Putting the debate on user fees to rest: A call for focus on what needs to be done for equitable financing for health
Bona Chitah, Economics Department, University of Zambia

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.

No magic bullets: keeping our health workers calls for deeper, wider changes
Rene Loewenson, Yoswa Dambisya, Riaz Tayob, Scholastika Iipinge

She has walked for 10 kilometers now. She can hear the child on her back, the harsh crying of an hour ago fading to exhausted whimpering. Her local clinic has not had a qualified nurse for some months, so she is walking the 20 kilometers to the nearest district hospital, hoping that by the time she gets there, the child will not have succumbed to the fever that she could not dampen with home treatment.

For this woman, as for many others in the region, the long walk to care is a consequence of inadequate numbers of critical and skilled health personnel, high levels of external and internal migration and poor distribution of staff in areas of high health need. Even where health workers are in place there is report of low staff morale. In 2005 health ministers in the Southern African Development Community (SADC) identified the non availability of skilled health professionals as a key factor undermining achievement of health Millennium Development Goals.

With the reality of poor communities bearing the brunt of a yawning gap between need and supply of health workers, health ministers in the East, Central and Southern African Health Community (ECSA-HC) resolved in 2007 to have in place by 2008 national strategies to recruit, motivate and retain health workers, using both financial and non-financial incentives. Since then both ECSA-HC and SADC have developed strategies for responding to the health worker crisis. A number of countries in the region have also developed and began to implement strategies, adding new measures to existing incentives. In March 2009, the ECSA-HC Ministers met again in Swaziland to review how far these commitments had been addressed.

Towards this, in February 2009, EQUINET and the ECSA-HC held a regional meeting, hosted by University of Namibia, to review evidence gathered from countries on how well incentives for health worker retention were working. These incentives are not always cash payments. The studies showed that dealing with poor working conditions, poor communication, unsupportive management and inadequate recognition is also important to attract health workers and to motivate them to stay.

As Hon Petrina Haingura, Deputy Minister of Health and Social Services in Namibia noted in opening the meeting, “We all know and understand that our governments are not in positions to provide huge salaries to our health workers but much more can be done within working environments. Health workers frequently complain and express dissatisfaction with management, poor leadership, lack of support and recognition; supervisors do not even know the word ‘thank you’ for good performance.”

The studies carried out in Kenya, Tanzania, Uganda, Swaziland and Zimbabwe gave evidence that the incentives most valued by workers were training and support for their career paths; improvements in services and working environments; housing mortgages / loans; recognition and reward for performance and accessible health care. Delegates at the meeting suggested that these be planned for and costed as a core set of strategies in health worker retention strategies in all countries in the region, even while further locally relevant strategies are considered.

Some of these strategies are being applied, but on a targeted or piecemeal basis, for selected health workers, or in specific programmes. Leaving it to individual facilities to set and apply these incentives seemed to lead to a vicious cycle of poorly resourced facilities, with weak management, having the least ability to attract staff, despite greater need. The evidence suggested that retention packages should preferably be health sector wide, with career path and training support based on analysis of responsibilities and tasks.

Prof Yoswa Dambisya of University of Limpopo summarised the learning from the region: “Non-financial incentives have been successful when they have been deliberately planned, with consultation across the board, as in Uganda; when they meet immediate needs through top-ups and allowances as in Malawi; when a combination of financial and non-financial incentives is used as in Zambia and Uganda; when incentives are used to attract health workers from private to public sector as in Uganda; when incentive programmes are integrated with SWAP or budgets as in Uganda and Malawi; and when national and donor funding were mobilised for an emergency human resource programmes in Malawi and Zambia”.

Moving from cash top-ups for selected personnel as an emergency response, to supporting career paths, health services and long term housing as an investment for retention moves us, therefore, from the realm of quick fixes to longer term change. It calls for long term planning of needs and services, and the information to support this. It demands management capacities, tools and guidelines, delivered through procedures and processes that build trust and participation. These features are often under-developed in health systems in the region, yet without them, even the best designed incentives remain largely on paper. Indeed one of the findings of the studies was that while many of the countries had made progress in setting policy measures for dealing with incentives for retention, delivery on the ground was still limited, in part due to gaps in these capacities. One sign of weak support for these capacities is the ironic exclusion from incentives schemes, training and professional exchanges of the very personnel who manage human resources for health.

These deeper, system wide changes are not just good for health worker retention, but for the quality and performance of services as a whole. But they do demand more than short term, ad hoc injections of project funds. One requirement is that governments in the region should increase the budgets for health to meet the Abuja commitment of 15% government spending on health. Analysis of experience with international and global funding suggests also that these funds are best pooled into sector wide funds, if they are to support system wide incentive schemes for health workers, with plans for their use harmonized with national plans.

This raises issues of sustainability and of shared international and national responsibility that need to be addressed. When a draft code of practice on the International Recruitment of health personnel was tabled at the January World Health Organisation Executive Board, however, the debate reported on it suggested that there is some way to go in reaching a shared understanding of how international responsibilities should be managed. In 2007, African countries, many of whom are source countries for migrating health workers, had requested a code that was more than voluntary. The WHO secretariat chose instead to stick to international practice of a non-binding agreement and presented a voluntary draft code, with some high income countries receiving health workers echoing this choice. African countries at the 2008 Executive Board thus again raised the need for an enforceable code, for the rights of communities in source countries to be considered and for a compensation mechanism to address losses. So the code was referred for more consultation.

