In this issue of the newsletter one author claims that this may be a year of a ‘perfect storm’ in health, where increased knowledge, widening health priorities, new institutional coalitions, economic challenges and innovations coalesce to create new ways of doing things. Some of these new approaches could advance health equity. For example in this newsletter there are contributions that call for a shift in focus from intellectual property as a stimulus for innovation in health technology to innovative policies for equity in research and development; from aid effectiveness to development effectiveness; or from downstream medical interventions to more upstream measures addressing the population-level determinants of ill health. Debates at the recent WHO Executive Board on reform of the organisation raised issues of equity in its leadership, organisation and funding. At the recently held World Social Forum, an ‘African Consensus’ presented alternative thinking about the continent and its economic and social development to the rapid liberalization and privatization policies of the ‘Washington Consensus’. Bona Chitah's editorial suggests that translating new thinking into health equity outcomes calls for feasible technical options, but more deeply demands an ethical foundation that is clear, shared and strong enough to navigate and sustain implementation, whatever the tide.
Editorial
Uganda has implemented a number of reforms to its health sector to make services more accessible to poor communities, including abolishing user fees, introducing public-private partnerships in service delivery, and decentralizing the management of health services to district and lower local government levels. Yet poor people continue to face barriers to use of health services. Costs of health services are still cited by poor people as being a barrier to using services, as are long distances to health centers, particularly for rural residents. Access to health care is thus an important equity issue in Uganda: Poor and disadvantaged people experience a greater burden of disease - but have poorer access to health care than those who have higher incomes.
These were the challenges discussed at a recent national meeting on health equity in Uganda hosted by HEPS Uganda, Makerere University School of Public Health and EQUINET. The meeting included presentations of work on disparities in health and access to health care, from researchers from academic, government and non government organisations. While the presentations reported on a range of initiatives to improve health in the poorest communities, they also gave evidence of the continuing challenges the country faces.
For instance, one study reported by the Institute of Public Health at Makerere University found in three districts of Uganda that the poorest households were 2.4 times more likely to suffer ill health than the richest. Infant and child mortality among the poorest Ugandans are reported to be double that in the richest group. Such inequities are also common in vulnerable groups that have greater need for health care. Addressing the needs of the poorest communities can be overshadowed by deficits in access to care for a much wider group of people. For example, the meeting was informed that despite a significant improvement in access to antiretroviral therapy (ART), demand for ART has continued to outstrip supply, and only about 60% of people who need ART can access it. Older persons were also described as having high health needs that may not be met due to wider poverty and isolation.
Not surprisingly a number of papers in the meeting thus explored the way resources are allocated to address these challenges. The first issue that arose was the overall shortfalls in health financing. The US$14 per capita reported to be spent on health was noted to be about a third of the resources needed for minimum health care services. While new resources have been mobilised nationally and internationally for AIDS, presenters reported that there is still a significant shortfall in funding for AIDS, especially at the district level. It was reported that out-of-pocket payments continue to exceed public sector spending, even though most poor people use public services and through fees have been abolished in the public sector. This is a barrier to health care for poor communities, and the source of these charges needs to be better understood to address them. The continued shortfall in overall financing also draws attention to whether budgets give special consideration to vulnerable groups. Concern was expressed in one presentation that district councils set budget priorities using a narrow definition of gender health needs within the community. Women have weak control over productive resources and household finances, and unless services give additional attention to this situation they will also lack command over the resources they need to protect their health.
Such disparities remain an issue to be addressed to promote health and access to health care in Uganda. There was wide agreement that such inequalities were avoidable and thus merited attention and action. Some actions were presented and discussed: The experience of community health insurance schemes was reviewed as one option for supplementing health resources. A study was presented showing that 81% of households surveyed in one rural district expressed willingness to enroll in Community Heath Insurance schemes and were willing to contribute on average Ushs.5,977 (US$3.4) per person per year. Further work needs to be done on how equitable and sustainable these schemes are, especially for the poorest. It was argued that strengthening decentralisation, through resource allocation that prioritises districts and community level, could also go a long way to strengthening the health care system used by low income groups, and thus addressing inequity. Various examples were presented of strategies to empower and mobilise communities to engage with their health services, including the Village Health Team Strategy and the use of media, drama and of participatory reflection and action methodologies.
Across these options it was agreed that ensuring fair opportunities for health should not be left only to the Ministry of Health, but should be a matter for all sectors. According to the Ministry of Health in Uganda, over the past fourteen years, considerable effort has been made to restore the functional capacity of the health sector, through increasing public health spending, reactivating disease control programmes and re-orienting services to primary health care in Uganda. However, the ministry observed in a 2007 report that there still remain significant challenges in matching need for health services with available resources, making equity or fairness an important issue for advancing national policies for the population as a whole (http://www.health.go.ug/policies.htm).
The people and organisations at the national meeting agreed to continue networking to advance health equity work, and formed a new Ugandan health equity network. This will create a platform and ignite further action for health equity at national level. With leadership from different institutions working in these areas the network will share evidence, knowledge and strengthen advocacy on areas of health equity that include: resource mobilisation and allocation to the health sector; addressing health needs of vulnerable groups; protecting health in trade policies and agreements; and advancing health rights, community empowerment and effective governance in health. While it was evident in the meeting that a lot of work is underway, it is not always shared and communicated within Uganda and in the East and Southern Africa region. The delegates thus agreed to strengthen and widen links between people and institutions working on equity in health, to promote research and practice in this vital area of national health policy.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. For more information on the health equity network in Uganda, contact HEPS Uganda at heps@utlonline.co.ug, working with Makerere University School of Public Health. Further information on the issues raised and the report of the Uganda national meeting is also available at the EQUINET website at www.equinetafrica.org.
Access to essential medicines is a necessary requirement for equitable health systems and improved population health. According to the United Nations Conference on Trade and development (UNCTAD) the number of people with regular access to essential medicines in developing countries increased from two to four billion in the five years between 1997 and 2002. However, UNCTAD also report that nearly 2 billion people do not access essential medicines, most living in least developed countries (LDCs). High medicine costs relative to incomes, inadequate public or international funding for medicines relative to need, limited local production and the limiting effects of intellectual property have contributed to this gap, together with weaknesses in health services.
