Editorial

The Commission on Social determinants of Health showed persuasively in 2008 that health is determined by the social conditions in which people are born, grow, live, work and age, referred to as the social determinants of health (SDH). These conditions are shaped by the distribution of money, power and resources from global, to local levels.

Health is therefore everyone’s business. Efforts to address SDH should be taken by all policy makers, and not just those within the health sector. Health services play a role but cannot do it on their own. For example, Kuruvilla and others in 2014 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121875/) showed that almost a half of the reduction in under-5 children’s deaths globally between 1990 and 2010 resulted from investments outside the health sector, such as in education and infrastructure. This was also recognised in the 1978 Alma-Ata Declaration on primary health care (PHC), with inter-sectoral action central to comprehensive PHC and ‘Health for All’. The Sustainable Development Goals (SDGs) also call for simultaneous, coordinated action across a range of sectors.

Despite this recognition, economists particularly in a ‘STRIVE’ consortium noted that cross–sectoral interventions are often underfinanced and their potentials benefits undervalued.

The consortium, with others such as UNDP, identified ‘co-financing’ as an approach where two or more sectors or budget holders, each with different development objectives, can co-fund an intervention or investment to advance their respective objectives simultaneously. Cross-sectoral co-financing does not necessarily need additional resources, therefore, but rather optimal allocation of existing resources. It is a relevant approach in financing high-impact interventions that leads to multi-sectoral benefits across the interconnected development goals and targets.

One example of such co-financing to address SDH is a conditional cash transfer that aims for multiple outcomes across sectors. In Mexico, for example, two social protection programmes, PROGRESA in 1997 and OPORTUNIDADES from 2002 gave such cash transfers directly to low-income rural households to enable and encourage parents to send their children to school, to use preventive and care services, and to improve child feeding and nutrition. Positive experience of this multi-sectoral approach has stimulated its spread to other Latin American countries. Malawi’s introduction of a cash transfer in 2008/9 to keep girls in school was found after 18 months to have led to improved girls’ school enrolment, test scores and reduced school drop-out, to have reduced girl’ risk of HIV by 64%, and to have reduced teen pregnancy and depression (https://tinyurl.com/96ktkyuj).

Economists argue for co-financing for SDH to improve public policy intervention, and value for money.

Public intervention is argued to be essential in SDH to correct for market failures in relation to efficiency, to deliver maximum outcomes at the lowest cost. Public intervention is needed to address market failures in relation to equity and the distribution of outcomes according to need. These market failures arise for various reasons, including asymmetries in access to information, barriers to using services and as a profit-focused market is a poor performer on public good. With many SDH influenced by markets in our current global and national economies, there is a clear economic rationale for public intervention to ensure equity in health.

Economists also argue that we need to integrate ‘health value for money’ to make optimal use of limited available funds, including by using innovative cross-sectoral co-financing approaches to address multiple SDH. Economic evaluations thus prefer cost-benefit analysis to assess whether multiple benefits across sectors outweigh the associated costs, to be able to point to ‘good value for money’. This does face challenges of measuring the multiple benefits accrued from multiple sectors, and the various opportunity and inter-sectoral costs. Notwithstanding these challenges, a cost-benefit analysis is argued to be more useful for public policy than cost-effectiveness analyses, as the latter have limited scope and focus on single outcomes, undermining the potential for achieving benefits across multiple sectors.

We thus have public health and economic arguments to encourage and inform co-financing investments to address SDH. In doing this, there are some issues to consider.

Countries in our region are already facing constraints, fluctuations and uncertainty in domestic and public financing. There is also limited financial autonomy within and between sectors. This implies that the resources for co-financing should be mobilised and pooled from multiple funders/ sectors and are best spent in the first instance on SDH that will have highest impact, to generate confidence in the approach.

Co-financing needs to address budgeting and reporting issues. In most setting, governments have siloed budgeting within single sectors, with little focus on cross-sectoral budgeting. The resource allocation and spending approach is also rigid, constrained, and slow to reform. Going forward, co-financing calls for a change in public budgeting and accounting and a move from input-based to output-based budgeting, that is the allocation of resources based on shared interventions and goals across sectors.

