Habitat III: How will the New Urban Agenda promote health and wellbeing?
Editor, EQUINET Newsletter

In this issue we have a numerous papers and videos reporting the discussions, debates and policy proposals at Habitat III in Quito, Ecuador in October. They provide evidence of the challenges for and visions of life in today's and tommorrow's cities, including in relation to improvements in health for all in the city. We will keep an eye on these debates from Habitat III that affect urban health equity and invite you to send us your views for the next newsletter. What do you see as the major urban health challenges in our region? What success stories do we have? And how has Habitat III has contributed to meeting challenges for and nourishing success towards meeting the right to health in our cities?

Transforming not absorbing: Messages from a dialogue on participatory learning from action
Members of the EQUINET pra4equity network

When the Global Symposium on Health Systems Research (GSHR) gathers health systems researchers in November 2016 to explore ‘resilience’ in health systems in a context of inequality and economic, social, environmental and health challenges, what learning and insights will we bring to the table?

Between August and October this year we carried out two rounds of discussion drawing in diverse voices from amongst the over 300 people globally in our pra4equity list, hosted by the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The first was to discuss our experiences in learning from action in participatory action research (PAR) and the second on what that implies for how we understand the concept of resilience.

The PAR process involves gathering and systematising lived experience to collectively analyse and validate the underlying causes, set, take and reflect on actions on these causes and draw knowledge from it. In earlier meetings we realised that people are less confident of this phase of learning from action. There was a demand to discuss further the processes for building the understanding, power and self-confidence to produce and evaluate change.

In the discussions, people drew attention to various methods they used to facilitate learning from action, including through the ‘but why’ method, progress markers and wheel charts, and mapping or taking photographs of change from initial findings as a means to reflect on the change and what has enabled or blocked it. These processes and tools have not only been used to review how far we have achieved intended actions and outcomes, but also to reflect on the thinking and hypotheses on what produces change. The collaborative development of hypotheses for change by those involved in the PAR (as a form of critical theory or using PAR forecasts, like weather forecasts) was seen to be integral to learning from action. So too was helping people to document their ongoing learning.

In our learning network we’ve also used the reflections across countries on actions on the same problem area as a form of ‘meta-analysis’, to share insights on what facilitates the implementation of change, what blocks it and why, drawing learning also from what is similar and different across countries.

The steps of action and learning often take several PAR cycles to address deeper determinants and build meaningful change. This is especially relevant when people are engaging on deeply rooted power relations or determinants that are beyond local control, such as addressing gender in South Sudan or commercial sex work in Malawi. While not always the case, some noted that this can take more than a decade of work in both high and low income settings, calling for sustained processes.

This raises challenges in some settings. Tracking of change may stop too early, those working in communities may lack the time or resources to record and report the change and the resources and attention to do this may not last for the time needed. Researchers or facilitators may not always be included in or able to stay with change processes that take place over years. PAR processes may also differ from the institutional cultures or priorities of universities or of the trade unions, social movements and other organisations that represent or work with the social groups involved.

The power imbalances involved are often protected by strong interests. We reflected that before applying any method, including PAR, we need to be clearer on its strategic possibilities, given the contexts and social actors. While this may lead to choices within range of approaches and forms of activism, it was asserted that a self-determined understanding of the symbolic and material dimensions of inequalities remains a powerful starting point for any approach.
Notwithstanding the difficulties, numerous examples of positive experience were shared! In Monrovia, for example, PAR implemented after the Ebola epidemic led to a shared, more comprehensive understanding of maternal health amongst the health workers and community members involved, pointing to actions to strengthen the continuity and interaction of the different services and roles needed to improve maternal health care.

In our discussions it was also suggested that the action and change in PAR should not only be seen in terms of material changes in conditions, although this is important. It can in addition be seen in the change in the people involved. As one participant noted in the discussion, “we pay too much attention to the actions and not enough to the actors.” For those often excluded from formal planning and decision making, it is important to appreciate how far they themselves are transformed in the process, in terms of their consciousness and self- confidence to produce change. This can start early in the PAR process, even from the first step of recognising and listening to shared experience.

