The barriers researchers face in having qualitative research published in many mainstream health and medical journals is limiting our understanding of important dimensions of health care. At a time when health systems are increasingly involving a range of disciplines in health teams and using more holistic models to respond to the mix of physical, psycho-social and environmental factors that lead to ill health, excluding qualitative work deprives decision makers of a significant body of knowledge that could inform decision making on health systems. “Furthermore, this effectively silences the voices of community members, particularly those who are marginalised across all countries”.
So argued 170 co-signatories from all regionals globally of a letter from the Social science approaches for research and engagement in health policy & systems (SHaPeS) thematic working group of Health Systems Global, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), and the Emerging Voices for Global Health. The full letter was published in June in the International Journal for Equity in Health and can be read at http://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0368-y
The signatories raised that many issues that affect both the effectiveness and equity of health systems cannot simply be ‘measured’ by numbers alone. Issues such as the subjective relationships and communication between health workers, clients and communities, the perceptions of and trust in services, the role of social literacy, or the values and preferences that managers, health workers and communities bring to systems affect health outcomes and therapeutic relationships. One young researcher argues in the letter that qualitative work “facilitates my understanding beyond what the numbers show”.
Researchers in east and southern Africa have in past EQUINET forums voiced similar views. They have raised the difficulties they face in publishing generally, not only in meeting the format, style and other demands of a journal paper, but also in finding the time for the process, given competing time pressures. Those working with qualitative research appear to face even higher barriers. The signatories to the letter stated “We are particularly disenchanted by our general experience of the limited and often inadequate publication of qualitative research in the major health and medical journals, and the resultant loss of important insights for those working in, or concerned with, health services and systems, including around clinical decision-making”.
For those working with participatory approaches the barriers can seem even more insurmountable. At a 2014 regional workshop on participatory action research, researchers raised that most traditional journals - and many funders - do not understand or appreciate these approaches. One researcher, from Malawi, described that despite his research leading to real changes, publishing it was an uphill task, calling for constant efforts to make to justify the approach, the role of community members as partners in the research and the use of subjective or qualitative evidence. Indeed in another article in this issue of the newsletter the authors comment: "research and publishing is the oxygen of academic life. But the regimes of control that surround contemporary approaches to publishing are choking creativity..."
The letter published by the health system researchers argues for methodological diversity in mainstream publication on health systems research, to build a more holistic and richer understanding of complex systems. Given the multiple factors, including subjective, dynamic and social factors, that influence health and the way services are delivered and experienced, it would indeed seem to oversimplify reality to give singular dominance to the old maxim that “what is measured counts” at the cost of the wider range of methods and lenses that we have to explore, analyse, and understand what counts.
The full letter referred to in this editorial was published as SHaPES, EQUINET, Emerging voices for global Health, Daniels, Loewenson et al., 2016, International Journal for Equity in Health 15:98 DOI: 10.1186/s12939-016-0368-y. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org or to the SHaPES working group in Health Systems Global http://www.healthsystemsglobal.org/
Editorial
Health Centre Committees (HCCs) are a mechanism through which community participation can be integrated into the health system to achieve a sustainable people-centered health system.
These community-based committees are increasingly becoming an established voice of the communities providing input into the health service delivery processes in the 16 East and Southern Africa (ESA) countries covered by EQUINET. In the Ngombe area of Lusaka, Zambia, for example, the Neighborhood Health Councils with local government have successfully addressed water and sanitation, garbage and housing concerns. In Kenya, Health Facility Committees manage funds from the Health Sector Services Fund for primary care, outreach and community based services. They link the facility with the community, to plan and oversee the performance of the services.
In a regional dialogue, delegates from ESA countries urged national authorities to better recognize and work with HCCs. Their recommendations, captured in EQUINET Policy Brief 37, included reforming public health laws to include provisions for participation and public information and to set laws that provide for the roles and duties of HCCs, backed by adequate information, training and resources for them to play these roles.
To advance these recommendations a consortium of organizations have come together in EQUINET to build and strengthen the capacity and effectiveness of HCCs, led by the Community Working Group on Health (CWGH) in partnership with the Training and Research Support Centre (TARSC) on photovoice and information sharing; University of Cape Town (UCT) School of Public Health on training programmes; and the Lusaka District Health Management Team (LDHMT) on legal provisions. With work in Kenya, Zambia, Malawi, South Africa, Uganda, and Zimbabwe and at ESA regional level, we are advocating for policy and legal recognition of HCCs, giving visibility to their roles as well as identifying and strengthening the different capacities that committees, communities and the health systems need for HCCs to implement these roles. This includes areas such as tracking and monitoring health system budgets and resources and their use and health system performance as well as the building social dialogue and accountability.