We need to recognise that the involvement of many funders may lead to mistrust in managing the pooled funds, including between ministries. Ministries may fear losing budget control and visibility with pooled funds and co-financers may fear weak accountability or corruption in use of such pooled funds. Strengthening the public finance management system to ensure transparency and accountability can help to address such mistrust, while visibly showing joint ministry contributions to a common programme, as was the case in Oportunidades in Mexico, can help to promote visibility in co-financing.

High-level policy stakeholders have critical role in decisions on co-financing, including in supporting its implementation in practice. For example, there might be a clear agreement to co-finance but political uncertainty and bureaucratic issues may limit the disbursements of funds to it. This needs time and engagement to inform and ensure the ‘buy-in’ of co-financing by national leaders and ministries. We also need to build the necessary cross sectoral dialogue and coordination mechanisms, and to facilitate the leadership and capacities for the approach.

All of this calls for evidence, including on successful experiences of cross-sectoral financing. Here we need to acknowledge an evidence gap in making the case in our region. We need in our region to generate and share evidence on the impacts and value for money evidence when making multi-sectoral interventions on SDH. This includes addressing the currently weak monitoring and evaluation of these initiatives and implementing research that informs policy decisions towards co-financing.

It is clear that we not only need attention to innovative ways of raising resources for health, but also innovative ways of using those resources to address SDH, especially those that are leading to inequities across multiple health and wellbeing outcomes. Co-financing offers one such approach. It calls for evidence and processes to build political and implementer support, trust and confidence, including to lever necessary reforms in our public finance management systems. If we can address the challenges, even for focused initiatives that we can learn from, we have the opportunity to use co-financing to support interventions that have greater value for money and multiple benefits across sectors, including for equity.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the STRIVE consortium can be found at http://strive.lshtm.ac.uk/.

Isaac is a 20 year old with aspirations of a better life. He came to urban Harare a few years ago after finishing school to start a new life. In his life in the city he has done this in ways he didn’t predict. He lives as a lodger in a small, smoky backyard shack and earns money from gathering and selling plastic waste. His most prized possession is a smart phone that is his link to friends, humour and, when he can afford data, to social media and market ideas. Behind a ‘healthy’ appearance he hides stress, hunger, worry about his future and frustration that he cannot afford the food, services, entertainment and life that he sees around him in the city.

Our growing cities are full of such young people, in urban areas that concentrate opportunities, information, social connections, ideas, enterprise, wealth, technology and services together with substandard living environments, pollution, food and income insecurity, violence and exclusion.

Published evidence shows that these risks and benefits are unequally distributed amongst urban residents. Recent migrants, residents of informal settlements and those living in informal housing, as lodgers or ‘backyard shacks’ have a vastly different experience of urban life than wealthier, more secure groups. These urban conditions pose particular challenges for people at different stages of life, whether as children, adolescents, adults or elderly people. We have for decades measured and implemented measures to address the social gap between urban and rural areas, with the disadvantage in the latter. However the growth in poverty and disadvantage and rising inequality within urban areas now demand attention. Published evidence appears to chase, lag behind or miss the rapid, diverse changes taking place in urban areas and is often silent on the features of urbanisation and social assets that promote wellbeing.

In 2016-18 we gathered and analysed diverse forms of evidence and experience on the social distribution of health in urban areas and on the opportunities for promoting health and wellbeing. In Harare, with the Civic Forum on Human Development and Harare youth, and in Lusaka, with the District Health Office and Lusaka youth, we listened to the perceptions and experiences of young people (18-25 year olds) from diverse settings and socio-economic groups in these two cities. We explored how far their experiences were captured in the evidence we collect across the countries in the region.

For young people in Harare and Lusaka, ‘health’ was a biomedical concept, linked to ‘absence of disease’, and to the various problems they see their health services treating. Indeed, the ‘health’ data we routinely collect in our region also commonly focuses on mortality, morbidity and negative indicators such as suicide and obesity, and on immediate determinants of these diseases such as food, water, sanitation, education and health care. This is problematic for young people like Isaac. They appear to be in ‘good health’, despite lacking decent standards of many of these immediate determinants, but this hides the mental and social challenges they experience, and ignores conditions and determinants that have longer term effects across their lives, including for the rising burden of chronic conditions and the growing challenge this poses to our urban health services.

