Silothemba looks lovingly at the little bundle nestled in her arms and beams with pride. “It wasn`t easy,” she says. “I nearly lost this baby. I bled a lot and had I not been here the nurses say I may not have made it too. I wasn`t eager to come to the waiting mothers home because my friends said the nurses keep you there for long and I have two small children at home. Actually I didn’t go to the home on the day the nurses said as I decided to go to the clinic when I felt labour pains. My local village health worker encouraged me to take their advice, however, and I am so happy that I did. My delivery was very difficult. It started at night and had I not been at the clinic my baby and I might not have survived”.
Silothemba is one of the many mothers in Zimbabwe who have benefited from waiting mothers homes. These facilities help to reduce home deliveries as they enable mothers to be at health facilities when labour begins. Nutrition gardens at clinics managed by health centre committees provide vegetables for pregnant women, and boost food security for those from poor households.. Kumbudzi clinic in Umzingwane district also has a kitchen project to support and promote nutrition amongst pregnant women.
In Zimbabwe currently 525 mothers die in every 100 000 live births, one of the highest maternal mortality rates in the world. Mother and newborn survival in Zimbabwe is affected by the ‘3 delays’, that is a delay in making a decision to seek health services, a delay in reaching a health facility and a delay in receiving quality services and care upon reaching a health facility. These delays and the deaths from them are greater in rural areas.
Before the waiting mothers homes were introduced, rural women often gave birth at home with the aid of traditional birth attendants. While convenient, these home births may expose women to risks from unhygienic conditions or limited ability to manage complications. Waiting mothers` homes increase mothers’ access to skilled birth attendants and emergency specialized care.
Women who deliver at home often lack adequate information on the risks associated with pregnancy and childbirth. Health monitors at community level indicate that the delay in deciding to seek health care is a major contributor to maternal deaths, as women decide to seek appropriate health care when it is too late. This delay is exacerbated by the fact that many women do not make these decisions themselves but defer to spouses or relatives, who may also lack knowledge on maternal and child health. Pregnant women also face barriers from long distances to health facilities, poor road networks, slow transport methods. They may thus deliver before they even reach the clinic. Women in many remote rural and resettlement areas live more than 25 kilometers away from health facilities, above the 10km maximum recommended by government. Going by ox drawn cart is not an option when there are pregnancy related complications have developed and many transport operators fear the risk associated with ferrying such passengers.
A waiting mother home reduces the stress of these barriers, giving time to travel to facilities, and reducing costs from different transport options. It brings mothers closer to the skilled health workers they need to manage normal deliveries or obstetric complications.
This puts the focus on the third delay, the delay in receiving adequate health care. With postpartum hemorrhage; obstructed labor and hypertensive disorders common causes of maternal death in Zimbabwe, health services need, but often lack, the staff, training, medicines and equipment to effectively respond to a mother’s needs. Most rural clinics have at least 2 trained nurses/midwives, but these health workers often face burnout due to overwork and lack electricity, running water and adequate medicines. Higher level referral services may themselves lack skilled personnel. Antenatal care services and waiting mothers homes allow health workers to monitor the mother before their labour and make early referrals to the next level of care for caesarians, vacuum extraction and induction if this is needed. Referral to these services may also face challenges in some areas from poor road networks, flooding rivers, a shortage of ambulances and poor communication channels. While waiting mother homes cannot solve these referral problems, they can give health workers more time to arrange options to address them.
To overcome the three delays, waiting mothers homes need to be backed by other service improvements. Primary health care services need to be available in remote and hard to reach areas, skilled obstetric care needs to be brought closer to rural women through regular visits to health facilities by doctors and stock-outs of relevant medicines avoided. Village Health Workers should be supported by strengthening their knowledge on maternal and child health and support for community led health promotion. Communities especially men should be involved and educated on the risks associated with maternity and the benefits of delivering at health services to encourage their partners to use and benefit from waiting mothers homes, to promote institutional deliveries and to argue for effective primary care and referral services.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
Editorial
For forty years the 1978 Declaration of Alma Ata on Primary Health Care has inspired and galvanised understanding, analysis and action on health. In our region, the aspirations and content that were included in the 1978 declaration were embedded in liberation movement goals and post- independence policies and informed the organisation and transformation of health services. Indeed a context of growing movements for social justice and emergent national health systems in the South was one source of the political momentum, values and practice that fuelled the Declaration. In various declarations over the past 40 years, African governments and communities have recognised the contribution of PHC to improved health equity in the region and voiced a need to accelerate efforts to implement it, even while resources bled out of public sector services.
