Editorial

If our health systems ‘listen’ better to people’s input, will this make them more responsive to people’s needs? Will strengthening people’s voice and role in decisions in health systems help overcome the significant inequalities that exist in east and southern Africa - and more widely - in access to and use of health services? What do we need to do to ensure that the substantial resources that flow to and in health systems reach the primary care and community level?

These were questions that we tackled at a recent regional joint workshop of the Community of Practitioners in Accountability and Social Action in Health (COPASAH) and the Regional Network for Equity in Health in East and Southern Africa (EQUINET) hosted by TARSC in Zimbabwe. Thirty people attended this workshop, including community health activists, civil society organisations, health workers, academics and researchers from Kenya, South Africa, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe. As a group, they came from a wide range of contexts and experiences, working with or representing people living with HIV and AIDS, elderly people, women and children, health workers and people whose health rights had been violated. Participants came from organisations whose goals included supporting and strengthening community roles in monitoring health service delivery, and advocating for equity and quality of health services and increased resources for health.

Given the wide social inequalities in our societies, all who attended the meeting are working in some way to invest in and support community capacities to articulate their needs, present their conditions, negotiate for resources that improve their lives, and monitor the delivery on state commitments towards improving health. We agreed that, in order for this to happen and for it to have an impact upstream, beyond the more common ways that people support health services - such as caring for people who are ill or contributing their own resources or time to improve services - people also need to have a greater role in the planning, delivery and monitoring of their health services.

We brought our own stories of how greater citizen engagement with service providers, especially around social action on health and social accountability in services, makes for more effective and acceptable health services. For example, participants from South Africa, Kenya and Zambia noted that setting up community-health worker committees had helped to improve dialogue and collective action. Uganda CSOs reported on a randomized field experiment of community-based monitoring of public primary health care providers in Uganda by Björkman and Svensson in 2007 that showed how social accountability mechanisms led to large increases in utilization of services and improved health outcomes.

For this to happen, however, we see that the health system needs to change. When the health system itself does not give any authority to frontline workers, it is difficult for the same workers to respond to communities. Decentralisation of power and resources within the system to local levels, together with the capacities for it, is thus necessary if people at community level are to be effective in providing input to the organisation of services. The health system needs to make clear what entitlements people have, and what obligations service providers have, and to communicate this widely to health workers and the public as a prerequisite for delivering health rights and building social accountability. If our health systems are to become more people-centred, they need to not only develop skills, knowledge and procedures around technical issues, but they also need the skills, knowledge and procedures for health workers and managers to facilitate meaningful community engagement and involvement, including in decision making. And these are most needed where the communities enter the system, that is, at the primary care level. To build ‘people centred’ health systems it is essential that resources, including medicines and skilled health workers, reach the primary care level.

This touches on the power dynamics within health systems. The inequalities in health systems are not just inequalities in relation to resources, or to access to services. There are also inequalities in power: between service providers and communities, between different kinds of health personnel and between different levels of the health system. This is an issue that is largely invisible but that has impact on the participation in and use of health systems by more marginalised groups. So a great part of our meeting tackled the sort of mechanisms and processes that can address this power imbalance. For example, mechanisms such as community prioritising of health needs, monitoring service delivery using community score cards, community- health centre meetings and community action planning, can help to make service providers more accountable to communities, and can potentially support and improve interactions between communities and frontline service providers. This strengthened interaction can then, if based on a mutual listening and understanding, lead to alliances between local health workers, managers and communities in negotiating with higher level authorities for improvements in services.

One of the ways of embedding a shift in power relations and to strengthen that alliance and interaction between communities and primary health care actors, is through using participatory reflection and action (PRA) approaches. PRA uses a variety of visual and verbal methods to provoke discussion, analysis and planning for action in such a way that it can strengthen the power that people have to change their own lives, their communities and the institutions that affect them. For the last 10 years, the pra4equity network in EQUINET has been exploring how this approach can support the strengthening of a people-centred health system. At our meeting we built on this to examine how PRA can be used to shift attention and resources towards the primary care level of the health system, to make those at higher level more accountable to the needs of communities, and to ensure the capacities of frontline services to deliver on those needs. In reviewing some of the blocks and deficits raised in our current health systems, we concluded that PRA does have a role to play in improving transparency, improving dialogue between rights holders and duty bearers, and establishing platforms for feedback and consultation.