The African Union (AU) seeks to strengthen local manufacturing of medicines on the continent as one remedy to this situation. AU leaders identified an over reliance on imports of medicines from outside the region as a key challenge. For example, Chaudhuri in 2008 observed that of Tanzania’s US$110 million pharmaceutical market in 2004/2005, $78 million or 71 percent came from imports and only 29 percent from local production. Out of the 3388 drugs registered for sale in Tanzania, only 269 products (or about 8%) were from Tanzanian local manufacturers. In contrast in Zimbabwe in the early 2000s the local pharmaceutical industry supplied nearly half of the country’s essential medicine requirements, according to the United Nations Industrial Development Organisation (UNIDO). Further as only South Africa has limited primary production of active pharmaceutical ingredient and intermediates, the local production underway in Africa is reliant on imported active ingredients. UNIDO indicates for Zimbabwe, for example, that while imports of finished pharmaceutical products do not face tariffs, inputs for the manufacture of pharmaceuticals do, with import duties ranging from 5 to 15 per cent, raising production costs.
To address the constraints and widen capacity for local production in the continent the AU set a Pharmaceutical Manufacturing Plan for Africa that was adopted by the AU Summit in 2007.
The AU Pharmaceutical Manufacturing Plan was complemented by a Pharmaceutical Manufacturing Business Plan (PMPA) that identified priority areas for actions, such as mapping of productive capacities, addressing intellectual property issues and capital requirements. The plan also raises the bottlenecks to medicine production in Africa. According to the text of the plan: “This Business Plan is based on the belief that industrial development and the development of the pharmaceutical sector is not in conflict with public health imperatives and that the industry should in fact be developed with the long term aim of promoting access to quality essential medicines.” Complementing the AU plan, the Southern African Development Community and the East African Community have also developed similar plans and proposed policy measures to overcome barriers to medicines access, such as pooling procurement to make medicines more affordable.
Despite the presence of these plans, there is still limited local medicine production on the continent. Setting up a pharmaceutical plant requires massive investments in infrastructure, technology, skilled professionals and strategic leadership. Many of these critical inputs were also identified as bottlenecks in the AU plan. Many African countries do not have adequate capital, and investors may be discouraged by high tariffs for and erratic supplies of electricity and water, ageing transport infrastructure, old plant and equipment and shortages of skilled industrial pharmacists and scientists. African countries also have lower capacities and resources for pharmaceutical research and development. One of the reasons therefore for the plans not being operationalized was the absence of strategic allies, resources and leadership to translate them into practice.
In recent years that scenario is beginning to change. New actors and partnerships are emerging in production of pharmaceuticals on the continent, providing new opportunities to deal with bottlenecks. These include the US$23 million Brazil-Mozambique plant for manufacture of anteretrovirals (ARVs), and the US$38 pharmaceutical plant set up in Uganda as a co-operation between Cipla (of India) and Quality Chemicals (Uganda) for the manufacture of ARVs and anti-malarials. These partnerships provide capital and strategic expertise that can be crucial for ESA countries in their efforts to set up local production. However to take advantage of this, ESA countries need an industrial policy that taps into the knowledge that exists in these countries, and that ensures the same technology transfer into Africa as these countries secured from high income countries.
These new opportunities for south-south co-operation provide a window of possibility for overcoming bottlenecks identified in the AU plan, but only if this is negotiated for as a key element of these emergent partnerships. South-south co-operation also needs to be complemented by, and not to displace regional processes. Regional level production and distribution agreements provide wider markets for medicines produced, generating economies of scale, better use of installed capacities, and greater possibilities of local supply of active ingredients and other raw materials. For example Varichem Pharmaceuticals, Zimbabwe, one of the first companies in Sub-Saharan Africa to manufacture generic antiretrovirals (ARVs), was issued with a compulsory licence to manufacture generic ARVs in April 2003 and produced its first generic ARVs in October 2003. Namibia and Botswana gave manufacturing licences to Varichem to supply medicines in their countries. Regional co-operation has been important to tap larger markets, to make full use of capacities that do exist, to harmonise medicine regulation and support skills development. It will continue to play a role in strengthening the negotiating position of countries in the region in ensuring that new partnerships in medicine production play a role in overcoming the bottlenecks identified in the AU plan to localise medicine production on the continent.
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
IMF policies are blocking the scale of public spending and hiring of doctors, nurses and teachers African countries need to meet health and development goals. Three recent reports respectively by the IMF’s Independent Evaluation Office (IEO), the Center for Global Development (CGD) and ActionAid International’s Education Team suggest that IMF policies place unreasonable limits to spending of available aid and to scaling-up public spending through overly austere policies that lack empirical justification.
The IMF's mission is to keep inflation under control and promote “macroeconomic stability”. Country access to World Bank aid and other bilateral foreign assistance is contingent upon “thumbs-up” approval from the IMF on macroeconomic policies. The multiplier benefits of major investments in public health and education can take 15 to 20 years to appear in the form of higher GDP growth and productivity rates. Each macroeconomic policy option has its own short-term and long-terms costs and benefits, but because the IMF is always demanding short-term fiscal solvency at any given time, many reasonable alternative macroeconomic policy options for hiring more doctors, nurses and teachers or making long-term investments in the health or education systems are not even being allowed for consideration or debate. So are IMF demands blocking the scale-up of public spending needed to fight AIDS and achieve the Millennium Development Goals (MDGs)? The three reports examine these issues.
The IEO report “The IMF and Aid to Sub-Saharan Africa,” available at http://www.ieo-imf.org/eval/complete/pdf/03122007/report.pdf, examined IMF loan programs to 29 Sub-Saharan African countries from 1999-2005 and found significant percentages of foreign aid were not programmed to be spent because:
* about 37 percent of all annual aid increases were diverted into building international currency reserve levels. Even in countries with sufficient currency reserves, only about $3 of every $10 in annual aid increases was programmed to be spent; the IMF redirected or diverted the remaining $7 out of every $10 into paying domestic debt, building international currency reserves, or both. Having so much new aid not being spent was certainly not the intention of the donors, or citizens in donor countries.
