Making markets work for menstrual health: overcoming the ‘dignity deficit’
Nolwazi Ncube, Save the Girl Child Movement, Zimbabwe

Menstrual health is often mistakenly classified solely as a ‘women’s issue’. Yet with their link to reproduction and fertility, menstrual health and hygiene are not simply women’s issues, but matters of family and national concern. This is even more important in our region given the high share of adolescent females and women of child-bearing age in the population. In addition, the education, survival and health of girls and of women have an impact on the whole family. An appreciation of this impact underpins the global Sustainable Development Goal (SDG) 4 that seeks to ensure inclusive education for all, and SDG 5 that promotes gender equality.

So having just commemorated International Women’s day on 8 March 2018, and ahead of Menstrual hygiene day next month on 28 May, it seems fitting to discuss the issue of menstrual health.

In 2016, ahead of the 11 October global commemorations of the International Day of the Girl Child, UNICEF released a report entitled ‘Harnessing the Power of Data for Girls: taking stock and looking ahead to 2030’ (https://data.unicef.org/resources/harnessing-the-power-of-data-for-girls/). The report presented a rather sombre picture of the state of gender equality in low-income countries, pointing to an unequal division of labour in homes that continues to burden the girl child and impede her educational outcomes.

Zimbabwe, like other countries in the region, has recognised the importance of educating girl children. The country has, over time, made strides with regard to gender parity in education, but still faces gaps in achieving it. To address some of these gaps, the 2005 five-year National Strategic Plan for the education of girls, orphans and other vulnerable children set out to accelerate progress towards universal primary education and to promote equity and empowerment through education. However, with the health, social and economic challenges in the country, the subsequent five-year plans launched in 2011 and 2016 gave more focus to orphaned and vulnerable children. It could have been easy to forget the day-to-day problems girls face with their changing reproductive health. But in a positive step in 2017, the Zimbabwe government introduced a duty rebate on the importation of raw materials (pulp, glue and virgin tissue) used in the manufacture of sanitary wear.

It is not the only country in the region to be taking up these pro-girl child measures.

Kenya has repealed sales tax on sanitary wear. Furthermore, since 2011 the Kenya government has allocated approximately 3 million US dollars to support the distribution of sanitary wear in schools in low-income communities. In 2016, Zambia’s Ministry of Health launched its ‘National guidelines for menstrual hygiene management’. In 2017, the Department of Women in South Africa drafted a ‘Sanitary dignity policy framework’.

In August 2017, I had the opportunity to engage the Deputy Director General of the Department of Women, Mr Prince Booi on this policy framework document. He highlighted that the policy aims to widen access to sanitary wear for extremely poor girls and women, where the provision of this service helps to restore their dignity. The name of this policy framework resonates with me, as it underscores the link between menstrual management and dignity. Girls and women without access to methods and materials for the hygienic management of their menstrual periods experience a cyclical threat to their dignity. Monthly, it can strip away their confidence and may even inhibit their mobility and capacity to carry out physical activities.

In the 1960s in America President Lyndon B Johnson declared ‘a national war on poverty’, using the term ‘dignity deficit’ to highlight the effect on men of unemployment and their inability to provide for their families as breadwinners within the home.

Women were far less in focus at the time. But women’s reproductive health is an even more powerful sign of the dignity deficit as described in 2017 by Arthur Brooks in an essay in ‘Foreign Affairs’ (https://www.foreignaffairs.com/articles/united-states/2017-02-13/dignity-deficit). In it he paints the picture of a polarised America in which the rate of births for unmarried mothers is five times higher in women reaching up to high school education than that of college educated women. This is even more profound in girl children. In my own advocacy work in Zimbabwe I have seen how unintended pregnancies lead to dropping out from school and a social reproduction of vulnerability, unemployment and poverty.

Indeed, when Scottish Member of Parliament Monica Lennon began lobbying in 2017 for a bill to ensure free access to sanitary products in schools, colleges and universities it was profiled as a bid to end ‘period poverty’.