For young people in Harare and Lusaka, having secure incomes, opportunities for entrepreneurship, education, shelter, public spaces, participation in government decisions and self-esteem were important for them to be and remain healthy. They believed these issues would become more challenging in the future, envisaging that as the city grew, it would become more competitive and overcrowded, threatening resources for health, including green spaces. Cities would demand even more of young people’s capacities for innovation and entrepreneurship, with a diminishing, rather than an increasing level of social solidarity.

How ready are we to address these concerns? The indicators we collect across the countries of the region provide a picture of disconnected facets and fragments that weakly reflect the combined current and future impact of these features of urban life on the different groups in the city. Not surprisingly, therefore, the systems and services that respond to them are also segmented and silo’ed. In 2016, the World Health Organisation (WHO) and UN Habitat suggested that we need to reclaim a more multidimensional understanding of equity to address the challenges in urban areas.

So what would such a more holistic, integrated and affirmative approach look like? One starting point may be to go back to the first principle of the WHO Constitution, that health is not merely the ‘absence of disease or infirmity’, it is “a state of complete physical, mental and social wellbeing. A concept of ‘wellbeing’ – or ‘buen vivir’ as applied in some countries – holds the potential to integrate psychosocial, social, time use, political, material, economic, service, governance and ecological determinants, all of which are affecting urban health.
By bringing them together, the concept draws attention to what balance (and imbalances) we are generating between these different dimensions of wellbeing and the current and future consequences of imbalances. The structural adjustment programmes exposed the inequalities that grow when economic strategies pursue growth at the cost of social deficits. The recent global student school strikes over climate justice point to young people’s concern that decisions made globally are dominated by certain economic interests to the cost of the degradation of nature and extinction of species. Achieving equity in wellbeing takes us beyond measuring and closing gaps between different groups of people to the strategies needed and assets we have to use to redress the imbalances that are generating these gaps and that have long term consequences.
The health sector has tried, through ‘health in all policies’ approaches, to persuade other sectors to adopt policies that promote health. To some extent this is still seen as a ‘health sector’ campaign, often taking place in parallel with increasingly biomedical personal care services and declining investment in public health capacities and authority.

In contrast, we found many integrated, collaborative approaches addressing these imbalances and the issues raised by Harare and Lusaka youth in different cities globally, from participatory urban planning in Kenya, to strengthening community safety in Honduras, environmental regeneration and urban agriculture in Brazil and urban youth collaborative engagement on school reforms in the USA. They point not only to the importance of public spaces for bringing together diverse services and interventions in area-based approaches, but also to the opportunities that exist in urban areas for encouraging local competencies and innovation and for facilitating the involvement of affected residents, like Isaac, as knowledge producers and participants in planning and action for health and wellbeing.

More detailed information on the evidence and processes referred to in this oped and the different people involved in this work can be found in EQUINET Discussion paper 117 Responding to inequalities in health in urban areas: Report of multi-method research in east and southern Africa, http://tinyurl.com/y3dv4pvm and other reports referred to in that document.

“I feel free- I am liberated by this new skill- I am now able to communicate my world.”
Meso Ulola, a community member from Bunia, eastern Democratic Republic of Congo pointed to his camera as the instrument of his liberation. Behind him a sequence of photographs from his community told a story: a pregnant woman blocked by a river from the road to health services; community members discussing issues around chalk images on a board; young men heaving logs across a river and images of a motorbike crossing a newly constructed bridge.

In the last five years EQUINET has through Training and Research Support Centre and Ifakara Health Institute been supporting institutions that work at community level to carry out participatory action research studies in east and southern Africa. In each of the nine country sites, in both rural and urban settings, these studies have explored how communities are interacting with health systems. The issues they addressed ranged from how to overcome the barriers people who consume harmful levels of alcohol face in adhering to ante-retroviral treatment, to how to improve communication between people and health workers in local health planning. The reports of these studies can be found on the EQUINET website (www.equinetafrica.org). However, we struggled with how the communities involved could themselves communicate the realities of their lives, actions and insights, and be useful to community discussion on how to address the determinants of health.