In preparation for a Global conference in Astana in 2018 to commemorate 40 years of PHC a new declaration is being drafted: “the Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals”. The text can be found at http://www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf. It notes a “renewed commitment to health and well-being for all based on universal health coverage (UHC)” and locates PHC as “a necessary foundation to achieve UHC”. Its focus is thus on UHC as the end and PHC as the means. It makes reference to the work of other sectors to address other health determinants in line with the Sustainable Development Goals, “ avoiding political and financial conflicts of interest”.
But the Alma Ata declaration was so much more ambitious and comprehensive in its vision and scope! It called for an economic order that would serve the attainment of health and reduce inequalities in health globally, while also recognising that the promotion and protection of people’s health is essential for socio-economic development. Its language on state duties and public rights is unambiguous. Its principles are no less relevant today than in 1978, even if changing contexts, health profiles and knowledge demand creativity in how it is applied.
As new statements and declarations circulate, let’s remind ourselves of key features of what the Alma Ata Declaration says:
“ I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.
II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.
IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.
VI Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”.
There is more, and the full declaration can be found at http://www.who.int/publications/almaata_declaration_en.pdf
Those engaging on statements and processes on PHC should carefully compare with the Alma Ata Declaration and ensure that we do not lose or blur its clarity of principles and content.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the Global conference on PHC see http://www.who.int/primary-health/conference-phc/en/
According to the United Nation’s 2017 International Migration Report, South Africa is host to an estimated four million migrants. This figure is set against a backdrop of a history of migration into South Africa that was marked by exploitative labour arrangements between South Africa and its neighbouring countries. This history is often treated with a ‘historical amnesia’ of the contribution of migrants to the South African economy and society. Migrants and particularly African migrants are met with a distrust and hostility that appears as xenophobia.
This hostility is also reflected in South Africa’s public health system, which does not adequately incorporate the reality of migration and health, nor address the needs of migrants. The South African Immigration Act is silent on the health rights and needs of migrants, placing them in a vulnerable situation and often leading to their exclusion from the public health system. This situation is worse for undocumented migrants, given their insecure legal status.
In contrast, recent media reports have often focused on ‘how an influx of health migrants’ has placed a strain on the country’s ability to deliver health care to its nationals. Some provincial health departments have lamented the strain on their limited resources due to the demand for services from migrants. These media reports and official pronouncements create conditions for refugees, asylum seekers and undocumented migrants to be denied access to health care services in public hospitals and clinics on the basis of their nationality or legal status. This was described by Crush and Tawonzera in 2011 as a form of ‘medical xenophobia’.
Denying migrants access to health care constitutes a violation of the internationally recognized right to access health care services, a right that is also enshrined in South Africa’s national law. The Bill of Rights in the South African Constitution enshrines equal rights for all persons in the country and affirms values of human dignity, equality and freedom. Migrants are covered by these constitutional rights, including the right to life, to dignity, freedom and security, to access information and to just administrative action. Section 27 of the Constitution guarantees everyone the right to basic health care, affirming that “everyone has the right to have access to health care services, including reproductive health care” and that “no one may be refused emergency medical treatment”.
The violation of migrants’ rights to access health care has grave consequences. For example, in 2015, a migrant woman lost her premature baby, allegedly due to denial of access to health care. In another incident, a migrant woman was forced to give birth at a bus station after allegedly being denied access to two hospitals in Gauteng province. Such denials of care violate rights. They have a gendered, racial and class impact, with poor, black women bearing the brunt of this discrimination.
Beyond the state’s legal obligation to provide access to health care services, there are public health reasons for providing health care services to migrants. The difficult journeys undocumented migrants, asylum seekers and refugees have had to make from their countries to South Africa may have exposed them to health problems, including communicable diseases. Treating these conditions makes public health sense as we live in a shared social space. The health of the local population is linked to that of the migrant population, given their integration into the wider community.
