In September this year the civic centre of Harare was buzzing with the sound of music and discussions, markets, installations, workshops and multiple activities. It was Shoko Festival time, and the museum, library and other civic buildings transformed into a magnet for young people to get away from the stresses of our shrinking economy and nourish our creativity.
Shoko festival is one of Zimbabwe’s fastest-growing international festivals and over seven years has grown into a major cultural event. The festival this year was held at a time when many are struggling with the socio-economic problems brought about by the myriad of problems in the economy. We wondered – is art a luxury at such a time? What can it contribute to improving our wellbeing in a harsh climate?
Our experience at the festival indicates that it is anything but a luxury!
This year’s festival was held with the theme ‘YOUtopia’, as a vibrant creative space in which people could explore and imagine the qualities they seek for themselves and their community or society. So we took advantage of the space and theme to take a discussion that we have been having as young people on what kind of city will improve our wellbeing to a wider audience.
In the past year as a group of young people in the Civic Forum on Human Development from diverse settings and suburbs in Harare we have been working with the Training and Research Support Centre in EQUINET to understand what is driving the inequalities in health in our urban areas, at least for ourselves as young people. With our health services often focused on treating diseases, we took a wider lens to build a more holistic understanding of what will promote our health today and in the future. In our own discussions we identified issues that go well beyond the scope of health services, including the way our cities provide spaces for us to create jobs, the green spaces and access to internet that we need to meet, connect and exchange ideas, and the access to urban land we need to have to grow food and build decent housing. We looked at how these issues are being addressed in other parts of the world and found a lot to inspire us on how we could do things differently here in Harare.
So we decided to participate in the Shoko festival with a stand on “picturing our urban futures” to hear and see what other young people thought. Over two days we explored what kind of city people, especially young people coming to Shoko festival wanted to live in? How did they imagine things could be different in ways that promote their wellbeing? We had an art table, where people drew in one half of the page features of areas they live, work or meet in in the city as they are now, and in the other half how they would like them to be. We had postits where people wrote short text on what they thought was affecting their wellbeing or what changes they wanted to see in for our cities to promote our wellbeing. We discussed what people saw as the different aspects of their wellbeing.
We had no rules and gave a free space and materials for young people to draw or write or say what they thought. Many youth preferred drawing their views than writing or talking.
By the end of the two days there were pink, yellow and green postits all over the glass wall on one side of the stand and artwork of all colours filling the wall on the other side and young people talking in between. We were surrounded by the analysis and the possible, in a space youth culture that radiated positive activism and ideas. Shoko is about celebrating positive youth culture that is trending and relevant in the cities that has been associated with hip-hop, dancehall to spoken word and comedy as well as graffiti and cutting edge ideas on how to use new media and technology.
The drawings were clear and the statements were short but full of meaning: “litter free and free wifi!” “a violence free city”, “ a safe city”. The tensions were economic, but also environmental and many were social or linked to mental stress.
The art work and postits highlighted how young people vision a different urban future to overcome the significant differences in opportunities for wellbeing that currently exist and to ensure that our cities work and promote health for all. Many showed how much mental stress is caused by bad conditions like public transport systems where touts push people into overcrowded combis, and how much people want to live in communities free of violence and of rising piles of waste and litter.
The art and postits showed the desire to move from roads with potholes, traffic congestion and chaos, environments with rubbish and poorly maintained parks to one where public spaces, roads and transport are safe and clean. Rather than have cities where the best buildings are for private finance and vendors compete for space with pedestrians, they visioned cities where the best buildings are for community processes and economic activities. They indicated that cities need to enable people to work and create jobs, including by giving access to free wifi, and people should have community spaces to gather and exchange views.
Are these visions of the future utopic? We don’t think so. They are a feasible, practical vision of what we should be demanding, contributing to and achieving for all in our cities and would do more for our health and wellbeing than all the medicines we consume.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
Editorial
Recognition of the health worker crisis in Africa has stimulated debate on what works to deploy and retain health workers in critical levels of African health systems. Most east and southern African (ESA) countries suffer a critical shortage of health workers with fewer than 2.5 skilled health workers per 1000 population, less than the level needed for the most necessary health interventions. The shortfall contributes to the persistence of high disease burdens and poorly developed health systems. These factors together with poor management systems and lack of appreciation of health workers drive further losses of health workers in a vicious cycle. With a Malawian woman having a probability of dying during childbirth that is 130 times greater than that of her American counterpart and faltering progress towards achieving millennium development goals in the region, acting on this health worker crisis has become a matter of global concern. While many policies and strategies are being proposed, answering the question what makes health workers stay in African health systems provides one direction for action.
Many factors responsible for health worker shortages, especially those related to global migration of health workers, are beyond the control of individual countries in ESA and call for wider international action. However there are important ways in which ESA countries can act to deploy and retain health workers in the health systems in the region, and there is learning to exchange from the combination of financial and non-financial incentives being used with varying degrees of success to retain available staff.
As an immediate measure many countries are using financial incentives like salary increases and allowances to send an early signal to attract or stem losses of health workers. To stabilize and sustain these, including in more inflationary environments, a range of non-financial incentives are also being used, such as training and career path-related opportunities, housing, transport, childcare facilities, free food, employee support centres, improvements in working conditions, better facilities and workplace security and improvements in management and human resource information systems.
