Editorial

As global leaders prepared for the G-20 Summit in Hamburg, they prioritised efforts to build functioning health systems “as a prerequisite for safeguarding disease outbreaks.” This is vital as the world prepares for the next Ebola-like emergency, but the organizational stress that comes with these shifts in priorities also requires attention if those efforts are going to succeed. Any attempt to strengthen health systems must take seriously well-recognized stressors such as increasing workloads, changing health needs, resource challenges, and less-often identified but routine challenges. Critical amongst these are the stresses posed by managing people and relationships in the uncertain contexts that are the norm for health systems.

Introducing new and revised policies is a major part of this chronic stress, even with the best intentions. The constant, and sometimes unconsidered, imposition of new initiatives and ideas on national health systems places great pressure on those working at the front lines of health care delivery and community engagement. Policy changes may include new treatment guidelines and protocols or quality assurance processes, as well as revised human resource and financial management rules, guidance on management structures such as community committees or new planning processes. New policies are often implemented in a top down manner through the hierarchy of public sector bureaucracy. Often, they are implemented without preparation or adequate information sharing. In addition, new policies frequently come hand in hand with rigid accountability mechanisms — such as those linked to results and performance-based financing or to targets set for health programs, or to finance-linked audit processes that are part and parcel of “good governance” strategies.

These types of accountability mechanisms contribute to creating a “compliance culture" that undermines the managerial flexibility needed to problem-solve and deal with chronic stress or acute challenges. All generally come with yet another new reporting requirement. In fact, the amount of reporting done by frontline health workers in countries such as Kenya and South Africa is simply astounding. As a result, health workers battle to cope with changing demands from managers and communities, whilst remaining poorly supported and resourced.

So, what do global leaders need to do to nurture everyday resilience in the face of chronic stress — and so also strengthen health systems?

First, they need to understand that the "personal" is absolutely integral to a functioning and responsive health system. Without emphasis and acknowledgment of this, efforts to strengthen health systems will be futile. Managing human relations is identified by public health system managers in Kenya and South Africa, including primary care clinics, as a constant challenge in their jobs, and one for which they rarely have adequate training, acknowledgment and resources. Constant policy change can undermine relationships, and is part of the wider organizational change commonly experienced by health systems. From the radical devolution of public management in Kenya in 2013, to the continuing processes of change experienced in South Africa since 1994, organizational change creates an unstable environment that makes managing other challenges — of people and resources — even more difficult.

Second, and most critically, global leaders must pay attention to how they engage with health systems. They should exercise their power much more cautiously than currently and in ways that empower others to lead and take action. They need to support national and local organizational capacity to problem-solve, motivate, and learn. The “Thinking and Working Politically” and “Doing Development Differently” networks call wholeheartedly for global leaders to take heed, by refraining from imposing rigid blueprint approaches and paying “far more attention to issues of power, politics and local context.” Ultimately, strong health systems depend on communities, health workers, managers, researchers and other local stakeholders being empowered to respond to the inevitable, future waves of change we all face. At Health Systems Global, our members represent these multiple groups.

Strengthening everyday resilience demands that we all — governments, donors, researchers, communities, health professionals — work with the resources that health systems already have — their people and relationships. This must be done as we take wider action to confront inequality at all levels. If we do not do that, then efforts to safeguard disease outbreaks will be meaningless.

This oped was originally produced as a blog for the G20 summit in July 2017 and was published on the Devex website and the Resilient & Responsive Health Systems (RESYST) website. For further information on this research programme visit http://resyst.lshtm.ac.uk/.

Civil society and communities should have a far greater direct involvement in the implementation of HIV and AIDS programmes for them to have a meaningful impact. This calls for an effective mechanism to channel funding to support and strengthen the capacity of civil society organisations. This was the resounding consensus at the Civil Society, HIV/AIDS and Africa: capacity, sustainability, partnerships conference being held in Johannesburg, South Africa from December 5 to 7. The meeting was co-hosted by the International HIV/AIDS Alliance and the UK Government's Department for International Development, and co-organised by UNAIDS and the Global Fund to Fight AIDS, TB and Malaria.

‘We need a shift in the way civil society relates to universal access and away from a lesser role to being an equal partner in the implementation of national strategies,’ Mark Stirling, UNAIDS' director for the regional support team for Eastern and Southern Africa, said at the opening ceremony of the conference. Stirling said Southern Africa in particular was hamstrung by bottlenecks that currently translated into an average of more than 80% of interventions falling behind targets to achieve universal access by 2010. There therefore needed to be a properly planned response to significantly ramp up the capacity and participation of civil society organisations to fill this gap.

