In September this year the civic centre of Harare was buzzing with the sound of music and discussions, markets, installations, workshops and multiple activities. It was Shoko Festival time, and the museum, library and other civic buildings transformed into a magnet for young people to get away from the stresses of our shrinking economy and nourish our creativity.
Shoko festival is one of Zimbabwe’s fastest-growing international festivals and over seven years has grown into a major cultural event. The festival this year was held at a time when many are struggling with the socio-economic problems brought about by the myriad of problems in the economy. We wondered – is art a luxury at such a time? What can it contribute to improving our wellbeing in a harsh climate?
Our experience at the festival indicates that it is anything but a luxury!
This year’s festival was held with the theme ‘YOUtopia’, as a vibrant creative space in which people could explore and imagine the qualities they seek for themselves and their community or society. So we took advantage of the space and theme to take a discussion that we have been having as young people on what kind of city will improve our wellbeing to a wider audience.
In the past year as a group of young people in the Civic Forum on Human Development from diverse settings and suburbs in Harare we have been working with the Training and Research Support Centre in EQUINET to understand what is driving the inequalities in health in our urban areas, at least for ourselves as young people. With our health services often focused on treating diseases, we took a wider lens to build a more holistic understanding of what will promote our health today and in the future. In our own discussions we identified issues that go well beyond the scope of health services, including the way our cities provide spaces for us to create jobs, the green spaces and access to internet that we need to meet, connect and exchange ideas, and the access to urban land we need to have to grow food and build decent housing. We looked at how these issues are being addressed in other parts of the world and found a lot to inspire us on how we could do things differently here in Harare.
So we decided to participate in the Shoko festival with a stand on “picturing our urban futures” to hear and see what other young people thought. Over two days we explored what kind of city people, especially young people coming to Shoko festival wanted to live in? How did they imagine things could be different in ways that promote their wellbeing? We had an art table, where people drew in one half of the page features of areas they live, work or meet in in the city as they are now, and in the other half how they would like them to be. We had postits where people wrote short text on what they thought was affecting their wellbeing or what changes they wanted to see in for our cities to promote our wellbeing. We discussed what people saw as the different aspects of their wellbeing.
We had no rules and gave a free space and materials for young people to draw or write or say what they thought. Many youth preferred drawing their views than writing or talking.
By the end of the two days there were pink, yellow and green postits all over the glass wall on one side of the stand and artwork of all colours filling the wall on the other side and young people talking in between. We were surrounded by the analysis and the possible, in a space youth culture that radiated positive activism and ideas. Shoko is about celebrating positive youth culture that is trending and relevant in the cities that has been associated with hip-hop, dancehall to spoken word and comedy as well as graffiti and cutting edge ideas on how to use new media and technology.
The drawings were clear and the statements were short but full of meaning: “litter free and free wifi!” “a violence free city”, “ a safe city”. The tensions were economic, but also environmental and many were social or linked to mental stress.
The art work and postits highlighted how young people vision a different urban future to overcome the significant differences in opportunities for wellbeing that currently exist and to ensure that our cities work and promote health for all. Many showed how much mental stress is caused by bad conditions like public transport systems where touts push people into overcrowded combis, and how much people want to live in communities free of violence and of rising piles of waste and litter.
The art and postits showed the desire to move from roads with potholes, traffic congestion and chaos, environments with rubbish and poorly maintained parks to one where public spaces, roads and transport are safe and clean. Rather than have cities where the best buildings are for private finance and vendors compete for space with pedestrians, they visioned cities where the best buildings are for community processes and economic activities. They indicated that cities need to enable people to work and create jobs, including by giving access to free wifi, and people should have community spaces to gather and exchange views.
Are these visions of the future utopic? We don’t think so. They are a feasible, practical vision of what we should be demanding, contributing to and achieving for all in our cities and would do more for our health and wellbeing than all the medicines we consume.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
Editorial
As global leaders prepared for the G-20 Summit in Hamburg, they prioritised efforts to build functioning health systems “as a prerequisite for safeguarding disease outbreaks.” This is vital as the world prepares for the next Ebola-like emergency, but the organizational stress that comes with these shifts in priorities also requires attention if those efforts are going to succeed. Any attempt to strengthen health systems must take seriously well-recognized stressors such as increasing workloads, changing health needs, resource challenges, and less-often identified but routine challenges. Critical amongst these are the stresses posed by managing people and relationships in the uncertain contexts that are the norm for health systems.
Introducing new and revised policies is a major part of this chronic stress, even with the best intentions. The constant, and sometimes unconsidered, imposition of new initiatives and ideas on national health systems places great pressure on those working at the front lines of health care delivery and community engagement. Policy changes may include new treatment guidelines and protocols or quality assurance processes, as well as revised human resource and financial management rules, guidance on management structures such as community committees or new planning processes. New policies are often implemented in a top down manner through the hierarchy of public sector bureaucracy. Often, they are implemented without preparation or adequate information sharing. In addition, new policies frequently come hand in hand with rigid accountability mechanisms — such as those linked to results and performance-based financing or to targets set for health programs, or to finance-linked audit processes that are part and parcel of “good governance” strategies.
