Forty years on from the Alma Ata declaration, those who are the most vulnerable are still the least likely to access quality healthcare and to live healthy lives. Research is critical for understanding and addressing the systems of power that undermine health and health equity. Leaders must invest in more inclusive, introspective and innovative research partnerships to strengthen robust, resilient and responsive health systems to achieve ‘health for all’.
At the 2018 Fifth Global Symposium for Health Systems Research in Liverpool, UK, delegates made a strong plea for action to address the ‘power and privilege’ that continues to undermine global health. In supporting health systems as a key foundation for ensuring the health and wellbeing of citizens and communities world over, this call was repeated to those participating in the 2018Global Conference for Primary Healthcare in Astana, Kazakhstan. The call for Astana to renew and build upon a promise made forty years ago in Alma Ata, Kazakhstan to achieve ‘health for all’ was a reminder for us to reflect on how far we have come, but also how far we have to go.
While the ambition remains as noble and important as it was in 1978, we are living in a completely different world with unprecedented challenges, with pollution, militarisation, unregulated commercial interests, polarising ideologies, pandemics and ageing populations, to name a few. These challenges are marked by increasing and intersecting inequalities, within countries and between them. We know that the impact of these political threats and social inequities affect those at the bottom of the ladder, if they are on the ladder at all.
At the same time, social voice and leverage, including social media initiatives like #MeToo, #TimesUp, and #PeriodPoverty, independent journalism, progressive legislative action and everyday activism by citizens and communities do hold those in positions of power to account. Citizen voice and community participation, a hallmark of Alma Ata, merits further consideration, scrutiny and support. They remain essential for mobilising the broader awareness, engagement and political commitment needed for domestic policies to materialize universal principles and goals, including human rights, gender equality, global solidarity, universal health coverage and the sustainable development goals.
We have had many recent historical markers raising the profile of health equity, including the birth of the UK National Health Service (NHS), the Alma Ata declaration for primary health care and the Commission for Social Determinants of Health. But, what does that mean in real terms if we do not learn, or change the power structures that continue to undermine health and equity?
As raised at the 2018 Global Symposium on Health Systems Research, the causes of bad (and good) health are multiple, and go beyond the health sector, so must we. Just as people’s lives and needs cannot be neatly divided into categories to match government structures or professional disciplines, our research, policy and practice needs to transcend these boundaries. Supporting effective multi-sectoral action for health needs not just greater technical understanding, but also research on how best to facilitate, monitor and govern multi-sectoral action inclusive of actors for whom health is not a shared starting point.
Engaging communities in policy, practice and research is essential. While recognizing the importance of community health worker programs, further understanding of the diverse actors that make up community ecosystems and who broker social change is needed through context specific, nationally embedded research. Greater understanding of the multiple social networks and power relations within and outside of communities is needed to ensure equitable partnerships to sustain the social changes that underpin effective health interventions.
Advances in commercial products, services, technologies, and business models have generated diverse forms of service provision, expanding the influence of the private sector. These advances have created novel opportunities to expand the reach of the health system, as well as challenges due to the misalignment with commercial interests. We need to invest more in learning how to strengthen various government capacities to effectively steer these opportunities and ensure that vigilance and a healthy critique about private sector engagement remains.
While some benefit from improvements in quality, affordable healthcare, healthy environments, and economic opportunities, others remain marginalized without adequate access or voice. We must continue to include and reach the most marginalized, move beyond polarising social identities, to build social solidarity that address systems and structures of power, otherwise we will be having this same conversation in another forty years. Research must not only continue to identify who is left behind and why, but also support understanding of how best to change that.
We often talk about power and privilege in terms of ‘the other’ or ‘them’ over there in another space. But in all senses we must look inward and reflect on our own position if we are to truly address the pervasive inequities that continue to shape our society and health. This is no truer than in the field of health policy and systems research. Health policy and systems research is more inclusive of marginalized voices than ever, but certain vulnerable populations, geo-political configurations and planetary concerns remain under-represented. The assessment of power, privilege and positionality remains central to our work in health policy and systems research, and so it be must elsewhere if we are to realize health for all.
This oped is updated from a blog that first appeared on the Health System Global site in October 2018 at https://tinyurl.com/y4aoz54g. and builds on discussions held at the Global Symposium on Health Systems Research in October 2018. Asha George is supported by the South African Research Chair's Initiative of the Department of Science and Technology and National Research Foundation of South Africa (Grant No 82769). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author and the NRF does not accept any liability in this regard.
Editorial
The current WTO negotiations, headed for the next trade ministers meeting in Hong Kong in December, look set for more protection of corporate rights and a further erosion of health rights in the General Agreement on Trade in Services (GATS) and the Trade Related Intellectual Property Rights Agreement (TRIPs). Outcomes in these discussions depend on a breakthrough in the agricultural negotiations.
While health is a basic human right, the protection of this right still has little recognition in the global trade agenda. The formal recognition of public health interests is in fact subjugated to the interests of corporate profit, with the protection of these corporate interests by rich countries.
While the TRIPs agreement allows violations of patent rights for public non-commercial use, compulsory licensing and parallel importation, these rights are not exercised because political pressure is brought to bear on countries that try to use them. TRIPs are creating a false scarcity of access to pharmaceutical drugs. Developing country governments and civil society campaigned at the 2001 Doha, Qatar World Trade Organisation (WTO) Ministerial Conference to improve access to drugs. This ended with a statement of ministers (restating the rights contained in the 1995 agreement) allowing countries to use flexibilities in the agreement to legally bypass patent rights.
Since achieving this confirmation of rights, global public health has suffered a series of defeats. Flexibilities are still not being used because unseen threats are made against countries that try to use their rights. The practical import of these deceptively generous rights in TRIPS is nullified, while rich countries are still able to exercise them (such as when the US accessed patented drugs to cope with the threat of a terrorist anthrax attack).
Even when flexibilities are exercised, African countries still have a problem that compulsory licensing under TRIPs can be used to produce mainly for local consumption. Countries with low or no local production capacity, cannot access branded drugs because of price. They cannot import generic drugs produced under compulsory licenses in other countries because other countries must comply with the local consumption regulations where up to 49% of production can be exported. Before the 2003 Cancun Ministerial, a settlement was reached allowing countries with limited local production capacity a waiver to import these drugs, but the waiver agreement is so onerous as to be useless. It has not been used once since coming into effect – not even by developed countries who can also take advantage of this flexibility to export drugs to poorer parts of the world.
The WTO Secretariat - supposedly merely international civil servants - also changed the signed text of the waiver, by including a footnote and asterisk after the signature. (The footnote refers to a document that was not part of the agreement, called the Chairman's text, which carries language about sustainable development and the fundamental rights to food, productive assets, development, health, education, economic, social and cultural autonomy, and self-determination but insists that signatories must resort to market mechanisms to claim these rights.) The US insists this footnote should guide the interpretation of the waiver, while developing countries regard it as irrelevant. The WTO Secretariat has refused to remove the asterisk and the footnote, despite the millions of lives affected by its addition.