As we follow the woman and her baby into the district hospital from the long walk, her hope is focused on the fact that she has come in time to save her baby. Our hope is that she will not need to make this walk again, and that African health systems provide the environments, task alignment, career paths and long term security to ensure that their health workers are found in the services where they are needed, backed by the wider economic improvements and political stability needed to keep them there.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on the health worker retention issues please visit the EQUINET website- www.equinetafrica.org. Information on the ECSA-HC resolutions and programme on health workers can be found at http://www.ecsahc.org/

Not for sale! Keeping an eye on the health sector in the services negotiations under the EU–ESA Economic Partnership Agreements
Munyuki E, Machemedze R, Mabika A, Loewenson R

It is increasingly clear that without accessible, equitable, quality health services we will continue to fall short on delivering on the health Millennium Development Goals or commitments made on access to treatment for AIDS and other major diseases. So the negotiations currently underway on services under the Economic Partnership Agreements (EPAs) between the European Union (EU) and East and Southern African (ESA) countries are a matter for wide public interest. In August last year we pointed to issues for concern in these negotiations. With the negotiations underway, these issues become an even greater matter for public and parliamentary concern: Will they bring new resources and partnerships in building our health services, or will they blow new holes in already fragile systems?

The EPAs were supposed to have been concluded in 2008, but when none of the African negotiating groups was able to reach a final agreement, most initialled Interim EPAs (IEPAs) with the EU to avoid trade disruption. Many countries, the African Union and the Economic Commission for Africa observed that the EPAs needed to more explicitly put development at the centre, and civil society called for more explicit protection of public health. The IEPA with SADC explicitly protected health by providing, in Article 3, that the application of the agreement should take into account the human, cultural, economic, social, health and environmental interests of the population and of future generations. The IEPA with other ESA countries did not. So countries are going into negotiations on specific trade issues, including trade in services, with different levels of protection in their framework agreement.

ESA countries have already been very cautious about liberalising trade in health services, given the need for public sector health services to be delivered outside the market to populations living below the poverty line and the need for additional government measures and subsidies to staff, and provide these services. Few ESA countries have thus committed their health services to liberalisation in the World Trade Organisation (WTO) GATS agreement, preferring to determine the pace and nature of any market opening within reversible domestic policies. In ESA, only Malawi and Zambia have made GATS level commitments in the health sector.

Meanwhile the EPA services negotiations are going on largely below the radar. While the umbrella Cotonou Agreement of June 2000 explicitly commits EU and ACP states to the development of the social sector, there are also strong signals that the liberalisation of all services will be actively promoted.

So it depends largely on what the negotiators agree in the coming months. ESA countries have no obligation to trade in health services and may elect, without prejudice, to explicitly exclude trade in health services. Under conditions of unequal access and differentials in coverage, ESA governments may justly feel that they cannot reduce government authorities to regulate providers, to compel cross subsidies, increase risk pools, manage health worker migration and other measures needed to ensure universal health care coverage. Hence the 2006 AU Conference of Ministers of Trade stated: “We shall not make services commitments in the EPAs that go beyond our WTO commitments and we urge our EU partners not to push our countries to do so.”

There are numerous arguments negotiators should be raising for excluding health services from EPA compelled trade liberalisation.

Both ESA and EU countries are signatory to international treaties, conventions and constitutional obligations to health and health care that create obligations to be discharged by the State Parties. Negotiators should be cautious about clauses in the services negotiations appear to undermine these commitments. Using the precautionary principle that applies in public health, those promoting clauses that appear to undermine these commitments should be asked to prove why they do not do so.

As raised in previous debates on trade and health, ESA countries need to protect the flexibilities already won under WTO agreements. the TRIPS agreement allows for government authorities to compulsory licensing and parallel importation. The GATS agreement provides for flexbility for governments to follow “a reasonable time-frame”, to bar foreign services suppliers from operating at the same conditions with local providers where this is necessary to protect health, or to grant more favourable treatment to service suppliers from regional bodies of only developing countries like SADC. ESA negotiators should resist any liberalisation process which forces them to take on obligations or a faster pace of liberalisation than that which obtains currently under the WTO process.

However we could go further. Protecting public health and access to health services demands more than a defensive posture in the negotiations. ESA countries could use the services negotiations to more explicitly protect public health and recognize state obligations to protect universal and equitable access to health services. For example, negotiators could include clauses that
 Recognize the priority for protection of public health as a guiding principle, as provided for in the EU-SADC IEPA.
 Commit parties to allowing government authorities and availing specific resources to the public health sectors of the ESA countries as part of the development dimension of the EPA.
 Commit the parties as in Article 25 of the Cotonou Agreement to make available adequate funds for improving health systems and primary health care, including for regulating the operations of the private health sector.
 Commit the parties to co-operation on ensuring ethical practice on the migration of health workers, including in terms of making technical and resource investments to address the costs to ESA countries of permanent health worker migration to the EU;
 Commit the parties to provide overseas development aid for health programmes in a manner that integrates with national financing arrangements and that avoid outflows of critical health personnel from public health services, in line with the principles of the Paris Declaration on Aid Effectiveness.

The services negotiations are an opportunity to raise again that the health sector should be part of the development chapter of a comprehensive EPA, as envisaged under article 34 of the Cotonou Agreement, and not simply a matter for market trading. Concluding the services negotiations before this is clarified would seem to be a case of the cart pulling the horse. Even more importantly, the cart should not be pulled in the dead of night. Given the significant ‘life or death’ impact for millions of people in the region of any discussions that affect health services, the negotiators should bring such issues to public and parliamentary forums for debate and feedback, before they conclude.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on the health issues in the EPA negotiations please visit the EQUINET website- www.equinetafrica.org. or SEATINI website (www.seatini.org)

Blind Optimism: Challenging the myths about private health care in poor countries
Anna Marriott, Oxfam GB

There is no question that a large-scale global expansion of health services is needed to reach the internationally agreed Millennium Development Goals for health. But how this massive scale up is to be achieved is the subject of considerable debate.

What exactly is the best way to reduce the number of women dying in pregnancy and childbirth and the number of children killed everyday by pneumonia and diarrhoea? How can we best ensure that, for those living with HIV and AIDS, anti-retroviral medicines are widely available?

For many international organisations and donors, an expansion of private sector health care delivery is considered the key to scaling up health care systems in poor countries. As a result, a growing number of influential organisations are pushing for increased funding of private sector health care, fostering the idea that those who can afford it should pay for their own private health care, and that governments should contract private providers to serve those who cannot.

