The global attention to equity and to Africa has grown. The 2006 United Nations Human Development Report, the 2005 UN Report on the World Social Situation and the 2006 World Bank World Development Review focused on inequalities and equity, while a WHO Commission on the Social Determinants of Health will report in 2008 on a global inquiry into options to improve health equity through action on the social determinants of health. Africa has been the focus of Commissions and special programmes. In 2007, the World Health Organisation Director General stated that improved health in Africa was one of the organisations’ top priorities.
Within Africa, millions of people experience deprivation of the most basic rights to water, shelter and food, millions of children have lost parents due to early adult death, a majority do not have secure incomes and many live in situations of conflict and social disruption. Also within the continent, health workers, teachers and others provide valuable services, state officials and university staff take on intense workloads with limited resources, and civil society and community organisations implement innovative local ways of improving life.
An enormous gap continues to exist between global attention and local reality.
On October 23 2007, EQUINET is launching a new publication- an analysis of equity in health in east and southern Africa. The book, “Reclaiming the resources for health: A Regional analysis of equity in health in east and southern Africa” explores the challenges and options for overcoming persistent inequalities in health in east and southern Africa (ESA). It is written by the EQUINET steering committee and jointly published by EQUINET with three African publishers, Weaver Press Zimbabwe, Fountain Publishers Uganda and Jacana publishers, South Africa.
The book presents a synthesis of the evidence gathered from a range of sources, including eight years of work in EQUINET, published literature on and from the region, data drawn primarily from government, intergovernmental, particularly Africa Union and UN sources and the less commonly documented and heard experience within the region, found in grey literature, in interviews and testimonials and gathered through participatory processes. In the analysis, we do not seek to simply describe our situation, but to understand it in ways that generate and inform affirmative action from within the region.
The evidence in the analysis points to three ways in which “reclaiming” the resources for health can improve health equity:
• for poor people to claim a fairer share of national resources to improve their health;
• for a more just return for ESA countries from the global economy to increase the resources for health; and
• for a larger share of global and national resources to be invested in redistributive health systems to overcome the impoverishing effects of ill health.
The region has the economic and social potential to address its major health needs. Yet improved growth has often occurred with falling human development indicators and increased poverty. In many ESA countries, widening national inequalities in wealth block poor households from the benefits of growth, while substantial resources flow outwards from Africa, leaving most of its people in poverty, and depleting the resources for health. The analysis adds evidence to the growing call for a more fair form of globalisation, and a more just return to Africa from the global economy. The report maps the trade, investment and production policies and measures that have strong public health impact, the options to address outflows, and to promote access to food, health care and medicines within economic and trade policies. National measures that redistribute these resources for wider economic and social gain provide clear pathways for equitable use of funds released from debt cancellation, improved terms of trade, increased external funding and other global measures.
While many of these actions lie outside the health sector, the analysis argues that health systems can make a difference, by providing leadership, shaping wider social norms and values, demonstrating health impacts and promoting work across sectors.
Drawing on a diversity of evidence and experience from the region, the analysis describes the comprehensive, primary health care oriented, people-centred and publicly led health systems that have been found to improve health, particularly for the most disadvantaged people with greatest health needs. While resource scarcities and selective approaches weakened these universal systems in recent decades, the lessons presented from the roll out of prevention and treatment for HIV and AIDS continue to demonstrate their relevance, particularly at district level.
The persistence of disadvantage in access to health care in those with highest health needs is thus of concern. The analysis explores the reasons for this, within the way health systems are funded and organised, and the barriers that disadvantaged people face in using health services.
Addressing these problems demands a strengthened public sector in health. Current average spending on health systems in the region is below the basic costs for a functional health system, or even for the most basic interventions for major public health burdens. Therefore one priority is for governments to meet the as yet largely unmet commitment made in Abuja to 15% of government spending on health, excluding external financing. We argue, however, for “Abuja PLUS” - for international delivery on debt cancellation and for a significantly greater share of this government spending to be allocated to district health systems.