Africa is pushing for a useable settlement in current negotiations, seeking to amend the TRIPs agreement and remove the onerous conditions in the waiver – so they can access low cost drugs. This has been summarily rejected by the US which wishes to retain current arrangements to protect profits and divert cheaper drugs into their markets. The EU is playing a brokering role, with the same ends as the US, but minimising the ambitions of the Africans in a more diplomatic way.
And with no progress on TRIPs, rich countries are making more demands on developing countries. The draft text on services for the Hong Kong Ministerial negotiations disregards developing countries submissions on domestic regulation and reflects the rich country proposals. It promotes the “list it or lose it” approach to regulations, requiring countries to list restrictive regulations or face losing them if challenged at the WTO. Developing countries have opposed the deception that the draft text reflects a possible consensus position: these objections have been “noted”, but not reflected in the text.
Regulatory measures are major impediments to international services trade. The GATS agreement – which regulates professional health services, health care services and health insurance – places disciplines on the state’s ability to regulate the service sector. Only “necessary” regulations can be validly imposed, with GATS demanding that ‘necessity’ be determined by the WTO and not by nations themselves – effectively outsourcing government regulatory power to the WTO's Dispute Settlement Body in Geneva. Therefore, GATS will seriously limit the ability of states to manage destructive competition and create adequate economies of scale. They will undermine the flexibility to use subsidies to the poor and cross-subsidisation. For poor countries, these commitments are effectively permanent because reversing commitments requires the payment of compensation that poor countries can ill-afford.
To add insult to injury, the EU demands countries in the south liberalise service sectors while giving European civil society “assurance” that their public services will not be put on the table. The EU says there is a crisis in the services talks with too few offers of liberalisation on the table from developing countries. Developing countries contend that offers from the rich countries do not match their export interests, so they cannot take the blame for the lack of progress in negotiations. To improve the liberalisation offers on the table, the EU proposes changes in the GATS negotiations process. Instead of countries volunteering a list of sectors the EU is demanding that target benchmarks be set for liberalisation of sub-sectors. Qualitatively, the EU wants: limits removed with respect to consumption of services abroad; increased access to cross border trade and commercial presence; removal of foreign equity ownership; and the reduction of discriminatory economic needs tests. Developing countries have rejected this aggressive pursuit of GATS.
The most important matter in the WTO remains agriculture, which could unblock all the other negotiations. Rich country subsidies allow produce to be sold at prices below the cost of production. These subsidies (to the tune of US$ 1 billion per day) play havoc with international commodity prices and undermine the export market interests of developing countries. Compounding this are demands for reduced import tariffs in developing countries. The subsidy cuts offered by the EU and US will have little or no impact and leave us far from an international trading system that promotes the type of food sovereignty needed for improved food security and nutrition outlined in earlier EQUINET newsletters.
The current WTO negotiations expose the extent to which proposals from the rich countries will seriously undermine advances in public health. The trade, political and other pressures brought to bear indicate that below a veneer of ‘democratic functioning’ the discussion on global trade continues to be held within institutional arrangements and processes that protect excesses of wealth and hide the exploitation of the poorest nations in the world.
* Riaz Tayob is from SEATINI and represents EQUINET's theme work on trade and health.
* Please send feedback or queries on the issues raised in this briefing to SEATINI at www.seatini.org or to the EQUINET secretariat at TARSC, email admin@equinetafrica.org EQUINET work on trade and health is available at the EQUINET website at www.equinetafrica.org
In the next six months countries in the east and southern African region will be negotiating the agreements on services in the European Union (EU) – East and Southern Africa (ESA) Economic Partnership Agreements. These services negotiations are already halfway through and are expected to be complete by the end of 2008. The negotiations currently cover mainly financial and telecommunications services, and say little about protecting social services. Yet many countries in the region are facing pressures to privatise health services, even though the growth of a private sector in health services withdraws resource and staff to service a wealthier minority at the cost of universal access to health care services for the majority.
Protecting the health of the populations in the sixteen eastern and southern Africa in the region is a development priority. Twelve of them are least developed countries (LDCs) with the lowest human development indicators in the world. Almost all these countries experience negative economic growth and falling disposable incomes, one in six children dies before their fifth birthday and more than half the population is still living on less than US$1 a day. The EU on the other hand, with whom the agreements are being negotiated, consists mainly of developed economies, five of which are among the ten largest economies in the world and most of their people enjoy high standards of living. These negotiations are clearly taking place between unequal partners.
Countries in ESA experienced a wave of liberalisation of health services under the Structural Adjustment Programmes (SAPs), with a fall in funding of and access to services by the poorest communities. Further liberalisation is opening up services to commercial players whose aim is to generate profit. Trade in health services is argued to increase access to health care in remote and under-serviced areas; to generate foreign exchange; to provide new employment, give access to new technologies; and to reap economic gains from remittances of health workers who migrate. However, these benefits are often only obtained in the private for profit health care sector, promoting internal migration from the public health sector to private health care, with unaffordable costs of care for poor and vulnerable members of society, whose needs must be assured by governments.
Governments in the region have recognised the need for public sector led services for access to health care in poor populations, even while some have permitted the growth of private services. Universal access to basic health services is a stated development goal in many ESA countries. Health is a human right enshrined in many national constitutions and various signed and ratified international legal instruments.
Yet there is little protection of the right to health or to health care in the interim EPA agreements initialled in 2007. When these were concluded, despite significant opposition from the region, their sections on development cooperation should have provided for protection of public health, but no such protection was included.
The SADC-EU EPA Article 3 (2) provided that ‘The Parties understand this objective to apply in the case of the present Economic Partnership Agreement as a commitment that:(a)the application of this Agreement shall fully take into account the human, cultural, economic, social, health and environmental best interests of their respective population and of future generations (my emphasis)’ This gives some basis for ensuring that the rest of the EPA negotiations protect health rights, and it will be important to keenly follow the SADC EPA negotiations to hold negotiators to the commitment to protect their people’s best interests in health. Despite lobbying from civil society, the ESA-EU EPA on the other hand does not contain any mention of protecting health except reaffirming the parties’ commitments to the realisation of the millennium development goals in the preamble to the agreement.
Both interim EPAs however included a clause opening the way for further negotiations in areas relevant to health, such as services, intellectual property rights, and investment. These further negotiations appear likely to motivate liberalisation of services. This is promoted in the guidelines set out in the General Agreement on Trade in Services (GATS) of the World Trade Organisation (WTO) and the EPA is modelled along GATS. It is likely to cover similar areas, including health and health related services, migration of health professionals, and health care financing.
How can ESA countries protect their health services in the negotiations?
Firstly, as a minimum, it is important that the EPA negotiations do not go beyond the framework agreed at the WTO in the GATS and do not include GATS-plus obligations. Negotiators should live up to the commitment of the 4th Ordinary Session of the AU Conference of Ministers of Trade in April 2006: ‘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.’