The World Bank is one such body, advocating private sector involvement in health care while decrying the failure of public health systems in poor countries.

But are institutions that promote the increased role of the private sector in health using reliable evidence to inform their policy decisions? What does the evidence of other countries tell us; countries that have successfully managed to achieve universal access to health care?

Recent research has found that worldwide, publicly financed and delivered services continue to dominate in higher performing and more redistributive health care systems. Studies suggest that no low or middle-income country in Asia has achieved universal or near-universal access to health care without relying solely or predominantly on tax-funded public delivery.

The country level evidence speaks for itself: in just ten years, Botswana, Sri Lanka, South Korea, Malaysia, Barbados, Costa Rica, Cuba and the India State of Kerala were all able to cut child deaths by between 40 and 70 per cent – thanks to committed action by governments in organising and providing health services.

At the same time, the evidence in favour of private sector solutions is far from strong. On the contrary, there is considerable and increasing evidence that there are serious failings inherent in private provision, which makes it a very risky and costly path to take.

In China the rapid proliferation in number of private health facilities since the 1980s has led to significant declines in productivity, rising prices and reduced utilisation. Lebanon has one of the most privatised health systems in the developing world, it spends more than twice as much as Sri Lanka on health care yet its infant and maternal mortality rates are two and a half and three times higher respectively. And due to wide scale private sector participation in Chile’s health care system it has one of the world’s highest rates of birth by Caesarean section – a more costly and profitable procedure than natural delivery and often unnecessary.

So why do so many influential institutions persist in pushing the role of the private sector?

A major part of the answer lies in a number of common assumptions that are made in favour of for-profit private health-care provision, and which tend to persist unchallenged in the debate.

Firstly many argue that the private sector is already the majority provider in poor countries and it is therefore ‘common sense’ to put it at the heart of scaling up health services. But closer analysis of the data in Africa reveals that nearly 40% of so-called ‘private providers’ are in fact unqualified shopkeepers selling drugs of unknown quality. The same data shows that across 15 sub-Saharan African countries only 3 per cent of the poorest fifth of the population who sought care when sick actually saw a private doctor. And even when the private sector is a significant provider it doesn’t mean overall health care access has improved – over half of the poorest children in Africa have no health care at all. As a Senior Civil Servant from the Ministry of Health in Malawi has stated, ‘When poor people cannot get free services they do not go to private clinics, they go to the bush first and look for herbs.’

Another assumption is that the private sector can provide additional investment to public health systems that need it, but South Africa is one example that demonstrates that to attract private providers to low-income risky health markets significant public subsidy is often required, meaning governments have less money to spend on public health care.

Thirdly it is often claimed that the private sector can achieve better results at lower costs, yet private participation in health care is associated with higher, rather than lower, expenditure. The US commercialised health system costs 15.2 per cent of GDP, while across the border the Canadian national health system costs only 9.7 per cent of GDP. Canada has lower infant and child mortality rates and 46 million Americans have no health care at all.

A fourth claim often made is that the private sector provides superior quality health care, yet the World Bank itself reports that the private sector generally performs worse on technical quality than the public sector. And poor quality in the unregulated informal private health care sector puts millions of lives at risk every day.

A fifth argument made in favour of private sector health care is that it can help reduce inequity and reach the poor, but evidence finds this is not the case. For example market reforms of public health systems in both China and Viet Nam have coincided with a substantial increase in rural people reporting illness but not using any health services.

The last assumption is that the private sector can approve accountability, yet there is no evidence that private health care providers are any more responsive or any less corrupt than the public sector, and when the private sector provides health services on behalf of the state it can make it more difficult for citizens to hold their government to account.

Oxfam’s new briefing paper, ‘Blind Optimism: Challenging the myths about private health care in poor countries,’ released on 11 February, examines these six arguments made in support of the private sector, and looks at the evidence, or lack of it, behind them. It demonstrates that there is an urgent need to reassess the arguments used in favour of scaling up private sector health care provision in poor countries, concluding that prioritising the private sector in health care delivery is extremely unlikely to deliver health for poor people.

Further information on Oxfam and the issues raised in this briefing please visit www.oxfam.org/en/campaigns/health-education/health and email
amarriott@oxfam.org.uk or email the EQUINET secretariat at admin@equinetafrica.org.

The Bamako Call to Action for Health Research: Features and reactions
Training and Research Support Centre, EQUINET secretariat

The Global Ministerial Forum on Research for Health was held In Bamako, Mali From 17-19 November 2008, significantly the first time in Africa. The 'Bamako Call to Action' declared at the end of the meeting is the outcome of four years of meetings, dialogue and survey of key stakeholders the three days of the conference. As many researchers from the region would not have been present in these processes, this editorial, drawn from various public sources, captures some key features of the Call to Action, and provides a “fly on the wall” snapshot of some of the comments and reflections around it. The call and editorials cited are provided in more detail in this newsletter.

In the opening statement to conference delivered by the WHO Regional Director for Africa, Dr Luis Sambo, WHO Director General Dr Chan underlined the key role of research in keeping health high on the political agenda saying: ”We must have evidence and we need the right kind of evidence … because in most countries, an appeal to health equity will not be sufficient to gain high-level political commitment. It will not be enough to persuade other sectors to take health impacts into account in all policies.”

The Call to Action recognises that “Research and innovation have been and will be increasingly essential to find solutions to health problems, address predictable and unpredictable threats to human security, alleviate poverty, and accelerate development;” As one focus the call proposes establishing November 18 each year as a World Day of Research for Health.

National governments are called on to
• give priority to the development of policies for research and innovation for health, especially related to primary health care, in order to secure ownership and control of their research for health agendas;
• allocate at least 2% of budgets of ministries of health to research;
• improve capacity in institutions, ministries, and throughout systems for the implementation of research policies; and to
• develop, set, and enforce standards, regulations, and best practices for fair, accountable, and transparent research processes.
Further recommendations are made to promote the translation and exchange of knowledge and the build research capacities, including in young researchers.

