Human rights approaches can advance maternal health: Lessons from Uganda
Mulumba, Moses, Primah Kwagala, The Center for Health, Human Rights and Development

One question being asked in relation to the recently adopted Sustainable Development Goals (SDGs) is how they relate to human rights based approaches. In the health sector for instance, SDG 3 aims to ensure healthy lives and the promotion of well-being for all ages. This includes a target of reducing the global ratio of women dying in childbirth to less than 70 in every 100 000 live births. While maternal mortality has fallen by almost 50 per cent since 1990, fourteen times more mothers do not survive childbirth in developing countries than in developed countries.

By 2014, Uganda’s maternal mortality rate was amongst the highest, with 360 mothers dying in every 100 000 live births, according to Uganda’s 2014/5 Annual Health Sector Performance Report. The country has failed by a large margin to realise the target set for maternal mortality in the Millennium Development Goals (MDGS), and what should be a healthy reproductive event continues to claim women’s lives in the country. The 2014 figures indicate that 6 000 Ugandan mothers die in childbirth annually, which is an average of sixteen daily, or one death every 90 minutes.

There have been a number of promising policy statements and interventions suggested by government to address this unacceptable level of mortality. Bottlenecks in the financing, delivery and uptake of maternal health services have however led to a shortfall in the delivery of these interventions. We view this situation as a complete failure by the state to deliver its constitutionally mandated obligations under Article 33 of the Constitution to provide the facilities and opportunities needed for women to realise their full potential; and to protect women and their rights, including their reproductive rights and functions in society.

The shortfall in maternal health services has been a focus of civil society advocacy in Uganda for some time. Civil society has consistently argued for the state to resolve the poor conditions in which mothers have to give birth in Uganda. It has used a human rights based approach in this, framing the demands in the language of legal rights and constitutional obligations. There is evidence of some success in this. A group of civil society organisations, led by the Center for Health, Human Rights and Development (CEHURD), acting together with two aggrieved families brought before the courts the deaths of two mothers. This was led as a constitutional challenge, arguing that the deaths occurred as a result of failures in the health system to provide basic commodities for safe deliveries. In this case, the Supreme Court directed the Constitutional Court to hear the case, on the basis that the failure by the government of Uganda to provide women with basic essential care was being challenged as a contravention of Uganda’s Constitution and the women’s rights.

The legal battle did not go without challenges. There were constant delays, with frequent adjournments due to non-appearances by the state or the failure to assemble a full panel of judges to hear the case. The state objected to the case, claiming that the judiciary had no authority to question the political decisions of the state. Initially the Constitutional court agreed with the state and dismissed the case. This was, however, reversed on appeal to the Supreme Court. In his judgment at the Supreme Court, Chief Justice Bart Katureebe stated that “….if a citizen alleges that a health policy or actions and omissions made under that policy are inconsistent with the constitution…., then the constitutional court has a duty to come in…”. The case is thus now before the Constitutional Court, as directed by the Supreme Court. The process to date raises an important point of law for the SDGs, and particularly Goal 16. This goal focuses on promoting peaceful and inclusive societies for sustainable development. It emphasizes access to justice for all and building effective, accountable and inclusive institutions at all levels. For the health sector, traditionally a reserve of public health and medical actors, the SDGs and human rights approaches indicate that other actors will now have a significant role to play.

The experience in Uganda already raises learning on this: The court process motivated civil society to advocate for health issues with one voice. It created awareness that social and economic rights are justiciable in Uganda, and that citizens can seek justice in the courts if other arms of government do not deliver on their obligations. The Ministry of Health has since pushed for increased funding for maternal health and parliament has made resolutions to support increased health financing and asked government to recruit more health workers to strengthen health services. The Ministry of Health has also now developed guidance on the mainstreaming of human rights in the provision of health care in Uganda.

The judiciary has also increased its understanding of health rights. Subsequent court judgments have, for instance, pronounced that access to emergency obstetric care is a human right, which was not the case previously. The courts have also held a local government authority accountable for a mother’s death where it failed to properly supervise the health professionals falling within its mandate.

