Forty years on from the Alma Ata declaration, those who are the most vulnerable are still the least likely to access quality healthcare and to live healthy lives. Research is critical for understanding and addressing the systems of power that undermine health and health equity. Leaders must invest in more inclusive, introspective and innovative research partnerships to strengthen robust, resilient and responsive health systems to achieve ‘health for all’.
At the 2018 Fifth Global Symposium for Health Systems Research in Liverpool, UK, delegates made a strong plea for action to address the ‘power and privilege’ that continues to undermine global health. In supporting health systems as a key foundation for ensuring the health and wellbeing of citizens and communities world over, this call was repeated to those participating in the 2018Global Conference for Primary Healthcare in Astana, Kazakhstan. The call for Astana to renew and build upon a promise made forty years ago in Alma Ata, Kazakhstan to achieve ‘health for all’ was a reminder for us to reflect on how far we have come, but also how far we have to go.
While the ambition remains as noble and important as it was in 1978, we are living in a completely different world with unprecedented challenges, with pollution, militarisation, unregulated commercial interests, polarising ideologies, pandemics and ageing populations, to name a few. These challenges are marked by increasing and intersecting inequalities, within countries and between them. We know that the impact of these political threats and social inequities affect those at the bottom of the ladder, if they are on the ladder at all.
At the same time, social voice and leverage, including social media initiatives like #MeToo, #TimesUp, and #PeriodPoverty, independent journalism, progressive legislative action and everyday activism by citizens and communities do hold those in positions of power to account. Citizen voice and community participation, a hallmark of Alma Ata, merits further consideration, scrutiny and support. They remain essential for mobilising the broader awareness, engagement and political commitment needed for domestic policies to materialize universal principles and goals, including human rights, gender equality, global solidarity, universal health coverage and the sustainable development goals.
We have had many recent historical markers raising the profile of health equity, including the birth of the UK National Health Service (NHS), the Alma Ata declaration for primary health care and the Commission for Social Determinants of Health. But, what does that mean in real terms if we do not learn, or change the power structures that continue to undermine health and equity?
As raised at the 2018 Global Symposium on Health Systems Research, the causes of bad (and good) health are multiple, and go beyond the health sector, so must we. Just as people’s lives and needs cannot be neatly divided into categories to match government structures or professional disciplines, our research, policy and practice needs to transcend these boundaries. Supporting effective multi-sectoral action for health needs not just greater technical understanding, but also research on how best to facilitate, monitor and govern multi-sectoral action inclusive of actors for whom health is not a shared starting point.
Engaging communities in policy, practice and research is essential. While recognizing the importance of community health worker programs, further understanding of the diverse actors that make up community ecosystems and who broker social change is needed through context specific, nationally embedded research. Greater understanding of the multiple social networks and power relations within and outside of communities is needed to ensure equitable partnerships to sustain the social changes that underpin effective health interventions.
Advances in commercial products, services, technologies, and business models have generated diverse forms of service provision, expanding the influence of the private sector. These advances have created novel opportunities to expand the reach of the health system, as well as challenges due to the misalignment with commercial interests. We need to invest more in learning how to strengthen various government capacities to effectively steer these opportunities and ensure that vigilance and a healthy critique about private sector engagement remains.
While some benefit from improvements in quality, affordable healthcare, healthy environments, and economic opportunities, others remain marginalized without adequate access or voice. We must continue to include and reach the most marginalized, move beyond polarising social identities, to build social solidarity that address systems and structures of power, otherwise we will be having this same conversation in another forty years. Research must not only continue to identify who is left behind and why, but also support understanding of how best to change that.
We often talk about power and privilege in terms of ‘the other’ or ‘them’ over there in another space. But in all senses we must look inward and reflect on our own position if we are to truly address the pervasive inequities that continue to shape our society and health. This is no truer than in the field of health policy and systems research. Health policy and systems research is more inclusive of marginalized voices than ever, but certain vulnerable populations, geo-political configurations and planetary concerns remain under-represented. The assessment of power, privilege and positionality remains central to our work in health policy and systems research, and so it be must elsewhere if we are to realize health for all.
This oped is updated from a blog that first appeared on the Health System Global site in October 2018 at https://tinyurl.com/y4aoz54g. and builds on discussions held at the Global Symposium on Health Systems Research in October 2018. Asha George is supported by the South African Research Chair's Initiative of the Department of Science and Technology and National Research Foundation of South Africa (Grant No 82769). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author and the NRF does not accept any liability in this regard.
Editorial
Isaac is a 20 year old with aspirations of a better life. He came to urban Harare a few years ago after finishing school to start a new life. In his life in the city he has done this in ways he didn’t predict. He lives as a lodger in a small, smoky backyard shack and earns money from gathering and selling plastic waste. His most prized possession is a smart phone that is his link to friends, humour and, when he can afford data, to social media and market ideas. Behind a ‘healthy’ appearance he hides stress, hunger, worry about his future and frustration that he cannot afford the food, services, entertainment and life that he sees around him in the city.