Institutions at the regional level are encouraged to assist countries through international collaboration, where needed, to build and strengthen research for health capacity and to network researchers to promote the quality, ethics and sustainability of research. Meanwhile all stakeholders are called on to implement the recommendations from the WHO Commission on the Social Determinants of Health, especially those related to health equity, including to promote research on technologies addressing neglected and emerging diseases which disproportionately affect low- and middle-income countries and to ensure civil society and community participation in the entire research process.

To support this, funders and international development agencies are called on to better align and harmonize their funding and programmes to country research and innovation for health plans and strategies, and the global health research architecture and its governance to improve coherence and impact, and to increase efficiencies and equity in research. At least 5% of development assistance funds it was felt should be earmarked for the health sector in research, including for support to knowledge translation and evaluation and for national research institutions, especially in low- and middle-income countries.

From many quarters there has been a positive response to the call as a relevant step forward. The Lancet in its 29 November editorial declares that substantial advances have been made at Bamako on previous discussions, and the journal calls for 2009 to be “the year when the promises of Bamako are acted upon”. According to the Science and Development Network of 20 November 2008, the WHO has said that the Call to Action would be "used as a blueprint for research development approaches, with commitments made to submit the communiqué to the 2009 World Health Assembly and to the UNESCO General Conference. Ok Pannenborg, a senior health advisor at the World Bank, said: "The World Bank Group is extremely happy with the outcome, with its focus on research and innovation and research for health. This call will play a huge role in World Bank workings in the next four years".

The process itself was already reported by some to have had an impact. Aissatou Touré from the Institute Pasteur Dakar in Senegal reported in the conference, for example, that after the Algiers meeting, a decision was made to create a commission for research in the country’s health ministry, incorporating all the different actors involved in research for health to define the national research agenda for years to come.

But others were more critical: On SciDev.Net's blog on the conference one delegate asked ““We’re not saying anything new – what is the progress we’ve made?”

"There are no mechanisms in the call," said Damson Kathyola, director of research at the Malawian Ministry of Health, cited in the Science and Development Network review. "The WHO should [now] create innovation mechanisms for the monitoring and evaluation of the implementation of the strategies in the call. "We know that we need research to improve the health situation of our people in our countries. But there is a disconnect between policy and the implementers. Who's going to implement this?"

The World Bank, WHO, UNESCO, the Council on Health Research for Development (COHRED) and the Global Forum for Health Research have committed to set up a multi-stakeholder governance mechanism for research for health, including civil society, as a platform to take Bamako beyond 2008. The intention is to better network and support existing organisations. Will this work, or will it add another player to the increasingly populated work of initiatives and alliances? And how long will this take to be felt by researchers, health workers and communities in the lowest income countries?

The need to move more rapidly to action was perhaps the most common of the frustrations voiced. On the blog site for “Tropical Diseases Research to foster innovation and knowledge application (TropIKA ) “, Chris Bateman, News Editor of the South African Medical Journal is quoted as saying “Lots of fine words have come out. But, as a wild thought, how would it be if each of the 42 ministers were to tell the conference what they intended to do in the next year in terms of applying research to service delivery and filling the gaps where the needs are? That to me would give the conference real bite.” Dr Lindiwe Makubalo, Ministry of Health, South Africa, added further that “…..it’s really time to look at where the blockages are and try to move them”.

One blockage observed was the relative inequality in power in research– between international funders and countries and between researchers and communities, affecting how time and resources are applied. “Could there have been more representation from the groups we (researchers + communicators about health research) claim to represent? It would have been good to know the views of such groups as well,” asked one delegate.

Unless these blockages to implementing practices that are increasingly called for in documents and conference rooms are honestly identified and addressed, then perhaps BMJ Editor-in-Chief, Fiona Godlee, has basis for her more skeptical fears that in four years time, delegates will be having the same conversations at the next conference. Indeed, perhaps this caution, and concerns that resources now be directed to action, often at more local levels, lay behind the clause in the Bamako call to “evaluate the effectiveness and value of the four-yearly ministerial fora prior to convening a further high-level inter-sectoral forum to discuss global research for health priorities”.

Financial crisis, cholera crisis…. A crisis of injustice
Rene Loewenson, Training and Research Support Centre

The word “crisis” is becoming more common than water. Multiple crises are converging- economic, climate, energy, food and social. After a long period of speculative financial boom, media in the wealthy countries of North America and Europe are filled with apocalyptic stories of financial crisis, unnerving the people in these countries, who still collectively hold almost 90% of total world wealth. For the half of the world’s adult population who own barely 1% of global wealth, however, the crisis has been going on for decades.

The chronic crisis for this significant majority of the world’s people has been evident in more than a generation of unemployment, landlessness, loss of assets, and deprivation, that has further grown during the financial booms of the last decades. During a period characterised as “economic success” in the highest income countries, malnutrition and food insecurity grew in the poorest countries in Africa, falling international prices reduced returns on production and a food supply chain increasingly controlled by a few transnational corporations was able to further drive down producer prices, especially threatening women smallholder food producers. What was a boom for the import/ export firms, shipping companies, large-scale farm enterprises, financiers and officials who tapped into these commercial and financial circuits, was a deepening economic and social crisis for women and children.

In 2008 attention began to be paid to this food crisis. Like the financial crisis, the food crisis has been growing over decades of aggressive agribusiness. The scale and cost of this liberalized and speculative food production system is now, however, outstripping the possibilities of the usual emergency relief response. The alarming increase in child malnutrition in east and southern Africa post 1990 signals the failure of this model of agriculture for the populations of the region, even while it offered growing profits for largely foreign owned agribusiness.