I would therefore argue that the South Africa state should develop a comprehensive multi-sectoral approach to migration and health, beyond infectious diseases and border control. Both the National Health Act and the Immigration Act should explicitly provide for migrant health care. The Immigration Act needs to be amended to adequately reflect the health rights of documented and undocumented migrants. The law should be supported by a comprehensive national policy, that also details how undocumented migrants should be treated, and that is applied universally across all provinces.
We need to advocate for and train health workers to implement migrants’ health rights. Such training, as a collaboration of the South African Department of Health and the Health Professions Council of South Africa, should create and foster an understanding among healthcare professionals of migrants’ health rights and needs. It should also include health administrators, as they are a point of entry for migrants attempting to access health care services.
These measures are necessary as a public health care system that excludes migrants creates conditions for poor public health for all. It increases the vulnerability of migrants, generates and magnifies discrimination and inequalities in health and violates migrants’ constitutional rights to access health care.
This is not just a health and human rights issue. It is also a matter of social justice. Migrant labour, often low wage, has been integral to South Africa’s society and economy, raising the profitability and savings of local business and consumers. It is also a matter of good public health practice. Delivering equitable access to care for migrants can reduce the health and social costs of disease, improve social cohesion, protect public health and human rights and contribute to healthier migrants in healthier local communities.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
We have a shorter newsletter and no editorial this month as we carry out essential review and maintenance work on our site. We hope the papers and content included still provide you with interesting materials for your work and analysis in and beyond the region. We have appreciated editorial contributions from a range of experiences and invite you to send us editorials written by you, and any links to videos, blogs, papers or other online resources you want to share on your perspective on the opportunities that we should be tapping in east and southern Africa for making immediate or longer term advances in equity in health.
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Current policy agendas raise an impetus for countries in east and southern Africa to be clearer with the public on what health care services they can expect to access. Commitments made to universal health coverage (UHC) and equity in health care point to a need to define the entitlements or service benefits that will be provided universally to respond equitably to population health needs. Constitutional provisions on the right to health care raise a demand to clarify what services people should be legally entitled to. Yet the gap between demand and resources suggest a need to clarify what can be funded and provided universally, taking costs into account. The diversity of funders and providers in most health systems in the region call for funders and providers to be aligned around these entitlements while social demand for public accountability calls for transparency on how resources and capacities are being used to deliver these entitlements.
As one response, many countries in east and southern Africa (ESA) have developed essential health benefit packages (EHBs) in order to define service benefits, to direct resources to priority, relevant and effective areas of health service delivery. EQUINET research in 2015-2017 through Ifakara Health Institute and Training and Research Support Centre working with ministries of health in Swaziland, Tanzania, Uganda and Zambia found that of the sixteen countries in the ESA region, thirteen had an EHB in place by 2016, albeit with different names and at different stages of design and implementation.
There was much in common in the way these EHBs were being developed and what they covered. The EHBs in the region cover similar services for communicable and non-communicable diseases, maternal and child health and public health. They generally combined an analysis of health burdens and cost-benefit or value-for-money to identify what services to include, taking on board policy goals and commitments. In some cases they took into account the priorities reported by stakeholders and external partners and, to a more limited extent, communities and parliamentarians. When countries used consultative, consensus-building design processes with wider stakeholders they widened awareness and debate on the choices to be made in what services to include, on the cost of care and on the entitlements included.
It would appear that the process for defining, costing and clarifying service benefits could be a key entry point for policy dialogue across stakeholders and an important basis to build an operational strategy for realising UHC in an equitable manner and for making clear the deficits to be met.
Indeed, ESA countries report a range of ways they are using their EHBs: They are being used as a tool for budgeting and planning at local government level; to guide priority setting and budgets; to purchase services from private, not-for-profit services and to monitor service performance. These areas of practice depend on quality system data, including from the from the private health sector, good population health information and data on the costs of services to both design, purchase and be accountable for delivery of the benefit.
While there are shortfalls in some of these areas of data, the funding gap has presented perhaps the greatest challenge in delivering on the EHB. ESA countries face clear challenges in reconciling the services they should provide to respond to population health need with the resources they have to do so. The estimates ESA countries calculated for what their EHBs would cost varied widely, from $4-$83/capita at primary care level to $22-$519/capita for referral services. In part this reflects differing assumptions and methods used for capital and recurrent costings. At the same time, in most ESA countries these figures point to a gap between the cost of a benefit package that responds to health needs, and the funds available for it, particularly in the public sector. Having these costs of the EHB raises a question for national and global levels of how, in the face of commitments to UHC, these costs will be met to turn the talk into action.