Our growing cities are full of such young people, in urban areas that concentrate opportunities, information, social connections, ideas, enterprise, wealth, technology and services together with substandard living environments, pollution, food and income insecurity, violence and exclusion.
Published evidence shows that these risks and benefits are unequally distributed amongst urban residents. Recent migrants, residents of informal settlements and those living in informal housing, as lodgers or ‘backyard shacks’ have a vastly different experience of urban life than wealthier, more secure groups. These urban conditions pose particular challenges for people at different stages of life, whether as children, adolescents, adults or elderly people. We have for decades measured and implemented measures to address the social gap between urban and rural areas, with the disadvantage in the latter. However the growth in poverty and disadvantage and rising inequality within urban areas now demand attention. Published evidence appears to chase, lag behind or miss the rapid, diverse changes taking place in urban areas and is often silent on the features of urbanisation and social assets that promote wellbeing.
In 2016-18 we gathered and analysed diverse forms of evidence and experience on the social distribution of health in urban areas and on the opportunities for promoting health and wellbeing. In Harare, with the Civic Forum on Human Development and Harare youth, and in Lusaka, with the District Health Office and Lusaka youth, we listened to the perceptions and experiences of young people (18-25 year olds) from diverse settings and socio-economic groups in these two cities. We explored how far their experiences were captured in the evidence we collect across the countries in the region.
For young people in Harare and Lusaka, ‘health’ was a biomedical concept, linked to ‘absence of disease’, and to the various problems they see their health services treating. Indeed, the ‘health’ data we routinely collect in our region also commonly focuses on mortality, morbidity and negative indicators such as suicide and obesity, and on immediate determinants of these diseases such as food, water, sanitation, education and health care. This is problematic for young people like Isaac. They appear to be in ‘good health’, despite lacking decent standards of many of these immediate determinants, but this hides the mental and social challenges they experience, and ignores conditions and determinants that have longer term effects across their lives, including for the rising burden of chronic conditions and the growing challenge this poses to our urban health services.
For young people in Harare and Lusaka, having secure incomes, opportunities for entrepreneurship, education, shelter, public spaces, participation in government decisions and self-esteem were important for them to be and remain healthy. They believed these issues would become more challenging in the future, envisaging that as the city grew, it would become more competitive and overcrowded, threatening resources for health, including green spaces. Cities would demand even more of young people’s capacities for innovation and entrepreneurship, with a diminishing, rather than an increasing level of social solidarity.
How ready are we to address these concerns? The indicators we collect across the countries of the region provide a picture of disconnected facets and fragments that weakly reflect the combined current and future impact of these features of urban life on the different groups in the city. Not surprisingly, therefore, the systems and services that respond to them are also segmented and silo’ed. In 2016, the World Health Organisation (WHO) and UN Habitat suggested that we need to reclaim a more multidimensional understanding of equity to address the challenges in urban areas.
So what would such a more holistic, integrated and affirmative approach look like? One starting point may be to go back to the first principle of the WHO Constitution, that health is not merely the ‘absence of disease or infirmity’, it is “a state of complete physical, mental and social wellbeing. A concept of ‘wellbeing’ – or ‘buen vivir’ as applied in some countries – holds the potential to integrate psychosocial, social, time use, political, material, economic, service, governance and ecological determinants, all of which are affecting urban health.
By bringing them together, the concept draws attention to what balance (and imbalances) we are generating between these different dimensions of wellbeing and the current and future consequences of imbalances. The structural adjustment programmes exposed the inequalities that grow when economic strategies pursue growth at the cost of social deficits. The recent global student school strikes over climate justice point to young people’s concern that decisions made globally are dominated by certain economic interests to the cost of the degradation of nature and extinction of species. Achieving equity in wellbeing takes us beyond measuring and closing gaps between different groups of people to the strategies needed and assets we have to use to redress the imbalances that are generating these gaps and that have long term consequences.
The health sector has tried, through ‘health in all policies’ approaches, to persuade other sectors to adopt policies that promote health. To some extent this is still seen as a ‘health sector’ campaign, often taking place in parallel with increasingly biomedical personal care services and declining investment in public health capacities and authority.
In contrast, we found many integrated, collaborative approaches addressing these imbalances and the issues raised by Harare and Lusaka youth in different cities globally, from participatory urban planning in Kenya, to strengthening community safety in Honduras, environmental regeneration and urban agriculture in Brazil and urban youth collaborative engagement on school reforms in the USA. They point not only to the importance of public spaces for bringing together diverse services and interventions in area-based approaches, but also to the opportunities that exist in urban areas for encouraging local competencies and innovation and for facilitating the involvement of affected residents, like Isaac, as knowledge producers and participants in planning and action for health and wellbeing.