Repeated outbreaks of disease also signal that people, usually in poor communities, are bearing the brunt of failed policies. Cholera is an avoidable disease that is prevented through safe water and sanitation systems. Zimbabwe has experienced a growing cholera crisis since August. By the first of December the United Nations reported 11,735 confirmed cases of cholera and 484 deaths in Zimbabwe. With the decline in functioning of clean water supplies, people’s mobility and a breakdown of the health sector’s capacity to contain the disease, the cases and fatalities continue to rise. Notwithstanding the economic decline in the country, Zimbabwe has the national wealth to secure basic water supplies and health care. The Zimbabwe Doctors for Human Rights correctly call the failure to do so a violation of human rights.

The globalization of media brings these crises to public attention with increasing speed. But does increasing awareness of such crises bring change?
While change often emerges from crisis, the last three decades suggest that this is not inevitable, particularly if the response fails to challenge the causes of the crisis.

The current financial crisis is possibly the deepest in recent history, but not the first. When the long boom of post-war economic growth ground to a halt in the 1970s, the response to financial decline was an aggressive pursuit of market policies, liberalisation and the opening of countries to transnational corporations. In the 1980s, after a spree of private bank lending, when heavily indebted countries were unable to pay back loans, the International Monetary Fund stepped into the financial crisis to bail out the Northern banks by offering loans to the indebted countries, restructuring their economies towards even greater liberalisation and market reform. These responses have generally served to protect existing wealth and the liberalised and speculative models of economic development that have both deepened inequality and that have been associated with the current crisis.

The response to the current financial crisis has starkly demonstrated the choices made over what merits protection. We have for some time known from United Nations data that saving several million lives annually by bringing safe water and sanitation to all would cost $10 billion a year. This money has never been found. Yet in October 2008, in one week, the US government provided a bail out package to the banks of $250 billion, 25 times this amount.

We are also seeing signs in the response of an efficient global machinery shifting the burdens of the financial and food crisis to the most vulnerable. According to the international non government organisation, GRAIN, players in the finance market - investment, equity and other funds – are turning to land as a strategic investment asset and haven for investment funds, even while the food and fuel crisis are driving acquisition of land for wealthy populations food and fuel needs. The organisation’s website lists over 20 such large investments in African countries alone, and notes an escalating trend. This month the South Korean firm Daewoo unveiled plans to lease one million acres of land (a land area the size of Belgium) in Madagascar, to meet Korean food needs. While loss of faith in markets may be triggering business to seek these deals, and deepening financial insecurity may trigger governments in Africa to make such deals, local farmers and communities are least consulted, and from the evidence of trends to date, are most likely to lose control over land, food and economic security.

So while powerful interests are oddly comfortable today talking about financial, energy, food, climate and other crises, there is silence on the crisis of injustice.

The increasing control of the world’s wealth by a diminishing number of players in the face of wide deprivation of the majority of people is a crisis of injustice. The pursuit of private wealth through appropriating collective natural, social and economic resources in a manner that undermines long term survival is a crisis of injustice. The failure of governments, nationally and globally, to meet basic human rights and needs when the resources are there is a crisis of injustice.

The quest for justice thus becomes a focus of ordinary people’s responses. There are many examples of this. In Zimbabwe this week, the Chitungwisa Residents and Rate Payers Association filed a lawsuit this month against the Zimbabwe National Water Authority for the lack of safe drinking water. While overshadowed by the scale of and necessary emergency responses to the cholera crisis, this action is nevertheless one by affected residents to call to account those in authority for how decisions are being made, how resources are being used and for whom power is being exercised. In this newsletter there is similar report of health activists calling leaders of high income countries to account: “For the developed country governments now to use their dominant position in our current system of global economic governance to deal with their own (largely self-inflicted) problems, while ignoring the much greater and longer-standing grievances of the developing world and the profound and urgent global challenges of ill-health, poverty and climate change, would be a betrayal”. As the legitimacy of current policies and institutions are being fundamentally challenged by the multiplicity of crises, more people are beginning to call it what it is- a crisis of injustice.

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

The CWGH @ 10: In Pursuit of Equity in Health through People Centred Health Systems
Itai Rusike, Community Working Group on Health

“We demand the inclusion of the Right to Health in the new Zimbabwe constitution!”

This was the slogan at the Community Working Group on Health 15th national conference. The conference was held in October 2008 in Harare and coincided with the organisation’s 10th anniversary celebrations.

The CWGH was born in early 1998, to lead and give visibility to community processes in health. Ten years later over ninety participants attended the conference, including CWGH national members, partners, activists, health cadres and Health Literacy facilitators from 21 of the 25 CWGH districts. The conference reviewed the path that the CWGH has walked through the past ten years. We noted that as much as the CWGH has over the years positioned itself as a voice in the health sector and built community power, still the health sector has continued to deteriorate. The current socio-economic and political environment has not only perpetuated the deterioration, but has also made it increasingly difficult for civil society to offer alternatives for health problems. It was thus noted that the network needed to not only strengthen the existing structures and processes in the network, but also to re-strategise on how best to use these to engage on and advance health under the prevailing harsh environment.

At the conference our health literacy facilitators from 21 districts reviewed the work they were doing to widen social awareness and action on health. Despite the political volatility, we heard from district after district that of actions being taken, including in engaging with the political leadership on health issues. The work of the facilitators has increased the involvement of communities in health actions within communities and around Primary Health care, whether within the community on environmental health, or mobilising resources to support health centres. These are being done through community level initiative with limited external support. It was clear to us that we need to strengthen the programme and these cadres, to cement the work we are doing at community level and translate information into action.

One of the clearest messages was to revive the Primary Health Centre (PHC) concept and comprehensive PHC , if there is hope for change in the health sector. Mary Sandasi, a CWGH national member pointed to the relevance of PHC even 30 years after the Alma Ata declaration to re-build the declining health sector, particularly as it puts the people at the centre of the health system. The CWGH will consistently engage with stakeholders and government to make PHC a more central policy principle, and we will strengthen community structures such as health centre committees and boards and committees at district and national level to organise public efforts to achieve this principle.

