Fidel Castro, leader of the Cuban revolution, passed away on Friday 25 November. He was a towering figure and one of the defining leaders of the 20th century. Leaders across Latin America sent tribute. Chile's Michelle Bachelet called him a 'leader for dignity and social justice in Cuba and Latin America", while El Salvador's president, Salvador Sánchez Cerén, said “Fidel will live forever in the hearts of those of us who fight for justice, dignity and fraternity.” As China’s official news agency Xinhua noted, he was “a pioneer in battling ... neoliberal globalisation, foreign debt and exploitation of natural resources.” CLASCO in Argentina pointed to his role, together with the Cuban people, of pointing to an alternative of a world "without injustices, without exclusions, without exploitation" ("Fidel era un hombre, como tantos otros. Pero Fidel se transformó, y lo hizo junto a las luchas del inmenso pueblo cubano, en un horizonte, en una promesa, en un destino utópico: el de construir un mundo sin injusticias, sin exclusiones, sin explotación; un mundo emancipado, liberado, solidario").
The transformation in Cuba was profound. Manuel Garcia Jr reflected the day after Fidel's death on the transformation he experienced first hand in 1959 Havana: "Every person, every place, every moment exuded the same sense of uplift. I was immersed in a national sense of freedom, and it soaked into my psyche and bones. This experience permanently magnetized my political compass, so that regardless of verbal arguments and logical constructs in later years, my compass always points my sympathies toward freedom for any people". The nearly 60 years since of struggle in Cuba, a small island of 11 million people, often battling powerful global forces, unquestionably generated some contradictions. Ahmed Kathrada in the Mail and Guardian notes that "history will always judge people differently based on who is writing it".
He also notes, however, together with many other voices from Africa, that Fidel Castro came from "a generation of leaders, who envisioned a more equitable society, based on mutual cooperation, especially between developing nations" and that he was one of the foremost supporters of Africa's liberation movements and anti-colonial struggles. The internationalism of Cuban people in Africa has been sustained to today: whether in the support by Cuban troops of Angola's resistance to an apartheid military attack in the 1970s, whether through providing medical education in Cuba for thousands of African doctors over many years, or sending many Cuban doctors to African countries, including the many who came to West Africa to help in the efforts to control Ebola in 2014/5. At the same time, Castro also pointed to the rift between rich and poor in African countries, as he did at the speech to the South African parliament in 1998.
Whatever the context and debates, Fidel was an unwavering champion of health justice, of the right to health and of progress in social determinants like literacy and food security. He was a driving force of a universal health care system in Cuba that is a responsible for making Cubans some of the healthiest people in the world. As the journal MEDICC noted in a tribute the day after his death: "Over the years, President Castro took an abiding interest in health and was at the forefront of promoting advances in health care, research and medical education: establishing rural hospitals and a national network of hundreds of community-based clinics, making prevention a cornerstone of training and service; generating extraordinary investments in biotechnology to develop novel vaccines and cancer therapies, and specialized services for Cuban newborns with heart disease. Finally, he considered the most significant “revolution within the revolution” to be the creation in the 1980s of the family doctor-and-nurse program, posting their offices on every block and farmland in Cuba. The outcomes of these efforts were not achieved by one man, but by 500,000 Cuban health workers, who were able to count on health as a government priority. Together, they faced dengue and neuropathy epidemics; and the scarcity of medicines, including for HIV-AIDS patients, after the collapse of the socialist bloc and tightening of the US embargo on Cuba in the 1990s. Their dedication has won a healthier nation".
It falls to us to continue the struggle for health justice with the same compass, solidarity and tenacity.
1. Editorial
From 14-18 November 2016, 2,062 delegates from 101 countries assembled in Vancouver, Canada, for the Fourth Global Symposium on Health Systems Research on the theme of ‘Resilient and responsive health systems for a changing world’. This year’s Symposium consisted of five days of 53 organised sessions, 248 oral presentations, 74 satellite and skills building sessions, 385 posters, and 155 e-posters. Social media played a great part in whipping up the spirit of engagement, before and during the Symposium. Blogs also played a role in generating energy before the Symposium; the most popular of these was a blog from the SHAPES thematic working group challenging the concept of resilience in health systems.
Since Cape Town, the world has shifted from efforts to achieve the MDGs to the launch of the SDGs, which maintain a focus on UHC, but call more strongly for a systems-orientated approach by embedding health in broader social and environmental perspectives. In support of these goals, there is even greater focus on research to reduce inequities in relation to marginalised and vulnerable groups. On the policy and implementation front, there has been a transition in the funding landscape from donor funding for interventions, towards emphasis on locally generated funds. In this context, the local production of health policy and systems research is also increasingly valued.
