Antibiotic Resistance – are we driving our own extinction?
Constance Georgina Khaendi Walyaro, Citron Wood Foundation

Antibiotics have been used for over 3,000 years.

Without fully understanding how they worked, many early civilizations used mould and other microbes to treat infected wounds and diseases, attributing their healing power to a magic that drove away the evil spirits that caused disease. In the 20th century advances in science brought new understanding of the role that certain organisms could play in controlling other disease causing organisms. This brought over a century of advances in the use of antibiotics such as penicillin, with significant gains in human survival. Yet today we face a new threat of microbes that are resistant to the array of antibiotics that we have developed in the past century, and our use of antibiotics appears to have made us vulnerable to the onslaught of even more virulent forms of organisms.

For most of the last century, antibiotics were regarded as ‘miracle drugs’. They were used to suppress many life-threatening infections and allowed for advances in other areas, such as surgery, by controlling the risk of infection. Some estimate that they contributed with public health gains to an average of 20 years greater life expectancy in the past century.

However, in this century we appear to be losing the battle against infectious diseases through strategies that rely on antibiotics. It has been more than 20 years since a qualitatively new class of antibacterial medicines have been discovered. More importantly, however, bacteria are fighting back. They have become more virulent in every region of the world and more resistant to the medicines used. The emergence of drug-resistant “super-bugs” has led to diseases that are more difficult and costly to treat, such as in the case of multi drug resistant TB.

How did we get into this position? Many reasons have been given, including poor infection-control practices and the misuse of antimicrobial medicines. Antibiotics were overprescribed without checking whether they were really needed. It was recently estimated that almost half of all current antibiotic prescriptions are unnecessary. Some people stopped taking them when their symptoms disappeared - even if still infected. Antibiotics have been mixed with animal feeds to boost livestock growth, contributing to a build-up of antibiotics and in response leading to more virulent bacteria in the food chain. As we used antibiotics more widely, so bacteria themselves evolved into forms that resisted their effect. Without adequate surveillance to track the impacts of this wide use of antibiotics, resistance silently grew.

According to the World Health Organization (WHO), antibiotic resistance (ABR) has now reached significant levels in all regions of the world. We still lack adequate accurate data on the current global situation. However, a 2014 WHO global report provides a picture from current evidence that is extremely worrying (http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1). The report indicates that in all regions there are high rates of resistance in the bacteria that cause common health problems such as urinary tract infections, pneumonia, diarrhoea and so on. Multi drug-resistant TB is spreading and there are also reports in some countries of resistance to the artemisinin used to treat malaria. In some parts of Africa, as many as 80 percent of the Staphylococcus aureus infections that cause common skin and wound infections are reported to be resistant to methicillin (MRSA).

These trends challenge disease control programmes that rely on treatment. They also challenge health systems. With growing resistance, when treatment with standard first-line antibiotics is no longer effective, more costly stronger second line drugs are used. However, these may not be available in resource-constrained settings. They also have severe side-effects which require monitoring during treatment - further increasing costs to services and communities. ABR adds new pressures on already strained health and development resources. Patients who cannot afford treatment may drop out of healthcare services and the bacteria spread further, especially for poor households, in a vicious cycle of virulent disease, costly care and falling survival.

What then can we do?

The key intervention is to reduce the environments in which infectious organisms breed, through improved living conditions and public health measures. Investing in safe water, improved sanitation, better housing, food preparation and waste management provides a sustainable, pro-poor approach with wider benefits, as do prevention measures such as vaccination.

At the same time WHO also advocates for a comprehensive master plan to combat ABR and to guarantee all - regardless of their economic status - uninterrupted access to antibiotics and other essential medicines of assured quality when needed. On the one hand new affordable medicines, diagnostic and surveillance tools are needed from platforms that foster innovation. However technology is not on its own a solution. We need guidelines and regulations that promote rational use of antibiotics in both human and animal medicine, including when not to use them. Antibiotics should be used only for treatment of diseases and completely banned as growth or food supplements. We need to educate the public to use antibiotics only when prescribed by a doctor, to complete the full prescription - even if people feel better, and to never share antibiotics with others or use leftover prescriptions.