This was a unique opportunity to bring together and build synergies between two bodies of work, on PRA approaches and on social accountability. It also raised the potential for PRA approaches to position our engagement on accountability within a dialogue between communities and their frontline health workers, for both to listen to and engage with the realities and experience of the other. We already have evidence, in the work of the pra4equity network published on the EQUINET site, that this improves local service quality for both health workers and communities. The question we are yet to test, and will be exploring in our follow up work, is whether this shared power is able to address imbalances in institutional resources and power within the health system, so that the resources, skills, commodities and authorities reach the primary and community level services, where they are most needed.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Further information on the issues raised in the oped can be found in the report of the meeting and other publications on the EQUINET website at www.equinetafrica.org and in the COPASAH website at www.copasah.net

Before the Commission on Health Research for Development report (1990) was the International Health meeting at Alma-Ata in 1978 when the existence of major health inequalities experienced by populations living in the developing world were exposed. It was in Alma-Ata where the concept of Primary Health Care for developing countries was proposed as a means of delivering health to all by the year 2000 – now long past.

To give credit where it is due, there were some tangible gains over the years that followed, as demonstrated by improved child and infant mortality rates, higher primary immunization rates, better education of the girl child and higher life expectancy. But poverty levels escalated over the years while the effects of HIV/AIDS turned into a third world health nightmare even as health sector structural adjustment programs ensured access to health care was virtually denied to the most poor thereby reversing the earlier positive trends.

In its landmark report of 1990, “Health Research: Essential Link to Equity in Development”, the Commission on Health Research for Development revealed the major discrepancies that existed in the global distribution of financial resources for health research. An estimated 80% of the global population living in the developing world were found to shoulder 95% of the global disease burden using only 5% of global investments for health research. At the national level, the health sector remained a low priority area to which only 0.1-3% of the GDP was allocated in the annual budgets. Health research was ranked even lower with less than 0.5% of the budget, if any. As a result, about 90% of all national health research funds were from development partners who ended up dictating research agendas in recipient countries. This health and research resources allocation imbalance at national and global levels has not changed much over the years with less than 10% of global spending on health research today still being devoted to diseases or conditions that account for 90% of the global disease burden – the 10/90 Gap (10/90 report 2001/02).

Given this scenario, it was no wonder that the health research agenda in nearly all developing countries, Africa included, was found to be dictated by development partners – “he who pays the piper calls the tune”. In order to positively influence their relationship with development partners, as correctly recommended by the CHRD, developing countries were requested to direct more of their resources into both health and research. The Commission then called on countries to allocate a minimum of 2% of their national health expenditures to research and for all internationally funded health programs to earmark 5% of budgets for health research support.

Credited to the CHRD report, a number of important global initiatives have been put in place since its release. The Commission for Health research and Development (COHRED) was, for example, established in 1993 to promote the concept of Essential National Health Research (ENHR). Also, implementation of the recommendations of an Ad-Hoc committee on health research which were published in 1996 led to the establishment of the Global Forum for Health Research in 1998 with the mandate of monitoring progress of health research in developing countries as well as tracking financial flows to redress existing disparities.

Following its establishment, the Forum has hosted regular annual Global Forum meetings and sustained release of widely disseminated update reports, “The 10/90 Report on Health Research”. The best remembered of all the Forum meetings is probably the International Conference 2000 (IC2000) held at the Shangli-La Hotel in Bangkok. It was at this conference that nations undertook to “take stock” of their accomplishments since the release of the CHRD report a decade earlier.

Findings of an African consultative process that involved 300 key informants from 110 institutions in 18 African countries that took place in preparation of the IC 2000 meeting were disheartening. With very few exceptions like South Africa, health research financing in Africa continued to be characterized by low global expeditures and insignificant national investments. Many countries had still not adopted the concept of Essential National Health Research (ENHR) though promising trends were evident where the concept had been grasped and implemented. In such countries, a “bottom-up” consultative process had been adopted by stakeholders in prioritization of national health problems thus creating a better sense of problem ownership by communities.

Success was however curtailed by inadequate program funding and poor national health research systems. It was also obvious from these consultations that health research was far from being recognized as an effective tool for health action, partly because quality research output and utilization remained low. Collaboration among various stakeholders like researchers, research institutions, institutions of higher learning, service delivery organizations, policy makers and external development partners remained below expectation in nearly all countries visited.

Despite the importance of equity in health care provision and research featuring prominently in both the Alma-Ata and CHRD recommendations, hardly any gains were evident on the ground. Encouragingly however, a number of countries were found to have policies or plans to put some in place. Major disparities in access to health care remain between the rich and the poor, urban and rural, between genders, along age ranges and ethnic lines.

