Editorial

Wishing you a creative, collaborative, healthy 2019
Editor, EQUINET newsletter


We are starting a new year as the old one ended with a stark warning from Tedros Ghebreyesus, the WHO director-general. “We cannot delay action on climate change. We cannot sleepwalk through this health emergency any longer.”

A Lancet Countdown on Health and Climate Change reports that global warming is affecting every aspect of human life, not only in terms of extremes of weather but in terms of falling food security and access to safe drinking water and clean air.

In our region, where people are highly dependent on agriculture, vulnerable to drought and flooding and already facing a deficit in food security, safe water and clean energy, the impact is reported to be increasing already intense social inequality. WHO estimates that almost one in four premature deaths in Africa have environmental causes, and that climate change is likely to increase the number of health emergencies and disease outbreaks.

In November this year, African ministers for health and environment adopted a ten-year framework to direct funds toward joint health and environment initiatives. The Strategic Action Plan to Scale Up Health and Environmental Interventions in Africa 2019-2029 is expected to promote government investment in addressing environmental problems that affect human health, such as air pollution, contamination of water sources, and ecosystem damage.

These are important commitments. But in our region most governments are not yet fulfilling the commitment they made in 2011 to allocate 15% of domestic government spending on health. Underfunded health sectors struggle to balance the demand for promotion, prevention and medical care and often retreat into the latter.

Climate change demands global co-operation and resources. During the COP 16, the world's high income countries agreed to mobilize 100 billion US dollars per year by the year 2020 for adaptation and mitigation in low income countries, through a Green Climate Fund (GCF). We are nearly at 2020 and it is reported by IPS that only 10 billion US dollars has been mobilized so far since the establishment of the Fund in 2006.

Raising the health consequences of climate change is an important lever for attention and action on these concerns. It should also be a means to put people, social justice and solidarity at the centre of this. The opposite is feared to be happening. For example, at the November World Innovation for Health Summit it was noted that effects such as ‘environmental migrancy’, as people move away from harsh conditions, and the competition for resources can generate self-protection and discrimination. Vandana Singh, author and professor urges that these challenges not make us surrender “our imaginations, our creativity, our wonderful human capacity to work together, to negotiate and argue and brainstorm—on the altar of fear”. The solutions to these complex issues are not simply technical. They are inherently social and thus political.

So on this and the many other challenges that will certainly confront us in 2019, we wish you righteous anger, imagination and creativity and deepening opportunities to work together, negotiate, argue and brainstorm in the interest of our collective health and wellbeing.

The African Continental Free Trade Agreement – what will it mean for our health?
Rangarirai Machemedze, SEATINI


In March 2018, when African Union leaders in Rwanda signed the African Continental Free Trade Agreement (AfCFTA), there was much talk about it being a new chapter for the continent in furthering the socio-economic integration enshrined in the 1991 Abuja Treaty. It’s important therefore to ask- what implications does it have for health equity?

The agreement establishes a free trade area between African countries, liberalising 90% of trade in goods between countries, removing import duties on goods originating from African countries to enhance trade between them. On the one hand this can potentially promote sustained economic progress, with potential health gains if it offers benefits to all local producers, including small scale producers, and if the economic benefits are equitably distributed. On the other hand it can lead to risks to health if the laws and institutional mechanisms protecting health in cross border trade are not adequate.

One way to predict what the impacts of the AfCFTA may be on health is to examine what happened in previous trade liberalization experiences, specifically those in the International Monetary Fund and World Bank led Structural Adjustment Programmes. These trade liberalisation policies were implemented across Africa in a context of weak safety nets and protection of public sector services, including in health, education and agriculture. The decline of these services and economic inequality that arose after that experience raise questions on how the AfCFTA will be implemented.

Supporting a health sector calls for a range of areas of value-added production, such as for medicines and technologies. Our economies have still weak development of these areas of production and tend to import them, while exporting more or less the same products. So will the AfCFTA be accompanied by measures to promote investment for value added production in an organised collaborative manner, such as for infrastructures, equipment, technology and medicines for the health sector? Given that prior liberalisation policies have been accompanied by cost escalation for the ordinary person, will it assess and take as a measure of its progress a fall for the population in the price of essential medicines, commodities and services for health?