These types of accountability mechanisms contribute to creating a “compliance culture" that undermines the managerial flexibility needed to problem-solve and deal with chronic stress or acute challenges. All generally come with yet another new reporting requirement. In fact, the amount of reporting done by frontline health workers in countries such as Kenya and South Africa is simply astounding. As a result, health workers battle to cope with changing demands from managers and communities, whilst remaining poorly supported and resourced.
So, what do global leaders need to do to nurture everyday resilience in the face of chronic stress — and so also strengthen health systems?
First, they need to understand that the "personal" is absolutely integral to a functioning and responsive health system. Without emphasis and acknowledgment of this, efforts to strengthen health systems will be futile. Managing human relations is identified by public health system managers in Kenya and South Africa, including primary care clinics, as a constant challenge in their jobs, and one for which they rarely have adequate training, acknowledgment and resources. Constant policy change can undermine relationships, and is part of the wider organizational change commonly experienced by health systems. From the radical devolution of public management in Kenya in 2013, to the continuing processes of change experienced in South Africa since 1994, organizational change creates an unstable environment that makes managing other challenges — of people and resources — even more difficult.
Second, and most critically, global leaders must pay attention to how they engage with health systems. They should exercise their power much more cautiously than currently and in ways that empower others to lead and take action. They need to support national and local organizational capacity to problem-solve, motivate, and learn. The “Thinking and Working Politically” and “Doing Development Differently” networks call wholeheartedly for global leaders to take heed, by refraining from imposing rigid blueprint approaches and paying “far more attention to issues of power, politics and local context.” Ultimately, strong health systems depend on communities, health workers, managers, researchers and other local stakeholders being empowered to respond to the inevitable, future waves of change we all face. At Health Systems Global, our members represent these multiple groups.
Strengthening everyday resilience demands that we all — governments, donors, researchers, communities, health professionals — work with the resources that health systems already have — their people and relationships. This must be done as we take wider action to confront inequality at all levels. If we do not do that, then efforts to safeguard disease outbreaks will be meaningless.
This oped was originally produced as a blog for the G20 summit in July 2017 and was published on the Devex website and the Resilient & Responsive Health Systems (RESYST) website. For further information on this research programme visit http://resyst.lshtm.ac.uk/.
There is increasing global focus on building resilient and responsive health systems to improve population health. It raises questions: What constitutes a resilient health system? Is it one that is able to absorb shocks? Is it one that is able to anticipate shocks and engage with their political and economic determinants? To what extent has this language of resilience enabled an approach towards sustaining health systems in the most economically efficient manner feasible, with minimal public sector investments? And what does this mean for people’s rights to health?
A retrospective look at lessons from key moments in health policy, research and practice sheds light on some of these concerns. Key documents such the 1974 Lalonde Report, the 1978 Alma Ata Declaration on Primary Health and the 1986 Ottawa Charter from the first International Conference on Health Promotion focused policy attention on health systems built on prevention of health problems and promotion of good health. The Alma Ata Declaration emphasized investments in primary health care and highlighted that people have a right and duty to participate individually and collectively in the planning and implementation of their health care. The policy focus moved away from medicalized health systems to more inclusive ones, with community-engagement based on human rights principles.
There was however a shift in health policy from the last 1980’s. Primary health care approaches and health promotion strategies were criticized for being unmanageable, lacking clear measurable targets and being costly to sustain. Alternative, selective approaches were advanced, focused on specific diseases and measurable, cost effective interventions. Disease specific programs grew for key areas such as HIV and AIDS, tuberculosis, malaria and maternal health, with funding mainly targeting these programs. Funding and incentivizing disease specific intervention targets carries the risk of weakening wider primary health care measures, including for community participation in health decision making. A disease focus can ignore determinants of epidemics and other ‘neglected’ diseases, and set up parallel programming siphoning key health personnel from the wider health system to the better resourced diseases specific projects. These effects lead to health systems that have weak links to communities and wider health problems, that are neither resilient not responsive and that leave people exposed to outbreaks of epidemics, such as Ebola virus disease and cholera.
The mindset of efficiency over-riding other considerations in health systems was heavily reinforced in the late 1980s and early 1990’s, when the World Bank and the IMF introduced neoliberal structural adjustment programs as a condition for loans. The major budget cuts to the social sectors, including health, from these programmes are well documented. Economic models that imply that public expenditure on systems and social roles is wasteful or inefficient combined with a pressure of reduced public funding for health services, as reported in EQUINETs regional equity analyses in 2007 and 2012, reducing investment in comprehensive primary health care despite its pro-poor benefit and reinforcing the narrow disease focus. It also enabled the health sector to be judged by the same principles as other areas of the market, within development frameworks that heavily promoted the ‘free market’, despite the global market being anything but free. At national level, poverty reduction strategy papers that were seen as dealing with ‘transitional poverty’, segmenting it as an unfortunate by product of an essentially positive approach, metamorphosed into national development plans that conceptualised national health policies and strategies more from an economic than a public health perspective.
