Changing the talk and the walk: Challenges for a different practice in health systems research
Amit Sengupta, Associate Global Co-ordinator, Peoples Health Movement

The Health Systems Research Symposium in Cape Town was an experience to savour. It was particularly refreshing in shifting away from the rather restricted vision of the earlier symposia in Montreux and Beijing. Opening it to debates on ‘people centered health systems’ raised the opportunity to move from the confines of the restricting, dominant neoliberal concept of Universal Health Coverage (UHC) that has circumscribed the discourse in the earlier symposia, with its focus on a narrow and preconceived template of issues, largely informed by the language of health financing and insurance. In contrast, this year’s symposium promoted a public health language of care (not just coverage) and of solidarity, equity, gender justice and rights.

Several speakers, especially in the plenaries, articulated the profound impact different dimensions of power and power relations are having on health systems. In the Peoples Health Movement, we see this as an important and extremely positive sign of our collective intent to confront and challenge these power relations. Several presentations talked about the role of social movements in building, safeguarding, nurturing and expanding health systems that are truly people centered.

There is, however, a gap between our rhetoric and our praxis. We need to integrate concerns about power and an articulation of the role of popular mobilization and of social movements in challenging power relations that undermine health into the priorities and practice of the research community. Here we have a gap, with too little practical translation of these concerns into research priorities and practice. Existing power structures play a hegemonic role in influencing research –using their financial clout and exercising dominance in the domain of ideas. Unless we are able to change this, our work will continue to be informed by a hegemonic discourse that legitimates injustice and inequity. This is a challenge for young researchers, to be bold and innovative in questioning the dominant paradigm of the current research system.

We need to build on the deliberations of the symposium to change our current practice, in all stages of the research cycle. Health research should name and interrogate the practices of those who perpetuate inequity at a grand scale by their cynical use of power. There is robust evidence on this that is waiting to be mined. It was heartening to see evidence in the symposium that there is now a growing interest in participatory research that places people at the center of research systems and not just as passive ‘beneficiaries’ of the outcomes of research. A research community that views research as a tool for change must give attention to the role of civil society and of social movements in catalyzing and driving sustainable change. Civil society is often seen as an afterthought in the research cycle. It is brought in late to legitimize often deceptive or limited evidence that maintains the status quo. Civil society in general and social movements in particular should, in contrast, have a meaningful and decisive counter-hegemonic role to drive an alternative research practice that can propel change, including research that is conceived of and driven by civil society. We need, for example, to develop work that examines the role social movements play in shaping, nurturing and advancing health systems that are solidarity based and sustained by the public.

In the symposium, there was talk of bringing to the foreground the ‘shadow reports’ that are produced by civil society at key forums. Surely we should walk the extra mile and view such shadow reports as the real reports? They present the popular concerns and aspirations and mainstream the voices of the unheard majority. Civil society thus has a task to produce evidence in such reports that is people driven, robust and that challenges the conventional wisdom replicated in the often glossier versions produced by multilateral organisations and well-heeled private foundations. The Peoples Health Movements’ Global Health Watch is one effort at taking up this challenge.

The long shadow of the current Ebola epidemic reminded all of us at the symposium about all that we have failed to do. It has directed our attention to the collective failure of public health and health research to harness evidence and action to promote public services - publicly owned, nurtured and conceived by the people. Health systems that are in the public domain are failing in many regions of the world, in spite of evidence that they are the main life-line for poor, marginalized and voiceless people. They are failing because of deliberate acts of commission that are bringing down, brick by brick, the edifice of public systems. They are failing because evidence that favours nurturing solidarity based public systems has been disregarded. Instead evidence has been used in a selective fashion to promote the notion that market based systems in healthcare delivery are superior. The Ebola epidemic was preventable, in part if overwhelming evidence on building public health systems had not been brushed aside. As a health research community we need to accept part responsibility for the current failure, in our not being vocal enough in the pursuit and use of good evidence.

As we look towards the next symposium due to take place in 2016, can we at least make partial amends for what we have failed to do? Can we collectively raise our evidence and voice to call for public health systems, built around solidarity and justice, rather than the current dominant model of spliced and diced healthcare delivery, designed for trade in the market?

These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the issues raised see the PHM website at http://www.phmovement.org/

Children’s rights provide a powerful lever to challenge chronic disease risks
Leslie London, School of Public Health and Family Medicine, University of Cape Town

Industry marketing aimed at children presents a major challenge to efforts to control the global crisis of non-communicable diseases (NCDs). Advertising and promotion of tobacco, alcohol, sugar-sweetened drinks and other unhealthy processed foods are common in all countries. They are a particular threat in countries with weak laws, poor enforcement and political cultures that are beholden to foreign investment. Africa is particularly vulnerable to unhealthy marketing by corporates.

Internationally, attention is growing on what works best to reduce the risk of NCDs, and to the role that human rights-based approaches have in this. In particular, the Convention on the Rights of the Child (CRC) can act as a strategic lever against health risks from corporate practice. Under the CRC, governments have obligations to protect children from economic exploitation and harm generated by the activities and products of tobacco, food and beverages industries. Governments are also obliged to protect children from information harmful to their health and development. This includes the marketing of unhealthy goods. However few governments in low-income countries implement measures to meet these particular obligations to protect the best interest of the child.