Given these reflections, we had a second, equally challenging discussion on the concept of resilience from a PAR lens. In part this was due to its adoption as a theme by the GSHSR and in part its increasing use in global discourse. Resilience has been used in environmental and physical sciences to describe the stability of a system against interference from external disturbances, but has migrated to the social sciences. The GSHR website says: “Resilience: absorbing shocks and sustaining gains…. Health systems must be resilient – able to absorb the shocks and sustain the gains already made….”

As was raised in June by Topp, Flores, Sriram and Scott, our network also challenged use of a term that implies ‘absorbing shocks’ and ‘stability’ when the system is an outcome of unjust and structural inequalities that undermine health. PAR has developed in many settings as a direct confrontation with these inequities, seeing their disruption as necessary for health. It would thus not comfortably be applied in the science of ‘absorbing shocks’, when these derive from such injustice.

At the same time some noted that there appears to be a second set of meanings to the term. Resilience has also been used in some contexts to refer to the capability to sustain a positive change or to resist negative change, to transform and move from a harmful equilibrium to new more positive one and the ability to self-organise into a healthier state. This appears to have greater resonance with the process in PAR, given that it draws in the learning from action on a system and intends to raise the direct power and capability of those directly affected.

Given how different these ‘meanings’ are, we noted that we need to understand explicitly and not assume how people are using the term resilience, including at GSHSR. It has often been applied in relation to shocks and emergencies, for example. However participants raised that ‘emergency’ responses commonly use command and control styles that do not strengthen the capacity of or build co-determination with the affected community. If resilience refers to the ability to move to a healthier state, then systems need to transform the conditions producing shocks to prevent them, and not merely to absorb them, and to do so in ways that are defined with and build the capabilities, voice and power of those directly affected.

Please send feedback or queries on the issues raised in this oped or interest in the pra4equity list to the EQUINET secretariat at admin@equinetafrica.org.

A focus on parliamentary roles in health in the region
Editor, EQUINET newsletter

In 2008 parliamentarians from Parliamentary Committees on Health in East and Southern Africa committed to raising the profile of health in all parliaments in the region, to strengthen their leadership, roles, capacities in and evidence for promoting, monitoring and advancing equity in health and health care. In this issue we have given attention to the role and work of African parliaments in health, both in the editorial and in various recently published items. Parliaments play a critical role in health, promoting public information and dialogue, scrutinising and reviewing laws, reviewing budget proposals and overseeing the implementation of policy and the functioning of the executive. There are numerous documents on the EQUINET site that report this parliamentary work in health since 2008, including on raising accountability on the Abuja commitment on domestic financing for health. This issue gives a glimpse into the more recent work and debates on health underway in African parliaments.

African parliaments networking to ensure delivery of key health goals
Hon Blessing Chebundo, Network of African Parliamentary Committees of Health

One reason why many of our health policies fail to be fully implemented in our region is that we lack a robust mechanism to make sure of this. Parliaments play a key role in this. They provide a link between government and citizens on laws and treaties, budgets and in overseeing in implementation of national programmes. In the early 1990s, most African countries initiated reforms for their parliaments to play a more effective and visible role in these functions.

The idea to bring the Portfolio Committees on health in the region together was first mooted in 2003, in part due to falling budget allocations to health, to the devastating impact of AIDS and to evident inequalities in access to funds and services. We recognized that as members of parliament (MPs) we needed to use our representative mandate to communicate social expectations and strengthen social voice and power in health. A core group of MP used our own resources to visit other parliaments in the region to share the idea and listen to the feedback. The network was finally launched in 2005 as the Southern and East Africa Parliamentary Committees on Health (SEAPACOH). Today we have widened to all of Africa and are the Network of African Parliamentary Committees on Health (NEAPACOH). So far we have active participation from Angola, Botswana, Benin, Burkina Faso, Burundi, Ethiopia, Ivory Coast, Gambia, Ghana, Kenya, Kingdom of Lesotho, Malawi, Mali, Morocco, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe and we welcome other parliamentary committees on health in the continent.

