Silothemba looks lovingly at the little bundle nestled in her arms and beams with pride. “It wasn`t easy,” she says. “I nearly lost this baby. I bled a lot and had I not been here the nurses say I may not have made it too. I wasn`t eager to come to the waiting mothers home because my friends said the nurses keep you there for long and I have two small children at home. Actually I didn’t go to the home on the day the nurses said as I decided to go to the clinic when I felt labour pains. My local village health worker encouraged me to take their advice, however, and I am so happy that I did. My delivery was very difficult. It started at night and had I not been at the clinic my baby and I might not have survived”.
Silothemba is one of the many mothers in Zimbabwe who have benefited from waiting mothers homes. These facilities help to reduce home deliveries as they enable mothers to be at health facilities when labour begins. Nutrition gardens at clinics managed by health centre committees provide vegetables for pregnant women, and boost food security for those from poor households.. Kumbudzi clinic in Umzingwane district also has a kitchen project to support and promote nutrition amongst pregnant women.
In Zimbabwe currently 525 mothers die in every 100 000 live births, one of the highest maternal mortality rates in the world. Mother and newborn survival in Zimbabwe is affected by the ‘3 delays’, that is a delay in making a decision to seek health services, a delay in reaching a health facility and a delay in receiving quality services and care upon reaching a health facility. These delays and the deaths from them are greater in rural areas.
Before the waiting mothers homes were introduced, rural women often gave birth at home with the aid of traditional birth attendants. While convenient, these home births may expose women to risks from unhygienic conditions or limited ability to manage complications. Waiting mothers` homes increase mothers’ access to skilled birth attendants and emergency specialized care.
Women who deliver at home often lack adequate information on the risks associated with pregnancy and childbirth. Health monitors at community level indicate that the delay in deciding to seek health care is a major contributor to maternal deaths, as women decide to seek appropriate health care when it is too late. This delay is exacerbated by the fact that many women do not make these decisions themselves but defer to spouses or relatives, who may also lack knowledge on maternal and child health. Pregnant women also face barriers from long distances to health facilities, poor road networks, slow transport methods. They may thus deliver before they even reach the clinic. Women in many remote rural and resettlement areas live more than 25 kilometers away from health facilities, above the 10km maximum recommended by government. Going by ox drawn cart is not an option when there are pregnancy related complications have developed and many transport operators fear the risk associated with ferrying such passengers.
A waiting mother home reduces the stress of these barriers, giving time to travel to facilities, and reducing costs from different transport options. It brings mothers closer to the skilled health workers they need to manage normal deliveries or obstetric complications.
This puts the focus on the third delay, the delay in receiving adequate health care. With postpartum hemorrhage; obstructed labor and hypertensive disorders common causes of maternal death in Zimbabwe, health services need, but often lack, the staff, training, medicines and equipment to effectively respond to a mother’s needs. Most rural clinics have at least 2 trained nurses/midwives, but these health workers often face burnout due to overwork and lack electricity, running water and adequate medicines. Higher level referral services may themselves lack skilled personnel. Antenatal care services and waiting mothers homes allow health workers to monitor the mother before their labour and make early referrals to the next level of care for caesarians, vacuum extraction and induction if this is needed. Referral to these services may also face challenges in some areas from poor road networks, flooding rivers, a shortage of ambulances and poor communication channels. While waiting mother homes cannot solve these referral problems, they can give health workers more time to arrange options to address them.
To overcome the three delays, waiting mothers homes need to be backed by other service improvements. Primary health care services need to be available in remote and hard to reach areas, skilled obstetric care needs to be brought closer to rural women through regular visits to health facilities by doctors and stock-outs of relevant medicines avoided. Village Health Workers should be supported by strengthening their knowledge on maternal and child health and support for community led health promotion. Communities especially men should be involved and educated on the risks associated with maternity and the benefits of delivering at health services to encourage their partners to use and benefit from waiting mothers homes, to promote institutional deliveries and to argue for effective primary care and referral services.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
Editorial
A growing number of the world’s workers are invisible to mainstream occupational health and safety (OHS): The vendor in Maputo or Nairobi trading on a city pavement, the person sorting waste on Durban’s municipal garbage dump, or the garment worker using her own home to make clothes for the local or international market.
These ‘atypical’ places of work have existed for many years, especially in developing countries. But OHS generally deals with formal workers in formal workplaces such as shops, factories, offices and mines. It does not accommodate much understanding of the social determinants of health, that is the relationship between risk, poverty and informal work, or how community health is affected by the conditions people work in.