We also need to better understand the scale and spread of the problem to raise awareness and plan for it in our region. In 1998, WHO Member States endorsed the Integrated Disease Surveillance and Response (IDSR) strategy. Yet, surveillance of ABR is still currently inadequate and poorly co-ordinated, and public health laboratories lack full capacities to test for antimicrobial susceptibility. The WHO Regional Office for Africa (AFRO) reports that only a few African countries carry out surveillance of drug resistance for many common and serious conditions. WHO AFRO has in response published a guide to facilitate the establishment of laboratory-based surveillance for priority bacterial diseases and some countries have set up collaborations for national and regional ABR surveillance. There is however no formal regional framework for collaborative surveillance and information sharing, and limited public reporting. This not only hinders efforts to track and control the emergence of drug resistant micro-organisms, but also to assess the effectiveness of policies and activities to manage the problem. We need better standards, capacities, tools and social literacy to determine, monitor and control ABR in humans, animals and in the food chain.

In the face of rising food prices, unemployment, inaccessible services and other problems, ABR can seem a distant problem. But it is not distant, and we can no longer assume the effectiveness of the medicines we have used for treating common microbial diseases. We need to act now to remedy the practices that have led to the emergence of this new threat to human survival.

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

Are we bringing African perspective to global health diplomacy?
Rene Loewenson, Moeketsi Modisenyane, Mark Pearcey

Diplomats, officials, civil society and private actors converging in May at the World Health Assembly bring to the spotlight the increasing extent to which decisions on policies and resources for health systems are taking place at global level. Beyond the health sector, global level negotiations on trade, investment, migration and climate have significant impacts on health. Foreign policy has traditionally concerned itself with economic and security issues. Health has been brought to foreign policy when epidemics have threatened trade or economic expansion, or as a way to generate positive relations between countries. Health diplomacy in colonial Africa did both, preventing disease from affecting colonial economic interests and providing medical services to legitimize colonial expansion.

Health has in recent decades assumed a higher profile as a goal of foreign policy at the global level, such as in the negotiation of global responses to treatment rights for people living with HIV, or the negotiation of competing interests around recruitment and migration of health workers. Political attention to health in global policy became more intense and sustained after 2000, with many new global conventions, funds and institutions. This raises twin challenges for African actors in global health diplomacy (GHD), to ensure that the norms and goals of public health are not lost in the differing norms and goals of foreign policy, and to ensure that African interests are advanced and protected within global processes.

With its high share of global mortality and illness, the stakes are high for Africa. Hence, for example, in the context of an HIV pandemic that was ravaging the continent, African countries played a lead role in negotiating the 2001 Doha declaration on the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) and Public Health, which provided for WTO Members’ right to protect public health and access to medicines for all. Africans also provoked the global negotiation on the recruitment of health workers, given that African health systems were losing millions of dollars invested in training of health workers and losing key people for service delivery. Raising such issues at the global level takes diplomacy beyond negotiating economic self-interest, and raises shared risk, and shared responsibility as a basis for collaboration across borders. While this presents new opportunities for addressing Africa’s health challenges, global solidarity is not a dominant feature of diplomacy, and health demands may be diluted or overshadowed in foreign policy processes as states secure their interests in response to financial, climate, resource, food and other threats to security. The transborder nature of GHD also raises caution in the public health community as it may disguise a more direct and influential hand of private interests, including in global health institutions.

New actors are also becoming increasingly influential in global diplomacy. Brazil, China and India, each facing their own health challenges, have become more engaged and influential in GHD, and south-south cooperation has opened up new avenues of influence, including for African countries. Countries in the ‘global south’ bring new perspective to global health: For example China’s principles of peaceful coexistence avoids interference or conditionality in the relations between states, with foreign policy used to widen its access to resources and markets and to speed up its own modernisation. Brazil’s pursuit of ‘structural cooperation in health’ in contrast brings a rights based approach to health, raising the precedence of health in global economic and trade platforms, such as in its negotiations on patents, counterfeits and technology transfer. We discuss other examples of approaches to diplomacy in EQUINET discussion paper 96 ‘Concepts in and perspectives on global health diplomacy’.