More detailed information on the evidence and processes referred to in this oped and the different people involved in this work can be found in EQUINET Discussion paper 117 Responding to inequalities in health in urban areas: Report of multi-method research in east and southern Africa, http://tinyurl.com/y3dv4pvm and other reports referred to in that document.
A little over 20 years ago the health and social inequities within our region and the opportunity to act on them motivated the founders of EQUINET to come together as an ‘equity catalyst’. The intention was to bring together our collective knowledge and experiences and to explore the challenges and possible solutions to the broad range of economic, social and environmental factors that determine the opportunities for and deficits in health in our region. Since then, we have built evidence, analysis and dialogue in different communities across the region on where and how to reclaim the resources for health, including through comprehensive, primary health care oriented, people-centred and publicly-led health systems.
Participating for EQUINET at the fourth People’s Health Assembly (PHA4) in Savar, Bangladesh in November last year we found that the People’s Health Movement (PHM) and the over 1200 participants from 80 countries raised the same demands that we are raising in our region. Yes, there has been growing wealth in the world over the last 20 years, improved access to information and technological innovations, and some people have seen improved life expectancy and falling infant mortality. But the reality is that health is anything but ‘healthy’ at a global level.
As PHM’s Amit Sengupta succinctly put it: “Eight people in the world have more wealth than 50% of the world population. Medicines exist, but only for some. We are seeing massive migration of populations in search of a more secure life. Our planet stands on the edge of destruction, while our health is for sale in the market.” We shared evidence at PHA4 of how the majority of people are not even able to meet their most basic needs for health and of how inequality within and between countries and regions in the world has grown and not fallen over the past decades. .
Why is this? Delegate after delegate at the PHA4 answered this question with a scathing critique of the neoliberal policies that have dominated the world order for the last four decades. From different countries people pointed to how a neoliberal ideology, which favours the unrestricted flow of capital between countries globally, drives minimal government social spending and limits regulations on the activities of private transnational corporations, has massively impacted on the health of people throughout the world.
This situation makes having a strong, vocal World Health Organisation (WHO) important. But in a plenary session at PHA4, David Legge explained the crisis in the WHO. When it was formed in 1948, its main funding came from its member states, who paid ‘assessed contributions’ according to the size of their population and their economy. Since a 1980 vote in the World Health Assembly to freeze assessed contributions, today only 20% of WHO’s budget is from member states – barely enough to cover their administrative costs – while the remaining 80% comes from voluntary contributions from member states, intergovernmental bodies and to a large extent from philanthrocapitalists like the Gates Foundation, often tied to particular programmes.
As a consequence, David raised that WHO’s work is controlled by these external funders rather than by its assembly of member states, affecting its independence and distorting its priorities and the coherence of its programmes. This has had a profound impact on WHO’s ability to support the implementation of comprehensive primary health care as set out in the Alma Ata Declaration and adopted by 134 countries in 1978.
It has also weakened the protection of health by other global actors. Many conversations in the PHA4 were about the impact of trade agreements on health. Jane Kelsey, a New Zealand lawyer, gave a shocking expose on how new generation agreements between countries and multinational investors are often negotiated in secret, preventing legislatures and the public from getting information on or regulating the health impacts of these corporate activities. She cautioned that this practice could lead to longer monopolies for medicines, to kerbing restrictions on standards for food and alcohol and for tobacco labelling, and to limits on governments’ ability to regulate private hospitals. Such agreements have led to situations where foreign investors can sue governments if state regulation in areas such as patents, mining licenses, privatised water contracts and health insurance substantially affect their profits. In 2017 alone 65 such claims were laid against 48 countries, with the sums claimed ranging from USD15million to USD1.5billion. These court cases can act as a form of intimidation of governments who try to put the health and wellbeing of their citizens ahead of corporate interests.
While this situation can leave us feeling despondent, in contrast PHA4 left us energised as we shared experiences of action and resistance from local to international level. At PHA4 we found a growing understanding that if we want change we will have to shape our own future, building alliances between community and civil society groups, academics, civil servants, journalists, international organisations and others.
We have seen evidence of this in our region. The successful campaign for universal access to antiretrovirals undertaken by the Treatment Action Campaign in South Africa in the 1990s, for example, saw such an alliance challenging the ethical basis for restricting global access to medicines. We heard at PHA4 about similar national and global struggles to campaign and litigate on critical issues related to the quality of and access to healthcare, to stop mining interests harming health and to advocate for more democratically led global health governance. These struggles for health are struggles for a more caring world.