While there is still a lot to be done, and while the constitutional case is still pending, the experience indicates that framing health demands in the language of legal rights and constitutional obligations, including through litigation and other legal processes, can assist to place health rights as a more central issue for the court of judges and the court of public opinion. Our experience indicates that such human rights based approaches have a role to play in taking action to implement global goals to ensure healthy lives and the promotion of well-being for all ages.

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

Case studies of experiences of mechanisms for social participation in health services

This month's editorial presents one of the many experiences of the mechanisms that exist at primary care level for community participation in health services and for communication between services and communities. A series of case study briefs have been produced on these experiences, highlighting their contribution to people centred health systems, but also their challenges. As noted by those working with health centre committees in the region, if the intention is to build PHC-oriented, people-centred health systems then these mechanisms need skills for activism and transformation to help build social participation and power and a range of capacities, tools and processes that support this. The case study brief on experiences in South Africa is included in this newsletter and we will include further case study briefs in forthcoming newsletters.

Communities shaping policy on health centre committee roles in Eastern Cape Province, South Africa
Therese Boulle, Leslie London, Zingisa Sofayiya Learning Network for Health and Human Rights, UCT

South Africa is in a process of transforming its health system from a centralised and largely curative model to a district health system implementing primary health care and addressing the social determinants of health. The strategies for this depend on an effective district health system, and this in turn depends in part on the role given to communities in health. But who shapes this role?

Public participation in health is covered in the country’s law and policy. South Africa’s 1996 Constitution provides for the right to health, health care, participation and association, and for public participation in policy-making. The 2003 National Health Act provides for participation at community level in clinic and community health centre committees. The 1988 Municipal Structures Act and the 2000 Municipal Systems Act create mechanisms within local government for communities to participate in decisions on local community developments through ward committees and local government councillors. These frameworks for participatory democracy need follow up to realise them in practice.

In September 2014 a National Colloquium found that while many provinces have established committees, there is a lack of clarity on their roles, affecting their functioning. The Department of Health at national level issued draft guidelines for HCCs in 2014 to address this gap. In the Eastern Cape, a policy was published in 2010 on the establishment and functioning of clinic and community health centre committees. It describes the roles, linkages, reporting and accountability of those in the committees. The policy seeks to involve communities in the planning and provision of health services, as a link between the community, health facility, and district health council and to foster co-operative governance. It sets out the community representation in the committees, drawn from women, the religious community, youth, non-government and community based organisations, traditional health practitioners and disabled people, with flexibility to include social groups relevant to the local context. This structure, while set in policy, is only slowly being operationalized in the districts. While in some districts the HCCs may be less functional, in the Nelson Mandela Bay Health District, where additional support has been provided by the university to the fifty clinics, all the committees except one are functional. Forums are held at sub-district and district level, as required by the policy, to monitor and support the committees and their members.

Communities in the Eastern Cape have played a role in formulating and implementing the guidance on their roles and functioning in the committees. In the Nelson Mandela Bay Health District, for example, health committees had been operating since 1996 but in a haphazard and variable manner, without guidelines for their functioning and erratic staff and management support. This frustrated members. In 2006 a team from the Eastern Cape Provincial Department of Health invited health committee members, health service, local government, community and other local stakeholders to a meeting to contribute and to provide substance to the policy on health committees. This workshop served to frame the draft policy, which was later sent to all districts for discussion before further review and feedback by HCC representatives. The amendments made in this process were integrated into the final policy that was adopted in 2009by the legislature in the province and published in 2010.

The policy provides for three-yearly review. In 2014 a review was initiated with HCC members, in consultation with the province. Workshops were held with the committees, facilitated by University of Cape Town. These reviews helped to make the policy more accessible, to support understanding of roles amongst HCC members, to raise roles that had been overlooked, challenges in implementation of functions and suggestions on improvements. It demonstrated tangibly to HCC members that their voices can be heard in amending and adapting policy to improve it. Reviewing the policy also made the HCC members clearer on how to monitor its implementation and the duties of service providers.