This raises the question: Are there uniquely African perspectives or approaches in GHD? This is not easy to answer by reading published materials- much diplomacy on health in Africa appears to be unrecorded in the public domain, or documented by northern or global actors. Across African countries, there is evidence of some principles more commonly informing foreign policy. Reciprocity and interdependence is rooted in traditional norms that give more weight to the interests of the community than those of the individual (‘I am because we are’). These principles informed the unity around struggles for national independence and Africans have continued to build unity in global engagement through alliances across sovereign states, such as in the Africa Group at the World Health Assembly. Liberation and nation building have also been central to recent African history. This ‘liberation ethic’ has continued to inform diplomacy post-independence, from the shared stance against apartheid South Africa to a foreign policy engagement on economic decolonization. As a form of public diplomacy, this foreign policy image has also been used to bolster domestic legitimacy. Many African countries are also explicitly pursuing developmental foreign policies, raising economic justice and seeking to protect the authorities needed for developmental states within international policy, albeit with some diversity of view on what a developmental foreign policy means.

How far have these approaches influenced global diplomacy on health, a sphere that has been more commonly associated with emergency relief and development aid? Africans are increasingly involved in GHD, and initiatives such as the ECSA Health Community Strategic Initiative on GHD seek to strengthen African engagement and influence in global health platforms. There is evidence from examples such as the 2001 Doha declaration, the claims on health worker migration or recent negotiations on technology transfer or on research and development that the liberation ethic, unity and developmental foreign policy are informing diplomacy on health. It is however difficult to read how far these principles are being actively crafted for the 21st century and used for health. For example, how do principles of sovereignty, non-interference and self determination that have been central to nation building accommodate the human rights approaches or concepts of shared risk and shared responsibility that are being used to raise health as a goal of global diplomacy? How effectively are newly emergent south-south alliances, such as BRICS, strengthening the unity (and regional integration) within African countries that is seen to be key to global engagement? What co-ordination across sectors and institutional changes need to take place within African countries to strengthen their hand in advancing a liberation ethic and developmental foreign policy in health negotiations at global level?

Further information on the issues raised in this editorial can be found in EQUINET Discussion paper 96 at http://www.equinetafrica.org/bibl/docs/GHD%20concept%20paper%20Jan2013.pdf. The discussion paper is an interim working paper to draw feedback and EQUINET invites you to send your comments on African approaches to health diplomacy to include in the next edition. Please email your comments and inputs on the questions raised to admin@equinetafrica.org.

Are we making progress in universal access to health workers? Reflections on the global health worker movement
Dr Francis Omaswa, ACHEST, Uganda

The 4th Global forum on Human Resources for Health (HRH) that took place in Dublin, Ireland in November 2017 provided a useful opportunity to reflect on how far we have progressed in the global movement on human resources for health. The achievement of Sustainable Development Goal (SDG) 3, including Universal Health Coverage will not be possible without universal access to skilled health workers. A global health workforce movement is thus critical to ensure this and that access to essential health services is not left to market forces alone, leaving many unable to access basic health services.

I coordinated the convening of the first Global HRH Forum in Kampala in 2008 as the Executive Director of the Global Health Workforce Alliance at the time and have attended all the subsequent forums in Thailand and Brazil. I was thrilled to witness in Dublin how the HRH movement remains alive and vibrant ten years after the first forum. It was attended by over 1000 delegates from over 70 countries representing government leaders, civil society, academia, employers, foundations, health care professional associations and unions, youth and the private sector.

Beyond the numbers, it was the outcomes of the Dublin Forum that represent potential advances in the health worker movement, globally, and in Africa.