Recognising the specific contexts affecting the approaches used in countries, there is scope for learning from the impact of measures being used in the region.
The Malawian health worker retention strategy, for example, is a combination of financial and non-financial incentives through a six-year, $272 million emergency human resources programme with budget support from the Government of Malawi, the Department for International Development (DFID) and The Global Fund for AIDS, Tuberculosis and Malaria. Blending these significant sources of budget support, the measures have (at least in the short term) managed to overcome the massive absolute shortfall across the system as a whole and to attract and retain health workers in Malawi. Some incentives address the factors that push workers out of the health system more directly. Swaziland responded for example to the high HIV and AIDS burden among the health workforce through the establishment of a wellness centre for health workers in collaboration with the Swaziland Nursing Association and the International Council of Nurses (ICN). Some countries have reduced the bureaucracy slowing the recruitment of health workers. Tanzania and Kenya have for example involved partners from the private sector to implement more easily administered emergency hiring plans for hard-to-staff areas.
Many countries face issues of internal migration and use incentives to more effectively retain workers in remote or underserved areas. Zambia, has for example, been able to attract staff to rural areas using a comprehensive package of financial and non-financial incentives, originally for doctors but currently extended to other health workers. Uganda made government service more attractive than the private sector through salary enhancement and non-financial incentives like training opportunities, support for research and a Yellow Star Award programme that recognises facilities that have consistently excellent performance. South Africa has used financial incentives in the form of rural and scarce skills allowances for under-served areas, in addition to compulsory community service.
Implementing these incentives and monitoring their impact calls for improved strategic management skills with greater flexibility to respond to rapidly changing conditions. A number of countries have set up autonomous health service boards and commissions to address health worker needs independently of the public service commissions to provide flexibility. This has had mixed results, depending on the resources and power that these boards have. The Zambian Health Service Board had a difficult beginning largely because most of the powers remained with the central public service commission. The Uganda Health Service Commission and the Health Board in Zimbabwe have been reported to function more effectively although their impact on health worker outcomes are not yet well assessed. Approaches that have evolved through consultation with all stakeholders, including the health workers and development partners, that are linked to strategic plans and funded from national budget or pooled funds, instead of vertical schemes, have tended to be more successful. Vertical schemes have suffered from lack of continuity and sustainability.
While experience is growing in the region around incentives for retention, assessing and sharing what works and what doesn’t work is constrained by lack of systematic documentation and limited monitoring and evaluation mechanisms. Success stories and success factors are thus not always well recognized locally or accessible to other countries. Weaknesses in monitoring and review systems also slow the response to unanticipated negative outcomes of schemes. For instance, in both Uganda and Tanzania, introduction of better pay for public sector health workers was accompanied by a net movement of health workers from faith-based facilities to government services, leaving many areas where only faith-based services were available to poor communities underserved. Recognising this, national and regional organizations in EQUINET are documenting experience and impacts in selected countries in the region.
There are good reasons for investing in retention incentives and for more effectively managing this aspect of health systems. Firstly, training health workers is costly and takes long; and without measures for retention there is no guarantee that the trainees will stay after completion of their studies. The loss of public sector training investments is an area of high cost of outmigration to the public health systems of Africa. Secondly, failure to retain staff has direct and knock-on costs, such loss of institutional memory, loss of morale and increased workload for the remaining workers and higher costs to the community to seek care at higher levels. In contrast retention strategies send an affirmative message to health workers that they are valued and this sends positive signals to attract more health workers. Further, measures for retention of health workers have positive implications for equity as they direct resources towards hard-to-staff facilities in rural, remote areas or those serving poor populations who have limited capacity to pay for private health care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. EQUINET Theme work on health worker retention is co-ordinated at Unversity of Namibia and is being implemented in co-operation with the ECSA Health Community. For further information and publications on this issue please visit www.equinetafrica.org.
The world has become a very small place for some. Globalisation and the movement of people and goods mean that it’s possible on the same day to wake up in Asia and go to sleep in America. Farm products grown in an Africa can be on shelves in Europe within days. Yet it can take the same time or longer for a woman from that African country to get to a hospital with a midwife to access maternal health services. Clearly, the benefits of the increasingly rapid movement of goods, services and information across countries are not obtained by all. How have women in low-income rural and urban communities in Africa experienced the impact of globalisation?
A workshop held in Nairobi in May 2011 reviewed this experience and the implications for research on globalisation and health in Africa. The workshop was convened as part of a research programme on globalization and women’s health in east and southern Africa co-ordinated by Karolinska Institute and TARSC. The research programme found, through analysis of the Millennium Development Goals (MDG) database, that African countries are becoming more integrated with world markets and that women’s occupational roles are changing, but with inadequate disaggregation of global databases like the MDG data to assess the impact of these changes on women’s health and nutrition. A review of literature on existing studies suggested however that while globalisation related economic and trade policies have provided urban employment and social opportunities for women, they have also been associated with time and resource burdens for them that have had negative consequences for their own and their families’ health and nutrition.
