Dr Tedros Ghebreyesus is the first African to be elected as the Director-General of the World Health Organisation (WHO) in its 70 year history. The massive margin for Tedros – 133 votes vs 50 for the UK candidate – suggests that the entire Global South voted for him. Professor David Sanders in this interview suggests that the vote almost certainly represents a vote against big power domination and machinations in the WHO which often appears to ignore the main challenges and aspirations of low and middle income countries. Professor Sanders notes that Dr Ghebreyesus needs to use his strong mandate – notably from the Global South – to truly reform the WHO and its operations in favour of the world’s poor majority. To do this, he needs to push strongly for member states to honour their commitments to the WHO and to rapidly and significantly increase their financial contributions. He also needs to ensure that the influence of the food, beverage, alcohol and tobacco industries to control non communicable diseases is resisted. This will be difficult given that a framework has been passed that allows non-state actors to participate in WHO policy-making processes. Further he argues that Dr Ghebreyesus must ensure that the health systems of low and middle income countries are strengthened so that health emergencies such as infectious disease outbreaks can be contained. This will ensure that agenda for health security isn’t focused on securing the health of rich country populations against contagion from the poor but on protecting all, particularly the most vulnerable. Hi raises that what will be interesting to watch over the next five years is whether the evident solidarity between low and middle income counties in voting in Dr Ghebreyesus as their candidate is maintained during the debates and decisions about world health.
Governance and participation in health
Uganda has released the result of Demographic Health Survey (UDHS 2016) highlighting the success in family planning and reproductive health. Uganda’s population is the second youngest in the world, with half of the country younger than 15.7 years old (just older than Niger’s median age of 15.5 years). As of January 2017, the population of Uganda was estimated to be 40 million, the age structure defines 49.9% in the below 15 years, 48.1% in 15-64 year of age group and the rest 2.1% are 64+ n the past 10 years, showing increasing growth rate (3.24 in 2016 est.), the country has added more than 10 million, from 24 to 35 million. DHS 2016 showed noteworthy success in maternal health care. Nearly three-quarters (74%) of live births were delivered by a skilled provider and almost the same proportion (73%) were delivered in a health facility which was almost half in 15 years back. Throughout the course of their lifetimes, Ugandan women have a 1-in-35 chance of dying due to pregnancy-related causes; every day, 16 women die in childbirth. However, the overall trend indicates a decline of pregnancy-related mortality over the time. Infant and child mortality rates are basic indicators of a country’s socioeconomic situation and quality of life. The country’s infant mortality rate was one of the highest in the world, but 2016 DHS showed steep declining trend. The Contraceptive Prevalence Rate (CPR) has risen steadily from a low starting point and moved upward sharply in most years in Uganda, on the other hand the unmet need of contraceptive is showing gradual decreasing trend. As the country’s population continues to grow, the majority of that growth is taking place in rural areas, where access to health services is extremely limited. PPD argues that with the call for universal access to reproductive health and family planning, the country is moving rapidly towards this goal. Such progress will help the country move closer to the targeted demographic that are linked with the larger development goals. Significant effort is argued to still be required to mitigate rural-urban disparity. Political commitment beyond the health sector, partner collaboration, community provision to increase community engagement is reported to lie behind the trends in the DHS key indicators report.
This paper seeks to advance the authors’ understanding of health policy agenda setting and formulation processes in a lower middle income country, Ghana, by exploring how and why maternal health policies and programmes appeared and evolved on the health sector programme of work agenda between 2002 and 2012. The authors theorised that the appearance of a policy or programme on the agenda and its fate within the programme of work is predominately influenced by how national level decision makers use their sources of power to define maternal health problems and frame their policy narratives. National level decision makers used their power sources as negotiation tools to frame maternal health issues and design maternal health policies and programmes within the framework of the national health sector programme of work. The power sources identified included legal and structural authority; access to authority by way of political influence; control over and access to resources (mainly financial); access to evidence in the form of health sector performance reviews and demographic health surveys; and knowledge of national plans such as Ghana Poverty Reduction Strategy. The authors argue that understanding of power sources and their use as negotiation tools in policy development should not be ignored in the pursuit of transformative change and sustained improvement in health systems in low- and middle income countries.
This article reports on the work of HealthNewsReview.org to monitor the quality of health and medical news coverage. To combat inaccuracies, HealthNewsReview requires three reviewers to assess each article, applying 10 criteria. These include whether the journalists have adequately considered the cost of the intervention, its potential harms and benefits, whether they had compared new ideas with existing alternatives, and whether they solely relied on a press release or used independent sources. Projecting forward, the author observes that there should be room for promoting health literacy, for example, explaining that people should focus on absolute not relative risk reduction. People should not be amazed by claims that a drug reduced the risk of a problem by 50% (relative risk reduction) when that may mean that the absolute risk reduction was only from 2 in 100 in the untreated group to 1 in 100 in the treated group – a 1% absolute risk reduction.
The health sectors of most countries focus almost exclusively on health care services. The potential of multi-sectoral collaboration thus remains untapped in many low- and middle-income countries. Different sectors have different contributions to make towards solving specific health problems. The authors argue that in each case, the profile, interests, incentives, and relationships of key individuals and sectors must be mapped and analysed to inform the design of approaches and systems to tackle a shared problem. The authors argue that collaborative and distributed leadership is key for effective governance of multi-sectoral action, with a need to build leadership capacity across sectors and levels of government and cultivate champions in different sectors who can agree on common objectives. They present options for countries to take a multi-sectoral approach for health, including ensuring that the universal health coverage agenda addresses the capacity of the health sector to work with other sectors, learning from multi-sectoral efforts that do not involve the health sector, improving the capacity of global institutions to support countries in undertaking multi-sectoral action, and developing a clear implementation research agenda for multi-sectoral action for health.
