A growing number of the world’s workers are invisible to mainstream occupational health and safety (OHS): The vendor in Maputo or Nairobi trading on a city pavement, the person sorting waste on Durban’s municipal garbage dump, or the garment worker using her own home to make clothes for the local or international market.
These ‘atypical’ places of work have existed for many years, especially in developing countries. But OHS generally deals with formal workers in formal workplaces such as shops, factories, offices and mines. It does not accommodate much understanding of the social determinants of health, that is the relationship between risk, poverty and informal work, or how community health is affected by the conditions people work in.
Some risks are general to all forms of informal work, such as the low and unreliable incomes earmed, and the lack of cover by work-related health insurance. In addition, the different places of work present different types of specific risk: for example, street vendors are exposed to the sun and to vehicle fumes; stall holders in built markets face fire hazards; and those sorting waste are exposed to broken glass, putrid meat and discarded batteries on waste dumps. The different employment relationships, including self-employment, disguised waged work and informal waged work, also influence the risks that workers and their families face.
These employment patterns present challenges to the discipline and the practice of OHS. Profound institutional disconnects are becoming more apparent because of the numbers of workers involved, in the global north and south, and because of the growing public awareness of the informal economy.
OHS policies, norms and standards are usually set nationally, but it is local government that has most control over day-to-day working conditions. For example, street vendors’ conditions of work are vitally affected by the presence or absence of local government provision of public toilets, shelters for trading, lighting and refuse removal. Industrial out-workers who use their homes as places of production are affected by zoning and planning regulations, housing density and roads (including for access to health services and to markets). While calls are being made nationally for job creation through support to informal enterprises, local governments have in contrast smashed people’s livelihoods through evictions and confiscation of assets, undermining workers incomes and health. Better vertical institutional coherence between local and national levels could enhance opportunities for informal workers to earn better and more reliable incomes.
There are also horizontal institutional tensions and gaps. At national level, macro-economic policies lead to increased poverty and inequality that cannot easily be redressed by social policies. At local government level, informal workers engage with local government officials from departments such as sanitation, public health and environmental health that may have different policies and practices for regulating informal work, and that have limited understanding of the positive economic role played by the informal workers.
Is a reformed and more inclusive occupational health and safety possible, not only conceptually, but also in terms of enabling realistic compliance, with shared responsibilities between the state, informal workers, and employers (where these exist)?
Innovative work done by the ILO and others have tended to allocate most of the responsibility for ensuring health and safety to the informal workers themselves. But it is known that poorer informal workers do not easily prioritise their own health above their need to earn better incomes and thus may not invest in improving the safety of their working conditions. For example, industrial outworkers earning piece rates for stitching garments may not take regular breaks; waste pickers may not use personal protective equipment if it slows their work down; or headload porters may not carry lighter loads when they earn according to loadweight.
New evidence of opportunities for informal workers to engage constructively with local government over improved OHS is emerging from a five-country research and advocacy study in Brazil, Ghana, India, Peru and Tanzania, being done by Women in Informal Employment: Globalizing and Organizing (WIEGO). WIEGO is a network that seeks to improve the status of the working poor in the informal economy, especially women, through support for increased organization and representation; improved statistics and research; more inclusive policy processes; and more equitable trade, labour, urban planning, and social protection policies. The network implemented participatory research with worker groups, many of whom are affiliates of WIEGO, followed by institutional mapping of OHS in each country and in selected major cities. The studies highlighted that new worker movements – organizations and associations, often structured along sectoral lines – are critical for effective engagement over recognition and improved conditions. These movements emphasise the right to work, advocate for recognition of informal work and many are collecting rigorous data about the contribution of informal work to the local and national economy, in order to strengthen their position. Their highest expressed priority, after higher and more reliable returns to their labour, is for access to health services.
We are now exploring pathways of policy influence, engaging in international and national OHS platforms and dialogues, and encouraging a change in the curriculum for OHS training. Powerful vested interests are obviously stacked against such reforms, including from within mainstream OHS disciplines, and from global owners of capital who are presently ‘off the hook’ in terms of their responsibility for the health and safety of the millions of workers who produce for them. However the research in each of the countries has identified encouraging points of entry and increasingly organized advocacy for a more inclusive OHS.
For more information on the issues raised in this op-ed please visit www.wiego.org and the OHS newsletter at http://wiego.org/ohs/newsletter , or write to Francie Lund lundf@ukzn.ac.za or Laura Alfers Laura.Alfers@wiego.org
Editorial
There is longstanding stated policy support for health equity in East and Southern Africa. Social protest over inequality and pressure around delivery on these policies is equally longstanding, from struggles for political and economic rights to recent struggles over constitutional rights to food, water, shelter, healthy environments and health care, to hold the state and corporates accountable in relation to these entitlements, or to negotiate fairer benefit for Africa from use of its resources in the global economy.