In the face of this funding gap, some countries have begun to explore new revenue sources from innovative financing, linking the EHB to policy dialogue on health financing. Resource constraints and vertical financing have, however, also motivated rationing of scarce resources, reducing the benefit to a smaller subset that can be funded from current budgets. This may focus resources on what is possible and avoid the frustration generated by the gap between aspiration and delivery. However, it also raises concerns on how to ensure fairness and public health effectiveness in the decisions on what services are covered and what is excluded. How should services treat people who present with a combination of conditions, one covered and one not? How to ensure the integration across services when some are funded and others not? How to avoid ‘minimum’ benefit packages becoming the ‘maximum’ provided? How to ensure that the poorest in the population get all their health needs addressed without costs that impoverish them?
In a regional dialogue within the countries involved the research, the EHB as a universal benefit was seen to be consistent with policy goals to build universal equitable health systems. It was seen to be a potentially useful measure to engage and build support from high-level political actors, funders, providers and communities on the different challenges that need to be addressed in implementing UHC, and to align public and private actors around national goals.
In facing the financing challenges given the desire to ensure universal provision of the benefit, it was felt that the EHB would be best funded through progressive tax financing and pooling of other social insurance, earmarked tax and private sector contributions to avoid segmentation and to ensure the universality of the benefit. At the same time it was felt that funding constraints not present a pressure to limit to curative services, and that the EHB include health promotion, public health and prevention measures, as both value for money, important for service integration and key for health sector engagement on inter-sectoral action for health.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the issue can be found in the regional meeting report at
http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Regional%20EHB%20Mtg%20Rep%20Nov2017.pdf , the country case study reports on the EQUINET website and synthesis paper at
http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Diss%20113%20EHB%20synthesis%202018.pdf
Menstrual health is often mistakenly classified solely as a ‘women’s issue’. Yet with their link to reproduction and fertility, menstrual health and hygiene are not simply women’s issues, but matters of family and national concern. This is even more important in our region given the high share of adolescent females and women of child-bearing age in the population. In addition, the education, survival and health of girls and of women have an impact on the whole family. An appreciation of this impact underpins the global Sustainable Development Goal (SDG) 4 that seeks to ensure inclusive education for all, and SDG 5 that promotes gender equality.
So having just commemorated International Women’s day on 8 March 2018, and ahead of Menstrual hygiene day next month on 28 May, it seems fitting to discuss the issue of menstrual health.
In 2016, ahead of the 11 October global commemorations of the International Day of the Girl Child, UNICEF released a report entitled ‘Harnessing the Power of Data for Girls: taking stock and looking ahead to 2030’ (https://data.unicef.org/resources/harnessing-the-power-of-data-for-girls/). The report presented a rather sombre picture of the state of gender equality in low-income countries, pointing to an unequal division of labour in homes that continues to burden the girl child and impede her educational outcomes.
Zimbabwe, like other countries in the region, has recognised the importance of educating girl children. The country has, over time, made strides with regard to gender parity in education, but still faces gaps in achieving it. To address some of these gaps, the 2005 five-year National Strategic Plan for the education of girls, orphans and other vulnerable children set out to accelerate progress towards universal primary education and to promote equity and empowerment through education. However, with the health, social and economic challenges in the country, the subsequent five-year plans launched in 2011 and 2016 gave more focus to orphaned and vulnerable children. It could have been easy to forget the day-to-day problems girls face with their changing reproductive health. But in a positive step in 2017, the Zimbabwe government introduced a duty rebate on the importation of raw materials (pulp, glue and virgin tissue) used in the manufacture of sanitary wear.
It is not the only country in the region to be taking up these pro-girl child measures.
Kenya has repealed sales tax on sanitary wear. Furthermore, since 2011 the Kenya government has allocated approximately 3 million US dollars to support the distribution of sanitary wear in schools in low-income communities. In 2016, Zambia’s Ministry of Health launched its ‘National guidelines for menstrual hygiene management’. In 2017, the Department of Women in South Africa drafted a ‘Sanitary dignity policy framework’.