PLOSBLOGS hosted a question and answer with the three final candidates for the World Health Organisation (WHO) Director General being directly elected by countries in the 2017 World Health Assembly. The article provides the questions and interview responses in full. The authors note in an analysis of the candidates’ responses that none of the candidates discussed issues of social justice in their responses regarding the societal determinants of health or mentioned the recommendations of the WHO Commission on Social Determinants of Health on global power asymmetries, specifically the need to “tackle the inequitable distribution of power, money, and resources.” In terms of the role of non-state actors in neutering public accountability at WHO, none of the candidates articulated the intrinsic differences in power and access between public-interest entities and corporate/philanthropic actors under the non-state actor rubric. All three seem to think FENSA will resolve the problems of private influence on the WHO agenda, which the authors of the article doubt. To improve health and health equity, all three candidates invoked Universal Health Coverage without specifying the role of public provision, comprehensive coverage, and equity in access, quality, and financing for health care systems. In relation to health equity and social determinants of health, all three candidates mentioned intersectoralism and social inclusion, partnerships, and WHO technical expertise, but did not give attention to the political context of these challenges.
In the past three decades in Ghana, the number of city dwellers has risen from four to 14 million; more than 5.5 million of whom live in slums. Urban growth exerts intense pressure on government and municipal authorities to provide infrastructure, affordable housing, public services and jobs. It has exacerbated informality, inequality, underdevelopment and political patronage. Some commentators warn of an impending urban crisis. Policymakers and international donors continue to prescribe better urban planning, slum upgrading, infrastructure investment and “capacity building” to “fix” African cities. While these are necessary, the authors argue that the success of any urban strategy depends on an informed appraisal of the political dynamics of urban neighbourhoods that define governance in Ghana’s cities and slums, in the interaction between politicians, entrepreneurs, traditional authorities and community leaders. The authors note that informal networks pervade formal political institutions and shape political strategy, and that political clientelism and the role of informal institutions are deepening alongside the strengthening of formal democratic institutions, but are often overlooked.
The author argues that destruction of the environment, human rights abuses and mass displacement have been ignored in the name of “development” that works to intensify neoliberal inequality. In response to legal attempts to hold it to account, the author argues that the World Bank has declared itself above the law. The latest attempt at accountability is a lawsuit filed in the U.S. federal court in Washington by EarthRights International, a human rights and environmental non-governmental organisation, charging that the World Bank has turned a blind eye to systematic abuses associated with palm-oil plantations in Honduras that it has financed. EarthRights International alleges that the World Bank has “repeatedly and consistently provided critical funding to Dinant, Honduran palm oil companies, knowing that Dinant was waging a campaign of violence, terror, and dispossession against farmers, and that their money would be used to aid the commission of gross human rights abuses.” The lawsuit reports that the International Finance Corporation’s ombudsman said the World Bank division “failed to spot or deliberately ignored the serious social, political and human rights context.” These failures arose “from staff incentives ‘to overlook, fail to articulate, or even conceal potential environmental, social and conflict risk’ and ‘to get money out the door.’ ” Despite this internal report, the suit says, the World Bank continued to provide financing and that the ombudsman has “no authority to remedy abuses.”
With the renewed call for community participation in health interventions after the Alma Ata Declaration, interest has been raised in volunteer community health workers (CHWs) acting as representatives of local communities. This study interrogates the dynamic interface between local communities and the government in the selection of CHW volunteers in a rural community. Data were collected through participant observation of community events, 35 in-depth interviews, 20 focus groups and 15 informal conversations and review of documents about Luwero district. Ambiguous national guidelines and poor supervision of the selection process enabled the powerful community leaders to influence the selection of village health teams (VHTs). Intended to achieve community involvement, the selection process was found to produce a disconnect in the local community where many members saw the selected VHTs as having been ‘taken away’. The authors argue that community involvement in the selection of VHTs took a form that, instead of empowering the local community, reinforced the responsibility of those in power and thus maintained the asymmetrical status quo.
During a recent civil society consultative meeting held in Karamoja sub-region in North Eastern Uganda to discuss with locals the review of mining law and policy in Uganda, participants from the community made statements about mining operations in the region: One participant stated; “As we talk here trucks and trucks ferry marble and the people of Rupa swallow dust.” Another participant said; “ they come here and cordon off large pieces of land beyond what is allowed under their licenses and the locals have nowhere to graze their cattle. They forget we are a pastoralist community. No one asks us whether we want the mining in the first place. We just see companies show up in our midst.” Karamoja sub-region in Uganda is endowed with a number of minerals including gold, marble limestone, gemstones and silver among others, and plays host to roughly 20 companies involved in the mining sector at different stages. However, this report suggests that there is a disconnect between local communities and the mining companies. Community members said they had very limited information about the sector, and complained of lack of consultation, exploitation and human rights abuses by the mining companies. The authors argue that local communities and indigenous people have the right to be consulted about mining projects because they bear the brunt of the negative impacts of mining, and as prior, informed consent is now a well recognised international best practice. This should, they propose, be included in law. They point, for example, to the Tanzania Mining Act 2010 that ensures that no discussions of mining can be engaged in without the representation of civil society and local small scale miners. In Ghana, New Mont Gold Company has adopted the use of community agreements, while the World Bank has published a Source Book – Mining Community Development Agreements, 2012 on how to develop and implement such community agreements.