So it confronts widely held social values when inequalities in health persist or widen, notwithstanding aggregate progress and economic growth. Why should women in Africa have 39 times the risk of dying in pregnancy and childbirth than those in high-income countries? Why, across the countries of East and Southern Africa should there be seven-fold differences in under five year mortality and 22-fold differences in the rate of women dying due to pregnancy and childbirth? Within some countries of the region nearly one in five children under five years die in the poorest households. Children of mothers with lowest education are five times more likely to be under-nourished than those with highest education.
People ask: Why shouldn’t all children, adolescents, mothers or households expect the nutrition, health and mortality outcomes of the most educated, wealthiest households or best performing geographical region of their country?
We live in an integrated regional community and global economy. Money, trade, raw materials and goods cross porous national borders. How then can such enormous differences between communities and countries be acceptable, particularly for conditions that can be prevented through technologies that have been known for over a century, including safe water, toilets, adequate food, decent shelter, access to midwives and so on? Why should huge numbers of people continue to suffer diseases of injustice?
In a 2007 Regional Equity analysis (http://tinyurl.com/9lrpl4e) , the EQUINET steering committee analysed the inequalities in health in East and Southern Africa and identified the policies and measures that could close them. The steering committee resolved to track what progress was being made in these areas, in a process called the Equity Watch. In 2012, EQUINET has produced a Regional Equity Watch that updates the 2007 analysis, drawing on a framework developed with review input from the East, Central and Southern African Health Community, WHO and UNICEF. The book is now available on the EQUINET website (www.equinetafrica.org) and acknowledges the many people and institutional contributors and processes that made input to it.
The 2012 Regional Equity Watch is essentially a watch on progress of what we know works to close gaps in health. It provides evidence on numerous policies and interventions that are being applied in health systems, agriculture, safe water and sanitation, in relation to employment and urbanisation and other areas that have closed gaps in inequality within the region. For example, investments in smallholder food production, especially for women farmers, have reduced inequalities in nutrition. Many countries have successfully implemented measures to encourage female children to enrol and stay in primary education. There are examples of activities that reduce urban poverty by enhancing employment, improving living conditions and investing in participatory planning, particularly in unplanned urban settlements. There are initiatives that have aligned national and international resources to support community management of safe water or to fund and support primary health care services and community health. There is promising practice in overcoming geographical differentials in access to health care through investments at primary care and community level, including through community health workers, community outreach, social organisation and participation, moving away from fee payments at point of care and integrating specific programmes within comprehensive primary care services. These practices underway repeatedly point to the possible.
However the 2012 Regional Equity Watch also asks why we are not making more progress in implementing the possible. It highlights that while there has been positive economic growth across most countries of the region in the whole of the 2000s, in many countries growth is occurring with increasing poverty and inequality, generating social disadvantage. Rapid, unserviced urbanisation, inadequate investment of profits and surpluses in new jobs, and significant disparities in access to agricultural resources, are common pathways found for growth with inequity. The Regional Equity Watch reports unacceptably slow progress in improving coverage of safe water and sanitation, low and unequal coverage of early childhood education and care and secondary education; inadequate public investment in improving access to land and other inputs for female smallholder food producers and inadequate resources - people, medicines and money- reaching and being absorbed by the community and primary care level of health systems. It raises concern about inadequate progress in formalising and resourcing mechanisms and capacities for participatory democracy and social power in health systems, particularly when observing the growing power that transnational corporates have in areas fundamental to health, such as in social determinants like food security or health service inputs like medicines.
Inequality within the region is overshadowed and underpinned by the scale of inequality globally. It points to a scale of inequality that needs to be more centrally and explicitly addressed in global dialogue, including on global development goals. At current rates of progress in narrowing the global gap in incomes, it would take more than 800 years for the bottom billion people – many of whom live in east and southern Africa – to achieve even 10 per cent of global income. The Watch points to the continuing net outflow of resources for health from the region, including through debt servicing, skilled worker out-migration, unfavourable terms of trade and extraction of unprocessed minerals and biodiversity. It questions the pro-cyclical, deflationary macroeconomic model that has dominated economic policy globally, given its failure to yield the sustained, inclusive or equitable growth needed to achieve social goals, and the unacceptable depths of deprivation and unacceptably wide and avoidable gaps in health and survival, and in coverage of services in our region. It raises frustration that slow progress in the strength, power and effectiveness of African voice in global decision making is being outstripped by a rapid pace of global extraction of African resources.
Many of the policy choices for a cohesive healthy society in East and Southern Africa raised in the 2012 Watch appear to be a matter of common sense. Beyond technical knowledge, therefore, their implementation depends on leadership and social action. In analysing progress and highlighting both the gaps and the possible, the 2012 Equity Watch aims to nurture and inform both the social intolerance for injustice and the affirmative leadership and demand for just alternatives.
Please send feedback or queries on the issues raised in this briefing or requests and comments in relation to the Regional Equity Watch 2012 to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org or download the 2012 Regional Equity Watch at http://tinyurl.com/8t2fqqf and http://tinyurl.com/8g6obf9.