Examples of research presented at the workshop similarly suggested that women’s involvement in export oriented coffee production in Uganda and in urban export processing zone (EPZ) factories in Tanzania had brought improved incomes for the women workers, but with longer working hours and weaker social protection. Improved incomes in both groups had not translated to better nutrition or dietary outcomes compared to women working in non EPZ factories or in farms producing food for local markets. For countries seeking to make a link between economic activity and improved health outcomes, this lack of improvement from globalisation related changes is a problem, especially given the context of Sub-Saharan Africa having the highest level of maternal mortality globally, with 900 maternal deaths per 100,000 live births, a level well above the targets aimed for in the MDG commitments. While globalisation has been associated with information, research and technological advancements and a wider demand for equity and rights for women, delegates also heard evidence that it has been associated with commercialised health care and reduced public funding, creating barriers to use of health services by poor women. Further, recent features of global markets - the 2008 financial crisis and the increased price of food and fuel – were raised by delegates as likely to intensify food insecurity, particularly for those already vulnerable to nutritional stress. Poor women in urban areas are likely to suffer more due to reliance on food purchases. A new trend of purchases or long-term leases for agricultural land by foreign investors for food exports and bio-could further threaten the local agricultural systems that commonly involve small scale women farmers, widening inequities in nutrition, health and access to livelihoods.
In discussing this evidence, delegates to the meeting identified that research on globalisation and women’s health in Africa needs to address three broad gaps, if the interests of low-income African women are to be better reflected in economic policies associated with globalisation:
i. to bring local evidence and voice into global policy processes;
ii. to highlight gaps between global policy commitments and local realities; and
iii. to ask the “what if?” questions, to explore and inform alternatives that would be more health promoting for African women and their livelihoods, and countries.
There are many specific areas of research that emanate from these three areas. For example, in the first, evidence on the experience and effect of global processes - whether IMF conditionalities, land grabs, commercialisation of services or other areas - needs to reach and be made accessible to national level and to those negotiating in global forums. Delegates noted that there is already evidence at local and regional level that could be useful for this, if reviewed and appropriately organised. This includes bringing together evidence from evaluations of global programmes and transnational activities in the different countries of the region.
However delegates also called for a shift in agenda formulation, with locally driven evidence and perspectives having greater influence on international agendas. Examples were given of research that explores such alternatives. For example, IDRCs Ecosystem and Human Health Programmes has supported work in Malawi to assess the effects of local production of nitrogen containing legumes. This was found to have not only improved soil fertility and reduced reliance on imported chemicals, but to also have improved the quality of diets and nutritional outcomes. Delegates concurred that this type of work had the potential of building partnership across actors, disciplines and countries, including with affected communities, that would better connect local level initiatives and evidence with global level processes and policies. While globalisation has raised attention to the injustice of the huge inequalities in women’s health globally, responding to these injustices calls for responses that strengthen the organisation of ideas, evidence and practice from the community level and their influence at national level, as a basis for the engagement in global processes.
For further information on this issue please read the background papers at http://sjp.sagepub.com/content/38/4_suppl and the report of the meeting available in the annotated bibliography at http://tinyurl.com/6zeeod5 at www.equinetafrica.org. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
According to UN reports, sub-Saharan Africa has the world’s highest rate of child mortality, with one in seven children dying before their fifth birthday. The region has witnessed a 22% decline in the under-5 mortality rate since 1990, although significant variation exists between countries. Although rates of infant mortality have declined since 1990, 17 of the 20 countries with the highest infant mortality rates are African. Maternal mortality is the health indicator that shows the widest gaps between rich and poor, both between and within countries. While data is scarce, WHO estimates that 900 women die per 100 000 live births in Africa. The continent, with the exception of Namibia, is identified by the UN as experiencing high or very high maternal mortality. Sub-Saharan Africa is also the region most affected by the HIV/AIDS epidemic, with over two thirds of all people living with HIV worldwide, and nearly three-quarters of AIDS-related deaths. There are some positive signs: the rate of new HIV infections has slowly declined, and 44% of adults and children in need of antiretroviral therapy had access to treatment, up from 2 % five years earlier. Efforts to combat malaria have progressed: the use of insecticide treated nets by children in 26 African countries rose from 2% in 2000 to 22% in 2008.
African countries have developed numerous strategies to reach the goals. In 2006, the African Union endorsed the Maputo Plan of Action on Sexual and Reproductive Health and Rights, and 22 countries have since set Maternal and Newborn Health Road Maps to improve sexual and reproductive health through laws, policies and health systems. The AU’s African Health Strategy 2007-2015 proposes to strengthen equitable health systems; the AU’s 2005 Gaborone Declaration commits to universal access to HIV prevention, treatment and care; the 2001 Abuja Declaration commits African states to allocate 15% of their national budgets to health and the 2008 Ouagadougou Declaration commits to advancing Primary Health Care and Health Systems in Africa. The 2010 African Union summit held in July in Kampala, passed a number of resolutions, including a renewed commitment to the 15% budgetary allocation to health; and CARMMA- the Campaign for the Accelerated Reduction of Maternal Mortality in Africa.
The African Union and its member states must, however, go beyond rhetoric to implement the promises set out in their declarations and produce tangible results. For example, the Global Fund has reported that as of 2007, out of 52 African countries (no data was available for Somalia), only three (Botswana, Djibouti, and Rwanda) had met the 15% target for health budgets, while three more (Liberia, Malawi and Burkina Faso) surpassed this target.