I saw a renewal and rejuvenation of the global HRH movement, with many new champions committed to act on the Dublin call to provide a skilled, supported and motivated health worker for every person in every village everywhere, and the 2008 Kampala Forum call for “Health Workers for All and All for Health Workers.” A Global Health Workforce Network (GHWN) hosted in World Health Organization, Geneva now brings together a range of stakeholders in the movement to organise activities around these commitments, with hubs around various fields such as education and training, leadership and governance, labour markets and civil society. A new civil society coalition on HRH was launched in Dublin to drive advocacy and accountability.

There was strong participation of Africans from all parts of Africa at the Dublin Forum. The African Platform on HRH held a side event, adopted a business plan and elected a new governing board that was empowered to update the Constitution, to support the visibility of the movement in Africa and to convene the 6th Forum of the African HRH Platform.

We were informed that implementation had been initiated of the recommendations and five year action plan of the UN Secretary General’s High Level Commission of Health Employment and Economic Growth. This commission demonstrated that employment in health and the health sector itself should not be seen as a cost but as a significant contributor to economic growth and employment, especially of women. The economies of high income countries all enjoy significant contributions from the health sector.

A new international fund named “Working for Health Multi-Partner Trust Fund (MPTF)” was launched during the 2017 Dublin forum as a collaboration between the International Labour Organization, the Organization for Economic Co-operation and Development and the World Health Organization to support countries expand and transform their health workforce. The Government of Norway has made the first contribution and urged others to invest. The fund should enable development partners to pool contributions for use by ‘pathfinder’ countries to apply innovative approaches to building a ‘fit-for-purpose’ health workforce, especially those countries that are struggling to provide access to health care and facing the threat of emerging epidemics.

The Dublin Forum also saw the launch of the International Platform on Health Worker Mobility. This platform seeks to maximize mutual benefits and mitigate adverse effects from the increasing rate and complexity of the movement of health workers. It will strengthen evidence, analysis, knowledge exchange and policy action on health worker migration, including to support implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel. The forum also made commitments to improving the safety and security of health workers by upholding international humanitarian law. It strongly condemned violence, attacks and threats directed against health personnel and facilities, given their long term consequences for health workers, for the civilian population and for the healthcare systems of the countries concerned and their neighbours.

A special feature not seen in previous forums was the Youth Forum in Dublin that set its own ‘call for action’. Attracting and retaining young health workers is critical if we are to avert the shortfall of 18 million health workers, and transform the health and social workforce.

It was significant that the 2017 forum took place during a doctors’ strike in my own country, Uganda, and a similar nurses’ strike in Kenya. One of the most powerful take-away reflections for me was that while several speakers from high income countries reported how money is chasing and seeking to attract scarce health workers, in most of our African countries, it is health workers who are underfunded and chasing money. Unless we act to address the imbalance in the demand for health workers between high and low income countries, African countries will continue to be drained of health workers going to high income countries, even while African people continue to suffer the shortages of skilled health workers that undermine their access to health care and delivery on SDG3.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the Dublin Forum can be found at http://hrhforum2017.ie/

Beyond New York and Vienna- what local change from global talk?

The editorials in this newsletter comment on two global events, two months apart. The first is the 18th International AIDS Conference held in Vienna in July, and the second the UN Summit on the Millennium Development Goals being held in New York in September. Both conferences have triggered a wealth of ideas, debates and publication, some of which we include in the newsletter. Both deal with heads of state commitments, made in prior conferences: The first to universal access to treatment for AIDS, the second to the eight MDGs. In the first editorial Sharonann Lynch reminds that after the “talk and spectacle”, many conference participants go back to work in impoverished realities. She suggests concrete people-centred strategies for delivering on treatment commitments in these conditions. In the second, Ranga Machemedze asserts that many living in the most impoverished realities have not yet benefited from the MDGs, even when progress has been made at national level, and asks what the UN Summit will do to close the gap. For both, the test of the global talk is the concrete local improvement it produces for the most disadvantaged communities.