We proposed to use photography as one tool for this. Facilitators and community members from the participatory work in seven sites coming from DRC, Kenya, South Africa, Tanzania, Uganda, Zimbabwe and Zambia were trained in photography skills and we embedded photography within the participatory work. We wanted the photos to express the lives of the people involved, to show the diversity of views, to allow both painful and hopeful images to surface, to pose questions, probe, give visions of solutions and actions. The photos were as much a means to encourage local community discussion as to raise wider awareness and community voice on issues. This was not an academic exercise, or about outsiders documenting people as victims, but about community members documenting their own situation and actions to improve social justice in health. We called it “Keeping an eye on equity: Community visions of equity in health”.

It wasn’t straightforward. How to recharge batteries of cameras in communities that had no electricity? How to share photographs so all could comment when internet access is limited and slow? However even from remote areas in Western Kenya or a border town in Zimbabwe, the photos were uploaded to a shared website, we sent comments to each other, and the stories began to emerge through the images. After several months, the photographers chose those images that best communicated their reality and stories. These were compiled, have been shown locally in each setting in different ways, and will be used in ongoing work. They were also compiled by TARSC into an exhibit from all the countries at EQUINETs regional conference on equity in health in September 2009, and used to stimulate discussion on the issues raised, and on the power of different kinds of evidence in catalyzing action on health equity. As one participant at the conference commented: “From other sources of evidence I imagined reality. From the photos I saw reality”.

Some of this work is now produced as a book newly available on the EQUINET website at www.equinetafrica.org/bibl/docs/Eye%20on%20Equity%20book2010.pdf. The book introduces and communicates the work underway, and opens discussion on community photography as a tool for change.

Did we achieve our goal, of raising reality and issues as communities see them, and giving communities more direct voice in advancing equity in health?

When we brought the work of all the countries together, new patterns emerged. For example children and women featured strongly across the images. Its clear that we feel injustice strongly when we see children in unfair and harmful situations. It motivates us to act. Women constantly appeared in the images as active not passive. The images showed how women, often invisibly, are using the resources available to take diverse actions for health. The photographs provided a new lens to discuss what was going on in communities, often raising issues that had become invisible or hidden. Discussing the experience, the community photographers observed that “the camera allowed is to connect with people in unexpected ways, and to hear people’s opinions of their health and health care. The camera seemed to open new channels of communication, raising issues that may otherwise have been buried”. Others observed, “our photographs made us look afresh at unhealthy situations. They have also encouraged us by showing what we have achieved”.

This is important given that our participatory research showed that our health systems have high legitimacy, but weak capabilities for social roles. They weakly address barriers and facilitators to uptake of services and there are many communication gaps between health workers and communities. These issues are well within our grasp to change, but communication is vital for this. The most vulnerable in communities often face an imbalance in power, skills and common language in communicating with health workers, and may deal with this by dropping out of services. Our experience suggests that community photography, embedded within participatory, collective processes, may be one way of offering new power to communities to collectively show their realities, without feeling limited by language.

The way we use and respond to photography has as much to with reclaiming the resources for health as the way we implement research or use evidence. We are bombarded by visual images every day of our lives – pictures on billboards, on many of the consumer products we buy, in leaflets, posters, books, on television or media. Every day we unconsciously interpret and respond to these images, influencing our attitudes, beliefs, values and life style. As Susan Sontag said in 1973, photographs invite us to think or feel in particular ways and “… are inexhaustible invitations to deduction, speculation and fantasy.” In our work as health facilitators and activists, we see that photography in the hands of communities has the potential not only to give communities the power to present reality as they see it, but to use these images to move people from a point of feeling to questioning, to thinking about what change is needed. This is the power of the visual in the right context – to play a part in this process.

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 the PRA reports on the EQUINET website and the Eye on Equity Book.

Health Centre Committees (HCCs) are a mechanism through which community participation can be integrated into the health system to achieve a sustainable people-centered health system.

These community-based committees are increasingly becoming an established voice of the communities providing input into the health service delivery processes in the 16 East and Southern Africa (ESA) countries covered by EQUINET. In the Ngombe area of Lusaka, Zambia, for example, the Neighborhood Health Councils with local government have successfully addressed water and sanitation, garbage and housing concerns. In Kenya, Health Facility Committees manage funds from the Health Sector Services Fund for primary care, outreach and community based services. They link the facility with the community, to plan and oversee the performance of the services.