As part of the work, UCT in South Africa is building a database of information on the current training materials and training programmes for HCCs to enable us to share materials, skills and experiences on capacity building in the region, and to advocate for HCC training that addresses their roles comprehensively. and their coverage of the key areas of functioning. LDHMT in Zambia has initiated an in-country process to review the laws and regulations that provide for the establishment and functioning of HCCs, and to document the Zambia experience for wider regional exchange. In Zimbabwe, the CWGH has supported the HCCs to engage with government, so that HCC members can speak out about their concerns on the health system and on the support they need to successfully implement their roles. Training on community photography by TARSC means that the members have visual tools as well as words to raise evidence on their problems and progress.
Most ESA countries still do not have laws that explicitly or adequately recognise the functioning of the HCCs. We are thus advocating for their legal status and for them to have constitutions. This is important for their accountability to communities. It is also necessary if they are to directly receive, manage and account for public funds as was the case with Neighbourhood Health Committees in Zambia in the 1990s. The HCCs’ current vague mandates weaken their effectiveness, role and legitimacy, for communities and local actors and at national-level. We are thus sharing information on HCC constitutions, and on laws, statutes or guidelines on HCCs in the region and promoting their inclusion in law, including by showing their important positive role in the health system.
As a consortium, we are building a regional database of institutions and organizations working with HCCs in ESA countries so that we can better exchange and share information on the training materials, programmes underway with HCCs and the learning from them. We invite colleagues to send information to EQUINET if they are working in this area. We are building innovative ways of sharing and learning from our work, that build more direct voice, such as through photovoice where cameras are being put into the hands of communities and HCC members to identify and document community perspectives, experiences and actions related to their health conditions to be used in local HCC dialogue and wider reflection and learning.
Members of HCCs are carrying out exchange visits to allow for more direct learning and collective understanding of problems and achievements, creating inspiration to keep working and resulting in the launch of new initiatives.
We have seen evidence of the positive impact of HCCs in improved health outcomes. In Zimbabwe for example, since 2009, HCCs have played a role in in decision-making on the use of performance based funds at clinics, promoting improvements in facility-based deliveries, improving uptake of antenatal care and postnatal care visits and supporting demand by communities for these resources to be used to ensure delivery on patients’ rights at clinics. They have also mobilized resources to develop clinics such as by building waiting mothers’ homes, fencing clinics, supporting community health workers and raising advocacy on the needs of local services at higher levels.
We are seeing an increasing appreciation of the role of HCCs in community and primary care health interventions, with increasing attention and support from government, international and national partners. Our HCC in-country exchange visits are proving to be an effective way of sharing knowledge and good practice, inspiring others to see their own potential and act when they see the practical successes of other HCCs. “HCC exchange visits are rich in knowledge and should always be a key part of HCC activities carried out at local, district, provincial and national levels,” said Brighton Ngoteni, the HCC chairperson of Mudanda Clinic in Manicaland, Zimbabwe.
Our regional exchanges have also shown us that HCCs can only be as strong as the communities that support them. For this, we need to have recognition of the right to health, including on constitutions in the region, and comprehensive primary health care approaches that support health literacy and that inform communities, include communities and the views they bring in plans and services and give feedback to the communities for a people centred approach to universal health systems.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org and find further publications on the issue on the EQUINET website at www.equinetafrica.org
In social theory, the dominant state is known as the hegemon. In the 19th century, hegemony came to denote the ‘Social or cultural predominance or ascendancy; predominance by one group within a society or milieu’. However, commentators on power have also used the term to describe the power of discourse - particularly in the field of governance. In this note we wish to draw attention to, and challenge, what we fear is an emerging hegemonic discourse in the field of health policy and systems work - the discourse of resilience.
In the past five years ‘resilience’ has been increasingly applied in health policy and systems research (HPSR) to refer to the need for distressed health systems (micro or macro) to ‘bounce back’ from shocks. Often implicit in this discourse, is the assumption that such systems were ‘there’ in the first place, or at the very least, that with a concerted effort they can get there. What a resilient health system means in this context is not clear - but we contend that, in a form of technocratic reductionism, resilience strategies and solutions are often divorced from meaningful assessment of the political economy and power dynamics that produced the health system crises in the first place.
Health systems in crises suffer from chronic deficiencies in many things - material and human resources central-level planning and coordination capacity and domestic financing to name but a few. The populations and communities seeking services from these deficient systems are more likely to have low levels of education, weak citizen engagement and to experience deep class inequity. Much of the technocratic discussion around ‘building resilience’ appears to bypass these issues, however, often focusing on tweaking inputs or health system components, and frequently emphasising self-reliance and behaviour change. This technocratic and formulaic approach to building resilience is at odds with the complex reality of health systems in each country.