In a changing global environment, African countries have made clear their intention for the World Health Assembly (WHA) to hold its global leadership in health. At the WHA in 2012, reforms of the World Health Organisation (WHO) were under discussion, with the aims of improving outcomes in agreed global health priorities, ensuring greater coherence in global health, and effective, efficient, responsive, objective, transparent and accountable performance. In a context of a multitude of new global institutions, foundations and alliances involved in health, African countries at the WHA collectively, through Senegal, raised that the WHO provides an organisational means for global processes to value multilateralism, inclusivity and respect for the authority of member states through the WHA. The Africa Group of countries called for the reform process to contribute “to the shaping of a stronger, more effective, more responsive and more responsible WHO.” In the discussion on the reforms, African countries unanimously urged for countries to ensure that whatever the reforms achieve, they must strengthen WHO’s position as the leading global agency for health.
Achieving this calls for more than rhetoric and statements of intent. In the past decades, the World Health Assembly provided a forum for states to review policies and strategies in health and make resolutions that they would implement. In recent years, a host of new players from non health sector agencies, non-governmental organizations, non-state providers of health, industry, faith-based organizations, civil society, foundations and corporates have become involved in decision making on and implementation of health strategies. Over the past decade more than 100 private global foundations have emerged working on different issues related to health. This multiplicity of actors bring multiple visions, mandates and modes of functioning to global policy processes. Alliances such as the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Health Workforce Alliance are now working on issues that the WHO has been working on over the years.
A Ugandan delegate to the 2012 WHA questioned the number of partnerships that WHO was now involved in, arguing that this detracted from its major mandate and role. African countries at the WHA observed that navigating this complex environment calls for WHO to rather strengthen its own intergovernmental nature and particularly the role of countries in its decision making processes. Permanent secretary of the Ministry of Health in Swaziland, Mr. Stephen Shongwe, said for example “As Swaziland we want to reiterate that the WHA is the supreme organ of the WHO and should have the final say in all the decisions. There should be flexibility for the WHA to make decisions. Resolutions should not just be crafted based on the recommendations of the Executive Board. Member states should be able to raise issues that may arise and not just be confined to the defined issues in the agenda.”
African countries’ concerns were addressed in part when the 65th WHA in 2012 resolved that any reform of the organisation be guided by the principle that the intergovernmental nature of WHO’s decision-making be paramount. The Director General was requested to present draft papers on WHO’s engagement with non governmental organisations and with private commercial entities.
However, while this may be a necessary condition for the organisation to claim global leadership in heath, will it be enough? Without the funds coming from the same member states, how will it deliver on its decisions? And will member states use their strengthened and collective decision making to safe guard public health, even in the face of corporates and foundations whose earnings exceed the GDP of many member states?
Global leadership in health demands an organisation that fearlessly and strategically protects public health. At a Special Session of the WHO Executive Board convened in November 2011 to consider the Reform Agenda, the WHO director General Margaret Chan then said that WHO, in "the interest of safeguarding public health", was "not afraid to speak out against entities that are far richer, more powerful, and better connected politically than health will ever be", adding that "we need to maintain vigilance against any real or perceived conflicts of interest."
Civil society actors at the WHA supported this role of public health protector, but questioned whether it is being delivered. They argued that the prospect of money has led the organisation to engage in partnerships that have weakened this leadership role. They held member states liable for this situation, observing that WHO can only become a stronger intergovernmental institution when member states increase their funding support.
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
Health systems in sub-Saharan Africa have been in a state of decline since the debt crisis of the 1980s and the subsequent effects of structural adjustment, chronic public under-investment and health sector reform. Zimbabweans experience a heavy burden of disease dominated by preventable diseases such as HIV infection and AIDS, malaria, tuberculosis, diarrheal diseases, nutritional deficiencies, vaccine preventable diseases and health issues affecting pregnant women and neonates. According to the latest Zimbabwe Demographic and Health Survey, the number of women dying due to maternal causes for the past 7 year period has increased in Zimbabwe from 725 deaths for every 100 000 live births in 2009 (2002-2009) to 960 deaths for every 100 000 live births in 2010/11 (2003-2010).
With this high burden of ill health, efforts to make sustained and equitable improvements in health are being made by various state and non state actors. One of the clearest objectives is to revive the Primary Health Care (PHC) concept. Primary health care, as contained in the Declaration of Alma-Ata 1978, is: " Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part, both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process."
Zimbabwe’s national health policy commits the Government “to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.”
Health Centre Committees (HCCs) are a mechanism through which community participation can be effectively integrated to achieve a sustainable people centered health system at the primary care level of the health system. They complement vital community level initiatives like community health workers, and mechanisms for public participation at all levels of the health system. In Zimbabwe, Health Centre Committees (HCCs) were originally proposed by the Ministry of Health and Child Welfare in the early 1980s to assist communities to identify their priority health problems, plan how to raise their own resources, organize and manage community contributions, and tap available resources for community development. In 2010 Health Centre Committees in two districts in Mashonaland East province collaborated with Village Health Workers to mobilize expectant mothers to deliver at health facilities nearest to them, contributing to improving maternal and neonatal survival. In Chikwaka community in Goromonzi district, the HCC has in 2011-2012 taken the lead in mobilizing financial and material resources- bricks, quarry, river, pit sand and labour- to construct a Maternity Waiting Home at a primary care facility in their ward. These are examples of how HCCs are able to organize, identified local health problems, tap into their own available resources and take action for community development.