However countries can go further. Under the terms of the interim EPAs, countries are free to exclude a wide range of sensitive goods and sectors from liberalisation. Our governments should take advantage of this flexibility to exclude health and related social services from liberalisation. For governments like Zambia and Malawi whose health service sectors are already open under GATS, they should not further entrench liberalisation under EPAs.
Negotiators must protect government policy space to remain key providers of health services in the EPA negotiations. Negotiators need to ensure that governments have full authority to regulate and control private for profit provision and financing of health services. Governments should also do formal health impact assessments in any health-related sector where liberalisation is being proposed, whether under GATS or the EPA. Commitments should be explicitly made in the EPAs on ethical recruitment and treatment of health workers and on EU investment in public budgets to produce and retain health workers in source countries.
ESA negotiators cannot treat health and health care services as a market matter, divorced from social issues. What is discussed in these negotiations are not just a matter of people’s survival, but also affect the cohesiveness and solidarity of societies and the support ESA countries are able to give to vulnerable communities. The negotiations on health services are thus a matter of public interest, and civil society should be involved. Public consultation on negotiations will surely strengthen the hand of negotiators by ensuring there is a strong public mandate to take firm positions on these vital health issues. Civil society should track the services negotiations, parliaments should ask questions about them, and we should continue to lobby for an EPA that respects the rights of the African people, especially the right to health. This means continuing to demand that ESA governments and the EU member states respect their obligations to international human rights instruments as they negotiate EPAs and that the people’s welfare takes priority.
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 or the full please visit SEATINI (www.seatini.org) or EQUINET www.equinetafrica.org.
The World Health Organisation is calling for a massive investment by the rich governments of the world into the health of the world’s poor. This is the conclusion of a report by the Commission on Macroeconomics and Health (CMH, 2001a), launched in London on 20.12.01. The report calls for an increased investment in health of US$27 billion per year by the year 2007. It is estimated that such an investment would save 8 million lives per year. Speaking at the launch, Jeffrey Sachs, the Commission’s chair reported that the new Global Fund for AIDS, TB and malaria (see IPHN bulletin 8 http://www.iphn.org/bulletin8.html) could be one of several vehicles for delivering such funds, delivering perhaps up to 30% of the total fund needed. He said, “We need to bankrupt the Global Fund as soon as possible to demonstrate that poor countries have the absorptive capacity and to force the US government to act.” This argument has strong similarities with calls from the United Nations Development Programme [UNDP] for health to be considered a ‘global public good’ (Kaul et al., 1999). The Commission itself refers to global public goods and defines them as ‘goods whose characteristics of publicness (nonrivalry in consumption and nonexcludability of benefits) extend to more than one set of countries or more than one geographic regions (CMH, 2001a, p.190).’ One of the six working groups was specifically focused on the subject of global public goods for health (CMH, 2001a, p.151 – see http://www.cmhealth.org/wg2.htm). A particularly strong emphasis in the commission’s report was on the status of health knowledge and information as a global public good (CMH, 2001a, pp.76-86).
What are Public Goods?
The concept of dividing goods into ‘public’ and ‘private’ goods arises from classical economics and can be dated back to the 18th century. According to this concept, characteristics of public goods include:
· Non-rivalry in consumption which means that one person’s use of a good does not prevent another person from using it (Kaul et al, 1999). This is termed by some as non-divisibility (Chen et al, 1999)
· Non-excludability, i.e. use of item is available to all people/groups of people (Kaul et al, 1999)
· Non-rejectability, individuals are unable to choose to forego consumption (Preker et al, 2000)
An example of a private good might be a piece of cake. If I eat it, no-one else can (i.e. it is rival). I may chose to share it with my friends, excluding others (i.e. excludable). I may choose not to eat cake (i.e. it is rejectable). On the other hand, traffic lights might be considered an example of a public good. My use of a traffic light does not prevent others from using it (i.e. it is non-rival). Traffic lights apply to all people (i.e. it is non-excludable) and it would be almost impossible to not use traffic lights (i.e. it is non-rejectable). Other examples of public goods might include peace, law and order and good macroeconomic management. However, this distinction between private and public goods is not always that clear cut. Although some goods might be purely private or purely public, there will be some that are mixed/impure. Goods which are non-rival amongst a certain group of people can be termed ‘club goods’ and those which are available to all but are rival can be termed ‘common pool resources’ (see figure 1). These ‘impure’ goods are more common than the pure type. Consequently, the term public good is often used to include both pure and impure public goods (i.e. the shaded area in figure 1 ) (Kaul et al, 1999). Commonly, five sectors of public goods can be identified, namely environment, health, governance, security and knowledge (Te Velde, 2002).
According to neo-classical economic theory, attempting to provide pure public goods through competitive markets will lead to sub-optimal quality, quantity and price (Preker et al, 2000). Two reasons for this can be identified for this. First, individuals motivated by self-interest only will tend to ‘free ride’ concerning the provision of these goods. Secondly, individuals will tend to make sub-optimal decisions on these issues if those decisions are made in isolation from others. Effective provision of public goods requires co-operation and measures which promote communication and build trust (Kaul et al, 1999). What are Global Goods?
In many cases, it is assumed that responsibility for provision of public goods rests with the nation state. However, there may be some cases where goods are global rather than national. Suggested criteria for deciding this include the requirement that global goods are quasi-universal in terms of:
· Countries, that is they involve more than one group · People, that is they involve several/all population groups, e.g. socio-economic groups, ethnic groups, gender, religion etc.
· Generations, that is they affect current and future generations In order to assess what kind of goods might be global in this regard, it may be useful to consider problems (i.e. global ‘bads’) which fulfil those criteria, for example banking crises, Internet crime and fraud, Ill-health due to increased trade and travel, drug abuse, smoking etc. (Kaul et al, 1999). Global public goods may be considered of two types. There are final global public goods which consist of desired outcomes and may be tangible, e.g. the environment or intangible, e.g. peace. For example, the World Bank recognizes five global public goods priorities, namely communicable diseases, environmental commons, information & knowledge, trade & integration and international financial architecture (World Bank, 2001). Secondly, there are intermediate global public goods which consist of international regimes, agreements and institutions which have the aim of delivering final global public goods. Examples might include frameworks for international transport and communication, health, the environment, demographics, judicial systems, human rights and macroeconomic policy (Kaul et al, 1999).
Is an Economics-based Definition of Global Public Goods Adequate?
