agreeing on a way forward over the next year, the committees agreed to operationalize the SEAPACOH Strategic Plan, including strengthening their own networking and communication across the region. This will enable those making progress in key areas of health to share information on achievements, to exchange experiences in their oversight of regional commitments and international agreements and to support new and innovative programmes to enhance health, including reproductive health. The adoption of common platforms and a regional agenda can only make the work of the individual committees stronger.
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 and the regional parliamentary meeting please visit the websites of PPD ARO: www.ppdafrica.org; EQUINET: www.equinetafrica.org; and APHRC: www.aphrc.org. The SEAPACOH strategic plan is at http://www.equinetafrica.org/bibl/docs/SEAPACOHstrategicplan09.pdf. The 2009 commitments are included in this newsletter and are also at http://www.equinetafrica.org/bibl/docs/RegParl%20mtg09%20res.pdf. The resolutions and report of the 2008 meeting are at http://www.equinetafrica.org/bibl/docs/REPMET0908parl.pdf and http://www.equinetafrica.org/bibl/docs/RESsep2008parl.pdf.
The Third EQUINET Regional Conference on Equity in Health in East and Southern Africa, held 23 –25 September 2009 in Munyonyo, Kampala, Uganda brought together over 200 government officials, parliamentarians, civil society members, health workers, researchers, academics and policy makers, as well as personnel from United Nations, international and non-governmental organisations from East and Southern Africa and internationally.
Conference delegates recognised the significant, growing, avoidable and unjust inequalities in health and in the resources for health in our countries, our region and our world. The conference reiterated the findings of the World Health Organisation Commission on the Social Determinants of Health that this social injustice is killing people on a grand scale.
We note that we have the resources for health within our region; that many resources important for health, including health workers, flow out of Africa; that the remaining resources do not reach those with greatest health needs, and that inequality blocks economic opportunities from reaching those who need them most.
We affirm that we stand for equity and social justice in health. We recognise that unless we address inequalities in health and in the resources for health, we will not achieve the policy goals set in the 1999 Southern African Development Community Protocol on Health, the resolutions of the Ministers of the East Central and Southern African Health Community, nor the United Nations Millennium Development Goals;
We affirm that it is imperative that we act to improve heath equity, and to reclaim the resources for health.
Our deliberations indicated that health equity is advanced when:
• health is integrated within national policies and goals,
• equity in health is a political and social goal, advocated, planned for and monitored,
• our health systems have strong public sectors, and redistribute resources towards those with highest health need, and
• the role of people – communities and health workers- is valued, resourced and supported;
Towards this, we call on all in the region, our international partners, and propose ourselves, to intensify efforts to:
Advance equity in health as a political and social goal and in all policies:
• Monitor and ensure that the right to health is included in our constitutions, provided for in our laws and universally applied, especially for vulnerable groups;
• Strengthen community awareness and capacity to claim these entitlements;
• Advocate for the promotion and protection of health in all policies, particularly those that provide for the social determinants of health, including education, safe water and sanitation; food sovereignty, energy and technology;
• Organise evidence and raise awareness on health implications of trade and intellectual property regimes and of new technologies and strengthen negotiating power to ensure that they protect health, particularly given the corporate control of resources;
Build universal, redistributive and people centred health systems:
• Identify and advocate for clear, comprehensive and integrated health care entitlements that secure universal coverage of health systems;
• Identify and implement options to strengthen, resource and organise primary health care and inter-sectoral action for health as a priority in health systems;
• Generate and share evidence on and implement options to close gaps in access to key services for priority health conditions, including for maternal, family and child health, for mental health and for improved nutrition;
• Organise the evidence, advocacy and political support to meet and go beyond the 2001 Abuja commitment of 15% government spending on health - excluding external funding; and to promote increased per capita spending on health, supported by debt cancellation;
• Meet the “people’s Abuja” of at least 25% of government spending in health allocated to the primary care and community level of the health system;.