Since 2008 and with technical partners like EQUINET and Partners in Population and Development Africa Regional Office, the network has annually brought together the health committee chair, clerk and several other MPs from committees across the continent. This provides a forum for parliamentary committees on health to share concerns, unify voice on common concerns and calls for action, to advocate for health as a fundamental human right and promote democratic principles in health, including in our engagement with global processes. It also allows us to share promising practice and lessons learned. Strategically, we use the annual conference to identify common challenges and resolve on areas for action and on commitments that national health committees/delegations undertake to implement and report progress on at the next conference. We have found that identifying joint areas of action that brings us on the same ‘wave length’ strengthens our effectiveness, individually and collectively. The experiences, views and success stories that we share inspire and inform the individual committees. For example from 2005 we took up a common cause on advocating our Ministries of Finance to meet the Abuja commitment of 15% of the government budget going to health, that raised attention to this issue and contributed to improved allocation in a number of countries. We also raised issues that affect other sectors and committees, such as the positions on intellectual property that are needed to support access to medicines. We produced with EQUINET parliamentary briefs on international treaties affecting health and other health issues that are common for all parliaments in the region. We have in the process built solidarity and collaboration with civil society organisations and regional networks, and with health professionals, academics, non-state actors, research institutes and international agencies. This has enabled us to better understand and synergise our different but complementary roles across all actors to ensure we deliver on social values and policy commitments, such as on health equity.

In our recently held 2016 NEAPACOH conference we have identified some key areas of attention and work for the coming year. Some are platforms we are sustaining from prior years, including to: facilitate greater public participation in health; to pursue and monitor achievement of equity in health; to advocate for improved health budgets and financing (in line with the Abuja commitment); and to promote access to key reproductive health, family planning and HIV/AIDS services. We agreed, further, to evaluate how far our governments have ratified and domesticated health related treaties and to engage on how far actions have been institutionalized and implemented to advance Universal Health Coverage and other Sustainable Development Goals (SDGs) that affect health, including within parliament. We see a need to mainstream the SDGs within the diverse areas of work of parliament, including the public information and consultation for them, and would want to spearhead work on this in health. We also plan to develop a handbook for African parliamentary health committee members as a practical resource to support their role.

The 2016 conference also raised a proposal for NEAPACOH to work with technical partners to evaluate how effectively parliamentary committees are taking forward resolutions, to understand the barriers and support practice. We will do this by visiting a selection of member committees in their countries before the next meeting.

The process of building this network has itself been a learning experience. Indeed we understand that the longevity of this network of parliamentary committees is unique in the continent, outside the formal all parliament unions. We have grown stronger over the years building on our constitution and founding values, and have a board of serving MPs from all five African regions chosen in our annual conference and an office hosted by the Parliament of Uganda. Over the 13 years since we were formed we have benefited from perseverance of leadership and retention of key founding personnel, from sound founding principles, and from a consistent collaboration with key technical partners in the region. At the same time we still have much to do to deliver on our mandate, to be more robust and effective at national, regional and continental level to protect shared health values and to play our role in ensuring that they are delivered on in practice.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. You can find out more on NEAPACOH at www.seapacoh.org

Will the new global health emergency funds secure or securitise health?
Garrett Wallace Brown, Olivia Wills, University of Sheffield, Rene Loewenson, TARSC

When leaders at the 2015 G7 summit called the 2014 Ebola epidemic ‘a wake-up call for all of us’ they acknowledged that the global response had been too slow, with inadequate health leadership, coordination and emergency funding. At the same time, as argued in the May 2016 editorial in the newsletter, emergency responses cannot be delinked from the strength and authority of health systems to prevent, detect and respond to emerging public health threats, nor to their power to engage sectors on their role in the economic, social, environmental, trade and other determinants of these threats. Shortfalls in public health capacities, including those set in the 2005 International Health Regulations (IHRs) are a warning sign of future outbreaks, often due to neglected diseases or public health risks that get inadequate attention or resources until they trigger large-scale and highly expensive outbreaks.

The two new global financing mechanisms introduced in 2015 to support health emergency responses are thus important additional resources. These are the World Health Organisation (WHO)’s Contingency Fund for Emergencies (CFE) and the World Bank’s Pandemic Emergency Facility (PEF).

The CFE emerged from discussions on the IHRs and was adopted at the 2015 World Health Assembly. It aims to fill the gap from the first 72 hours of a declared health emergency until resources from other financing mechanisms begin to flow. It covers all countries regardless of income to prevent events that have substantial public health consequences. As defined in the IHR, these may be due to infectious agents, chemicals, radiation, food safety or other hazards that can escalate into a public health emergency of international concern. The fund is triggered by national request and the level of funding is decided on a case-by-case basis from a $100m fund. It can support personnel; information technology and information systems; medical supplies; and field and local government support. To date, the CFE has disbursed $8.5 million for interventions related to the Zika virus in South America, on yellow fever in central Africa, and drought related food insecurity in Asia.