Despite setting their roles and functions as early as the 1980’s, HCCs still do not yet have a statutory instrument that specifically governs their roles and functions. This is a gap in the formal provisions for how communities should organize on health and PHC at primary care (health centre) level. While PHC is not only an issue for the health sector, and is thus taken up by more general local government structures, it is necessary that mechanisms exist within the health sector to align the health system to PHC and community issues, as well as to link and give leadership input to these more general structures.
The absence of formal recognition may mean that other sectors do not act on health as it is not adequately profiled in their wider deliberations. The 2009-2013 National Health Strategy recognized this gap and made specific note of the importance of establishing health centre committees within the health system. The strategy identifies that “…during the next three years, communities, through health centre committees or community health councils will be actively involved in the identification of health needs, setting priorities and managing and mobilizing local resources for health”.
A 2009 Training and Research Support Centre (TARSC) and CWGH assessment on PHC (http://tinyurl.com/5rdnh7v) found Health Centre Committees (HCCs) functioning (ie having met) in only 40% of the 20 districts surveyed. The HCCs present these were found to lack coherent integration with planning systems, and to be functional in only a third of sites. Nevertheless HCCs were found in this survey to be associated with higher levels of satisfaction with services, attributed to the communication, improved understanding and support for morale that they build between communities and health workers.
HCCs offer an opportunity to take forward the shared local priorities across health workers and communities and to discuss how to accommodate differing priorities between them. In a 2004 study by Loewenson et al (http://tinyurl.com/c8bd86k) , HCCs were associated with improved PHC outcomes compared to areas where they did not exist.
HCCs ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors. In doing this, they promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development. Primary Health Care (PHC) approaches seek to build and depend on a high level of ownership and participation from involved and affected communities. The HCC is the mechanism by which people get involved in health service planning at local level. In Zimbabwe Health Centre Committees (HCCs) identify priority health problems with communities, plan how to raise their own resources, organize and manage community contributions, and advocate for available resources for community health activities. They discuss their issues with health workers at the HCC, report on community grievances about quality of health services, and discuss community health issues with health workers.
CWGH and TARSC in partnership with the Primary Health Care taskforce have developed HCC guidelines that have been proposed as the basis for a Statutory Instrument to formally recognize the role of these structures. An HCC Training Manual developed by TARSC and CWGH has been peer reviewed by the Ministry of Health and Child Welfare to strengthen the capacities to deliver on their roles, backed by health literacy activities that strengthen the wider community literacy on health to encourage wider input to and hold these mechanisms accountable. While community participation demands much more than HCCs, institutionalizing and giving a formal mandate to HCCs is critical and key to achieving a sustainable people centered health system in Zimbabwe.
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
Population health deals with health beyond the individual. It addresses the combined impact of social determinants such as environment and social structure and includes health care. With the role of pharmacists traditionally centering on the supply and distribution of medicines, pharmacists, particularly in low and middle income countries, have been viewed as having little to do with population health. Yet ironically, the community pharmacy is often the first port of call for most people with minor ailments. Pharmacists are thus strategically positioned to provide essential services that promote, maintain and improve the health of the population in the broadest sense.
Pharmacy is an age old profession that deals with the science of making and administering medicines. Over the years, the profession has evolved to encompass a wide range of service areas. In high income countries these areas and roles are well defined and structured. In low and middle income countries, this is not the case. Often pharmacists in these counties have to carve their own individual career pathways that may not bear any relationship to their professional training. In most cases however, pharmacists in low and middle income countries work in dispensing roles, mainly in community pharmacies.
In high income countries, pharmacists routinely engage in public health programs such as disease screening, pregnancy testing and counseling, immunization and counseling for at-risk populations among others roles. In lower income countries, where ironically the need is greater, pharmacists’ involvement in population health is at best minimal.
Economic growth in low and middle income country economies is taking place at a rate faster than ever, but key health and demographic indicators remain stunted. The time is ripe for the profession of pharmacy to stand up and be counted, and for pharmacists to play a more central role in population health.
The community pharmacy holds a number of benefits as a setting for public health interventions. With extended opening hours and no appointment needed for advice, community pharmacies are more accessible than other settings. In some high income countries it has been reported that on average at least nine in every ten residents visit a community pharmacist at least once a year. In lower income countries, even though this frequency may be smaller, the services that local pharmacies provide to the community could have much greater impact. For instance, community pharmacies could be a source of information related to health and well-being that could have far-reaching impact in communities that lack access to such information. Clients who visit a pharmacy to seek information may also obtain other products they need, giving a return to both the pharmacist and the client.