The European Scientific Network on Law and Tobacco (ESNLT) hosted a roundtable in mid-2019 to generate a better understanding of the successes and potential constraints of a child rights-based approach to address the global NCD epidemic. (See https://www.rug.nl/rechten/onderzoek/expertisecentra/ghlg/outcome_document_25_june_geneva.pdf). Participants were researchers, mainly from high-income countries, with some from low- and middle-income countries. The meeting also involved personnel from World Health Organisation and UNICEF staff working on NCDs and human rights. In the meeting, participants shared experiences of using a child-rights approach in domestic and international responses to NCDs and identified new opportunities to use a child-rights approach and to advocate for these approaches to be applied in addressing industry behaviours relevant to the risk factors for NCD.

Participants in the meeting explored how to apply a child rights-based approach to support regulation of NCD-related risks, particularly in low-income countries, vulnerable settings and trade policies, and how best to disseminate this knowledge more widely. Various recommendations were made in the meeting. Participants proposed networking with academics and civil society working with broader child rights and health equity issues to advance awareness, advocacy and implementation of these approaches, working also with public health networks like EQUINET in low- and middle-income countries, especially where civil society space is constrained. It was proposed that regional blocs such as the East Africa Community and Southern African Development Community be engaged to promote effective regulation of NCD risks related to marketing practices, including in relation to online and cross-border marketing and trading. Participants observed that evidence needed to be generated and shared on effective strategies and that this knowledge be brought into online and distance training courses to strengthen regulatory capacities and into postgraduate training linking human rights, law and public health. One suggestion was for a test case to be brought in one country that has constitutional provisions protecting these rights, such as South Africa. These actions could tap into existing resources. For example, the World Federation of Public Health Nutritionists has set up a mechanism for reporting conflicts of interest. The learning from this could be consolidated and shared.

It was significant that the ESNLT engaged beyond high-income countries and is addressing wider risk factors for NCDs. Bringing together a diverse set of actors in the meeting helped to build links across different disciplines and opened avenues for future collaboration. Linking with existing networks can help to identify capacity gaps and to stimulate and support research and advocacy. Education of both public health and law professionals can expose each to the respective field of the other to promote collaboration and team approaches. This interaction has already been stimulated by the meeting. For example, soon after it, one of the participants was invited to give a keynote address at the Association of Schools of Public Health Conference in Africa to highlight the role of law in public health.

The meeting also proposed that international organizations, such as WHO, UNICEF, the Office of the United Nations High Commissioner for Human Rights, the UN Human Rights Committee and the UN Committee on the Rights of the Child, link to reduce capacity gaps and overlaps in their work and outputs. A child rights-based approach and qualitative assessment of country performance could be included in WHO assessments of how far regulations targeting the main risk factors are implemented. Evidence on NCD-related issues could be included in country reporting to the Committee on the Rights of the Child and shadow reporting by civil society promoted.

This is not simply a technical matter. Industry actors are well-resourced, powerful and able to thwart regulation of NCD risk factors. This power imbalance calls for co-operation across international and national organizations, civil society organizations, academia and public officials. For regional networks such as EQUINET, the fact that every country in Africa has ratified the CRC and all but 6 have ratified the African Charter on the Rights and Welfare of the Child offers an opportunity and policy space to use human and child rights-based approaches to tackle health equity challenges, including the prevention of corporate and market-induced risks for NCDs.

Choosing impertinence to provoke debate: global cartoonists express the SDGs
Editor, EQUINET newsletter

At Rio+20 in 2012, country leaderships promised to strive for a world that is just, equitable and inclusive, and committed to work together to promote sustained and inclusive economic growth, social development and environmental protection for the benefit of all. They set a mandate to develop a set of sustainable development goals (SDGs) for consideration by the UN General Assembly at its 68th session in 2013. These SDGs should be coherent with and integrated into the UN development agenda beyond 2015.

The 17 Sustainable Development Goals are:
• Goal 1 End poverty in all its forms everywhere
• Goal 2 End hunger, achieve food security and improved nutrition and promote sustainable agriculture
• Goal 3 Ensure healthy lives and promote well-being for all at all ages
• Goal 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
• Goal 5 Achieve gender equality and empower all women and girls
• Goal 6 Ensure availability and sustainable management of water and sanitation for all
• Goal 7 Ensure access to affordable, reliable, sustainable and modern energy for all
• Goal 8 Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all
• Goal 9 Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation
• Goal 10 Reduce inequality within and among countries
• Goal 11 Make cities and human settlements inclusive, safe, resilient and sustainable
• Goal 12 Ensure sustainable consumption and production patterns
• Goal 13 Take urgent action to combat climate change and its impacts
• Goal 14 Conserve and sustainably use the oceans, seas and marine resources for sustainable development
• Goal 15 Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss
• Goal 16 Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels
• Goal 17 Strengthen the means of implementation and revitalize the global partnership for sustainable development

They are simple statements with great intent. They respond to a harsh reality of spectacular progress and spectacular inequality.

How widely are these goals known by those most affected by the situations they seek to address? The SDGs add to many other current global commitments: the Universal Declaration of Human Rights, the Programme of Action for the Least Developed Countries for the Decade 2011-2020 (the Istanbul Programme of Action), the political declaration on Africa’s development needs, the Doha Declaration on Financing for Development, the United Nations Framework Convention on Climate Change and the Millennium Development Goals, amongst others. Over the years these statements of international cooperation have built a growing vocabulary of aspiration. No doubt the 17 goal statements will also attract many words and terms, targets and data, discussions, interpretations and explanations.