As raised in various reports, including by EQUINET, Oxfam and the Municipal Services Project, and by S Nishtar in her submission to the 2016 World Economic Forum, this mindset has opened the doorway in the current decade to the commodification of our public health systems in the market place, and in some settings to the sale of public assets or private sector roles that have commercialised the provision of health care and deepened inequities. The effect has been to slowly but surely weaken the role of the state in resilient and responsive health systems. It is therefore not surprising that the private sector role is growing in our health systems in the region, whether in terms of provisioning of services, or in the heavily promoted role of social health insurance and even voluntary and community health insurance (rather than mandatory insurance or taxes) as a vehicle for service funding, with the untested promise in the region of more resources and more efficient funding. As private actors have gained an increasing role in our health systems, they are also giving increasing voice to the private sector in health agenda setting at national and global level, most recently raised in the debates on the Framework for engagement of non-state actors in the World Health Organisation. It is thus not surprising to find that the current proposals on universal health coverage that we hear in the region are dominated by business models centred on health insurance rather than human rights principles.
These trends raise a challenge for us: To carry out research that critically interrogates that assumptions and paradigms introduced into our region and to explore how to defend and advance comprehensive primary health care and human rights based approaches in health systems. This implies more questioning from the region at global level of the assumptions that are driving this role of the market and the private sector in our health systems, and what implications it has for rights-holders and duty bearers. This has two evident implications: it implies that we cannot continue to allow a retreat of the state from the health sector, whether in terms of diminished funding, weakened regulatory power, public health services or participatory governance. It also implies that we bring communities, their rights and evidence, more centrally into the setting of policies, priorities and in shaping services, not simply as a means of taking on unfunded service burdens, but as the central resource for the state and public sector in building resilient and responsive health systems.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
The EQUINET newsletter intends to raise the visibility and accessibility of evidence about and from east and southern Africa on different aspects of equity in health. Now in its 197th issue, it has since its inception shared a total of nearly 12 000 papers, articles, resources and other information on and from the region on areas related to health equity.
Launched in May 2001 by EQUINET from within the region and appearing monthly for the sixteen years since then, it has included new knowledge and evidence on a range of areas, from values, policies and rights, financing, health worker issues, clinical and health service practices through to health determinants and governance that have a bearing on improved delivery on policy commitments to equity in health. Thank you to the many people generating evidence and debate on these areas and to those who have helped the newsletter to be a consistent vehicle for sharing this information.
While it appears monthly in members’ email boxes, what may be less well known is that the current database of 11 500 articles compiled over the years on the EQUINET website is a resource that can be searched by themes and by title, author or text key words, to support research and evidence for social and policy dialogue.
This database may itself be an interesting source of evidence for those reviewing policy trends in the region. While it provides an accessible source of specific information for people working on equity in health and its determinants, it may also provide an interesting insight into the rise and fall of attention to specific issues in the region, from HIV and the retention of health workers, to emergencies, chronic conditions and universal coverage. Some areas, such as gender equity, poverty and social participation in health, have also had persistent presence since the first newsletter in 2001, albeit with less visible focus and with different lenses and perspectives. For others, such as privatisation and the public-private mix of health services, there appears to have been a deficit in attention, with far less open access publication, despite their importance for health equity in the region.
The sixteen years of the newsletter also provide an insight into the changing nature of evidence. In 2001 there was a predominance of formal publications in journals, reports and print media. This continues, with a slow improvement in journal papers being led by authors from within the region. Today, however, there is a more diverse mix in the forms of evidence, adding an increasing presence of blogs, videos, talks, photojournalism and art forms. This has brought new voice to the evidence and analyses on health equity, although many still face barriers in access to digital media.
We’d like to hear your voice.
As we head towards the 200th issue, let us know where the newsletter has been useful to you and what improvements you would want to see.
For our 200th issue, we invite you to send us in August and September 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 (whether generally, or on a specific aspect), and how and by whom they could be taken forward.
Please send feedback or queries or editorial or url links to information to the EQUINET secretariat: admin@equinetafrica.org
A group of senior scientists—researchers, academics and intellectuals—from various parts of the world, with over 250 years’ combined experience of working to improve the oral health of communities, independent of any institution, government body or corporate entity, met in Colombia in March 2017 and prepared a statement on their analysis of the problem and recommendations about what should be done. This editorial presents paragraphs extracted from the statement. The full statement, referred to as La Cascada Declaration, together with associated papers, is available at https://lacascada.pressbooks.com/front-matter/introduction/.
We are concerned that the dental profession, worldwide, has lost its way.
Despite current knowledge of the causes of oral diseases, globally most people continue to experience significant levels of disease and disability. Although technological and scientific developments over the last 50 years have contributed to improvements in the quality of life for some, oral diseases continue to cause pain, infection, tooth-loss and misery for a vast number of people. While in many middle and high income countries, there have been marked overall improvements in oral health, oral health inequalities both between and within countries are now a major problem. The overall improvements in oral health have been the result of general improvements in living standards and conditions, changing social norms in society (improvements in personal hygiene and reduction in smoking) and the widespread use of fluoride toothpastes, rather than due to the clinical interventions of dentists.
Globally the profession has had little direct impact on the scale of the problem. Clinical interventions account for only a small proportion of improvements in the health of populations. This is as true of oral health as of general health.