Most African countries have porous borders and many have weak capacities to check the quality and safety of goods crossing borders. When unsafe food products, chemicals, alcohol and other products that could harm health are poorly checked at borders there is a risk to public health. So too is the risk to health of cross border movement of substandard medicines. There are already reports by WHO of such medicines appearing in markets in some of our countries. Competition and wider markets provide a potentially health incentive for reducing prices of goods, so the AfCFTA could enhance access to low cost generic drugs from efficient producers within the continent. This benefit and the control of public health risk from harmful products and unsafe foods calls, however for significantly improved port health capacities in all our countries to accompany the flow of goods. Will the AfCFTA thus include specific measures to enhance these capacities in line with the International Health Regulations, and apply them at all the various points where goods cross borders?

If the AfCFTA promotes the freer movement of personnel, it could enhance availability and possibly accessibility of skilled personnel, including health workers, especially for countries experiencing acute shortages. But it could also do the opposite, as we have already experienced in our countries, where skilled health professionals are pushed or pulled to higher income areas and services, further deepening existing inequalities in their distribution. And the movement of people itself has the potential to spread disease across countries. So will the AfCFTA be introduced together with measures for training and resourcing personnel to manage the cross border spread of infection and to enhance equity within the continental access to skilled health workers?
The liberalisation of trade holds the promise of wider access to new goods and services, and to the spread of innovation across the continent. This can be very positive for health. At the same time changes in dietary patterns, employment conditions, physical environments and lifestyles can change consumption patterns in ways that are not always healthy. We have seen the consequences of this in the negative effect of consumption of processed foods and sweetened products in levels of obesity and diabetes for example. Our countries need strong public health laws and capacities and good communication capacities to manage such issues and avoid the epidemic of non-communicable diseases that has been witnessed in other regions.

The AfCFTA will certainly lead to changes in production and industries with implications for incomes and public revenues. As tariffs that protect domestic industries are removed, they are exposed to competition. If they have the capital and capacity to manage the change they may succeed, but if not they may close. For the public the question may thus be “what will happen to my job and my income?” Without adequate social security schemes in the continent, any significant negative shifts in jobs and incomes for countries who become net importers rather than net producers could be very harmful for health.

Given that import duties will be eliminated on 90% of goods traded between countries the public sector will lose the revenues generated from these import duties. Countries will thus need to diversify their sources of revenue. For some the growth in production may generate new tax revenue, for others that do not see the same production growth, their tax revenues may fall. As we have seen in the structural adjustment programmes, when this happens public health budgets are cut, with increasing dependency on external funders for the right to health care. As our countries intend to mobilise domestic financing for universal health coverage, what plans are there associated with the AfCFTA to make sure that it doesn’t lead to widening inequality in achieving this across the continent?

The AfCFTA could be a tool for fostering south-south cooperation on the continent, with a range of potential benefits for health. Countries could provide mutual support to strengthen areas of inadequacies and reduce inequalities across the continent. However, the issues raised above indicate that trade alone cannot achieve this without complementary measures to ensure wider benefits within and between countries, cooperation on production of health commodities and technologies, and strengthened capacities and measures to protect public health. As the negotiations to finalise the texts and implementation continue, it is imperative that the health sector takes an active role, not only to understand the implications of the AfCFTA, but to negotiate for measures in it that will safeguard the health of the people.

Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the AfCFTA text see https://www.tralac.org/documents/resources/african-union/1964-agreement-establishing-the-afcfta-consolidated-text-signed-21-march-2018-1/file.html

Breathing life into constitutional rights to health in Uganda
Jacqueline Nassimbwa and Mulumba Moses, CEHURD, Uganda


In 2011 civil society petitioned the Uganda Constitutional Court (Petition 16 of 2011) for its failure to put in place systems to prevent maternal deaths in public health facilities. This failure was argued to be a violation of the right to the highest attainable standard of health guaranteed in the country’s constitution.