EQUINET is taking forward and is part of this in our region. We are building collective ideas and action in a range of areas, including on the health effects of our extractive industries, on food security, on living and social conditions, on comprehensive primary health care and our laws and rights in health. PHA4 showed us how many activists there are in the same struggles in all corners of the world and that working at all levels, locally, nationally, regionally and with our comrades internationally is more important than ever.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. Read more about PHA4 at https://phmovement.org/peoples-health-assembly-dhaka-3/
In the same month that it reaffirmed the 1978 Alma Ata Declaration’s commitment to “the fundamental right of every human being to the enjoyment of the highest attainable standard of health” in its October 2018 Declaration of Astana, the World Health Organisation (WHO) launched, with much fanfare and hubris, its “first investment case” for 2019-2023, as a proposal that could “save up to 30 million lives”.
Despite the rhetoric of the Astana Declaration, the WHO appears to be in a political moment where it is under pressure to justify, in economic terms, its existence as a global governance structure for health. To convince the doubting reader, the investment case promised “economic gains of US$ 240 billion” as the return to be made on increasing annual country contributions by US$10 billion to enable the WHO to meet its annual budget of US$14 billion.
Two things are striking. Firstly, the investment case purports to lay the basis for “a stronger, more efficient, and results-oriented WHO …and … highlights new mechanisms to measure success, ensuring a strict model of accountability and sets ambitious targets for savings and efficiencies.” This is the language of the private sector.
There is nothing wrong with working more efficiently, but the WHO should be placing health equity and human rights at the centre of its work and should guard against efficiency and managerialism coming at the expense of equity and social justice. The bureaucracy and inefficiency of the WHO needs addressing, but the idea that the solution lies in the application of New Public Management is a political choice, rather than a necessary outcome of clear analysis.
Secondly, the parlous state of WHO funding is not a coincidence. It is the result of a systematic decline in assessed contributions by member states, particularly the United States, over past decades. Whereas assessed contributions were 75% of WHO’s budget in 1971, the Peoples Health Movement and others showed in 2017 that this is now about 25% of the institution’s budget and that countries that do pay, choose to put most funding into voluntary contributions. Voluntary contributions can be tied to particular programmes, meaning countries can determine the work of WHO through funding dependence. WHO’s budget has also been stagnant for the past eight years, which is why the organisation now has to go cap-in-hand, clutching a seemingly miraculous investment case argument, to beg for the budgets it has been starved of for the past decade.
It is astonishing, but deeply revealing, that the WHO has to justify human life in monetary or investment’ terms. Who would have thought the Constitution of the World Health Organization which 70 years ago heralded the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being would end up in such abysmal decline?
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. The WHO Investment case referred to in the editorial can be found at https://tinyurl.com/yavqzjvk
Antimicrobial resistance (AMR) is one of the most serious current threats to global public health, food security and thus development. It may make standard treatments ineffective for many communicable diseases, including pneumonia, tuberculosis, malaria and HIV/AIDS. Without effective antibiotics, chemotherapy and everyday dental and surgical procedures become increasingly dangerous, due to the risk of complications from infection.
AMR refers to the ability of microorganisms such as bacteria, viruses, and some parasites to stop antimicrobial medicines such as antibiotics, antivirals and antimalarials from controlling them.
One of the reasons for this resistance across all countries is the overuse of antimicrobials, or use when they are not needed or suitable. This may happen in various sectors beyond the use of medicines in health services. It may happen, for example, in agriculture and aquaculture, such as to prevent infection and increase growth in chickens, cows or fish, and in the environment, where antibiotic residues may be found in waste water from humans and farms, together with unused medicines that are not properly disposed of.
Supporting this drive for change, a global action plan to tackle AMR was endorsed in 2015. The 2015 World Health Assembly set the goal of this global action plan as “to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them.”
There is an urgent need for the world to change the way it prescribes and uses antibiotics to address AMR, rather than only relying on the development of more powerful antimicrobials. AMR is often talked about in terms of ‘drugs and bugs’. We need to move beyond this focus to think about how AMR and interventions to address it affect people in their day to day lives, at home, at work and in their communities. This is important if we are to ensure the reach, effectiveness and impact of the strategies used, so that they leave no one behind. We need to understand how men, women and different groups in society may have different levels of exposure to and risk of AMR, or different levels of impact from AMR, to identify ways of addressing them.
For example, increasing antibiotic resistance and inadequate safe water and sanitation in health care institutions may raise women’s risk during pregnancy and childbirth. Women and men may have different levels of exposure and vulnerability to diseases that have already shown signs of AMR, such as tuberculosis, HIV, malaria, gonorrhea and urinary tract infections. The World Health Organization (WHO) observed that men who have sex with men may be at greater risk of getting drug-resistant strains of gonorrhea, as some may not seek treatment given the stigma they face.
Women make up 67% of the global health and social sectors workforce and are often concentrated in lower-level, lower-paid jobs, with unsafe working conditions. For example, health workers and cleaners may not be provided with gloves, masks and other protective clothing, leaving them exposed to resistant microbes through their work. Likewise in agricultural settings, people working without protective equipment or cleaning facilities with cattle, pigs and poultry that are infected with drug resistant bacteria may also be exposed to these strains. Workers infected with these resistant bacteria in their work may then spread them to family members and friends.