The world has witnessed significant growth in social inequalities between the rich and the poor. …Austerity policies worldwide (commonly referred to as ‘structural adjustment programs’ in the global South) have diverted social and welfare spending away from the public to the private sector in the belief that ‘the market’ can meet social needs, despite evidence to the contrary. This has led to the creation of a two-tier health service—one for the rich, and the other, limited and often of poorer quality, for the majority.
Corporations and insurance companies are increasingly taking over the provision of health services, including dental services, in many countries. The treatment regimens that they promote are designed more to ensure adequate returns on investment for their shareholders than to improve the health status of the community, resulting in a tendency for the provision of excessive and sometimes inappropriate treatments.
Major food and beverage companies continue to promote the consumption of refined carbohydrates, free sugars in drinks, confectionary and in processed foods, even though these are major contributory factors for dental decay, not to mention obesity and diabetes. Advertisements of these products frequently and unjustifiably imply health benefits.
We believe that the dental profession, as presently constituted, is inappropriately educated for dealing adequately with oral health problems faced by the public. In many countries, there is an overproduction of dentists, most of whom provide services only in the main urban centers where private practice is more lucrative and services often fail to reach those in more remote areas of the country. In some cases, overproduction results in unemployment.
While there is no doubt that the intention of the profession is to improve health, commonly used treatment regimens for tooth decay (drillings and fillings) and gum diseases (scaling and polishing) do not by themselves arrest or control their progression. Furthermore, filling teeth inevitably leads to a cycle of replacements of increasing size, ultimately shortening the life of the dentition.
Dentistry is drifting, it seems, away from its task of prevention and control of the progression of disease and of maintaining health. The mouth has become dissociated from the body, just as oral health care has become separated from general medicine.
We believe dentistry is in crisis. Things must change.
Since clinical interventions account for only a small proportion of health improvements, the dental professions should be in the forefront of efforts that call for a reduction in income disparities and for a more just world in which everyone has access to resources and conditions for good health and well-being. Those industries whose products are harmful to health, especially producers of free sugars in foods, drinks, and producers of foods containing refined carbohydrates, should be required to label their products as harmful (just as has been done in many parts of the world in relation to tobacco and alcohol). The decline in government spending on the social sector cannot be justified in the light of excessive expenditures on war, the military, arms and other destructive initiatives. Corporations and industry should not be permitted to unduly influence research or clinical practice.
The dental profession is over-trained for what they do and under-trained for what they should be doing. Control of the most common oral diseases requires relatively little training and could and should be performed in most cases by community healthcare workers. Demonstration projects on the effectiveness of such approaches are needed.
Dentistry should become a specialism of medicine, just as ENT (ear, nose & throat), ophthalmology, dermatology, etc. are specialisms of medicine. As such, oral health physicians would be responsible for providing leadership of the oral health team, in the management of advanced disease and the provision of emergency care, relief and management of pain, infections and sepsis, management of trauma, diagnosis and management of soft-tissue pathologies and, where justifiable from the point of view of the maintenance of health, interventions to re-establish a functional dentition and orofacial reconstruction. Since the management and control of most common diseases could be undertaken by primary healthcare workers, a relatively small number of such oral health physicians would need to be trained. In addition, a relatively small number of public health dentists would be needed to coordinate oral health needs assessments, implement and evaluate community-based oral health improvement strategies and to act as oral health advocates to ensure the closer integration of oral health into wider policies.
The implications of the above recommendations are obvious: changing dentists into oral health physicians necessitates thorough revision of the education profiles of dental schools: an overhaul of the current curriculum for training of dentists; a reduction in the number of dentists trained; and an improvement in the quality of courses, especially ensuring that training is linked to the needs of the population.
The current state of dentistry worldwide is dire. It requires radical solutions. This short declaration has been produced to stimulate discussion about what needs to be done in the interest of the health of the majority of humankind. We recognise that the changes may take time to implement. Each country will need to assess how best to bring these about.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
The World Health Organisation has its first ever director-general from Africa, after the election of Dr Tedros Adhanom Ghebreyesus, the former Ethiopian health minister, who will begin his term in July 2017. In a speech to the World Health Assembly Dr Tedros Adhanom talked about growing up in Ethiopia, saying he comes from a background of “knowing survival cannot be taken for granted, and refusing to accept that people should die because they are poor.” He spoke about the need for universal access to health care, a better response to health emergencies and the need to tackle gender-based violence, as well as threats to global health like climate change. He wrote in his application "“I envision a world where everyone can lead healthy and productive lives, regardless of who they are or where they live.” We look forward to contributing to what this implies for health equity, globally and in our region.
In front of us in one of our rural districts is a road accident with injured passengers including children. They are distressed - the local public hospital has no ambulance and they are trying to find enough money to assure the private ambulance service that they will be able to pay the fee before they will send the ambulance. The fee is more than they can afford, but if they don’t find someone to pay and get people to care quickly the injured people could have complications or suffer avoidable deaths.
This is not the only problem people who have emergencies face. Ambulances can take long to respond. Many ambulances too do not have basic equipment or adequately trained staff to take care of patients during transit, also complicating their recovery or risking fatalities in transit. Emergency departments are under resourced, without adequate equipment and staff to cope with the critically ill patients coming to them, including patients who have delayed seeking care until they have an acute emergency. In some countries in our region, a critical shortage of doctors and other skilled health workers has affected the quality of the response to emergencies. Yet in others, like South Africa and Uganda, ambulances are better equipped and staffed, and people arriving at emergency facilities find doctors and nurses on stand-by and ready to receive patients and give them prompt care.