In response the judgement stated

“…Much as it may be true that government has not allocated enough resources to the health sector and in particular the maternal health care services, this court is………reluctant to determine the questions raised in this petition. The Executive has the political and legal responsibility to determine, formulate and implement polices of Government……….. This court has no power to determine or enforce its jurisdiction on matters that require analysis of the health sector government policies…”

The court argued that it had no role in reviewing or commenting on government policies or on how they are operationalized. It stated that judging on the issues raised in the petition implied taking over the role of the government executive, and that the injustice was not a constitutional but a political issue.

The Constitutional court thus dismissed the case. However, in an appeal to Uganda’s High Court the dismissal was struck down, with a ruling that the Constitutional Court had erred and that it indeed had a mandate to hear the case. The case has since gone back to the Constitutional court with a date for the hearing still pending.

The to and fro on this case reflects the challenges arising when claiming a right to health that is implicit within a national constitution. Clearly stating the right to health in the constitution is important for it to be promoted, enforced and safeguarded. If not stated in the constitution, its implementation depends on the actions of politicians, state officials, the courts and civil society. In particular, the preamble, “We the people…” in the constitution mandates the citizenry to advance these provisions.

While some countries in east and southern Africa do explicitly provide the right to health care, the right to health is often not explicitly stated. In Uganda, the 1995 Constitution, currently in force, has provisions on rights to life, privacy, freedom from torture and education amongst others. It does not, however, explicitly provide for the right to health. This right is rather found in the national objectives and directive principles of state policy. It thus depends on a mix of political, judicial and social action.

In an EQUINET case study by CEHURD (https://tinyurl.com/y6uppusb), we reviewed how this less explicitly provided right to health in the Uganda Constitution is being implemented through political, judicial and popular mechanisms.

Politically, the government executive has made international commitments to the Sustainable Development Goals in line with a Uganda Vision 2040. This policy vision aligns government initiatives to fulfilling duties and responsibilities, including for health care. It commits government to ensure policies and laws and build state capacities to implement programmes to realise health rights. In the health sector, for example, the ministry of health has a policy commitment and plans to ensure universal health coverage to realise the right to health care.

Such positive political intentions draw attention to how far they are being implemented. Parliamentarians as political actors have passed progressive laws to reflect changing social perspectives on health rights. However, there are gaps that need to be addressed. For example, old, colonial laws are still in force that do not reflect human rights principles, such as those governing the control of sexually transmitted diseases (termed ‘venereal diseases’ in the law).

Further, a gap in delivery on political intentions can be seen through the disparities in service coverage for particular social groups and lack of a clear co-ordinating mechanism for different sectors to address health determinants. It can also be assessed from how far policies are being framed for and services delivered to address controversial issues, such as abortion, access to contraceptives and education on sexuality for sexually active adolescents.

Beyond these political measures, there is an option for judicial implementation of the right to health. Indeed, there has been some increase in litigation on the right to health in Uganda, although with still few cases filed, and even less with favourable judgements. In a 2009 case the court dismissed a petition on the potential toxicity of chemicals sprayed for malaria prevention as not violating constitutional provisions on the right to health. In contrast in 2010 the court declared female genital mutilation, being practiced in certain Ugandan cultures, as a violation of the constitution, and specifically a violation of the rights of women and the right to health.

These poor outcomes could be explained by a lack of understanding of the human rights doctrine amongst judicial officers and lawyers. This may, for example, be a reason for the dismissal of Petition 16 cited earlier, later overturned by the High Court. It could explain the caution in the courts over litigation on social rights. This suggests a need for advocacy and capacity building with these key judicial stakeholders on their role in taking forward the right to health and the use of appeal processes to take up cases where the outcome may be seen to be unfair.

Beyond the political and judicial routes to implementation of the right to health, there is also the possibility of social action advancing these rights. There has been a rise in popular implementation of the right to health as implicitly provided in the Constitution in Uganda, more commonly through the actions of organized groups. In our review, we found experiences of campaigns, demonstrations, coalition formation and industrial action.

For example, in the ‘Walk to Work’ campaign in 2011, people were encouraged to walk to work daily to protest increasing prices of fuel, food, and transportation and poor social service delivery. The campaign, identified as political opposition due to its leadership, met police suppression and incarceration of campaigners and was banned in 2012.