If words and targets begin to mystify intent and to obscure reality, particularly for those most directly affected, we may need other tools. Cartoonists from sixteen countries globally in the Cartooning for Peace network have, for example, portrayed their lens on the 17 SDGs in a book published in June 2015, and found at http://fr.calameo.com/read/002524839b003362c3438 . They present images of the goals for sustainable development as “work that is still precarious”. Visit the link and you will see some that are aspirational, and many that are picture codes, communicating without a word the contradictions that exist in the face of the SDGs.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For information on the SDGs see https://sustainabledevelopment.un.org/focussdgs.html . Cartooning for Peace is an initiative born in 2006 that now brings together 125 cartoonists globally. For more information see http://www.cartooningforpeace.org/?lang=en.

Choosing pathways that lead to universal coverage: what are the options?
Di McIntyre, University of Cape Town Health Economics Unit, University of Cape Town

There is consensus that states have an obligation to ensure Universal coverage (UC), through creating and realising an entitlement for everyone to be protected against the costs of health services and to have access to the effective, quality services they need. From an equity perspective, social solidarity is essential to achieve UC, through income cross-subsidies (from the rich to the poor) so that payments are based on the ability to pay, and risk cross-subsidies (from the healthy to the ill) so that people access health services based on need and not ability to pay.

So what options do east and southern African (ESA) countries have to reach this goal? While there may be some distance before reaching UC, the choices made at this stage are critical for ensuring steady progress towards it.

The 2010 World Health Organisation’s World Health Report unequivocally states that it is not feasible to achieve UC through voluntary enrolment in health insurance schemes. A number of ESA countries are introducing community-based health insurance (CBHI) as one means of pre-payment. These schemes will not move a country towards UC, although they may temporarily assist vulnerable households until mandatory pre-payment funding increases considerably and user fees are removed. However there is a potential danger that their existence may allow governments to abrogate their responsibility to promote mandatory pre-payment funding mechanisms.

Voluntary schemes can only be complementary or supplementary to mandatory pre-payment financing mechanisms, including tax and mandatory insurance. From international experience, mandatory pre-payment funding is well over 60% (and often over 70%) of all health service expenditure in countries that have health systems that are regarded as universal.

Many African countries are now discussing or introducing mandatory health insurance (MHI) schemes. However, caution should be exercised. If MHI contributions are placed in a separate pool to benefit the contributors only (which often is the case) this creates a tiered and inequitable system that does not ensure that all have the same service benefit entitlements. If the goal is to achieve universal coverage, then it is critical to minimise fragmentation in funding pools to achieve cross-subsidies. This means that if MHI is introduced, the funds collected from it should be pooled with those from government revenue to fund benefits for the whole population.

There has also been some investigation into introducing MHI contributions by those outside the formal employment sector. This should receive more critical assessment than there has been to date, especially as such contributions are strongly regressive and generate little revenue. If there is political insistence on generating funding from those outside the formal employment sector, indirect taxes, such as VAT, are a more equitable and efficient mechanism for achieving this goal, particularly in low-income countries. However, in the context of the large income inequalities present in many east and southern African countries, efforts to improve the collection of taxes from high net-worth individuals and multinational corporations may be more appropriate. Further, some countries are generating revenue for health from royalties on natural resources such as gold, copper and oil, and not only from taxes.

There is often an almost automatic assumption that there is no ‘fiscal space’ to increase funding of health services from government revenue. It is important to critically examine this assumption.

Government revenues in ESA countries range widely from about 12% of GDP in Madagascar to 33% in the DRC, while government expenditure ranges from less than 13% of GDP in Madagascar to 33% in Mozambique. These ranges are considerably lower than the levels in advanced economies for both government revenue (36%) and expenditure (44%). Government debt levels are considerably lower in ESA countries, ranging from less than 26% of GDP in Zambia to 64% in Madagascar, than the average for advanced economies of over 100%. Given that all of these measures are expressed relative to GDP and that some lower-income countries are able to attain higher levels of revenue and expenditure, there does appear to be scope to explore increasing the fiscal space within the so-called emerging markets and low-income countries.

Health financing policy choices not only relate to how revenue is mobilised for UC. Purchasing involves determining service benefit entitlements (what services are purchased with the pooled funds and how people will be able to access these services) and how service providers will be paid. Attention should be given to more active purchasing. This requires identifying the health service needs of the population, aligning services to these needs, paying providers in a way that creates incentives for the efficient provision of quality services, monitoring the performance of providers and taking action against poor performance. Active purchasing is critical for ensuring that available funds translate into effective health services accessible to all.

Moving towards universal coverage also requires improvements in service delivery and management. In particular, emphasis should be placed on improving services at the primary health service level, which are effective in reaching the poor and which are able to address most of the health service needs of the population in ESA countries. Improving primary health services offers the greatest potential for increasing population coverage affordably. In addition, it is important to broaden the decision-space of managers at facility and district level, so that they can be more responsive to patients’ and staff needs and to the incentives created through active purchasing. Equally decentralisation of management responsibility should be accompanied by development of governance structures that allow for accountability to the local community.