‘We need funding models to move away from the status quo, and need a quantum shift for an effective response,’ Stirling said. The Chair of the International HIV/AIDS Alliance's Board of Trustees, Callisto Madavo, noted that good models exist for channelling money to support community-based responses, and these need to be expanded: ‘We have many examples of successful models and it is imperative that these experiences are shared so that we can accelerate our responses.’

Madavo said that ‘the most successful responses to HIV and other development challenges are built on local leadership, commitment and responsibility’. As communities are closest to people affected by HIV and often make the first response in addressing HIV, ‘without the active and influential participation of communities there is a real danger that the increased funding now available for HIV could not be well spent and not reach those most in need’. He said this could only be overcome through changes in policies and approaches that incorporated the experience over the past two years.

One of the major funders of HIV and AIDS programmes, the Global Fund, wants to encourage more civil society organisations to be amongst the principal recipients of their funding. Principal recipients are local stakeholder institutions (and there can be more than one in a country) who co-ordinate partnership, provide technical leadership, manage funds and monitor, evaluate and report on programmes. Christopher Benn, the Global Fund's executive director of external relations indicated that change was needed to ‘make sure that civil society is a principal recipient in more countries’. He added that the perception that funds for HIV programmes was drying up was unfounded and that ‘unprecedented’ resources were available. He said that $10-billion had been pledged for the Fund, while PEPFAR was expected to announce the extension of its mandate, to the tune of $30-billion over the next two to five years. Therefore, he said, the availability of resources was not the most critical issue, instead ‘capacity building for scaling up responses is the most critical, and we need to scale up dramatically.’

Although the Global Fund recently approved a budget of US$1,1 billion in Round 7 of funding proposals, only 50% of proposals had been approved and there were concerns about implementation capacity: ‘I hope we don't find ourselves in a position where we had the resources, but could not implement them,’ Benn said.

While the conference provided success stories of civil society roles in effectively reaching communities, both funding organisations and civil society need to take on the challenges of channelling resources to community level on a vastly increased scale. As Madavo indicated, ‘A consensus seems to be emerging on a new paradigm for effective capacity development centred on building effective states and forging engaged societies. The challenge is to unleash, nurture, and retain capacity. That requires a political environment that encourages participation, excellence, learning, and innovation. The new paradigm for capacity development emphasises the dual objectives of building effective states and forging engaged societies.’ And the conference also had a resounding consensus on the test for how successful new approaches are – that they effectively channel resources to communities, where they are most needed for the response to HIV.

The International HIV/AIDS Alliance, established in 1993, is a global partnership of nationally-based organisations working to support community action on AIDS, support south-south co-operation, and undertake operations research, training and good practice development and policy analysis and advocacy. They can be contacted via their website at http://www.aidsalliance.org/. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.

Dear Mr. Jim Yong Kim,
We have the honor to address you in our capacities as special procedures mandate-holders of the United Nations Human Rights Council. We are writing to you with regard to the World Bank’s draft Environmental and Social Framework (“ESF”), which was released for consultation on July 30, 2014. We would like to share with you a number of concerns relating to the approach to ‘Safeguards’ reflected in the current draft ESF.

At the outset, we wish to underscore the significance of the Bank’s first adoption of such standards some thirty years ago. And we commend the Bank for its continued recognition of the central importance of a carefully calibrated framework of standards to ensure that its programs to promote sustainable development, poverty elimination, environmental protection and social standards do not have a negative impact on a diverse range of important values. Most of those values represent important components of international human rights law, to which the Bank’s Member States have subscribed within the framework of the United Nations. It is because the Safeguards implicate human rights so directly that we have chosen to write to you as independent human rights experts appointed by United Nations Member States to provide our inputs to the Bank’s consultation process.

As the Bank seeks to revise and adapt its Safeguards approach to the challenges of the twenty-first century, we believe that it is imperative that the standards should be premised on a recognition of the central importance of respecting and promoting human rights. But there is no such provision in the current draft. Instead, by contemporary standards, the document seems to go out of its way to avoid any meaningful references to human rights and international human rights law, except for passing references in the Vision statement and Environmental and Social Standard (ESS). The Bank restricts itself to noting that its operations are, in ways that are not explained or elaborated, ‘supportive’ of human rights and that it will ‘encourage respect for them in a manner consistent with the Bank’s Articles of Agreement’. As noted below, however, the convoluted and anachronistic interpretation of the Articles that has so far prevailed ensures that this is a largely empty undertaking.