Several themes emerged from the discussion and debate during this Symposium. First, it is important to recognise the many meanings of resilience. Health system resilience and responsiveness is anchored in people living and working within their communities. But, we need to be cautious not to romanticise communities as resilient, when what they are doing is coping in difficult situations. Systems need to be resilient precisely so that the burden of such resilience does not fall on the most vulnerable in our societies. Health systems resilience needs to be qualified by an explicit focus on equity and social justice, and support the empowerment of the most vulnerable. Second, discussions amongst participants highlighted the importance of resilient and responsive health systems as ones which provide integrated, people-centred services, with a focus on primary health care as the frontline of routine services and outbreak response. Subnational actors, including communities, are reservoirs of resilience for health systems. Resilient health systems are those which operate from the “end-user back”, and not from the organisation forward. Nevertheless, governments have the responsibility for steering all actors – public and private – in the interests of the broader community.
Third, while some discourse on resilience emphasises health security, such a perspective can sometimes be counter-productive, and should be balanced with the protection of health rights and health system strengthening. Health security should be an inclusive concern of the entire global community, and never a reason to exclude or marginalize. Fourth, the resilience discourse should be positioned within achieving the SDGs and mobilising collaboration and leadership across sectors. This together with integration and a move away from vertical approaches will help achieve the sustainable management of health systems. Symposium delegates repeatedly stressed the importance of people and relationships, flexibility and the capacity to mobilize new resources. Fifth, the Symposium gave occasion to highlight the struggles of indigenous peoples against historic privileges, including in high income countries. This has received insufficient attention in the Symposia to date. People in high income countries have much to learn from the experiences of low and middle income countries as well as from their own indigenous or marginalized populations.
The Symposium identified several areas for action for HSG, for researchers, funders and policy makers.
The Fourth Global Symposium has allowed our community to hold a light to the concept of resilient and responsive health systems, recognising their importance for achieving UHC and the SDGs, while acknowledging the potential shortcomings. Resilience adds a useful lens to our existing concepts and approaches, but it does not replace or supersede them. The world is changing, and resilience and responsiveness are needed now more than ever. The accumulated knowledge we have as a community builds on the continuing Symposia agenda of improving the science needed to accelerate Universal Health Coverage; to be more inclusive and innovative towards achieving UHC; and to make health systems more people-centred. For the next two years, Health Systems Global as a community of practitioners and researchers will look to remain at the vanguard of defining the field of health policy and health systems, while impacting our broader communities, and improving our global society.
The full statement is found at http://healthsystemsresearch.org/hsr2016/wp-content/uploads/Vancouver-Statement-FINAL.pdf and further information on Health Systems Global and the conference can be found on the HSG website at http://healthsystemsresearch.org/hsr2016/
2. Latest Equinet Updates
This document provides the detailed legal frameworks and relevant legal clauses from 16 East and Southern African countries for Diss paper 108: Corporate responsibility for health in the extractive sector in East and Southern Africa (ESA) produced by EQUINET through Training and Research Support Centre to inform policy dialogue to improve the legal frameworks for the duties and corporate social responsibility of extractive industries in the ESA region.
While international and global guidance documents set out health obligations for extractive industries (EIs), these standards, including UN conventions, may be voluntary if they are not included in national laws, unless the national constitutions specifically provide otherwise. Given the spread of EIs across the ESA region, it would be important to ensure that corporate duties in relation to health are upheld across the region, including through regional guidance to harmonise laws. This document was produced by EQUINET through Training and Research Support Centre and with support from Medico International. It aims to inform policy dialogue to improve the legal frameworks for the duties and corporate social responsibility of EIs in the ESA region. It presents evidence to support policy dialogue and health advocacy. It reviews the literature on EIs and health in ESA countries, explores key guidance principles/ standards on health in EIs, and analyses from review of laws how far they are contained in domestic legislation of ESA countries. Using good practice in existing ESA laws and international guidance, the document proposes the content for regional guidance for policy and law in the region. As is being implemented in other regions of Africa, there is scope for regional guidance and harmonisation of laws relating to EIs, including in relation to health. While no single law in ESA countries addresses all aspects of international guidance on protection and health and social welfare in EIs, in combination the laws in ESA countries provide clauses that could form the basis of such regional guidance. Drawing from different ESA laws legal guidance is proposed for health and social protection covering: 1. Award of prospecting rights/licenses and EI agreements; 2. Resettlement of affected communities due to mining activities; 3. OHS for employed workers and contractors in the mining sector; 4. Health benefits for workers, families and surrounding communities; 5. Environment, health and social protection for surrounding communities; 6. Fiscal contributions towards health and health services; 7. Stimulation of forward and backward links with local sectors and services supporting health; 8. Post-mine closure obligations for public health; and for 9. Governance of these issues, including for good corporate governance practices, public transparency and accountability, constructive dialogue, reporting and oversight, to foster a relationship of confidence and mutual trust between EIs and the societies in which they operate.