So far, this paper has considered the concept of global public goods from the perspective of neo-classical economics. However, the validity of defining global public goods in this way has been challenged by some people. For example, Wolfgang Reinicke, Director of the Global Public Policy Project, an economist with long experience of working in the World Bank, said, “In most societies, the spectrum of public goods goes far beyond what a classic economic definition of joint consumption and non-excludability would capture. It is far more important for the members of each society to determine - in a transparent, democratic process - what is and what is not in the public interest (Reinicke, 2001).” Supplying Global Public Goods As seen earlier, classical economic theory predicts that competitive markets will provide public goods in a sub-optimal way. This leads to the problem of how public goods, in general and global public goods, in particular can be supplied. Two key factors have been identified in determining how sub-optimal provision through markets will be. These factors are the ‘degree of publicness’ of the goods and the number of beneficiaries. The latter factor is a particular problem for global public goods whose beneficiaries number billions and who are represented by more than 180 nation states. These states have their own self-interests and there are a diverse range of interest groups within the world’s population (Kaul et al, 1999). There is therefore a strong argument for international aid to be used to finance global public goods. Three building blocks for this argument are that:
· The private sector will not provide a sufficient amount of public goods · Individual countries have insufficient incentives to make an optimal contribution to global public goods because benefits do not accrue equally nationally · Poor countries lack the resources to make a full contribution to global public goods (Te Velde, 2002)
Increasingly, the World Bank is seen as a financing mechanism through which global public goods can be provided. The Global Environment Fund would be one such example and it has been proposed that the Global Fund for AIDS, TB and Malaria be administered in a similar way (Unknown, 2002). Global public policy networks are also seen as having an important role in the area of supply of global public goods because they bring together diverse interest groups and can address transnational issues which no single group can address alone. Examples include:
· Placing issues on the global agenda, e.g. landmines, Jubilee 2000 · Facilitating setting of global standards, e.g. World Commission on Dams · Developing mechanisms for producing/sharing critical knowledge, e.g. Consultative Group on International Agricultural Research [CGIAR] · Creating markets where they are lacking, e.g. GAVI · Developing mechanisms for innovative implementation , e.g. Global Environment Facility · Creating trust and promote participation - reducing democratic deficit – an example of what happens when this fails would be the demonstrations in Seattle and against the workings of the World Bank (Reinicke, 2001).
Is health a global public good?
Traditionally, diseases can be divided into three groups, communicable diseases, communicable diseases and injuries. Because treatment of infectious diseases produces benefits to people other than those treated (termed positive externalities by economists), the control of communicable diseases has been widely considered a public good. However, because most of the determinants of non-communicable disease appear to be individual lifestyle choices, e.g. diet, tobacco use, exercise etc. treatment of these diseases is widely seen as a private good (Chen et al, 1999). However, applying strict classical economic criteria to health goods would result in very few being considered ‘pure public goods’ because most have some degree of excludability, rivalry and rejectability. For example, a vaccine given to one person is not available for another and people may choose not to be vaccinated (Preker etal, 2000).
However, even if health is accepted as a public good, much of it is likely to be seen as a national public good rather than one with global implications. For example, Te Velde considers primary health care as a national public good and only the prevention of disease spread across borders as a global public good (Te Velde, 2002). However, others have argued that health has become much more of a global public good because of a number of influences of globalization. First, increased international linkages through trade, migration and information flows not only provide opportunity for cross-border transmission of infectious agents but also allow ‘transmission’ of behavioural and environmental risks. Secondly, increased pressure on common-pool global resources, e.g. air and water, brings its own threats (Chen et al, 1999). Examples of health effects which can be considered global public goods as a result of globalization might include:
· Health effects of environmental change, e.g. global warming, ozone depletion, toxic waste disposal · Tobacco usage – this is not only influenced by individual behaviour but by global marketing campaigns · Illicit drug use – globalization has made control of drug trafficking more difficult (Chen et al, 1999)
However, all these issues are based on the same logic as focusing on the cross-border transmission of infectious disease as a global public good, namely that the causes and effects of disease, particularly in an era of globalization, are not limited to national boundaries and need to be approached on a global level. Another logic for considering health as a global public good can be considered in terms of the global imperative for poverty reduction (Te Velde, 2002). This is being used by a number of politicians as a basis for investment in health and development, for example Gordon Brown, the UK’s Finance Minister. The basis of this argument is that investment in health is a key element of an effective poverty reduction strategy and reducing poverty in poorer countries is essential if conflict is to be reduced, communicable disease controlled and environmental damage minimized. In a presentation to the UK Health and Development Forum in London in February 2002, a WHO economist distinguished between ‘health as a global public good’ and ‘global public goods for health’. For an area of health to be considered a global public good he explained that efforts to promote it would need to produce global health and economic benefits. On this basis, control of communicable disease, e.g. polio eradication is widely considered a global public good. On the other hand, there are many global public goods for health, that is global public goods which have health effects. Examples would include medical technologies, tobacco control and trade agreements. He also stressed the importance of ‘access goods’ – those goods which allow a person to benefit from a global public good. For example, a radio allows a person access to the radio waves which can be considered a global public good. He argued for health systems to be considered an access good in relation to many of the technological advances in health which could be considered global public goods (Woodward, 2002).
Conclusions It seems uncontroversial that certain aspects of health can be considered a global public good, particularly the control of infectious diseases which can spread across national borders. However, in an increasingly globalised world, it can be argued that, more and more, the cause and effects of disease are transnational. Finally, it can be argued that all of health should be considered a global public good because it is a key component of another global public good, poverty reduction, and because the global community has determined that it should so be considered. The report of the Commission on Macroeconomics and Health is not always explicit about the way it is interpreting health as a global public good. The main argument of the report is that rich countries should invest in the health of poorer countries as a way of supporting economic development and contributing to poverty alleviation. This is presumably of value to the international community and could therefore be considered a global public good. Some of this thinking is seen in statements associated with the commission which claim that controlling the diseases of the poor will promote political and social stability (CMH, 2001b). This is also seen in some of the quotes attributed to the Commissioners. For example, Manmohan Singh, a former Indian Finance Minister said, “We have an historical opportunity to combine and use resources and know-how to ensure better health and greater economic growth in just a couple of decades. If we want equity and security in our lifetime and for future generations, we cannot afford to miss this opportunity.” Takatoshi Kato of the Bank of Tokyo-Mitsubishi said, “We must begin to see development assistance more in terms of an investment in the future – in the protection of the global well-being, including peace, healthy populations, a healthy environment and a more equitable economic system (CMH, 2001c).” These statements clearly see investment in the health of poor people as contributing to a wide range of global public goods including equity, security, peace and a healthy environment. However, when the report refers explicitly to global public goods, it does so in a much more limited way, for example to refer to the work of global institutions (p.13) and the importance of health information and knowledge (pp.76-86) (CMH, 2001a).