More specifically focused on the health sector, in late 2017 the Uganda Medical Association (UMA), launched an industrial action over poor salaries, poor working and living conditions and inadequate medical supplies preventing medical personnel from performing their duties. This too met an immediate government response in a court challenge to the legality of UMA, an order by the Minister of Health for the workers to return to work and deployment of military doctors to hospitals. Later, however, government negotiated with the medical workers, improving their welfare and salaries. This measure for popular implementation yielded more positive results on health rights, perhaps given its less partisan political nature.

These diverse experiences found in Uganda, further detailed in the case study report, point to the fact that applying a right to health that is not explicitly provided in the constitution is possible. It calls for and generates political, judicial and popular measures, and possibly demands a mix of all.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. Please visit the EQUINET website to read the case study report and other publications on health rights.

How do we keep our health workers in remote rural areas?
Rambelani Nancy Malema and Livhuwani Muthelo, University of Limpopo

Although half of the world population lives in rural and remote areas, these areas are serviced by only a quarter of the world’s nurses and less than a quarter of the doctors. In our region the ratios are even worse, where only 16 doctors service every 100 000 people living in remote rural areas.

The global shortage of health workers, estimated by World Health Organisation to reach 18 million by 2030, has motivated resolutions in the World Health Assembly and other fora for member states to find ways of retaining their health workers, through incentives and working environments that encourage people to stay in rural areas. Most recently in 2016, a High-level Commission on Health Employment and Economic Growth recommended investing in rural education and creating decent jobs in the rural health sector, particularly recognising the contributions of nurses and midwives to improved health.

Notwithstanding these calls, rural and remote areas continue to fail to attract and retain health workers. So beyond statements of good intention, what practical measures should we be implementing to improve the retention of health workers in our rural areas?

It begins with how health workers are enrolled and trained. Our training institutions need to review their admission policies to enrol students from rural backgrounds. They need to include information on rural health care in the curriculum and to integrate rural community experiences to expose students to these environments. Our undergraduate and postgraduate curricula and continuing education programmes should be oriented to building competencies for the shift from hospital-based approaches to preventive, affordable, integrated community-based, people-centred primary and ambulatory care in rural areas, as well as in building capacities for public health and preventing and managing epidemics.

Financial incentives have commonly been used to attract and retain health workers in rural areas. In addition to allowances, they may be given as bursaries for further education, study loans and occupation-specific dispensations. There is evidence that these measures have motivated health workers to remain in rural areas. But they can also be eroded if they lose value over time.

This makes the living conditions, availability of electricity, proper sanitation, access to schools, telecommunication and internet equally important to enhance retention, together with support for career development and advancement, such as by creation of senior positions in rural institutions. There are new opportunities in using information technologies to enhance rural practice and avoid professional isolation. Providing scholarships, bursaries or other education subsidies and improving living and working conditions can have a more positive effect than compulsory service requirements. Health workers, like others, appreciate their jobs when treated with dignity and respect.

From our review of the literature in a new EQUINET discussion paper 115, we found that many such strategies are being used. There were some cautions on how we apply these strategies. For example, compulsory measures appear to be best accompanied by relevant support and incentives. Mitigatory strategies such as task shifting should not become ‘task dumping’ and replace more substantive solutions. Ad hoc financial incentives should not be applied so selectively that they motivate some workers, while demotivating others. They should also not be used as a substitute for a more substantive review of working conditions and of disparities in salaries between different health professionals.

It is evident that there is no single approach. There are options, and countries need to choose strategies that are relevant for their own context and in consultation with key stakeholders. This needs to be embedded in the strategic processes for national health planning and financing. Addressing this issue calls for robust management and communication processes and skills, backed by credible evidence from monitoring and evaluation systems, to ensure that the chosen strategies are relevant, appreciated and continually updated.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. Please visit the EQUINET website to read the publications on health worker retention.