3. Equity in Health
Inequalities in health persist worldwide and one of the starting points for remedial action is collecting data that reveal patterns of inequality. Yet countries have varying capacities for monitoring health inequality. This is due in part to data-related issues such as weaknesses in the health information systems, especially in many low- and middle-income countries; lack of availability or poor quality of health data; and a limited ability to disaggregate data across all health topics within countries. Overcoming these challenges in the long term requires substantial investments in the health information infrastructure. In the short-term, countries need innovative approaches to best harness the potential of their existing data to improve monitoring efforts. In this article the authors make the case for stratifying data at the level of subnational geographical regions, such as provinces, states or districts. The wider use of an area-based unit of analysis as a complementary way to analyse data at the individual or household level has certain practical advantages that are relevant to low- and middle-income countries as well as high-income countries. First, this approach opens up new possibilities concerning the data that can be used for within-country monitoring, in terms of both health data and data about dimensions of inequality. Second, since interventions to reduce inequities are likely to be implemented at the local administrative level, regional monitoring of health inequalities may be a useful tool for benchmarking, with implications for resource allocation, planning and evaluation. Third, area-based measures may provide a more intuitive understanding of health inequalities and may help to identify possible points for intervention. Alongside these advantages, some caution is needed when adopting an area-based unit of analysis. There is the risk of committing a so-called ecological fallacy (i.e. making assumptions about individuals based on population-level patterns, or in this case, erroneously drawing conclusions about the health of individuals using area-based data). In many countries, health inequality monitoring systems could be strengthened by expanding the capacity for, and practice of, area-based health inequality monitoring. Adopting an area-based unit to express health inequality has several merits. Monitoring health inequalities by geographically defined subgroups can help to identify disadvantaged regions that are falling behind in terms of health indicators and to guide improvements in these areas.
A new report by UNAIDS released prior to World AIDS Day 2016 reveals concerning trends in new HIV infections among adults. The Prevention gap report shows that while significant progress is being made in stopping new HIV infections among children (new HIV infections have declined by more than 70% among children since 2001 and are continuing to decline), the decline in new HIV infections among adults has stalled. The report shows that HIV prevention urgently needs to be scaled up among this age group. The Prevention gap report shows that an estimated 1.9 million adults have become infected with HIV every year for at least the past five years and that new HIV infections among adults are rising in some regions. New HIV infections among adults declined by only 4% in eastern and southern Africa since 2010. The Prevention gap report gives the clear message that HIV prevention efforts need to be increased in order to stay on the Fast-Track to ending AIDS by 2030. “We are sounding the alarm,” said Michel Sidibé, Executive Director of UNAIDS. “The power of prevention is not being realized. If there is a resurgence in new HIV infections now, the epidemic will become impossible to control. The world needs to take urgent and immediate action to close the prevention gap.”
4. Values, Policies and Rights
The UN General Assembly Human Rights Council on 29 September 2016 adopted a resolution (A/HRC/33/L.29) which established a mandate for a Special Rapporteur on the Right to Development. The draft of the resolution was presented by Venezuela on behalf of the member states of the Non-aligned Movement and China, and was adopted by a vote of 34 in favour, two against and 11 abstentions. The Council decided to appoint, for a period of three years, a Special Rapporteur on the right to development, whose mandate will include: to contribute to the promotion, protection and fulfilment of the right to development in the context of the 2030 Agenda for Sustainable Development and other internationally agreed outcomes of 2015; to engage and support efforts to mainstream the right to development among various United Nations bodies, development agencies, international development, financial and trade institutions, and to submit proposals aimed at strengthening the revitalized global partnership for sustainable development from the perspective of the right to development; to contribute to the work of the Working Group with a view to supporting the accomplishment of its overall mandate, taking into account, inter alia, the deliberations and recommendations of the Working Group while avoiding any duplication; to submit any specific study by the Human Rights Council in accordance with its mandate; to submit an annual report to the Human Rights Council and to the General Assembly covering all activities relating to the mandate. In his remarks introducing the draft proposal, Ambassador Mr. Jorge Valero (Bolivarian Republic of Venezuela), on behalf of the Non-Aligned Movement (NAM), recalled that in the Vienna Declaration and Programme of Action on the Right to Development, the Council committed to elevate the right to development to the same level as other human rights and fundamental freedoms. South Africa’s Permanent Representative to the United Nations in Geneva, Ambassador Nozipho Joyce Mxakato-Diseko, speaking on behalf of the African Group expressed the support of the African continent for the draft resolution proposed by NAM and China. Ambassador Mxakato-Diseko underscored that 2016 was a crucial year for the start of the implementation of the 2030 Agenda for Sustainable Development.
5. Health equity in economic and trade policies
The author argues in relation to the BRICS summit in October 2016, that BRICS is no longer just an economic grouping but is fast emerging as a political force in global decision-making. Having successfully launched its New Development Bank and Contingent Reserve Arrangement, BRICS now plans to launch its own credit rating agency to end the dominance of the likes of Standard & Poor's or Moody's and Fitch and to bring in emerging economies' perspectives to further enhance their standing and competitiveness in international markets. Similarly, learning from the July 12 Arbitration on South China Sea, BRICS Legal Forum endorsed in August 2016 its own robust arbitration mechanisms to address the problem of double standards of advanced nations. In addition to a now-functioning disputes resolution centre in Shanghai, such as a BRICS-wise arrangement will include commercial arbitration allowing BRICS to resolve disputes for foreign investors. Faced with continuing global financial crisis, leaders have also been discussing developing a BRICS bond market to address challenges of debt securities trading to strengthen their existing lack of liquidity making them vulnerable to foreign portfolio investors.