• Support plans and strategies for harmonising the various health financing schemes into one framework for universal coverage, reducing out of pocket payments, providing for cross subsidies and pooling resources from progressive tax funding and prepayment schemes;
• Support the removal of user fees through a sustainable, planned strategy that strengthens the health system;
• Support the development and implementation of plans to deploy and retain health workers in decent working conditions and to ensure consistent availability of vital and essential drugs and supplies at primary and district levels of health systems;
• Draw on the growing body of evidence on the causes of health worker migration and measures for health worker retention, promote constructive engagement across health workers, trade unions and governments to ensure that country driven strategies for retention are negotiated, resourced, implemented and monitored;
• Strengthen public sector systems and capacities, including for financial management, to improve equity in the allocation of resources, and to absorb and effectively use the resources for health;
• Through civil society and parliaments, monitor how funds are used and how services are provided;
• Ensure effective regulation of the private-for-profit sector so that it complements public sector provision and to prevent negative impacts on health equity;
• Identify, make visible and overcome the barriers that disadvantaged and vulnerable communities face in accessing and using health and essential services;
• Noting that AIDS is one of a number of disease burdens and that approaches to HIV and AIDS should integrate with programmes for all major health problems, resource and strengthen rights based, holistic, integrated primary health care oriented approaches to prevention, treatment and care for HIV and AIDS, that recognize and act on the social barriers to access and uptake of services; that build links between communities and services; that recognize and train traditional healers, community health workers, peer support networks and non-medical health providers; that provide prevention and treatment to health care workers; that strengthen local safety nets and that address disparities in access to services across gender, area and income and for children, commercial sex workers and other vulnerable groups.
Recognise and support the central role of people – communities and health workers –leadership and alliances in advancing health equity:
• Recognise and formally provide in laws, budgets, mechanisms and programmes for the central role of people in health systems; to build informed empowered communities and health workers and participatory processes for community involvement in health;
• Demand and strengthen capable strategic leadership, stewardship and management in health systems; who consult, engage with and harness the range of constituencies and resources needed to advance health equity;
• Develop the communication, engagement, capacities and networking to strengthen government, civil society, health worker, parliament and researcher alliances to shape, advocate, implement and monitor the policies that promote health equity;
Monitor and make visible progress and gaps in advancing health equity:
• Monitor and make visible the progress and gaps in advancing health equity through implementing an Equity Watch at country and regional level, in a manner that builds alliances across actors; that analyses health disparities, including gender differentials; that makes visible progress against benchmarks and drivers of health equity; that complements a core framework of parameters with deeper district and household level assessment and that combines different forms of evidence, including from community level photography, to stimulate action on equity.
• Develop and promote investment in and capacities for a research agenda on health equity, including on new challenges, such as how climate change and globalisation are affecting health; on operational issues, such as how health systems are functioning after the removal of user fees; and to inform policy development, such as on the effects of the private-for-profit sector and of commercialisation in health systems on health equity;
• Build capacities amongst researchers to involve stakeholders from the earliest stages of research and to effectively communicate evidence.
We call for these efforts to be supported by wider levels of social justice globally and for a more just return for east and southern African countries from the global economy. The net outflow of resources from Africa must be reversed and the strategic resources of Africa used for the development and security of its populations.
We call on our international partners to advocate and engage with us to achieve:
• The global commitment to and resourcing of the universal rights to health in the International Convention on Economic and Social Rights, the Convention on the Rights of Children and the Convention on the Elimination of Discrimination against Women,
• G8 targets of universal access to prevention, treatment and care for HIV and AIDS and the UN Millennium Development Goals;
• Debt cancellation, with the resources released channelled to human development;
• Economic justice, fair trade, and democracy in the governance of global financial institutions;
• Bilateral and multilateral agreements that recognise and redress the resource outflows that affect African health and health systems, particularly from health worker migration.
• Genuine partnerships and external funding aligned to national priorities, that are developed through participatory and informed consultation with the people.
We will all take these commitments forward into our various organisations and forums. The conference has set a programme of work and action for all of us. EQUINET, as a consortium of institutions from the region, is committed to take and support these actions to advance health equity, to produce and share evidence and good practice and to advocate and monitor equity and social justice, especially through the equity watch. EQUINET is committed to building the intergovernmental, parliamentary, civil society, health worker and academic forums in East and Southern Africa to strengthen our values based leadership, democratic states and regional integration and co-operation in Africa, to reclaim the resources for health and advance health equity.