In August 2017, I had the opportunity to engage the Deputy Director General of the Department of Women, Mr Prince Booi on this policy framework document. He highlighted that the policy aims to widen access to sanitary wear for extremely poor girls and women, where the provision of this service helps to restore their dignity. The name of this policy framework resonates with me, as it underscores the link between menstrual management and dignity. Girls and women without access to methods and materials for the hygienic management of their menstrual periods experience a cyclical threat to their dignity. Monthly, it can strip away their confidence and may even inhibit their mobility and capacity to carry out physical activities.
In the 1960s in America President Lyndon B Johnson declared ‘a national war on poverty’, using the term ‘dignity deficit’ to highlight the effect on men of unemployment and their inability to provide for their families as breadwinners within the home.
Women were far less in focus at the time. But women’s reproductive health is an even more powerful sign of the dignity deficit as described in 2017 by Arthur Brooks in an essay in ‘Foreign Affairs’ (https://www.foreignaffairs.com/articles/united-states/2017-02-13/dignity-deficit). In it he paints the picture of a polarised America in which the rate of births for unmarried mothers is five times higher in women reaching up to high school education than that of college educated women. This is even more profound in girl children. In my own advocacy work in Zimbabwe I have seen how unintended pregnancies lead to dropping out from school and a social reproduction of vulnerability, unemployment and poverty.
Indeed, when Scottish Member of Parliament Monica Lennon began lobbying in 2017 for a bill to ensure free access to sanitary products in schools, colleges and universities it was profiled as a bid to end ‘period poverty’.
The measures taken by Zimbabwe, Kenya, Zambia and South Africa are thus important equity measures, particularly in overcoming market barriers to menstrual health and dignity. They are also ahead of those taken in many higher income settings. Whilst the City of New York legislated in 2016 for the roll out of free sanitary wear in public schools, homeless shelters and prisons, sanitary wear is still subject to sales tax in other districts in the state and other US states have not followed its example. At the same time, African countries can also look to other countries for further good practice. The 2013 documentary ‘Menstrual man’ and the 2018 movie ‘PadMan’ illuminate the work of Arunachalam Muruganantham in India for example. He confronted gender barriers in championing menstrual management and inventing a low-cost sanitary pad-manufacturing machine that is now used by rural women in India to locally manufacture sanitary pads.
These market measures and initiatives signal a potential shift in the recognition of the importance menstrual health in countries – taking it from a position of being hidden to one that is profiled and addressed in the public sphere, and more importantly an issue that has implications for equity and dignity.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
HIV represents an unprecedented pandemic, and one that is forcing civil society to innovate to meet the challenges. Civil society engaging on HIV has carried out one of the most vocal, widespread and innovative advocacy campaigns in health, drawing on language and approaches from other sectors and regions. HIV activists have in the process brought human rights into health advocacy, even in settings where rights are perceived to be foreign and confrontational. Why do civil society advocacy groups working on HIV choose to express their claims in the language of human rights? How do they understand this choice? What impact do they see it having? What impact does it have?
I explored these questions in sub-Saharan Africa, a region hard hit by the pandemic.
The answers might surprise: the decision to use rights was fueled by individual belief not pressure from external funders. It was also the individual empowerment effects of ‘rights-talk’, rather than their legal effect, that activists felt to be most important.
I explored the experience of nine local civil society organizations selected from four countries (Ghana, Uganda, South Africa, Botswana), located respectively in three sub-regions of sub-Saharan Africa (West , East and Southern Africa). Choosing from the three regions provided insight into civil societies operating in different contexts and at different levels - local, national, regional. To allow for a systematic comparison, I chose organizations that vary in the extent to which they use human rights in advocacy. The case studies drew on 145 semi-structured interviews conducted with these organizations, as well as with others in the HIV sector. I also reviewed relevant events, documents and press accounts.
Over the past twenty years many funders have embraced the human rights framework. While I am not suggesting that international funders are not important, I found that their preferences were not particularly influential in whether organizations used rights-based advocacy. Groups using this framework didn’t lose interest when it became less popular with external funders, nor did their interest rise or fall with changes in funding. Many of the civil society groups have at least a dozen funders who usually support particular projects rather than the organization as a whole. Because organizations have so many funders, any single funder rarely influences the framework an organization chooses for its advocacy.