Some risks are general to all forms of informal work, such as the low and unreliable incomes earmed, and the lack of cover by work-related health insurance. In addition, the different places of work present different types of specific risk: for example, street vendors are exposed to the sun and to vehicle fumes; stall holders in built markets face fire hazards; and those sorting waste are exposed to broken glass, putrid meat and discarded batteries on waste dumps. The different employment relationships, including self-employment, disguised waged work and informal waged work, also influence the risks that workers and their families face.
These employment patterns present challenges to the discipline and the practice of OHS. Profound institutional disconnects are becoming more apparent because of the numbers of workers involved, in the global north and south, and because of the growing public awareness of the informal economy.
OHS policies, norms and standards are usually set nationally, but it is local government that has most control over day-to-day working conditions. For example, street vendors’ conditions of work are vitally affected by the presence or absence of local government provision of public toilets, shelters for trading, lighting and refuse removal. Industrial out-workers who use their homes as places of production are affected by zoning and planning regulations, housing density and roads (including for access to health services and to markets). While calls are being made nationally for job creation through support to informal enterprises, local governments have in contrast smashed people’s livelihoods through evictions and confiscation of assets, undermining workers incomes and health. Better vertical institutional coherence between local and national levels could enhance opportunities for informal workers to earn better and more reliable incomes.
There are also horizontal institutional tensions and gaps. At national level, macro-economic policies lead to increased poverty and inequality that cannot easily be redressed by social policies. At local government level, informal workers engage with local government officials from departments such as sanitation, public health and environmental health that may have different policies and practices for regulating informal work, and that have limited understanding of the positive economic role played by the informal workers.
Is a reformed and more inclusive occupational health and safety possible, not only conceptually, but also in terms of enabling realistic compliance, with shared responsibilities between the state, informal workers, and employers (where these exist)?
Innovative work done by the ILO and others have tended to allocate most of the responsibility for ensuring health and safety to the informal workers themselves. But it is known that poorer informal workers do not easily prioritise their own health above their need to earn better incomes and thus may not invest in improving the safety of their working conditions. For example, industrial outworkers earning piece rates for stitching garments may not take regular breaks; waste pickers may not use personal protective equipment if it slows their work down; or headload porters may not carry lighter loads when they earn according to loadweight.
New evidence of opportunities for informal workers to engage constructively with local government over improved OHS is emerging from a five-country research and advocacy study in Brazil, Ghana, India, Peru and Tanzania, being done by Women in Informal Employment: Globalizing and Organizing (WIEGO). WIEGO is a network that seeks to improve the status of the working poor in the informal economy, especially women, through support for increased organization and representation; improved statistics and research; more inclusive policy processes; and more equitable trade, labour, urban planning, and social protection policies. The network implemented participatory research with worker groups, many of whom are affiliates of WIEGO, followed by institutional mapping of OHS in each country and in selected major cities. The studies highlighted that new worker movements – organizations and associations, often structured along sectoral lines – are critical for effective engagement over recognition and improved conditions. These movements emphasise the right to work, advocate for recognition of informal work and many are collecting rigorous data about the contribution of informal work to the local and national economy, in order to strengthen their position. Their highest expressed priority, after higher and more reliable returns to their labour, is for access to health services.
We are now exploring pathways of policy influence, engaging in international and national OHS platforms and dialogues, and encouraging a change in the curriculum for OHS training. Powerful vested interests are obviously stacked against such reforms, including from within mainstream OHS disciplines, and from global owners of capital who are presently ‘off the hook’ in terms of their responsibility for the health and safety of the millions of workers who produce for them. However the research in each of the countries has identified encouraging points of entry and increasingly organized advocacy for a more inclusive OHS.
For more information on the issues raised in this op-ed please visit www.wiego.org and the OHS newsletter at http://wiego.org/ohs/newsletter , or write to Francie Lund lundf@ukzn.ac.za or Laura Alfers Laura.Alfers@wiego.org
This year, as we look back upon 26 years of World Aids Days, we honour the millions of heroes and heroines who fought the good fight against AIDS but are no longer with us. We need to make sure that this day and the year that follows is about what we do to ensure that people continue living positive, productive lives, with great decency and dignity.
As a young person, I grew up hearing statistics like more than 4 young people are infected with HIV every minute and over 6 000 are newly infected every day. Over half of all new HIV infections were amongst young people in my age group. We had even been called the doomed generation, because many of us had never known a world without HIV and AIDS. AIDS had become our disease and it was feared that within a decade, we would be reduced to mere statistics.
