Nurses play an essential role in the post 2015 global agenda of ensuring universal health care. They make up majority of the health workforce. Health systems cannot successfully function without nurses. They influence how systems function, change or are delivered, through the values, knowledge and experience they bring. Their lives and work are affected by the policy decisions and health system roles that are expected to achieve the post 2015 global agenda. So the Southern African Network of Nurses and Midwives (SANNAM) have argued that nurses must be included in the political and policy discussions and health system transformation efforts currently underway.
The Southern African Network of Nurses and Midwives (SANNAM), a network of National Nurses Associations (NNAs) in the 15th Southern African Development Community (SADC) countries met in Pretoria, South Africa in February 2014 to examine the post 2015 proposals for Universal Health Coverage (UHC). The meeting reviewed the proposals from the ongoing global consultations on the focus post- 2015 for ensuring UHC and sustainable development globally.
The report of High Level Panel of eminent persons on the post- 2015 global development agenda and an evaluation of progress on MDGs 2000–2013 have identified a need to secure the planet for all in a sustainable way and to ensure that the global agenda puts people first and at the centre of future development efforts. These reports identify a universal agenda with transformative shifts in five thematic areas:
i. leaving no one behind as a principle of universality in access, sharing resources and assets in all sectors;
ii. putting sustainable development at the centre, including as a means for improving people’s health;
iii. transforming economies and jobs for inclusive growth, with what is drawn from earth’s resources distributed equitably;
iv. building peace and effective, open and accountable institutions that protect human rights; and
v. forging new global partnerships, given that action in one sector, country, and community influences the others.
These proposals obtained broad support from nurses in the SANNAM meeting.
The performance of health systems is necessary to achieve this post 2015 vision. As the 2011 World Health Organisation (WHO) global conference in Brazil on social determinants of health reported, good health requires a universal, comprehensive, equitable, effective, responsive and accessible quality health system. It also depends on the involvement of and dialogue with other sectors and actors, and on effective collaboration in coordinated and inter-sectoral policy actions. The health sector contributes to sustainable development and human rights, and plays a role in ensuring that economic activities do not harm and do benefit social wellbeing. For example South Africa’s extensive ARV programme has contributed widening the benefit from medical technology and raising life expectancy, and the implementation of the National Health Insurance scheme is mobilizing economic resources for universal access to services.
However, SANNAM delegates noted that health systems in many countries fall short of their potential, resulting in a large numbers of preventable deaths and disability, especially for poor people. While UHC means that all people should be able to use the quality health services that they need and do not suffer financial hardship in paying for them, many countries are not achieving this.
So while the goals are noble, a lot more attention needs to be given to how they will be achieved. In the SANNAM meeting, nurse leaders from all countries in the region discussed this further. There are a number of challenges to implementation in our region. There are resource constraints, health professional shortages, migration and distribution of health professionals, household poverty and poor performance of services. Services face challenges in the adequacy of nursing education, with shortages and inadequate skills mix in health workers, loss of a caring ethos and inadequate social participation in services. Shortfalls in leadership, professional competencies and service resources and weak application of governance styles that involve people have led to falling morale. Negative conditions encourage individual practices that further worsen the system, such as moonlighting practices. Unless these and other constraints are addressed, UHC goals may remain aspirations rather than reality.
At the heart of the changes needed, SANNAM members identified the need for a paradigm shift from hospital-centered to community-centered health care. This calls for a rights-based approach to healthcare, where the individual and community are central to the processes for promoting health, preventing and treating disease and care for chronic illness or disability.
Nurses identified that they play a key role in implementing these transformations in health systems. Their competencies, communication and approaches to care can facilitate (or if absent block) peoples uptake of services. They can support (or impede) patient and family-centred care, cultural congruence and team based approaches with other health workers and sectors. They can deliver services in a way that supports people’s role and rights, and that reviews and improves service performance.
Taking goals and policies to implementation thus demands more attention to the people and practice environments of key personnel responsible for delivering on these goals, such as nurses. For example, there is need to promote a positive working environment for nurses and professional associations, to develop creative ways to involve frontline nurses individually and through their associations and networks in policy and practice changes and in evaluation and review, to integrate their proposals and improve responsiveness and feedback. The systems to support this need to be put in place, from Chief Nursing Officers within national ministries of health, and cascading down to provinces and districts to primary care level. The models identified should be backed by adequate resources, management practices and information, and by academic preparation of nurses for their role. Incentives should be oriented to rewarding and supporting implementation of key roles and outcomes, including the communication with and involvement of communities, patients and other sectors.
