Editorial

The theme for the November 2015 62nd East, Central and Southern African Health Community (ECSA-HC) Health Ministers Conference on transitioning from Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs) provided a timely opportunity for countries in the region to frame priorities for health for the next 15 years. In his opening remarks to the Health Ministers Conference, the Minister of Health for Mauritius, the Honorable Anil Kumarsingh Gayan pointed to the SDGs as an ambitious framework that looked at health holistically in terms of healthy lives, including and beyond health care. As detailed also by the World Health Organisation representative Dr Rufaro Chatora at the conference, the transition is from a disease and poverty focused agenda to one that is more focused on the policy goals that apply to all countries. Hon Minister Gayan cautioned that the goals must not remain ‘in a state of aspiration’, and called for them to be addressed through ‘African solutions to African problems’.

While many of the SDGs contribute to health, SDG 3 raises the need to ‘ensure healthy lives and promote well-being for all at all ages’ and lists a daunting array of ambiguous targets (such as universal health coverage). Many of these are open to interpretation and strategic thinking in regards to their implementation, including in terms of how they are integrated into national, regional and continental development plans, such as the African Union’s Agenda 2063: ‘The Africa we want’. With global discussion underway on indicators, funding and other ways of operationalizing the SDGs, the region has a window of opportunity to shape these agendas, rather than react to those set outside the region.

Minister Gayan highlighted the importance of inspiring regional leadership and collective action across countries to steer the SDG agenda to advance health and address mutual concerns across countries in the region through an agenda set within the region. This, he indicated, called for regional organisations to be ‘innovative, responsive, imaginative and effective’.

The ECSA HC Best Practices Forum (BPF), Directors Joint Consultative Conference and Health Ministers Conference, this year involving about 150 delegates from ministries of health, health experts and researchers, heads of health research and training institutions from ECSA countries and diverse collaborating partners in and beyond the region, provided a unique opportunity to blend experience, evidence, exchange, policy review and networking to contribute to such features. It included inputs from diverse actors in the region on universal health coverage (UHC), on health financing, on regional collaboration in the surveillance and control of communicable diseases, on the situation and responses to non- communicable diseases (NCDs), on global health diplomacy and on innovations in health professional training.

The BPF conference raised a number of key recommendations aimed at supporting the transition from the MDGs to the SDGs, including; strengthening mandatory pre–payment for health, and monitoring, evaluation and shared learning across the ESCA-HC members on measures for this and on progress towards UHC; strengthening and sharing capacities and knowledge for tracking and reporting communicable diseases and for responding to outbreaks; increasing ECSA initiatives for health professional training and recognition of qualifications across countries in the region; strengthening regional capacity and evidence in global health negotiations; strengthening investment in research and the use of evidence in health policy, and facilitating ‘south-south knowledge exchange’ in various areas, including on multi-sectoral measures and capacities to detect and control NCDs and traumas; and in global health diplomacy.

Such regional exchange, co-ordination and voice was found in EQUINET’s research as one factor - amongst others- in effective engagement in global health negotiations. In the ECSA HC conference, regional co-operation was raised in various discussions as an important platform for solving a number of problems, including for countries with excess to deploy skilled professionals to countries with scarcities, or for more rapid deployment of capacities for response to emergencies. At the same time, EQUINET’s research also found that regional organisations are often bypassed or lack formal voice in global processes. It was thus interesting that the ECSA HC Director General Professor Yoswa Dambisya launched one of the few examples of a successfully secured regionally based Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GF) grant, which will align programs and provide increased capacity for tuberculosis monitoring and response in the region. This capacity will not only increase the ability of states in the region to detect new cases of tuberculosis, but also provides the possibility for new capacity scale-up to detect other neglected communicable diseases (NCDs) as laboratory resources and expertise increase.

There were, however, a number of signals on the challenges to further strengthen such regional roles. Minister Gayan in his opening speech pointed to how shortfalls in payment of membership fees to the regional body weakens the financial forecasting and planning needed to take forward a proactive agenda. The recent experience of weak implementation of the WHO Code of Practice on the International Recruitment of Health Personnel signaled deficits in technical follow through on policies. At the same time the conference also raised the role of domestic investment in country driven research and ministerial leadership to effectively support and coordinate such follow through.

With the long-term nature of the issues being tackled, these annual regional conferences need a consistency of focus on issues that are key for the region and strategic use of time to share and review the learning from implementation of regional recommendations as ‘African solution to African problems’. The involvement of many of the countries in several regional economic communities also necessitates co-ordination of efforts across these regional bodies.