There are also different levels of knowledge and different attitudes and practices relating to the use of antibiotics amongst people, prescribers, policy makers and pharmacists. For example, younger people and those with less education may not have correct information and knowledge on what illnesses antibiotics work for. In 2014 in Spain, researchers found, for example, that young men were more likely to believe that antibiotics are effective against viruses such as flu (they are not) and to incorrectly seek prescriptions for antibiotics to manage such conditions.
Given that AMR is occurring everywhere in the world, it is critical to effectively cover all these negative effects. This means that in sectors with a known risk of AMR, there are measures to monitor which groups in the population may be experiencing higher exposures to and rates of AMR, or may not have sufficient access to quality-assured and affordable medicines when needed. Monitoring such health impacts thus needs not only to be undertaken by the health sector, but also by other sectors such as agriculture and environment.
As the examples in this editorial indicate, a strategy for effective coverage would need to pay attention to the differences in exposure, risk and impact between males and females and between different socioeconomic groups, taking features such as occupation and working conditions into account. It would need to analyse equity and gender differentials to ensure that no one is left behind.
A WHO working paper, ‘Tackling antimicrobial resistance (AMR) together – Working Paper 5.0: Enhancing the focus on gender and equity’ (https://tinyurl.com/yakxvzqo) addresses this issue. It explores how to include a focus on gender and equity in efforts to tackle AMR.
It highlights the need to better understand how gender and other social determinants affect the exposure and behavior of different groups in the population in relation to their use of antibiotics and to prescribing practices. For example, it points to use of existing studies to tailor health campaigns and messages to better reach key groups such as young men or doctors or to reach settings where antimicrobials are mis- or over-prescribed, making use of diverse media. These include, for example, social media, YouTube videos and an interactive game on AMR. These resources can be found at http://apps.who.int/world-antibiotic-awareness-week/activities/en. The WHO paper also provides some guidance for countries on how to explore and manage gender and equity considerations in AMR in their national action plans. The WHO secretariat is encouraging review, dissemination and feedback to the secretariat at whoamrsecretariat@who.int on this working paper, to support its use in practice.
In July 2018 a WHO survey found that 100 of 194 member state countries had national action plans for AMR in place and 51 countries had plans under development. There is demand, scope and information now available to improve how these action plans are designed and implemented so that no one is left behind.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
We are starting a new year as the old one ended with a stark warning from Tedros Ghebreyesus, the WHO director-general. “We cannot delay action on climate change. We cannot sleepwalk through this health emergency any longer.”
A Lancet Countdown on Health and Climate Change reports that global warming is affecting every aspect of human life, not only in terms of extremes of weather but in terms of falling food security and access to safe drinking water and clean air.
In our region, where people are highly dependent on agriculture, vulnerable to drought and flooding and already facing a deficit in food security, safe water and clean energy, the impact is reported to be increasing already intense social inequality. WHO estimates that almost one in four premature deaths in Africa have environmental causes, and that climate change is likely to increase the number of health emergencies and disease outbreaks.
In November this year, African ministers for health and environment adopted a ten-year framework to direct funds toward joint health and environment initiatives. The Strategic Action Plan to Scale Up Health and Environmental Interventions in Africa 2019-2029 is expected to promote government investment in addressing environmental problems that affect human health, such as air pollution, contamination of water sources, and ecosystem damage.
These are important commitments. But in our region most governments are not yet fulfilling the commitment they made in 2011 to allocate 15% of domestic government spending on health. Underfunded health sectors struggle to balance the demand for promotion, prevention and medical care and often retreat into the latter.
Climate change demands global co-operation and resources. During the COP 16, the world's high income countries agreed to mobilize 100 billion US dollars per year by the year 2020 for adaptation and mitigation in low income countries, through a Green Climate Fund (GCF). We are nearly at 2020 and it is reported by IPS that only 10 billion US dollars has been mobilized so far since the establishment of the Fund in 2006.
Raising the health consequences of climate change is an important lever for attention and action on these concerns. It should also be a means to put people, social justice and solidarity at the centre of this. The opposite is feared to be happening. For example, at the November World Innovation for Health Summit it was noted that effects such as ‘environmental migrancy’, as people move away from harsh conditions, and the competition for resources can generate self-protection and discrimination. Vandana Singh, author and professor urges that these challenges not make us surrender “our imaginations, our creativity, our wonderful human capacity to work together, to negotiate and argue and brainstorm—on the altar of fear”. The solutions to these complex issues are not simply technical. They are inherently social and thus political.
So on this and the many other challenges that will certainly confront us in 2019, we wish you righteous anger, imagination and creativity and deepening opportunities to work together, negotiate, argue and brainstorm in the interest of our collective health and wellbeing.