In the face of injustice it is imperative that we act.
A note from the editor: This oped presents the resolutions made and adopted by delegates at the EQUINET Regional Conference September 2009. In future issues of the newsleter we will give profile to specific areas of and reflections from the conference, whose ideas, community and exchanges re-energised and informed our work, actions and interactions towards advancing health equity. The abstract book for the conference is available at http://www.equinetafrica.org/bibl/docs/EQ%20Conf%20Sep09%20abstract%20bk.pdf and the conference report will be available on the EQUINET website in November. Please contact the EQUINET secretariat admin@equinetafrica.org for any queries or feedback on issues relating to the conference or resolutions. For further information on the conference, the papers presented or EQUINET work please visit the EQUINET website at www.equinetafrica.org.
Throughout Southern Africa, there are few programmes to protect the health of workers, or occupational health. Public funding in the region for occupational health services and the enforcement of occupational health laws generally comes from tax or social security funds. However these funds are inadequate to do more than run basic systems. Programmes to develop personnel, do research or expand services into new areas such as for informal sector workers or for women, rural or other marginalised workers, often relies on aid from high income countries.
These areas are some of the more challenging areas of occupational health, and often those with greatest burdens to population health. They are thus important for workers, communities and countries. Yet as aid funded, the developmental objectives for such programmes are often set by funders, with little in-country stakeholder consultation, and with relatively unpredictable financing.
Two recent Southern African regional programmes have deviated from this. These are the Swedish International Development Agency funded Work and Health in Southern Africa (WAHSA) programme and the Fogarty International Centre funded University of Michigan Southern African programme in Occupational and Environmental Health. To their credit, and strongly contributing to positive features noted in the evaluation of these programmes, the international partners involved in both the WAHSA and Michigan programmes made efforts to consult with relevant stakeholders in the region. Nevertheless their objectives and support are still subject to the priorities of their funding agencies.
The “Paris Declaration on Aid Effectiveness” (the “Paris Declaration”) in 2005 established new ground rules. At the 2005 conference convened by the high income OECD countries, but also including developing country representation, a revised and co-ordinated approach to development aid was promised. The Paris Declaration aimed to better manage the process of providing aid; ensure alignment with national development strategies and encourage beneficiary control and leadership in development programmes.
There is already recognition of some gaps between the noble promises and the outcomes to date. A 2009 OECD report commented on some fragmentation of effort, observing that ‘‘the international development effort now adds up to less than the sum of its parts’’. Sixteen Sub-Saharan countries were noted to have between 24 and 30 external funders, and eight of these to have between 15 and 20 external funders, suggesting that the rationalisation intentions of the Paris Declaration have not been met. The north – south network ‘Reality of Aid’ (http://www.realityofaid.org/) noted that there has been limited community participation in setting in-country agendas for aid. In their January 2007 newsletter, the network argue that the influence of external funders in recipient country policies has persisted through funder -imposed conditions on funding. This was highly contentious during the discredited Structural Adjustment Programmes of the 1980’s, and a United Nations Conference on Trade and Development report in 2000 identified eighty two governance-related conditions out of an average of one hundred and fourteen conditions for each IMF and World Bank agreement in Sub-Saharan Africa.
Despite the promise of better co-ordination, the Paris Agenda has also left a significant gap in partnership on occupational health, despite recognition of the contribution of employment and workplace risks to health equity in the recent report of the WHO Commission on the Social Determinants of Health. Funding for occupational health does not seem to be on the agenda of any major bilateral funder (excluding foundations such as the US Fogarty International Centre and the US National Institutes of Health). Given negative experiences of early termination of long term external funding support to occupational health in the region in the 1990s, the Paris Agenda offered optimism for sustained predictable support to this neglected area. Instead, since 2005, two bi-regional externally funded programmes in Southern Africa (WAHSA) and in Central America (SALTRA) met early termination, as the funding agency realigned from regional to country support.