Some issues were raised during the policy review: Greater support was urged from facility managers and local government councillors who were seen to be critical members for the functioning of committees, but inadequately involved. Communication between communities and services was observed to be weaker than set in the policy. Community members were found to distrust the complaint box process where HCCs monitor the opening of complaints boxes, recording and resolution of complaints. The committees noted that very limited resources are made available to support their work, including for transport, communication or capacity development. The HCCs made various proposals in the review, to ensure include processes for establishing committees and re-election every three years; to formally recognise HCC members; to make the reporting obligations of facility managers clearer; to include ongoing capacity building and skills development in the policy and to proactively support opportunities to discuss and engage with local communities and give feedback on issues to communities to build confidence in the system.

The process taught lessons about how people can shape and use their policies for participation on health. HCC members feel empowered when they know policies, not only to understand their own roles and responsibilities, but to ensure that they are enforced and that service and local government personnel are accountable for their roles.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised please visit www.equinetafrica.org.

Bring the right to health into Uganda’s Constitution this year!
Moses Mulumba, Executive Director, Center for Health, Human Rights and Development, Uganda

Uganda’s Constitution has much to make our country proud—including chapter four which has strong commitments to fundamental rights and freedoms, such as freedom of expression and the promise of non-discrimination.

These sacred freedoms are not always upheld or enforced—but that is a matter for another day! As a first principle, the fact that these guarantees are enshrined in our Constitution shows the potential to protect, promote and defend the human rights of all people in the country. They provide the entry point for citizens from all walks of life to hold our duty bearers to account.

Every ten years we must ask: what is missing from our Constitution? What should be amended to adapt to our changing environment? In 2015, Parliament will consider proposed revisions to our Constitution.

It is this vital opportunity that motivated the Center for Health Human Rights and Development (CEHURD) and a team of partners, on World Human Rights Day, to submit a bold proposal to the Uganda Law Reform Commission —that included in the revisions being considered by parliament in 2015, there should be an explicit guarantee for all citizens of the right to the highest attainable standard of physical and mental health.

Those who framed our Constitution, despite their wisdom, did not expressly cater for the right to the highest attainable standard of health in its substantive articles, but rather placed it under the non binding State policies and objectives. It is now urgent for the country to correct this.

Why? Simply put: because when it comes to health, our leaders and policy makers are failing the citizens.

Uganda’s astonishingly poor health indicators speak volumes. Unlike its neighbours, which have shown important advances, Uganda has had a stagnant rate of maternal deaths for the past decade alongside rising HIV incidence and declining condom use. Uganda has a stubborn burden of drug resistant tuberculosis and, according to the World Health Organisation 2005 report on malaria, Uganda has the world's highest malaria incidence, with 478 cases for every 1 000 people every year. This disease burden is coupled with ailing public health facilities that lack essential services like water and electricity.

Unfortunately, health services have been eclipsed by rural electrification and infrastructure as political priorities for investment. Health care is seen by government as an area for charitable donation or as spending on ‘consumption’. This is extremely shortsighted. There should be no trade-off between building roads or building health services. This is a false dichotomy. We cannot develop as a country economically if our population is sick, or if families are one attack of cerebral malaria short of impoverishment!

Countries that have expanded access to free, essential services have found that those investments have yielded real benefit to their citizens, including in terms of less absenteeism from work and schooling due to ill health, and increases in economic productivity at the household level.

In reality, in receiving taxes from people, government is bound by a social contract to account back to the people on how their resources are being used.
The structural adjustment programmes that liberalized and reduced public funding to social services located health in the market place and weakened this state duty. Now is the time to redeem it. We believe that a strong constitutional norm is needed to raise the role and accountability of the state in health care and raise pressure to address the social conditions that affect our health.

Including the right to the highest attainable standard of health as a constitutional right provides a bench mark for government, private sector and society to respect, protect, fulfil and promote it. Without a clear obligation, incontrovertibly stated in the Constitution, our policymakers will continue to look on this right as ‘optional’, not fundamental to the duties of government.

Other countries, such as South Africa, Kenya and recently Zimbabwe, have taken this step to ensure clear expression of the right to health care and to the social determinants of health in their Constitutions. Their people have raised social pressure for these rights and taken up their implementation through social action and strategic litigation, to ensure that government is accountable for these obligations and to build more equitable health systems.

CEHURD and partners have thus submitted a proposal to the Uganda Law Reform Commission to include in the Constitution provisions for citizens to realize the right to the highest attainable standard of health; to access basic medical and emergency treatment, reproductive health services including family planning, medicines and health information, and for people who would otherwise not be able to afford health services and commodities to access social protection to enable them to do so.