The measures taken by Zimbabwe, Kenya, Zambia and South Africa are thus important equity measures, particularly in overcoming market barriers to menstrual health and dignity. They are also ahead of those taken in many higher income settings. Whilst the City of New York legislated in 2016 for the roll out of free sanitary wear in public schools, homeless shelters and prisons, sanitary wear is still subject to sales tax in other districts in the state and other US states have not followed its example. At the same time, African countries can also look to other countries for further good practice. The 2013 documentary ‘Menstrual man’ and the 2018 movie ‘PadMan’ illuminate the work of Arunachalam Muruganantham in India for example. He confronted gender barriers in championing menstrual management and inventing a low-cost sanitary pad-manufacturing machine that is now used by rural women in India to locally manufacture sanitary pads.

These market measures and initiatives signal a potential shift in the recognition of the importance menstrual health in countries – taking it from a position of being hidden to one that is profiled and addressed in the public sphere, and more importantly an issue that has implications for equity and dignity.

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

We have a right to demand better! Rights based activism in Africa as a determinant of health
Kristi Heather Kenyon, Global College, University of Winnipeg, Canada

HIV represents an unprecedented pandemic, and one that is forcing civil society to innovate to meet the challenges. Civil society engaging on HIV has carried out one of the most vocal, widespread and innovative advocacy campaigns in health, drawing on language and approaches from other sectors and regions. HIV activists have in the process brought human rights into health advocacy, even in settings where rights are perceived to be foreign and confrontational. Why do civil society advocacy groups working on HIV choose to express their claims in the language of human rights? How do they understand this choice? What impact do they see it having? What impact does it have?

I explored these questions in sub-Saharan Africa, a region hard hit by the pandemic.

The answers might surprise: the decision to use rights was fueled by individual belief not pressure from external funders. It was also the individual empowerment effects of ‘rights-talk’, rather than their legal effect, that activists felt to be most important.

I explored the experience of nine local civil society organizations selected from four countries (Ghana, Uganda, South Africa, Botswana), located respectively in three sub-regions of sub-Saharan Africa (West , East and Southern Africa). Choosing from the three regions provided insight into civil societies operating in different contexts and at different levels - local, national, regional. To allow for a systematic comparison, I chose organizations that vary in the extent to which they use human rights in advocacy. The case studies drew on 145 semi-structured interviews conducted with these organizations, as well as with others in the HIV sector. I also reviewed relevant events, documents and press accounts.

Over the past twenty years many funders have embraced the human rights framework. While I am not suggesting that international funders are not important, I found that their preferences were not particularly influential in whether organizations used rights-based advocacy. Groups using this framework didn’t lose interest when it became less popular with external funders, nor did their interest rise or fall with changes in funding. Many of the civil society groups have at least a dozen funders who usually support particular projects rather than the organization as a whole. Because organizations have so many funders, any single funder rarely influences the framework an organization chooses for its advocacy.

The organizations instead chose human rights primarily due to a mix of principles and structural factors. Organizations with a leader with a strong human rights orientation and regular interaction with other employees were more likely to choose a rights-based approach. In settings where human rights are not a common discourse, groups manage to thrive- even in isolation - when they had powerful “rights champions” as leaders. Such leaders have been able to incubate a rights-oriented organizational culture, attracting personnel who have, or will acquire a similar orientation.

People who worked for organizations that gave strong attention to human rights in advocacy often held strong personal belief in the framework. Respondents often explained this passionately, describing human rights as core to their dignity and identity. Rather than being a topic or a strategy, human rights were described as a fundamental part of who they were, what they believed in and how they saw the world.

I expected that groups would choose human rights over other approaches because they are linked to legal enforcement, in ways that development work or public health may not be. I thought perhaps the choice to use human rights in advocacy was rooted in an expectation of a government response and legal accountability. Instead, respondents saw the most important impact of human rights as their empowering effect for individuals, particularly amongst those seeking health care. They saw rights as empowering people living with HIV to demand services owed to them, and to make requests from a position of power and entitlement, rather than one of weakness and desperation.

One respondent described the shift in mindset that she saw accompanying rights-based advocacy, as “creating in people’s minds” the idea that they “have the right to demand better.” Respondents gave accounts of these demands: “When you say, ‘It’s my constitutional right, doctor. I am not going to leave this room without having treatment,’ therefore the doctor will make sure that you get the treatment […] They don’t make a mistake.”