The 2015 G7, indicating reasons of accountability and effectiveness, located the PEF at the World Bank. It is currently being finalized for launch at the end of 2016, uniquely as an insurance mechanism rather than a grant fund, to support follow up measures in emergencies after initial funding, such as from CFE. It is only focused on infectious disease outbreaks that could become cross border epidemics. Unlike the CFE, only low income countries are eligible for PEF financing. Funds are provided through two delivery windows: an insurance mechanism for up to $500 million per outbreak, and a cash injection between $50 and $100 million. The disbursement criteria are yet to be clarified. The World Bank expresses its anticipation that an insurance model will bring ‘greater discipline and rigor to pandemic preparedness and incentivize better pandemic response planning’, including by building ‘better core public health capabilities for disease surveillance and health systems strengthening, toward universal health coverage’. However it is both ambiguous and problematic that the PEF is yet to state the specific measures for supporting and measuring these aims.

Although born from different governance processes, the two funds do have some links. For example, the CFE intends to be a first response and the PEF a subsequent deeper resource package. They make reference to one another, recognizing the need to interact for coherence of emergency responses.

However, only the CFE has a formal relationship with the IHRs and its core capacities, only the CFE is universal in coverage of all countries, comprehensive in addressing the full spectrum of cross border public health risks enumerated in the IHRs, including radiation, chemical and other risks, and only the CFE is managed under intergovernmental funding rules and institutional frameworks, with explicit support for system functions such as health information, planning and health worker mobilization.

It is not clear why the PEF seemingly circumnavigates the institutional and intergovernmental mechanisms of the IHRs. Two explanations stand out: Firstly, the PEF is a product of G7 processes, which similar to the establishment of the Global Fund in 2000, have supported funds that are independent of WHO governance processes. Secondly the PEF seeks to create an insurance market that will incentivize certain health system conditions to access the funds. The funding mechanism involves reinsurance and proceeds of ‘catastrophe bonds’ (capital-at-risk notes) issued by the International Bank for Reconstruction and Development purchased by insurance-linked securities and catastrophe bond investors, with development partners and international agencies covering the cost of the premiums and bond coupons. As a new financing mechanism drawing in development funds the trigger criteria for funding and reforms to be incentivized, as yet unstated, need to be carefully reviewed.

G7 countries are presently encouraging G20 countries to financially back the PEF and its insurance agenda this September in Hangzhou. But what of the CFE? It covers a wider spectrum of public health risks, fits most comfortably within the IHR framework and aligns more clearly with efforts to strengthen core IHR capacities and national response plans. How far will the PEF, despite its role to fund the ‘deeper’ response, strengthen the health systems to be more effective in detecting and responding to emergencies, and even more importantly in preventing them. How will the PEF explicitly strengthen capacities for the IHR, provide direct funding support for system capacities and align with existing national plans and intergovernmental frameworks? How far will both funds strengthen the community literacy, networks and capacities and the primary health care systems that are needed for effective prevention, preparedness and containment, or link with the rising mobilization of resources and personnel from within Africa, noting the significant role these played in the last major Ebola epidemic.

The addition of new global resources for managing public health are welcome. However, global measures need to reach beyond measures for surveillance and containment if they are to stretch beyond a remedial securitization of global health. Securing health calls for local, national and regional capacities for and global investment in systems that can identify, prepare for, prevent and manage significant public health risks, and for a re-invigorated public health authority and capability to mobilise attention to those communities and action on those key determinants of health that are often ignored, until the onset of such mass scale events.

Please see the full brief at http://tinyurl.com/jsgsgnh and send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.

We need to understand beyond what the numbers show to improve health systems
Editor, EQUINET newsletter

The barriers researchers face in having qualitative research published in many mainstream health and medical journals is limiting our understanding of important dimensions of health care. At a time when health systems are increasingly involving a range of disciplines in health teams and using more holistic models to respond to the mix of physical, psycho-social and environmental factors that lead to ill health, excluding qualitative work deprives decision makers of a significant body of knowledge that could inform decision making on health systems. “Furthermore, this effectively silences the voices of community members, particularly those who are marginalised across all countries”.