* aid spending was curtailed due to the IMF’s insistence on very low inflation levels. Countries that failed to achieve to 5-7 percent inflation a year were only allowed to spend 15 percent, or just $1.50 of every $10 of their annual aid increases. At a seminar in London in April 2007, Joanne Salop, lead author of the report, said the IEO report team recommended that as the 5-7 percent threshold was the operative IMF policy, it should be publicly stated and clarified - but the IMF Executive Board and management rejected the recommendation.
The IEO report found the IMF Executive Board and senior management were not enthusiastic about donors' emphasis on “poverty reduction” or new efforts to scale-up aid and spending for the MDGs. Without strong leadership directing real policy changes in this regard, the report found, staff simply reverted to prioritising macroeconomic stability over other goals. Yet IMF leadership is overly cautious about deficit spending “crowding out” available credit for the private sector, despite mounting evidence for the reverse, as noted by IMF’s Sanjeev Gupta in a 2006 IMF report (“Macroeconomic challenges of scaling up aid to Africa: a checklist for practitioners,” IMF, 2006. p.26).
The CGD report “Does the IMF Constrain Health Spending in Poor Countries? Evidence and an Agenda for Action,” available at http://www.cgdev.org/doc/IMF/IMF_Report.pdf further explores the implications of this IMF austerity. Produced by fifteen experts from policy-making positions in developing countries, academia, civil society, and multilateral organisations, it reviews experience from Mozambique, Rwanda and Zambia. The report found that: “IMF-supported fiscal programs have often been too conservative or risk-averse”, and have led to underspending of development aid, as they have “not done enough to explore more expansionary, but still feasible, options for higher public spending.” The report calls on the IMF to “explore a broader range of feasible options,” with “less emphasis on negotiating short-term program conditionality.”
The ActionAid International Education Team report “Confronting the Contradictions: The IMF, wage bill caps and the case for teachers,” (http://www.actionaidusa.org/imf_africa.php), found that IMF policies - by varying degrees of influence in setting the level of funds available public sector employees' wages or “wage bill ceilings" - require many poor countries to freeze or curtail teacher recruitment. This leads to persisting chronic and severe teacher shortages. In all three countries studied, inflation-reduction and deficit reduction targets and the wage bill ceiling is too low to allow governments to hire enough teachers to achieve the 40:1 pupil-teacher recommended by the Education for All-Fast-Track Initiative, thereby compromising the quality of education in these countries.
For health and education advocates who are trying desperately to maximize budgets, wages and get every last doctor, nurse and teacher hired, such empirically unfounded economic policy-making is totally unacceptable. An array of reasonable alternative policy options for increasing public spending is being unnecessarily omitted from consideration.
The ActionAid report calls for IMF advice to provide a range of policy options so that governments and other stakeholders – including parliaments and civil society –can make informed choices about macroeconomic policies, wage bills and the level of social spending.
The report also highlights the growing policy contradiction in the foreign aid system: as the richest donor countries try to scale-up spending and foreign aid, they also block the ability of many poor countries to spend that aid because of the IMF loan programs they have approved. A July 4, 2005 New York Times editorial appropriately summarized this current contradiction in donor policies: “There is a desperate need for greater policy coherence in a period when many national governments, including Washington, are sensibly exhorting African governments to spend more on primary health care and education, while international financial institutions largely controlled by those same Western governments have been pressing African countries to shrink their government payrolls, including teachers and health care workers.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit www.actionaidusa.org.
A new report on the funding by nine African and Latin American countries on HIV/AIDS has found that countries must do more to ensure a comprehensive response to the epidemic—incorporating prevention, treatment, care and support. The study, undertaken by NGO research institutes in each country, was jointly coordinated by Idasa in South Africa and Fundar in Mexico.
The study, entitled Funding the Fight: Budgeting for HIV/AIDS in Developing Countries will be discussed by researchers during a one-day meeting taking place in Johannesburg this week. This research project makes a remarkable contribution to the field of HIV/AIDS resource-tracking, in that comparable budget analysis studies were undertaken by civil society organisations.
The study found that while many countries have developed national strategic plans and programmes, these were poorly costed and budgeted. It also found that the tracking of resources allocated towards HIV/AIDS in national budgets was hindered by weak or absent links between allocations and their intended objectives and outputs. Governments have inadequate systems in place to track the allocation of resources for HIV/AIDS.
Yet the research yielded a number of important findings. In Africa most countries, until recently, have focused on prevention more than treatment. This despite the fact that WHO/UNAIDS estimates that 3.8 million Africans are in need of treatment, while only 150 000 people are currently receiving the life-prolonging drugs. The study notes the boost to HIV/AIDS spending following the recent announcement and launch of ARV treatment programmes in South Africa, Mozambique, Kenya and Namibia. However the researchers caution that even though governments may increase their allocations to provide treatment, this programme may be undermined if more money is not made available to strengthen the health system overall.
In the Latin American countries, where HIV/AIDS prevalence is below 1%, the bulk of government spending on HIV/AIDS is earmarked for providing antiretroviral treatment. In Argentina 90%, in Chile 80%, Ecuador 74% and Nicaragua 54% of the national AIDS budget is committed to providing treatment and care and support, with less resources available for prevention. The researchers warn that treatment alone may not be enough to curb the epidemic and that the governments of Latin America need to increase their allocations and commitment to prevention.
The Report points out that all the African countries are falling below the 15% target agreed upon by Governments at an OAU Summit in Abuja in 2001. Amongst the African countries, the health allocations as a share of total government expenditure range from 6% in Kenya to approximately 15% in Mozambique. South Africa’s allocation is estimated to be just under 12%. Health budgets in the Latin American countries, with the exception of Nicaragua, were primarily financed through state revenue, whereas in the African countries, except South Africa, they tend to rely primarily on donor funds.