Beyond Vienna: possible game-changers for scaling up optimal AIDS treatment
Sharonann Lynch, HIV/AIDS Policy Advisor, Campaign for Access to Essential Medicines, Médecins Sans Frontières/Doctors Without Borders (MSF)

After the 18th International AIDS Conference (IAC) has wound down in Vienna, the word in the hallways is that the science is in: earlier initiation of treatment and improved antiretroviral (ARV) drug regimens are better for individual patients and communities, and may even ultimately reduce transmission of HIV. Some of the new data presented at the conference come from MSF's project in Lesotho, where I worked from 2006 to 2009. In a two-year study of 1,128 patients from rural Lesotho, where the government has adopted new World Health Organization (WHO) guidelines, patients starting treatment earlier (at CD4 count <350) were 70% less likely to die, 40% more likely to remain in care, and >60% less likely to be hospitalized compared with those started when their disease was already advanced (CD4 <200).

After all the talk and spectacle, many of us—people with HIV/AIDS, clinicians, researchers, and activists—will have to go back to reality: to townships and rural villages still ravaged by the virus; to congested clinics with waiting lists for treatment; and to rich country capitals where donors are ignoring the science and retreating from their commitment to fully fund universal access to treatment, telling us to get used to this new reality—we are in the midst of global economic recession, after all.

At the conference there was a lot of talk about cost-effectiveness and efficiency as a means to mitigate funding shortfalls. Sure, we need to avoid waste and the obscene number of consultants and reports that sit on shelves in Washington, Geneva, and London. But how do the actual people fit in to these crude calculations? What is the cost-benefit to their lives, families, and communities?

We are advocating for a different vision: for patient-centered efficiencies that will increase access to treatment and reduce the burden on patients in taking toxic drugs, reporting excessively to health facilities, and traveling great distances to seek care. We also want efficiencies to reduce the requirements on the health system, for example through task-shifting and community-based, out-of-facility approaches to drug dispending and social support. And economists are telling us these sorts of efficiencies will even be cost-saving in the long run.

So how do we build on Lesotho's example and get more patients on treatment? Here are some forward-looking ideas that could change the game:
* Invest in rigorous research and pilot projects to explore the feasibility and impact of "treatment as prevention." Treatment is increasingly understood to have major prevention benefits, in addition to reducing HIV- and TB-related illness and death.

Support research to radically simplify and optimize the package of ARV treatment, including:
* Dose optimization: If shown to be effective, reducing the dose of some ARVs could potentially treat up to one-third more patients without a cost difference.
* New drug development: Develop new ARV drug delivery platforms and slower-releasing drugs, which could help to decrease the burden on patients as well as the cost per patient per year.
* Accelerate commercialization of point-of-care diagnostics: new instrument-free, point-of-care CD4 cell count blood tests, once available, could be rapidly deployed to the field for use in identifying more patients at the lowest levels of care, while we redouble efforts to develop a point-of-care viral load test.

And additionally;
* Create and implement a financial transaction tax (FTT): billed by some as the "Robin Hood tax" (including activists at IAC dressed up in feathered green hats and bows and arrows), a tiny tax of 0.005% on foreign currency transactions could generate an estimated $33 billion per year for global health needs and other issues affecting the developing world. Such a "tax and treat" strategy could deliver the sufficient, regular, and predictable funding to pay for scale-up, provided donors make good on their existing commitments to the Global Fund and other financing mechanisms.
* Ensure an enabling policy environment to usher in these new innovations, including aggressive use of Trade-Related Aspects of Intellectual Property (TRIPS) flexibilities and an effective patent pool.

If we want to bend the curves of the HIV epidemic, we should seriously consider and put into action radical game-changers such as these.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This article is Open Access and was reprinted freely under a Creative Commons license. http://speakingofmedicine.plos.org/2010/07/23/msf-beyond-vienna-possible-game-changers-for-scaling-up-optimal-aids-treatment. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see MSF's website at http://aids2010.msf.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.

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.


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Bring the right to health into Uganda’s Constitution this year!
Moses Mulumba, Executive Director, Center for Health, Human Rights and Development, Uganda

Uganda’s Constitution has much to make our country proud—including chapter four which has strong commitments to fundamental rights and freedoms, such as freedom of expression and the promise of non-discrimination.