For pharmacists to assume population based roles both they as a profession and the community they work in need to believe that they are capable and suitably trained for it. This calls for a change in the way pharmacists are viewed and ere behave. Pharmacists must be comfortable with roles in population health and view them as opportunities. Studies have reported that while pharmacists valued population health functions, they were more comfortable with achieving health improvements through medicines. There is thus need for interventions to improve the confidence of pharmacists in using their skills for population health. From the community side, the public need to shift their view of pharmacists to see them as professionals that are also involved in population health services.
There are many ways that pharmacists could be involved in health promotion. They could carry out or be involved in education programmes on safe and effective medication as well as on other community health-related topics, such as exercise, health and nutrition. In major cities in Africa where pharmacies are readily accessible, this is a ready-made opportunity to provide valuable information on HIV and AIDS, on teen pregnancy and on other health risks. The increased use of the emergency contraceptive pill in some Africa countries may make people less concerned about pregnancy, but raise the risk of HIV transmission, undermining prevention programmes. On issues such as these, pharmacists should be in the frontline of providing information and protecting the public from such unintended consequences. Pharmacists can be involved in educational programmes that start at an early age, such as through school health programmes, to help children develop good health practices that can continue into adulthood. Their education programmes could also reach out to community leaders, legislators, regulators, public officeholders, school officials, religious leaders among others.
We also suggest that pharmacists participate in population health policy development. By linking social factors, lifestyles and the environment, in a holistic manner, to utilization of medicines, pharmacists can broaden the scope of prevention and population health. They can ensure that policies are formulated with a better understanding of the relationship between drug therapy and the many other factors that affect health outcomes.
These are some examples, and we propose that there be wider dialogue on how pharmacists can play a vital role in maintaining and promoting population health, especially in low and middle income countries. This should include participating in global, national, state, and institutional efforts to promote population health and integrating these efforts into their practices. There should be a role for pharmacists in improving community health through population-based care; in developing disease prevention and control programs; in providing health education; and in collaborating with local authorities to address local need.
To achieve this, the onus is on the profession to view such roles as opportunities and not as unnecessary burdens, and to take the next steps.
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, http://www.muchs.ac.tz/ and www.pharmasystafrica.com
Walk into many international meetings on health in Africa and you will hear discussion on development aid, and international support for programmes to respond to major diseases. The Global Forum for Health Research (Forum 2012) held in Cape Town had a different focus: it provided a platform for how countries across all income groups could invest in research and development (R&D) as a source of innovation to meet their health needs and as an investment in development and job creation.
Held under the title “Beyond Aid: Research and Innovation as key drivers for Health, Equity and Development”, Forum 2012 was organised by the Coalition on Health Research for Development (COHRED), which merged in 2011 with the Global Forum on Health Research (GFHR).
Dr. Francisco Songane, Chair of the Steering Committee for Forum 2012, reflected “There is a misconception that developing countries rely on international aid. National Governments may find it hard to meet targets for R&D spending, but they remain the major funders of research”.
Naledi Pandor, South African Minister of Science and Technology and co-host of the Forum confirmed this and the power of investment in R&D. She observed that “the ability to cycle between the laboratory, clinic and field site provides a very powerful platform for translational research”. Investing in this link in South Africa gave the country an advantage over countries that focused on the basic sciences or clinical research, but not both. According to Minister Pandor, this positions South Africa to respond to health need and to emerging markets in Africa, to advance African-led innovation in drugs, diagnostics, vaccine development and other product-oriented innovation, including in relation to gene therapy, cell therapies and tissue engineering.
Dr Songane, Dr Carel Ijsselmuiden, executive director of COHRED, and other speakers at the Forum raised that achieving these synergies between innovation and economic and social benefit means that “we, in the health sector, need to open the doors of our community, and actively work with the other sectors”. They proposed that we need to shift from an aid paradigm to negotiating investment in and benefit from R&D in health.
The Pharmaceutical Manufacturing Plan for Africa, adopted by the Summit of the African Union in 2007, was raised as a promising example, with its emphasis on a coordinated approach to local medicines production based on countries needs. The research agenda to support the plan seeks to produce evidence on the productive capacities, intellectual property, political, geographical, economic and financing issues that affect the manufacture of medicines, to inform the necessary interactions across multiple government ministries, regulatory authorities, financial investors and private and public research, development, teaching and healthcare delivery institutions.
The Forum also raised issues of equity, at both global and regional levels.
Firstly there are inequities in the current distribution of both capacities to invest and in the sharing of benefits from investments in R&D. For example, Carel Ijsselmuiden pointed to a recent report on the impact of sequencing of the human genome. This report demonstrated that the potential economic return on the initial investment had gone to the global north, rather than the south, where there was no capacity to build on knowledge produced by the project. "The south has to develop the capacity to compete in this type of domain," he said. "The continuing emphasis on aid may stop us seeing this new picture of the world that is emerging."