As the Paris Agenda discussions recognised, achieving meaningful impacts in health outcomes or in institutional policies, capacities and practices calls for long-term time frames and commitments to plans, backed by predictable resources and clear processes for monitoring, evaluation and reporting. Uncertain funding leads beneficiaries and funding partners alike to focus on quick returns, rather than deeper impacts. Funding agencies, partners and local recipients may thus set and focus on meeting targets that seem feasible in short term time frames to justify use or continuity of funding, while not adequately yielding the long term gains from these investments. So, for example, numbers trained may be given more attention as targets than longer term structural outcomes, such as the integration of trained personnel into positions in institutions where they are able to influence policy and practice.
Past experience with development aid in this area has raised more questions than answers. How do national and regional organisations involved in a neglected area like occupational health strengthen self determined planning, resourcing and negotiation of programmes and partnerships in conditions of volatile external aid? How can unpredictable, limited and often inadequate funding be organised to support longer term capacity development? How can just demands for accountability and effectiveness be aligned to equally just demands for predictability and recognition of complexity? How best can the self interests of different partners be made explicit, negotiated and factored into partnerships from the beginning?
One way of addressing national leadership must be for countries to improve their own resources for occupational health, not just to run the systems, but to enhance and improve them. If we pursue “fair trade not aid”, then occupational health could be funded in a sustainable manner from improving returns on economic activities and strategic resources in the region. During the structural adjustment era, occupational health responsibilities were deregulated and corporate obligations and taxes reduced to attract foreign investment (which often did not materialise). The public health costs of structural adjustment in Africa are now recognised through the Macroeconomic Commission on Health. Claims for improved public funding for the health sector have had greater recognition, such as in the 2001 Abuja commitment made by African heads of state. There has not been a similar recognition for improved regulation and funding for occupational health. Yet as production and financial activities are increasingly globalised, with recognition of the environmental, economic and social obligations this generates, so too should investment in occupational health be prioritised and located as a matter of international responsibility, in line with fair trade, economic justice and rights to health.
It is time for a movement from within and beyond the trade unions, occupational health, economic and trade justice communities to link with the public health and health justice activists to raise occupational health within global, regional, national and local agendas. To support this with sustained and self determined action within the region, we need to strengthen regional organisation and networking to provide evidence for and engage with local and regional policy, including with intergovernmental forums such as SADC, to ensure sustainable domestic and regional resourcing of occupational health, and to advocate on the priorities for occupational health in the region within the international community.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For more information on occupational health in the region visit the EQUINET website and the WAHSA website at www.wahsa.net
Health systems throughout sub-Saharan Africa have been in a state of decline since the debt crisis of the 1980s and the subsequent effects of structural adjustment, chronic public under-investment and health sector reform. In this context, with the fragile health systems resulting, the proliferation of global health actors and initiatives (GHIs), that we have witnessed over the past decade, presents a risky strategy for catalyzing sustained and equitable improvements in health.
Vertical, selective GHIs could either establish a ‘virtuous cycle’ of positive synergies with health systems strengthening, or enter a ‘vicious cycle’, where they perpetuate or accentuate existing health system deficiencies, creating a greater dependence on vertical programmes for the rapid delivery of life-saving interventions. The publication in the Lancet this year (2009; (Vol 373 pages 2137 – 2169) of a review of the impact of GHIs on health systems by the World Health Organization’s Maximizing Positive Synergies (WHO MPS) initiative has therefore attracted attention and controversy.
The review noted the positive association between GHIs and improved outcomes, particularly in terms of HIV/AIDS, TB, Malaria and vaccine-preventable child deaths. However, it did not adequately answer the question of whether vertical and selective disease-based GHIs have had a positive or negative effect on health systems more broadly, nor whether they could have been better designed or implemented to optimize across-the-board health improvements.
This is because the review faced many methodological limitations. The first was a lack of good quality studies and evidence on the issue. This is a consequence of the minimal resources invested in establishing the monitoring systems needed to assess the effects of GHIs on health systems. Further, there is limited appreciation in the health community of the kinds of methods needed to study complex and large socially-mediated systems.