East and southern African countries have some way to go in moving toward UC. The choices made at various points in the journey will be important for achieving that goal. While the detail of those choices will depend on the context in each country, international experience and regional evidence suggest that far more emphasis should be placed on government revenue funding for health services and that funds from mandatory health insurance schemes should be pooled with funds from government revenue. We also need a richer body of evidence, including from research, to support active purchasing of services and measures for addressing service delivery and management challenges, as these are essential if universal access to services of appropriate quality is to be achieved.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org and read EQUINET Discussion paper 95: McIntyre D (2012) ‘Health service financing for universal coverage in east and southern Africa’

Citizens making things happen
Risha Chande, Twaweza, Tanzania

Seven out of ten Tanzanians think that have no say in what Government does. Yet seven out of ten Tanzanians also think that voting is their only means of influence over Government. This may sound contradictory, but at core, they both reflect the same sentiment. Aside from the choices they make during elections, citizens do not feel that they influence government decision-making or activity. They appear to have little trust that formal institutions or local government officials will address their issues, and formal political institutions seem to play minimal roles in people’s lives. Nine out of ten people report that they have not interacted with their member of parliament in the last year, half have not interacted with their street or village chairman to raise issues and only one in seven citizens are members of any political party.

These findings were released by Twaweza in a research brief titled Citizens making things happen: are citizens active and can they hold government to account? The brief is based on data from Twaweza’s Sauti za Wananchi, Africa’s first nationally representative mobile phone survey that interviews households across Mainland Tanzania.

Sauti za Wananchi, (http://www.twaweza.org/uploads/files/Sauti-za-Wananchi-English.pdf) was initiated by Twaweza as a response to the concern that policy makers make decisions for the whole country, but with poor information on the experiences and realities of a large majority of citizens and on whether their policies are working on the ground across different places. It provides timely, low cost and reliable data and is a nationally representative barometer of the reality reported by Tanzanians. In 2014, together with our partners, we expect to conduct 20 survey rounds, and use widespread dissemination and intensive media outreach to share the findings, especially with policy actors, to shine a light on citizens’ experiences and views.

So how are people taking up their concerns? Despite the apparently low levels of interaction with formal channels uncovered by Sauti za Wananchi, 6 out of 10 citizens report that they made joint or collective complaints to officials in their community in the last 12 months, sometimes repeating the same complaint. Common complaints ranged from seeking improvements in local public services, to teacher absenteeism and access to clean and safe water. Just over a quarter of people reported raising complaints about the absence of drugs at local facilities, generally complaining several times in the past year.

When it comes to raising issues within the community, Sauti za Wananchi found that people are fairly vocal about problems they face. Eight out of ten citizens raise their issues in the groups they belong to, and three out of ten have called in to a radio station or complained to a friend. In contrast, people are much less likely to walk out of a discussion, attend a demonstration or protest or to refuse to pay tax, and far less report that they would or use force to achieve a political cause.

Community groups thus play a more significant role in people’s lives. Seven out of ten Tanzanians belong to one, often religious groups, but also savings and loans groups. Community solidarity appears to be high: almost all citizens believe that if an unforeseen incident, such as house fire, occurred, their community would get together to help. The same confidence doesn’t extend beyond immediate communities, and when asked whether they trust people generally, nine out of ten people felt that you had to be very careful with others. Citizens also strongly feel that they can rely on themselves to get things done. Seven out of ten citizens respond positively to statements about their own ability to overcome challenges, find solutions to their problems and accomplish their own goals.

People also contribute collectively to their services: Seven out of ten citizens directly contribute to constructing or maintaining public facilities, most giving money and the rest contributing time. While the level of tax collection is low, people are in one way or another contributing to the running of government. However these collections are not well regulated. The lack of transparency and checks and balances mean that contributions may not be collected fairly or used productively. In fact, four out of ten of those who contributed to local facilities say they were forced to do so, eroding public trust.

Sauti za Wananchi paints an interesting picture of the experience of Tanzanians. Rakesh Rajani, Head of Twaweza at the time, summed it up: “Tanzanians are active members of community groups and undertake collective action to complain to officials in their community. They also feel that they are able to tackle obstacles and make things happen in their own lives but express feelings of powerlessness when it comes to their influence over government. Thus far citizens have shied away from the more emphatic and vocal forms of citizen agency such as tax refusal, protests or walk outs. However significant service delivery challenges remain in all major sectors. If the Government does not become more responsive to this softer engagement, we may see citizens become more aggressive in the future.”

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the evidence, issues and processes raised in this op-ed please visit Twaweza at www.twaweza.org and read the full report at http://www.twaweza.org/uploads/files/CitizenAgency-EN-FINAL.pdf

Civil society defines the changes that must happen for delivery on UHC
Itai Rusike, Executive Director-Community Working Group on Health, Zimbabwe

The way a healthcare system is designed, financed and performs has consequences for inequality. User fees, for example, prevent people from accessing healthcare and push over 100 million people each year into poverty. The 2001 Abuja Declaration committing at least 15% of their budgets to health was signed by African governments with a goal that every member of society have access to healthcare when they need it, without risk of financial ruin. Thirteen years later, less than ten countries in the Africa region have increased their national or provincial budget to at least 15%, as stipulated in the declaration. Less than 10% of African people are reported to be protected from financial risks associated with using health care, even though health care plays an important role in the still unfinished business of achieving the Millennium Development Goals. Unless health budgets are adequate to meet priority health needs, inequalities in access to health services will remain high and these goals will not be achieved for all.

The concept of universal health coverage (UHC) offers an opportunity to address these challenges. UHC is seen as a means to deliver on the principle of Health for All that was set out more than 30 years ago in the Alma-Ata declaration. In 2005, there were calls to revitalize primary health care (PHC). The principle of universal coverage was reaffirmed in the 2008 world health report on PHC and various subsequent World Health Assembly resolutions. In May 2012 in the World Health Assembly, WHO Director General Margaret Chan’s asserted that UHC is “the single most powerful concept that public health has to offer” to reduce the financial impoverishment caused by people spending on health care and to increase access to key health services. In December of that year, the United Nations General Assembly adopted a resolution on UHC, urging governments to move towards providing all people with access to affordable, quality health-care services, given the important role that health care plays in achieving international development goals.