The organizations instead chose human rights primarily due to a mix of principles and structural factors. Organizations with a leader with a strong human rights orientation and regular interaction with other employees were more likely to choose a rights-based approach. In settings where human rights are not a common discourse, groups manage to thrive- even in isolation - when they had powerful “rights champions” as leaders. Such leaders have been able to incubate a rights-oriented organizational culture, attracting personnel who have, or will acquire a similar orientation.
People who worked for organizations that gave strong attention to human rights in advocacy often held strong personal belief in the framework. Respondents often explained this passionately, describing human rights as core to their dignity and identity. Rather than being a topic or a strategy, human rights were described as a fundamental part of who they were, what they believed in and how they saw the world.
I expected that groups would choose human rights over other approaches because they are linked to legal enforcement, in ways that development work or public health may not be. I thought perhaps the choice to use human rights in advocacy was rooted in an expectation of a government response and legal accountability. Instead, respondents saw the most important impact of human rights as their empowering effect for individuals, particularly amongst those seeking health care. They saw rights as empowering people living with HIV to demand services owed to them, and to make requests from a position of power and entitlement, rather than one of weakness and desperation.
One respondent described the shift in mindset that she saw accompanying rights-based advocacy, as “creating in people’s minds” the idea that they “have the right to demand better.” Respondents gave accounts of these demands: “When you say, ‘It’s my constitutional right, doctor. I am not going to leave this room without having treatment,’ therefore the doctor will make sure that you get the treatment […] They don’t make a mistake.”
While the above quotation is from South Africa, where health rights are included in the Constitution, even in settings without such constitutional provisions respondents gave very similar accounts. They saw rights language as transforming people from passive recipients of care to active participants engaged in their own health, and as engaged citizens rightfully demanding services from the state.
The findings indicated that “human rights” may yield important effects in places that human rights scholars seldom look. Beyond state actions and high-profile venues such as the United Nations and national courts, people are wielding human rights in their day-to-day interactions in ways that have meaningful influence on their lives. It appears that human rights-based advocacy has a unique impact. It changes people’s self- perceptions of power in relation to the state and enables them to claim services to which they are entitled from a position of greater strength. Those exposed to human rights-based advocacy were reportedly more likely to seek health care services, to be more informed about their rights, to ask questions of health care providers, and to query delays or denials of service.
It would be interesting to see what these findings imply for other areas of public health. They suggest that human rights-based activism could be an overlooked, but powerful positive determinant of health.
A version of this oped was originally published in Open Global Rights: www.openglobalrights.org/empowering-language-of-rights-underlies-increasing-use-in-hiv-advocacy/. Further information can be found in ‘Resilience and Contagion: Invoking Human Rights in African HIV Advocacy’, McGill-Queens University Press, at www.mqup.ca/resilience-and-contagion-products-9780773550995.php?page_id=119256&
The 4th Global forum on Human Resources for Health (HRH) that took place in Dublin, Ireland in November 2017 provided a useful opportunity to reflect on how far we have progressed in the global movement on human resources for health. The achievement of Sustainable Development Goal (SDG) 3, including Universal Health Coverage will not be possible without universal access to skilled health workers. A global health workforce movement is thus critical to ensure this and that access to essential health services is not left to market forces alone, leaving many unable to access basic health services.
I coordinated the convening of the first Global HRH Forum in Kampala in 2008 as the Executive Director of the Global Health Workforce Alliance at the time and have attended all the subsequent forums in Thailand and Brazil. I was thrilled to witness in Dublin how the HRH movement remains alive and vibrant ten years after the first forum. It was attended by over 1000 delegates from over 70 countries representing government leaders, civil society, academia, employers, foundations, health care professional associations and unions, youth and the private sector.
Beyond the numbers, it was the outcomes of the Dublin Forum that represent potential advances in the health worker movement, globally, and in Africa.
I saw a renewal and rejuvenation of the global HRH movement, with many new champions committed to act on the Dublin call to provide a skilled, supported and motivated health worker for every person in every village everywhere, and the 2008 Kampala Forum call for “Health Workers for All and All for Health Workers.” A Global Health Workforce Network (GHWN) hosted in World Health Organization, Geneva now brings together a range of stakeholders in the movement to organise activities around these commitments, with hubs around various fields such as education and training, leadership and governance, labour markets and civil society. A new civil society coalition on HRH was launched in Dublin to drive advocacy and accountability.