‘Building resilience’ rarely seems to involve a direct examination of, or challenge to, the structural conditions that contribute to overarching health system dysfunction, including historical colonial legacies, current trade and aid structures, tax and health insurance structures. We are concerned that the discourse of resilience will follow the trend of global health policy reforms being fuelled by the perceived immediacy of a problem instead of careful analysis of root causes and strategies likely to prevent recurrence in the long-term. Recent examples include the Ebola epidemic and now Zika, in which resilience discourse is getting close to that of the global health security agenda in which the main concern is transnational epidemics from the south to the north. The rise of hegemonic resilience discourse has effectively enabled global health stakeholders to replace the conversation about systemic failures at multiple levels which supports a far more long term vision, with an action-oriented discourse that implies much shorter time-frames.
A conscious discussion is needed to reframe what the health system community means when we use the term ‘resilience’. Resilience and the linked concept of sustainability of health programming have value, as long as they are not divorced from the material changes that need to occur to support them and the requirement for a more balanced relationship among national states (trade, flow of resources, and others). Use of these terms should build on previous work and consensus around social determinants of health, right to health and people-centered health systems. This means resilience should be situated on a continuum rather than replacing important advances around health systems and its relation with equity, fairness and human rights.
Ultimately, we contend that a more ambitious and nuanced application of the term ‘resilience’ is required if the term is to contribute to improving LMIC health systems’ capacity to withstand political, financial, epidemiological and environmental shocks. We must also do everything possible to prevent such shocks in the first place. But at the very least, we in the health policy and systems community need to start acknowledging the dangers of using ‘resilience’ as part of a de-politicised and technocratic discourse.
This piece was first posted as a blog for Health Systems Global (HSG) http://tinyurl.com/j968dqc. The authors are thematic leads of the cluster on Power in Health Systems in the SHaPeS Technical working group of HSG. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
Successive epidemics of international concern such as SARS, Ebola, Zika have raised the focus on responses to health emergencies, as ‘global health security’. It has also given new attention to the implementation of the International Health Regulations (IHR), including as an agenda item in the World Health Organisation’s 2016 World Health Assembly.
The IHR were adopted globally by member states in the WHO in 2005, including by all 46 countries in its Africa region. They seek to prevent, protect against, control and provide a public health response to the international spread of diseases “…in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” Countries were required by June 2012 to have developed core public health capacities for surveillance, reporting on and response to public health risks and emergencies, including at ports of entry. This includes capacities to provide specialized staff, multi-sectoral teams and laboratories and local investigations to prepare for, prevent and rapidly contain and control cross border public health risks that may be due to infectious diseases, food safety, and to chemical, radiation and zoonotic hazards. Countries unable to meet these core capacities by June 2012 could request for an extension to 2014 and in exceptional circumstances to June 2016. So we are now a month away from the time all countries were expected to have achieved these core capacities.
These capacities are not delinked from the core capacities needed to protect public health within countries, nor from comprehensive primary health care approaches that seek to engage all sectors to promote health and prevent ill health. Within countries, these capacities are not just a matter for the health sector. They call for society, state, private sector and non-state organizations to promote public health. For example, preventing communities living near mines from being poisoned by arsenic or mercury contamination of water, soil, and food calls for intervention from local authorities, planners, mine managers, state sectors responsible for infrastructure, mining, environment, health and labour, workers and communities. This includes workers and families who migrate from other countries to work on mines and who may otherwise return with long term lung, gastrointestinal, neurological or renal problems. While focusing on cross border risks, the presence of uncontrolled environmental risks, or of cholera, typhoid and other epidemics within African countries is not unimportant for the IHR, and certainly not for people in that country. These problems signal weaknesses in public health that may lead to risks spilling across borders. They may also arise from trade or economic determinants that are international in scope.
Hence, as we approach June 2016, while there has been progress in implementing the IHR, it is a matter of concern that there are still deficits in the core capacities. An October 2015 WHO report compiled feedback from 118 of 196 States Parties to the IHR on a self-assessment questionnaire on progress made in developing these core capacities. It showed that progress had been made globally in legislation and policy; coordination and collaboration with other sectors; improved detection, early warning, preparedness and emergency response capacities and in communication with the public and to stakeholders.