Stigma and exclusion had hindered the efforts of many young people seeking the counselling, testing, treatment and support they required to ensure that those who were not infected remained uninfected, and the infected and affected were well cared for. Many carried the virus for years without knowing.
HIV changed our communities and civilizations, hacking away more than twenty years of hard gains in education, food security and socio- economic development; making our families poorer, and driving us into poverty.
While the scale of devastation caused by the epidemic was unmatched, we also knew that we could beat it - with quality treatment and effective prevention. So we began to fight back, to reclaim our spaces through advocacy, education and awareness. We changed and reclaimed our lives, forcing the epidemic into retreat in many places.
We were not always supported. To save lives we had to successfully confront the monopolies that endorsed skewed TRIPS+ trade agreements, greatly limiting the flexibilities that were won within TRIPs in the Doha Declaration to protect public health and increase access to essential medicines. We had to confront transnational corporations that had tried to challenge Indian law in an attempt to shut down 'the pharmacy of the developing world' - one of the largest producers of affordable generic medication. We had to claim our right to affordable and accessible quality medication.
But we are not done yet.
According to the UNAIDS GAP Report 2014, less than 50% of the 35 million people living with HIV globally know they are HIV positive. Adolescent girls and young women in Sub-Saharan Africa account for a quarter of the new infections. Gender based discrimination, poverty, and the denial of their economic, social and cultural rights continues to drive the epidemic. We are also facing high rates of antibiotic resistance and a reduction in the effectiveness of other medicines we have struggled to access. As a result people with drug resistant diseases like MDR TB need more expensive drugs. This has put a great burden on health services that are already underfunded.
World AIDS Day 2014 and every day after presents the opportunity for us to harness the power of social change to put people first and to close the gap. Ending the AIDS epidemic by 2030 is possible, but only if we leave no-one behind.
Closing the gap means enabling all people, everywhere, to access the services they need,
• By closing the HIV testing gap, so that the 19 million people who are unaware of their HIV-positive status can begin to get support.
• By closing the treatment gap, so that all 35 million people living with HIV have access to life-saving medicine.
• By closing the gap in access to medicines and care for all children living with HIV, and not just the 24% who have access today.
• By closing the gap in power so that young women, children, people of all ages, income and cultures can be included as part of the solution.
We are not done yet. Let’s close the Gap!
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
On the 29th July this year, I embarked on a three-month training program of an East and Southern African Regional People’s Health University (RPHU) themed “Past, Present and Future struggles for Health equity”. The RPHU was organized by EQUINET and PHM for health activists from the region. As a member of PHM-Uganda and an activist for the struggle for health for all, I couldn’t miss the opportunity. I was enthusiastic to join others from the region to explore these issues further. I wanted to ground myself in the discourse of health equity, to get a firm understanding of what it means in the context and reality of my country and the region, and to appreciate how equity can be achieved for the millions that continue to suffer a wider spectrum of different forms of health injustice. I wanted to learn from others in the region how the struggle for health equity and social justice has evolved over the years, the successes and failures but also opportunities to fight back against systems of oppression and to build a people-centred health system.
Like the rest of sub-Saharan Africa, Uganda has been battered by the COVID-19 pandemic. The social pains of COVID-19 have been profound in the areas of health, livelihoods, education and governance. Although the COVID-19 pandemic can’t be blamed on anyone in Africa, Africans, and especially the leadership, can’t be excused for any failures to adequately respond to it, for our weak health systems and for an unacceptable absence of an Afro-centric power and strategy to counter the hegemony of global powers in access to essential health technologies.
The RPHU brought together a diverse pool of well-informed persons on all the topics covered. The topics and issues included for discussion exposed the wide range of issues affecting health equity. In fact the topics needed more time to articulate and especially for participants to have time to share and reflect on their own lived country-specific experiences. However, the resources availed before and after sessions were sufficient to help those interested to immerse in the literature, to further grasp the subject matter.
I enjoyed the discussions around the social determinants of health, linking health systems to comprehensive Primary Health Care. These concerns and those of power, values, and laws remain central in building health equity in Africa. The exposure I got to the external factors driving health inequity in our region was a wake-up call, including when global governance frameworks are championed and imposed on Africa by international agencies and western countries. .