Having health as a constitutional right does not mean that people should expect to immediately be healthy, nor does it mean that our government must put in place expensive health services for which they have no resources. It means that government and public authorities should take progressive measures such as investing resources and developing and implementing policies and action plans which will lead to available and accessible health care for all in the shortest possible time, and to fair distribution of public resources for this. It also means that the public and private sector have a duty to promote public health.

Isn’t it time that our politicians and leaders take this step to commit to the right to the highest attainable standard of health? Citizens will be watching closely how far government gives priority to this critical right in the current constitutional reform process, at a time of common epidemics of preventable sickness and death. Surely we cannot wait another decade to make this commitment as a country!

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the CEHURD website: www.cehurd.org

EQUINET newsletter invites submissions
EQUINET steering committee

New year greetings! The EQUINET newsletter is now in its 168th issue and has been disseminating information on health equity in east and southern Africa for seventeen years. Thanks to all who have contributed. We'd like to hear more from you! We invite readers to submit short think pieces, debate pieces and information for the newsletter relating to the diversity of health equity issues affecting east and southern Africa. Please submit oped pieces of 1000 words or less with author name and institution to admin@equinetafrica.org. We also welcome information on useful resources, published papers, conferences and research grants on health. The newsletter and EQUINET website have searchable databases of publications on health equity in east and southern Africa as a resource for those engaging in various areas of research, policy and activism in health.

UN Special Rapporteurs Open Letter to the World Bank on the issue of human rights
Alston P: UN Special Rapporteur on extreme poverty and human rights, with 26 other Special Rapporteurs, 12 December 2014

Dear Mr. Jim Yong Kim,
We have the honor to address you in our capacities as special procedures mandate-holders of the United Nations Human Rights Council. We are writing to you with regard to the World Bank’s draft Environmental and Social Framework (“ESF”), which was released for consultation on July 30, 2014. We would like to share with you a number of concerns relating to the approach to ‘Safeguards’ reflected in the current draft ESF.

At the outset, we wish to underscore the significance of the Bank’s first adoption of such standards some thirty years ago. And we commend the Bank for its continued recognition of the central importance of a carefully calibrated framework of standards to ensure that its programs to promote sustainable development, poverty elimination, environmental protection and social standards do not have a negative impact on a diverse range of important values. Most of those values represent important components of international human rights law, to which the Bank’s Member States have subscribed within the framework of the United Nations. It is because the Safeguards implicate human rights so directly that we have chosen to write to you as independent human rights experts appointed by United Nations Member States to provide our inputs to the Bank’s consultation process.

As the Bank seeks to revise and adapt its Safeguards approach to the challenges of the twenty-first century, we believe that it is imperative that the standards should be premised on a recognition of the central importance of respecting and promoting human rights. But there is no such provision in the current draft. Instead, by contemporary standards, the document seems to go out of its way to avoid any meaningful references to human rights and international human rights law, except for passing references in the Vision statement and Environmental and Social Standard (ESS). The Bank restricts itself to noting that its operations are, in ways that are not explained or elaborated, ‘supportive’ of human rights and that it will ‘encourage respect for them in a manner consistent with the Bank’s Articles of Agreement’. As noted below, however, the convoluted and anachronistic interpretation of the Articles that has so far prevailed ensures that this is a largely empty undertaking.

While the Bank is clearly committed to ending extreme poverty and improving the quality of life of people in developing countries, the pursuit of these worthy goals does not automatically ensure that the resulting programs and projects will promote and respect human rights. We acknowledge that it is not the Bank’s role to act as an enforcer of human rights, but there are a great many other ways in which it can assist governments in meeting their own international obligations, provide support and advice on how programs and projects might be made more human rights compliant, and build knowledge and understanding of human rights into its own work. By opting not to take these steps, the Bank is setting itself apart from other international organizations and agencies which have long since recognized the importance of human rights in the context of carrying out their specialized mandates, and have also rejected the notion that human rights are somehow problematically ‘political’ in ways that the many other accepted goals of development policy are not.