COSATU reflected in relation to the Southern African Development Community (SADC) heads of states summit the need for concrete solutions to the concrete problems faced rather than policy statements that do not improve the lives of the people. COSATU identifies the following key issues as key for SADC: desperate conditions of poverty, hunger, and unemployment, human rights abuses, exploitation of natural resources and environmental degradation, job losses and starvation wage crisis, policy crisis and poverty. They call for policies for active industrialisation and to tackle underdevelopment, as raised at the 2016 SADC Civil society Apex Forum and the Southern African Peoples Solidarity Forum held on the sidelines of the SADC Summit. Whilst COSATU welcomed small steps towards a paradigm shift in the Industrialisation policy debate, they called for concrete steps to build the regions manufacturing base and industrial capacity to produce goods and services, in order to stimulate economies and create the much needed jobs, enhance decent work and improve the quality of life for the majority of people and called for bold and inspiring leadership.
The ‘Rise of the South’ and the role of ‘emerging powers’ in global development has animated much of the political and economic discourse of the past decade. There is, however, little empirical evidence on the contribution that emerging Southern partners make to sustainable development, due to the lack of common measurement systems for South–South cooperation (SSC). This case study utilises the analytical framework developed by the Network of Southern Think Tanks (NeST) to assess the range, extent and quality of South Africa’s peace, governance and economic support to the Democratic Republic of the Congo (DRC). The study reveals that South Africa, in absolute financial terms, is a significant development partner in the DRC, and even exceeds the traditional donors when its aid is measured in proportion to gross national income. The qualitative field research highlights that South Africa’s approach to development co-operation to a large extent reflects the core values of SSC, although with a mixed bag of successes and failures in terms of the results of co-operation activities. This pilot study of the South Africa–DRC development partnership is one of the first in which the NeST conceptual and methodological framework has been tested for the purpose of further refining tools and indicators for SSC analysis, so as to assist the future monitoring and evaluation endeavours of South Africa and other emerging development partners.
The author analyses that Trump’s victory in the US elections is partly because the world is changing. He writes that the world is witnessing a civilisational shift – the slow, painful death of the Western Empire. Even in rich America millions of people go hungry and without shelter. He argues thus that Africa will in this current era use its own resources and ingenuity to prosper. He notes that if Trump rejects the TTIP (Transatlantic Trade and Investment Partnership) and the TPP (Trans Pacific Partnership) then he can count on his support. Tandon welcomes the idea that he might scrap AGOA (which he sees as divisive of Africa) and Obama's "Power Africa" $7 billion initiative. These “initiatives” he argues are to help corporate America, not Africa. He also notes that if Trump talks with Russia, China, Iran and Syria, then he could help forces of peace and reconciliation that the world badly needs. He notes that Trump does not have Africa on his map and has criticised the notion of "exporting democracy", which Tandon also welcomes.
6. Poverty and health
the 2030 Agenda for Sustainable Development (2030 Agenda) and the Sustainable Development Goals (SDGs) expressly identifies establishing universal social protection systems as in several of the international community’s new goals. The SDGs, unlike the Millennium Development Goals (MDGs), explicitly state the need for social protection. Target 1.3 calls on states to “implement nationally appropriate social protection systems and measures for all, including social protection floors (SPFs)1, and by 2030 achieve substantial coverage of the poor and the vulnerable”. SPFs are not only an essential tool in combating poverty, but also form the basis for food security and housing, especially for vulnerable groups; they have the power to promote social cohesion, make an important contribution to helping people into decent employment and enable parents to send their children to school even during economic crises; all goals which are outlined in the Agenda 2030. By securing household incomes, social protection leads to an increase in private consumption and boosts domestic demand. Finally, well-implemented social protection programmes that give households a predictable source of income may also be able to reduce pressures for migration: there is a broad consensus that besides economic growth and investment in human development (in particular in education and health), social protection is one of the core requirements of any poverty reduction strategy, and is an important precondition for an inclusive and cohesive society, and for stabilising fragile states. Consequently, it is also an indispensable instrument in combating the root causes of migration. Establishing SPFs on sound financial footing is primarily a task for the national governments. The ILO Social Protection Floor Recommendation, 2012 (No. 202) urges governments to consider using a variety of methods to mobilise the necessary resources for their nationally-defined social protection floors. Such methods may include effective enforcement of tax and contribution obligations, but also setting new priorities in their spending behaviour. To solve the problem of funding for SPFs, a Global Fund for Social Protection is proposed, with resources from both the high- and low-income countries to close the funding shortfall between what poorer countries can reasonably afford and address funding for emergencies. The author argues also that developed countries have an obligation to support partner countries in their efforts to strengthen their social security systems, while simultaneously ensuring that the partner countries will be able to sustain these systems themselves in the long run.