This situation is compounded by conditions that increase the risk of traumatic injury. For example, the state of our roads in Zimbabwe’s road network raises concern, especially when they are further damaged by heavy rains and other climate disasters. Poor roads not only raise the risk of accidents, but also mean that ambulances cannot easily access patients in need. During the rainy season, rural roads become even more impassable, making access for emergency services even more difficult. While communities assist with emergencies where they can, local transport operators sometimes take advantage of poor conditions to overcharge desperate patients in need of acute care, including pregnant women, carers of sick children and elderly people. In the absence of adequate investment in roads and services, poor people pay the price. Allocating funds to improve road systems will prevent accidents and also make it easier for ambulances to reach emergencies. Yet in 2017, of the US$15 million that the Harare City Council said it needed to improve the road network in Harare alone, it received only US1.2m from the Zimbabwe National Road Administration (Zinara).
The situation may be even worse when air rescue emergency services are needed, as a key component of an effective emergency care system. Yet air rescue emergency services are an even more scarce healthcare resource, and as in Zimbabwe, the only public service for this may be the Air Force. There are private services for those able to afford the costs of private insurance or providers, but these are unaffordable for the majority, and thus only used by a minority of people.
In the common discussions on universal health coverage and emergency responses, it is important that we at minimum ensure availability, accessibility and affordability of effective and good quality emergency medical services for everyone in the public. Good quality emergency medical services provide an immediate response to a variety of illnesses and injuries and the treatment and transportation of people in health situations that may be life threatening. They should provide universal quality care to all those who need it at the time they need it to save their lives, prevent suffering or disability. Although the current situation varies from country to country in the region, for many this is not yet delivered.
The situation contradicts the fact that in Zimbabwe, as for seven other countries of the region, according to EQUINET policy brief 27, the constitution guarantees citizens the right to health care, including emergency medical services. Section 76 (3) of Zimbabwe’s Constitution states this as, “No person may be refused emergency medical treatment in any health care institution.” Of course no service would refuse care, but a situation of inadequate investment in affordable, accessible and good quality emergency services, including ambulances can be understood to be a form of denial, or refusal. The Zimbabwe Constitution makes this clear in stating that the state must take reasonable legislative and other measures, within the limits of the resources available to it, to achieve the progressive realization of this right. Whilst public emergency services offered by state-owned health institutions, the air force, the police and fire brigade are weak and poorly resourced, people’s rights are violated and they are exposed to high payments for private services, or worse still disability or death.
It is evident that this is a core duty of the state and must be adequately funded. When public emergency care services are not adequately funded, staffed or provided, it leads to a growth of commercial and privatized services. While this is a private sector response to demand, and can help to minimize morbidity and mortality if of good quality and properly regulated and monitored, it is not appropriate to rely on the private sector for this service, and leads to inequities in access to care. The driving force of private provision is maximizing profits and not the needs of the most disadvantaged members of society. A trend towards privatization of emergency medical services thus has highest burdens for the poorest, adding to the stresses in often tough economic environments of accessing services and meeting medical bills. A 2016 study by the Zimbabwe Coalition on Debt and Development on a public-private partnership in one major central hospital in Zimbabwe found that residents faced challenges in realizing their right to health care, due to the high cost of services, unfair treatment of those who cannot pay, ‘…deepening inequality between the haves and have-nots’ and report of corruption in the demand by staff for differing levels of cash payments. They attributed this violation of rights to health care to the ‘private vendor profit motive’ and diminished public control.
Beyond improving public funding of emergency care services, we can also take advantage of technology advances. For example, health facilities have used mobile phones to alert ambulance services and to support those attending to patients whilst waiting for an ambulance or medical personnel, improving the possibility of improved outcomes for patients. A ‘Dial-a-Doc’ initiative by one mobile operator in Zimbabwe works with enlisted services of medical practitioners at a call center to respond to phone-in requests for information and help from the public. A similar service is available in South Africa, Zambia and Malawi.
At the same time, we cannot keep relying on the health services to manage growing risks in the environments we live and work in. Death and disability from traumatic injuries from road traffic accidents on poor roads, from climate disasters and other accidents, and acute health crises in pregnancy, for children and others, and due to unsafe working conditions are largely preventable and should not be filling our health services. We need to have a commitment from all sectors that play a role to identify and reduce their role in traumatic injury and illness.
As economies improve they should show marked reductions in such trauma, but even under challenging economic conditions, adequate, affordable and accessible public emergency care services must be secured.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
The 2017 World Health Assembly (WHA70) will be held in Geneva from 22 to 31 May 2017. The agenda and initial documents are being made available at http://apps.who.int/gb/e/e_wha70.html.
WHA70 has a wide ranging agenda, including the election of a new Director General; the management of emergency responses and antimicrobial resistance; research and development (R&D) for neglected diseases; the capacities for and evaluation of preparedness for the International Health Regulations (IHR) 2005, migrant health; and the Sustainable Development Goals (SDGs), amongst other items. It will discuss progress in the implementation of resolutions from prior WHAs and the governance and programmes of the World Health Organisation (WHO).