While it is difficult to isolate specific HIV/AIDS allocations from the overall health budget, the report finds HIV/AIDS earmarked funds consume less then 4% of health budgets in the Latin American countries included in the study, ranging in 2002, from under 1% in Chile to 3.5% in Argentina. In Africa, the priority accorded to HIV/AIDS programmes in health budgets varied significantly—from 1.6% in Mozambique, to 11.4% in Kenya in 2002. In South Africa the HIV/AIDS allocations have climbed steadily from 0.67% of the consolidated national and provincial health budget in 2000/1, to 3.86% in 2004/5. HIV/AIDS-specific allocations made up 0.49% of South Africa’s overall national budget in 2004/5.
An important finding from the Report is that the increasing allocations being made to HIV/AIDS may be squeezing out other health priorities. In all countries the researchers observed that while HIV/AIDS allocations have been increasing, this has not been matched by a commensurate increase in allocations to the health sector overall. Without adequate attention to strengthen and support overall health infrastructure, facilities and medical personnel, HIV/AIDS programmes will be undermined, and simultaneously the health care delivery will strain under the burden of HIV/AIDS.
The report urges African countries to increase their own financial commitments to HIV/AIDS interventions. It points out that with the exception of South Africa, most African countries rely to a great extent on donor funding. Greater commitment of state funds is essential to the longevity of scaled-up programmes, particularly treatment.
The report has been able to yield very valuable findings, and the researchers are calling for budget reforms and greater transparency of government allocations for, and actual spending on, HIV/AIDS. This information will enable civil society and citizens to better understand and monitor how much is being spent on HIV/AIDS, for what programmes, and in what regions and provinces. Effective government responses to AIDS require us to know where the money is coming from, where it is going, and how well it is being spent.
For more information contact: Alison Hickey, Manager, AIDS Budget Unit, Idasa. Cell: 083 280 2759; Teresa Guthrie, Project Co-ordinator, AIDS Budget Unit, Idasa. Cell: 082 872 4694. To order a hard copy of the report, contact: nomzi@idasact.org.za A full electronic version will be available October 2004: www.idasa.org.za
EQUINET is currently carrying out work in line with the SADC Business Plan on HIV and AIDS on monitoring, protomting good practice, supporting research and sharing information on health systems and equity issues in treatment access. More information on this programme is available from the EQUINET secretariat at TARSC, email admin@equinetafrica.org.
She has walked for 10 kilometers now. She can hear the child on her back, the harsh crying of an hour ago fading to exhausted whimpering. Her local clinic has not had a qualified nurse for some months, so she is walking the 20 kilometers to the nearest district hospital, hoping that by the time she gets there, the child will not have succumbed to the fever that she could not dampen with home treatment.
For this woman, as for many others in the region, the long walk to care is a consequence of inadequate numbers of critical and skilled health personnel, high levels of external and internal migration and poor distribution of staff in areas of high health need. Even where health workers are in place there is report of low staff morale. In 2005 health ministers in the Southern African Development Community (SADC) identified the non availability of skilled health professionals as a key factor undermining achievement of health Millennium Development Goals.
With the reality of poor communities bearing the brunt of a yawning gap between need and supply of health workers, health ministers in the East, Central and Southern African Health Community (ECSA-HC) resolved in 2007 to have in place by 2008 national strategies to recruit, motivate and retain health workers, using both financial and non-financial incentives. Since then both ECSA-HC and SADC have developed strategies for responding to the health worker crisis. A number of countries in the region have also developed and began to implement strategies, adding new measures to existing incentives. In March 2009, the ECSA-HC Ministers met again in Swaziland to review how far these commitments had been addressed.
Towards this, in February 2009, EQUINET and the ECSA-HC held a regional meeting, hosted by University of Namibia, to review evidence gathered from countries on how well incentives for health worker retention were working. These incentives are not always cash payments. The studies showed that dealing with poor working conditions, poor communication, unsupportive management and inadequate recognition is also important to attract health workers and to motivate them to stay.
As Hon Petrina Haingura, Deputy Minister of Health and Social Services in Namibia noted in opening the meeting, “We all know and understand that our governments are not in positions to provide huge salaries to our health workers but much more can be done within working environments. Health workers frequently complain and express dissatisfaction with management, poor leadership, lack of support and recognition; supervisors do not even know the word ‘thank you’ for good performance.”
The studies carried out in Kenya, Tanzania, Uganda, Swaziland and Zimbabwe gave evidence that the incentives most valued by workers were training and support for their career paths; improvements in services and working environments; housing mortgages / loans; recognition and reward for performance and accessible health care. Delegates at the meeting suggested that these be planned for and costed as a core set of strategies in health worker retention strategies in all countries in the region, even while further locally relevant strategies are considered.
Some of these strategies are being applied, but on a targeted or piecemeal basis, for selected health workers, or in specific programmes. Leaving it to individual facilities to set and apply these incentives seemed to lead to a vicious cycle of poorly resourced facilities, with weak management, having the least ability to attract staff, despite greater need. The evidence suggested that retention packages should preferably be health sector wide, with career path and training support based on analysis of responsibilities and tasks.
Prof Yoswa Dambisya of University of Limpopo summarised the learning from the region: “Non-financial incentives have been successful when they have been deliberately planned, with consultation across the board, as in Uganda; when they meet immediate needs through top-ups and allowances as in Malawi; when a combination of financial and non-financial incentives is used as in Zambia and Uganda; when incentives are used to attract health workers from private to public sector as in Uganda; when incentive programmes are integrated with SWAP or budgets as in Uganda and Malawi; and when national and donor funding were mobilised for an emergency human resource programmes in Malawi and Zambia”.
Moving from cash top-ups for selected personnel as an emergency response, to supporting career paths, health services and long term housing as an investment for retention moves us, therefore, from the realm of quick fixes to longer term change. It calls for long term planning of needs and services, and the information to support this. It demands management capacities, tools and guidelines, delivered through procedures and processes that build trust and participation. These features are often under-developed in health systems in the region, yet without them, even the best designed incentives remain largely on paper. Indeed one of the findings of the studies was that while many of the countries had made progress in setting policy measures for dealing with incentives for retention, delivery on the ground was still limited, in part due to gaps in these capacities. One sign of weak support for these capacities is the ironic exclusion from incentives schemes, training and professional exchanges of the very personnel who manage human resources for health.