In March 2018, when African Union leaders in Rwanda signed the African Continental Free Trade Agreement (AfCFTA), there was much talk about it being a new chapter for the continent in furthering the socio-economic integration enshrined in the 1991 Abuja Treaty. It’s important therefore to ask- what implications does it have for health equity?
The agreement establishes a free trade area between African countries, liberalising 90% of trade in goods between countries, removing import duties on goods originating from African countries to enhance trade between them. On the one hand this can potentially promote sustained economic progress, with potential health gains if it offers benefits to all local producers, including small scale producers, and if the economic benefits are equitably distributed. On the other hand it can lead to risks to health if the laws and institutional mechanisms protecting health in cross border trade are not adequate.
One way to predict what the impacts of the AfCFTA may be on health is to examine what happened in previous trade liberalization experiences, specifically those in the International Monetary Fund and World Bank led Structural Adjustment Programmes. These trade liberalisation policies were implemented across Africa in a context of weak safety nets and protection of public sector services, including in health, education and agriculture. The decline of these services and economic inequality that arose after that experience raise questions on how the AfCFTA will be implemented.
Supporting a health sector calls for a range of areas of value-added production, such as for medicines and technologies. Our economies have still weak development of these areas of production and tend to import them, while exporting more or less the same products. So will the AfCFTA be accompanied by measures to promote investment for value added production in an organised collaborative manner, such as for infrastructures, equipment, technology and medicines for the health sector? Given that prior liberalisation policies have been accompanied by cost escalation for the ordinary person, will it assess and take as a measure of its progress a fall for the population in the price of essential medicines, commodities and services for health?
Most African countries have porous borders and many have weak capacities to check the quality and safety of goods crossing borders. When unsafe food products, chemicals, alcohol and other products that could harm health are poorly checked at borders there is a risk to public health. So too is the risk to health of cross border movement of substandard medicines. There are already reports by WHO of such medicines appearing in markets in some of our countries. Competition and wider markets provide a potentially health incentive for reducing prices of goods, so the AfCFTA could enhance access to low cost generic drugs from efficient producers within the continent. This benefit and the control of public health risk from harmful products and unsafe foods calls, however for significantly improved port health capacities in all our countries to accompany the flow of goods. Will the AfCFTA thus include specific measures to enhance these capacities in line with the International Health Regulations, and apply them at all the various points where goods cross borders?
If the AfCFTA promotes the freer movement of personnel, it could enhance availability and possibly accessibility of skilled personnel, including health workers, especially for countries experiencing acute shortages. But it could also do the opposite, as we have already experienced in our countries, where skilled health professionals are pushed or pulled to higher income areas and services, further deepening existing inequalities in their distribution. And the movement of people itself has the potential to spread disease across countries. So will the AfCFTA be introduced together with measures for training and resourcing personnel to manage the cross border spread of infection and to enhance equity within the continental access to skilled health workers?
The liberalisation of trade holds the promise of wider access to new goods and services, and to the spread of innovation across the continent. This can be very positive for health. At the same time changes in dietary patterns, employment conditions, physical environments and lifestyles can change consumption patterns in ways that are not always healthy. We have seen the consequences of this in the negative effect of consumption of processed foods and sweetened products in levels of obesity and diabetes for example. Our countries need strong public health laws and capacities and good communication capacities to manage such issues and avoid the epidemic of non-communicable diseases that has been witnessed in other regions.
The AfCFTA will certainly lead to changes in production and industries with implications for incomes and public revenues. As tariffs that protect domestic industries are removed, they are exposed to competition. If they have the capital and capacity to manage the change they may succeed, but if not they may close. For the public the question may thus be “what will happen to my job and my income?” Without adequate social security schemes in the continent, any significant negative shifts in jobs and incomes for countries who become net importers rather than net producers could be very harmful for health.
Given that import duties will be eliminated on 90% of goods traded between countries the public sector will lose the revenues generated from these import duties. Countries will thus need to diversify their sources of revenue. For some the growth in production may generate new tax revenue, for others that do not see the same production growth, their tax revenues may fall. As we have seen in the structural adjustment programmes, when this happens public health budgets are cut, with increasing dependency on external funders for the right to health care. As our countries intend to mobilise domestic financing for universal health coverage, what plans are there associated with the AfCFTA to make sure that it doesn’t lead to widening inequality in achieving this across the continent?