The People’s Coalition on Food Sovereignty unites with the farmers, agricultural workers, small-scale food producers, indigenous peoples and the peoples of the world in commemorating World Food Day 2016. To call attention to the hunger being experienced by the majority of the world’s population, the coalition has called it World Hunger Day with the theme “Fight Food Injustice and Repression!” This calls attention to repression of farmers and activists for food justice. In 2015, the Pesticides Action Network – Asia-Pacific claimed that almost six farmers, indigenous people and/or land activists were being killed every month in relation to land struggles and conflicts, and many cases remain unreported. In 2016 they argue that there has been intensifying repression of farmers, indigenous peoples, agricultural workers, and other small-scale food producers. People’s Coalition on Food Sovereignty condemn this repression and point to the need to change the structural causes of widespread hunger and intensifying monopoly control over the world’s agriculture and food systems.
7. Equitable health services
Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women’s health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women’s health and global cancer control, with new approaches to bringing policy to action. .
The tools presented in this publication assess mother and child health (RMNCH) change over time and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, results are presented from Tanzania and Peru. The Policy and Programme Timeline tool shows that Tanzania’s RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. All lifesaving RMNCH commodities were included on their essential medicines lists, but the health worker density (7.1/10,000 population), is below the 22.8 WHO minimum threshold.
8. Human Resources
Neglected tropical diseases produce an enormous burden on many of the poorest and most disenfranchised populations in sub-Saharan Africa, where a dearth of skilled health providers limits primary care efforts to address such diseases. Consequently, many countries rely on nurses and community health workers to engage with under-served and hard-to-reach populations. This review of the literature was conducted to assess the role nurses and community health workers play in the primary, secondary, and tertiary prevention of neglected tropical diseases in sub-Saharan Africa. Articles published between January 2005 and December 2015 were reviewed in order to capture the full scope of nurses’ and community health workers’ responsibilities for neglected tropical disease control within their respective countries’ health systems. A total of 59 articles were identified that fit all inclusion criteria. It reports that successful disease control requires deep and meaningful engagement with local communities and that horizontal or multidisease control programs can create complimentary interactions between their different control activities as well as reduce costs through improved program efficiencies.
9. Public-Private Mix
Public-private partnership (PPP) has been suggested as a tool to assist governments in lower to middle income countries fulfil their responsibilities in the efficient delivery of health services. In Tanzania, although the idea of PPP has existed for many years in the health sector, there has been limited coordination, especially at a district level – which has contributed to limited health gains or systems strengthening obviously seen as a result of PPP. This case study was conducted in the Bagamoyo district of Tanzania, and employed 30 in-depth interviews, document reviews, and observations methods. A stakeholder analysis was conducted to understand power distribution and the interests of local actors to engage non-state actors. The study findings reveal several forms of informal partnerships, and the untapped potential of non-state actors. Lack of formal contractual agreements with private providers including facilities that receive subsidies from the government is argued to contribute to inappropriate distribution of risk and reward leading to moral hazards. Furthermore, findings highlight weak capacity of governing bodies to exercise oversight and sanctions, which is acerbated by weak accountability linkages and power differences. Disempowered Council Health Services Board, in relation to engaging non-state actors, is shown to impede PPP initiatives. Effective PPP policy implementation at a local level depends on the capacity of local government officials to make choices that would embrace relational elements dynamics in strategic plans. Orientation towards collaborative efforts that create value and enable its distribution is argued to facilitate healthy partnership, and in return, strengthen a district health system. This study highlights a need for new social contracts that will support integrative collaboration at the local level and bring all non-state actors to the centre of the district health system.
The funding of healthcare in South Africa is a highly contentious issue, involving a variety of stakeholders. Royal Philips released the South Africa results of the first edition of its Future Health Index (FHI) in July 2016. The FHI is an extensive international study which explores how countries around the world are positioned to meet long-term global health challenges through integration of health systems and adoption of connected care technologies. The report revealed that cost is a significant barrier to healthcare in South Africa and that HCPs and patients indicate improving access to healthcare services as a core priority for local government. Health status indicators in South Africa as a whole are reported to be worse than that in other upper middle income countries. Privately insured people though have outcomes comparable to best in world. However, this comes at a high cost. People in South Africa who cannot afford private medical insurance have some of the worst outcomes in terms of healthcare. The report identifies that approximately 40% of total healthcare funds in South Africa flow via public sector financing intermediaries (primarily the national, provincial and local Departments of Health), while 60% flow via private intermediaries.