SANNAM delegates observed that it is therefore critical that nurses, amongst others, understand the health policy issues and the policy-making processes underway and are actively involved in them. The experience nurses bring will help to align the policies and strategies to real conditions and expectations in the system, and contribute to building the post 2015 agenda from the bottom up.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
1. Editorial
2. Latest Equinet Updates
The Journal of Health Diplomacy (JHD) is now receiving manuscripts for its third issue, titled: Africa, health and diplomacy. This issue is broadly concerned with the theory and practice of health diplomacy of African states, as a co-operation with the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The issue will include invited and submitted manuscripts. To be considered for the latter, please submit your proposed manuscript to the Managing Editor at the email below by 3 November 2014. Manuscripts submitted to JHD will undergo a peer-review process, with referees selected for their particular knowledge/experience on the topic of the manuscript. Authors are asked to ensure that their identity is not revealed directly or indirectly on any page. Manuscripts that are being considered for publication elsewhere, or that have been previously published must not be submitted to the journal. A complete set of author guidelines is available at the website shown. JHD welcomes contributions from all academic disciplines, including international relations, political science, anthropology, sociology, history and geography. We are also interested in interdisciplinary perspectives that cross the boundaries between different theoretical fields and represent novel understandings of health diplomacy.
The World Health Organisation (WHO) ‘Global Code of Practice on the International Recruitment of Health Personnel’ (hereinafter called the “Code”) adopted by the World Health Assembly (WHA) in May 2010 was the culmination of efforts by many different actors to address the maldistribution and shortages of health workers globally. African stakeholders influenced the development of the Code, but two years after its adoption only four African countries had designated national authorities, and only one had submitted a report to the WHO secretariat. This synthesis report is part of the Regional Network for Equity in Health (EQUINET) programme of work on Contributions of global health diplomacy to health systems in sub-Saharan Africa: Evidence and information to support capabilities for health diplomacy in east and southern Africa. The programme aims to identify factors that support the effectiveness of global health diplomacy (GHD) in addressing selected key challenges to health strengthening systems in eastern and southern Africa (ESA). The report compiles evidence from various research strategies undertaken to examine the above issues surrounding the WHO Code that involved an extensive review of literature; a ‘fast-talk’ session at the 66th World Health Assembly in May 2013 involving stakeholders from African countries to gauge views and concerns relating to the Code; a region-wide questionnaire survey implemented in 2013 to obtain views of government informants on issues affecting and measures for managing health workers, including migration of health workers in ESA countries; and three country case studies undertaken in Kenya, Malawi and South Africa concluded in 2014 to provide an in-depth exposition of perspectives on the Code and its implementation.
Gender inequalities are important social determinants of health. We set out to critically review the literature relating to gender equity and sexual and reproductive health (SRH) in Eastern and Southern Africa with the aim of identifying priorities for action. During November 2011, the authors identified studies relating to SRH and gender equity through a comprehensive literature search. Gender inequalities were found to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Social and biological determinants combined to increase women’s vulnerability to maternal mortality, HIV, and gender-based violence. Health systems significantly disadvantaged women in terms of access to care. Men fared worse in relation to HIV testing and care with social norms leading to men presenting later for treatment. Gender inequity in SRH requires multiple complementary approaches to address the structural drivers of unequal health outcomes. These could include interventions that alter the structural environment in which ill-health is created. Interventions are required both within and beyond the health system.
3. Equity in Health
Africa is a rich continent. Some of those riches – especially oil, gas and minerals – have driven rapid economic growth over the past decade. The ultimate measure of progress, however, is the wellbeing of people – and Africa’s recent growth has not done nearly as much as it should to reduce poverty and hunger, or improve health and education. To sustain growth that improves the lives of all Africans, the continent needs an economic transformation that taps into Africa’s other riches: its fertile land, its extensive fisheries and forests, and the energy and ingenuity of its people. The Africa Progress Report 2014 describes what such a transformation would look like, and how Africa can get there. Agriculture must be at the heart that transformation. Most Africans, including the vast majority of Africa’s poor, continue to live and work in rural areas, principally as smallholder farmers. In the absence of a flourishing agricultural sector, the majority of Africans will be cut adrift from the rising tide of prosperity. To achieve such a transformation, Africa will need to overcome three major obstacles: a lack of access to formal financial services, the weakness of the continent’s infrastructure and the lack of funds for public investment.
The Africa Progress Report 2014 describes how African governments and their international partners can cooperate to remove those obstacles – and enable all Africans to benefit from their continent’s extraordinary wealth.
4. Values, Policies and Rights
This paper explores litigation as a mechanism for the realization of the economic, social and cultural. Though it is often the last resort after all advocacy methods have been rendered futile, it is argued to draw government to the drawing board remembering the obligations in the international human rights instrument that it bonds itself for proper economic and social development. By its self, litigation may not yield the desired result but if backed up by strong advocacy the results are far more reaching.
5. Health equity in economic and trade policies
The author asserts "there will be no drilling in paradise". Soco International, a British oil company, has abandoned plans to drill for oil in Virunga National Park in the Democratic Republic of the Congo (DRC). The park is a World Heritage Site, and UNESCO says it is Africa's richest trove of natural beauty and biodiversity. Soco will leave in about a month, after completing a seismic survey of the park's Lake Edward, where drilling was to have commenced. Tens of thousands of local people depend on the lake for fish, and it is also home to thousands of hippopotamuses. Soco has vowed not to drill in the park without permission from UNESCO, and to keep out of all the world's 981 World Heritage Sites. The firm was under pressure after an expert report last month on the status of the park. French company Total pulled out last year. The DRC government has yet to remove overall permission for oil companies to search and drill for oil in the park.