Indeed, I am rethinking my approach to activism and advocacy in general. My quest and challenges continue to be around building a community-driven, people-centred activism that is self-sustaining and able to drive change. In Uganda, the public is often passive and inclined to fall into despondency, especially on political matters. My take-home struggle is to build a mass movement of actors collectively working for a common purpose of health equity. Financing that struggle for health equity, and particularly our dependency on western philanthropy continues, however, to be the “elephant in the room” for me. It must be confronted head-on. If indeed we are to achieve health equity on the continent, we must find the drive, resources and strategy within ourselves.
As the days of the training moved towards the end, key questions continue to linger in my mind. Is there a correct order in the sequence of actions to realize health equity? What should a country like Uganda prioritize, given the limited resources? Can a country achieve health equity without democracy, or should the struggle first centre on political liberation, and then the rest follows? The RPHU couldn’t cover all these wider issues, but in my mind, I can’t see health equity being realized in a corrupt, inept and undemocratic space, where the voice of a common person doesn’t matter and the abused are so powerless to fight back.
As we go into the final week, I recommend to the organizers, lets reimagine the post-training initiatives. We are still discussing the post RPHU activities, but what participants do after the training is the most fundamental aspect. How can the organizers continue to nurture collaboration, and partnership beyond the training? Can EQUINET and PHM continue to provide a platform where peer-activists from the RPHU can continue to share and learn from one another, or engage in joint initiatives of common interest in the region? As was well articulated in the RPHU, no country can achieve health equity alone. We need a concerted effort across the region.
The private for-profit sector in east and southern African (ESA) countries cannot be ignored. With private health insurance growing, considerable out-of-pocket payments at point of service, rising investment in private for-profit hospitals including for medical tourism and a widening spread of informal providers, ESA countries need to pay attention to this sector as part of measures towards achieving universal health coverage (UHC).
The for-profit sector can add new resources and services to the health sector. But if left unregulated it can also lead to distortions in the quantity, distribution, price and quality of health services that affect the ability of countries to provide adequate and accessible services. For example, for-profit providers may concentrate in areas where wealthy populations live, ignoring areas of high health care need. The cost of both private health care and insurance tends to be high and unaffordable for low income communities. The presence of a for-profit private sector in countries that have a shortage of health workers may lead to an internal brain drain of skilled health workers from the public sector, due to better pay, leaving poor people with poorly staffed public sector services.
A review of laws on the private sector in east and southern Africa for a forthcoming EQUINET discussion paper shows that while many ESA countries have laws to register or license new private providers, few, except Namibia, South Africa and Zimbabwe, have adequate laws to regulate private health insurance. Few countries monitor the type and quality of services provided by private practitioners, clinics and hospitals once they are registered. Charges for health care services or insurance do not seem to be controlled, directly or indirectly, to any meaningful extent in any ESA country, while there is evidence from some countries of unfair business practices. This means that the law does not adequately address the affordability, access or quality issues that are central to achieving UHC.
The current situation suggests that it is time to move from an over-reliance on voluntary self-regulation by private health professionals and associations to developing policies, laws and instruments that clarify and organise the operations of private for-profit health care providers and insurers in line with national health goals. Several countries have recognised this and are beginning to update and improve their laws, although in most cases without clear policy guidance.
So one starting point may be for Ministries of Health to develop with stakeholders, including Ministries of Finance, an over-arching policy on the private for-profit health sector to guide and set the objectives for the law, separating the roles and duties of funders, purchasers and providers. This requires proactive consultation, building communication and trust between stakeholders and the introduction of laws governing the sector. It would seem timely to initiate this in all ESA countries, given the growth of the sector, even if the private for-profit health sector is not yet large.
The policy and subsequent laws should facilitate and create incentives for private health professionals and organisations to address the health needs of disadvantaged populations. They should also control against any health market distortions that jeopardise national health goals.
The laws should set standards on service quality, on emergency services and on the benefit packages, enrolment practices and sustainability of health insurance plans. The law should set obligations for the private sector to report to regulators and inform patients, health insurance beneficiaries and the public at large of their entitlements. Penalties should be set at appropriate levels to discourage breaches of these obligations, but at the same time there should be positive incentives, such as alternative reimbursement mechanisms, that help to shift the behaviour of the private health sector.
Having the laws on paper is only one step of the process. Enforcement of the law is still a challenge in many ESA countries. Maintenance of appropriate databases and monitoring of the law is still not well developed. In some countries private stakeholders greatly influence the content and degree of enforcement of regulations. Governments thus need to invest in the resources and capacities to develop, use and enforce the law, whether at central level or in a decentralised system. For this, legal, financial and public health skills are required, as well as the ability to collect, analyse, use and communicate information. Governments need to ensure that the legal requirements of multiple pieces of legislation are well-understood by regulators, health sector institutions and personnel, and the public.