There was strong participation of Africans from all parts of Africa at the Dublin Forum. The African Platform on HRH held a side event, adopted a business plan and elected a new governing board that was empowered to update the Constitution, to support the visibility of the movement in Africa and to convene the 6th Forum of the African HRH Platform.
We were informed that implementation had been initiated of the recommendations and five year action plan of the UN Secretary General’s High Level Commission of Health Employment and Economic Growth. This commission demonstrated that employment in health and the health sector itself should not be seen as a cost but as a significant contributor to economic growth and employment, especially of women. The economies of high income countries all enjoy significant contributions from the health sector.
A new international fund named “Working for Health Multi-Partner Trust Fund (MPTF)” was launched during the 2017 Dublin forum as a collaboration between the International Labour Organization, the Organization for Economic Co-operation and Development and the World Health Organization to support countries expand and transform their health workforce. The Government of Norway has made the first contribution and urged others to invest. The fund should enable development partners to pool contributions for use by ‘pathfinder’ countries to apply innovative approaches to building a ‘fit-for-purpose’ health workforce, especially those countries that are struggling to provide access to health care and facing the threat of emerging epidemics.
The Dublin Forum also saw the launch of the International Platform on Health Worker Mobility. This platform seeks to maximize mutual benefits and mitigate adverse effects from the increasing rate and complexity of the movement of health workers. It will strengthen evidence, analysis, knowledge exchange and policy action on health worker migration, including to support implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel. The forum also made commitments to improving the safety and security of health workers by upholding international humanitarian law. It strongly condemned violence, attacks and threats directed against health personnel and facilities, given their long term consequences for health workers, for the civilian population and for the healthcare systems of the countries concerned and their neighbours.
A special feature not seen in previous forums was the Youth Forum in Dublin that set its own ‘call for action’. Attracting and retaining young health workers is critical if we are to avert the shortfall of 18 million health workers, and transform the health and social workforce.
It was significant that the 2017 forum took place during a doctors’ strike in my own country, Uganda, and a similar nurses’ strike in Kenya. One of the most powerful take-away reflections for me was that while several speakers from high income countries reported how money is chasing and seeking to attract scarce health workers, in most of our African countries, it is health workers who are underfunded and chasing money. Unless we act to address the imbalance in the demand for health workers between high and low income countries, African countries will continue to be drained of health workers going to high income countries, even while African people continue to suffer the shortages of skilled health workers that undermine their access to health care and delivery on SDG3.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the Dublin Forum can be found at http://hrhforum2017.ie/
At this time last year we wished you progress towards health and justice in the year.
Our editorials in 2017 reflect some of the mountains that have to be moved for this: At several points of the year - in February and June - contributors highlighted preoccupations with emergencies, bio-security and migration that trigger discrimination and exclusion, rather than solidarity and shared responsibility. In March and in September we heard about the increasing privatisation of public spaces, public institutions and public health services, and in April about the extraction of minerals and other resources from our countries without fair benefit for local communities.
However, the 2017 contributions also point to ideas and forces that move these mountains: such as the news in February of thousands of people gathering at Habitat3 around people’s right to the city and to healthy urban life; the demand in March by civil society to open up a closed world of global policy making; the claim in April for regional economic communities to set health standards in mining that should apply across the region; the organisation of collective African voice May’s World health assembly to more strongly advance ideas and interests from the region; and examples raised in September and October of how recognising and nurturing people’s rights, evidence and power generates a critical resource for health systems. In the beginning of 2017 one editorial painted a scenario of a future world where inclusion and investment in wellbeing is recognised not only as a matter of rights and justice, but as vital for our collective survival. So it was inspiring in the end of the year to hear a group of young contributors share ideas of urban futures that would overcome the significant differences in opportunities for wellbeing that they seek to demand, contribute to and achieve.
These ideas and forces are all rooted in the challenging conditions described. But they are also challenging these conditions, envisaging both a direction for change and a power to transform that lies in people’s hands. A Sudanese proverb says that we desire to bequeath two things to the next generation; the first one is roots, the other one is wings. Let’s move forward into 2018 with both!
In July 2017, I attended a conference by the Institute of Development Studies (IDS) themed ‘Unpicking Power and politics for transformative change: Towards Accountability for health equity’. The conference examined the practices and politics shaping accountability in health systems from local to global levels. As a southern African, these are my reflections on this from the conference discussions.