As the health sector deteriorates, the gap between rich and poor has continued to widen. Poor people struggle to access health, and higher income groups claim a larger share of public health sector resources. We see EQUINET’s ‘Reclaiming Resources for Health’ book as a resource to inform how we can address unfair, avoidable differences in health. For example, the CWGH has over the past decade taken up equity issues with the Parliamentary Portfolio Committee on Health (PPCH), the Ministry of Health and Child Welfare (MoHCW) and other stakeholders to push for resources to go to services that support poor communities. We have for many years raised attention to the need for more resources to go to disease prevention, for example, and continue to see this as an issue, to ensure that we have safe living environments and communities.

While we commemorated our tenth anniversary, it was difficult to call it a celebration given the collapse of our health care delivery system. What we did celebrate was the dedication and commitment that people have put into the organisation and the struggle for health in the past ten years. The CWGH has grown to be a prominent voice in health, has won the hearts of many to champion peoples health issues and has given greater profile to the positive force that people provide in dealing with health problems. We have grown from strength to strength, but so too have the challenges we face!

To back our efforts to address these, the CWGH membership unanimously endorsed that the network champion the right to health, and push its inclusion in the production of a new Zimbabwe constitution. Taking the theme for the year; ‘CWGH @ 10: In Pursuit of Equity in Health through People Centred Health Systems’ we see that embedding the right to health in our constitution will give us the bottom line we need to make it clear that everyone has a claim to health and health care, no matter what the economic, socio-political, race, creed, gender or other feature. It will be a right that we will fight to include, through social action, and that we will ensure is not left on paper, but protected and promoted, through social action.

Further information on Community Working Group on Health can be found at www.cwgh.org.zw. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.

Alma-Ata after 30 years: Still relevant for Africa?
Rotimi Sankore, Coordinator, Africa Public Health Alliance & 15% Now Campaign

In the context of Africa’s present health crisis, only people suffering from policy blindness can fail to see that Africa’s survival as a continent depends on going beyond merely declaring emergencies, and actually financing and implementing universal primary health care (PHC).

In September 1978, the International Conference on Primary Health Care was held in Alma-Ata, Kazakhstan, then part of the Union of Socialist Soviet Republics (USSR). Led by the World Health Organisation (WHO), the conference produced the Alma-Ata Declaration, which underlined the need for governments to protect the health of all citizens and emphasised that health for all is both a socio-economic (or development issue), and also a human right. The conference also highlighted the inequalities between developed and developing countries, and between the elite and ordinary people within countries.

One of the most significant outcomes of the conference through the Alma-Ata Declaration identified primary health care as ‘the most efficient and cost effective way to provide health care’. This has been recently reemphasised by the current Director General of the WHO Dr Margaret Chan.

Going by its definition of ‘essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation’ and the principle that ‘[h]ealth services must be shared equally by all people irrespective of their ability to pay and all (and rich or poor, urban or rural) must have access to health services’, it was assumed at the time that with effective implementation PHC would lead to health for all by the magical year 2000.

Based also on the understanding of health agencies, professionals and academic institutions that ‘primary health care needs to be delivered close to the people’ through ‘maximum use of both lay and professional health care practitioners’, experts have distilled down the basic principles of primary health care to several core factors, including: • Public education for the identification, prevention, and control of prevailing health challenges • Education on and provision of proper food supplies and nutrition, including adequate supply of safe water and basic sanitation • Provision of maternal and child care, including sexual and reproductive health education, and family planning • Immunisation and vaccinations against major infectious diseases. • Prevention and control of locally endemic diseases • Appropriate treatment of common diseases using the most up-to-date, cost effective and appropriate technology • Promotion of mental, emotional and spiritual health • Provision of essential drugs and commodities.

It cannot be emphasised enough that these primary health care principles can only be possible through long-term sustainable and combined financing of both health systems, and disease specific interventions. The phantom debate over ‘health systems versus disease specific interventions’ is a false one and a diversion equivalent to asking if food is more important than water to human life. It should be reasonably obvious that health systems without medicines and commodities are as useless as medicines and commodities without health systems. This applies to all health issues, whether malaria, TB or HIV/Aids.

Sustainable and long-term health financing must therefore mean identifying the specific challenges and obstacles to primary health care, and on the basis of costed plans work out clear and timely frameworks for resolving these obstacles. In addition to disease specific and wider health system challenges, this includes focusing on the resolution of key obstacles such as the lack of policies and financing sustainable plans for reproductive and sexual health, and resolving Africa’s critical health workforce shortage.

This editorial comes from the joint EQUINET newsletter issue with Pambazuka for the thirty years of Primary Health Care. The Africa Public Health Alliance & 15% Now Campaign engages African governments, global and African and institutions on implementation of the AU Africa Health Strategy, Health MDGs and fulfilling the AU Abuja pledge to allocate 15% of domestic national resources to health. For further information on the issues raised contact admin@equinetafrica.org

Bringing population health back into primary health care
Chan Chee Khoon: Universiti Sains Malaysia

In 1974, four years before the International Conference on Primary Health Care (PHC) was convened in Alma-Ata, USSR, the Canadian Ministry of National Health and Welfare published the Lalonde Report, named after the incumbent Liberal Party health minister Marc Lalonde.

Taking its cue from Thomas McKeown’s findings on the historical decline of tuberculosis mortality in England and Wales, the Lalonde Report challenged the presumption that improvements in human health by and large flowed from advances in (bio)medical knowledge, feeding through to professional practice and individual care.

McKeown’s writings on the main drivers of population growth and mortality decline in the early industrializing countries spawned vigorous debates. In addition to economic growth and improvements in food intake and nutritional status which McKeown himself highlighted, others argued also for the population health impacts of birth spacing and family size, housing and sanitary reforms (sewage disposal), and clean water and safe milk supplies (pasteurisation and eradication of bovine TB from livestock herds).