Achieving these goals is, however, first and foremost a political process. It involves a political negotiation between different interest groups in society over what services are provided, how services are allocated and who should fund them.

On this understanding civil society organisations have come together to form a network - the African Platform for Universal Health Coverage (AFP- UHC) - to remind African leaders of their duty to shape health policies so that everyone can enjoy their right to health. Civil society organisations have already contributed to increased community roles in decision-making in health; have acted as watchdogs of service delivery and demanded accountability on policy commitments. Civil society has represented and defended the rights of poor and vulnerable people. In doing so they are vital for building more equitable health systems. The organisations involved bring existing civil society organisations together in national coalitions, engaging the public and governments through a variety of tools, including stakeholder engagement, policy briefs, strategic meetings and press briefings. Member organisations have held radio talk shows in Ethiopia, workshops in Egypt, public marches in Ghana, meetings targeted at policy makers in Kenya, campaigns challenging inequalities and user fees in Malawi, television programmes and lobbying of the Prime Minister in Mali, a public march in Kampala and a UHC Day commemoration in Zimbabwe.

The AFP-UHC thus brings civil society organisations together to contribute to, support and implement policies promoting UHC, on the basis that health is a human right. The organisations seek to bring UHC to the political agenda of African countries. The network thus seeks to support national non state organisations to advocate that UHC be achieved through people-centered, right based approaches, in a manner that guarantees people’s right to health services. The network measures its value by the extent to which it is able advocate for and achieve an increase in public sector health budgets and in the political commitment towards health. These changes are seen as key to improving the lives and wellbeing of the most vulnerable people in the society, whose rights to health are usually infringed though their sustained neglect by governments.

The network expects to see governments abolish user fees, raise and spend budgets for health more equitably, increase public sector health financing, ensure that UHC is included in global and national goals post 2015 and that governments set targets and deliver on those goals.

The author is the Zimbabwe coordinator of the African Platform for Universal Health Coverage (AFP- UHC), a network of African non government organisations with a long experience working together to demand a set of measures from governments to move towards Universal Health Coverage. Further information on the network can be found at http://www.africaforuhc.org/. Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.

Claiming our space: Using TRIPS flexibilities to protect access to medicines
Aulline H. Mabika, Percy F. Makombe, SEATINI

In February this year the WHO Director General, Margaret Chan caused a storm when she was quoted in Thailand saying that the country should negotiate with pharmaceutical companies before issuing a compulsory license. She encouraged the nation’s public health ministry to improve its relationship with drug companies to strike the right balance in accessing drugs. Chan’s statement created the impression that there was something wrong with compulsory licensing that needed to be corrected through negotiating with pharmaceutical companies.

If the comments were meant to shock and awe, they achieved exactly that! Shocked treatment access advocates sought clarification from the DG herself on the alleged statements. Five days after the comments appeared in the Bangkok Post of February 2, civil society received information that a letter was dispatched to Thai’s Minister of Health, Mongkol Na Songkhla. There had been a misunderstanding, the Director General said. She regretted that her comments “were misrepresented in the media, and may have caused embarrassment to the government of Thailand. They should not be taken as criticism of the decision of the Royal Thai government to issue compulsory licences which is entirely the prerogative of the government, fully in line with the TRIPS agreement.”

For the avoidance of doubt, the Director General went on to say the following:
"WHO unequivocally supports the use by developing countries of the flexibilities within the TRIPS agreement that ensure access to affordable, high quality drugs. This includes the use of compulsory licensing, as described in paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health. The decision whether to issue a compulsory license for a pharmaceutical product is a national one. There is no requirement for countries to negotiate with patent holders before issuing a compulsory licence."

This statement helped to clarify an impression that pharmaceutical companies have higher priority than people’s lives. For Africa this is particularly important, with Southern Africa the epicentre of the global HIV epidemic with 34 % of global AIDS deaths occurring in the region. While AIDS places a heavy burden on households and health systems generally, the cost of treatment for AIDS continues to be disproportionate to the incomes of affected families and of governments.

According to Oxfam reports, prices of some treatment regimens for AIDS are on the rise. This is saddening evidence coming six years after the historic signing of the Doha Declaration on TRIPS and Public Health in 2001. Fierce generic competition has helped prices for first-line AIDS drug regimen to fall by 99% from $10,000 to roughly $130 per patient per year since 2000. However prices for second-line drugs remain high due to increased patent barriers in key generics producing countries like India. Patients who develop resistance to first line regimens need these second line drugs, and the number is likely to grow over time, as will the unaffordable cost to health systems.

As outlined in the EQUINET / SEATINI leaflet on using TRIPS flexibilities (at www.equinetafrica.org) countries have full authority under TRIPS to use compulsory licensing or parallel importation of drugs if their laws provide for this and they need them for public health., Most (but not all) countries in the region have now passed the relevant laws for this. But the political and diplomatic pressure to dissuade governments from using these TRIPS flexibilities keeps mounting. A case in point is the legal action against the Indian government by a pharmaceutical company, Novartis. Novartis is challenging a section of India's Patents Act that aims to restrict certain kinds of patents. Novartis brought a civil lawsuit against the Indian government after the country rejected in January 2006 the company's attempt to patent a new version of its leukaemia drug, Gleevec, on the basis that the drug is a new formulation of an existing drug. If Novartis wins the case it could potentially set a precedent for other pharmaceutical companies seeking patent protection for formulations of drugs made before 1995, including antiretrovirals.