These deeper, system wide changes are not just good for health worker retention, but for the quality and performance of services as a whole. But they do demand more than short term, ad hoc injections of project funds. One requirement is that governments in the region should increase the budgets for health to meet the Abuja commitment of 15% government spending on health. Analysis of experience with international and global funding suggests also that these funds are best pooled into sector wide funds, if they are to support system wide incentive schemes for health workers, with plans for their use harmonized with national plans.
This raises issues of sustainability and of shared international and national responsibility that need to be addressed. When a draft code of practice on the International Recruitment of health personnel was tabled at the January World Health Organisation Executive Board, however, the debate reported on it suggested that there is some way to go in reaching a shared understanding of how international responsibilities should be managed. In 2007, African countries, many of whom are source countries for migrating health workers, had requested a code that was more than voluntary. The WHO secretariat chose instead to stick to international practice of a non-binding agreement and presented a voluntary draft code, with some high income countries receiving health workers echoing this choice. African countries at the 2008 Executive Board thus again raised the need for an enforceable code, for the rights of communities in source countries to be considered and for a compensation mechanism to address losses. So the code was referred for more consultation.
As we follow the woman and her baby into the district hospital from the long walk, her hope is focused on the fact that she has come in time to save her baby. Our hope is that she will not need to make this walk again, and that African health systems provide the environments, task alignment, career paths and long term security to ensure that their health workers are found in the services where they are needed, backed by the wider economic improvements and political stability needed to keep them there.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on the health worker retention issues please visit the EQUINET website- www.equinetafrica.org. Information on the ECSA-HC resolutions and programme on health workers can be found at http://www.ecsahc.org/
At the 3rd Global Forum on Human Resources for Health, Recife, Brazil, November 2013 a group of civil society organisations and regional networks produced a statement of commitment on the key role of health workers in universal systems. The statement from EQUINET, European Public Health Alliance, Health Poverty Action, Health Workers for All and All for Health Workers, Latin-America Association of Social Medicine ALAMES , Medicus Mundi International Network MMI, People’s Health Movement PHM, Public Services International PSI, The Centre for Health Sciences Training, Research and Development CHESTRAD and WEMOS is shown below.
The health workforce crisis remains a core barrier to achieving the Millennium Development Goals (MDGs) for health with only 31% and 12% respectively of 75 Countdown countries likely to attain MDGs 4 and 5. Despite donor and country commitments at the 1st and 2nd Global Forums on Human Resources for Health, the global health workers’ shortage persists. Of the 57 countries identified as falling below the WHO target only 19 have seen an improvement in their aggregate health worker density. Earlier commitments to increase domestic resources or external aid, as well as implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, remain largely unfulfilled.
National and international funds have been channelled to strengthen health workforce programs, like task shifting and the scaling-up of community health worker’s programmes. However, too little investment has been targeted at the recurrent costs of health workforce development, for instance on salaries, education and social protection measures for health workers. The inequitable distribution of health workers through increased mobility and migration within and between countries adversely affects access to health.
Health workers and a robust health system are essential for universal health coverage (UHC), and realizing the right to health through universal health systems.
Therefore at the 3rd Global Forum on Human Resources for Health in Recife, Brazil, we, the undersigned representatives of civil society organizations hereby commit that we will:
• Help amplify the voices of health workers, especially those at the lower levels of care and support their work to influence national and global health policies and plans.
• Assist local civil society organizations to ensure their voices are heard in global and national health workforce policy discussions.
• Assist in strengthening the capacity of patient groups to advocate for equitable and quality services staffed by sufficient, competent and equipped health workers at all levels of care.
• Recognise the gender dimensions of the health workforce and champion the rights of women health workers, and
To catalyse a strong movement for health workers, we will:
• Advocate for governments at all levels to institute plans and allocate adequate resources for human resources for health (HRH) to ensure that every person has access to a trained, supported and equipped health worker.
• Press bilateral and multilateral organizations and civil society actors to increase health workforce development efforts and financing, including of national training institutions, in alignment with government plans.
• Work with training institutions, professional and regulatory bodies to achieve quality in health worker education, including on the social determinants, so that every health worker is competent to provide quality care and accountable to the populations they serve.
Strengthen the advocacy of health workers and civil society for improved infrastructure, support and working conditions
• Support the development of a strong, motivated, public workforce to counter some of the ill- effects of an increasingly globalised, inequitable and unstable economy and rapidly changing health and demographic patterns.
• Commit our own resources and expertise to assist in converting HRH policy and plans into action.
To ensure accountable HRH systems at national and global levels, we will:
• Work with governments, the Global Health Workforce Alliance, the World Health Organization, and other stakeholders to develop mechanisms to measure progress towards improved and equitable access to competent health workers
• Monitor and report on progress of public HRH commitments made by global actors and governments.
• Assist citizens and health workers in developing strategies to enhance accountability of national and global actors and challenge inequitable policies that impact on HRH development.
• Increase transparency of our programmatic and technical contributions to national HRH strategies and attempt to reduce onerous reporting requirements placed on countries. We will commit ourselves to supporting a strong public sector for health workforce development and be accountable in our own funding and technical programs to mitigate the ‘internal brain drain’ from the public to the private sector.
We will hold donors, government and multilateral actors accountable to:
• Ensure that economic governance arrangements and fiscal space enables the development of a strong national health workforce as a long-term investment in the wellbeing of the people and the economy of a country. The return on investment to employ a health worker is many times higher than to bail out a bank.
• Provide the leadership, resources and stewardship needed to fulfil commitments made to urgently and effectively address the health workforce crisis and ensure improved and equitable access for every person to competent health services.
• By 2015, develop, finance, and implement HRH action plans, including strengthening national training institutions, with concrete targets and integrate them into national health plans.
• Ensure that health workers and civil society organizations are active partners in the health workforce policies, planning and development.
• Promote equitable access to health care by investing especially in health workers at primary and community levels and in community structures to facilitate citizens’ voices.
• Improve investment in health workforce development, including salaries and social protection, and in national training institutions in order to rapidly increase numbers of HRH.