A second limitation was the lack of quality control of the data used by the WHO MPS collaborative group. Good, moderate and poor quality data appear to have been treated equally, including potentially biased information provided by GHIs themselves. On top of this, most members of the writing group had a direct conflict of interest with the subject matter, so the conclusions and recommendations read as a result of political negotiation, rather than an independent synthesis of the available evidence.
As a third limitation, the review only examined four actors: the Global Fund to Fight Against AIDS, TB and Malaria, GAVI, the World Bank’s Multi-Country AIDS Programme (MAP), and the US President’s Emergency Plan for AIDS Relief (PEPFAR). It therefore didn’t capture the effects of more than a hundred other global health actors and initiatives, despite the fact that one of the biggest problems for countries is the cumulative effect of numerous GHIs.
Finally, the conceptual framework of the review was designed to examine the effect of GHIs on health systems, but the conclusions of the review muddled the assessment of the impact of GHIs on health systems with impacts on health outcomes and outputs. Clearly, the Global Fund, GAVI, PEPFAR and MAP have had a positive impact on health outputs and outcomes. It would have been hard to avoid doing so considering the billions of dollars spent by these four GHIs, and the general four-fold increase in development assistance witnessed since 1990, described by Ravishankar and others in the same issue of the Lancet (2009, Vol 373, pages 2113 – 2124).
The question of whether vertical and selective disease and vaccine-based GHIs have had a positive or negative effect on health systems is perhaps academic. What is more important is that GHIs are henceforth able to maximize their positive synergies with broader health systems needs.
In this regard, in spite of its limitations, the WHO MPS initiative has been an important and valuable exercise. It has drawn attention to the need for further monitoring and assessment of the relationship between GHIs and health systems strengthening. This should include paying greater attention to the global health architecture as a whole, and efforts such as the International Health Partnership launched by some bilateral and multilateral health funding agencies to reduce the wasteful fragmentation, duplication, competition and conflicts amongst different actors and initiatives. Secondly, it has highlighted the need for GHIs to ensure that external development assistance for health is invested in a more coherent, equitable and comprehensive manner.
However, for GHIs, health sector and civil society actors, including those in east and southern Africa, the challenge is in knowing how to move forward. For example, if GHIs are to pay more attention to health systems strengthening, who will coordinate this? As a follow-up to the work and deliberations of the High Level Taskforce on Innovative Financing for Health, the World Bank, the Global Fund and GAVI are now discussing how they can create a shared platform for financing and supporting health systems strengthening.
But what will this mean? Will the World Bank take the lead in defining the policy agenda, and if so, will it promote a conservative and neoliberal policy agenda? Or will an expanded and modified version of the Global Fund and GAVI take charge? What of the role of the WHO, the International Health Partnership and countries themselves? With a global health architecture that remains over-populated, disorganized and competitive, there is a danger that countries may experience a series of uncoordinated and selective health systems strengthening initiatives. Agreeing to the fact that GHIs must pay more attention to health systems strengthening is only the start of a process.
While there is welcome attention to how official aid can be better managed to support health systems strengthening, there has been little discussion about how private finance will be harnessed to support equitable health systems development. The Gates Foundation, working with the International Finance Corporation, the African Development Bank and a German development finance institution have recently created a new private equity fund that will invest in small- and medium-sized private health companies in sub-Saharan Africa. Such an initiative runs contrary to the evidence that expanding commercialized health care will be harmful to equity and health systems strengthening.
Furthermore, the attention placed on health systems strengthening does nothing to plug the existing resource gaps of many countries. How do we campaign for a comprehensive Primary Health Care agenda when there is are still too few health workers, or inadequate funds for medicines? With the economic recession and signs of some donors cutting back on development aid, the competition for scarce resources may get worse.
This situation calls for the global health community to develop a set of positions and campaign on three distinct, but inter-related issues: The first is the architecture of development assistance for health, to work towards a coherent system for funding equitable health systems development and on-going improvements in access to effective health care. The second is that of health systems policy itself, particularly in relation to the appropriateness and fairness of different health financing strategies, as well as the role of markets and the private sector. Finally, the third, resonating with the call to meet the full content of the 2001 Abuja commitment at national and international level, is that of expanding both domestic and international resources for health in Africa.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For papers on health systems (fair financing, health worker retention) effects of GHIs visit the EQUINET website and the Economic Governance for Health network website at www.eg4health.org
A concern for health equity is not new in global health. Equity was central to the World Health Organization (WHO) 1946 constitution, and to the work that culminated in the Declaration of Alma Ata in 1978. Despite this, the health agenda has mostly focused on securing progress on priority challenges. This has contributed to substantial advances in average life expectancy in most parts of the world. Yet the global health community has often seemed unable to counter the widening inequities brought by uneven progress.