UNDP is perhaps the lead agency in trying to promote a broadening of the concept of public goods to embrace all aspects of health, presumably in an attempt to encourage rich governments to provide additional non-aid funds for global health based on self-interest arguments. However, many NGOs have reservations about this approach. These reservations include:
· Concerns about pursuing arguments based on classical economic models · Fear of marginalizing more basic concepts such as equity and health as a human right · Fear of promoting inappropriate solutions, e.g. more stringent immigration controls as a way of controlling infectious disease · Fear of promoting vertical programmes · Risk of promoting northern agendas and further marginalizing country priorities · The confusing nature of the concepts and terms (Keith, 2002)
Discussion questions Is the concept of global public goods useful to us? How do we wish to define this? Do we see health as a global public good? On what basis do we come to that conclusion? Does this cover all aspects of health or just certain parts?
by Dr. Rene Loewenson, Director, Training and Research Support Centre, Zimbabwe and Professor Alan Whiteside Director, Health Economics and HIV/AIDS Research Division, University of Natal, South Africa.
Introduction
HIV/AIDS is having a disastrous impact on the social and economic development of countries most affected by the epidemic. In much of Africa and other affected regions, this epidemic will prove to be the biggest single obstacle to reaching national poverty reduction targets and the development goals agreed on at the United Nations
Millennium Summit. The challenge is immense: How do countries reduce the proportion of people living in poverty when up to a quarter of households are decimated by AIDS? How do countries
deliver on policies aimed at equity in access to economic opportunities and social services when AIDS widens economic differentials and undermines service delivery? How do countries deliver on promises to improve quality of life for coming generations when 40 million children will grow up orphaned by AIDS? How does a country like South Africa deliver on its goal of being a regional engine of growth with over 4 million HIV-positive people and the fastest growing infection rate in the world? The devastation caused by HIV/AIDS is unique because it is depriving families, communities and entire nations of their young and most productive people. The epidemic is deepening poverty, reversing human development achievements, worsening gender inequalities, eroding the ability of governments to maintain essential services, reducing labour productivity and supply, and putting a brake on economic growth. These worsening conditions in turn make people and households even more at risk of, or vulnerable to, the epidemic, and sabotages global and national efforts to improve access to treatment and care. This cycle must be broken to ensure a sustainable solution to the HIV/AIDS crisis. The response to HIV/AIDS so far has focused, rightly so, on the challenge of containing the epidemic and preventing new infections through advocacy, information and education campaigns, behaviour change communication, condom distribution, programmes targeting groups that are particularly vulnerable to infection, and other key interventions. The other part of the response is focusing on treatment and care for people living with HIV and AIDS — efforts that are expected to intensify as new treatments become more accessible and affordable. Both prevention and treatment are top priorities in not only saving lives and reducing human suffering, but also in limiting the future impact on human development and poverty reduction efforts.
However, despite intensifying efforts focused on
prevention and care, the epidemic continues to spread unabatedly, and as people infected by HIV become ill and die, its devastating impact is now being felt in the worst affected countries. Assuming that life-prolonging treatment will not be universally available in poor countries ‘overnight’, death rates from AIDS will continue to soar before leveling off. Recent estimates from the UN Population Division show that the population of the 45 most affected countries will be 97 million smaller in 2015 than it would have been in the absence of HIV/AIDS. Most of this loss is due to sharp increases in mortality among young adults. In the absence of national and global action to mitigate the developmental impact of HIV/AIDS, households, communities and civil society organizations will continue to bear the brunt of this tragic disaster. They are at the front lines of coping with the impact of HIV/AIDS, responding directly to the needs of people and often working with little government support. Communities are mobilizing themselves, showing great resilience and solidarity, despite their vulnerability to external shocks such as premature death of their most productive members. The response to HIV/AIDS has tended to ignore the bigger picture of the implications for development and poverty reduction. Research has been undertaken to study the impact of the epidemic, but very little has been done about it. Discussions on the implications of HIV/AIDS among development experts and policy makers has been extremely limited, and both national and global development targets and goals have been formulated without taking into account the added challenges resulting from sharp increases in AIDS-related adult mortality rates. With the same inevitability as the cyclonic and heavy rains which caused catastrophic floods in Mozambique twice in the last 18 months, with widespread devastation and loss of life, the current HIV prevalence forewarns an AIDS epidemic that is only beginning in many countries. The scale and scope of this epidemic over the next decade can be broadly predicted, planned for and mitigated. However, like people living on the riverbanks, we seem unable or unwilling to take action on the flood until we are knee-deep in water. This is not helped by the denial and the chronic, slow-moving and dispersed nature of both the epidemic and its impacts. It takes significant leadership to plan ahead, sometimes ahead of public perceptions, to deal with AIDS, and in so doing to divert resources from other more apparent problems. Yet taking meaningful steps towards mitigation demands visionary leadership armed with information on the scope and nature of the epidemic, its impacts and on options for responding. Creative, albeit scattered, individual, community and national efforts provide examples of good practice. The time is overdue to apply these more widely in those areas where we must make a difference, put in place plans to achieve this, and back them with resources.
Note: The Equinet Newsletter will pause for the month of August
We always hear that maternal deaths are avoidable, yet they remain a main cause of mortality. Whenever a woman dies while giving birth, we absorb the fact as though it was normal, despite the pain caused to her family, her children and her partner. Silence engulfs the mourners and after burial, the deceased woman is registered into the records and included in public health statistics.
These are the facts: According to Cook, Dickens and Fathalla in 2003, every year more than 500 000 women die from pregnancy complications or childbirth globally, and 99 percent of these deaths occur in developing countries. According to the Road Map for Accelerating the Reduction of Maternal and Neonatal mortality and morbidity in Uganda 2007-2015, sixteen women die every day in Uganda due to maternal mortality. This means that 6000 women die every year and leads to an estimated maternal mortality rate of 345 per 100 000 live births.
This tide of death due to pregnancy and childbirth occurs for various reasons. The health sector is chronically underfunded compared to health need, leading to lack of available, well supervised trained midwives in services close to communities. Referrals for complicated cases face problems of lack of ambulances and of emergency obstetric care in referral hospitals. Health workers may be demoralized in such conditions and show poor attitudes to clients. Within communities, partners may give women inadequate support and resources to make timely use of services, especially when poorly equipped local services mean that they have to travel some distance to facilities. Participatory research carried out by HEPS (Uganda) in 2008/9 found that women get weak support in maternal health issues from their male partners.
These problems have contributed to the deaths of many women, especially the poorest women, who constitute a large share of the population. These women are also the bread winners of and carers for many rural families. The Ugandan government acknowledges in its Road Map for Accelerating the Reduction of Maternal and neonatal mortality and morbidity that maternal mortality occurs because of the three delays. The first of these is a delay in making the decision to seek care. The second delay is in identifying and reaching a medical facility, while the last is in receiving of adequate and appropriate treatment. It is a duty of government to address these delays, including any shortfalls in funding of the health sector that may be connected to the weaknesses in service delivery that lead to these maternal deaths.
In 2011, building on civil society advocacy on these three delays, the Centre for Health, Human Rights and Development (CEHURD) took a further step of petitioning the constitutional court, seeking declaration(s) that the non-provision of healthcare in government health facilities leading to the death of mothers is an infringement on rights to life and health.