Notwithstanding the challenges, the conference highlighted the potential of ECSA-HC and other regional processes in facilitating the exchange and sharing of policy relevant evidence and ‘south-south’ learning. The contribution of such institutional resources and processes should not be overlooked in asserting African health priorities in the global health agenda. While this is more a ‘marathon’ than a ‘sprint’, for the window of opportunity of current discussions on the SDG indicators and financing, the time to voice African health priorities in this global SDG process is now.

Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org. For further information on the ECSA HC Regional Conferences please visit the ECSA HC website at http://www.ecsahc.org/

‘Life is a series minor explosions whose echo, fading away, settles comfortably at the back of our minds’ - Dambudzo Marechera

By 2050, over 1.2 billion people will live in sub-Saharan Africa's cities, with a potential for growing differences on what people gain from them and in their quality of life. Young people today will be living that future and wonder what kind of healthy, or unhealthy futures the cities hold for them. Health literature is full of talk of targets and data, but speaks little of these dreams and fears.

When a fee hike of nearly 12% was proposed in South Africa this year, students took to the streets in protest. The protests against the exclusion the fees implied for poor families linked street action to social media using the hashtag ‘#feesmustfall’. They connected with student protests against racial inequalities in academia earlier in the year and ended with a statement from President Zuma that fee rises would be ruled out for the next year. Spread on twitter, facebook, blogs and news outlets, the images of protest by students, ’born frees’ who never experienced apartheid rule, evoked images of 1976 student protests against apartheid language policies. These protests, nearly 40 years apart, have very different contexts, notwithstanding the generational rift that some say has grown in these four decades in South Africa between those who fought the ‘struggle’ who are now in government, and those ‘born free’ after 1994, resisting policies of exclusion, new and old. However, both previous and current struggles appear to have been driven by imagining a different future. In a 2013 interview, Achille Mbembe noted how the promise and vision of a different, just future was a key driver in the anti-colonial struggle. Youth today continue to envision a just future, and protest where the actions of the present governing institutions take them away from it.

How we imagine, visualize, communicate and share the imaginings of our futures appears to be important for how we organise to realise them. One force affecting future wellbeing in east and southern Africa is urbanisation. Masterplans for many African cities were shaped by colonial policies of segregation, at a time where today’s growth and poverty levels were not anticipated. The way cities and people have grown in and around these initial urban plans can appear disorganised, violent and unhealthy, with infrastructural and social challenges, where formal institutions and services struggle to cope using current resources and tools. For example, Lusaka, Zambia was built to a colonial garden city plan that has been taken over by ‘unplanned’, and formerly illegal, settlements on its North, South and Western fringes. A new masterplan is being implemented in the city, drawn up in 2009 by the Japan International Cooperation Agency, commissioned by the Zambia Ministry of Local Government and Housing and Lusaka City Council. It seeks to address the challenges by restructuring the city and demolishing homes and businesses in the formerly ‘unplanned’ settlements, all of which are sites of Lusaka’s significant informal activity. Aspects of such plans, which include ‘multi-facility economic zones’ to attract foreign investment and low density gated developments, portray a vision of an African urban future which excludes some and privileges others.

Ironically, those engaged in informal waste recycling in the city are currently drawing some income from these developments, as they have created a source of construction waste which can be collected and recycled into further building materials in the city. Women, facing significantly lower earnings than men, play a significant role in recycling construction waste, innocently contributing to the construction of spaces that will ultimately exclude them, economically and physically, pushing them into less healthy and more marginal spaces. Filip De Boeck in ‘The Johannesburg Salon’ in 2011, highlights this irony, pointing to a similar process in Kinshasa. He adds that this not only affects peoples’ physical conditions, but also their imaginings of their cities and even their own self-image and perceived place within the cities. Farmers at risk of relocation due to a ‘Cité du Fleuve’ development commented to him, "Yes, we'll be the victims, but still it will be beautiful."