As institutions involved in health in Africa, we expect no ambiguity on this from WHO. Governments should be encouraged to use the flexibilities provided to them in the WTO TRIPS Agreement, including issuing compulsory licenses, to access generic drugs. With the Global Fund for AIDS, TB and Malaria and UNAIDS, still more needs to be done to bring down the cost of these drugs, particularly of the second line regimens, and to make them affordable on a long term basis.

For our part, we expect our governments and parliaments to ensure that our national laws incorporate TRIPs flexibilities, that our authorities are organised to implement them and that our populations are organised to protect their use. We expect our governments to reject clauses in bilateral trade agreements that attempt to remove authority to use these flexibilities. We have regional intergovernmental organisations such as COMESA and SADC to share information, resources and expertise and to harmonise legislation.

We can also stimulate the production and marketing of generic drugs, increasing returns to producers and access for people who need them. We can work through these same regional organisations to collectively issue compulsory licenses for common public health problems. In Latin America, for example, ten countries joined efforts to get agreements from generic manufacturers and originators on generic drug production. If ESA countries use regional frameworks to collectively issue compulsory licenses for the same drug, this builds a large enough market to encourage producers to invest in producing cheaper, generic versions of these drugs.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org and please visit the SEATINI website at www.seatini.org. EQUINET work on health equity in economic and trade policy and further information on TRIPS flexibilities is available at the EQUINET website at www.equinetafrica.org.

Closing the gap: from implementing to publishing research in Africa
Rebecca Pointer, Rene Loewenson, Training and Research Support Centre

This past week the Global Forum for Health Research (GFHR) has held its 11th annual Forum in Beijing, attracting hundreds of people from across the world. The GFHR advocates for greater equity in health research, noting that while developing countries that carry the heaviest health burdens; they command only a fraction of global health research funding. Under the theme of “Equitable Access: Research challenges for health in developing countries”, Forum 11 heard that global commitments to improving health will not be reached without significantly greater investments in the health sectors of low income countries. According to Stephen Matlin, the forum's executive director, globally, about $125 billion a year is being spent on health research, a four-fold increase over the past 20 years, "In spite of that increase, a relatively small fraction of the total is devoted to health problems of the poor and to people living in developing countries".

New resources for health are being made available, drawing attention to who influences their use? To what extent will communities in low income countries influence new investments, particularly towards their health needs? How far will new spending be influenced by knowledge generated from within these countries? In a world of competing approaches, how accessible and prominent is local knowledge within policy forums?

There is cause for concern when evidence suggests that the problem of inequitable research funding is compounded by similar inequalities in the publication of research. A recent review of research publication by Smith Esseh (2007) of the “Strengthening African Research Culture and Capacities Project” found that dissemination of developing country research findings is declining. ‘Africa is the second-largest continent, and has over 900 million people, and therefore should be a world leader in global scholarship. In 1960-1979, scholarly publishing began to rise in Africa, a result of gains in social and political independence. However, in 1980-1985 scholarly publishing plateaued. From 1986 to now, scholarly publishing in Africa has been declining steadily.’ (http://scholarlypublishing.blogspot.com/2007/07/strengthening-african-research-culture.html; http://ocs.sfu.ca/pkp2007/viewabstract.php?id=83). The inequalities are not only north-south: they also exist within Africa. Scholarly publishing in Africa was found to be concentrated in only seven countries, accounting for 75% of scholarly publishing in the continent, while the other forty-five countries account for only 25%.

For east and southern Africa, it would be important to follow up whether such a finding also holds for scholarly publishing in health. Publication is vital for research findings to reach wider audiences, for peer review and to build an accessible body of local and regional knowledge to inform policy. The links are not always direct, but it is clear that unpublished work remains hidden from policy processes.

In his opening address to the 22nd Annual Joint Scientific Conference of the National Institute for Medical Research in Arusha, Tanzania on 7 March 2007, Tanzanian Minister for Health and Social Welfare David Mwakyusa described the problem: ‘Researchers must know that if they cannot efficiently and effectively deliver to the stakeholders their research findings, then they have failed to accomplish their mandate. In fact, un-disseminated research findings do not only become useless but also make for multiple losses to the nation; a waste of precious time, a loss of funds invested in the work and human power, a loss of productivity and a loss to people’s welfare.’

Ensuring effective dissemination of research and knowledge is thus even more important in Africa, where research resources are inadequate relative to health burdens. Yet the major global progress made in access to information over the last decade remains elusive to many health professionals, especially those working in rural district and primary health care services, who still struggle to access or disseminate information. According to Couper and Worley (2007), ‘The unequal distribution of health care between developed and developing worlds is matched by a similar unequal distribution of health information [and yet] the health problems of Africa are most likely to be solved by people in and from Africa, who know the right questions to ask to get practical solutions and can then access the necessary information.’ (http://www.rrh.org.au/articles/subviewafro.asp?ArticleID=644)

African scholarly works are poorly distributed, barely marketed, and hardly accessed. Poor access to information has been found to be one factor driving skilled health workers out of service in remote areas. Researchers struggle to access scientific literature. The circulation numbers for African journals are often low. Smith Esseh (2007) reports for example that African universities have very low budgets for journal access and publication, ranging from a budget of 50 cents per student (Ghana) to $2.66 per student (Cape Coast) to the high of $9.00 per student (Dar es Salaam). Lack of access to journals has a two way effect, limiting access to international research in Africa and limiting dissemination of work from Africa. African researchers have raised in EQUINET forums the many other challenges they face in getting their research published, including language barriers, lack of confidence and mentorship in publication, lack of exposure to journals and writing skills. Recognising this, EQUINET has increased its investment in support for publication of research produced in the network and capacity building of writing skills within and across its research networks. A recent EQUINET Writing Workshop for Scientific Publication in Lilongwe, Malawi in October 2007 highlighted the importance of researchers identifying dissemination goals at an early stage of research, and of strengthening capabilities for dissemination within all research programmes.