While the above quotation is from South Africa, where health rights are included in the Constitution, even in settings without such constitutional provisions respondents gave very similar accounts. They saw rights language as transforming people from passive recipients of care to active participants engaged in their own health, and as engaged citizens rightfully demanding services from the state.

The findings indicated that “human rights” may yield important effects in places that human rights scholars seldom look. Beyond state actions and high-profile venues such as the United Nations and national courts, people are wielding human rights in their day-to-day interactions in ways that have meaningful influence on their lives. It appears that human rights-based advocacy has a unique impact. It changes people’s self- perceptions of power in relation to the state and enables them to claim services to which they are entitled from a position of greater strength. Those exposed to human rights-based advocacy were reportedly more likely to seek health care services, to be more informed about their rights, to ask questions of health care providers, and to query delays or denials of service.

It would be interesting to see what these findings imply for other areas of public health. They suggest that human rights-based activism could be an overlooked, but powerful positive determinant of health.

A version of this oped was originally published in Open Global Rights: www.openglobalrights.org/empowering-language-of-rights-underlies-increasing-use-in-hiv-advocacy/. Further information can be found in ‘Resilience and Contagion: Invoking Human Rights in African HIV Advocacy’, McGill-Queens University Press, at www.mqup.ca/resilience-and-contagion-products-9780773550995.php?page_id=119256&

Are we making progress in universal access to health workers? Reflections on the global health worker movement
Dr Francis Omaswa, ACHEST, Uganda

The 4th Global forum on Human Resources for Health (HRH) that took place in Dublin, Ireland in November 2017 provided a useful opportunity to reflect on how far we have progressed in the global movement on human resources for health. The achievement of Sustainable Development Goal (SDG) 3, including Universal Health Coverage will not be possible without universal access to skilled health workers. A global health workforce movement is thus critical to ensure this and that access to essential health services is not left to market forces alone, leaving many unable to access basic health services.

I coordinated the convening of the first Global HRH Forum in Kampala in 2008 as the Executive Director of the Global Health Workforce Alliance at the time and have attended all the subsequent forums in Thailand and Brazil. I was thrilled to witness in Dublin how the HRH movement remains alive and vibrant ten years after the first forum. It was attended by over 1000 delegates from over 70 countries representing government leaders, civil society, academia, employers, foundations, health care professional associations and unions, youth and the private sector.

Beyond the numbers, it was the outcomes of the Dublin Forum that represent potential advances in the health worker movement, globally, and in Africa.

I saw a renewal and rejuvenation of the global HRH movement, with many new champions committed to act on the Dublin call to provide a skilled, supported and motivated health worker for every person in every village everywhere, and the 2008 Kampala Forum call for “Health Workers for All and All for Health Workers.” A Global Health Workforce Network (GHWN) hosted in World Health Organization, Geneva now brings together a range of stakeholders in the movement to organise activities around these commitments, with hubs around various fields such as education and training, leadership and governance, labour markets and civil society. A new civil society coalition on HRH was launched in Dublin to drive advocacy and accountability.

There was strong participation of Africans from all parts of Africa at the Dublin Forum. The African Platform on HRH held a side event, adopted a business plan and elected a new governing board that was empowered to update the Constitution, to support the visibility of the movement in Africa and to convene the 6th Forum of the African HRH Platform.

We were informed that implementation had been initiated of the recommendations and five year action plan of the UN Secretary General’s High Level Commission of Health Employment and Economic Growth. This commission demonstrated that employment in health and the health sector itself should not be seen as a cost but as a significant contributor to economic growth and employment, especially of women. The economies of high income countries all enjoy significant contributions from the health sector.

A new international fund named “Working for Health Multi-Partner Trust Fund (MPTF)” was launched during the 2017 Dublin forum as a collaboration between the International Labour Organization, the Organization for Economic Co-operation and Development and the World Health Organization to support countries expand and transform their health workforce. The Government of Norway has made the first contribution and urged others to invest. The fund should enable development partners to pool contributions for use by ‘pathfinder’ countries to apply innovative approaches to building a ‘fit-for-purpose’ health workforce, especially those countries that are struggling to provide access to health care and facing the threat of emerging epidemics.