While the Bank is clearly committed to ending extreme poverty and improving the quality of life of people in developing countries, the pursuit of these worthy goals does not automatically ensure that the resulting programs and projects will promote and respect human rights. We acknowledge that it is not the Bank’s role to act as an enforcer of human rights, but there are a great many other ways in which it can assist governments in meeting their own international obligations, provide support and advice on how programs and projects might be made more human rights compliant, and build knowledge and understanding of human rights into its own work. By opting not to take these steps, the Bank is setting itself apart from other international organizations and agencies which have long since recognized the importance of human rights in the context of carrying out their specialized mandates, and have also rejected the notion that human rights are somehow problematically ‘political’ in ways that the many other accepted goals of development policy are not.

In many contexts, the international community has accepted that development and human rights are interdependent and mutually reinforcing. This has been recognized, for example, in the 1993 Vienna World Conference on Human Rights, the 2000 Millennium Summit and the 2005 and 2010 World Summits. Reference might also be made to a document that is cited on the Bank’s own website which is the 2003 UN Common Understanding adopted by the United Nations Development Group. The Common Understanding requires that human rights guide all development cooperation and that development cooperation “contributes to the development of the capacities of ‘duty-bearers’ to meet their obligations and/or of ‘rights-holders’ to claim their rights”. It is fair to say that the vast majority of development actors, from the European Investment Bank to the United Nations Development Programme, have expressed a clear commitment to human rights in their policies, thus making the Bank an increasingly isolated outlier in this regard.

The Bank’s official reluctance to engage operationally with human rights also stands in marked contrast to the lessons that its formal statements suggest it has drawn from its own experience, including through the work of the Nordic Trust Fund (“NTF”). The Bank acknowledges on its website and in many of its non-operational policy analyses that a focus on human rights can improve development outcomes. This is consistent with the seminal insight provided in the work of Amartya Sen, undertaken in his capacity as a Presidential Fellow at the Bank, who argued that freedoms are essential means for achieving development. There are many examples of analyses and reports by the Bank that highlight the potential or actual importance of human rights in promoting the achievement of the Bank’s proclaimed goals, such as those relating to gender equality and the role of women in society.

Rather than seeing human rights as a means by which to facilitate the participation and empowerment of the beneficiaries of development, the Bank’s proposed new Safeguards seem to view human rights in largely negative terms, as considerations that, if taken seriously, will only drive up the cost of lending rather than contributing to ensuring a positive outcome. While a 2010 report by the Bank’s Independent Evaluation Group (“IEG”) concluded that the benefits of Safeguards outweigh their costs, the approach in the draft Safeguards seems to be driven by the desire to privilege rapid approval of loans over all else, an orientation which has long been identified as a problem for the Bank. A sense of being increasingly in competition with other lenders to secure the ‘business’ of developing country borrowers seems to be at the root of this approach. The Bank has defended its increased reluctance to engage with human rights on the basis that alternative sources of development financing are emerging, which do not require meaningful Safeguards, thus providing the latter with a significant advantage over the Bank. In our view, the failure of other lenders to require that projects they fund should respect human rights standards is not a valid reason for the World Bank to follow suit. We believe that the problems that will flow from such a race to the bottom are already becoming apparent, and it will be for us, in different contexts, to make this clear to the relevant lenders.

Human rights are not merely a matter of sound policy, but of legal obligation. As an international organization with international legal personality, and as a UN specialized agency, the Bank is bound by obligations stemming not only from its Articles of Agreement, but also from human rights obligations arising under ‘general rules of international law’ and the UN Charter. Moreover, each of the 188 Member States of the World Bank has ratified at least one (and, in almost all cases, several) of the core international human rights treaties.16 Those States are also bound by human rights obligations stemming from other sources of international law. It is widely recognized that Member States should take their international human rights obligations into account when acting through an international organization such as the World Bank. States that borrow from the Bank also continue to be bound by their own international human rights obligations in the context of Bank-financed development projects and the Bank has a due diligence responsibility not to facilitate the violations of their human rights obligations, or to otherwise become complicit in such violations.

In the past, the Bank has often pointed to its ‘non-political mandate’ to argue that it is prohibited from, or at least restricted in, its ability to deal with human rights more directly. But the Bank’s Articles of Agreement should be interpreted in the context of today’s international legal order, rather than that of the mid-1940s. The Bank and its Member States are bound by both the Articles of Agreement, and by international human rights law. The provisions of the Articles can clearly be interpreted in a way that underlines their consistency with international human rights law. Since all States have long ago accepted human rights as a “legitimate concern of the international community” the suggestion that these remain little more than political considerations is not sustainable.

Our call for the Bank to include HR within its overall program objectives does not amount to suggesting that the Bank should ‘sanction’ countries with a poor human rights record. Consistent with international law, with its own obligations and with those of its Member States, the Bank should acknowledge the relevance of human rights in its overall program objectives, as well as incorporate human rights due diligence into its risk management policies. The Bank should also avoid funding projects that would contravene the international human rights obligations of its borrowers.