In many contexts, the international community has accepted that development and human rights are interdependent and mutually reinforcing. This has been recognized, for example, in the 1993 Vienna World Conference on Human Rights, the 2000 Millennium Summit and the 2005 and 2010 World Summits. Reference might also be made to a document that is cited on the Bank’s own website which is the 2003 UN Common Understanding adopted by the United Nations Development Group. The Common Understanding requires that human rights guide all development cooperation and that development cooperation “contributes to the development of the capacities of ‘duty-bearers’ to meet their obligations and/or of ‘rights-holders’ to claim their rights”. It is fair to say that the vast majority of development actors, from the European Investment Bank to the United Nations Development Programme, have expressed a clear commitment to human rights in their policies, thus making the Bank an increasingly isolated outlier in this regard.

The Bank’s official reluctance to engage operationally with human rights also stands in marked contrast to the lessons that its formal statements suggest it has drawn from its own experience, including through the work of the Nordic Trust Fund (“NTF”). The Bank acknowledges on its website and in many of its non-operational policy analyses that a focus on human rights can improve development outcomes. This is consistent with the seminal insight provided in the work of Amartya Sen, undertaken in his capacity as a Presidential Fellow at the Bank, who argued that freedoms are essential means for achieving development. There are many examples of analyses and reports by the Bank that highlight the potential or actual importance of human rights in promoting the achievement of the Bank’s proclaimed goals, such as those relating to gender equality and the role of women in society.

Rather than seeing human rights as a means by which to facilitate the participation and empowerment of the beneficiaries of development, the Bank’s proposed new Safeguards seem to view human rights in largely negative terms, as considerations that, if taken seriously, will only drive up the cost of lending rather than contributing to ensuring a positive outcome. While a 2010 report by the Bank’s Independent Evaluation Group (“IEG”) concluded that the benefits of Safeguards outweigh their costs, the approach in the draft Safeguards seems to be driven by the desire to privilege rapid approval of loans over all else, an orientation which has long been identified as a problem for the Bank. A sense of being increasingly in competition with other lenders to secure the ‘business’ of developing country borrowers seems to be at the root of this approach. The Bank has defended its increased reluctance to engage with human rights on the basis that alternative sources of development financing are emerging, which do not require meaningful Safeguards, thus providing the latter with a significant advantage over the Bank. In our view, the failure of other lenders to require that projects they fund should respect human rights standards is not a valid reason for the World Bank to follow suit. We believe that the problems that will flow from such a race to the bottom are already becoming apparent, and it will be for us, in different contexts, to make this clear to the relevant lenders.

Human rights are not merely a matter of sound policy, but of legal obligation. As an international organization with international legal personality, and as a UN specialized agency, the Bank is bound by obligations stemming not only from its Articles of Agreement, but also from human rights obligations arising under ‘general rules of international law’ and the UN Charter. Moreover, each of the 188 Member States of the World Bank has ratified at least one (and, in almost all cases, several) of the core international human rights treaties.16 Those States are also bound by human rights obligations stemming from other sources of international law. It is widely recognized that Member States should take their international human rights obligations into account when acting through an international organization such as the World Bank. States that borrow from the Bank also continue to be bound by their own international human rights obligations in the context of Bank-financed development projects and the Bank has a due diligence responsibility not to facilitate the violations of their human rights obligations, or to otherwise become complicit in such violations.

In the past, the Bank has often pointed to its ‘non-political mandate’ to argue that it is prohibited from, or at least restricted in, its ability to deal with human rights more directly. But the Bank’s Articles of Agreement should be interpreted in the context of today’s international legal order, rather than that of the mid-1940s. The Bank and its Member States are bound by both the Articles of Agreement, and by international human rights law. The provisions of the Articles can clearly be interpreted in a way that underlines their consistency with international human rights law. Since all States have long ago accepted human rights as a “legitimate concern of the international community” the suggestion that these remain little more than political considerations is not sustainable.

Our call for the Bank to include HR within its overall program objectives does not amount to suggesting that the Bank should ‘sanction’ countries with a poor human rights record. Consistent with international law, with its own obligations and with those of its Member States, the Bank should acknowledge the relevance of human rights in its overall program objectives, as well as incorporate human rights due diligence into its risk management policies. The Bank should also avoid funding projects that would contravene the international human rights obligations of its borrowers.