The Dublin Forum also saw the launch of the International Platform on Health Worker Mobility. This platform seeks to maximize mutual benefits and mitigate adverse effects from the increasing rate and complexity of the movement of health workers. It will strengthen evidence, analysis, knowledge exchange and policy action on health worker migration, including to support implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel. The forum also made commitments to improving the safety and security of health workers by upholding international humanitarian law. It strongly condemned violence, attacks and threats directed against health personnel and facilities, given their long term consequences for health workers, for the civilian population and for the healthcare systems of the countries concerned and their neighbours.

A special feature not seen in previous forums was the Youth Forum in Dublin that set its own ‘call for action’. Attracting and retaining young health workers is critical if we are to avert the shortfall of 18 million health workers, and transform the health and social workforce.

It was significant that the 2017 forum took place during a doctors’ strike in my own country, Uganda, and a similar nurses’ strike in Kenya. One of the most powerful take-away reflections for me was that while several speakers from high income countries reported how money is chasing and seeking to attract scarce health workers, in most of our African countries, it is health workers who are underfunded and chasing money. Unless we act to address the imbalance in the demand for health workers between high and low income countries, African countries will continue to be drained of health workers going to high income countries, even while African people continue to suffer the shortages of skilled health workers that undermine their access to health care and delivery on SDG3.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the Dublin Forum can be found at http://hrhforum2017.ie/

Wishing you roots and wings in 2018!
Editor, EQUINET newsletter

At this time last year we wished you progress towards health and justice in the year.

Our editorials in 2017 reflect some of the mountains that have to be moved for this: At several points of the year - in February and June - contributors highlighted preoccupations with emergencies, bio-security and migration that trigger discrimination and exclusion, rather than solidarity and shared responsibility. In March and in September we heard about the increasing privatisation of public spaces, public institutions and public health services, and in April about the extraction of minerals and other resources from our countries without fair benefit for local communities.

However, the 2017 contributions also point to ideas and forces that move these mountains: such as the news in February of thousands of people gathering at Habitat3 around people’s right to the city and to healthy urban life; the demand in March by civil society to open up a closed world of global policy making; the claim in April for regional economic communities to set health standards in mining that should apply across the region; the organisation of collective African voice May’s World health assembly to more strongly advance ideas and interests from the region; and examples raised in September and October of how recognising and nurturing people’s rights, evidence and power generates a critical resource for health systems. In the beginning of 2017 one editorial painted a scenario of a future world where inclusion and investment in wellbeing is recognised not only as a matter of rights and justice, but as vital for our collective survival. So it was inspiring in the end of the year to hear a group of young contributors share ideas of urban futures that would overcome the significant differences in opportunities for wellbeing that they seek to demand, contribute to and achieve.

These ideas and forces are all rooted in the challenging conditions described. But they are also challenging these conditions, envisaging both a direction for change and a power to transform that lies in people’s hands. A Sudanese proverb says that we desire to bequeath two things to the next generation; the first one is roots, the other one is wings. Let’s move forward into 2018 with both!

Accountability for Health Equity: Reflections for Southern Africa
Cynthia Ngwalo Lungu, Johannesburg, South Africa

In July 2017, I attended a conference by the Institute of Development Studies (IDS) themed ‘Unpicking Power and politics for transformative change: Towards Accountability for health equity’. The conference examined the practices and politics shaping accountability in health systems from local to global levels. As a southern African, these are my reflections on this from the conference discussions.

Accountability for health equity is essentially about citizens being able to hold governments to account to deliver health for all. It is about inclusivity and ensuring better health for the less privileged, marginalised and vulnerable people.

It is commonly known that within Southern Africa public sector financing for health is meagre and below the 15% committed to in the Abuja declaration. People in need struggle to access health care. In some countries people walk up to 30 km to get to the nearest health centre, only to find that it doesn’t have the basic resources to function. In countries where the health system has largely been privatised it can be virtually impossible for poor people to afford health care. This situation is worsened when there is abuse of resources, a lack of transparency in health management, a lack of public information on health budgets and expenditures, when budget and policy processes are centralised in a top down approach that allows for little or no citizen participation in decision-making.

In response, the region has seen a rapid development of social accountability initiatives that trigger active citizenship, where communities actively participate in health decision making and hold governments to account on how resources are mobilised and used. The Centre for civil society capacity building, a Mozambican organisation, recounted in conference how social accountability initiatives in that country have improved transparency in resources for health and but influenced the development of formal national mechanisms for health accountability using scorecards for citizens to input to decisions and provide feedback on services.