The UN report, Keeping the Promise – United to Achieve the Millennium Development Goals for the 2010 MDG summit being held in late September in New York has a paragraph on Africa stating that the continent is lagging behind on many of the MDGs, that progress has been made in some African countries but that the poorest ones remain “a grave concern, especially in the wake of the hard hitting financial and economic crisis”. The UN note in the report that while aid to Africa has increased in recent years, it still lags far behind commitments made. Will the Summit produce the resources called for by the UN through delivery of these commitments? Will the UN MDG Summit in September go beyond rhetoric to action? Will it unleash the resources to move from the many strategies to practice?
After all is said and done in September, one sign of that must be the extent to which whatever is said is translated into local level interventions and reaches vulnerable groups. This needs to be tracked, but the UN only collects MDG data aggregated at the national level, making it difficult to track how far this is being achieved. There is no provision in country reports for disaggregation of country-level data to assess sub-national progress on the MDGs. The reports do not therefore capture the stark inequalities among different regions, socio-economic, ethnic, racial and cultural groups within countries on accessing the resources for health or achieving the MDGs.
And should we be measuring targets or rates of progress? The World Bank noted in 2010 that uniform goals like reducing infant mortality by two-thirds, maternal mortality by three-quarters can underestimate progress in poor countries and communities. Why? Because the greater the distance to the goals from low starting points in poor countries, the greater the improvement needed to reach the targets. Is it the rate of progress, or the likelihood of achieving the targets that should be evaluated? While the target is the outcome we are aiming for, Fukuda and Greenstein argued in 2010 that the rate of progress tells more about the likelihood of achieving it along the way, and would place more pressure on governments to do more.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This editorial has been edited from the original that appeared in the Health Diplomacy Monitor Special Issue on the UN Summit on the Millennium Development Goals, Vol 1 Issue 3. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see the Global Health Diplomacy website at www.ghd-net.org.
Editors Comment: In mid-December of 2005, the World Bank hosted a gathering of academics, policy analysts, policy makers and development practitioners at Arusha, Tanzania on the theme of New Frontiers of Social Policy. The meeting reviewed progress on commitments made at the 1995 World Summit for Social Development (WSSD). The Arusha meeting proposed a number of new frontiers for social policy: First the transformation of subjects and beneficiaries into citizens”, recognizing their rights and strengthening their capacity to claim these rights, including through alliances between the poor and other segments of society. The second new frontier of social policy was identified as fostering an enabling, accessible, responsive and accountable state, with institutional mechanisms that offer redress against power inequities. The third new frontier was identified as strengthening the capacity of states to mobilize revenue from their citizens, with enabling international support, diminishing reliance on external aid. The meeting called for greater emphasis on equity outcomes in social policy. Chan Chee Khoon, Professor of Health and Social Policy at Universiti Sains Malaysia comments on these meeting outcomes. An extended version of this paper has been accepted for publication in Global Social Policy and will be published by SAGE Publications in Global Social Policy 6(3) December 2006 - © SAGE Publications 2006. This shorter version has been produced for the EQUINET newsletter with permission from the author and Sage Publications
Notwithstanding the language and imagery of pioneering intellectual endeavor, my first (Anglophone) reaction to the Arusha statement was, déjà vu again? Just as Jeffrey Sachs and the WHO Commission on Macroeconomics and Health recycled human capital theory, so are we now revisiting Dudley Seers (The Meaning of Development), redistribution-with-growth, basic (human) needs, and other 1960s vintage wisdom recast in 21st century guise? What precisely is novel in the statement?
Novelty aside, three important points are noteworthy in the Arusha statement:
Firstly, it prominently endorsed a rights perspective, going beyond human needs. A rights perspective, it should be noted, can be accommodated or co-opted within a market-oriented approach. So for instance, Tony Blair and New Labor can declare that the de facto right-to-health of UK citizens is still intact even as German medical teams are brought in to attend to NHS patient backlogs, NHS patients are sent to France or India for treatment, NHS support services are outsourced to Kaiser Permanente, etc. In effect, this transforms the debate over state versus market, into a comparative assessment of the performance efficiencies of service providers, whether public, private, voluntary, for-profit, or some hybrid of these. Oddly, these debates often seem oblivious to parallel trends in fiscal reforms and the declining fiscal capacity of states, which the Arusha statement attempts to address through domestic mobilization of revenues.
Secondly, the Arusha statement endorsed a more embedded analysis of institutions, states, and other actors, in order to elucidate the success and failures of international development approaches to poverty reduction.
This is appropriate, indeed overdue. Going beyond states, it should also be extended to international organizations including the Bretton Woods institutions (BWIs). For instance, the World Bank has itself been subject to forces pushing for privatization (divesting its development lending role to private capital markets), much in the way that welfarist states are urged to selectively offload their more profitable (or commercially viable) social services to the private sector.
Challenged by the 2000 Meltzer Commission recommendations to cease lending to ‘credit worthy’ middle-income countries’(i.e. to stop competing with private lenders), the World Bank seems to have re-positioned itself as an even more influential promoter of the interests of private capital, even as it tries to harmonize this with “poverty reduction” (trickle down theory, a rising tide lifts all boats, what’s next? a sideways lurch towards horizontal equity?). We see, for instance, expanded roles for the International Finance Corporation (IFC) and the Multilateral Investment Guarantee Agency (MIGA) within the World Bank Group, with IFC and MIGA commitments to private sector borrowers rising from 3.3% of World Bank loans in 1980 to 25% in 2000. The World Bank Private Sector Development Strategy, 2002, (para. 87) emphasized the lead role of the Bank in insuring and catalyzing private investment in ‘more risky environments’ and in supporting ‘the development of cross-border private investment’ , crowding in (sic) ‘private investment rather than crowding it out’.