• Assist in development of robust HRH information systems to facilitate improved planning and management and
• Respect and implement the Global Code of Practice on the International Recruitment of Health Personnel including additional enforceable legislation and redistribution mechanisms to compensate for the international ‘brain drain’ that exacerbates global health inequalities.
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
At the just ended World Health Assembly (WHA 66) member states reviewed progress in implementing the WHO Global Code of Practice on International Recruitment of Health Personnel. This was the first review report since the adoption of the Code three years ago. The Secretariat report tabled at the WHA showed that few African countries had designated authorities for monitoring and reporting on the Code, and that only one African country had submitted a report on implementation. This low response has been commented on in April 2013 EQUINET newsletter (http://www.equinetafrica.org/newsletter/index.php?issue=146)
When the report on the health workforce, which included progress on the Code, was discussed at the WHA, the discussion was somewhat muted. Only fourteen member states commented on the report, and only eleven made reference to the Code. African countries speak as a group on issues through a nominated delegate. Burkina Faso spoke for the 46 WHO-AFRO member states, and Ethiopia spoke in support of Burkina Faso. Those that attended the WHA in 2010 when the Code was adopted observed the contrast to the exciting atmosphere of intense debates and the large number of voices that were heard at that stage.
So what has happened over the last few years? At a side event at the WHA, participants took stock of the progress, or lack thereof, in the implementation of the Code. The side event was organised by Medicus Mundi Internationales together with the Governments of Malawi and Belgium, EQUINET and AMREF. Participants raised various challenges that member states faced in getting the implementation of the code off the ground, including their lack of preparedness, the poor mobilisation of national level stakeholders and limited engagement of civil society since the Code was adopted. Ministries of Health were also reported to be overwhelmed with other issues. WHO and some countries reassured that despite low reporting, work was underway. The fact that many countries had reported was seen as a positive sign, given the voluntary nature of the code, as was the commitment of Northern countries, (USA, EU) and WHO Secretariat to support its implementation.
The muted African member state reaction to the report at the WHA by the Secretariat may, as raised above, be explained by the diplomacy process of the Africa Group, where African ministers reach agreed positions, as they did on this issue, giving little added value in countries making further individual statements. While shared position and voice is an important feature and strength of African diplomacy, it is also common practice for countries to state/restate their position as they “align themselves with the statement made by the delegate for...... region”. This allows countries to give force behind specific areas and for country experiences to add weight to positions raised. African countries may also have been reluctant to raise their voice in the WHA process given lack of input to the Secretariat report, as raised earlier.
Whatever the reason, and this needs to be further explored, the low profile adopted by African member states on this occasion may have sent a message that the Code is not perceived to be a key policy instrument for the region to address its continuing challenges over the production, retention and migration of health workers. If so, then given the energy that went into its adoption, where are the shortfalls?
There are lessons from other processes at the WHA. Voluntary codes may fall out of attention as other issues demand more urgent government attention. If this is the case then the implementation of the only other WHO Code - on breast milk substitutes – provides a lesson on the role of civil society to galvanise countries into action, particularly with technical support of WHO. Civil society has kept the code on breast milk substitutes alive and current and generated pressure within countries to ensure that it is implemented. Is this possible for the Code of Practice on International Recruitment of Health Personnel? In theory it is achievable. The loss of health workers in countries of highest health need is still a concern, and communities and health workers have an interest in the issue, as it affects their rights and services.
Civil society organisation on health worker issues has partly been through the Global Health Worker Alliance (GHWA). The fact that the GHWA currently has no executive director weakens its support for civil society input, and creates uncertainty about its future. The third global forum on health workers organised by WHO and the GHWA will be held in Recife, Brazil in November 2013. It should provide an opportunity to review and give profile to the role of the Code in addressing health worker issues, and give new momentum to the role of civil society in its implementation. This however does need civil society, health worker organisations and academics within countries to ask questions on the implementation of the Code, to ask delegations for feedback from the discussions held at the WHA, and to know, share information on and support implementation of the Code.
It is also a matter of concern that reforms at the WHO Secretariat have diminished the capacity of the unit dealing with health worker issues. Fewer people are now contending with an increasing workload, weakening the capacity of that unit to play a leading role in support of member states and the wider community.
A number of civil society organisations, including MMI/Peoples Health Movement, and the International Federation of Medical Students Associations (IFMSA) spoke as observers at the WHA deliberations on the Code. Most of the presentations raised the weakening of these institutional capacities for supporting its implementation and called for a stronger Health Systems Policies and Workforce unit at WHO Secretariat and a stronger GHWA.
In a world of rapidly shifting policy attention, it seems to be important to organise and secure the resources, institutional roles and capacities for implementation when negotiating new instruments, particularly if they are voluntary as the Code is. The next few years will be a test of whether the slow implementation is a feature of countries preparing for a marathon rather than a sprint, or whether it is a feature of diminishing interest in the race. Issues are also sustained when they have a place in the current focus of policy attention. The focus of this year’s WHA and of much current global engagement in heath was on universal health coverage (UHC). It was thus important that health workers were identified as a central element of that policy.
This then may be the important message that we need to send. Delivering on UHC is not possible without health workers, and one sign of that delivery at global level is the extent to which countries are operationalizing the Code and implementing its intentions. The international agreements negotiated by member states at the WHO are instruments for achieving UHC, whether voluntary or not, as are the global and national capacities in governmental and non-state institutions for leading and being accountable on their implementation.
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
From the 1-3 July 2007, African leaders will meet in Accra, Ghana at the 9th Ordinary Session of the Assembly of the African Union. The major agenda item is the proposal and plans for the United States of Africa. Africa’s Under-development as manifested in its public health catastrophe is not on the AU summit agenda. This raises the crucial question of the kind of unity African leaders wish to achieve. Significantly the debate about the proposed union has revolved mainly around political issues without commensurate attention to the development issues which were no less important to the founders of the Pan African movement.
It is now six years since Heads of State of African Union member states pledged in Abuja in 2001 to commit at least 15% of national budgets to health. To say it is tragic that in 2007 only two out of fifty three AU member countries (Botswana and Seychelles) have clearly met that pledge does not even begin to describe the situation. It is beyond tragedy.