The petition draws on maternal death reviews from government hospitals, where the cause of death has been cited as lack of facilities, equipment or consumables. Health workers cite that they did not have equipment for monitoring the deliveries in the theatre and labour suites, including materials like gloves, and noted that there were inadequate trained heath workers.
When complications happen, if women report late to services this reduces their chances of survival. However, the reported shortfalls in health care services have meant that even when they arrived early at hospitals, when labour pains started, women were still at risk. Two cases were cited in the petition. In one, a young woman arrived at 8:00am and died at around 9:00pm when her uterus ruptured, due to obstructed labour. In the second, the woman went to a government Health centre first before being taken to a government district hospital. She could not be saved after she had a retained twin. This woman was reported to have arrived at 2:30pm but to have not been attended to by health workers until she died just after midnight at 12:30am. In both instances, the hospital reports point to lack of basic equipment and supplies for deliveries and lack of staffing.
The petition contends that these deaths, arising from the non-provision of basic maternal health care services in government hospitals, is a violation of the right to life guaranteed under Article 22 of the Constitution of Uganda. The petition contends that the right to health under Objectives XIV and XXII is violated when government health workers and government fail to provide the required essential care during the period before and after childbirth. This happens when there is inadequate staffing for maternal health, specifically midwives and doctors, frequent stock-outs of essential drugs for maternal health and lack of Emergency Obstetric Care Services at Health Centres III, IV and hospitals.
In taking on this public interest litigation case, CEHURD, and the wider civil society groups who support the petition have acted for a wider concern in society on unacceptable levels of maternal death. Principal State Attorney Patricia Mutesi was reported on Sunday 23 October’s Monitor (www.monitor.co.ug) to have argued that a court determination would amount to usurping of power of the Executive and the Parliament to determine on economic policies. However, Mr David Kabanda, the petitioners’ attorney, said the State objection was misconceived because the matter before court is seeking for court interpretation whether the acts and omissions at the various health centres contravene the Constitution. Irrespective of its outcome, the petition has widened awareness of the right to health and social expectations on maternal health. Uganda National Health Consumers Organisation (UNHCO) has raised advocacy on the issue (http://unhco.or.ug/news) and a coalition of over 35 civil society organizations has since been formed on maternal health, which is taking up wider health issues, including budget monitoring. This coalition is providing learning and networking on health rights generally, building social activism using evidence from the real situation in health services and the social concerns in communities.
The petition sets a precedent on one of the ways of progressively realising the right to health in a resource constrained setting. It may inform the way we address other obligations and entitlements, like access to medicines. Social action through constitutionally set channels is one way society can act to prevent unacceptable death in vulnerable women and to advance health equity in Uganda.
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 the CEHURD website: www.cehurd.org
In June, at the East, Central and Southern Africa Health Community (ECSA HC) 12th Best Practices Forum held under the theme: Innovation and Accountability in Health Towards Achieving Universal Health Coverage, about 130 participants deliberated for three days and proposed recommendations for policy and practice, including to enhance delivery on existing policy commitments. The recommendations covered diverse areas relating to the theme, covering: improving adolescent and young people’s health; equity in access to eye health; innovative approaches for food safety and improved quality of life; addressing harmful substance use and mental health problems; achieving water and sanitation global health targets; tackling emerging and re-emerging health threats and a regional ’One Health Approach’ for managing recurrent outbreaks. The full recommendations can be found on the ECSA HC website. What is also important, however, is the process by which these proposals are made and reviewed.
The East, Central and Southern Africa Health Community (ECSA HC) is a regional inter-governmental organisation. It reports to, and receives guidance from the Conference of Health Ministers (HMC).
Over the years, ECSA HC has held a Best Practices Forum (BPF). The BPF aims to encourage and strengthen policy dialogue among the diverse stakeholders involved in evidence-based policy decision making. The BPF attracts a wide range of health actors, including senior officials from ministries of health of ECSA-HC member states, the constituent health professions colleges of the ECSA College of Health Sciences, health research institutions, collaborating partners, civil society organisations and other health experts and implementers from the region and beyond.
While the HMC is the highest policy organ of ECSA HC, the Directors Joint Consultative Committee (DJCC) is its highest technical organ. The DJCC consists of the directors of health services, the deans or heads of health faculties and training institutions, the heads of health research institutions and senior officials in the constituent colleges within the ECSA College of Health Sciences. The DJCC informs the health ministers through persuasive evidence-based recommendations. The BPF, in turn, is a critical step and an important platform for presenting and interrogating findings from the member states, from the region and beyond. It provides a platform for a free participation and open exchange of ideas by technical people, researchers, civil society, partner organisations and ministry of health senior officials. The experience, evidence and analysis from the region presented and debated in this forum inform the recommendations to the DJCC and from there to the health ministers in the HMC.
As applied in the recent 12th BPF, the main theme and sub-themes are set by the health ministers at their previous HMC. Submissions are then invited from the countries and from ECSA HC partners, stakeholders and researchers within the thematic areas. Suitable abstracts are then selected for presentation to prime the discussions in these areas at the BPF. It is a unique feature of the BPF that at the start of the meeting there are no draft recommendations tabled for discussion. Rather the participants draft them in an open and free spirit of intellectual engagement, drawing on their collective experience and the evidence presented. These recommendations are then submitted to the DJCC for their consideration.
To complete the loop, the recommendations made at the BPF, as validated by the DJCC, are presented to the HMC. For example for the 12th BPF held in June this year followed by the 28th DJCC, the recommendations will be presented to the HMC in October this year. The HMC will be held under the same theme as for the BPF and DJCC, and the recommendations will be tabled for the Ministers to consider as the basis for their resolutions. While the recommendations of the DJCC may be used as a guide to enhance the programming and prioritisation of their activities, until they are affirmed or changed by the HMC, the resolutions of the HMC are binding on member states and on the ECSA HC secretariat.
Most of the follow up work to implement the recommendations happens within the countries. However, there are also regional approaches that are within the mandate of ECSA HC and in association with partners for some priority areas. The action points are thus directed to both the member states and the ECSA HC Secretariat as appropriate.
Over the past twelve years by convening the BPF, ECSA HC has developed and institutionalised a mechanism and processes by which it engages both the ‘consumers’ and ‘producers’ of research evidence in policy dialogue. This is often done in a demand-driven manner, with the HMC and DJCC identifying gaps and calling for evidence in areas that draw presentations at the subsequent BPF. However, some presentations and research findings also emerge ‘bottom-up’ from work by stakeholders in the region that raise new evidence and issues within the broad thematic areas under consideration. Some presentations report on the implementation and findings of work that was mandated in prior DJCCs and HMCs and what it means for the health system. Some also track delivery on prior policy commitments, the outcomes achieved and the barriers faced.