While these efforts have achieved varying positive outcomes, they often tackle ‘low hanging fruit’, addressing local challenges like health worker attitudes or cleanliness within the vicinity of health facilities, thereby bringing about change in local practice. While these changes are commendable, they are often tied to project timelines, are localised and often do not trigger national level changes. Community level initiatives have struggled to address more systemic challenges, such as access to information, budget setting or expenditure tracking and bottlenecks in procuring and supplying medicines. The IDS meeting argued that this is because social accountability efforts have failed to respond to higher level constraints affecting the ability of local service providers to respond to community feedback. Much more broadly social accountability initiatives have in some cases failed to recognise the complex power dynamics that are typical of health systems. Social accountability efforts ought to engage with power if they are to bring about equity and social justice, otherwise, there is the risk that initiatives will simply replicate existing social hierarchies.

Another factor affecting these social accountability initiatives is sustainability and ability to outlive short-term project timelines. There is a need to cultivate an active citizenship that raises voice to point out accountability concerns without relying on external drivers. Given the weaknesses in general environments to support this, we need to recognise and explore the role of formal structures for accountability in health, notwithstanding their pitfalls. This implies critically considering the extent to which the community voice can be integrated with local level formal accountability structures without being compromised or ‘swallowed’ by them. In the Northern part of Malawi, for example, the Catholic Commission for Justice and Peace has cultivated an active citizenship that engages within the formal mechanisms in health, as a form of structured and sustainable citizen engagement with the health system.

From the convening it was very clear that social accountability initiatives should respond to particular contexts. For example, in the case of politically charged states within Southern Africa, communities and civil society pushing for health rights and social justice are often tackling a wide range of issues that may confront power and carry unintended political connotations. Traditional social accountability tools and approaches which work in accommodative participatory environments may not be useful in politically charged contexts as Social accountability proponents become human rights defenders who need a unique set of skills to pursue issues without risking their own lives and security. The operating environment calls for unique capacities, language, strategies and mechanisms to achieve results without exacerbating conflict.

While many of these social accountability initiatives appear to focus on public sector services, there are other non-state and private for profit actors involved in the delivery of health care. Across the region health has attracted markets and business operators resulting in a range of providers, in some cases in public -private -partnerships. How do we ensure that in the face of a growing private sector, public interests continue to take centre stage as a means to achieving equity in health? What mechanisms can be used to hold these private actors to account on social goals and health needs, when their preoccupation is with profit margins and ‘fair returns’? Lessons from the negative effects of pluralistic health markets in other countries, such as Mongolia, can be used by the region to inform the development and implementation of sound regulation of the ‘business of health’ and to ensure that PPP’s and health financing schemes including health insurance are developed in an accountable manner and in line with equity goals.

These are significant challenges, but there are also opportunities to strengthen accountability through innovation. Despite low internet penetration and high telecommunication charges in some parts of the region, information technology is spreading. Throughout the region, technology is fast becoming a powerful tool in pushing for social economic rights- with the click of a button communities can voice public health concerns or access critical health sector information. With these tools, the means to accountability for transformative change may indeed lie in people’s hands!

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the IDS meeting can be found at http://www.ids.ac.uk/opinion/naming-the-moment

What do Harare youth think needs to happen in our cities to improve our wellbeing?
Busisiwe Shumba, Sithembile Zimbeva, Piason Mareya, Simon Kapombe, Bridget Kajawu, Shingirai Denhere, Arthur Nyandwe and Ishmael Makaya, Harare

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.

To fight the next Ebola, the G20 need to empower people to respond to everyday challenges
Lucy Gilson, Resilient & Responsive Health Systems (RESYST), London School of Hygiene and Tropical Medicine

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/.

Take health systems out of the market place to build their resilience
Mulumba, Moses, Center for Health Human Rights and development, Uganda

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 as a health equity resource from the region
Editor, EQUINET Newsletter

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

Dentistry in crisis: time to change
Lois Cohen, Gunnar Dahlen, Alfonso Escobar, Ole Fejerskov, Newell Johnson, Firoze Manji, La Cascada, Colombia

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.