Subsidies allocated to the poor, for example, continued to benefit the rich while marginalized populations were further relegated to the periphery of health care provision. Research on equity in health remained extremely low though necessary for igniting debates on the need for equitable distribution of resources for health. Among other recommendations, participants in the Africa consultative process strongly recommended “that equity be brought to the surface and that research guides the process of not only identifying the disparities but also proposes appropriate responses and helps to monitor progress towards equity”

The Bangkok IC 2000 meeting identified three key challenges for Africa: building appropriate capacities to undertake research, development of effective national research systems and creation of research enabling environments. Establishment of an African Forum to advocate for more attention to research as an essential tool for development was highly recommended as an important point of starting to address the challenges. Besides articulating the African voice on research, it would also catalyze building of coalitions, South-South and North-South linkages, effective regional and global networking as well as acting as a broker for resources for health research.

The African Health Research Forum was launched in November, 2002 at the Global Health Research Forum meeting in Arusha, Tanzania as the result of efforts of a regional steering committee appointed at the IC 2000 meeting. Over the last three years, the Forum has undertaken a regional survey on health research networks, hosted consensus building meetings with representatives of 15 key research networks and other major stakeholders and participated in discussions hosted by WHO/AFRO, NEPAD, and Private-Public Partnership Initiatives among others. The Forum has also been invited to sit in the WHO/AFRO and East Africa Health Research Advisory Council and hopes to continue seeking invitations to other similar regional and sub-regional health research committees in furtherance of the execution of its mandate.

Among other initiatives so far undertaken by the Forum is a Health Research Leadership Training program being pilot-tested with two Anglophone and two Francophone countries. Like the establishment of a regional forum, nurturing of leadership in health research was identified as another crucial tool for advancing health knowledge production and utilization in Africa. This IDRC funded initiative is a collaboration between African Health Research Forum (AfHRF) and the Canadian Global Coalition for Health Research which targets training of mid-career level epidemiologists, social scientists, policy makers and community health care workers using a “team-training” concept. The teams would then be expected to act as national focal points in the advocacy for generation and use of research knowledge for improvement of their people’s health. Although the training is primarily through individual and group learning, two week “institutes” are organized once a year to expose the groups to prominent regional health research leaders and other resource persons as part of the learning process.

Learning emphasis for the teams focuses on the importance of equity, ethics, methodology, team play, management and governance in research. AfHRF is therefore in a unique position not only to advocate for more attention on the hitherto forgotten important area of equity in health research but to also bargain for more national, regional and global health resources to be directed to benefit the more disadvantaged in society. An example of such avenues was the release and dissemination of an AfHRF and the WHO Africa Advisory Committee on Health Research (AACHR) crafted “Voice on Health Research” at the Mexico Health Ministers Summit and the 2004 Global Forum Meeting. Given the emerging important roles that NEPAD initiatives and the United Nations Millennium Health Development Goals are likely to play in the future in Africa, AfHRF will aspire to maintain close links with them with a view to advancing the shared visions of health research stakeholders in Africa.

* Prof William M Macharia (MBChB.,MMed,MSc) is with the African Health Research Forum.

* Please send comments to editor@equinetafrica.org

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

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

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

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

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

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

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

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

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

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

Equity issues infuse our experience of COVID-19 in the region and globally. It should also infuse the response.

It is not well measured in the aggregate data commonly reported, nor in the media profile given to individual cases in elite groups, but COVID-19 spreads through and worsens social inequality. While the first spread of the pandemic may have come through richer, more mobile people and while all social classes have been affected by COVID-19, it would appear that the spread of the coronavirus exploits and exacerbates the social inequalities in the way we live, work, trade and travel in the region.

People living in lower income areas are often crowded in smaller, poorly ventilated homes, with many generations living in the same crowded home, without safe water supplies to wash hands and immune systems are already battered by undernutrition, infectious and chronic diseases. Crowded transport systems, dusty, poorly ventilated working environments and pollution from cooking fuels and houses sited near landfills and industries raise the risk of respiratory diseases, asthma and occupational lung diseases, making people more susceptible to severe effects of the virus. If resilience refers to the ability to restore the ‘normal’ that we had before COVID-19 and all the inequalities that put people at risk, then we should not aim for resilience. We should aim for change.