The AfCFTA could be a tool for fostering south-south cooperation on the continent, with a range of potential benefits for health. Countries could provide mutual support to strengthen areas of inadequacies and reduce inequalities across the continent. However, the issues raised above indicate that trade alone cannot achieve this without complementary measures to ensure wider benefits within and between countries, cooperation on production of health commodities and technologies, and strengthened capacities and measures to protect public health. As the negotiations to finalise the texts and implementation continue, it is imperative that the health sector takes an active role, not only to understand the implications of the AfCFTA, but to negotiate for measures in it that will safeguard the health of the people.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the AfCFTA text see https://www.tralac.org/documents/resources/african-union/1964-agreement-establishing-the-afcfta-consolidated-text-signed-21-march-2018-1/file.html
In 2011 civil society petitioned the Uganda Constitutional Court (Petition 16 of 2011) for its failure to put in place systems to prevent maternal deaths in public health facilities. This failure was argued to be a violation of the right to the highest attainable standard of health guaranteed in the country’s constitution.
In response the judgement stated
“…Much as it may be true that government has not allocated enough resources to the health sector and in particular the maternal health care services, this court is………reluctant to determine the questions raised in this petition. The Executive has the political and legal responsibility to determine, formulate and implement polices of Government……….. This court has no power to determine or enforce its jurisdiction on matters that require analysis of the health sector government policies…”
The court argued that it had no role in reviewing or commenting on government policies or on how they are operationalized. It stated that judging on the issues raised in the petition implied taking over the role of the government executive, and that the injustice was not a constitutional but a political issue.
The Constitutional court thus dismissed the case. However, in an appeal to Uganda’s High Court the dismissal was struck down, with a ruling that the Constitutional Court had erred and that it indeed had a mandate to hear the case. The case has since gone back to the Constitutional court with a date for the hearing still pending.
The to and fro on this case reflects the challenges arising when claiming a right to health that is implicit within a national constitution. Clearly stating the right to health in the constitution is important for it to be promoted, enforced and safeguarded. If not stated in the constitution, its implementation depends on the actions of politicians, state officials, the courts and civil society. In particular, the preamble, “We the people…” in the constitution mandates the citizenry to advance these provisions.
While some countries in east and southern Africa do explicitly provide the right to health care, the right to health is often not explicitly stated. In Uganda, the 1995 Constitution, currently in force, has provisions on rights to life, privacy, freedom from torture and education amongst others. It does not, however, explicitly provide for the right to health. This right is rather found in the national objectives and directive principles of state policy. It thus depends on a mix of political, judicial and social action.
In an EQUINET case study by CEHURD (https://tinyurl.com/y6uppusb), we reviewed how this less explicitly provided right to health in the Uganda Constitution is being implemented through political, judicial and popular mechanisms.
Politically, the government executive has made international commitments to the Sustainable Development Goals in line with a Uganda Vision 2040. This policy vision aligns government initiatives to fulfilling duties and responsibilities, including for health care. It commits government to ensure policies and laws and build state capacities to implement programmes to realise health rights. In the health sector, for example, the ministry of health has a policy commitment and plans to ensure universal health coverage to realise the right to health care.
Such positive political intentions draw attention to how far they are being implemented. Parliamentarians as political actors have passed progressive laws to reflect changing social perspectives on health rights. However, there are gaps that need to be addressed. For example, old, colonial laws are still in force that do not reflect human rights principles, such as those governing the control of sexually transmitted diseases (termed ‘venereal diseases’ in the law).
Further, a gap in delivery on political intentions can be seen through the disparities in service coverage for particular social groups and lack of a clear co-ordinating mechanism for different sectors to address health determinants. It can also be assessed from how far policies are being framed for and services delivered to address controversial issues, such as abortion, access to contraceptives and education on sexuality for sexually active adolescents.
Beyond these political measures, there is an option for judicial implementation of the right to health. Indeed, there has been some increase in litigation on the right to health in Uganda, although with still few cases filed, and even less with favourable judgements. In a 2009 case the court dismissed a petition on the potential toxicity of chemicals sprayed for malaria prevention as not violating constitutional provisions on the right to health. In contrast in 2010 the court declared female genital mutilation, being practiced in certain Ugandan cultures, as a violation of the constitution, and specifically a violation of the rights of women and the right to health.
These poor outcomes could be explained by a lack of understanding of the human rights doctrine amongst judicial officers and lawyers. This may, for example, be a reason for the dismissal of Petition 16 cited earlier, later overturned by the High Court. It could explain the caution in the courts over litigation on social rights. This suggests a need for advocacy and capacity building with these key judicial stakeholders on their role in taking forward the right to health and the use of appeal processes to take up cases where the outcome may be seen to be unfair.
Beyond the political and judicial routes to implementation of the right to health, there is also the possibility of social action advancing these rights. There has been a rise in popular implementation of the right to health as implicitly provided in the Constitution in Uganda, more commonly through the actions of organized groups. In our review, we found experiences of campaigns, demonstrations, coalition formation and industrial action.
For example, in the ‘Walk to Work’ campaign in 2011, people were encouraged to walk to work daily to protest increasing prices of fuel, food, and transportation and poor social service delivery. The campaign, identified as political opposition due to its leadership, met police suppression and incarceration of campaigners and was banned in 2012.