A tribute to those who provoke us to think again
Editor, EQUINET News

While working on this month's issue we got news of the passing of an inspiring African thinker, Samir Amin, and then later in the month of the previous UN Secretary General Kofi Annan and pay our respects to both. In different ways and forums they challenged thinking and agendas from an African and southern lens. From Dakar, Senegal, where Samir Amin led the Third World Forum, Vijay Prashad notes that Amin explored and wrote about both the dangers and possibilities of our current world. In the face of a "world system with finance in dominance and people whipping from one precarious job to another" he pointed to both the need and possibility of Africa making different choices and creating and advancing an alternative. "As long as we are resisting, he would say, we are free." We include one of the many articles published on his work and ideas in this issue.

Back to our editorial this month on waiting mother shelters. Papers included in this issue point to a continuing research debate on their effectiveness, with one review finding no evidence of this from randomised control trials. Yet the evidence from experience of their use in Zimbabwe in the editorial suggests a need to think beyond measured service and morbidity outcomes to understand their value for improving wellbeing, and to understand how, beyond individual interventions, different elements of comprehensive primary health care come together to improve health and wellbeing.

Waiting mothers homes save lives: what we have learned from Zimbabwe
Nonjabulo Mahlangu, Mandy Mathias, Mongi Khumalo, Thabiso Sibanda, Zimbabwe

Silothemba looks lovingly at the little bundle nestled in her arms and beams with pride. “It wasn`t easy,” she says. “I nearly lost this baby. I bled a lot and had I not been here the nurses say I may not have made it too. I wasn`t eager to come to the waiting mothers home because my friends said the nurses keep you there for long and I have two small children at home. Actually I didn’t go to the home on the day the nurses said as I decided to go to the clinic when I felt labour pains. My local village health worker encouraged me to take their advice, however, and I am so happy that I did. My delivery was very difficult. It started at night and had I not been at the clinic my baby and I might not have survived”.

Silothemba is one of the many mothers in Zimbabwe who have benefited from waiting mothers homes. These facilities help to reduce home deliveries as they enable mothers to be at health facilities when labour begins. Nutrition gardens at clinics managed by health centre committees provide vegetables for pregnant women, and boost food security for those from poor households.. Kumbudzi clinic in Umzingwane district also has a kitchen project to support and promote nutrition amongst pregnant women.

In Zimbabwe currently 525 mothers die in every 100 000 live births, one of the highest maternal mortality rates in the world. Mother and newborn survival in Zimbabwe is affected by the ‘3 delays’, that is a delay in making a decision to seek health services, a delay in reaching a health facility and a delay in receiving quality services and care upon reaching a health facility. These delays and the deaths from them are greater in rural areas.

Before the waiting mothers homes were introduced, rural women often gave birth at home with the aid of traditional birth attendants. While convenient, these home births may expose women to risks from unhygienic conditions or limited ability to manage complications. Waiting mothers` homes increase mothers’ access to skilled birth attendants and emergency specialized care.

Women who deliver at home often lack adequate information on the risks associated with pregnancy and childbirth. Health monitors at community level indicate that the delay in deciding to seek health care is a major contributor to maternal deaths, as women decide to seek appropriate health care when it is too late. This delay is exacerbated by the fact that many women do not make these decisions themselves but defer to spouses or relatives, who may also lack knowledge on maternal and child health. Pregnant women also face barriers from long distances to health facilities, poor road networks, slow transport methods. They may thus deliver before they even reach the clinic. Women in many remote rural and resettlement areas live more than 25 kilometers away from health facilities, above the 10km maximum recommended by government. Going by ox drawn cart is not an option when there are pregnancy related complications have developed and many transport operators fear the risk associated with ferrying such passengers.

A waiting mother home reduces the stress of these barriers, giving time to travel to facilities, and reducing costs from different transport options. It brings mothers closer to the skilled health workers they need to manage normal deliveries or obstetric complications.