ECSA-HC continues to work towards strengthening this approach in the hope that it helps to close the gaps in evidence for policy dialogue from the region and in channels for researchers and implementers to present their experience and findings in a way that influences policy. In doing this, the organisation hopes that relevant research and policy, which are two sides of the same coin, can be increasingly connected. The BPF model is being replicated in West Africa through the West African Health Organisation (WAHO), suggesting that it is perceived as a worthwhile effort.
One major challenge with the BPF approach, however, is in the identification of ‘best practices’. While this is based on an open call for and submission of abstracts, the ECSA HC does not have the capacity to ensure that all the best practices in each area come to the fore and there may be limited publicity of the BPF as the outlet for relevant research findings. It has also become evident that a lot of experience and research evidence that is seen to be relevant and useful by policy actors in the DJCC and HMC does not make its way into formal journals for wider dissemination.
Notwithstanding such challenges, the BPF stands out as a useful and unique home-grown solution to the false divide between researchers and implementers on the one hand, and decision and policy makers on the other. It does so by providing a platform for the free input, exchange of and debate on ideas, embedding this within the policy processes and structures of the organisation. Looking at the journey over the last twelve years, one is justified to suggest that in the next twelve years, the BPF could itself be identified as a ‘best practice’ for the East, Central and Southern African region.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the ECSA HC BPF please visit https://ecsahc.org/
When EQUINET was formed in 1998, all east and southern African countries had public policy commitments to improve health equity. This was a statement of values, and needed to be protected socially, as much as it demanded information on how to achieve it. As people from government, unions, civil society, parliament, academia from other institutions in the region, we saw that research could inform and reinforce this policy intention. We could expose the extent and forms of avoidable, unfair inequality and their determinants and propose ways of advancing equity in health. With inequalities a reflection of the power people have to direct resources towards their wellbeing, we saw research and knowledge as not neutral in these power relations.
This year we reflected on our experience from over two decades of EQUINET research on how, and how far our research practice had achieved these intentions.
Policies have been articulated and knowledge generated in our region by many, including ourselves on the inclusive economic policies, comprehensive public services and rights-based approaches to addressing social inequality. Yet our realities are increasingly driven by a global economy and a regional response that is generating instability, environmental and social costs; increasing extraction and export of natural resources; rising levels of precarious labour, social deficits and destruction of cultures. Our public institutions have become weaker and even basic forms of wellbeing commodified, disrupting cohesion, solidarity and collective agency. ESA countries are framed as ‘under-developed’ and ‘aid recipients’, with populations undergoing a ‘development pathway’, despite the economic insecurity, resource depletion and social deficits associated with this pathway. Responding to these trends, people in the network have done work to expose and show the harms and violations in people’s experience of these trends, and to point to opportunities for alternative policy and practice.
Research on these issues has involved relationships and dialogue with key constituencies, from the onset and throughout the process, and efforts to ensure rigour, quality, validity and ethical practice. We have shared results in a range of media and interactions. Implementation research, appreciative inquiry, realist review, benefit incidence analysis, policy analysis and other designs have, with the new lenses brought by diverse disciplines in the network, taken us outside biomedical paradigms and the ‘core curative care business’ that the health sector has retreated to, exploring the choices made in a range of sectors and what this means for the wellbeing of current and future generations.
However, the battle of ideas and struggle over wealth and power that lies at the heart of the trends generating inequalities in health in our region raise not just WHAT is investigated, but also WHO asks the questions, WHOSE assumptions are brought to bear and HOW the research is done. Research can explain and show alternatives to disempowering narratives of the inevitability of the status quo and generate knowledge in ways that empower those affected to affirm their reality, to reflect on the causes of their problems and to more directly articulate alternative explanations and build the self-confidence and organisation to produce change and to learn from actions taken.
Like others working on social justice, we are on a constant learning curve on how to do this. Participatory action research has, for example, provided a particularly powerful means for people to create counter-narratives to dominant characterizations that ignore or undermine them, transforming people from objects to subjects and strengthening strategic action and review. Yet we are still learning how to embed PAR within the democratic functioning of social organisations as well as testing, such as through online PAR, how to amplify the organisation, consciousness and voice from largely local PAR processes to engage global level drivers of inequity, without losing their authenticity. We’ve been excited by methods and capacities that allow for the complexity of the many overlapping stories in our lives and countries, including narrative research, ‘fiction’, theatre, photography, and social media, We’ve appreciated how technologies used in research are deeply connected to the processes and interests that use them.
Doing this work excites, reveals, generates energy and many collective ‘aha’ moments!. But it also exhausts, demands many hours of time and absorbs all those involved in social processes. Many talk about facing the double task of researching on inequities, while also challenging inequity in a global research system that undervalues the cross disciplinary, reflexive and participatory approaches and interactions that are features of equity related research. People in the region, particularly at local level, face travel, visa, cost, gender, class and racial barriers that exclude them from engaging in northern-based global processes.
In this context, being in a consortium network and the partnerships with the network have provided support, resources, exchanges and peer review for more self-determined work. The wide range of disciplines, lenses and constituencies in the network have provoked us to be more creative. Yet our region is changing, encountering new opportunities and challenges. We cannot afford to be over-comfortable in old relationships, methods and practice. So the question stays on the agenda: how can our research practice better promote equity and justice in health?
We welcome your feedback or queries on the issues raised in this oped – please send them to the EQUINET secretariat: admin@equinetafrica.org. Please visit http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Diss120%20Research%20for%20HE%202019%20lfs.pdf to read the discussions, ideas and examples in the full paper that the editorial draws from. Several papers included in this newsletter also provide interesting experiences and reflections on research for equity and equity in research systems.
Since the 2005 World Health Assembly resolution calling for member states to pursue universal health systems, there has been growing interest in how this can be achieved in low- and middle-income countries.
The promotion of universal coverage means that health systems should seek to ensure that all citizens have access to adequate health care (adequately staffed with skilled and motivated health workers) and financial protection from the cost of using health care. Universal coverage requires both income cross-subsidies (from the rich to the poor) and risk cross-subsidies (from the healthy to the ill) in the overall health system. This stems from our understanding of equity, which requires that people should contribute to the funding of health services according to their ability to pay and benefit from health services according to their need for care. Prior work in the fair financing theme in EQUINET indicates that there is still a heavy dependence on external funding in some east and southern African (ESA) countries and heavy burdens on poor people through high levels of out of pocket financing.
A key impetus for the World Health Assembly resolution was the growing evidence on the extent to which households in many countries were being impoverished by having to pay for health care on an out-of-pocket (OOP) basis. This has led to an international consensus that prepayment health care financing mechanisms (tax funding and health insurance) should be the preferred sources of funds and that reliance on OOP payments should be reduced, if not completely eliminated. A number of ESA countries have removed user fees at some or all public sector facilities (e.g. South Africa, Uganda and Zambia). While there have been positive effects, such as dramatic increases in the use of public facilities particularly by poorer groups, this has been hard to sustain where there is inadequate funding of public facilities from tax revenue and/or grants from overseas development aid. This has meant that some facilities do not have medicines available and have too few staff to cope with the increased number of patients. Where this has occurred, patients have had to increasingly rely on private health services, paid for on an OOP basis and again face the possibility of impoverishment if costs were high relative to their income levels.