10. Resource allocation and health financing
Oxfam have announced that it is now possible to count the cost of paying for healthcare for households around the world. A group of experts tasked with developing the indicator framework to measure progress towards the Sustainable Development Goals (SDGs), have agreed to measure financial risk protection of universal health coverage by ‘’proportion of the population with large household expenditures on health as a share of total household expenditure or income”. This signals a great shift in from the previous dangerous indicator that would just measure population with access to health insurance or a public health system. The previous indicator was flawed because it did not measure whether or not people were actually financially protected against potentially catastrophic costs for health care. It would have also failed to measure progress across different income groups or by gender. It was also dangerous as it sent a signal to governments around the world that health insurance was the route to achieving Universal Health Coverage despite robust and scientific evidence that many voluntary health insurance schemes have exacerbated inequality. The change to the new indicator that ‘measures what matters’ was advocated for civil society organisations, academics, development agencies and statistical authorities expressed their deep concerns through letters, lobbying and public statements.
In Tanzania, reasons for low use of maternal care are complex, including shortage of resources, long distances to services, high costs and low capacity to provide services. ‘Gender exclusion’, in this case the exclusion of men in planning or implementing interventions, is also identified to be a major barrier to achieving improved maternal and child health. The author reports that men were involved in the implementation of Tanzania's NHIF/KfW prepaid health insurance card scheme in various ways: during its design; inauguration; registration; and in community sensitisation at the village level and health facilities. At the health care facilities, women are encouraged to attend with their partners during antenatal visits. This is to ensure they are all tested together for HIV, as well as educated on how to take care of the pregnancy and prepare for delivery. This encouraged male involvement and payment of because of any costs of using services. Women had a different views with regard to men’s involvement in the provision of reproductive and child health care services. Participants identified strategies to improve male involvement in the implementation of NHIF/KfW prepaid insurance card in Pangani District. Communication between partners was one of the ways to increase their men’s involvement. In the villages, there are routine meetings every three months. During the meeting, participants discussed various topics and made decisions together for the betterment of the whole community. Men pointed out that giving them more knowledge about health care services and facility practices would enhance their participation in care. The author argues that improvement in the health care provision and community sensitisation of the importance of male partner involvement in the implementation of maternal and child health care programmes needs to be prioritised in order to improve their participation and mitigate the effect of socio-economic and cultural barriers to access.
South African Health Minister, Dr Aaron Motsoaledi, announced that a draft set of the National Health Insurance (NHI) ‘financing scenarios’ are ready for provincial health Members of Executive Councils (MECs) in October 2016. According to the legal brief Policy Watch, the Minister said that – in finalising government policy on universal healthcare – the department will consider each scenario and carefully reflect on the ”very useful suggestions” received from stakeholders following the release of a draft White Paper in December 2015 for comment. Noting that the costs associated with implementing universal healthcare are ”influenced by many factors, including design elements and the pace of implementation,” Dr Motsoaledi emphasised the importance of focusing on the implications of each funding scenario for incrementally introducing the necessary reforms. With that in mind, the draft scenarios will be informed by an “estimation framework” based on “configurations” of projected service demand, service delivery and associated costs ‘at each level of care. There are views that there are many uncertainties and unaddressed issues in the White Paper, including in the funding model. Meanwhile, the Treasury has allocated South African Rand 4.5bn to renovate healthcare facilities across 11 NHI pilot projects and allocated SAR300 million on developing a national electronic medicine stock management system, a key element for NHI outlined in the White paper.
Africa’s population is estimated to reach 2.5 billion by 2050, raising a challenge for progress toward Universal Health Coverage (UHC), the principle that everyone receives needed health services without financial hardship. The primary reason for investing in UHC is argued to be a moral one: it is not acceptable that some members of society should face death, disability, ill health or impoverishment for reasons that could be addressed at limited cost. However, UHC is also argued to be a good investment. Prevention of malnutrition and ill health is likely to have enormous benefits in terms of longer and more productive lives, higher earnings, and averted care costs. Effectively meeting demand for family planning will accelerate the fertility transition, which in turn will result in higher rates of economic growth and more rapid poverty reduction. And strong health and disease surveillance systems halt epidemics that take lives and disrupt economies. The authors report for example that In 2015, the forgone economic growth due to Ebola amounted to more than a billion US dollars in the three countries hit by the epidemic.
11. Equity and HIV/AIDS
Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. This study in 2015 identified facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. The authors found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed.
Within the HIV public health domain, interest is growing in universal test and treat (UTT) strategies. This refers to the expansion of antiretroviral therapy (ART) in order to reduce onward transmission and incidence of HIV in a population, through a “treatment as prevention” (TasP). This paper focuses on how masculinity influences engagement with HIV care in the context of an on-going TasP trial. Data were collected in January–November 2013 using 20 in-depth interviews, 10 of them repeated thrice, and 4 focus group discussions, each repeated four times. The accounts detailed men’s unwillingness to engage with HIV testing and care, seemingly tied to their pursuit of valued masculinity constructs such as having strength and control, being sexually competent, and earning income. Given fears regarding getting an HIV-positive diagnosis, men preferred traditional medicine. Further primary health centres were not seen to be welcoming to men discouraging their readiness to test for HIV. These tensions were amplified by masculinity norms. Men struggled with disclosing their HIV status, and used various strategies to avoid or postpone disclosing, or disclose indirectly. In contrast women were found to access care readily. The authors argue that UTT and TasP promotion should use health service delivery models that address these tensions.