This puts the focus on the third delay, the delay in receiving adequate health care. With postpartum hemorrhage; obstructed labor and hypertensive disorders common causes of maternal death in Zimbabwe, health services need, but often lack, the staff, training, medicines and equipment to effectively respond to a mother’s needs. Most rural clinics have at least 2 trained nurses/midwives, but these health workers often face burnout due to overwork and lack electricity, running water and adequate medicines. Higher level referral services may themselves lack skilled personnel. Antenatal care services and waiting mothers homes allow health workers to monitor the mother before their labour and make early referrals to the next level of care for caesarians, vacuum extraction and induction if this is needed. Referral to these services may also face challenges in some areas from poor road networks, flooding rivers, a shortage of ambulances and poor communication channels. While waiting mother homes cannot solve these referral problems, they can give health workers more time to arrange options to address them.

To overcome the three delays, waiting mothers homes need to be backed by other service improvements. Primary health care services need to be available in remote and hard to reach areas, skilled obstetric care needs to be brought closer to rural women through regular visits to health facilities by doctors and stock-outs of relevant medicines avoided. Village Health Workers should be supported by strengthening their knowledge on maternal and child health and support for community led health promotion. Communities especially men should be involved and educated on the risks associated with maternity and the benefits of delivering at health services to encourage their partners to use and benefit from waiting mothers homes, to promote institutional deliveries and to argue for effective primary care and referral services.

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

Safeguarding the principles of the Alma Ata Declaration on PHC
Editor, EQUINET Newsletter


For forty years the 1978 Declaration of Alma Ata on Primary Health Care has inspired and galvanised understanding, analysis and action on health. In our region, the aspirations and content that were included in the 1978 declaration were embedded in liberation movement goals and post- independence policies and informed the organisation and transformation of health services. Indeed a context of growing movements for social justice and emergent national health systems in the South was one source of the political momentum, values and practice that fuelled the Declaration. In various declarations over the past 40 years, African governments and communities have recognised the contribution of PHC to improved health equity in the region and voiced a need to accelerate efforts to implement it, even while resources bled out of public sector services.

In preparation for a Global conference in Astana in 2018 to commemorate 40 years of PHC a new declaration is being drafted: “the Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals”. The text can be found at http://www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf. It notes a “renewed commitment to health and well-being for all based on universal health coverage (UHC)” and locates PHC as “a necessary foundation to achieve UHC”. Its focus is thus on UHC as the end and PHC as the means. It makes reference to the work of other sectors to address other health determinants in line with the Sustainable Development Goals, “ avoiding political and financial conflicts of interest”.

But the Alma Ata declaration was so much more ambitious and comprehensive in its vision and scope! It called for an economic order that would serve the attainment of health and reduce inequalities in health globally, while also recognising that the promotion and protection of people’s health is essential for socio-economic development. Its language on state duties and public rights is unambiguous. Its principles are no less relevant today than in 1978, even if changing contexts, health profiles and knowledge demand creativity in how it is applied.

As new statements and declarations circulate, let’s remind ourselves of key features of what the Alma Ata Declaration says:

“ I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.

IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.

VI Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”.

There is more, and the full declaration can be found at http://www.who.int/publications/almaata_declaration_en.pdf

Those engaging on statements and processes on PHC should carefully compare with the Alma Ata Declaration and ensure that we do not lose or blur its clarity of principles and content.

Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the Global conference on PHC see http://www.who.int/primary-health/conference-phc/en/

Ensuring health and access to health care for migrants: A right and good public health practice
Ncumisa Willie: Research Advisor, South African Human Rights Commission, South Africa

According to the United Nation’s 2017 International Migration Report, South Africa is host to an estimated four million migrants. This figure is set against a backdrop of a history of migration into South Africa that was marked by exploitative labour arrangements between South Africa and its neighbouring countries. This history is often treated with a ‘historical amnesia’ of the contribution of migrants to the South African economy and society. Migrants and particularly African migrants are met with a distrust and hostility that appears as xenophobia.

This hostility is also reflected in South Africa’s public health system, which does not adequately incorporate the reality of migration and health, nor address the needs of migrants. The South African Immigration Act is silent on the health rights and needs of migrants, placing them in a vulnerable situation and often leading to their exclusion from the public health system. This situation is worse for undocumented migrants, given their insecure legal status.