In the annex, we have highlighted our particular concerns with elements of the proposed ESF. Our aim is to indicate specific means by which a human rights dimension would strengthen the Bank’s new Framework and ensure its compliance with international law. As Bank President, you have repeatedly undertaken that this revision process will not result in a dilution of the human rights components of the Safeguards. We believe that honoring this promise requires a significantly different approach from that which is now being pursued and there are strong legal, policy and instrumental reasons why human rights should be given a central role in the work of the Bank. The current Safeguard Review process provides a critical opportunity for the Bank to fully integrate human rights in its policies and standards. We will be submitting this letter together with its annex to the World Bank’s public consultation process and plan to issue a press release in due course. We stand available to engage further with the Bank in this process and can be reached for any comments and views on our letter. Your response will be made available in a report to be presented to the Human Rights Council for its consideration.

For further information on this open letter see www.ohchr.org/Documents/Issues/EPoverty/WorldBank.pdf

To a peaceful, just and healthy new year
EQUINET steering committee

The steering committee of the Regional Network for Equity in Health in East and Southern Africa wish all a healthy new year and renewed energy in our efforts to advance equity and social justice in health. The editorial this month shows how wide is the deficit, but also how vigorous the struggle!

We are not done yet. Lets close the gap!
Constance Georgina Khaendi Walyaro, Kenya

This year, as we look back upon 26 years of World Aids Days, we honour the millions of heroes and heroines who fought the good fight against AIDS but are no longer with us. We need to make sure that this day and the year that follows is about what we do to ensure that people continue living positive, productive lives, with great decency and dignity.

As a young person, I grew up hearing statistics like more than 4 young people are infected with HIV every minute and over 6 000 are newly infected every day. Over half of all new HIV infections were amongst young people in my age group. We had even been called the doomed generation, because many of us had never known a world without HIV and AIDS. AIDS had become our disease and it was feared that within a decade, we would be reduced to mere statistics.

Stigma and exclusion had hindered the efforts of many young people seeking the counselling, testing, treatment and support they required to ensure that those who were not infected remained uninfected, and the infected and affected were well cared for. Many carried the virus for years without knowing.

HIV changed our communities and civilizations, hacking away more than twenty years of hard gains in education, food security and socio- economic development; making our families poorer, and driving us into poverty.

While the scale of devastation caused by the epidemic was unmatched, we also knew that we could beat it - with quality treatment and effective prevention. So we began to fight back, to reclaim our spaces through advocacy, education and awareness. We changed and reclaimed our lives, forcing the epidemic into retreat in many places.

We were not always supported. To save lives we had to successfully confront the monopolies that endorsed skewed TRIPS+ trade agreements, greatly limiting the flexibilities that were won within TRIPs in the Doha Declaration to protect public health and increase access to essential medicines. We had to confront transnational corporations that had tried to challenge Indian law in an attempt to shut down 'the pharmacy of the developing world' - one of the largest producers of affordable generic medication. We had to claim our right to affordable and accessible quality medication.

But we are not done yet.

According to the UNAIDS GAP Report 2014, less than 50% of the 35 million people living with HIV globally know they are HIV positive. Adolescent girls and young women in Sub-Saharan Africa account for a quarter of the new infections. Gender based discrimination, poverty, and the denial of their economic, social and cultural rights continues to drive the epidemic. We are also facing high rates of antibiotic resistance and a reduction in the effectiveness of other medicines we have struggled to access. As a result people with drug resistant diseases like MDR TB need more expensive drugs. This has put a great burden on health services that are already underfunded.

World AIDS Day 2014 and every day after presents the opportunity for us to harness the power of social change to put people first and to close the gap. Ending the AIDS epidemic by 2030 is possible, but only if we leave no-one behind.

Closing the gap means enabling all people, everywhere, to access the services they need,
• By closing the HIV testing gap, so that the 19 million people who are unaware of their HIV-positive status can begin to get support.
• By closing the treatment gap, so that all 35 million people living with HIV have access to life-saving medicine.
• By closing the gap in access to medicines and care for all children living with HIV, and not just the 24% who have access today.
• By closing the gap in power so that young women, children, people of all ages, income and cultures can be included as part of the solution.