Licensing and facility inspection should be strengthened and extended to examining the quality of care. Anti-competitive behaviour should be investigated and acted against. Regulators need to negotiate and apply mechanisms to reduce rising costs within both the hospital and insurance sector and ensure that laws are regularly updated in line with public health and other objectives. From the lens of service providers, government should harmonise the functions of different regulatory authorities, to avoid multiple, burdensome and costly requirements.
In conclusion, in a globalising world, with liberalised economies and growing private markets, including in health, leaving such an influential and growing sector poorly regulated would be a major obstacle on the path to universal health coverage. Governments need to act soon to address this gap in their stewardship of the health system.
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 and read the forthcoming EQUINET Discussion paper 99: Doherty J (2013) Legislation on the for-profit private health sector in east and southern Africa
Worldwide, according to World Health Organisation (WHO) in 2001, mental and behavioural disorders affect 450 million people and account for 15% of the overall burden of diseases from all causes. Yet, nearly two-thirds of those affected do not receive adequate care due to stigma, discrimination, neglect and poverty. Mental health is an integral part of the whole health of a person. Even when physical illness predominates, the mental health status of the person can influence the course and outcome of physical illness. While the prevalence and pattern of mental health disorders are similar in high and low income countries, for low income countries the challenges of providing mental health services are myriad. They range from mental health being given low priority by policy makers, to poor or unavailable services in terms of infrastructure and services, to inadequate health workers oriented to mental health care needs.
Health worker shortages have received increasing attention of late as one of the most critical gaps in the provision of services. Too often, however, the critical gap in mental health personnel is overlooked. There is a particular shortage of mental health workers in low income countries. Estimates show that there is an average of one psychiatrist for two million people in low-income countries compared to one for every 10,000 people in the high-income countries. In Kenya for example, there is one psychiatrist per four million people and mental health services at the primary level are largely left to general nurses and clinical officers. Kiima and colleagues in 2004 found that these personnel readily recognise psychosis, but are less able to recognise learning disorders, emotional disorders and conduct disorders in children and adolescents. Primary care staff who feel uncertain of their skills in this area may not adequately diagnose mental health problems, or may refer cases to higher level facilities. Besides being expensive, this leaves a large number of mentally ill patients untreated. The social and economic cost, as with other areas of unmet need, then falls on the individual, family and community.
It seems unlikely, in the foreseeable future, that we will achieve the psychiatrist: population ratio levels in developing countries that compare to what has been attained in developed countries. This is especially so as internal and external migration draw specialized personnel out of our health systems and out of services in poorest communities where health needs are high. How then can we meet the significant deficit in addressing a public health burden like mental health, at a time of major shortfalls in our health systems?
WHO has in recent years proposed task-shifting as one way of filling the gap in availability of health workers. This implies transferring skills to less academically qualified but more available personnel to provide key services. There are some emergent efforts in Kenya to replicate this for mental health services. The various mental health issues and service roles in different stages of the cycle of prevention, treatment and care are explored to assess where task-shifting provides a feasible possibility to reach the community and improve service provision. These efforts must still be shown to make a real difference in effective services for communities. They need to link skilled health personnel with those in frontline care through supervision and support so still demand these high skill personnel for leadership, and in research and higher training. So task shifting makes it even more important to find effective options for retaining these high skill personnel in their own countries and to link their own desired career paths to the needs of the health system. Kenya has been notable in the region for its production and retention of psychiatrists and could make a very interesting case study on the success of national retention psychiatrists, even though these personnel may not be equitably distributed in the country.
The task shifting debate also draws attention to wider, primary health care (PHC) oriented and innovative options that integrate mental health into other promotive, preventive and curative services at community level. A holistic approach is in accordance with the WHO definition of health, that encompasses physical, social and mental wellbeing. Wiley-Exley in 2007 in a 10-year review of community mental health care in low- and middle-income countries showed that community based care can provide improvements in mental health, even though more work is needed in specific areas such as services for children and adolescents. Preliminary work by Jenkins in Kenya shows that retraining of primary health workers in mental health can have an impact in the number of correctly diagnosed mental health cases and the quality of referrals. Othieno and colleagues, with Department of psychiatry, University of Nairobi and with EQUINET support, have worked with community members in Kariobangi in the suburbs of Nairobi using participatory methods to recognize and find ways of dealing with cases of mental illness in their community. A similar approach has been used to encourage compliance among those with HIV infection who engage in harmful alcohol use. These case reports, both found in more detail on the EQUINET website, suggest that participatory action research methods could be effective in detection and management of mental health issues at primary care services and in the community. More work is needed in this area and if replication in other parts of the country proves its efficacy, it could be included in the curriculum for the health workers at all levels. As noted with the task shifting discussion, however these approaches should be complemented by developing referral and tertiary services, and skilled personnel. This is not only needed to support the implementation and supervision of PHC approaches to mental health, but also because as the needs are recognized, referrals from the primary care facilities are bound to increase.