However the barriers we describe go beyond the capabilities of individual researchers. They also arise in the opportunities available for accessing and disseminating information. Global developments do give some cause for optimism. The massive increase in internet use in Africa, by 625% in the past seven years, suggests new options for accessing and disseminating research. Online journal publishing and open access publication has grown in health, offering new channels for publication and new opportunities for African researchers to obtain information. The growing list of African health journals found at African Journals Online (http://www.ajol.info/) (92 under health and medicine) suggest that the old barriers posed by print production will be less of a limiting factor than they have been in the past.

This raises new questions of how to avoid differentials in access to internet becoming a basis for social differentials in influence over health policies. At the same time as the GHRF researchers were meeting in Beijing, a summit of African politicians, international lenders and leaders of the IT industry met in Kigali, Rwanda on October 31st 2007. They noted that fewer than 4% of Africans currently have an Internet connection. A goal was set at this meeting for interconnection with broadband lines of the capitals of all African states by 2012. As with other resources for health, equitable access to this vital information link across the health research community in Africa, including those in low income rural settings, will depend on public policy and investment to make it more widely accessible within and beyond these capital cities, and specific measures to stimulate its uptake and effective use amongst those currently marginalised.

TARSC is the secretariat for EQUINET. Please send feedback or queries on the issues raised in this briefing or any follow up queries on EQUINET activities to support writing skills to admin@equinetafrica.org.

Combating childhood malnutrition in Sub-Saharan Africa
Mickey Chopra: Medical Research Council, South Africa

Sub-Saharan Africa is the only region in the world where the absolute number and proportion of under-nourished children has increased in the last decade. East Africa is the sub-region experiencing the largest increases in numbers of underweight children –projected to increase by 36% from 1990 to 2005. Findings for stunting (chronic under-nutrition) and wasting (acute under-nutrition) are similar. Under-nutrition is the underlying cause of over half of child deaths. Even mild to moderate malnutrition can lead to significant deficits in cognitive and physical development.

One reason for the dismal nutritional status of children in Africa is the continual lack of food for many in the region. In less than four decades, Sub-Saharan Africa has been transformed from a continent that was a net exporter of food to one that is now heavily dependent on food imports. According to the Food and Agricultural Organisation, Africa’s food imports have risen from 8% in 1985 to 18% of world imports in 2001. A decline in agricultural and rural investment in Africa has led to a 12% decline in agricultural productivity for the workers in the region in the 1990s. Any growth in agricultural output has thus been achieved mostly from expanding the area under cultivation.

The United Nations Millenium Development Goals Hunger Task Team in 2004 summarised the consequences of this path to meeting food needs:
“Expanding the area under food production is inherently unsustainable, as the supply of new lands in densely populated areas of Africa is largely exhausted or must be maintained as natural systems for biodiversity conservation and other ecological services. The first effect in Africa and elsewhere in the tropics has been to expand into land that was previously available for fallows. Leaving land fallow allows land under cultivation the necessary time to recover from the effects of the crops taking nutrients from the soil. As a result of the reduction or elimination of fallows, soil fertility has fallen dramatically in many places, and yields are reducing with time. As the land becomes exhausted, there develops a serious tendency to continually sub-divide land among family members, which leads to smallholdings that are too small to produce a family’s food”.

Significantly, the yields of most important food grains, tubers and legumes (maize, millet, sorghum, yams, cassava and groundnuts) in most African countries are no higher today than in 1980. The environmental impacts of deforestation and drought, floods and the loss of topsoil are being compounded by the lack of investment. Only about 4% of land under cultivation in Africa is irrigated. This compares with 14% in Latin America and the Caribbean, a region with similar population densities and resource endowments. Fertilizer application is 15% lower today than in 1980. The number of tractors per worker is 25% lower than in 1980 and the lowest in the world. Africa’s share of total world agricultural trade fell from 8% in 1965 to 3% in 1996.

However, poor food security or poverty alone is not the whole story. Otherwise how does one explain the experience of many countries and populations that managed to achieve significant reductions in malnutrition before similar reductions in poverty? How does one explain the presence of malnutrition in situations where food is widely available? If one compares, for example, the experience in one region of Sri Lanka, Indonesia, the Philippines and Thailand, in the 1980s and 1990s, Sri Lanka and Thailand showed rapid improvement in nutrition, Indonesia showed slower but consistent improvement, and the Philippines little progress. Malnutrition in Latin America decreased from about 21% in 1970 to 7.2% in 1997, while income poverty decreased by only about 1% over the same time period.

Clearly reducing malnutrition is not solely dependent on increases in income. Gains in Latin America are attributed to good care practices (such as improved complementary feeding) access to basic health services, including family planning, safe water and sanitation and to women’s education and the cash resources they control.