We are not done yet. Let’s close the Gap!

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

Changing the talk and the walk: Challenges for a different practice in health systems research
Amit Sengupta, Associate Global Co-ordinator, Peoples Health Movement

The Health Systems Research Symposium in Cape Town was an experience to savour. It was particularly refreshing in shifting away from the rather restricted vision of the earlier symposia in Montreux and Beijing. Opening it to debates on ‘people centered health systems’ raised the opportunity to move from the confines of the restricting, dominant neoliberal concept of Universal Health Coverage (UHC) that has circumscribed the discourse in the earlier symposia, with its focus on a narrow and preconceived template of issues, largely informed by the language of health financing and insurance. In contrast, this year’s symposium promoted a public health language of care (not just coverage) and of solidarity, equity, gender justice and rights.

Several speakers, especially in the plenaries, articulated the profound impact different dimensions of power and power relations are having on health systems. In the Peoples Health Movement, we see this as an important and extremely positive sign of our collective intent to confront and challenge these power relations. Several presentations talked about the role of social movements in building, safeguarding, nurturing and expanding health systems that are truly people centered.

There is, however, a gap between our rhetoric and our praxis. We need to integrate concerns about power and an articulation of the role of popular mobilization and of social movements in challenging power relations that undermine health into the priorities and practice of the research community. Here we have a gap, with too little practical translation of these concerns into research priorities and practice. Existing power structures play a hegemonic role in influencing research –using their financial clout and exercising dominance in the domain of ideas. Unless we are able to change this, our work will continue to be informed by a hegemonic discourse that legitimates injustice and inequity. This is a challenge for young researchers, to be bold and innovative in questioning the dominant paradigm of the current research system.

We need to build on the deliberations of the symposium to change our current practice, in all stages of the research cycle. Health research should name and interrogate the practices of those who perpetuate inequity at a grand scale by their cynical use of power. There is robust evidence on this that is waiting to be mined. It was heartening to see evidence in the symposium that there is now a growing interest in participatory research that places people at the center of research systems and not just as passive ‘beneficiaries’ of the outcomes of research. A research community that views research as a tool for change must give attention to the role of civil society and of social movements in catalyzing and driving sustainable change. Civil society is often seen as an afterthought in the research cycle. It is brought in late to legitimize often deceptive or limited evidence that maintains the status quo. Civil society in general and social movements in particular should, in contrast, have a meaningful and decisive counter-hegemonic role to drive an alternative research practice that can propel change, including research that is conceived of and driven by civil society. We need, for example, to develop work that examines the role social movements play in shaping, nurturing and advancing health systems that are solidarity based and sustained by the public.

In the symposium, there was talk of bringing to the foreground the ‘shadow reports’ that are produced by civil society at key forums. Surely we should walk the extra mile and view such shadow reports as the real reports? They present the popular concerns and aspirations and mainstream the voices of the unheard majority. Civil society thus has a task to produce evidence in such reports that is people driven, robust and that challenges the conventional wisdom replicated in the often glossier versions produced by multilateral organisations and well-heeled private foundations. The Peoples Health Movements’ Global Health Watch is one effort at taking up this challenge.

The long shadow of the current Ebola epidemic reminded all of us at the symposium about all that we have failed to do. It has directed our attention to the collective failure of public health and health research to harness evidence and action to promote public services - publicly owned, nurtured and conceived by the people. Health systems that are in the public domain are failing in many regions of the world, in spite of evidence that they are the main life-line for poor, marginalized and voiceless people. They are failing because of deliberate acts of commission that are bringing down, brick by brick, the edifice of public systems. They are failing because evidence that favours nurturing solidarity based public systems has been disregarded. Instead evidence has been used in a selective fashion to promote the notion that market based systems in healthcare delivery are superior. The Ebola epidemic was preventable, in part if overwhelming evidence on building public health systems had not been brushed aside. As a health research community we need to accept part responsibility for the current failure, in our not being vocal enough in the pursuit and use of good evidence.

As we look towards the next symposium due to take place in 2016, can we at least make partial amends for what we have failed to do? Can we collectively raise our evidence and voice to call for public health systems, built around solidarity and justice, rather than the current dominant model of spliced and diced healthcare delivery, designed for trade in the market?