The WHA is being held at a time when military conflict has terrorized populations and forced displacement internally and across borders, disrupting lives, livelihoods and food supplies, and heightening the risk of epidemic outbreaks. African migrants leaving due to conflict or to seek economic opportunity face many health challenges, including physical and psychological stress and abuse, and poor access health services. Migrancy affects transmission of infectious diseases, including to northern countries now experiencing warmer temperatures due to climate change. WHO has proposed migrant-sensitive health policies that incorporate a public health approach, with universal, equitable access to quality health services that would also assist in surveillance, detection and control of infectious and other health problems and financial protection for migrants. However, there is a wide gap between this and the situation in practice.
Progress has been made in the development of a vaccine against Ebola and control of the yellow fever epidemic in central Africa. The accelerated process for use of the former as an experimental vaccines in health care and frontline workers has raised ethical and equity concerns, while non availability of yellow fever vaccine stocks in the latter case led to fractional dosing (of one fifth of the normal vaccine dose) to stretch resources as an emergency response, which, as indicated by WHO, does not confer longer term protection and is not a measure for routine vaccination. These issues and a Zika virus disease outbreak recently reported in Angola from the Aedes vector responsible for transmitting dengue fever, yellow fever and chikungunya virus infections points to the need for strengthened public health measures to prevent, detect and control communicable diseases, within and across countries. Although much attention has been given to acute infectious disease emergencies, the rising level of non-communicable diseases (NCDs) in ESA countries, including trauma/injuries and cancers represents a major immediate and long term challenge, driven largely by conditions and policies outside the health sector, with health systems that are poorly equipped to detect, prevent and manage them.
These health threats take place against the backdrop of underfunded health systems and inadequate skilled health workers and medicines in our region, particularly in areas of high health need. While 18 million workers are estimated to be needed globally to achieve Universal Health Coverage and maintain pace with SDGs, by 2030 Africa is projected to have a shortage of 6 million health workers. Inadequate and increasingly costly medicines and health technologies undermine equitable access, in a global environment of growing microbial resistance and one that still raises investment, technology transfer and intellectual property barriers to development and production in areas of high health need. This directly links measures to combat antimicrobial resistance to those that ensure community health literacy and equitable access at affordable cost to good quality old and new antibiotics, vaccines and diagnostic tools, and measures for public investment in R&D, local production, pooled procurement and the lifting in practice of intellectual property barriers affecting public health.
There has been progress, particularly in emergency responses. For example, the WHO has set up a Health Emergencies Programme to co-ordinate emergency prevention and response; a collaboration agreement with the Africa Centre for Disease Control (AU-CDC) has stimulated work to build a regional health workforce for emergencies. Incident Management Systems have been established in a number of African countries to strengthen coordination of responses to emergencies and nine African countries have implemented Joint External Evaluations of their IHR core capacities. The WHO Contingency Fund for Emergencies and the Africa Public Health Emergency Fund have been established and have enabled quick response to zika, cholera and yellow fever outbreaks, although with challenges to address, including their alignment to national resources and delays in operationalising and slow disbursement of these funds.
This investment in detection and control of epidemics is welcomed, but the concern in the region is also to prevent epidemics from occurring in the first place. This needs continuous strengthening of health information systems and population surveys to map disease risks and burdens and assess vulnerabilities in the region, to raise and ensure that African priorities are planned for and responded to at local, national, regional and global level.
An East Central and Southern African Health Community (ECSA HC) April 2017 meeting of senior officials and technical actors with input from Geneva-based diplomats in the Africa Group of Health Experts noted that this calls for a pooling of efforts, to respond to emergencies, to co-ordinate R&D and to share capacities and experience in building integrated health systems. Such comprehensive measures recognise that health systems are not simply technical in nature, but signal our social values, including for example in the way migrants are treated, or in how the health workers in conflict and emergency zones are cared for and protected.
Delegates at the ECSA HC meeting called for integrated systems and a one-health approach, rather than a proliferation of new silo’ed vertical programmes and committees. Health for population groups like mothers and children or for settings like urban health should not be treated as another vertical programme, but addressed through making clear linkages with comprehensive health systems and ‘health-in-all-policies’. After a long period of investment in specific disease programmes, investments are now seen to be needed in the institutional arrangements, processes and information systems that support coordination, collaboration and integration of actions within health systems, with other sectors and within and across countries.
A focus on prevention demands action upstream, to map and identify risk and vulnerability and to control vectors and risk environments, both for infectious and non-infectious risks, including those related to chemicals, radiation and food safety. Integration calls for resources and strategies for prevention and response to epidemics and emerging challenges such as NCDs to be linked to broader measures applied to build robust, competent and comprehensive health systems that enroll and involve their communities. It calls for measures to reduce the costs of health technologies and treatment programmes, and to strengthen the independent country and regional regulatory agencies, databases and public health agencies needed to inform and support responses within and across countries.