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 EQUINET: www.equinetafrica.org.
HIV represents an unprecedented pandemic, and one that is forcing civil society to innovate to meet the challenges. Civil society engaging on HIV has carried out one of the most vocal, widespread and innovative advocacy campaigns in health, drawing on language and approaches from other sectors and regions. HIV activists have in the process brought human rights into health advocacy, even in settings where rights are perceived to be foreign and confrontational. Why do civil society advocacy groups working on HIV choose to express their claims in the language of human rights? How do they understand this choice? What impact do they see it having? What impact does it have?
I explored these questions in sub-Saharan Africa, a region hard hit by the pandemic.
The answers might surprise: the decision to use rights was fueled by individual belief not pressure from external funders. It was also the individual empowerment effects of ‘rights-talk’, rather than their legal effect, that activists felt to be most important.
I explored the experience of nine local civil society organizations selected from four countries (Ghana, Uganda, South Africa, Botswana), located respectively in three sub-regions of sub-Saharan Africa (West , East and Southern Africa). Choosing from the three regions provided insight into civil societies operating in different contexts and at different levels - local, national, regional. To allow for a systematic comparison, I chose organizations that vary in the extent to which they use human rights in advocacy. The case studies drew on 145 semi-structured interviews conducted with these organizations, as well as with others in the HIV sector. I also reviewed relevant events, documents and press accounts.
Over the past twenty years many funders have embraced the human rights framework. While I am not suggesting that international funders are not important, I found that their preferences were not particularly influential in whether organizations used rights-based advocacy. Groups using this framework didn’t lose interest when it became less popular with external funders, nor did their interest rise or fall with changes in funding. Many of the civil society groups have at least a dozen funders who usually support particular projects rather than the organization as a whole. Because organizations have so many funders, any single funder rarely influences the framework an organization chooses for its advocacy.
The organizations instead chose human rights primarily due to a mix of principles and structural factors. Organizations with a leader with a strong human rights orientation and regular interaction with other employees were more likely to choose a rights-based approach. In settings where human rights are not a common discourse, groups manage to thrive- even in isolation - when they had powerful “rights champions” as leaders. Such leaders have been able to incubate a rights-oriented organizational culture, attracting personnel who have, or will acquire a similar orientation.
People who worked for organizations that gave strong attention to human rights in advocacy often held strong personal belief in the framework. Respondents often explained this passionately, describing human rights as core to their dignity and identity. Rather than being a topic or a strategy, human rights were described as a fundamental part of who they were, what they believed in and how they saw the world.
I expected that groups would choose human rights over other approaches because they are linked to legal enforcement, in ways that development work or public health may not be. I thought perhaps the choice to use human rights in advocacy was rooted in an expectation of a government response and legal accountability. Instead, respondents saw the most important impact of human rights as their empowering effect for individuals, particularly amongst those seeking health care. They saw rights as empowering people living with HIV to demand services owed to them, and to make requests from a position of power and entitlement, rather than one of weakness and desperation.
One respondent described the shift in mindset that she saw accompanying rights-based advocacy, as “creating in people’s minds” the idea that they “have the right to demand better.” Respondents gave accounts of these demands: “When you say, ‘It’s my constitutional right, doctor. I am not going to leave this room without having treatment,’ therefore the doctor will make sure that you get the treatment […] They don’t make a mistake.”
While the above quotation is from South Africa, where health rights are included in the Constitution, even in settings without such constitutional provisions respondents gave very similar accounts. They saw rights language as transforming people from passive recipients of care to active participants engaged in their own health, and as engaged citizens rightfully demanding services from the state.