These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the issues raised see the PHM website at http://www.phmovement.org/

Reflections on the 3rd Global Symposium on Health Systems Research
Sharmila Mhatre, IDRC Canada

The final session of what was without a doubt one of the best symposiums in health lent itself to reflection on four days of sessions that sparked debate and hopefully action on people centred health systems. As a funder of health systems research in low and middle income countries for over a decade, International Development Research Centre has supported the Health Systems Research Symposium from its birth, with an aspiration that be one of the processes that contribute to access to health and health care for all.

So what were the key messages that I heard and have taken home.
Professor Thandika Mkandawire began by articulating that we need health systems to be democratic, social, inclusive and to contribute to development. At the same time Prof Irene Agyepong reminded us of a Nigerian proverb that a “goat that belongs to the whole village belongs to nobody - this is how health systems can be described, but we must not let it go that way.”
So as a funder I ask myself whether I will stick to, as one panelist said “the politics of the achievable”? My answer is no, as it would not do justice to the energy, excellence and commitment that I witnessed from participants over the course of the last three days and more importantly it would not do justice to the people who have no access to health or do not have a voice.

I’ve organised what I have heard into: the “not to dos”, the “must dos”, and the “how to do”.

As a ‘not to do’ Rene Loewenson reminded us that by simply putting people in the middle does not make it a people centred health system.

So what must we do? In terms of how we do people centred health system research, the knowledge that matters is the knowledge that facilitates change, as we were reminded by Kumanan Rasanathan. As Nancy Edwards suggested we must move from gold standards to platinum standards of methods. In practice this means, quoting several people from the conference:
• Firstly, that people’s knowledge and role in the production, analysis and interpretation is a critical driver of people centred health systems. It means that people are in control and researchers are the facilitators of the process.
• Secondly, making data work for people rather than have people work for data. In one session someone spoke about “chasing data to fit with multiple donors’ agendas”. We need to incorporate multiple types of evidence and to bring in other practices and methods.
• Thirdly, while strengthening capacities are key, we cannot assume that none exist. We should recognise that capacity strengthening goes beyond training to actually shifting power, as noted by Aku Kwamie.

As a further ‘not to do’ Gita Sen reminded us that we cannot confuse the PC of People Centred with the PC of Political Correctness. We must break divides of race, gender, class, caste, culture or language and come together. This was illustrated eloquently despite the English language barrier by Lina Roso Polomo, a researcher from Mexico, as she explained how international guidelines do not always recognise the cultural diversity of our countries.

So if accountability is brought in by people, then as Kausar Khan eloquently relayed, the ‘must do’s’ include duties for us to reduce ethnic and racial divides as we facilitate, mobilise, fund, engage and catalyse people-centred health systems. It cannot be ‘us’ and ‘them’ as Martin McKee reminded us. At the conference I saw reflected in the program the silos being reduced as ‘systems’ sessions starting to integrate with ‘disease’ sessions, and discussions moved to bridge social movements with think tanks. Inclusion and integration are key. After all, as Lucy Gilson said on the first day of the symposium, the challenge that we must squarely address is governance.

Throughout the conference there was concern about the double-edged sword of Ebola, that has served this community with deep and significant challenges. The West African Health Organisation is demonstrating commitment to work with all of us to address Ebola and the system failures that it has starkly uncovered. WHO, UNICEF and European funders are advancing initiatives that address both basic science and health systems but as a global community we must do more and USAID and the World Bank called a number of meetings throughout the symposium to discuss this.

Moving from the ‘not to dos’ and the ‘must dos’ to the ‘how to do’, the wisdom of the Emerging Leaders (young researchers) is the take home lesson for all of us here. They said that to change mindsets we need to see, talk about and deal with the gorilla in the room. To make an impact we need to take the time to stop and reflect, with others that are like minded and also with those who are not. Lastly they told us that in each of us we have the capacity to lead as we bridge divides to build collective ownership of health systems that - quoting Sheik, Ranson and Gilson from the Health Policy and Planning Supplement on the Science and Practice of People-Centred Health Systems - truly “serve people and society”.

These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the global symposium visit http://hsr2014.healthsystemsresearch.org/