12. Governance and participation in health
As special-interest associations, community-based organisations fill an institutional vacuum, providing basic services to ensure a robust response to crises of poverty. It is at this local level that people, however limited their incomes or their assets, tend to reveal their true wealth: the ingenuity that they need to solve their own problems and those of their communities. Community based organisations (CBOs) are locally based membership organisations that work to provide services to their own communities. They have emerged in response to the need for collective social action. Their main characteristic is the importance that they attach to self-help, based on the principle of traditional communal values, reciprocity and interdependence. The author argues that CBOs can serve as a channel through which African governments can facilitate development at the grassroots level. While the CBOs need capacity-building to strengthen their skills in areas such as bookkeeping and accounts, experience indicates that the related needs assessments should be carried out jointly with communities. Examples show considerable grassroots enthusiasm for decentralisation within communities that can be mobilised by winning the confidence and trust of local and traditional communities and their leaders. CBOs are argued to provide the basis for a bottom-up approach in the fight against social exclusion and in national decision-making.
This paper aims at contributing to the debate on ways in which actors in development cooperation such as international NGOs or bilateral agencies could engage in a relevant, legitimate and effective way to achieving universal access to health. MMI identify that relevant, legitimate and effective health cooperation contributes to achieving universal access to health and is fully aware of its structural role, responsibilities and limitations; and continuously reflects on how to improve its approaches and practices. MMI argue that there is still a lack of platforms in which actors in health cooperation can critically reflect their own practices and approaches, share information and experiences, learn from each other and have an opportunity to further develop their institutional and personal skills and practices. They also suggest that a paradigm shift is required that breaks with the continuum process of development cooperation for health as it has been conducted during the last 50 years.
The author observes that the role and reach of the World Health Organisation has been contested since it was created in 1948. The debate is commonly couched in terms of whether the organisation is ‘fit for purpose’ although whose purpose is not always made clear. There have been several attempts at WHO reform since its establishment, directed to making it fitter for a still contested purpose. The current round of ‘WHO reform’ was launched in 2010 following a budget crisis and it continues as the new director‐general settles into the job. The current reform program addresses: funds mobilisation, budgeting, evaluation, relationships with non‐state actors, relationships within the secretariat (between headquarters, the regions and the country offices), WHO’s role in global health governance, the emergency program and the management of the WHO’s staff. The capacity, effectiveness and accountability of WHO is critical to the project of equitable health development globally. Nevertheless, there have been shortfalls. The root causes of WHO’s disabilities are argued to include the freeze on WHO revenues, the dysfunctions associated with WHO’s highly decentralised organisational structure, and the lack of accountability of member states for their contribution to WHO decision making and their implementation of WHO resolutions. In this paper the author reviews the evolution of the current reform program and some of the major elements of the reform, with the shortfalls, disabilities and reform options within the broader context of global health governance. The author argues that the reform of WHO, to realise the vision of its Constitution, will require a global mobilisation around the democratisation of global health governance.
13. Monitoring equity and research policy
The San of South Africa are one of the most researched communities in the world. Their indigenous knowledge and genetic makeup have been of great interest to researchers as they are ancestors of the first hunter-gatherers in Africa. While the media and researchers have continued to want to engage with the community, TRUST, a global initiative which seeks to reduce exploitation in North-South research collaborations, alongside the San Council created a contract to protect the community from exploitation, and to ensure that the San also benefit from any research. This paper outlines a locally driven Code of Ethics for involving San people in research that has been initiated by a range of organisations in Southern Africa. Referencing the original research and media contract, this is now being finalised into the first indigenous-developed ethics code in Africa.
14. Useful Resources
This HIV Gender Assessment Tool, published by the Joint United Nations Programme on HIV/AIDS and the Stop TB Partnership, aims to assist countries in assessing their HIV and tuberculosis (TB) epidemics and responses from a gender perspective, to ensure that the responses are gender-sensitive, transformative and effective in responding to HIV and TB and to support countries in the submission of gender-sensitive concept notes to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The UNAIDS HIV Gender Assessment tool was developed recognising the need for more systematic data collection on gender equality and HIV, as revealed by the mid-term review of the UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV 2010– 201410 and was developed in a UNAIDS Secretariat led consultative, multi-stakeholder process.
In this video from Health Systems Global, Professor Christina Zarowsky and poster presenters from the symposium explain their understanding of and debates on the concept of resilience.