David de Ferranti, who retired in 2005 as World Bank vice-president for the Latin America and Caribbean department, found it necessary to reiterate that “much of what the World Bank actually does directly helps to improve the climate for private investment: implementing trade reforms and removing restrictive regulations on foreign direct investment; expanding private provision of utilities and infrastructure; strengthening essential legal and judicial infrastructure for private markets; freeing business from harmful and superfluous regulations” (cited in de Ferranti 2006. The World Bank and the Middle Income Countries, in Rescuing the World Bank ed. Nancy Birdsall Wash. DC,: Center for Global Development).
Thirdly, the Arusha statement quite rightly cautions against a targeted approach as an undiscriminating policy response to demonstrable social inequities in development. Thandika Mkandawire, UNRISD director, has recently authored an insightful review of universalism versus selectivity through targeting in social policy and development practice (Targeting and Universalism in Poverty Reduction. UNRISD Programme Paper Number 23. Geneva: 2005). He examines the circumstances and the forces behind the shift from universalism toward selectivity in social policy discourses addressing poverty in the developing countries. He then reviews the lessons learnt from such policy approaches and related practices: the administrative difficulties and transactional costs of targeting in the poor countries, the political economy bases of policy choices and program preferences, and the contingent and sometimes unpredictable effects of policy choices on individual incentive. In particular, he pays special attention to the cost-effectiveness argument which the advocates of selectivity deploy as a major consideration in its favour.
One aspect he does not dwell upon though is that targeting as a policy choice is eminently compatible with the concerns of influential sectors, including entrepreneurs and investors, seeking profitable opportunities in service sectors which thus far have been the domain of the public sector. The modern welfarist state acts importantly as a risk pooler in coping with uncertainty, whether arising from social, natural, or created environments. Publicly provided (or publicly financed) social services often entail cross-subsidies and risk pooling (in effect, an implicit social contract rooted in solidarity) to ensure a more equitable access to essential services than would be the case with purely market-driven production and distributional systems. With the devolution of social services to private enterprise, entrepreneurs in search of investment prospects would be primarily interested in the “market-capable” segments of society (if the state demurs from extending this effective demand, through public financing, to those without the disposable incomes).
Not surprisingly, as the flipside of privatization, voluntarism has emerged as a popular slogan, in rhetoric if not in substance, along with an ascendant neo-liberalism (George Bush Sr’s thousand points of lights, Mahathir’s caring society as counterpoint to Malaysia, Inc., etc). Social capital and civic society likewise are appealing to the World Bank as private capital proceeds to undermine a sense of community worldwide.
Seen in that light, targeting is also the persuasive face and generic template for the privatization of essential social services, persuasive because it draws upon considerable intuitive appeal. The intuitive appeal is not without reason, and targeting can in fact achieve quite positive results under certain favorable circumstances, e.g. when targeting is used to direct and to fine-tune extra benefits to low-income groups within the context of what are fundamentally universalist policies (targeting within universalism). As distinct from this however, targeting versus universalism has remained as the preferred policy axis for much of the international development establishment, prompting Thandika Mkandawire to observe that “one remarkable feature of the debate on universalism and targeting is the disjuncture between an unrelenting argumentation for targeting, and a stubborn slew of empirical evidence suggesting that targeting is not effective in addressing issues of poverty (as broadly understood)”.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. Further information and publication on EQUINET work on public health policy is available at the EQUINET website at www.equinetafrica.org.
Our health systems are sites of constant change and struggle. In east and southern Africa national health services centred on comprehensive primary health care (PHC) have been ‘reorganised’ through waves of liberalisation, privatisation, disease focused verticalisation, performance based financing and many other reforms. People have come to services to find new rules for what is free and what is charged, for what medicines and supplies are present and what is not, and community health activities and workers have appeared, disappeared and appeared again.
The drive for a universal national health service was embedded in national liberation struggles. The PHC approach was a global concept that resonated strongly with popular expectations of what post independent health systems should look like. Many of the subsequent changes have emerged as waves of international reform, increasingly influenced by global level actors. When we ask people in participatory sessions to form a human sculpture of how their health systems are organised around a patient visiting for care, the sculpture most commonly has health workers, managers and others looking upwards to the next level to get the resources and attention they need to solve problems, (most looking away from the patient), usually with the person representing a powerful but distant global funder elevated in both power and stature on a chair in a far corner of the room.
While these may be caricatures, they raise the question- when it comes to changes in health systems, who counts? Whose views, expectations, ideas, evidence, numbers, analysis and knowledge is used to generate change?
This matters because health is ‘a state of mental, physical and social wellbeing and not just the absence of disease’, because health outcomes reflect conditions that are socially created, and health systems are thus social institutions, built out of and influencing society. The explosion of knowledge on the biomedical basis of disease and on risk factors in public health has informed massive advances in survival. It has, however, weakly addressed and often ignored the social context and determinants of health and the social nature of health systems. As a consequence we face persistent and sometimes widening inequality in health and in access to services, rising levels of multiple morbidity and chronic conditions, epidemic resurgence and antibiotic resistance, amongst other challenges.