In these past few weeks, all roads led to the G8 Summit in Germany. In what has become an annual ritual since the turn of the century, international campaigners Bono, Bob Geldof and an impressive assortment of Development and AIDS related organisations led the calls for more aid to Africa, and for Africa not to be forgotten in the clamour over climate change. As usual, selected African leaders turned up with begging bowls and for photo calls. Leading international campaigners have since described the aid pledged by the G8 this month as 'a farce' and 'grossly inadequate'.
We know that many of the more developed countries have played historical roles in under developing Africa. 400 years of industrial scale slavery, in addition to colonialism, ruthless exploitation of Africa’s resources, cynical ‘interventions’ and the debt burden have cost Africa dearly. The ‘foreign’ aid to Africa is a percentage of what has been taken out in human and natural resources, and is but a small step towards repairing the damage done to Africa.
But we also know that African leaders cannot seriously expect other countries to commit to, or meet pledges to ‘save’ Africa when they themselves appear indifferent to Africa’s future. To be going forward with plans for African unity without simultaneously meeting the most fundamental commitment to African development – that of health - is misguided to say the least.
It is comical for us to be calling on the G8 countries to meet the recent Gleneagles pledges when the vast majority of AU member states have not met their own Abuja 2001 pledge. This is not a pledge we can afford to pass unfulfilled. The Africa Public Health Rights Alliance (APHRA) and its '15% Now!' Campaign revealed on Human Rights Day (December 10) 2006 that by crossing continental, sub regional, country, health, disease specific and development information from a wide range of agencies and institutions we computed that an estimated 8,000,000 Africans are dying annually from preventable, treatable and manageable diseases and health conditions – mainly Malaria, TB, HIV, child and maternal mortality. This figure does not include organ related disease (heart, liver, kidney and lung diseases), an assortment of cancers, vaccine preventable diseases and so forth which could very easily add another million – or more. The consistency of these figures over the past six years alone means that Africa has suffered an estimated 48,000,000 preventable deaths since 2001.
By coincidence, the dream of the United States of Africa is planned to be actualised by 2015, the same year the Millennium Development Goals are to be met. If Africa’s health catastrophe continues unabated we could loose another 72,000,000 lives by then. This is the equivalent of whole nations dying out within a year or a decade. Many African countries (such as Botswana, Burundi, Eritrea, Gambia, Lesotho, Liberia, Libya, Namibia and
Swaziland) have populations of between 1-8,00,000. Most of the island countries have populations of less than a million. Even Africa’s most populous countries (DRC, Ethiopia, Kenya, South Africa, Sudan - with the exception of Nigeria at 130,000,000) all have populations of between 30-80,000,000.
It would therefore not be an exaggeration to describe over 120 million preventable deaths between 2001 and 2015 as genocide – by inaction. In this case and for every life lost, government indifference to Public Health is the equivalent of an Interehamwe machete or Nazi gas chamber. If we were set up memorials to the preventable deaths from one year alone, we would need 100 stadiums in Africa with the capacity to each host 80,000 skulls – each a stadium of shameful silence, and a monument to government without responsibility.
Africa Must Unite! But for it to be a meaningful unity it must not be a unity of the dead. It must not be unity as a continental graveyard.
Meeting the 15% pledge will be a significant indication that African leaders care for their countries and are prepared to live up to their primary responsibility of keeping their citizens alive and healthy. No meaningful and sustainable development of Africa can happen without sustainable financing for health care. Indeed the status of public health is the most significant indicator of social and economic development. This is why the Right to Health is the most crucial Right of all – we all have to be alive and well to exercise any other Rights. The dead have no Rights – except perhaps the ‘Right to a decent burial’.
To postpone the meeting of the 15% pledge to the future is to accelerate the death of Africa. We call on the African Union to place the 2001 15% pledge on the July 2007 summit agenda and at the very least to introduce it as urgent business [under item vii, AOB]. We further call on them to make it a major agenda item of the next summit or to call a special summit dedicated to meeting the 15% pledge. This should be preceded by a special summit of Finance and Economic Development Ministers
To further illustrate the full scale of Africa’s health disaster, it is not enough to demonstrate only the unprecedented scale of preventable death. It is also crucial to demonstrate the scale of Africa’s impotence and one example will suffice.
Without health workers, no amount of free medicines can be delivered to citizens, and all ‘foreign’ AID is meaningless. Yet many African governments have no clue how close to death their countries are due to shortage of health workers of all categories.
The DRC with a population of 57 million, roughly equivalent to the populations of UK, France and Italy has only 5,827 doctors compared to the
France’s 203,000, Italy’s 241,000 and the UK’s 160,000. But it is not just a case of the most developed countries being able to train more health workers, or to poach from Africa to make up their shortfalls. Cuba with a population of about 11 million has roughly the same population as Malawi, Zambia or Zimbabwe. But Cuba has 66,567 Doctors compared with Malawi’s 266, Zambia’s 1,264 and Zimbabwe’s 2,086. Not surprisingly, Cuba has roughly the same life expectancy (77 years) as the G8 Countries, the Scandinavian and other developed countries while the average life expectancy for African countries compared to it here is 37 to 40 years. The success of Cuba in the areas of health care and education demonstrates it can be done. Despite issues with the Castro government, western countries have visited Cuba to study how they have achieved their health success. To come anywhere near meeting the World Health Organisation recommended health worker’s to patient ratio or meeting the health based MDG’s these African countries compared to Cuba will need to train and retain roughly 59,000 Doctors each in 8 years. The DRC will need to train and retain at least 150,000. The numbers for nurses, pharmacists and most categories of health workers are comparable across board. This should be Africa’s priority.
In other words, there is no alternative to long term in country sustainable financing to rebuild Africa’s Public Health systems including health workers and improved working conditions and remuneration for them, adequately equipped clinics and hospitals, improved sanitation and environmental health, clean drinking water and so forth. Without these Africa may achieve its dream of continental unity, but it will be a fools paradise.