The recently completed World Health Assembly has the potential to be a turning point in addressing health inequities. Two resolutions were passed, fundamentally grounded in a concern for equity and social justice - one on 'primary health care, including health systems strengthening' (available at http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R12-en.pdf) , and another on 'reducing health inequities through action on the social determinants of health' (available at http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R14-en.pdf).
Around 50 countries spoke in strong support of the resolution on primary health care, and almost 40 countries intervened in support of acting on the social determinants. There was a constructive consensus in favour of both texts, with discussion centred on the strength and tone of the resolutions. Throughout the Assembly, multiple references were made to the importance of social justice and fairness in the plenary and across the agenda items.
The events that sparked these resolutions from WHO - the convening of the Commission on Social Determinants of Health in 2005 and the groundswell of support from countries for the renewal of primary health care, leading to the 2008 World Health Report - reflect an increasing understanding and intolerance for widening health inequities in the modern era. There is increasing support for the idea that health equity should be seen as a key development goal and as a measure of the progress of the global community.
Such consensual support would have been unthinkable until relatively recently and has strongly built on the explosion in knowledge of health inequities, both within and between countries, in the last twenty years. The broad range of civil society and academia have made important contributions in terms of advocacy, the generation of knowledge and the demonstration of innovative strategies to address the social determinants. The Commission's damning diagnosis - 'social injustice is killing people on a grand scale' - owes much to this work.
So what now? The twin resolutions call for a broad range of actions based on the values of Alma Ata from the international community, member states and the WHO secretariat. The Assembly's understanding of both primary health care and addressing the social determinants of health emphasises the key role of multi-sectoral action, beyond the necessary but insufficient functioning of health systems, if health inequities are to be reduced. Achieving such action issues a difficult challenge to health leaders at global, national and local levels.
Anyone who believes in health equity should be encouraged by these developments. Of course, the resolutions by themselves will not achieve health for all. But they provide a powerful endorsement of the report of the Commission and of the need for renewal of primary health care. The challenge in implementing these resolutions, to contribute towards improved health equity, is one to which civil society can continue to make a vital and essential contribution.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit http://www.who.int/topics/primary_health_care/en/ for PHC and http://www.who.int/social_determinants/en/index.html for SDH.
For the health sector, finding new ways of thinking about strategies to address health inequities is critical if achievement of the Millennium Development Goals is to be remotely possible. Over the past few years, the notion that a Framework Convention on Global Health could help to address some of the most fundamental inequities in health at global level, has been gaining ground. First proposed by Larry Gostin, a leading scholar in the field of health and human rights in 2007, the idea that a new model of global health governance could succeed where ethical exhortations and/or appeals to international legal norms have failed, is very attractive. Indeed, it is not only in health that increasing attention is being turned to these 'Framework Conventions'. The Internet Governance Project (IGP), an alliance of academics that focuses on Internet policy and how information and communication technology affects the interests of civil society, also proposed in 2004 the idea of a Framework Convention as an institutional option for internet governance globally.
Is a Framework Convention on Global Health the missing spark in our efforts to address the yawning and seemingly growing health inequalities around the world? Is it possible that such a Framework Convention will provide answers hitherto lacking in the debates and strategies to strengthen equitable people-oriented health systems? To do so, it is first necessary to understand what is meant by a Framework Convention.