In a regional dialogue, delegates from ESA countries urged national authorities to better recognize and work with HCCs. Their recommendations, captured in EQUINET Policy Brief 37, included reforming public health laws to include provisions for participation and public information and to set laws that provide for the roles and duties of HCCs, backed by adequate information, training and resources for them to play these roles.

To advance these recommendations a consortium of organizations have come together in EQUINET to build and strengthen the capacity and effectiveness of HCCs, led by the Community Working Group on Health (CWGH) in partnership with the Training and Research Support Centre (TARSC) on photovoice and information sharing; University of Cape Town (UCT) School of Public Health on training programmes; and the Lusaka District Health Management Team (LDHMT) on legal provisions. With work in Kenya, Zambia, Malawi, South Africa, Uganda, and Zimbabwe and at ESA regional level, we are advocating for policy and legal recognition of HCCs, giving visibility to their roles as well as identifying and strengthening the different capacities that committees, communities and the health systems need for HCCs to implement these roles. This includes areas such as tracking and monitoring health system budgets and resources and their use and health system performance as well as the building social dialogue and accountability.

As part of the work, UCT in South Africa is building a database of information on the current training materials and training programmes for HCCs to enable us to share materials, skills and experiences on capacity building in the region, and to advocate for HCC training that addresses their roles comprehensively. and their coverage of the key areas of functioning. LDHMT in Zambia has initiated an in-country process to review the laws and regulations that provide for the establishment and functioning of HCCs, and to document the Zambia experience for wider regional exchange. In Zimbabwe, the CWGH has supported the HCCs to engage with government, so that HCC members can speak out about their concerns on the health system and on the support they need to successfully implement their roles. Training on community photography by TARSC means that the members have visual tools as well as words to raise evidence on their problems and progress.

Most ESA countries still do not have laws that explicitly or adequately recognise the functioning of the HCCs. We are thus advocating for their legal status and for them to have constitutions. This is important for their accountability to communities. It is also necessary if they are to directly receive, manage and account for public funds as was the case with Neighbourhood Health Committees in Zambia in the 1990s. The HCCs’ current vague mandates weaken their effectiveness, role and legitimacy, for communities and local actors and at national-level. We are thus sharing information on HCC constitutions, and on laws, statutes or guidelines on HCCs in the region and promoting their inclusion in law, including by showing their important positive role in the health system.

As a consortium, we are building a regional database of institutions and organizations working with HCCs in ESA countries so that we can better exchange and share information on the training materials, programmes underway with HCCs and the learning from them. We invite colleagues to send information to EQUINET if they are working in this area. We are building innovative ways of sharing and learning from our work, that build more direct voice, such as through photovoice where cameras are being put into the hands of communities and HCC members to identify and document community perspectives, experiences and actions related to their health conditions to be used in local HCC dialogue and wider reflection and learning.

Members of HCCs are carrying out exchange visits to allow for more direct learning and collective understanding of problems and achievements, creating inspiration to keep working and resulting in the launch of new initiatives.

We have seen evidence of the positive impact of HCCs in improved health outcomes. In Zimbabwe for example, since 2009, HCCs have played a role in in decision-making on the use of performance based funds at clinics, promoting improvements in facility-based deliveries, improving uptake of antenatal care and postnatal care visits and supporting demand by communities for these resources to be used to ensure delivery on patients’ rights at clinics. They have also mobilized resources to develop clinics such as by building waiting mothers’ homes, fencing clinics, supporting community health workers and raising advocacy on the needs of local services at higher levels.

We are seeing an increasing appreciation of the role of HCCs in community and primary care health interventions, with increasing attention and support from government, international and national partners. Our HCC in-country exchange visits are proving to be an effective way of sharing knowledge and good practice, inspiring others to see their own potential and act when they see the practical successes of other HCCs. “HCC exchange visits are rich in knowledge and should always be a key part of HCC activities carried out at local, district, provincial and national levels,” said Brighton Ngoteni, the HCC chairperson of Mudanda Clinic in Manicaland, Zimbabwe.

Our regional exchanges have also shown us that HCCs can only be as strong as the communities that support them. For this, we need to have recognition of the right to health, including on constitutions in the region, and comprehensive primary health care approaches that support health literacy and that inform communities, include communities and the views they bring in plans and services and give feedback to the communities for a people centred approach to universal health systems.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org and find further publications on the issue on the EQUINET website at www.equinetafrica.org