Policies providing for female education, social safety nets, affordable food and public health services have contributed to improvements in nutrition even with minimal changes in poverty levels. In Sri Lanka, high levels of female education have been linked to improved child nutrition and child survival. Sri Lanka’s impressive performance in nutrition is also attributed to the establishment of social safety nets, especially the free or heavily subsidised distribution of rice, providing a minimum consumption floor. More recently, Save the Children UK in 2004 pointed to the universal, equitable and efficient public health system in Sri Lanka as an important reason for the low levels of maternal and child mortality in the country. Thailand incorporated nutrition as an important part of its National Economic and Social Development Plan (NESDP). This led to the establishment of an extensive community-based network of village health communicators and volunteers with existing village committees and leaders. These groups focus in communities on the fulfilment of basic needs such as optimal nutrition, provide education for this and monitor progress this through community-based growth monitoring.

A similar mobilisation of communities, health systems and national resources is required if we are to make a start in combating childhood malnutrition in Africa. This is an essential step if there is to be sustainable development in the region. Co-ordinated by the Health Science Research Council, EQUINET has embarked on a programme in east and southern Africa to collect and share information on case studies of how health systems address the wider social and economic factors affecting nutrition and lever action on these factors.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org. EQUINET work on food security and nutrition is available at the EQUINET website at www.equinetafrica.org. Work by the Medical Research Council of South Africa (MRC) is available at www.mrc.ac.za.

Communities shaping policy on health centre committee roles in Eastern Cape Province, South Africa
Therese Boulle, Leslie London, Zingisa Sofayiya Learning Network for Health and Human Rights, UCT

South Africa is in a process of transforming its health system from a centralised and largely curative model to a district health system implementing primary health care and addressing the social determinants of health. The strategies for this depend on an effective district health system, and this in turn depends in part on the role given to communities in health. But who shapes this role?

Public participation in health is covered in the country’s law and policy. South Africa’s 1996 Constitution provides for the right to health, health care, participation and association, and for public participation in policy-making. The 2003 National Health Act provides for participation at community level in clinic and community health centre committees. The 1988 Municipal Structures Act and the 2000 Municipal Systems Act create mechanisms within local government for communities to participate in decisions on local community developments through ward committees and local government councillors. These frameworks for participatory democracy need follow up to realise them in practice.

In September 2014 a National Colloquium found that while many provinces have established committees, there is a lack of clarity on their roles, affecting their functioning. The Department of Health at national level issued draft guidelines for HCCs in 2014 to address this gap. In the Eastern Cape, a policy was published in 2010 on the establishment and functioning of clinic and community health centre committees. It describes the roles, linkages, reporting and accountability of those in the committees. The policy seeks to involve communities in the planning and provision of health services, as a link between the community, health facility, and district health council and to foster co-operative governance. It sets out the community representation in the committees, drawn from women, the religious community, youth, non-government and community based organisations, traditional health practitioners and disabled people, with flexibility to include social groups relevant to the local context. This structure, while set in policy, is only slowly being operationalized in the districts. While in some districts the HCCs may be less functional, in the Nelson Mandela Bay Health District, where additional support has been provided by the university to the fifty clinics, all the committees except one are functional. Forums are held at sub-district and district level, as required by the policy, to monitor and support the committees and their members.

Communities in the Eastern Cape have played a role in formulating and implementing the guidance on their roles and functioning in the committees. In the Nelson Mandela Bay Health District, for example, health committees had been operating since 1996 but in a haphazard and variable manner, without guidelines for their functioning and erratic staff and management support. This frustrated members. In 2006 a team from the Eastern Cape Provincial Department of Health invited health committee members, health service, local government, community and other local stakeholders to a meeting to contribute and to provide substance to the policy on health committees. This workshop served to frame the draft policy, which was later sent to all districts for discussion before further review and feedback by HCC representatives. The amendments made in this process were integrated into the final policy that was adopted in 2009by the legislature in the province and published in 2010.

The policy provides for three-yearly review. In 2014 a review was initiated with HCC members, in consultation with the province. Workshops were held with the committees, facilitated by University of Cape Town. These reviews helped to make the policy more accessible, to support understanding of roles amongst HCC members, to raise roles that had been overlooked, challenges in implementation of functions and suggestions on improvements. It demonstrated tangibly to HCC members that their voices can be heard in amending and adapting policy to improve it. Reviewing the policy also made the HCC members clearer on how to monitor its implementation and the duties of service providers.

Some issues were raised during the policy review: Greater support was urged from facility managers and local government councillors who were seen to be critical members for the functioning of committees, but inadequately involved. Communication between communities and services was observed to be weaker than set in the policy. Community members were found to distrust the complaint box process where HCCs monitor the opening of complaints boxes, recording and resolution of complaints. The committees noted that very limited resources are made available to support their work, including for transport, communication or capacity development. The HCCs made various proposals in the review, to ensure include processes for establishing committees and re-election every three years; to formally recognise HCC members; to make the reporting obligations of facility managers clearer; to include ongoing capacity building and skills development in the policy and to proactively support opportunities to discuss and engage with local communities and give feedback on issues to communities to build confidence in the system.

The process taught lessons about how people can shape and use their policies for participation on health. HCC members feel empowered when they know policies, not only to understand their own roles and responsibilities, but to ensure that they are enforced and that service and local government personnel are accountable for their roles.

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 please visit www.equinetafrica.org.