These sacred freedoms are not always upheld or enforced—but that is a matter for another day! As a first principle, the fact that these guarantees are enshrined in our Constitution shows the potential to protect, promote and defend the human rights of all people in the country. They provide the entry point for citizens from all walks of life to hold our duty bearers to account.

Every ten years we must ask: what is missing from our Constitution? What should be amended to adapt to our changing environment? In 2015, Parliament will consider proposed revisions to our Constitution.

It is this vital opportunity that motivated the Center for Health Human Rights and Development (CEHURD) and a team of partners, on World Human Rights Day, to submit a bold proposal to the Uganda Law Reform Commission —that included in the revisions being considered by parliament in 2015, there should be an explicit guarantee for all citizens of the right to the highest attainable standard of physical and mental health.

Those who framed our Constitution, despite their wisdom, did not expressly cater for the right to the highest attainable standard of health in its substantive articles, but rather placed it under the non binding State policies and objectives. It is now urgent for the country to correct this.

Why? Simply put: because when it comes to health, our leaders and policy makers are failing the citizens.

Uganda’s astonishingly poor health indicators speak volumes. Unlike its neighbours, which have shown important advances, Uganda has had a stagnant rate of maternal deaths for the past decade alongside rising HIV incidence and declining condom use. Uganda has a stubborn burden of drug resistant tuberculosis and, according to the World Health Organisation 2005 report on malaria, Uganda has the world's highest malaria incidence, with 478 cases for every 1 000 people every year. This disease burden is coupled with ailing public health facilities that lack essential services like water and electricity.

Unfortunately, health services have been eclipsed by rural electrification and infrastructure as political priorities for investment. Health care is seen by government as an area for charitable donation or as spending on ‘consumption’. This is extremely shortsighted. There should be no trade-off between building roads or building health services. This is a false dichotomy. We cannot develop as a country economically if our population is sick, or if families are one attack of cerebral malaria short of impoverishment!

Countries that have expanded access to free, essential services have found that those investments have yielded real benefit to their citizens, including in terms of less absenteeism from work and schooling due to ill health, and increases in economic productivity at the household level.

In reality, in receiving taxes from people, government is bound by a social contract to account back to the people on how their resources are being used.
The structural adjustment programmes that liberalized and reduced public funding to social services located health in the market place and weakened this state duty. Now is the time to redeem it. We believe that a strong constitutional norm is needed to raise the role and accountability of the state in health care and raise pressure to address the social conditions that affect our health.

Including the right to the highest attainable standard of health as a constitutional right provides a bench mark for government, private sector and society to respect, protect, fulfil and promote it. Without a clear obligation, incontrovertibly stated in the Constitution, our policymakers will continue to look on this right as ‘optional’, not fundamental to the duties of government.

Other countries, such as South Africa, Kenya and recently Zimbabwe, have taken this step to ensure clear expression of the right to health care and to the social determinants of health in their Constitutions. Their people have raised social pressure for these rights and taken up their implementation through social action and strategic litigation, to ensure that government is accountable for these obligations and to build more equitable health systems.

CEHURD and partners have thus submitted a proposal to the Uganda Law Reform Commission to include in the Constitution provisions for citizens to realize the right to the highest attainable standard of health; to access basic medical and emergency treatment, reproductive health services including family planning, medicines and health information, and for people who would otherwise not be able to afford health services and commodities to access social protection to enable them to do so.

Having health as a constitutional right does not mean that people should expect to immediately be healthy, nor does it mean that our government must put in place expensive health services for which they have no resources. It means that government and public authorities should take progressive measures such as investing resources and developing and implementing policies and action plans which will lead to available and accessible health care for all in the shortest possible time, and to fair distribution of public resources for this. It also means that the public and private sector have a duty to promote public health.

Isn’t it time that our politicians and leaders take this step to commit to the right to the highest attainable standard of health? Citizens will be watching closely how far government gives priority to this critical right in the current constitutional reform process, at a time of common epidemics of preventable sickness and death. Surely we cannot wait another decade to make this commitment as a country!

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the CEHURD website: www.cehurd.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.