In the annex, we have highlighted our particular concerns with elements of the proposed ESF. Our aim is to indicate specific means by which a human rights dimension would strengthen the Bank’s new Framework and ensure its compliance with international law. As Bank President, you have repeatedly undertaken that this revision process will not result in a dilution of the human rights components of the Safeguards. We believe that honoring this promise requires a significantly different approach from that which is now being pursued and there are strong legal, policy and instrumental reasons why human rights should be given a central role in the work of the Bank. The current Safeguard Review process provides a critical opportunity for the Bank to fully integrate human rights in its policies and standards. We will be submitting this letter together with its annex to the World Bank’s public consultation process and plan to issue a press release in due course. We stand available to engage further with the Bank in this process and can be reached for any comments and views on our letter. Your response will be made available in a report to be presented to the Human Rights Council for its consideration.

For further information on this open letter see www.ohchr.org/Documents/Issues/EPoverty/WorldBank.pdf

It is time to raise critical questions around the wide and growing enthusiasm for Universal Health Coverage (UHC), which is increasingly seen as a silver-bullet solution to health care needs in low- and middle-income countries. Although confusion still exists as to what UHC actually means, international development agencies typically define it as a health financing system based on pooling of funds to provide health coverage for a country’s entire population, often in the form of a ‘basic package’ of services made available through health insurance and provided by a growing private sector.

Global health agencies such as the World Health Organization, and international financial institutions such as the World Bank, are promoting this approach in response to the rise in catastrophic out-of-pocket expenditure for health services, and in the face of crumbling public health systems in the global South (both of which were precipitated by the fiscal austerity imposed by organizations such as the World Bank and the International Monetary Fund in the 1980s and early 1990s). In this new model, UHC prescribes a clear split between health financing and health provision, allowing for the entry of private insurance companies, private health providers and private health management organizations. The logic is that health care challenges require an immediate remedy, and since the public system is too weak to respond, it is strategic to turn to the private sector.

In short, the UHC model is built on, and lends itself to, standard neoliberal policies, steering policy makers away from universal health options based on public systems. Building and improving the public healthcare system is not part of this mainstream narrative, with the state generally confined to managing the system.

Although these programs are now zealously promoted by global health agencies, the evidence to support their implementation remains extremely thin. Giedion, Alfonso and Díaz in a review of existing evidence for the World Bank published in 2013 observed that reliable data upon which to evaluate their performance are hard to come by and methodologies designed to collect good evidence are singularly lacking, illustrated by the highly contested data of some early health reforms based on universal insurance in the South (e.g. Chile, Colombia and Mexico), which have nonetheless been used to legitimize the current UHC agenda.

In a paper recently published by the Municipal Services Project, we argue that secure finances for health care are a necessary but insufficient condition for systems that are equitable and provide good quality care. We analyze the reasons why finances need to be channeled through well-designed public systems if they are to be spent efficiently. We further argue that, in glossing over the importance of public provisioning of services, many proponents of UHC are actually interested in the creation of health markets that can be exploited by capital.

In Europe, 20th-century reforms have intensified health being delivered as a market commodity. The more recent experiences of Brazil’s SUS, India’s Arogyasri and Thailand’s Universal Health Care Coverage scheme all show features of this neoliberal model, within very diverse settings and reforms. They all show a persistence or expansion of private sector participation in provision of care, despite the fact that all are tax-funded health systems. In all cases, public funding does not match needs and this opens space for the progressive creep of the private sector into the larger health system. In Brazil, while the SUS has expanded public primary care services, hospital care remained largely publicly paid and privately provided. Despite a strong policy commitment to universal public sector health systems in Brazil and Thailand, the neoliberal ethos and its promotion of private provisioning appears too strong to shake off. Consequently all three countries have a powerful private for profit sector in health. This influences the functioning of the system as a whole, ratcheting up costs, jeopardizing the integrity of the public sector and drawing away resources, both financial and human, from resource-starved public facilities.

The three countries typify the challenges that LMICs face while attempting to construct universal systems that borrow from the internal logic of a UHC that is not based on public systems, where ideological pressures prevent the adoption of an entirely public system of care provision. The challenges of providing high quality and equitable health care are most acute in low and middle-income countries because of faster growing populations, higher prevalence of infectious diseases, and growing burdens of non-communicable illnesses. We would argue that re-imagining public health care – rather than the private sellout of health systems via a neoliberal agenda in UHC – is the only way forward in building truly universal health outcomes.

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 see the Municipal Services Project website at www.municipalservicesproject.org and the MSP Occasional Paper, ‘Universal Health Coverage: Beyond Rhetoric’ at: http://www.municipalservicesproject.org/publication/universal-health-coverage-beyond-rhetoric.