This resonates with the WHO 2030 agenda calling for a One World One Health approach, that involves strengthening health systems for universal health coverage and inter-sectoral action for health. However two years from the declaration of the SDGs, it is surely time to focus attention on moving from pronouncements to what actions have been taken to implement the SDGs, particularly in terms of the public health issues that are a priority for the region. These are issues for whoever is elected as the new DG, whether from Africa or not. How far are the necessary actions being financed and delivered? What progress has been made in equitable development of and access to research and innovation? What progress is WHO making in reclaiming its leading role in health within the United Nations system, backed by the necessary increase in fixed contributions from countries to ensure its autonomy as global public health authority? What progress have countries made in improving progressive financing and reducing dependence on out of pocket funding? How far have all countries put in place the integrated, comprehensive primary health care oriented systems and public health leadership and capacities needed to meet these challenges and to progressively meet the right to health, leaving no-one behind?
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
The African Union (AU) African Mining Vision envisages a mining sector on the continent that contributes to the continent’s development, not only in terms of its economic growth, but also through mining processes that are “safe, healthy, gender and ethnically inclusive, environmentally friendly, socially responsible and appreciated by surrounding communities.” An increasing number of multinational companies from all regions globally are extracting mineral resources in east and southern Africa (ESA), but how far are these extractive industries (EIs) delivering on this vision of flourishing, healthy communities in their vicinity?
Notwithstanding the price fluctuations in the sector, EI exports have yielded significant returns, with oil, gas and mineral exports from the continent estimated in 2009 to be worth roughly five times the value of international aid inflows. They have, however, been associated with rapid but unsustainable growth and high levels of inequality, especially where they have limited forward or backward linkages into the national economy, and where they do not adequately invest in or protect the social and economic development of local communities.
A demand for socially responsible EI practice has already led to over 25 international standards, codes, performance standards and guidance documents from United Nations (UN) institutions, international agencies, including the International Finance Corporation, civil society and from business itself. The standards relate to business and human rights, to labour, health, environmental and social obligations, to socially responsible investment and practice and to transparency in governance of the sector. The international standards relating to health in EIs are detailed in a recent EQUINET report (Discussion paper 108) and policy brief available on the EQUINET website. As a condition for granting mining or prospecting rights, they cover duties to assess and prevent health, social and environmental risks and to ensure fair process and health, social and livelihood protections for communities that are relocated due to mining. During the mining processes, they include prevention of harm to the health of workers and surrounding communities, making fair fiscal contributions to health care and ensuring fair benefit and transparency in their operations. They also include post closure obligations in relation to any longer term health and social harm.
Recognising regional need and benefits, African states have resolved to harmonise standards and laws for the sector at sub-regional level, in west Africa, through ECOWAS, and southern Africa, through SADC. A number of ESA countries, such as South Africa, Mozambique, Zambia and Kenya, have also set in place initiatives to bring local standards and practice for EIs in line with global best practices.
The rapid expansion of the sector into new areas, the legislative gaps in countries with newer sectors, the differences in power between multinational actors and under-resourced states and communities, amongst other factors, have led to various areas of harm and conflict that call for such rights and duties to be made clear. Notwithstanding the employment, income and fiscal contributions they bring, EIs have been reported to bring health risks for workers and surrounding communities. These risks arise from hazardous working conditions and degraded or polluted environments, from the displacement of local people, several thousand in some cases, without adequate replacement of living conditions, resources, services and livelihoods, and from generous tax exemptions that limit EI contributions to social services. The EQUINET discussion paper summarises some of this published evidence. It also reports evidence of discontent or protest from local communities, who feel excluded from decisions and frustrated by grievance handling mechanisms. Indeed, the African Commission on Human and People’s Rights has established a Working Group on Extractive Industries, Environment and Human Rights Violations in Africa to examine and propose measures to prevent and provide reparation for such negative impacts, while civil society campaigns, like ‘Publish what you pay’ have sought greater transparency in EI operations. These conditions suggest that it would be timely to give more attention to realising the intentions to harmonise regional standards on EIs and to ensure that health is included within this.
An analysis of the laws on EIs and health in the ESA region in Discussion paper 108 indicates some general findings across the region: There is generally protection in current ESA laws of occupational health for workers employed by EIs, of duties to the environment, and of fiscal and post mine closure duties. There is, however, weaker protection in current ESA laws of the health and social wellbeing of communities displaced by mines, of families living around mines and of health duties post-closure, such as in relation to chronic diseases. In the laws analysed, fewer countries included duties on forward and backward links with local sectors, communities and services.
It was however a positive finding that where there are gaps in the law, there are also clauses in the law of one or more individual ESA countries that are aligned to international standards that may guide what may be included in the laws of others.
Such ‘good practice’ clauses could inform the content of harmonised regional standards. Their origin from ESA countries of different size and income also suggests that it would be feasible to apply them more widely across the region. The EQUINET discussion paper and policy brief at http://tinyurl.com/gr6yyza present suggested clauses for regional guidance on health in EIs (and the laws they derive from), in line with international and continental standards.