So argued 170 co-signatories from all regionals globally of a letter from the Social science approaches for research and engagement in health policy & systems (SHaPeS) thematic working group of Health Systems Global, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), and the Emerging Voices for Global Health. The full letter was published in June in the International Journal for Equity in Health and can be read at http://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0368-y

The signatories raised that many issues that affect both the effectiveness and equity of health systems cannot simply be ‘measured’ by numbers alone. Issues such as the subjective relationships and communication between health workers, clients and communities, the perceptions of and trust in services, the role of social literacy, or the values and preferences that managers, health workers and communities bring to systems affect health outcomes and therapeutic relationships. One young researcher argues in the letter that qualitative work “facilitates my understanding beyond what the numbers show”.

Researchers in east and southern Africa have in past EQUINET forums voiced similar views. They have raised the difficulties they face in publishing generally, not only in meeting the format, style and other demands of a journal paper, but also in finding the time for the process, given competing time pressures. Those working with qualitative research appear to face even higher barriers. The signatories to the letter stated “We are particularly disenchanted by our general experience of the limited and often inadequate publication of qualitative research in the major health and medical journals, and the resultant loss of important insights for those working in, or concerned with, health services and systems, including around clinical decision-making”.

For those working with participatory approaches the barriers can seem even more insurmountable. At a 2014 regional workshop on participatory action research, researchers raised that most traditional journals - and many funders - do not understand or appreciate these approaches. One researcher, from Malawi, described that despite his research leading to real changes, publishing it was an uphill task, calling for constant efforts to make to justify the approach, the role of community members as partners in the research and the use of subjective or qualitative evidence. Indeed in another article in this issue of the newsletter the authors comment: "research and publishing is the oxygen of academic life. But the regimes of control that surround contemporary approaches to publishing are choking creativity..."

The letter published by the health system researchers argues for methodological diversity in mainstream publication on health systems research, to build a more holistic and richer understanding of complex systems. Given the multiple factors, including subjective, dynamic and social factors, that influence health and the way services are delivered and experienced, it would indeed seem to oversimplify reality to give singular dominance to the old maxim that “what is measured counts” at the cost of the wider range of methods and lenses that we have to explore, analyse, and understand what counts.

The full letter referred to in this editorial was published as SHaPES, EQUINET, Emerging voices for global Health, Daniels, Loewenson et al., 2016, International Journal for Equity in Health 15:98 DOI: 10.1186/s12939-016-0368-y. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org or to the SHaPES working group in Health Systems Global http://www.healthsystemsglobal.org/

Learning from regional work on health centre committees
I Rusike, T Nkrumah, C Chimhete, F Kowo and E Mutasa, Community Working Group on Health

Health Centre Committees (HCCs) are a mechanism through which community participation can be integrated into the health system to achieve a sustainable people-centered health system.

These community-based committees are increasingly becoming an established voice of the communities providing input into the health service delivery processes in the 16 East and Southern Africa (ESA) countries covered by EQUINET. In the Ngombe area of Lusaka, Zambia, for example, the Neighborhood Health Councils with local government have successfully addressed water and sanitation, garbage and housing concerns. In Kenya, Health Facility Committees manage funds from the Health Sector Services Fund for primary care, outreach and community based services. They link the facility with the community, to plan and oversee the performance of the services.

In a regional dialogue, delegates from ESA countries urged national authorities to better recognize and work with HCCs. Their recommendations, captured in EQUINET Policy Brief 37, included reforming public health laws to include provisions for participation and public information and to set laws that provide for the roles and duties of HCCs, backed by adequate information, training and resources for them to play these roles.

To advance these recommendations a consortium of organizations have come together in EQUINET to build and strengthen the capacity and effectiveness of HCCs, led by the Community Working Group on Health (CWGH) in partnership with the Training and Research Support Centre (TARSC) on photovoice and information sharing; University of Cape Town (UCT) School of Public Health on training programmes; and the Lusaka District Health Management Team (LDHMT) on legal provisions. With work in Kenya, Zambia, Malawi, South Africa, Uganda, and Zimbabwe and at ESA regional level, we are advocating for policy and legal recognition of HCCs, giving visibility to their roles as well as identifying and strengthening the different capacities that committees, communities and the health systems need for HCCs to implement these roles. This includes areas such as tracking and monitoring health system budgets and resources and their use and health system performance as well as the building social dialogue and accountability.