‘Beyond aid’ should be taken to not mean ‘beyond solidarity and fairness’. In the past the GFHR has drawn attention to the highly uneven distribution of resources for health research between high and low income countries. At regional level, Forum delegates in various sessions pointed, therefore, to the need for collaboration and pooling of resources and knowledge within and across regions, to avoid a widening gap. The technological possibilities for such collaboration are growing. As stated by Dr Songane, “new communication technologies are making up for a lack of infrastructure and resources. The possibilities are exciting – virtual collaboration, sharing of data, and the use of mobile health technology to reach even remote rural areas”.
At global level, a Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG) established by the World Health Assembly (WHA) has in 2010 been examining the current financing and coordination of R&D globally, particularly in relation to neglected diseases and the needs of developing countries. In its report (www.who.int/phi/CEWG_Report_Exec_Summary.pdf) the CEWG proposed minimum shares of gross domestic product to be set for government funded health research and a global convention to address issues of equity and sustainability in financing for R&D. Minister Pandor welcomed new models, like UNITAID’s patent pool for AIDS medicines, which allows generics producers to make cheaper versions of patented medicines by enabling patent holders to license their technology in exchange for royalties.
Raising a second dimension of equity, young researchers at the Forum raised in a communiqué that work on R&D must be framed as a public responsibility, given that health is a human right, and must thus reach and benefit all communities. Youth and other delegates raised that communities’ local or indigenous knowledge should be respected, protected and integrated within research and knowledge systems, and innovations developed in ways that ensure fair partnerships, sharing of evidence and benefit, and collective, social entrepreneurship.
Further, in a session on the Equity Watch work in EQUINET, presenters from research institutions, Ministries of Health, regional and international agencies in east and southern Africa pointed to the need to overcome inequities in access to already known technologies for health, including the housing, food, water, primary health care and other key social determinants of survival. Their country and regional analysis highlighted economic growth paths that raise inequity in access to these resources, such as through unplanned urbanisation, insecure employment, or poor investment in small holder farming. They also presented evidence of public policies and measures within the health system and in other sectors such as education that close the gap.
Forum 2012 called for a different mindset, for innovation and research to be given more attention, given their role as drivers of health, equity and development. Discussions in the Forum raised that equity in health, while desired, cannot be assumed to be an outcome of research and innovation. It is also not adequately addressed by aid. The policies and measures for ensure equity as an outcome- whether through fair sharing of benefits, solidarity and collaboration on capacities and resources, inclusion of communities and their knowledge, or equitable access to existing technologies for health - need to be explicitly negotiated, implemented and monitored.
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 http://www.forum2012.org/presentations/ and www.equinetafrica.org
Following meetings of senior African education sector officials, experts and stakeholders on the eve of the Conference of Ministers of Education of the African Union (COMEDAF) in April in Abuja, Nigeria, the Africa Public Health Alliance and 15% plus Campaign called on African Education Ministers to prioritise the development of an African Multi-sectoral Human Resources Development Plan as a pre requisite to meeting Africa's development goals.
In a statement by the organisation, its coordinator Mr Rotimi Sankore stated that "While universal free, or affordable education is a development goal in its own right, the education sector also has a special role in developing the human resources that are a pre-requisite for meeting all of Africa's overall development goals"
Elaborating further he observed that in virtually every key sector of the economy and society, most African countries are operating at between 25 percent to 75 percent of the required human resources capacity, with the health sector particularly affected. Citing the conference host country Nigeria as an example, he noted that Nigeria has only about 25 percent of the doctors it needs, about 45 percent of nurses and midwives, and about 12 percent of pharmacists, a feature linked to poor performance in key areas such as maternal and child health.
With similar or worse gaps in various areas such as the engineering fields, it's no surprise that many African countries are lagging behind in overall human and social development.
Along side this is the crucial matter of overall poor investment in health, human and social development issues, with 33 African countries investing well below $40 per capita in health, compared to Cuba at $642 per capita, or Costa Rica at $413 per capita, both countries closer to African country development levels but with better health outcomes.
As the Africa Public Health Alliance 15% + Campaign we note that even if we suddenly had all the financial resources required for health services tomorrow morning, we would well find that most African countries do not have the human resources capacity to effectively absorb and utilise the financial investment.
No entrepreneur will ever purchase a hundred airplanes for an airline, and then employ only twenty five pilots and expect the other seventy five planes to fly. Yet this is the scenario in most African countries, where there is a strange expectation that we can meet the Millennium Development Goals and other development targets without the pre requisite human resources and infrastructure.
Considering that Africa's population is set to double from current one billion to two billion by 2050, it is imperative that Africa's education ministers work with other sectors of economy and society to prioritise in each country and at reqional level, the development of a Human Resources Development Plan that identifies what level of human resources are required for each sector, what is currently available, and what policy and investment is required to fill the gaps in the shortest possible time.
Public statement of the Africa Public Health Alliance 15% + Campaign 25 April 2012 at the Conference of African Ministers of Education Abuja 26/27 April 2012. 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 contact media@africapublichealth.net.