Alternative practices reflect and support different imaginings of urban futures and the power residents have to affect them. A recently formed Master’s in Spatial Planning program at the University of Zambia (UNZA) has, for example, investigated informal sites in Lusaka, home to nearly three quarters of the city’s inhabitants, according to C. Swope in 2014. The University is advancing a ‘Community Led Slum Upgrading and Planning Studio’ project in collaboration with the Lusaka City Council and the non- government organisation ‘People’s Process on Housing and Poverty in Zambia’. This work brings together students, local government officers, civil society members and residents to decentralise how urban plans are made, sharing and learning from their different experiences, capacities and visions of the city and its future. For example, in the Mahopo Enumeration Project in 2015, the university and the Peoples Process on Housing and Poverty in Zambia, Zambia Homeless and Poor Peoples Federation and Lusaka City Council collectively surveyed the Mahopo Informal Settlement in Lusaka. They engaged young people living in the area to survey their own environments and analyse the information gathered. Through this the community identified health and education facilities as priority areas of concern, followed by the quality of housing units and access to markets. The actions proposed by residents, students and council involve all stakeholders in their implementation.

In the battle for ideas, there is power in who draws, controls and shares visions, even more so with the expansion of information and social media. Beyond the statistics of mortality and disease, or the numbers of toilets and coverage rates, those who seek to build healthy cities should not forget to engage with our visions of the future, especially those we hold as young people. Edgar Pieterse of the African Centre for Cities described, at an International workshop on African cities in 2012, how imagined visions of the future in the speculative design of cities have been used in neoliberal discourse to assess risk and promote designs that contribute to social exclusion. But speculation of the future, in design, art, writing, science and politics, also provides a space that can be occupied by communities to imagine and share alternative futures. Speculation and visioning is by definition born from the inside, from one’s imagination. As seen with South Africa’s students or the alternative urban design in Lusaka, when residents, students and other social groups are given space to shape and communicate vision, it can be a potent motive force in bringing people together to resist harmful practice, and more importantly to realise fairer, more inclusive alternatives.

This issue of the newsletter highlights some of the spaces where this kind of imagining is taking place. For example, Justices Sachs and Cameron, of South Africa’s Constitutional Court, describe how the Court’s Art Collection provides a repository of visions of the ideals of human dignity, equality and freedom in the country. These pieces communicate the values of the court and engage the collective imagination in ways that words cannot. Jonathan Dotse, curator and writer on AfroCyberPunk, explores a future Accra in his short story ‘Virus!’ in which a young woman’s control of her health is mediated by an internal ‘biocore’ computer connected to a city wide digital grid, which 3bute hyperlink to videos, drawings and other imagined narratives from the continent on people’s scenarios of future urban epidemics. OpenParlyZW is an online non-partisan initiative created by a group of young people to demystify what is taking place in parliament for young people, using social media, opening new conversations around these ‘houses of power’ in their futures. These and other examples in the newsletter provide many ways in which sites of dreaming, counterfactual thinking and urban speculation are taking place, all aiming to reinvigorate the social and political imaginary and open opportunities for inclusion in the thinking about and struggle for healthy African urban futures.

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

Challenges of high costs, out of pocket spending, regulation and quality affect the contribution the for-profit private sector makes in healthcare, according to presenters in a session on ‘Private sector and Universal Health Coverage: Examining evidence and deconstructing rhetoric’ hosted by Oxfam and Dr. Anuj Kapilashrami, of the Global Public Health Unit, University of Edinburgh, in the July 2015 International Conference on Public Policy.

The session aimed to look at new and existing evidence on the role of the private for-profit sector in health, and to critically evaluate this in the context of achieving UHC in low- and middle-income countries. The five papers on experiences in Asia and Africa presented at the session looked at a wide range of private sector actors in health care delivery but raised a number of common themes and challenges.

One common feature was high levels of out-of-pocket spending (OOPS), or cash payments by households for services, medicines and other charges. This was found for example where state insurers pay for services from private providers. Asha Kilaru presented study findings that people covered by state insurance schemes in Karnataka, India still had out of pocket spending for services, even for schemes where all costs should be covered. The study found that 93% of those insured by at least one government scheme sought care from a private hospital, and that only 8% reported receiving completely free care. Even where healthcare was provided for free, additional costs, such as multiple hospital referrals for different tests and treatment, meant OOPS still occurred. One of the respondents’ interviewed in the study stated:
‘Only the operation [C-section] was free. At the government hospital, a C-section would be only Rs3-4000, but we went to a private hospital since we had insurance and wound up spending so much. It seems like government are agents that send us to a private hospital. In this yojana [Yeshasvini insurance scheme] the government spends and we also spend’.