15. Jobs and Announcements
CODESRIA’s Program on Humanities is organising a two day workshop on the sidelines of the bi-annual Pan-Africa Film and Television Festival in Ouagadougou, Burkina Faso in partnership with la Guilde Africaine des Réalisateurs et Producteurs on “‘Emergence’ on Screen and on Stage.” It explores the idea of emergence in various forms: the spouse emerging from an abusive marriage, the student emerging from a period of scholarly mediocrity, the person emerging from a life of poverty and hardship, the community finally freeing itself from the oppressive tyrant and the poor society attaining the heights of wealth all embody the idea of the shedding of shackles to achieve better states of being. Practitioners interested in participating in the workshop are invited to send papers of 5000 words and a CV with full contact details including email addresses and phone numbers to CODESRIA no later than December 27. See website for details.
The Alliance for Health Policy and Systems Research (AHPSR) announces its first ever essay competition on the future of health policy and systems research. The winning paper will be published as a background paper for a high level conference on “Health Policy and Systems Research: 20 years on” that will take place in Stockholm Sweden, in April 2017. In addition, a cash prize of USD $7,500 will be awarded to the authors of the winning paper. Prizes of USD $2,500 and USD $1,000 will be awarded to the authors of the 2nd and 3rd place papers. Much has changed in the 20 years since the WHO Ad-Hoc Committee on Health Research highlighted the need to strengthen Health Policy and Systems Research that led to the establishment of the AHPSR. Today as the world transitions from the MDGs to the SDGs, and in light of recent crises resulting from outbreaks, disasters, and conflicts, the need for health policy and systems research is increasingly recognised. The AHPSR invites essays on how the field can continue to evolve to respond to these and other needs, as well as the role that international entities can play in shaping this evolution. Essays should be no more than 5000 words, essays and written in English. They should reflect on the role and contributions of Health Policy and Systems Research in strengthening health systems and future challenges in the context of Agenda 2030; identify strategies and innovative approaches to ensure the greater use of health policy and systems research by relevant actors and stakeholders; and explore opportunities to further strengthen the position and role of the AHPSR in advancing the field.
Previously known as the African Institute for Agrarian Studies(AIAS), and renamed to SMAIAS in 2016 in honour of its late Founder and Executive Director, Professor Sam Moyo, the SMAIAS in Harare has been in operation for over thirteen years. The SMAIAS aims to enhance Africa’s agrarian transformation by promoting informed participation towards effective land and agrarian policies and reform, by means of Pan- African and South-South partnerships, interdisciplinary research initiatives, policy dialogues, training, and information dissemination. It interacts with various organisations and countries to assist them in developing capacity for policy formulation and research. It also facilitates policy dialogue among governments, academics, civil society and others on land and agrarian developments, especially on the land rights of marginalised social groups. Under the overall authority of the Board of Trustees and the direct supervision of the Chairperson of the Board of Trustees, the Executive Director will be expected to provide intellectual, administrative and strategic leadership to the secretariat of the SMAIAS. Only African citizens will be considered for this post.
Urgent Action Fund-Africa (UAF-Africa) seeks a Communications and Knowledge Management Programme Officer who will translate UAF-Africa’s strategic plans into effective social justice initiatives and results. Guided by feminist principles and values, the Fund advocates for gender equality, not only as a matter of human rights, but also as a fundamental prerequisite for social change, global security, and sustainable peace. In addition to her core business of Rapid Response Grant making, UAF-Africa also runs alliance building and advocacy initiatives in collaboration with other national, regional and international social justice organisations.
Urgent Action Fund-Africa (UAF-Africa), is a consciously feminist and women’s human rights pan- African Fund, registered in Nairobi, Kenya. UAF-Africa seeks a Partnerships & Development Manager who will translate UAF-Africa’s strategic plans into effective social justice initiatives and results. Guided by feminist principles and values, the Fund advocates for women’s equality, not only as a matter of human rights, but also as a fundamental prerequisite for social change, global security, and sustainable peace. In addition to her core business of Rapid Response Grant making, UAF-Africa also runs alliance building and advocacy initiatives in collaboration with other social justice organisations,
The decline in new HIV infections among adults has stalled. The UNAIDS Prevention gap report shows that worldwide an estimated 1.9 million adults have become infected with HIV every year for at least the past five years and that the number of new HIV infections is rising in some regions. The report shows that HIV prevention efforts must be reinvigorated if the world is to stay on the Fast-Track to ending the AIDS epidemic by 2030. In the lead-up to World AIDS Day 2016, the hands up for #HIVprevention campaign will explore different aspects of HIV prevention and how they relate to specific groups of people, such as adolescent girls and young women, key populations and people living with HIV. Starting in September 2016, the campaign will offer people a space to express their views on what they think needs to be done to strengthen HIV prevention efforts. UNAIDS is asking people around the world to submit: A photograph of a word or short phrase written on the palm of their hand summarising what is needed to strengthen HIV prevention efforts, for example more condoms, empowerment, inclusion, pre-exposure prophylaxis (PrEP), rights for women and girls. People may also submit a short video message (maximum 30 seconds) explaining what in their view needs to be done to reduce new HIV infections in their community.
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