For the African region, reporting by March 2015 showed that African countries were also making progress on a number of core capacities. Not surprisingly given the responses and investments after the Ebola epidemic, the most notable improvements were in surveillance and laboratory capacities. Improvements in these areas are seen to be essential for early warning system for detection of any public health events for rapid response and control, to prevent them spilling over borders. There has been investment in surveillance and laboratory capacities in Africa through an Integrated Disease Surveillance Response, and international support for African and sub-regional communicable disease control centers for detection and early warning of infectious disease risks. There has, however, been less progress in preparedness, in capacities at ports of entry, and in capacities to deal with chemical and food safety risks. It suggests that while the region may be better prepared to deal with infectious disease epidemics, this may not be the case for other public health risks.
The progress suggests that the global health security agenda has given great focus to control of infectious diseases and ‘biosecurity’, not least as a response to the international spread of recent epidemics of Ebola virus and Zika virus. Significant new global resources are being mobilised for emergency responses. Assessment tools and reporting systems are being discussed in the WHO, with some proposals for new global mechanisms, global financing facilities and independent assessment by global actors.
However global health security cannot be reduced to emergency responses and infectious disease control, nor can the prevention of cross border disease be delinked from the measures taken from local to national level within countries and between countries in their regions to strengthen the primary health care and public health functioning of health systems. Uganda was able to respond to its 2000 Ebola epidemic within two weeks from first case to confirmation and controls being implemented. This speed of response was as much to do with the strength of systems within districts and the strength of communication between local and national levels of the health systems as the sophistication of its laboratory capacities. The spread of cholera and typhoid epidemics in Africa draws more from inadequate investment in safe water, sanitation and waste management systems and weak public health inspection than from gaps in emergency preparedness. New viral epidemics are emerging as poor communities and animal vectors are being squeezed into closer proximity by mono-cropping and mining activities; and new emergencies such as rising antimicrobial resistance are deeply embedded in how health systems function and interact with the public and with the pharmaceutical industry. Rising levels of chronic conditions in many African countries that foretell a future crisis of escalating unaffordable costs for countries and households are contributed to by cross border trade in harmful processes and products.
The global health security agenda cannot thus be narrowed to one of emergency responses to infectious disease. Instead, global health security also needs to identify and act on the determinants to prevent such emergencies. The IHR as an overarching umbrella for international public health obligations recognises this. So too, in their intent, do the Sustainable Development Goals. While many determinants of global health security lie outside the health sector, and while resources are indeed needed to deal with emergencies and their economic and social impacts, a health sector response to preventing and controlling emergencies needs to link with and support longer term health systems strengthening. This starts locally, within countries and particularly with the comprehensive primary health care and public health approaches that are needed to identify, prevent and manage risk before it grows into an emergency.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
The EQUINET website and bibliography and newsletter databases will be undergoing a significant software upgrade in February 2016 so we will not be producing a March issue of the newsletter on 1 March 2016. We hope we have given you alot of interesting material ranging from papers, reports, bibliographies, online books and graphics in this issue the meantime and the newsletter will resume on 1 April 2016. We aim to ensure that any periods in which the bibliography databases will be unavailable during the upgrade are as brief as possible. Please email us on admin@equinetafrica.org if you have any queries or feedback, and we also look forward to receiving submissions, reports and articles from you!
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/
The EQUINET steering committee wishes you a healthy new year, and one that brings greater justice in our communities, countries and globally.
This is a short newsletter, given the time of year. However, the EQUINET newsletter is now 15 years old, and the monthly issues share a growing number of stories of both the challenges to health equity, and the many examples of innovative practice within the region. At a recent regional conference in 2015, delegates raised that in our east and southern African region, we still do not adequately document or publish what we are doing, so that our story is often told by others, or not at all. Until the lions write their story, tales of the hunt will always glorify the hunter. We have used the EQUINET newsletter to give more profile to publication from and on our region, and have included journal papers and reports, but also new media such as videos, online interviews, maps, tools, graphics and exhibits. We will be listening even more for this in 2016.
So we are asking you to please speak out and share your ideas, work and stories on health! Please send us your reports, papers, news, conference announcements or other forms of information [to admin@equinetafrica.org], or write a short piece that we can use as an editorial.
We also invite you to be involved in the work that EQUINET will be carrying out in 2016 to inform and strengthen learning and action on health equity. Our website (www.equinetafrica.org) provides more information on these activities.
We look forward to working with you in the coming year!
‘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.
The poorest countries in the world have been unable to reach agreement at the World Trade Organisation (WTO) on relief from global rules that would allow access to much needed medicines for their citizens. The 16 October 2015 meeting to resolve the impasse has been suspended indefinitely according to reports by IP-Watch in Geneva.