As the respondent indicated, high costs of care can be a burden to both households and the state. While this particular scheme (Yeshasvini) claimed to be self-funded, Kilaru found that it received Rs. 40 crore (equivalent to more than US$6 million) as a government grant in 2012-13 and Rs. 45 (or almost US$7 million) crore in the 2013-14 budget.

Jane Doherty, from University of the Witwatersrand, South Africa presented evidence in the session on the for-profit private healthcare sector in east and southern Africa. She noted that out of sixteen countries, ‘no country places a ceiling on the prices that its private hospitals may charge’ (although there may be some limitations to reimbursement payments made by insurers in two of the countries). Her study found ‘little control of the fees charged by health professionals or limits placed on their total incomes, except in Kenya’.

These challenges in controlling out of pocket spending and the overall costs of private healthcare present significant obstacles to achieving universal health coverage, and especially to ensuring access to healthcare for the poorest. Another recurring barrier to equitable access that was highlighted is the location of private services. Indranil Mukhopadhyay of the Public Health Foundation of India reported from a mapping of India’s private healthcare provision that urban, metropolitan areas have the majority of private hospitals. In rural areas, where more poor people live, the private sector is largely comprised of individual practitioners. Moreover, almost half of India’s private hospitals were located in cities with a population of more than 5 million. Mumbai alone has 16% of all India’s private hospitals. The same bias towards urban provision was reported by Jane Doherty in east and southern Africa.

Iornumbe Usar, of Queen Margeret University, Edinburgh, investigated perceptions of shops selling medicines in Nigeria. His paper for the session highlighted major concerns around ‘pervasive regulatory infringements’ by these shops, especially in selling medicines beyond the scope of their licenses, as well as the lack of training of their staff. The paper raised the challenges of regulating medicine vendors in Nigeria in order to improve their quality, highlighting how this has been constrained by inadequate funding, weak institutional capacity, the often-remote location of the shops, and conflicts between the different agencies responsible for regulation.

The same problem of poor regulation was reported by Jane Doherty in relation to for-profit private providers in east and southern Africa. Both an absence of regulation, and poor enforcement of regulation where it exists, were found to contribute to distortions in the wider health system, such as in treatment decisions or in the brain drain of health personnel from the public sector. She observed that ‘there is little monitoring by governments of quality and health outcomes, or attention to how the private health sector supports national health objectives’. She observed that there is also little regulation to guard against anti-competitive behaviour, such as when insurers, providers and pharmacies are all owned by the same company. She flagged in her presentation the challenges to regulation in the region, including patchy regulatory frameworks, the high cost of introducing new regulation, limited available information on the private sector, and the resistance of key stakeholders to regulation, or their “capture” of regulation to safeguard their own interests. In South Africa, for example, attempts to regulate dispensing fees for pharmacists have been resisted heavily.

As Doherty concluded, these ‘legislative gaps and enforcement problems, together with the fact that prices are not contained in any meaningful way, either through price controls or active reimbursement mechanisms, mean that for-profit private care in the region is likely to become increasingly unaffordable for any but the wealthiest’. Yet, Doherty also concluded that the for-profit private sector is growing, so that these impacts need to be addressed.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information see the full papers from the meeting at http://tinyurl.com/psma5ov; Oxfam’s 2009 paper “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” www.oxfam.org/en/research/blind-optimism and the EQUINET discussion papers 87 http://tinyurl.com/3gky5k2 and 99 http://tinyurl.com/ou2dh4n on the growth and legislation of the private health sector in east and southern Africa. Oxfam will be hosting additional discussion on its Global Health Check blog on the issues raised in the coming months.

In a 2015 report on the Representation and Participation of Key Populations on Country Coordinating Mechanisms (CCMs) in Swaziland, Lesotho, South Africa, Botswana, Zimbabwe and Zambia, (http://tinyurl.com/obuudjv) Aidspan noted that key population representatives (KPRs) “have often in the past been seen as somewhat token CCM members” and that “their ability to contribute, and the quality of their participation in the processes of these bodies [is] unclear”.

We believe indeed that building the capacity of KPRs to contribute their indispensable share to the governance of Global Fund-supported programs is a central condition for achieving the vision of ending HIV, tuberculosis and malaria as public health threats by 2030.
Women and girls, men who have sex with men, people who inject drugs, transgender people, sex workers, prisoners, refugees and migrants, people living with HIV, adolescents and young people, orphans and vulnerable children… Giving those groups a voice by opening the doors of CCMs to their representatives is a major step in the right direction. But to unleash their potential to be heard and become a trusted force for change, they need support to build essential skills and competencies.