Accountability for health equity is essentially about citizens being able to hold governments to account to deliver health for all. It is about inclusivity and ensuring better health for the less privileged, marginalised and vulnerable people.
It is commonly known that within Southern Africa public sector financing for health is meagre and below the 15% committed to in the Abuja declaration. People in need struggle to access health care. In some countries people walk up to 30 km to get to the nearest health centre, only to find that it doesn’t have the basic resources to function. In countries where the health system has largely been privatised it can be virtually impossible for poor people to afford health care. This situation is worsened when there is abuse of resources, a lack of transparency in health management, a lack of public information on health budgets and expenditures, when budget and policy processes are centralised in a top down approach that allows for little or no citizen participation in decision-making.
In response, the region has seen a rapid development of social accountability initiatives that trigger active citizenship, where communities actively participate in health decision making and hold governments to account on how resources are mobilised and used. The Centre for civil society capacity building, a Mozambican organisation, recounted in conference how social accountability initiatives in that country have improved transparency in resources for health and but influenced the development of formal national mechanisms for health accountability using scorecards for citizens to input to decisions and provide feedback on services.
While these efforts have achieved varying positive outcomes, they often tackle ‘low hanging fruit’, addressing local challenges like health worker attitudes or cleanliness within the vicinity of health facilities, thereby bringing about change in local practice. While these changes are commendable, they are often tied to project timelines, are localised and often do not trigger national level changes. Community level initiatives have struggled to address more systemic challenges, such as access to information, budget setting or expenditure tracking and bottlenecks in procuring and supplying medicines. The IDS meeting argued that this is because social accountability efforts have failed to respond to higher level constraints affecting the ability of local service providers to respond to community feedback. Much more broadly social accountability initiatives have in some cases failed to recognise the complex power dynamics that are typical of health systems. Social accountability efforts ought to engage with power if they are to bring about equity and social justice, otherwise, there is the risk that initiatives will simply replicate existing social hierarchies.
Another factor affecting these social accountability initiatives is sustainability and ability to outlive short-term project timelines. There is a need to cultivate an active citizenship that raises voice to point out accountability concerns without relying on external drivers. Given the weaknesses in general environments to support this, we need to recognise and explore the role of formal structures for accountability in health, notwithstanding their pitfalls. This implies critically considering the extent to which the community voice can be integrated with local level formal accountability structures without being compromised or ‘swallowed’ by them. In the Northern part of Malawi, for example, the Catholic Commission for Justice and Peace has cultivated an active citizenship that engages within the formal mechanisms in health, as a form of structured and sustainable citizen engagement with the health system.
From the convening it was very clear that social accountability initiatives should respond to particular contexts. For example, in the case of politically charged states within Southern Africa, communities and civil society pushing for health rights and social justice are often tackling a wide range of issues that may confront power and carry unintended political connotations. Traditional social accountability tools and approaches which work in accommodative participatory environments may not be useful in politically charged contexts as Social accountability proponents become human rights defenders who need a unique set of skills to pursue issues without risking their own lives and security. The operating environment calls for unique capacities, language, strategies and mechanisms to achieve results without exacerbating conflict.
While many of these social accountability initiatives appear to focus on public sector services, there are other non-state and private for profit actors involved in the delivery of health care. Across the region health has attracted markets and business operators resulting in a range of providers, in some cases in public -private -partnerships. How do we ensure that in the face of a growing private sector, public interests continue to take centre stage as a means to achieving equity in health? What mechanisms can be used to hold these private actors to account on social goals and health needs, when their preoccupation is with profit margins and ‘fair returns’? Lessons from the negative effects of pluralistic health markets in other countries, such as Mongolia, can be used by the region to inform the development and implementation of sound regulation of the ‘business of health’ and to ensure that PPP’s and health financing schemes including health insurance are developed in an accountable manner and in line with equity goals.
These are significant challenges, but there are also opportunities to strengthen accountability through innovation. Despite low internet penetration and high telecommunication charges in some parts of the region, information technology is spreading. Throughout the region, technology is fast becoming a powerful tool in pushing for social economic rights- with the click of a button communities can voice public health concerns or access critical health sector information. With these tools, the means to accountability for transformative change may indeed lie in people’s hands!
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the IDS meeting can be found at http://www.ids.ac.uk/opinion/naming-the-moment