The findings indicated that “human rights” may yield important effects in places that human rights scholars seldom look. Beyond state actions and high-profile venues such as the United Nations and national courts, people are wielding human rights in their day-to-day interactions in ways that have meaningful influence on their lives. It appears that human rights-based advocacy has a unique impact. It changes people’s self- perceptions of power in relation to the state and enables them to claim services to which they are entitled from a position of greater strength. Those exposed to human rights-based advocacy were reportedly more likely to seek health care services, to be more informed about their rights, to ask questions of health care providers, and to query delays or denials of service.
It would be interesting to see what these findings imply for other areas of public health. They suggest that human rights-based activism could be an overlooked, but powerful positive determinant of health.
A version of this oped was originally published in Open Global Rights: www.openglobalrights.org/empowering-language-of-rights-underlies-increasing-use-in-hiv-advocacy/. Further information can be found in ‘Resilience and Contagion: Invoking Human Rights in African HIV Advocacy’, McGill-Queens University Press, at www.mqup.ca/resilience-and-contagion-products-9780773550995.php?page_id=119256&
The barriers researchers face in having qualitative research published in many mainstream health and medical journals is limiting our understanding of important dimensions of health care. At a time when health systems are increasingly involving a range of disciplines in health teams and using more holistic models to respond to the mix of physical, psycho-social and environmental factors that lead to ill health, excluding qualitative work deprives decision makers of a significant body of knowledge that could inform decision making on health systems. “Furthermore, this effectively silences the voices of community members, particularly those who are marginalised across all countries”.
So argued 170 co-signatories from all regionals globally of a letter from the Social science approaches for research and engagement in health policy & systems (SHaPeS) thematic working group of Health Systems Global, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), and the Emerging Voices for Global Health. The full letter was published in June in the International Journal for Equity in Health and can be read at http://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0368-y
The signatories raised that many issues that affect both the effectiveness and equity of health systems cannot simply be ‘measured’ by numbers alone. Issues such as the subjective relationships and communication between health workers, clients and communities, the perceptions of and trust in services, the role of social literacy, or the values and preferences that managers, health workers and communities bring to systems affect health outcomes and therapeutic relationships. One young researcher argues in the letter that qualitative work “facilitates my understanding beyond what the numbers show”.
Researchers in east and southern Africa have in past EQUINET forums voiced similar views. They have raised the difficulties they face in publishing generally, not only in meeting the format, style and other demands of a journal paper, but also in finding the time for the process, given competing time pressures. Those working with qualitative research appear to face even higher barriers. The signatories to the letter stated “We are particularly disenchanted by our general experience of the limited and often inadequate publication of qualitative research in the major health and medical journals, and the resultant loss of important insights for those working in, or concerned with, health services and systems, including around clinical decision-making”.
For those working with participatory approaches the barriers can seem even more insurmountable. At a 2014 regional workshop on participatory action research, researchers raised that most traditional journals - and many funders - do not understand or appreciate these approaches. One researcher, from Malawi, described that despite his research leading to real changes, publishing it was an uphill task, calling for constant efforts to make to justify the approach, the role of community members as partners in the research and the use of subjective or qualitative evidence. Indeed in another article in this issue of the newsletter the authors comment: "research and publishing is the oxygen of academic life. But the regimes of control that surround contemporary approaches to publishing are choking creativity..."
The letter published by the health system researchers argues for methodological diversity in mainstream publication on health systems research, to build a more holistic and richer understanding of complex systems. Given the multiple factors, including subjective, dynamic and social factors, that influence health and the way services are delivered and experienced, it would indeed seem to oversimplify reality to give singular dominance to the old maxim that “what is measured counts” at the cost of the wider range of methods and lenses that we have to explore, analyse, and understand what counts.
The full letter referred to in this editorial was published as SHaPES, EQUINET, Emerging voices for global Health, Daniels, Loewenson et al., 2016, International Journal for Equity in Health 15:98 DOI: 10.1186/s12939-016-0368-y. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org or to the SHaPES working group in Health Systems Global http://www.healthsystemsglobal.org/
The EQUINET steering committee wishes you a healthy new year, and one that brings greater justice in our communities, countries and globally.
This is a short newsletter, given the time of year. However, the EQUINET newsletter is now 15 years old, and the monthly issues share a growing number of stories of both the challenges to health equity, and the many examples of innovative practice within the region. At a recent regional conference in 2015, delegates raised that in our east and southern African region, we still do not adequately document or publish what we are doing, so that our story is often told by others, or not at all. Until the lions write their story, tales of the hunt will always glorify the hunter. We have used the EQUINET newsletter to give more profile to publication from and on our region, and have included journal papers and reports, but also new media such as videos, online interviews, maps, tools, graphics and exhibits. We will be listening even more for this in 2016.