This newsletter includes the Istanbul Declaration, adopted by delegates to the first Global Human Development Forum in Istanbul in March 2012. The Declaration calls on the world community, gathering soon at the United Nations Conference on Sustainable Development (Rio+20) in June 2012, to set and implement global and national development strategies that emphasise social inclusion, social protection, and equity. This is in recognition of the fact that economic development has too often gone hand in hand with environmental degradation and increased inequality. Who sets those development strategies matters. One paper in this newsletter points, for example, to the disproportionate power over the global economy of just over 100 transnational corporations. Another questions the influence of private wealth in the underfunded global 'protector' of public health, the World Health Organisation. Within such asymmetries of power and influence the work at Rio+20 cannot end with aspirations. It also needs to tackle how institutions and processes need to change to deliver on these aspirations.
Pneumonia is one of the top five deadly diseases for children in Malawi. It causes more deaths than measles, malaria and AIDS combined. Infection with Streptococcus pneumonia and can cause a range of illness, from relatively mild ear infections to fatal pneumonia, meningitis and sepsis. It was estimated by Ministry of Health in 2011 that childhood pneumonia accounted for 18 percent of deaths of children under five years.
This death is avoidable and unnecessary. Childhood pneumonia is preventable through living in a well ventilated housing, avoiding indoor pollution through using improved stoves, pot lids and clean fuels among other factors. It can also be prevented with a simple vaccine.
In November 2011, World Pneumonia Day, Malawi launched and added the new pneumonia vaccine (Pneumococcal Conjugate Vaccine (PCV 13) to its routine immunization chart. Bright Masangwi Chisale (male) was the first child to receive the new oral vaccine in Lilongwe-Malawi. His immunization was presided by Malawi’s Minister of health Hon Dr Jean Kalirani. In 2012, 1.2 million Malawian children under the age of one will be vaccinated against pneumonia. This is being co-financed by the Government of Malawi, with government putting in $0.20c per dose and the Global Alliance for Vaccine and Immunization(GAVI Alliance) putting in $11.17 over three years for each of the 1.2 million children immunized to cover the systems, vaccine and outreach costs. These are huge investments and their effectiveness will need to be tracked in the expected improvements in child mortality.
Vaccines are one of the best technical options for disease prevention. Many vaccines, not all, protect a child for a lifetime. As they are one of the most cost effective interventions to prevent illness, they should be given priority in the allocation of resources, particularly in a low income country like ours with many competing health priorities.
However without GAVI support the introduction of the vaccine would not have been possible as the cost would have been too high. It is encouraging that in 2011 vaccine manufactures gradually reduced vaccine prices. However the costs remain high. Malawi pays 15 cents to 20 cents per dose for its vaccines. But it is estimated that the vaccine for pneumonia cost $2.50 to $3.50 per dose. With Malawi’s total government expenditure on health at $22.00, this cost would be unaffordable. Unless there are further reductions in vaccine price it will be difficult for countries like Malawi to afford these effective technologies to prevent childhood and adult mortality, without depending on external funders.
Even the most effective vaccines will only have an impact if they are actually made available to the children who need them. The need is clearly higher in low income countries like Malawi. So should the funding of vaccines be a matter of ad hoc external funding? Or should vaccines rather be considered a global public good, to be funded more predictably at global level, and equitably allocated to countries based on their populations and need.
It will then be up to the country to ensure vaccine outreach. Low income countries like Malawi are able to achieve high vaccination coverage rates through primary care services and outreach campaigns. Malawi has achieved such high coverage as immunization services are administered by the cadre closest to communities, the Health Surveillance Assistants (HSA), who are trained to administer the vaccine. These cadres are found in the most hard to reach areas, and are given support from Ministry of Health. While the programme has support from World Health Organisation, UNICEF, the GAVI Alliance and civil society, the delivery system through primary care cadres is a primary responsibility of the government.
It is possible to ensure that no child dies from a vaccine preventable disease. However this needs the vaccine industry to continue to make vaccines cheaper and more accessible. It needs global level funding for vaccines with a mechanism for predictable and equitable collection and allocation of global funding of vaccines as a public good. It needs governments to resource a health system that ensures a chain of delivery of the vaccines to the community level cadres and facilities, and to all the adults and children who need them. It needs communities to take up the vaccines.
While the discussion today is on the vaccine for childhood pneumonia, tomorrow it may be other vaccines, such as those for malaria, typhoid or dengue fevers. It is a welcome development to hear that malaria vaccine trials are showing positive results in the sites where they have been tested. A vaccine for malaria will be a major contribution to public health in Africa.
Vaccines alone are not enough to solve all of our persistent health problems. We still need to focus on the deeper causes such as improving indoor air quality, improved nutrition, improved case management/ treatment and strengthening health systems, as this will produce much wider and long term health gain than vaccinations. However, ensuring access to pneumococcal vaccines should be something we do today to protect children’s right to life.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org
In the 1990s and early 2000s leaders of African countries persistently called for compensation for the loss of publicly trained health workers from low income African communities to the high income communities of Europe, North America and Australia. A November 2011 British Medical Journal paper by Edward Mills et al reported on the magnitude of the loss to health worker training investments in African countries to be US$2.17bn, ranging from $2.16m for Malawi to $1.41bn for South Africa. At the same time the benefit to destination countries of recruiting trained doctors was estimated at $2.7bn for the United Kingdom and $846 mn for the United States.