In contrast, recent media reports have often focused on ‘how an influx of health migrants’ has placed a strain on the country’s ability to deliver health care to its nationals. Some provincial health departments have lamented the strain on their limited resources due to the demand for services from migrants. These media reports and official pronouncements create conditions for refugees, asylum seekers and undocumented migrants to be denied access to health care services in public hospitals and clinics on the basis of their nationality or legal status. This was described by Crush and Tawonzera in 2011 as a form of ‘medical xenophobia’.

Denying migrants access to health care constitutes a violation of the internationally recognized right to access health care services, a right that is also enshrined in South Africa’s national law. The Bill of Rights in the South African Constitution enshrines equal rights for all persons in the country and affirms values of human dignity, equality and freedom. Migrants are covered by these constitutional rights, including the right to life, to dignity, freedom and security, to access information and to just administrative action. Section 27 of the Constitution guarantees everyone the right to basic health care, affirming that “everyone has the right to have access to health care services, including reproductive health care” and that “no one may be refused emergency medical treatment”.

The violation of migrants’ rights to access health care has grave consequences. For example, in 2015, a migrant woman lost her premature baby, allegedly due to denial of access to health care. In another incident, a migrant woman was forced to give birth at a bus station after allegedly being denied access to two hospitals in Gauteng province. Such denials of care violate rights. They have a gendered, racial and class impact, with poor, black women bearing the brunt of this discrimination.

Beyond the state’s legal obligation to provide access to health care services, there are public health reasons for providing health care services to migrants. The difficult journeys undocumented migrants, asylum seekers and refugees have had to make from their countries to South Africa may have exposed them to health problems, including communicable diseases. Treating these conditions makes public health sense as we live in a shared social space. The health of the local population is linked to that of the migrant population, given their integration into the wider community.

I would therefore argue that the South Africa state should develop a comprehensive multi-sectoral approach to migration and health, beyond infectious diseases and border control. Both the National Health Act and the Immigration Act should explicitly provide for migrant health care. The Immigration Act needs to be amended to adequately reflect the health rights of documented and undocumented migrants. The law should be supported by a comprehensive national policy, that also details how undocumented migrants should be treated, and that is applied universally across all provinces.

We need to advocate for and train health workers to implement migrants’ health rights. Such training, as a collaboration of the South African Department of Health and the Health Professions Council of South Africa, should create and foster an understanding among healthcare professionals of migrants’ health rights and needs. It should also include health administrators, as they are a point of entry for migrants attempting to access health care services.

These measures are necessary as a public health care system that excludes migrants creates conditions for poor public health for all. It increases the vulnerability of migrants, generates and magnifies discrimination and inequalities in health and violates migrants’ constitutional rights to access health care.

This is not just a health and human rights issue. It is also a matter of social justice. Migrant labour, often low wage, has been integral to South Africa’s society and economy, raising the profitability and savings of local business and consumers. It is also a matter of good public health practice. Delivering equitable access to care for migrants can reduce the health and social costs of disease, improve social cohesion, protect public health and human rights and contribute to healthier migrants in healthier local communities.

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

A pause for review and one last reminder
Editor, EQUINET newsletter

We have a shorter newsletter and no editorial this month as we carry out essential review and maintenance work on our site. We hope the papers and content included still provide you with interesting materials for your work and analysis in and beyond the region. We have appreciated editorial contributions from a range of experiences and invite you to send us editorials written by you, and any links to videos, blogs, papers or other online resources you want to share on your perspective on the opportunities that we should be tapping in east and southern Africa for making immediate or longer term advances in equity in health.

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Can essential benefit packages be a lever for universal health systems?
R Loewenson, M Mamdani, EQUINET


Current policy agendas raise an impetus for countries in east and southern Africa to be clearer with the public on what health care services they can expect to access. Commitments made to universal health coverage (UHC) and equity in health care point to a need to define the entitlements or service benefits that will be provided universally to respond equitably to population health needs. Constitutional provisions on the right to health care raise a demand to clarify what services people should be legally entitled to. Yet the gap between demand and resources suggest a need to clarify what can be funded and provided universally, taking costs into account. The diversity of funders and providers in most health systems in the region call for funders and providers to be aligned around these entitlements while social demand for public accountability calls for transparency on how resources and capacities are being used to deliver these entitlements.