The Global Fund and its success against AIDS, TB and malaria owe a lot to the extraordinary contributions of civil society representatives worldwide. With the new rules of engagement in the Global Fund governance systems, activists with high levels of formal education are now making room for a new generation of civil society representatives, whose level of preparedness varies considerably, as highlighted in the Aidspan report. These new arrivals must absorb a tremendous volume of information and data that is made available, at an increasing speed, about the Fund, its partners and health-related issues.

A variety of toolkits, manuals, guidelines, tutorials and training workshops has already been produced around Global Fund policies and processes. But these good initiatives are scattered, developed separately, written primarily in English, sometimes in French and Spanish, and generally not designed with a focus on the specific needs of less-educated or extremely marginalized groups. Let’s face it: how many KPRs have been efficiently trained through sporadic two or three-day workshops? How many have excelled basing their knowledge and understanding of program implementation through Global Fund orientation sessions? Self-education and workshops cannot by themselves be substitutes for a better structured and adapted training curriculum for KPRs.

In a 2014 study on the engagement in the funding model of key populations from 11 countries (at http://tinyurl.com/qxwuzd7), the Global Fund Board’s communities delegation observed: “In cases where community representatives had received capacity building over the longer term, KPs were empowered to engage, raise concerns, challenge existing power structures and decision making processes and influence final outcomes. In cases where capacity building was lacking, KP representatives were engaged only in a tokenistic way and faced stigma during the process, labelled as incompetent and seemingly reinforcing negative preconceptions about key affected communities”.

KPRs have access to extended networks and an intimate knowledge of the needs and priorities of some of the most hard-to-reach communities. They bring a unique expertise that other CCM members, be they doctors, academics, government representatives or other high-level officials don’t have. But to make the most of it, to enter CCM discussions confidently and influence public health decision-making in a credible way, they must learn to speak the language spoken at CCM meetings and in public health circles. They need to master the technical complexities of Global Fund procedures and be fully at ease with using the language of decision makers to represent the interests of their groups. This needs long-term capacity building.

We see four main components for such a curriculum, which could be conceived as a training-of-trainers program to reach out to members of marginalized communities in their own languages. Program management, from design to evaluation, is an area where KPRs and communities can bring true innovation, especially in monitoring and qualitative program evaluation. Good governance of their own community organizations is another essential component of their credibility. Advocacy is a third area that requires special skills, especially in the context of a complex international multistakeholder partnership. To develop and implement effective strategies that attract attention to their cause or to play constructive watchdog functions, KPRs must be able to conduct needs assessments and evaluations of service delivery systems, notably public ones.

Underlying those three areas, the importance of information literacy cannot be overstated. To keep learning, KPRs must develop essential skills to navigate their way through a vast and expanding array of information resources (websites, social media channels, mailing lists, databases, etc.). This is critical to building their networks, understanding where their priorities fit in the bigger picture, and keeping a strategic watch over the most relevant developments in their field of interest while avoiding information overload.

This may seem like a formidable challenge. The good news is that today’s internet offers cheap and reliable channels to deliver certified courses in multiple languages at no cost to participants, to connect to a global and diverse audience, reaching out to distant individuals at their own pace and offering a space for networking with their peers around the world. Although face to face training will remain indispensable to provide more targeted support, open online courses can offer an extraordinary channel to deliver training to very large groups, to monitor its results and to address concerns over fake, ineffective and costly training. The KPRs’ skills and knowledge gaps, as well as the technology to deliver a program that addresses them, can quite easily be figured out. For the Global Fund and its partners, it is mostly a matter of making this a priority and investing in the design and development of a curriculum for maximum impact, in a coordinated way.

Community leaders and KPRs represent the untapped ‘human resources’ of current and future public health efforts. By pooling together different capacity building initiatives and internet possibilities, public health training for KPRs is at our grasp. Let’s support their capacity to be heard, if we really hope to win the fight against disease.

A longer version of this post was published in Aidspan’s Global Fund Observer newsletter Issue 266 28 May 2015 http://tinyurl.com/pd7bhz3 and in R. Bourgoing’s Aid Transparency blog at http://tinyurl.com/owr4qb2 and it has been used with the authors permission. Hélène Rossert is a US-based Global Fund advocate and former Vice Chair of the Global Fund Board. Robert Bourgoing is an aid transparency advocate and trainer, and former Manager of Global Fund Online Communications.