As part of the work, UCT in South Africa is building a database of information on the current training materials and training programmes for HCCs to enable us to share materials, skills and experiences on capacity building in the region, and to advocate for HCC training that addresses their roles comprehensively. and their coverage of the key areas of functioning. LDHMT in Zambia has initiated an in-country process to review the laws and regulations that provide for the establishment and functioning of HCCs, and to document the Zambia experience for wider regional exchange. In Zimbabwe, the CWGH has supported the HCCs to engage with government, so that HCC members can speak out about their concerns on the health system and on the support they need to successfully implement their roles. Training on community photography by TARSC means that the members have visual tools as well as words to raise evidence on their problems and progress.

Most ESA countries still do not have laws that explicitly or adequately recognise the functioning of the HCCs. We are thus advocating for their legal status and for them to have constitutions. This is important for their accountability to communities. It is also necessary if they are to directly receive, manage and account for public funds as was the case with Neighbourhood Health Committees in Zambia in the 1990s. The HCCs’ current vague mandates weaken their effectiveness, role and legitimacy, for communities and local actors and at national-level. We are thus sharing information on HCC constitutions, and on laws, statutes or guidelines on HCCs in the region and promoting their inclusion in law, including by showing their important positive role in the health system.

As a consortium, we are building a regional database of institutions and organizations working with HCCs in ESA countries so that we can better exchange and share information on the training materials, programmes underway with HCCs and the learning from them. We invite colleagues to send information to EQUINET if they are working in this area. We are building innovative ways of sharing and learning from our work, that build more direct voice, such as through photovoice where cameras are being put into the hands of communities and HCC members to identify and document community perspectives, experiences and actions related to their health conditions to be used in local HCC dialogue and wider reflection and learning.

Members of HCCs are carrying out exchange visits to allow for more direct learning and collective understanding of problems and achievements, creating inspiration to keep working and resulting in the launch of new initiatives.

We have seen evidence of the positive impact of HCCs in improved health outcomes. In Zimbabwe for example, since 2009, HCCs have played a role in in decision-making on the use of performance based funds at clinics, promoting improvements in facility-based deliveries, improving uptake of antenatal care and postnatal care visits and supporting demand by communities for these resources to be used to ensure delivery on patients’ rights at clinics. They have also mobilized resources to develop clinics such as by building waiting mothers’ homes, fencing clinics, supporting community health workers and raising advocacy on the needs of local services at higher levels.

We are seeing an increasing appreciation of the role of HCCs in community and primary care health interventions, with increasing attention and support from government, international and national partners. Our HCC in-country exchange visits are proving to be an effective way of sharing knowledge and good practice, inspiring others to see their own potential and act when they see the practical successes of other HCCs. “HCC exchange visits are rich in knowledge and should always be a key part of HCC activities carried out at local, district, provincial and national levels,” said Brighton Ngoteni, the HCC chairperson of Mudanda Clinic in Manicaland, Zimbabwe.

Our regional exchanges have also shown us that HCCs can only be as strong as the communities that support them. For this, we need to have recognition of the right to health, including on constitutions in the region, and comprehensive primary health care approaches that support health literacy and that inform communities, include communities and the views they bring in plans and services and give feedback to the communities for a people centred approach to universal health systems.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org and find further publications on the issue on the EQUINET website at www.equinetafrica.org

Critiquing the Concept of Resilience in Health Systems
Stephanie Topp, Walter Flores, Veena Sriram and Kerry Scott

In social theory, the dominant state is known as the hegemon. In the 19th century, hegemony came to denote the ‘Social or cultural predominance or ascendancy; predominance by one group within a society or milieu’. However, commentators on power have also used the term to describe the power of discourse - particularly in the field of governance. In this note we wish to draw attention to, and challenge, what we fear is an emerging hegemonic discourse in the field of health policy and systems work - the discourse of resilience.