6. Resource allocation and health financing
As high out-of-pocket payment dominates Nigeria’s healthcare spending and with low priority accorded to health by state and local governments, Nigeria’s quest to attain universal health coverage by 2015 is argued in this article to be bleak. The absence of financial protection has led most Nigerians to depend on out-of-pocket payment for healthcare financing with insurance penetration, which is a measure of the relationship between premiums earned and the nation’s Gross Domestic Product, put at less than 6 percent, according to industry experts. Experts explain that achieving universal health coverage would be hard to attain without expanding the fiscal space (through increasing domestic tax revenues, expanding tax base, developing social health insurance, and getting debt relief. Analysts believe that there is need to expand contributions from large profitable companies and tax mobile phone operators to fund healthcare.
Other innovations include tobacco and alcohol exercise tax, excise tax on foods that contribute to an unhealthy diet, and additional levy on top of existing VAT rate as is in the case with countries like Chile.
Some issues to consider in evaluating each innovative method include administrative costs, magnitude of the potential revenue, political acceptability and whether such funds should go into Consolidated Government Revenues or be earmarked.
7. Governance and participation in health
Mobile health (mHealth) approaches for non-communicable disease (NCD) care seem particularly applicable to sub-Saharan Africa given the penetration of mobile phones in the region. The evidence to support its implementation has not been critically reviewed. The authors systematically searched PubMed, Embase, Web of Science, Cochrane Central Register of Clinical Trials, a number of other databases, and grey literature for studies reported between 1992 and 2012 published in English or with an English abstract available. The search yielded 475 citations of which eleven were reviewed in full after applying exclusion criteria. Five of those studies met the inclusion criteria of using a mobile phone for non-communicable disease care in sub-Saharan Africa. Most studies lacked comparator arms, clinical endpoints, or were of short duration. mHealth for NCDs in sub-Saharan Africa appears feasible for follow-up and retention of patients, can support peer support networks, and uses a variety of mHealth modalities. Whether mHealth is associated with any adverse effect has not been systematically studied. Only a small number of mHealth strategies for NCDs have been studied in sub-Saharan Africa. They report that there is insufficient evidence to support the effectiveness of mHealth for NCD care in sub-Saharan Africa and present a framework for cataloging evidence on mHealth strategies that incorporates health system challenges and stages of NCD care to guide approaches to fill evidence gaps in this area.
8. Useful Resources
Amidst austerity measures today, we find ourselves increasingly precarious and pixelated; atomized, alienated, and irreparably glitched. For the inaugural issue of The State, the theme was kept intentionally vague; fifteen writers from around the world responded in myriad voices and ways. Topics range from sociohistorical looks at sewers and single parenting throughout the ages, to reimagining a weedy field as a portmanteau of globalisation. Others take a more personal approach, interrogating experiences of Afropolitanism, of being a person of colour in post-9/11 America, and of returning to the Gulf with your tail between your legs. They are joined by two ‘website-specific installations’—exploring joblessness and speaking in tongues—which are scannable within these pages. THE STATE is a publishing practice that investigates South-South reorientations, alternative futurisms, transgressive cultural criticism, the transition from analogue to digital, and the sensuous architecture of this “printernet.”
9. Jobs and Announcements
Global Public Health invites the submission of full-length articles for a special journal issue on the theme Participatory Visual Methodologies and Global Public Health, co-edited by Claudia Mitchell and Marni Sommer, Send note of intention to submit & working title to evasquezgph@gmail.com
The Journal of Human Development and Capabilities (JHDC) is pleased to announce a call for papers for a special issue on Health and Disability. This call for papers aims to advance the state of knowledge and expertise regarding health, disability and human development, as well as the linkages among them and a range of policies, institutions, and social structures that influence such links and their dynamics. Submissions related to this topic are welcome. In particular, though not exclusively, we welcome submissions in the following themes: i) Social justice and resource allocation; ii) Health system financing and access; iii) Public health and health policy; iv) Disability, poverty and human development; v) Social determinants of health and disability; vi) Disability definition and measurement; vii) HIV/AIDS and antiretroviral therapies; viii) Health care services and provision, and; ix) Maternal, child and reproductive health. Full papers in English, in .doc or .docx formats should be submitted by November 30th, 2014. Strict compliance with this deadline is required. Papers submitted will be evaluated through a standard peer review process. Authors of the selected papers will be notified by e-mail. Submission of a paper implies that the author has the intention of publishing the paper in the JHDC, and it is not currently under evaluation at another journal.
In the next step towards a Framework Convention on Global Health (FCGH), the proposed global health treaty grounded in the right to health and aimed at health equity, the proposers seek to secure a place in the UN Sustainable Development Goals resolution in 2015 for the FCGH, in particular, calling for the launch of a UN/WHO process towards the treaty. Towards this goal and beyond, the FCGH platform statement is now open for endorsements. All are welcome to endorse, and endorsements is encouraged on behalf of organizations where that is possible. The statement provides key principles and core content of the FCGH, as well as explanations of the need for the treaty. The FCGH platform statement and information on endorsement is found at the website shown, together with other briefing materials.
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