Mortality from typhus fever, a major killer in the 19th century, had shown continuous decline over the ensuing decades in the UK, such that by 1906, three years before Charles Nicolle discovered that the body louse transmitted typhus, London County Council reported no more deaths from that disease. Typhus fever, closely associated with poverty, poor housing, overcrowding, and poor hygiene was much less common among the middle and upper classes in 19th century England. Its decline was arguably linked to the increased availability of public baths, wash-houses, and widening use of cotton clothing, particularly underwear, which allowed for improved personal cleanliness.

Sonja and John McKinlay similarly concluded from their historical analyses that the fall in infectious diseases between 1900-1973, which accounted for 69% of the overall decline in US mortality during that period, could only be explained to a very limited extent (about 3%) by medical intervention.

In retrospect, the Lalonde Report might perhaps be judged prophetic (or lucky), given the as yet limited evidence base which might have restrained a more cautious technocracy professing evidence-based policy and practice. In any case, the thesis was reinforced by subsequent findings from Sweden, France, Ireland, and Hungary, which supported the view that social and environmental changes were the key factors in their decline in infectious mortality.

By the time of the Alma-Ata declaration, these findings from medical history and population healh were resonating strongly with more contemporary experiences from community-based primary health care in China, Bangladesh, Kerala, and Cuba. Notably, both perspectives shared a similarly broad vision of disease causation, rooted in what might be called a social ecology of health and disease.

Population health strategies in particular, according to the Canadian Advisory Committee on Population Health, address the entire range of factors that determine health, in contrast to traditional health care which focuses on risks and clinical factors related to particular diseases. Population health strategies furthermore are designed to affect the entire population, rather than individuals one at a time who already have a health problem or are at significant risk of developing one.

By the late 1980s, critics had highlighted weaknesses in the arguments of McKeown: the relative contributions of fertility and mortality changes to population growth during the period in question, the early conflation of TB mortality with pneumonia and bronchitis (affecting the timing of TB’s decline), the under-emphasis of water supply and sanitary reforms from the 1870s on, and to a lesser extent, the contribution of isolation and quarantine to the control and reduction of infectious disease. The decline of child labor (and its associated early life effects on adult health) has been proposed more recently as a contributory factor from the 1850s onwards, but this too is contested.

On the limited contribution of medical interventions to population health however, there was much less disagreement. Simon Szreter, who had played a prominent role in the critical re-appraisal of McKeown’s work, summed up the consensus thus: ‘The medical profession’s scientific leaders have, since McKeown’s time, had to change their tack and concentrate on the future, rather than the past, as the field in which they can stake the claim that they can save humanity from all its ailments with science.’

In less grandiose terms, the claim might be more plausible in the less developed countries, which still had (and for many still continue to have) large burdens of infectious disease in the mid-20th century, at a time when modern biomedical science in principle could have had a more significant impact on public health and in patient care (with vaccines, antimicrobials and control of disease transmitting organisms).

The availability of diagnostics and the ongoing campaigns for access to anti-retrovirals for instance testify to the potential impact of biomedical science for the public health control of the HIV pandemic. Access to lifesaving treatment for infected individuals is emphatically a moral and ethical imperative. But a public health approach to anti-retroviral treatment goes beyond an individual focus. Equally important, the availability of effective therapy may in some situations encourage those at high risk to come forward for voluntary testing, and hence reduce the pool of infected-but-unaware individuals who constitute one of the drivers of the pandemic.

It is nonetheless noteworthy that the population health perspectives pioneered and promoted by McKeown and Lalonde continue to be relevant to modern epidemics. The SARS epidemic outbreak of 2002-2003 subsided largely in the absence of reliable diagnostics, vaccines, or efficacious therapies, notwithstanding the rapid success in isolating and sequencing the SARS coronavirus. Its control was credited to established public health measures such as isolation, contact tracing, ring fencing, and quarantines, and the economic and financial stakes involved ensured that SARS would not be a ‘neglected disease’.

Likewise, the Nipah outbreak in Malaysia (1998-1999) was rapidly brought under control without vaccines or efficacious therapies, once the modes of transmission were established. The knowledge that Nipah encephalitis was linked to a newly recognised paramyxovirus which could be transmitted through close proximity to live, infected pigs but not via insects, or suspended airborne particulates, or contact with raw or prepared meats (ascertained from virological studies, field epidemiology, and clinical medicine), allowed for its rapid control in humans, even as this control decimated the pig farming industry in parts of Southeast Asia.

These recent experiences, thirty years on, teach us that modern biomedical science has an important integral role to play in informing the social ecological perspective which undergirds PHC for the 21st century.

In appraising this contribution of modern biomedical science to disease control and population health, it is, however, useful to distinguish between its contribution to knowledge-based practices and coping responses, as opposed to an undue focus on commodifiable consumables. This distinction (neatly demonstrated by the Nipah example) is especially pertinent in ensuring that advances in biomedical science in support of PHC are not left the strategic priorities of market-driven research and product development, but are backed by publicly funded and rationally deployed needs-driven research in the biomedical sciences.

This editorial comes from the joint EQUINET newsletter issue with Pambazuka for the thirty years of Primary Health Care. For further information on the issues raised contact admin@equinetafrica.org or ckchan50@yahoo.com.

Primary health care and health for all: Can we align to achieve?
Anthony Seddoh, WHO Africa Region Inter-country Support Team: Harare, Zimbabwe

Thirty years after the 1978 Declaration of Alma Ata, it seems the world is still at odds on how best to implement the principles of primary health care. The slow progress in improving health outcomes for all raises questions about the effectiveness of current ways of doing business. A concerted global alliance of global and country actors need to set positive and realistic paths to implement the intentions of Alma Ata.

Sixty years ago, the World Health Organisation (WHO) stated in its constitution that health is a “a state of physical, mental and social wellbeing, not only the absence of disease or infirmity’. Thirty years later, the Alma Ata declaration on Primary Health Care (PHC) among other things declared that “health is a fundamental right” and set a thirteen point understanding to ensure this right. This understanding captured concepts of essential care, universally accessible and affordable to individuals and families in the community through their full participation, in a spirit of self determination. It located PHC as an integral part both of the country’s health system, but involving all related sectors and aspects of national and community development.