This experience has demonstrated that while it is critical to reduce out-of-pocket payments for health care, it is equally important to improve public funding of health services. This is particularly so, if we are to progress toward universal health systems that provide financial protection and access to needed health care for all. Although private health insurance is a form of prepayment financing, it does little to contribute to universal coverage in low- and middle-income countries. This is because very few people can afford the premiums for such insurance and only those who contribute benefit from the services funded by private insurance schemes. Instead, what is required is the creation of as large a pool of funds as possible that can be used to fund health services that will benefit the entire population. This can be achieved through allocations to the health sector from tax funds, which can be supplemented by mandatory (i.e. compulsory) health insurance contributions by those with the financial means to contribute in this way. Development aid funds can also contribute to this integrated pool of funds, but given the unreliability of external funding and that this source is unlikely to be sustainable in the long term, it is critical that the emphasis increasingly is placed on domestic public funding for health services.
For many years, we have been told that this is simply not possible. The reality is that unless we take steps to make increased domestic public funding of health care possible, we will never achieve universal health systems in Africa. What steps are required? There is a need to increase tax revenue. A number of African countries (including Kenya, South Africa and Uganda) have managed to dramatically increase tax revenue without increasing tax rates, through improved tax collection. Consideration is also being given by some countries to introduce new taxes whose burden falls on the wealthy (such as levies on foreign exchange transactions). Equally importantly, the allocations from tax revenue to the health sector should be increased. Most ESA countries are very far from the Abuja target of devoting 15% of government funds to the health sector. The ability of governments to allocate more funds to the health sector is enhanced greatly by debt relief. Malawi is one country that has made progress towards the Abuja target. This has occurred due to active lobbying by parliamentarians, who put forward a private members bill to secure a government commitment to move towards this target. From the Malawian experience, it is clear that it is important to emphasise that it was the Heads of State that signed the Abuja Declaration (rather than simply Ministers of Health). Many parliamentarians and government officials are unaware or ill-informed about the Abuja target. In addition to improved general tax funding of health services, mandatory health insurance contributions (which are often very similar to a dedicated health tax) could be introduced. The key lesson from other low- and middle-income countries, particularly in Latin America, is that it is critical to integrate general tax allocations for health and mandatory insurance contributions in a single pool of funds to be used for the benefit of the entire population if universal coverage is to be achieved.
While improved domestic public funding of health services will not happen overnight, we need to start moving in this direction as a matter of urgency. We need to understand better how countries have managed to improve their tax collection and how some have managed to successfully motivate for increased allocations to the health sector. We need to continue to mobilise for debt cancellation to free up limited domestic resources for funding social services. We need to protect our health systems from interventions promoted by international organisations that will take us further from achieving universal coverage (such as efforts to commercialise health care delivery and funding). We need to convince our policy-makers that universal health systems can only be achieved through improved domestic public funding of health services.
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 the Health Economics Unit website at http://heu-uct.org.za/ and the EQUINET website at www.equinetafrica.org.
There have been dramatic changes to municipal services such as water and electricity since the end of apartheid in South Africa, with considerable research having gone into the impacts of commercialisation and cost recovery on low-income households. The research has revealed a complex and often negative relationship between the marketisation of these services and access and affordability for the poor. It has also been shown to have direct and very negative public health implications, most acutely in low-income township and rural areas.
Less obvious, and much less researched, have been the impacts of changes in service delivery on the mental health of low-income residents and household members. The fact that there is a relationship between poor mental health and poverty in general has now been well established. Common mental disorders (notably, anxiety and depression), while once thought to be the preserve of the rich who could afford the ‘luxury’ of worrying about emotional issues, have in fact been shown to have higher prevalence in low-income households. It has also been suggested that there is a cycle of vulnerability between poverty and marginalization, physical ill health, emotional distress, and mental disorder.
What, then, might be the links between poverty, mental health and the shift towards market-oriented reforms in basic services? A preliminary detailed ethnographic study of ten low-income families coping with a serious mental disorder (schizophrenia) in Cape Town pointed to several problems including:
• Health and safety problems. Household members have difficulties in ensuring appropriate use of medication (due to lack of water), practicing adequate hygiene, growing their own food, and with general comfort (such as being warm and dry). There are also concerns about being forced to use open fires, candles and paraffin stoves for cooking and warmth, leading to additional health and safety worries such as poisoning, fires, and respiratory infections.
• Time and energy. Considerable time and energy are spent searching for alternative sources of water and electricity and having to live with limited supplies of both.
• Social tensions. Respondents expressed concern with having to borrow money or water from neighbours and family members, leading to additional stresses in the lives of
household members and often to tensions within families and neighbourhoods, exacerbating the stigmas typically attached to mental disorders.
• Social activities. Reducing service consumption has implications for people’s social lives and household entertainment. Most of the households interviewed owned a television or radio, for example, but were reluctant to use them due to electricity costs. One family member reported being bored at home and therefore spending time with peers who encouraged him to use drugs. This has important implications for health, as co-morbid substance abuse has been shown to play a role in relapse of schizophrenia as well as being implicated in the onset of psychosis.
• Relapse. The stress of not being able to afford adequate services, or having these services cut off or restricted, would appear to add considerable stress to the person with the mental disorder, possibly contributing to a worsening of the disorder and/or a relapse.
• Impact on care-giving environment. Inadequate services would appear to increase levels of stress and burden for the caregiver(s), with implications for their own mental health. This then impacts on the family member with the mental disorder as well as the household as a whole, as the caregiver’s ability to care for the family may be compromised. Women appear to be the most affected by this as the primary caregivers.
Households experienced considerable financial hardship as a result of cost recovery strategies on basic services, with 29% of household income being spent on water and electricity on average, and arrears on water and electricity bills as high as R18 200. This situation caused anxiety and added considerably to overall family stress.
While households used a range of strategies to minimise water usage, the need to save water was a further source of anxiety and conflict. Similarly, concerns were raised about electricity usage and cut-offs, with disability grants being used to pay for fuel and basic services in many households.
While direct links between experiences of service delivery difficulties and the onset or relapse of mental disorder cannot be drawn, but it is clear that uncertainty about services in the context of poverty add to overall stress levels. Much remains to be done in terms of realising the rights of people with mental disorders (and their families) in South Africa. Without considering the broader context of poverty and service delivery it will not be possible for them to adequately improve their lives.
Editors comment: This issue of the newsletter presents material on mental health and equity, and we note the limited publication found in this area. EQUINET invites further contributions on mental health in Africa, and particularly in relation to equity issues. Please send contributions, feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. Further information on issues raided in the briefing or the Municipal Services Project see http://www.queensu.ca/msp/ Greg Ruiters, Institute for Social and Economic Research, Rhodes University Grahamstown.