To date, there are approximately four existing framework conventions, two better known conventions under the UN machinery, namely, the UN Framework Convention on Climate Change and the WHO Framework Convention on Tobacco Control, and a convention on the Protection of the Ozone Layer, as well as a Council of Europe Framework Convention for the Protection of National Minorities. A framework convention provides a mechanism for international consensus that avoids focus on details that may be contentious and contested and which may bog down negotiations. It rather establishes principles and norms for international action, setting up a procedure for later negotiation of more detailed arrangements. This was evident in the early agreements needed to set up the Global Convention on Climate Change, which is now overseen by the Conference of States Parties to the convention, with subsequent rounds to establish targets globally.
Gostin argued in 2008 that a Framework Convention on Global Health could significantly improve global health governance and would, amongst other goals, “...commit States to a set of targets, both economic and logistic, ...set achievable goals for global health spending as a proportion of Gross National Product,...build sustainable health systems; and create incentives for scientific innovation for affordable vaccines and essential medicines.” However, central to the purported benefits of the Framework Convention is the notion that “governments should care about serious health threats outside their borders” in that such threats pose direct health, economic and security risks.
Is this likely to offer us more leverage than other forms of policy engagement, particularly those using existing international human rights mechanisms related to the right to health, such as, for example, holding governments accountable for core obligations regarding the right to health? The experience in relation to other Framework Agreements is perhaps salutary. Firstly, negotiations to provide teeth to the Framework Convention on Climate Change through the Kyoto protocol remain locked in dispute, despite the agreement on the basic principles in the Framework Convention. Indeed, the huge quantum of effort invested in lobbying, advocacy, research and policy work since adoption of the Convention to support stricter controls of greenhouse gas emissions has remarkably little to show for the years of investment. Secondly, the ability to strike a deal within the UN system relies on careful diplomacy usually guided by the lowest common denominator acceptable to a wide range of national players and networks, usually dominated by rich and powerful nations. The likelihood of the outcome of such a set of circumstances generating a Framework Convention that fundamentally challenges global power relations therefore seems low. Thirdly, whereas the Climate Change and Tobacco Control Framework Conventions challenged interests that were fundamentally corporate-driven, a Framework Convention on Global Health would be essentially directed at nation states. Such states may either be those actors who need to be convinced that their own interests lie in improving the health of populations outside their border, or states whose weak economies and subservient trade relationships undermine the extent of their sovereignty and ability to regulate independently to realise the right to health of their own peoples. In the latter case, the value of such a Framework Convention, which is likely to be replete with general provisions and non-binding targets, appears singularly weak.
However, the most important consideration is really the extent to which a Framework Convention on Global Health is able to strengthen opportunities for civil society engagement and building agency on the part of those most adversely affected by global health inequalities. Inasmuch as Gostin suggests that a Framework Convention on Global Health “would stimulate creative public/private partnerships and actively engage civil society stakeholders,” it is the extent to which such engagement offers meaningful mechanisms for preferentially strengthening the collective agency of the most marginalised groups, within and between countries that will be the test of whether the Framework Convention on Global Health really promotes equity and the right to health, or whether, like much other international policy-making, it proves a nice-sounding but ineffectual sump into which health equity activists invest endless amounts of energy, with not much to show for it.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit the EQUINET website- www.equinetafrica.org.
The way we finance health and health care makes a significant difference to the coverage and accessibility of our health care systems. It has thus been an issue capturing increasing attention from the international community, including from United Nations Children’s Fund (UNICEF), the European Union, the High Level Taskforce on International Innovative Financing for Health Systems who have all held consultations on this in the first quarter of 2009. The UNICEF meeting reviewed the evidence base on the imposition of a ‘price’ for use of health care services - user fees – and considered options and support for feasible health financing mechanisms. UNICEF itself was questioning the necessity and value of user fees in resource constrained settings, particularly given the opportunity costs, transaction costs and barriers posed to utilisation. The EU meeting sought input to its policy on health care financing for developing countries. The meeting reviewed a draft policy that was oriented towards support for general tax financing for public health care systems augmented by Social Health Insurance as a feasible next best alternative modality for long term sustainable health care financing.
There seems to be wide agreement on the question of maintaining tax revenue as the core of health financing, and on the introduction of SHI as the major source of additional domestic funds for health. The debates are more about how to implement these mechanisms in low resource settings.