The problem does not lie in the extraordinary scientific innovation and creativity that lay behind these medical advances. The problem lies in one form of knowledge subjugating others, excluding and disempowering others from the creative processes that transform society, a mistake akin to suggesting that the trunk of the elephant is the whole elephant.
That knowledge as socially constructed is not a new concept. This understanding has been central to social sciences and to cultural, anticolonial, gender and indigenous struggles. With the failure to implement what is known, in health sciences it has led to increased attention to fields such as health systems and policy research, where rather than absolute prescriptions, there is a quest to better understand ‘what works where and for whom’.
This wider lens will generate a better understanding of context in health sciences. Will it also overcome a tendency for ordinary people to be the last to know the waves of reforms transforming their health systems? Freire argued decades ago that meaningful social transformation, including of health systems, can only occur with the deep involvement of the people affected. The incubation of the PHC approach, the efforts to build national health services across diverse countries, the refusal to allow health care to be commodified, the gains in access to improved living and working conditions have all been a product of social and political action.
This type of action does not grow out of knowledge and perspective built in distant corridors. In the last century activist scientists such as Orlando Fals Borda in Latin America pointed to a different understanding of science, one that seeks to not only understand the world but to transform it, and, as importantly, one in which knowledge is built from lived experience and from the learning and self-awareness that grows from action. Participatory action research (PAR) has developed in different forms as a method for such science. It overcomes the separation between subject and object. Those affected by the problem are the primary source of information and the primary actors in generating, validating and using the knowledge for action, and using action and change as a means to new knowledge. A new methods reader on ‘Participatory action research in health systems’ produced by EQUINET and TARSC with Alliance for Health Policy and Systems Research and IDRC Canada that can be obtained on the EQUINET website in end September details the principles and methods of PAR, its challenges and the many ways and levels at which it is being used.
In different parts of the world, PAR has built a more direct link between theory building and practice in health systems. Workers and unions have used PAR to expose and organise for change in working conditions that are harmful to their health. Young people in high and low income countries have used it to raise visibility of and engage with authorities on harmful community environments. Indigenous communities have used it to negotiate the organisation of their health care. It has been used in continuous processes in local authorities in shaping PHC, learning from cycles of transformation.
The practice of PAR flags that change is not itself a problem in health systems in east and southern Africa. It is rather a problem when the knowledge used to guide this change does not draw on the experience, knowledge and wisdom of those directly involved, through methods that build their power to inform, learn from and shape that change.
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 read Participatory action research in health systems: a methods reader, available on the EQUINET website www.equinetafrica.org from end September 2014
At the recent 2014 International AIDS Conference we heard that 35 million people are living with HIV, but 55% haven’t been tested. Under the 2013 WHO guidelines, UNAIDS reported in 2013 that the HIV treatment coverage in low and middle-income countries represented only 34% of the 28.6 million people eligible in 2013. Medicines for malaria, pneumonia and other common conditions don’t reach many low income communities and there are new challenges in ensuring the long term treatment for chronic conditions.
Access to medicines continues to be a major preoccupation in African health systems. Beyond the unequal distribution of access to essential medicines globally and within countries, resistance to anti-malarials, antibiotics, and treatments for TB and other conditions can worsen the problem. The new medicines developed are frequently more expensive and may also require more stringent supervision to ensure they are properly used. For example in the 2014 AIDS Conference it was noted that there is a 10 fold price increase from first to second line treatment, and the World Health Organization (WHO) reported in 2012 that the 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB) longer and more expensive treatment. These medicines are often imported, at a cost that consume a large share of health budgets. Countries in east and southern Africa (ESA) often draw on support from external funders to meet these costs.
This rising challenge, coupled with high levels of dependency on external producers and funders makes ESA countries very externally dependent when it comes to medicines. This, and the potential contribution that pharmaceutical manufacture could make to economies and trade within the continent, especially given the rich natural resources for medicines, prompted the African Union and its sub regions in east and southern Africa to come up with plans to enhance local pharmaceutical production. African Ministers of Finance, Planning and Economic Development in Nigeria in March 2014 noted: “There is growing consensus that strengthening the local production of essential medicines is a priority, along with advancing industrial development and moving the continent towards sustainability of treatment programmes for HIV, tuberculosis and malaria, and improving access to safe and effective medicines to treat a broad range of communicable and non-communicable diseases.”
The Pharmaceutical Manufacturing Plan for Africa (PMPA), the Southern Africa Development Community (SADC) Pharmaceutical Business Plan 2007-2013 and the East African Community (EAC) Regional Pharmaceutical Manufacturing Plan of Action 2012-2016 all propose policy measures to create the conditions for and support local production, as one, albeit not the only way to strengthen access to medicines.
The same plans are also rather clear about the obstacles that have to be overcome to achieve this, including in terms of ensuring adequate legal provisions, improved and reliable energy, transport and other infrastructure, technology, skills and research and development capacities to enable and sustain production and finance capital. The same 2014 conference of African Ministers of Finance, Planning and Economic Development cited above noted in its statement: “The challenges the pharmaceutical industry faces in upgrading facilities and production practices in Africa include the requirement for large capital investments and the need for experts, specially trained workers, increased regulatory oversight and regulatory harmonisation at the regional and continental levels in order to create bigger markets.”