So we are asking you to please speak out and share your ideas, work and stories on health! Please send us your reports, papers, news, conference announcements or other forms of information [to admin@equinetafrica.org], or write a short piece that we can use as an editorial.
We also invite you to be involved in the work that EQUINET will be carrying out in 2016 to inform and strengthen learning and action on health equity. Our website (www.equinetafrica.org) provides more information on these activities.
We look forward to working with you in the coming year!
Much attention has recently been given to raising an adequate level of resources for health, especially to achieve goals of universal coverage. But if these resources are to reach those who need them, we also need to allocate resources fairly. This is particularly important given the very different access different social groups have to health care. In spite of the recognition by many countries for needs based resource allocation, including my own country, Zambia, our experience suggests that we still face many obstacles to put this intention into practice.
Data in Zambia shows, for instance, that although the allocation formula was radically revised with policy support in 2004/5 to incorporate deprivation and population weights, the new formula has still not been fully implemented. We realize that applying a formula to redistribute resources on the basis of need is not just a technical issue, but has significant political implications. We found in our research in 2007 and 2010 that applying a formula that takes deprivation into account in Zambia implies a loss of over 30% of revenue for the wealthiest districts, if immediately implemented. This raised considerable resistance towards an immediate implementation of the revised formula from key stakeholders such as district health management teams, as well as from the political leadership in the affected districts.
Allocating a fair share of health care resources to those with greatest health need is not only an ethical issue. It also makes public health sense to reduce the burden of disease, improve the uptake of health care and reduce avoidable inequalities in health. It makes economic sense in terms of poverty reduction and improved productivity, Needs based allocation of resources combines with other elements of priority setting in health, including the setting of basic entitlements and ensuring the effectiveness of health interventions. So why have we faltered in achieving this goal?
A common explanation is that the available resources are too limited to allocate equitably. How do you distribute an unfair total amount fairly? Prior work in EQUINET has shown that it is easier to reallocate new resources equitably when budgets are increasing than to redistribute static or shrinking budgets. In 1995 to 2006 in Zambia, according to the Ministry of Health, the total health expenditure per capita ranged from $17.50 in 1999 to $58.00 in 2006, but the government share was only between 8 – 14 per cent of this. The resource allocation formula was applied only to the recurrent budget, and between 2004 and 2009, the per capita recurrent budgets to districts ranged between only US$1.50 and US$ 4.14. How much impact can be achieved on inequalities in access and coverage health when such limited resources are being reallocated? So even though fair resource allocation is a demand that arises from the scarcity of health care resources, it is itself limited by that scarcity. Breaking this vicious cycle would be important for equity.
It is thus a problem that the significant resources that come from external funders are not themselves subject to a needs based resource allocation formula. National Health Accounts data in Zambia show that 44% of health finances are spent on district health services comprising the district health management offices, district hospitals and health centres, and 20% on provincial and tertiary facilities. Of these expenditures, the share of external funding was 42%, and funding earmarked for HIV/AIDS made up almost 25% of this. These funds are disbursed as vertical funding for specific targeted programmes and purposes. The funds are distributed primarily to achieve geographical coverage, with less concern for equity, as has been the case for Prevention of Mother to Child Transmission and general ante-retroviral treatment programmes that command significant resources.
While the adequacy of funds available for reallocation and the segmentation of external funds may weaken resource allocation, there is a deeper issue: Priority setting - and thus allocation- has not been strongly grounded in ethical values or social norms. It makes a difference whether financing decisions, including those related to the allocation of resources, are based on the pursuit of equity and social justice, on utilitarian issues of efficiency, including economic efficiency, or on an egalitarian liberalism that aims for steadily improving coverage, complemented by individual actions to enhance uptake.
The lack of a shared ethical premise supporting resource allocation may be the most significant constraint to advancing the fair allocation of resources. Experiences of resource allocation in Zambia suggest that reforms aimed at enhancing fairness in resource allocation falter more easily when they are not protected, or demanded, by a strong expression of social norms and values. It could thus be the key factor leading to uncertainty, and sometimes failure to implement resource allocation in a consistent and committed way for the effective strengthening of the health system in low resource settings. So while we build the technical measures and institutional capacities to more fairly allocate the resources for health, we also need to ensure that the ethical foundation it is based on is clear, shared and strong enough to sustain implementation on the face of the other blocks we face.
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, and reports on equity in resource allocation please visit the EQUINET website at www.equinetafrica.org.