There are also social inequalities in a response to COVID-19 that provides less access to and continuity of care for COVID-19 and other health problems. It raises burdens on those who are already more vulnerable. As is happening in all countries affected by austerity, the chronic underfunding of and weaknesses in our public health services undermine care for poorer communities and protection of the health workers who work in them, notwithstanding the efforts being made by health ministries and other stakeholders. Private providers have expanded their role, but often without adequate public co-ordination and leadership and generally unaffordable for low income communities and enterprises. As noted by UNFPA, women represent a large share of health and social sector workers who are more at risk, while increased household tensions during lockdowns are increasing domestic and gender violence.

We are learning that a well-funded public health infrastructure is essential to keep all healthy and safe, that investing in prevention is primary and that transparency on resource flows is critical. Globally, with protectionist responses from high income countries, patent barriers and past policies of importing rather than locally producing medicines and other health technologies in the region, ESA countries, like poor households, are last in the purchase queue. ESA countries are often dependent on charitable contributions or rising debt to obtain health technologies that should be regarded as a right and as public goods. Global mechanisms that depend on charity and two tier systems risk aggravating inequality in access across countries.

Without a vaccine, the response has largely been one of command and control, sometimes militarised, putting whole sectors, areas and communities into lockdown. Many households in the region already live hand-to-mouth and do not have the social security to stop work, or the means to work remotely, so lockdowns increase income inequality. Restrictions on public transport without safe alternatives leave poor households trying to reach essential services stranded. Macro-economic concerns have motivated formal sectors like mining to restart, but do not address these socio-economic insecurities in more marginalised communities. Migrants returning home or located away from home are sometimes stigmatised and treated more as a public health risk than a vulnerable community.

These inequities call for local, national and regional responses. Social isolation measures have proved critical for the technical response to COVID-19. Yet for people who are compelled to work to secure daily incomes for their families, dialogue to find the best ways to protect both public health and livelihoods would seem to be more effective and sustainable than criminalising their actions. A biosecurity, top-down, secretive and militarised response to COVID-19 in the name of public health damages the trust, participation and collective solidarity that are essential for effective public health. In part this reflects whose knowledge and experience counts. Importing modelled concerns from high income countries on the adequacy of hospital resources can focus attention away from areas that the specific epidemiological and health system conditions in the region demand. While journal articles and scientific advisors compete for political attention, the experience, ideas and agency of those directly affected by the epidemic is often marginalised.

Yet there are many positive experiences in the region to report. Public officials, health workers, volunteers, including community health workers and health facility committees, have worked overtime to reach households, trace contacts and organise responses. Communities have formed solidarity networks to support vulnerable households with food and care and have held the state accountable for interventions. Parents have schooled children and teachers have found alternative ways to teach students during lockdowns. Small enterprises and local universities have produced affordable face masks and other technologies; local producers have switched lines to produce ventilators and local artists have produced music and murals to promote social awareness. Communities have provided support for returning migrants; diaspora and local people have crowd funded for support initiatives and local enterprises have contributed to solidarity funding of health technologies. COVID-19 has provoked social attention on health worker and gender rights. It has shown that ignoring social inequalities in health and their determinants and under-investing in comprehensive primary health care and public health threaten our society and economies as a whole.

We need to measure, publicly report on and visibly address these dimensions of inequality and to integrate the experience and ideas of all those affected. Not doing so undermines the effectiveness of our current and future responses. As Anand Giridharadas has said: “Your health is as safe as that of the worst-insured, worst-cared-for person in your society. It will be decided by the height of the floor, not the ceiling”. Even while African political leaderships are calling for global leaders to stop the debt outflow and patent and procurement barriers that are undermining responses within the region, we need to also confront the inequality that COVID-19 is intensifying within our countries.

So we are reaching out to you! Are you working on or concerned by any of these dimensions of inequality? Are there others that you want to raise? If so, please share your concerns, ideas and work! As a community that promotes equity values, EQUINET would like to learn more, share more, inform and voice more on these issues. If you have blogs, webinars, poems, art, stories, case studies, published work or videos on these issues or other equity concerns in the region that you want to share, please let us know so we can provide a platform to share them. Let us know if there are interesting case studies that we can support, or if you have ideas for joint work with EQUINET. Send feedback to us by email or on the feedback form on the EQUINET website and we will follow up with you.

The pandemic is a threat. It must also be an opportunity in our region to confront conditions and mantras that have generated the worsening inequality, rights violations, precarious labour, capital outflows, underfunded and commercialised systems and ecological decline that make us vulnerable to epidemics and that undermine capacities to respond in our collective interest.

We welcome your feedback on the issues and invitation in this oped – please send them to the EQUINET secretariat: admin@equinetafrica.org. Please visit our website for information sheets produced by EQUINET.