At the forefront of resistance to this application from least developed countries (LDCs) were the United States, Canada and Australia, in positions raised in June and again on 16 October. The LDCs have a two-fold demand that amounts to a request for a waiver from the application of WTO rules on intellectual property (IP) rights, such as patents (which protect owners of new medicines), data and marketing rights. Firstly, they have requested an extension of the 2013 waiver related to pharmaceutical products, currently expiring on 1 January 2016. Secondly, they have petitioned through Uganda, as LDC representative, for a general exemption from applying the WTO intellectual property rights agreement (TRIPS), granted until 2021. Their position is that it ought to be granted for as long as countries remain designated as least developed according to the United Nations. Most LDCs are in Africa.
Over 140 non-governmental organisations have come out in support of the LDC petition. Médecins Sans Frontières accused the US, Australia and Canada of seeking to worsen access to medicines in LDCs by weakening the exceptions granted to them.
Some reports imply that LDCs were ‘collateral damage’ for other IP interests for the US. The US Trade Representative failed to reach the high standards of protection sought in the mega-regional trade and regulatory agreement called the Trans-Pacific Partnership (TPP). Commercial US stakeholders were reported in an October 2015 paper by Knowledge Ecology International (KEI) to be upset with the concessions made in this flagship trade deal, with an informed but unnamed source stating, "the TPP did not deliver as expected on IP [Intellectual Property] and so we are under a lot of pressure not to give in more on IP."
In contrast, the LDCs’ proposals were supported by developing countries, including Cambodia, Cuba, Brazil, China, Uruguay and by the Africa Group. Norway and the European Commission also supported the LDCs request, as did the World Health Organization (WHO), the United Nations Development Programme and UNAIDS.
The costly nature of pharmaceutical drug production and the complex rules on production for export to countries with public health needs requires the certainty of a permanent waiver. According to James Love of KEI, "A permanent waiver of drug patent obligations is needed. No country will amend its patent laws if the waiver is limited in time, like the previous extensions...”
The public health basis for the LDC application is also evident. In a statement in June 2015, Uganda’s representative put the case to WTO members that 63% of people living with HIV in LDC countries still had no access to appropriate treatments. The United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States in its 2014 report indicated that most LDCs had not yet met the Millennium Development Goals on health, stating that LDCs “also need financial and technological support to derive maximum development benefits from the waivers granted under the WTO TRIPS agreement.”
LDCs, as the poorest countries in the world, serve as some measure of the level of civilisation of the global economic order. These countries are in effect asked to repeatedly expend scarce domestic resources and diplomatic capital supplicating rich countries at the WTO for exemptions from international rules that clearly do not take their interests into account. It is refreshing that the WHO is taking the side of the LDCs and access to medicines in this instance as the position has been less clear in the past. For example, Third World Network raised in 2010 that the WHO initiatives on “counterfeit” drugs threatened medicines access by conflating legitimately produced generic drugs with drugs that were illegally produced or traded, given that the term ‘counterfeit’ is used to denote trademark infringements in intellectual property rules.
The LDCs request for a waiver signals that the access to medicines activism that secured the 2001 WTO Doha Declaration on Public Health was just the start of a battle against vested interests pursuing profits at the expense of human life. The 2001 Declaration was in fact a statement of legal rights that all countries enjoyed already, but over which poor countries had to ensure legal certainty at global level as they were under threat. For example, the US Special 301 list designated countries deemed to violate intellectual property rights, as unilaterally imposed sanctions with negative economic and reputational effects. Given that the WTO disciplines unilateral action by states that affects multilateral trade, the US undertook to not use Special 301 in violation of the WTO, according to Chakravarthi Raghavan in 2000. However the US repeatedly breached this undertaking, such as in its placement of Thailand on the 2007 watch list for issuing compulsory licenses for patented pharmaceutical products.
The industry has significant lobbying power and the preponderantly US-based branded products pharmaceutical industry is one of the most profitable in the world. According to a 2014 BBC report, the sector made a 42% margin of profit in 2013 in the US, compared to about 29% for the banks. Many US pharmaceutical companies held tens of billions of dollars offshore to avoid US taxes, according to Bloomberg’s Richard Rubin on 4 March 2014.The cost of such concentrated corporate power is evident in the fact that US medicines prices are almost twice that compared to other developed countries. US policies are rationalised with ideas of free trade, competition and the full functioning of markets. The super-profits being made by branded pharmaceutical companies should lead even free trade proponents to be concerned about the enormous rents they extract from the market. The suspension of discussions on the LDC waiver on Friday coincided with the US and developed countries stating they would also not make binding commitments for special treatment of LDCs on other issues at the next WTO Ministerial meeting scheduled for 15 to 18 December in Nairobi.
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.