More specifically focused on the health sector, in late 2017 the Uganda Medical Association (UMA), launched an industrial action over poor salaries, poor working and living conditions and inadequate medical supplies preventing medical personnel from performing their duties. This too met an immediate government response in a court challenge to the legality of UMA, an order by the Minister of Health for the workers to return to work and deployment of military doctors to hospitals. Later, however, government negotiated with the medical workers, improving their welfare and salaries. This measure for popular implementation yielded more positive results on health rights, perhaps given its less partisan political nature.
These diverse experiences found in Uganda, further detailed in the case study report, point to the fact that applying a right to health that is not explicitly provided in the constitution is possible. It calls for and generates political, judicial and popular measures, and possibly demands a mix of all.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. Please visit the EQUINET website to read the case study report and other publications on health rights.
Although half of the world population lives in rural and remote areas, these areas are serviced by only a quarter of the world’s nurses and less than a quarter of the doctors. In our region the ratios are even worse, where only 16 doctors service every 100 000 people living in remote rural areas.
The global shortage of health workers, estimated by World Health Organisation to reach 18 million by 2030, has motivated resolutions in the World Health Assembly and other fora for member states to find ways of retaining their health workers, through incentives and working environments that encourage people to stay in rural areas. Most recently in 2016, a High-level Commission on Health Employment and Economic Growth recommended investing in rural education and creating decent jobs in the rural health sector, particularly recognising the contributions of nurses and midwives to improved health.
Notwithstanding these calls, rural and remote areas continue to fail to attract and retain health workers. So beyond statements of good intention, what practical measures should we be implementing to improve the retention of health workers in our rural areas?
It begins with how health workers are enrolled and trained. Our training institutions need to review their admission policies to enrol students from rural backgrounds. They need to include information on rural health care in the curriculum and to integrate rural community experiences to expose students to these environments. Our undergraduate and postgraduate curricula and continuing education programmes should be oriented to building competencies for the shift from hospital-based approaches to preventive, affordable, integrated community-based, people-centred primary and ambulatory care in rural areas, as well as in building capacities for public health and preventing and managing epidemics.
Financial incentives have commonly been used to attract and retain health workers in rural areas. In addition to allowances, they may be given as bursaries for further education, study loans and occupation-specific dispensations. There is evidence that these measures have motivated health workers to remain in rural areas. But they can also be eroded if they lose value over time.
This makes the living conditions, availability of electricity, proper sanitation, access to schools, telecommunication and internet equally important to enhance retention, together with support for career development and advancement, such as by creation of senior positions in rural institutions. There are new opportunities in using information technologies to enhance rural practice and avoid professional isolation. Providing scholarships, bursaries or other education subsidies and improving living and working conditions can have a more positive effect than compulsory service requirements. Health workers, like others, appreciate their jobs when treated with dignity and respect.
From our review of the literature in a new EQUINET discussion paper 115, we found that many such strategies are being used. There were some cautions on how we apply these strategies. For example, compulsory measures appear to be best accompanied by relevant support and incentives. Mitigatory strategies such as task shifting should not become ‘task dumping’ and replace more substantive solutions. Ad hoc financial incentives should not be applied so selectively that they motivate some workers, while demotivating others. They should also not be used as a substitute for a more substantive review of working conditions and of disparities in salaries between different health professionals.
It is evident that there is no single approach. There are options, and countries need to choose strategies that are relevant for their own context and in consultation with key stakeholders. This needs to be embedded in the strategic processes for national health planning and financing. Addressing this issue calls for robust management and communication processes and skills, backed by credible evidence from monitoring and evaluation systems, to ensure that the chosen strategies are relevant, appreciated and continually updated.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. Please visit the EQUINET website to read the publications on health worker retention.
While working on this month's issue we got news of the passing of an inspiring African thinker, Samir Amin, and then later in the month of the previous UN Secretary General Kofi Annan and pay our respects to both. In different ways and forums they challenged thinking and agendas from an African and southern lens. From Dakar, Senegal, where Samir Amin led the Third World Forum, Vijay Prashad notes that Amin explored and wrote about both the dangers and possibilities of our current world. In the face of a "world system with finance in dominance and people whipping from one precarious job to another" he pointed to both the need and possibility of Africa making different choices and creating and advancing an alternative. "As long as we are resisting, he would say, we are free." We include one of the many articles published on his work and ideas in this issue.
Back to our editorial this month on waiting mother shelters. Papers included in this issue point to a continuing research debate on their effectiveness, with one review finding no evidence of this from randomised control trials. Yet the evidence from experience of their use in Zimbabwe in the editorial suggests a need to think beyond measured service and morbidity outcomes to understand their value for improving wellbeing, and to understand how, beyond individual interventions, different elements of comprehensive primary health care come together to improve health and wellbeing.