Implementing the vision of a socially responsible, healthy and inclusive mining sector clearly calls for more than law. In relation to health, there is evidence of the need for strengthened enforcement and practice, such as to revisit over-generous fiscal exemptions, to integrate health more centrally in tools for and approvals from impact assessment, to strengthen public sector co-ordination and capacities to monitor and prevent health risks, and to provide public information and meaningful mechanisms for community voice and agency in measures to protect their health. However, having harmonised regional standards may help to raise awareness and understanding amongst the different public sectors, private actors and communities of their roles, rights and duties in relation to health in EIs, and give support to the social and institutional processes and measures needed to promote healthy practice.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. You can read further evidence in EQUINET Discussion paper 108 Corporate responsibility for health in the extractive sector in East and Southern Africa at http://tinyurl.com/zm7afbk and Policy brief 42 at http://tinyurl.com/gr6yyza
While economics is not World Health Organisation (WHO)’s core expertise, the impact of poverty and income maldistribution on population health clearly justifies the organisation working with other agencies within or outside the UN system to focus much more attention on questions of disparity. Things being the way they are right now, it is thus difficult to make sense of the shrinking scope of WHO’s role in global health governance.
One factor could be the wide and ambiguous use of slogans about ‘stakeholders’ and the fait-accompli of ‘multi-stakeholder platforms’ and ‘public-private partnerships’. The term ‘stakeholders’, bundling together public interest civil society organizations with international NGOs, private sector enterprises and philanthropies under the term ‘non-state actors’, appears to endow all of these private ‘stakeholders’ with the right to a ‘seat at the table’, with only the tobacco and arms industries declared off limits. Such ‘sitting rights’ jeopardize people’s human rights as enshrined in various instruments, including the right to health.
‘Donor’ countries (the US in particular) continue to push the WHO towards working with industry through such ‘multi‐stakeholder partnerships’, rather than giving it the chance to implement regulatory and fiscal strategies that could make a real difference. Bilateral funders and big philanthropies demand that WHO provide data according to their particular interests, beyond the compilation of country-reported statistics. They focus on providing technical interventions, and introduce a bias away from interventions on the right to health or social determinants.
This treatment of WHO is part of a wider onslaught on the UN system generally. The whole UN system is held hostage to short-term, unpredictable, funding. The freezing and periodic withholding of countries’ assessed contributions and tightly earmarked voluntary contributions creates dependence on private philanthropy. It applies a sustained pressure to adopt the multi‐stakeholder partnership model of program design and implementation that gives global corporations an undeserved ‘seat at the table’.
If the WHO reform is to realise the vision of its Constitution, it will require a global mobilization around the democratization of global health governance, within the wider global mobilization for human rights and equity in global economic and political governance. Globalization has created new collective health needs that cross old spatial, temporal and political boundaries. In response, we need global health governance institutions that represent the many, not the few; and that are sufficiently agile to act effectively in a fast-paced world and capable of bringing together the best ideas and boundary-shattering knowledge available.
Yet the WHO seems strangely detached from the broader political turmoil and changes unfolding around the world. WHO may point to its 193 member states and claim to be universally representative, but it is far from politically inclusive. Like the alienation felt by millions around the world, many members of the global health community have turned elsewhere to move issues forward and get things done. We thus see a steady decline of WHO, clinging to obsolete political institutions and bureaucratic models, yet kept alive by member states as an essential public institution. This decline is not because WHO is not needed, but because it has not adapted to and is not publicly financed for a changing world. It is not the WHO that we need today.
Political innovation must thus become a fundamental part of the process of WHO reform. We need to think: How might virtual and interactive town halls improve communication between global health policy-makers and the constituencies they serve? How might the closed world of global policy-making be opened up and strengthened through virtual public consultations, feedback and monitoring systems? How might the concept of global citizenship become institutionalized within our global health institutions, especially WHO?
We also need to challenge the re-legitimation of the ‘free trade agenda’ in health that has strengthened intellectual property (patent) protection regimes despite their well-known negative consequences for public health. We need to question the mantra of the ‘realistic costing of outputs’ that prescribe programme implementation models where programmes comprise a set of planned outputs from prescribed activities with known costs. This approach leaves little, if any, room for flexibly managing complexity in planning and implementing systems. It makes health actors, including WHO, wary of the longer term implementation processes needed in health systems, partly because they disrupt ‘production schedules’ demanded by funders.
These models also contradict our understanding that health care is just one of the factors influencing health and can only be considered part of the solution. As the 2008 WHO Commission on the Social Determinants of Health stated, “Social injustice is killing people on a grand scale and constitutes a greater threat to public health than a lack of doctors, medicines or health care services”. The conditions under which people live and work, their socioeconomic development, education, housing and other conditions have a major impact on health behaviours and outcomes. A robust analysis of the root causes of the preventable global disease burden is thus essential to understand which ‘stakeholders’, or duty bearers, are part of the problem and which are part of the solution. Consistent with human rights principles and the findings of the 2008 Commission report, such analysis enables us to identify which can be trusted to have a seat at the policy table.
This influence of social injustice on health and the analysis of root causes of preventable disease appears most obscured in the influence of external funders over health ministries in the global south. It keeps them focused slogans such as ‘development assistance’ and ‘public-private partnerships’ that in their design serve the agenda of the richest 1%. In so doing it sustains a world view of the beneficence of private enterprise and that accepts as natural and unchanging conditions of global inequality and environmental degradation.
This editorial draws on points raised in the work of PHM and other colleagues, including K Detavernier, M Kok, K Lee, D Legge and E Pisani. For further information visit the PHM website at http://www.phmovement.org/ . Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.