The simplest mechanism is that of financing through tax revenue. There is evidence that systems that are more dependant on tax revenue have less inequality (measured through the Gini co-efficient) with regard to resource distribution and therefore a higher level of equity within the system. Recognition was made of the need to have with this a systematic resource allocation mechanism as well as a package of care that general tax revenue will purchase, to support a rationale priority setting process and to ensure fairness. It was noted that tax funded systems are more suited to achieving this. Yet increasing these tax revenues cannot simply depend on overall economic growth, as there appears to be little evidence so far that economic growth has translated into immediate gains for resourcing the health sector. There is thus need for evidence and dialogue on the options for strengthening tax revenue sources, including the role of sector wide approaches, of budget support to the health sector and of overall budget support.
Although Social Health Insurance (SHI) is often raised as an equitable option for financing universal coverage, there is limited or zero revenue generation from social security schemes in the African region. In countries such as Ghana, Tanzania and Rwanda, SHI schemes are substantially financed through taxation or support from external resources (such as the Global Fund). They therefore appear to be more hybrid tax based systems with additional transaction costs that may be generating inefficiencies in resource use and allocation. In the same countries coverage of social and private health insurance schemes is extremely limited, raising serious concerns about equity in revenue generation and in service provision and consumption. In other countries, such as South Africa, where private health insurance exists along side some social security mechanisms, the private insurance is limited in terms of coverage and yet consumes a relatively high share of total health expenditures – demonstrating again potential inefficiencies and inequality. We thus need to further analyse and evaluate equity issues in the implementation of social health insurance to inform whether and how to implement these schemes.
So there are clear areas for further work to advance progressive, equitable health financing in Africa.
It is therefore worrying that we are still locked into endless debates on user fees. These debates generate diverse opinion. In health systems in which user fees have been removed at a broad level (South Africa, Uganda, Zambia) as well as those where the user fee exemptions have been targeted at specific vulnerable groups such as child and pregnant women (in support of child, maternal and reproductive health) the evidence of increased utilisation is clear. The evidence also shows that the transaction costs of user fee administration negates any positive contribution of user fees themselves in additional revenue or value terms. The contribution of user fees to health revenues remains low. Some institutions and country representatives strongly support community financing, such as through mutual funds, as well as user fees in public sector facilities. Yet some institutions and country representatives strongly support community financing, such as through mutual funds, and user fees in public sector facilities.
This draws attention from more substantial issues, such as the fact that government commitments to improved health sector funding remains low. Countries have been slow to increase their health sector budgets, let alone reach the 15% of government budget for health set in the 2001 Abuja heads of state commitment and the Southern African Development Community commitments for the Maputo targets. Making these promised increases to the health sector budget would exceed any resources that could be raised through user fees.
One problem is that the debate on health financing is fed by a mix of evidence, values and anecdotes. Relevant evidence is not always available for health sector financing decisions, and ethical and value considerations affect the design of and preferences in health care financing. The case for user fees (alongside community financing initiatives) is often made without evidence and based on institutional interests, rather than on the basis of health system development and improvement of population health. Disappointingly at the UNICEF meeting earlier this year, no consensus was reached and further consultative processes were proposed.
Given the weight of evidence showing the negative balance in the impact of user fees on health systems and population health, I would argue that there is, however, sufficient evidence to put this issue to rest. Rather than continuing the debate on user fees, we should shift to debates on more substantive approaches to resource mobilisation, including:
* How to achieve increased health sector budgets
* How to strengthen tax revenue sources and funding for sector wide and budget support
* How to assess the equity issues in the implementation of social health insurance to inform policy decisions whether and how to introduce SHI
* How to promote accountability and transparency in the way health systems use their funds
Meanwhile as we need to move on in Africa to focus debates and build coherence on these wider financing policies, we also note the proliferation of different donor meetings on this issue. The situation is calling for a harmonised approach among donors and international agencies, if not in terms of harmonised funding, at least in terms of a common position that external funders can adopt on financing options that strengthen the health system. This would be in line with the Paris Declaration on Aid Effectiveness and Harmonisation, so perhaps the World Health Organisation should take some leadership in co-ordinating this?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on health financing issues please visit the EQUINET website- www.equinetafrica.org.