The WHO constitution’s definition of health and the Alma Ata declaration together prompt a diametrical but complementary state that need to be concurrently addressed if health is to be attained: The first deals with the clinical determinants of health, pushing for the absence of disease in individuals. The second addresses the determinants of health that predispose or prevent individuals from attaining a state of mental, physical and social wellbeing as a fundamental right. These include appropriate governance, the absence of war, economic and infrastructure development, adequate infrastructure and aid policies. A unique moment occurred in 1978 to bring these complementary understandings together.

Before the ink could dry on the Alma Ata declarations it had, however, already generated polarised antagonism. It was considered too socialist with an excessive preference of government providing state managed intervention. From a capitalist standpoint, it was a ridiculous proposition, too costly and defying economic reasoning. The conservative duo of JA Walsh and KS Warren launched the Selective PHC debate, arguing that it is probably more efficient to save children and limit population growth. The two main PHC proponents, WHO and UNICEF soon drifted apart, as UNICEF promoted a selective package of low cost interventions. With resource flows following selective PHC, Primary Health Care was translated in most countries to mean a basic package of services to be delivered at district and community levels based on a selected number of interventions with some outreach services, with a watered down district health strengthening based on this.

Why nobody asked at the time whether there was any moral significance to be attached to a person’s life or pointed out that choices based on state preferences for total health gain can be justified over financial resource allocation efficiency is difficult to comprehend. Aside from efficiency based arguments being ridiculous propositions founded on utility based preference or embodying unattractive equity assumptions; the economic bargain in a healthy population should at least have also appealed to responsible international choice.

Alot has since been achieved from the advance in technology in dealing with specific clinical determinants of specific diseases. It could be argued that a saturation point has been reached, where increases in financial and human investments in existing technologies are yielding less than proportional gains. Despite this the selective interventions approach continues to define health and health services delivery. It was given a new lease on life by the World Bank through its World Development Report 1993, ‘Investing in Health’. This report, which hardly acknowledged PHC, commoditised and delinked health from development and moved the world closer to the interventionist approach to health – intervening at a selective point in the epidemiology of a disease or health system.

This approach has since had wide global appeal. Currently there are over thirty WHO resolutions on AIDS, TB or Malaria alone, more than all other subjects. The health Millennium Development Goals (MDGs) have further entrenched this disease specific approach to resource mobilisation. There are over eighty major global health initiatives linked to the health MDGs, providing over US$ 100 million annually. The Italian Global Health Watch reported in 2008 that the Global Fund has allocated approximately US$ 3.5 billion to countries for interventions on AIDS, TB and Malaria, mainly in Africa. Together, these initiatives have thrown billions of dollars at addressing diseases and improving clinical health conditions and made up a significant part of health sector budgets.

PHC is hardly mentioned in these initiatives. Member States went to sleep on PHC except for anniversaries, and the occasional mention linked to district health system strengthening. For various reasons the world assumed an emergency mode to address what are considered new and urgent public health issues. Single disease interventions that lend themselves to easily recognisable financial accountability, quantitative monitoring and evaluation held greater appeal for funders, especially when twinned with arguments of weak domestic governance and public policy failures and capacity limitations.

While these initiatives on clinical determinants hummed with measurable outcomes on specific diseases, the nexus of poverty and ill health was exacerbated. As a result, inequalities in health have deepened to a significantly greater level than thirty years ago. There is a growing trend in urban slum development, a decline in state services, market failures in privatised economies, growing food insecurity and massive deprivation of rights to health care.

Hence while a lot has been done in the past thirty years to deal with disease in individuals, the unique opportunity provided by the Alma Ata Declaration to also address the determinants of health have largely been lost. Thirty years later we see the costs of this omission in a burden of poverty and disparity related ill health that ill matches the level of knowledge or technological advance achieved globally.

As we approach another anniversary for PHC expectations are high. People expect that their physical and mental health will be promoted in a safe social, economic and political environment. They expect to have quality health systems that provide preventive services, diagnose, treat and manage disease injury, and reduce the severity and repeated occurrence of disease. They do not expect to see wide social and economic disparities in these basic entitlements. In Africa, furthest from delivery on these expectations globally, the Ouagadougou declaration on Primary Health Care issued on April 30th 2008 called for a renewal of the Principles of Primary Health Care and its implementation in developing countries and by the international community.

Such declarations are encouraging. However their implementation calls for resolution of the longstanding debate of the past thirty years. These debates are not academic. They present in choices made over the policy measures, relative allocation of institutional, social and financial resources and complementary systems for dealing with the social determinants of health (mostly dealt with by actions outside the health sector) and those reducing the health, social and economic inequalities that arise due to the burden of disease (mostly dealt with within the health sector). There are no clear answers for how a conceptual framework of Primary Health Care in 2008 will address this.

And while there is a massive coalition of global initiatives dealing with diseases, there is no clear coalition of global institutions supporting or funding the determinants of health, the second factor in the PHC equation. At global level, Bretton Wood institutions and OECD initiatives for debt relief and poverty reduction have led in some African countries to short lived increases in spending on health and education, no global initiatives so far adequately address the determinants of health.

This leaves PHC as an orphan with no global home. WHO’s attempt to foster parent PHC is inadequate given the pluralistic global environment. The state of poverty and the winds of change in international health resource priorities will make rational choices among the various dimensions impossible and predispose countries to the dictate of new interventions and their implementation. While the debates over the conceptual understanding of PHC will not end in 2008, at least 2008 could mark the turning point for a new institutional response, that builds a Global Alliance to generate the momentum and support for countries to implement PHC and that generates policy learning based on practice from the bottom up, reminiscent of another basis for the Alma Ata declaration.

A WHO or UN resolution creating such a global alliance would be a befitting PHC birthday gift for the millions of people seeking more than another conference. It will squarely put implementation right at the door step of a recognisable entity that can mobilise the needed funds and support countries with implementation.

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