In the past five years ‘resilience’ has been increasingly applied in health policy and systems research (HPSR) to refer to the need for distressed health systems (micro or macro) to ‘bounce back’ from shocks. Often implicit in this discourse, is the assumption that such systems were ‘there’ in the first place, or at the very least, that with a concerted effort they can get there. What a resilient health system means in this context is not clear - but we contend that, in a form of technocratic reductionism, resilience strategies and solutions are often divorced from meaningful assessment of the political economy and power dynamics that produced the health system crises in the first place.

Health systems in crises suffer from chronic deficiencies in many things - material and human resources central-level planning and coordination capacity and domestic financing to name but a few. The populations and communities seeking services from these deficient systems are more likely to have low levels of education, weak citizen engagement and to experience deep class inequity. Much of the technocratic discussion around ‘building resilience’ appears to bypass these issues, however, often focusing on tweaking inputs or health system components, and frequently emphasising self-reliance and behaviour change. This technocratic and formulaic approach to building resilience is at odds with the complex reality of health systems in each country.

‘Building resilience’ rarely seems to involve a direct examination of, or challenge to, the structural conditions that contribute to overarching health system dysfunction, including historical colonial legacies, current trade and aid structures, tax and health insurance structures. We are concerned that the discourse of resilience will follow the trend of global health policy reforms being fuelled by the perceived immediacy of a problem instead of careful analysis of root causes and strategies likely to prevent recurrence in the long-term. Recent examples include the Ebola epidemic and now Zika, in which resilience discourse is getting close to that of the global health security agenda in which the main concern is transnational epidemics from the south to the north. The rise of hegemonic resilience discourse has effectively enabled global health stakeholders to replace the conversation about systemic failures at multiple levels which supports a far more long term vision, with an action-oriented discourse that implies much shorter time-frames.

A conscious discussion is needed to reframe what the health system community means when we use the term ‘resilience’. Resilience and the linked concept of sustainability of health programming have value, as long as they are not divorced from the material changes that need to occur to support them and the requirement for a more balanced relationship among national states (trade, flow of resources, and others). Use of these terms should build on previous work and consensus around social determinants of health, right to health and people-centered health systems. This means resilience should be situated on a continuum rather than replacing important advances around health systems and its relation with equity, fairness and human rights.

Ultimately, we contend that a more ambitious and nuanced application of the term ‘resilience’ is required if the term is to contribute to improving LMIC health systems’ capacity to withstand political, financial, epidemiological and environmental shocks. We must also do everything possible to prevent such shocks in the first place. But at the very least, we in the health policy and systems community need to start acknowledging the dangers of using ‘resilience’ as part of a de-politicised and technocratic discourse.

This piece was first posted as a blog for Health Systems Global (HSG) http://tinyurl.com/j968dqc. The authors are thematic leads of the cluster on Power in Health Systems in the SHaPeS Technical working group of HSG. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.

Implementing the International Health Regulations cannot just be about epidemic emergencies
Rangarirai Machemedze, SEATINI, Rene Loewenson, TARSC

Successive epidemics of international concern such as SARS, Ebola, Zika have raised the focus on responses to health emergencies, as ‘global health security’. It has also given new attention to the implementation of the International Health Regulations (IHR), including as an agenda item in the World Health Organisation’s 2016 World Health Assembly.

The IHR were adopted globally by member states in the WHO in 2005, including by all 46 countries in its Africa region. They seek to prevent, protect against, control and provide a public health response to the international spread of diseases “…in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” Countries were required by June 2012 to have developed core public health capacities for surveillance, reporting on and response to public health risks and emergencies, including at ports of entry. This includes capacities to provide specialized staff, multi-sectoral teams and laboratories and local investigations to prepare for, prevent and rapidly contain and control cross border public health risks that may be due to infectious diseases, food safety, and to chemical, radiation and zoonotic hazards. Countries unable to meet these core capacities by June 2012 could request for an extension to 2014 and in exceptional circumstances to June 2016. So we are now a month away from the time all countries were expected to have achieved these core capacities.