In research that we carried out in 2013 and 2014, we found signs of progress in overcoming these obstacles, but also many challenges. Kenya, Uganda and Zimbabwe, for example, produce medicines that are not only consumed in their own countries, but are exported to other countries in the region. Some of the factors that appear to support this include the presence of a sound regulatory framework for the pharmaceutical sector, partnerships with other countries bringing investments in manufacturing and in capacities for it (such as in Uganda), local skills and research and development institutions that can support the technology for local production. Further, existing practice points to the critical importance of regional trade as a way of ensuring adequately sized markets to provide a return on investments. These are examples in practice of measures that are articulated in the regional plans.
However, we also found that while many countries have national pharmaceutical policies that articulate such goals, they also depend on policy in other areas, such as energy and infrastructure, and that there is a gap between policies and their implementation.
The implementation gap is evident in a number of areas. One is in the extent to which governments are supporting local production with tax and other incentives to create a conducive investment, business and trade environment. For example there could be stronger measures to exempt duty and value added tax (VAT) on imported pharmaceutical raw materials and packaging materials to stimulate local production and reduced corporate tax rates, investment tax credits and other incentives for companies to set up production. Yet sometimes we find that the opposite is in place. For example in Zimbabwe imported drugs were in 2000 exempted from duty and VAT, while the raw materials and packaging needed for local manufacturing attracted duties of up to 40% and VAT of 15%. This increases the cost of locally produced drugs, especially when other countries are not placing these high charges on their producers, making imports cheaper than locally produced medicines. This doesn’t make sense given the policy intentions and we should at least level the playing field and avoid tariff structures that promote de-industrialisation!
There is also a gap in the dialogue that should be going on between governments, pharmaceutical companies and training institutions on what capacities, skills and personnel are needed for the pharmaceutical industry and how these can be attracted and developed, including through schemes to attract and retain appropriate personnel in the public service and in countries.
While there is an emerging interest in south-south partnership agreements on some of these areas, it is equally important that attention be given to implementing the regional plans, to use memberships of Common Market for Eastern and Southern Africa, the Southern African Development and the East African Community to negotiate for a tripartite Free Trade Area between the three blocs to widen markets for medicines and to strengthen regional interactions on the technology, infrastructure, capacities, research and development and capital needed for pharmaceutical production.
In a continent with such high health need and demand for treatment, surely we need to not only be asking when we will get better access to medicines, but when we will get better control over access to medicines?
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
There is a dire shortage of professional health care workers to deliver essential health services in sub-Saharan Africa, including life-saving antiretrovirals (ARVs) for people living with HIV and AIDS. Donor support for disease-specific interventions for AIDS, tuberculosis, and malaria has increased markedly in recent years. However, funding for recurrent costs for these interventions, such as increasing salaries and creating new posts, has remained taboo.
The Global Fund to Fight AIDS, TB and Malaria (GFATM) was created largely due to pressure from activists and non-governmental organisations (NGOs) who fought to have a global financing facility that would pay for ARVs – something that was considered off-limits to donors before 2002. In 2005, a specific "window" of funding was created to support health systems, including human resource costs. Since then the option has been integrated within specific disease components.
Although there is some degree of uncertainty about the scope of GFATM support for human resource costs in future rounds, country applicants have an opportunity to request such support in Round 7. The GFATM should provide unambiguous and continued support for funding salaries and other "recurrent" human resource costs. Bilateral donors should follow suit.
Lesotho is a case in point. The country has the third highest HIV prevalence in the world after Swaziland and Botswana – and is the poorest of the three. It is struggling with a catastrophic health worker situation that threatens to make it impossible for the country to scale-up and sustain HIV care and treatment for the more than 270 000 Basotho presently living with HIV and AIDS.
In January 2006, Doctors Without Borders/Médecins Sans Frontières (MSF), an international medical humanitarian organisation, launched a programme in Lesotho in Scott Hospital Health Service Area (HSA), a rural health district with a catchment population of 220 000. The programme provides decentralised HIV care and treatment, including ART, integrated into existing primary health care services. In the first year, more than 3 500 people were enrolled in HIV care and over 1 000 had initiated ART at Scott Hospital and 14 rural health centres.
Scott Hospital HSA has a higher than average health worker coverage rate. Still, according to an assessment of workloads in Scott Hospital HSA carried out by MSF in August 2006, there are up to 45 consultations per nurse per day not including HIV-related consultations. With the introduction of dedicated HIV services, the workload in the past year has increased dramatically. The World Health Organisation recommends that nurses should conduct no more than 20 consultations per day.
Between January and July 2006, at least 18 nurses left the HSA for "greener pastures". Ten new nurses were hired after July 2006, but six additional nurses left, leaving more than a quarter of nursing posts vacant.
With more than 35 000 people estimated to be living with HIV and AIDS in Scott Hospital HSA alone, at least 5 000 of whom are in urgent clinical need of ART, the needs far outstrip the capacity of health facilities and health workers. MSF has employed several strategies to cope with these shortages – from providing mobile MSF medical teams to bring "in-service" support to nurses to task-shifting to new cadres of community health workers to introducing measures to improve staff retention.
Ultimately, however, immediate measures will need to be put in place at the national level to recruit and retain skilled nurses and other professional health care workers, including as a necessary first step, increasing their salaries. Without major investments in retention of skilled staff, ART programmes – including the MSF-supported programme – are vulnerable to collapse.