Despite acknowledgement that migration is driven by social, political and economic causes, it was deemed justifiable to take actions to more fairly manage these flows and their consequences. African countries made submissions in various international forums for governments of destination countries to notify governments of source countries on the number of health workers employed, their professional status and their contractual rights and obligations, and to provide equal treatment to migrant and local health workers. In addition, the African countries urged for restrictions on unethical recruitment and employment practices and proposed that compensation for losses from permanent migration could be organised through investment and tax remittance arrangements, and through technical and other resource inflows to support health professional training in Africa.
Responding to these pressures in the context of a crisis of health worker shortages in many African countries, in 2004 the World Health Assembly resolved to develop a multilateral response through a non-binding code of practice on the international recruitment of health workers. After consultation and negotiation, the Code of Practice on the International Recruitment of health workers was adopted at the 2010 World Health Assembly, almost 20 years since the World Health Organisation members agreed on such a code, the 1981 International Code of Marketing of Breast Milk Substitutes. Strong compliance by African countries with provisions of this code would advance us towards the diplomatic “finishing line” in the effort to more fairly manage health worker migration.
Regrettably however, by June 2011 (the latest reporting available) only 48 countries had reported even their National Authority for the code to WHO, with only 13 of these from Sub-Saharan Africa and only seven from the 16 in east and southern Africa (Kenya, Mauritius, Swaziland, Uganda, Democratic Republic of Congo, Angola and Namibia). More may have reported since then. The low reporting of even this administrative information raises concern about how far the code is known and implemented, and whether the reporting at the 2012 WHA will be an active tool to raise both its positive impacts and its shortfalls, or a passive bureaucratic ritual.
The 2010 code sets out the responsibilities, rights and ethical responsibilities of stakeholders to ensure fair recruitment and equitable treatment practices for the health workers who would have migrated, including to avoid recruiting health workers within existing domestic contractual obligations. Health workers are also obliged to be transparent about their contractual obligations.
In relation to health workforce development and health systems sustainability, the code discourages active recruitment from countries with critical health workforce shortages; encourages utilization of code norms as a guide when entering into bilateral, regional, and multilateral arrangements to further international cooperation and coordination; identifies the need to develop and support circular migration policies between source and destination countries; encourages countries to develop sustainable health systems that would allow for domestic health services demand to be met by domestic human resources; and places particular focus on the need to develop health workforce policies and incentives in all countries that support the retention of health workers in underserved areas.
The code appears to be a milder instrument than what African countries pushed for given that it is not legally binding. Its voluntary nature makes it a weak instrument as there are no specific commitments to return investments in stabilising the socioeconomic conditions of health workers or supporting training in low income countries. The code has become ‘the response’ to policy discussions on the relative costs and benefits of health worker migration. It does not fully address the African concerns that motivated to its negotiation and final adoption, but its presence has curtailed further discussion of these concerns.
One of the measures to assess the impact of the code is through monitoring its implementation and tracking the action taken by WHO member states. Member states are obliged to report to the WHO Secretariat on their actions on the code every three years, beginning in 2012. Given that the code is not fixed, and that its contents are considered as dynamic and subject to review, monitoring becomes one of the tools for keeping alive issues and concerns that were not fully addressed.
With the WHA only three months away, states, civil society and health worker associations should look for signs of progress, or otherwise, in the areas covered by the code, and ensuring that these are raised at the Assembly. Some of the questions this raises are:
Are there national coordination mechanisms for all relevant stakeholders and partners to facilitate policy dialogue and implementation on health workers?
Has there been any development of policies and practices since 2010 encouraging circular migration (such as migration within countries in east and southern Africa) and return migration from destination countries?
Is there policy or law requiring recruiters to follow ethical recruitment practices that covers state and private and non state actors?
Are there positive developments in collaboration of source countries and destination agencies or countries to sustain health worker development and training? Are there any new bilateral, regional, multilateral arrangements – soft law instruments – on health workers between source and destination countries?
Are there any new development assistance efforts (including mechanisms for compensation) to support coordination and collaboration on health worker migration between destination and source countries?
Are the regional bodies keeping and publicly reporting an annual scorecard of performance in the region against the agreed key indicators?
If the feedback on these questions indicate that the global code, as has been the case for many of its international precursors, is a useful signal of policy intent but not effective for managing costs and benefits, then the initial demand of the African countries for a more fair deal on the migration of health workers fairness still needs to be raised and addressed. African countries should use the forthcoming WHA in May of 2012, to strongly scrutinize developments around the implementation of the code. The results of this first assessment should help point towards concrete action to be taken on the implementation of the code.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org. For further information on the code visit http://www.equinetafrica.org/bibl/docs/Polbrief28%20Code.pdf