As one response, many countries in east and southern Africa (ESA) have developed essential health benefit packages (EHBs) in order to define service benefits, to direct resources to priority, relevant and effective areas of health service delivery. EQUINET research in 2015-2017 through Ifakara Health Institute and Training and Research Support Centre working with ministries of health in Swaziland, Tanzania, Uganda and Zambia found that of the sixteen countries in the ESA region, thirteen had an EHB in place by 2016, albeit with different names and at different stages of design and implementation.

There was much in common in the way these EHBs were being developed and what they covered. The EHBs in the region cover similar services for communicable and non-communicable diseases, maternal and child health and public health. They generally combined an analysis of health burdens and cost-benefit or value-for-money to identify what services to include, taking on board policy goals and commitments. In some cases they took into account the priorities reported by stakeholders and external partners and, to a more limited extent, communities and parliamentarians. When countries used consultative, consensus-building design processes with wider stakeholders they widened awareness and debate on the choices to be made in what services to include, on the cost of care and on the entitlements included.

It would appear that the process for defining, costing and clarifying service benefits could be a key entry point for policy dialogue across stakeholders and an important basis to build an operational strategy for realising UHC in an equitable manner and for making clear the deficits to be met.

Indeed, ESA countries report a range of ways they are using their EHBs: They are being used as a tool for budgeting and planning at local government level; to guide priority setting and budgets; to purchase services from private, not-for-profit services and to monitor service performance. These areas of practice depend on quality system data, including from the from the private health sector, good population health information and data on the costs of services to both design, purchase and be accountable for delivery of the benefit.

While there are shortfalls in some of these areas of data, the funding gap has presented perhaps the greatest challenge in delivering on the EHB. ESA countries face clear challenges in reconciling the services they should provide to respond to population health need with the resources they have to do so. The estimates ESA countries calculated for what their EHBs would cost varied widely, from $4-$83/capita at primary care level to $22-$519/capita for referral services. In part this reflects differing assumptions and methods used for capital and recurrent costings. At the same time, in most ESA countries these figures point to a gap between the cost of a benefit package that responds to health needs, and the funds available for it, particularly in the public sector. Having these costs of the EHB raises a question for national and global levels of how, in the face of commitments to UHC, these costs will be met to turn the talk into action.

In the face of this funding gap, some countries have begun to explore new revenue sources from innovative financing, linking the EHB to policy dialogue on health financing. Resource constraints and vertical financing have, however, also motivated rationing of scarce resources, reducing the benefit to a smaller subset that can be funded from current budgets. This may focus resources on what is possible and avoid the frustration generated by the gap between aspiration and delivery. However, it also raises concerns on how to ensure fairness and public health effectiveness in the decisions on what services are covered and what is excluded. How should services treat people who present with a combination of conditions, one covered and one not? How to ensure the integration across services when some are funded and others not? How to avoid ‘minimum’ benefit packages becoming the ‘maximum’ provided? How to ensure that the poorest in the population get all their health needs addressed without costs that impoverish them?

In a regional dialogue within the countries involved the research, the EHB as a universal benefit was seen to be consistent with policy goals to build universal equitable health systems. It was seen to be a potentially useful measure to engage and build support from high-level political actors, funders, providers and communities on the different challenges that need to be addressed in implementing UHC, and to align public and private actors around national goals.
In facing the financing challenges given the desire to ensure universal provision of the benefit, it was felt that the EHB would be best funded through progressive tax financing and pooling of other social insurance, earmarked tax and private sector contributions to avoid segmentation and to ensure the universality of the benefit. At the same time it was felt that funding constraints not present a pressure to limit to curative services, and that the EHB include health promotion, public health and prevention measures, as both value for money, important for service integration and key for health sector engagement on inter-sectoral action for health.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the issue can be found in the regional meeting report at
http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Regional%20EHB%20Mtg%20Rep%20Nov2017.pdf , the country case study reports on the EQUINET website and synthesis paper at
http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Diss%20113%20EHB%20synthesis%202018.pdf

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