The GFATM, bilateral donors, and all other relevant actors, must clearly state, with money on the table, their support for funding salaries and other interventions to support human resources for health. Affected-country governments must then meet this commitment with emergency plans to address the human resource crisis.
As for Lesotho, an emergency human resource plan needs to be developed and donors need to step up to the plate. The US Millennium Challenge Account is committing an unprecedented US $140 million for health infrastructure. "Brick and mortar" projects are welcome, but without support for health care workers, this construction/renovation programme will be tantamount to supplying computer hardware without software to run programmes.
Funding salaries on a recurrent basis and supporting other initiatives to stem the loss of health workers and bring relief to overburdened staff and the thousands of patients they serve is a critical requirement in order to expand and sustain HIV/AIDS care and treatment.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, admin@equinetafrica.org. Further information on MSF and its programmes can be found at www.msf.org and on EQUINET work on AIDS and health systems www.equinetafrica.org.
Following the 1994 elections in South Africa, the new ANC government committed itself to the development of a District Health System that would meet the health needs of local communities and allow for grassroots input into the management of primary health care. Ten years later, there is still indecision and confusion surrounding the governance and financing of primary health care delivery and it is not clear which authorities will take leading responsibility for administering the district health services.
Municipal health workers together with their provincial counterparts and community health workers stand in the front line of delivering primary health care to the majority of South Africans. The SAMWU/MSP/IHRG National Survey into the State of Occupational Health and Safety in the Municipal Health Clinics asks “Who cares for health care workers?” While the health care profession embraces important ethics of service and sacrifice in meeting the health needs of the public, our research points to neglect of the health and well-being of health care workers themselves.
We found little taking place to identify hazards, evaluate risks, prevent workplace injury and illness and ensure that the conditions in which health workers care for others allows them to care also for themselves. Even where measures are provided, there is little employee involvement in shaping these health and safety practices.
We found that probably the biggest health and safety hazard facing health care workers in the public health sector in South Africa is the shortage of staff. Growing queues of patients lead to stress, burnout and increase the risk of accidental injury. Lack of facilities, equipment, and medicines further frustrate clinic staff and add to tensions between staff and the communities.
This situation is not simply a management problem- it is also reinforced and reproduced by health workers themselves. The inclination of the majority of health workers to accept appalling working conditions, to isolate themselves, and to individualise their workplace traumas, stress and exhaustion, presents an enormous challenge to SAMWU and other unions organising in the public health sector.
We intend to shape an alternative to that neglect. As activist investigators, we are challenging the silence and neglect that characterises work in the health sector. This starts with our research activity - asking questions; identifying workplace hazards; documenting case studies of workplace injury and illness; interviewing management and workers in the clinics; sharing stories of needle-prick incidents; interrogating policy and protocols; challenging employers’ non-compliance; discovering rights and responsibilities; and examining the extent of effective representation and functioning of health and safety committees.
* This briefing is edited by the EQUINET secretariat at TARSC. Please send feedback or queries on the issues raised in this briefing to Nick Henwood, IHRG at ihnick@ihrg.uct.ac.za or to the EQUINET secretariat email admin@equinetafrica.org .
* The research report cited will be available in late January as a downloadable pdf file from the Municipal Services Project website (http://www.queensu.ca/msp/) or from the EQUINET website at www.equinetafrica.org
We, the SADC Health Ministers gathered at Roodevallei, Pretoria, on 30 August 2002 deliberated over the severe famine facing the SADC region [...]
We, the SADC Health Ministers [...] recognize that the famine is super-imposed on an already severe HIV/AIDS pandemic in the region. Both the famine and HIV will lead to deeper impoverishment of the people of the region, and further compound the magnitude of premature death of vulnerable groups namely children and women, from diseases aggravated by poverty like HIV/AIDS and malnutrition, such as malaria, TB and diarrhoeal diseases.
Notwithstanding the effect of the famine on productivity, combined with the HIV/AIDS pandemic household food security through reduced productivity is further compromised and an additional burden placed on already overstretched health systems.
We, the Ministers, recognise the current severe shortfall in food production and food availability in the region, with a cereal deficit of 4,071,300 metric tonnes (MTs) in the region. We also recognise the complex causes of the famine but identify the high levels of poverty in the region as a key factor underlying the current disaster. In the countries affected by the famine, between 1996 and 2001, the number of people living below the poverty line has stayed the same or increased, with on average 68% of the population living below the poverty line in 2001. We further recognise that poor people are most vulnerable to any adverse events.
We note with great concern, the environmental and agricultural factors as a cause of the drought and famine in Africa, with an estimated 500 million hectares affected by soil degradation since 1950, including as much as 65% of agricultural land. A combination of inequitable distribution of land, poor farming methods and unfavourable land tenure and ownership systems have led to the decline in productivity of grazing land, falling crops and diminishing returns from water supplied. Nearly two- thirds of Africa is semi -arid, and Southern Africa is one of the sub regions that is most affected. This dryness makes the land vulnerable to degradation.
Economic factors contribute significantly to this situation. High debt burdens and unequal trade have undermined effective responses by Southern African countries. In particular, greatly increased subsidies to U.S. and European farmers threaten the viability of farming in the region [...]