We are for a United Africa. But it must be a unity of the living, and of a healthy African people – able to enjoy full civil, social, economic and political Rights - not a unity of the diseased, dead and dying.
Successfully unity can only be based on successful development of which health is the corner stone.
The Africa Public Health Rights Alliance and its 15% Now campaign call on you to join the undersigned below in signing the petition calling
on AU member countries to fulfil their 15% Abuja pledge as the first genuine step towards a healthy United States of Africa.
You can sign by sending your name, position, organisation and country to
africa_15percentnowcampaign@yahoo.com - Also stating if signing in a personal or organisational capacity.
*Signatories to the petition do not necessarily endorse the views expressed in this article.
Article originally published by Pambazuka News, 21 June 2007: http://www.pambazuka.org/en/category/comment/42108
EQUINET calls for Abuja PLUS! EQUINET advocates for governments to meet their Abuja commitment to 15% government spending on health, excluding external funding, PLUS debt cancellation and international support to meet at least US$60 per capita on health systems. Information and publication on EQUINET work on health financing is available at the EQUINET website at www.equinetafrica.org.
It is increasingly clear that without accessible, equitable, quality health services we will continue to fall short on delivering on the health Millennium Development Goals or commitments made on access to treatment for AIDS and other major diseases. So the negotiations currently underway on services under the Economic Partnership Agreements (EPAs) between the European Union (EU) and East and Southern African (ESA) countries are a matter for wide public interest. In August last year we pointed to issues for concern in these negotiations. With the negotiations underway, these issues become an even greater matter for public and parliamentary concern: Will they bring new resources and partnerships in building our health services, or will they blow new holes in already fragile systems?
The EPAs were supposed to have been concluded in 2008, but when none of the African negotiating groups was able to reach a final agreement, most initialled Interim EPAs (IEPAs) with the EU to avoid trade disruption. Many countries, the African Union and the Economic Commission for Africa observed that the EPAs needed to more explicitly put development at the centre, and civil society called for more explicit protection of public health. The IEPA with SADC explicitly protected health by providing, in Article 3, that the application of the agreement should take into account the human, cultural, economic, social, health and environmental interests of the population and of future generations. The IEPA with other ESA countries did not. So countries are going into negotiations on specific trade issues, including trade in services, with different levels of protection in their framework agreement.
ESA countries have already been very cautious about liberalising trade in health services, given the need for public sector health services to be delivered outside the market to populations living below the poverty line and the need for additional government measures and subsidies to staff, and provide these services. Few ESA countries have thus committed their health services to liberalisation in the World Trade Organisation (WTO) GATS agreement, preferring to determine the pace and nature of any market opening within reversible domestic policies. In ESA, only Malawi and Zambia have made GATS level commitments in the health sector.
Meanwhile the EPA services negotiations are going on largely below the radar. While the umbrella Cotonou Agreement of June 2000 explicitly commits EU and ACP states to the development of the social sector, there are also strong signals that the liberalisation of all services will be actively promoted.
So it depends largely on what the negotiators agree in the coming months. ESA countries have no obligation to trade in health services and may elect, without prejudice, to explicitly exclude trade in health services. Under conditions of unequal access and differentials in coverage, ESA governments may justly feel that they cannot reduce government authorities to regulate providers, to compel cross subsidies, increase risk pools, manage health worker migration and other measures needed to ensure universal health care coverage. Hence the 2006 AU Conference of Ministers of Trade stated: “We shall not make services commitments in the EPAs that go beyond our WTO commitments and we urge our EU partners not to push our countries to do so.”
There are numerous arguments negotiators should be raising for excluding health services from EPA compelled trade liberalisation.
Both ESA and EU countries are signatory to international treaties, conventions and constitutional obligations to health and health care that create obligations to be discharged by the State Parties. Negotiators should be cautious about clauses in the services negotiations appear to undermine these commitments. Using the precautionary principle that applies in public health, those promoting clauses that appear to undermine these commitments should be asked to prove why they do not do so.
As raised in previous debates on trade and health, ESA countries need to protect the flexibilities already won under WTO agreements. the TRIPS agreement allows for government authorities to compulsory licensing and parallel importation. The GATS agreement provides for flexbility for governments to follow “a reasonable time-frame”, to bar foreign services suppliers from operating at the same conditions with local providers where this is necessary to protect health, or to grant more favourable treatment to service suppliers from regional bodies of only developing countries like SADC. ESA negotiators should resist any liberalisation process which forces them to take on obligations or a faster pace of liberalisation than that which obtains currently under the WTO process.
However we could go further. Protecting public health and access to health services demands more than a defensive posture in the negotiations. ESA countries could use the services negotiations to more explicitly protect public health and recognize state obligations to protect universal and equitable access to health services. For example, negotiators could include clauses that
 Recognize the priority for protection of public health as a guiding principle, as provided for in the EU-SADC IEPA.
 Commit parties to allowing government authorities and availing specific resources to the public health sectors of the ESA countries as part of the development dimension of the EPA.
 Commit the parties as in Article 25 of the Cotonou Agreement to make available adequate funds for improving health systems and primary health care, including for regulating the operations of the private health sector.
 Commit the parties to co-operation on ensuring ethical practice on the migration of health workers, including in terms of making technical and resource investments to address the costs to ESA countries of permanent health worker migration to the EU;
 Commit the parties to provide overseas development aid for health programmes in a manner that integrates with national financing arrangements and that avoid outflows of critical health personnel from public health services, in line with the principles of the Paris Declaration on Aid Effectiveness.
The services negotiations are an opportunity to raise again that the health sector should be part of the development chapter of a comprehensive EPA, as envisaged under article 34 of the Cotonou Agreement, and not simply a matter for market trading. Concluding the services negotiations before this is clarified would seem to be a case of the cart pulling the horse. Even more importantly, the cart should not be pulled in the dead of night. Given the significant ‘life or death’ impact for millions of people in the region of any discussions that affect health services, the negotiators should bring such issues to public and parliamentary forums for debate and feedback, before they conclude.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue and reports on the health issues in the EPA negotiations please visit the EQUINET website- www.equinetafrica.org. or SEATINI website (www.seatini.org)