These capacities are not delinked from the core capacities needed to protect public health within countries, nor from comprehensive primary health care approaches that seek to engage all sectors to promote health and prevent ill health. Within countries, these capacities are not just a matter for the health sector. They call for society, state, private sector and non-state organizations to promote public health. For example, preventing communities living near mines from being poisoned by arsenic or mercury contamination of water, soil, and food calls for intervention from local authorities, planners, mine managers, state sectors responsible for infrastructure, mining, environment, health and labour, workers and communities. This includes workers and families who migrate from other countries to work on mines and who may otherwise return with long term lung, gastrointestinal, neurological or renal problems. While focusing on cross border risks, the presence of uncontrolled environmental risks, or of cholera, typhoid and other epidemics within African countries is not unimportant for the IHR, and certainly not for people in that country. These problems signal weaknesses in public health that may lead to risks spilling across borders. They may also arise from trade or economic determinants that are international in scope.

Hence, as we approach June 2016, while there has been progress in implementing the IHR, it is a matter of concern that there are still deficits in the core capacities. An October 2015 WHO report compiled feedback from 118 of 196 States Parties to the IHR on a self-assessment questionnaire on progress made in developing these core capacities. It showed that progress had been made globally in legislation and policy; coordination and collaboration with other sectors; improved detection, early warning, preparedness and emergency response capacities and in communication with the public and to stakeholders.

For the African region, reporting by March 2015 showed that African countries were also making progress on a number of core capacities. Not surprisingly given the responses and investments after the Ebola epidemic, the most notable improvements were in surveillance and laboratory capacities. Improvements in these areas are seen to be essential for early warning system for detection of any public health events for rapid response and control, to prevent them spilling over borders. There has been investment in surveillance and laboratory capacities in Africa through an Integrated Disease Surveillance Response, and international support for African and sub-regional communicable disease control centers for detection and early warning of infectious disease risks. There has, however, been less progress in preparedness, in capacities at ports of entry, and in capacities to deal with chemical and food safety risks. It suggests that while the region may be better prepared to deal with infectious disease epidemics, this may not be the case for other public health risks.

The progress suggests that the global health security agenda has given great focus to control of infectious diseases and ‘biosecurity’, not least as a response to the international spread of recent epidemics of Ebola virus and Zika virus. Significant new global resources are being mobilised for emergency responses. Assessment tools and reporting systems are being discussed in the WHO, with some proposals for new global mechanisms, global financing facilities and independent assessment by global actors.

However global health security cannot be reduced to emergency responses and infectious disease control, nor can the prevention of cross border disease be delinked from the measures taken from local to national level within countries and between countries in their regions to strengthen the primary health care and public health functioning of health systems. Uganda was able to respond to its 2000 Ebola epidemic within two weeks from first case to confirmation and controls being implemented. This speed of response was as much to do with the strength of systems within districts and the strength of communication between local and national levels of the health systems as the sophistication of its laboratory capacities. The spread of cholera and typhoid epidemics in Africa draws more from inadequate investment in safe water, sanitation and waste management systems and weak public health inspection than from gaps in emergency preparedness. New viral epidemics are emerging as poor communities and animal vectors are being squeezed into closer proximity by mono-cropping and mining activities; and new emergencies such as rising antimicrobial resistance are deeply embedded in how health systems function and interact with the public and with the pharmaceutical industry. Rising levels of chronic conditions in many African countries that foretell a future crisis of escalating unaffordable costs for countries and households are contributed to by cross border trade in harmful processes and products.

The global health security agenda cannot thus be narrowed to one of emergency responses to infectious disease. Instead, global health security also needs to identify and act on the determinants to prevent such emergencies. The IHR as an overarching umbrella for international public health obligations recognises this. So too, in their intent, do the Sustainable Development Goals. While many determinants of global health security lie outside the health sector, and while resources are indeed needed to deal with emergencies and their economic and social impacts, a health sector response to preventing and controlling emergencies needs to link with and support longer term health systems strengthening. This starts locally, within countries and particularly with the comprehensive primary health care and public health approaches that are needed to identify, prevent and manage risk before it grows into an emergency.

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

Announcement on the newsletter and website

The EQUINET website and bibliography and newsletter databases will be undergoing a significant software upgrade in February 2016 so we will not be producing a March issue of the newsletter on 1 March 2016. We hope we have given you alot of interesting material ranging from papers, reports, bibliographies, online books and graphics in this issue the meantime and the newsletter will resume on 1 April 2016. We aim to ensure that any periods in which the bibliography databases will be unavailable during the upgrade are as brief as possible. Please email us on admin@equinetafrica.org if you have any queries or feedback, and we also look forward to receiving submissions, reports and articles from you!