The analysis presents progressive options for mobilising these additional domestic resources for health systems without burdening poor households, and for increasing spending on district and primary health care systems. One of the areas of increased spending is on health workers. Without health workers there is no health system. In the face of massive shortfalls and significant outflows of health workers, the analysis explores incentives countries in the region are using to train, retain and ensure effective and motivated work of health workers, and the strategic capacities and role of health workers in designing and implementing these plans.
These approaches are not without challenge, whether from local elites, competing approaches or global trade pressures. Yet health is a universal human right, and international and regional conventions call for a ‘bottom line’ of rights and obligations to protect people’s health. One basis for the positive potential for achieving equity in health in the region is in the significant social pressure for these goals, and the social resources, networks and capabilities that exist to achieve them. The analysis points to the many ways health systems can act to empower people, stimulate social action and create powerful constituencies to advance public interests in health. Tapping these potentials calls for a robust, systematic form of participatory democracy and a more collectively organised and informed society.
To champion these values, policies and measures, to monitor progress and enhance accountability, the analysis proposes a set of targets and indicators that signal progress in key dimensions of health equity, and towards meeting regional and global commitments. EQUINET, as a network of institutions in the region, is committed to implementing and supporting the building of knowledge, skills and learning to meet these goals.
The analysis is presented as resource for the people, institutions and alliances working in and beyond the region towards goals of improved health and social justice. EQUINET, as a network of institutions within the region, itself remains committed to generating knowledge, facilitating dialogue and analysis, and supporting practice to deliver on these goals within the region.
The book” Reclaiming the Resources for Health” will be available after its launch on 23rd October from EQUINET (admin@equinetafrica.org)or from the publishers in the region (Weaver Press, Fountain Publishers and Jacana). See EQUINET Updates below for contact information. For feedback on this brief please contact the EQUINET secretariat at admin@equinetafrica.org. For further information on the issues raised in this brief please also visit the EQUINET website at www.equinetafrica.org.
Editorial
The Third EQUINET Regional Conference on Equity in Health in East and Southern Africa, held 23 –25 September 2009 in Munyonyo, Kampala, Uganda brought together over 200 government officials, parliamentarians, civil society members, health workers, researchers, academics and policy makers, as well as personnel from United Nations, international and non-governmental organisations from East and Southern Africa and internationally.
Conference delegates recognised the significant, growing, avoidable and unjust inequalities in health and in the resources for health in our countries, our region and our world. The conference reiterated the findings of the World Health Organisation Commission on the Social Determinants of Health that this social injustice is killing people on a grand scale.
We note that we have the resources for health within our region; that many resources important for health, including health workers, flow out of Africa; that the remaining resources do not reach those with greatest health needs, and that inequality blocks economic opportunities from reaching those who need them most.
We affirm that we stand for equity and social justice in health. We recognise that unless we address inequalities in health and in the resources for health, we will not achieve the policy goals set in the 1999 Southern African Development Community Protocol on Health, the resolutions of the Ministers of the East Central and Southern African Health Community, nor the United Nations Millennium Development Goals;
We affirm that it is imperative that we act to improve heath equity, and to reclaim the resources for health.
Our deliberations indicated that health equity is advanced when:
• health is integrated within national policies and goals,
• equity in health is a political and social goal, advocated, planned for and monitored,
• our health systems have strong public sectors, and redistribute resources towards those with highest health need, and
• the role of people – communities and health workers- is valued, resourced and supported;
Towards this, we call on all in the region, our international partners, and propose ourselves, to intensify efforts to:
Advance equity in health as a political and social goal and in all policies:
• Monitor and ensure that the right to health is included in our constitutions, provided for in our laws and universally applied, especially for vulnerable groups;
• Strengthen community awareness and capacity to claim these entitlements;
• Advocate for the promotion and protection of health in all policies, particularly those that provide for the social determinants of health, including education, safe water and sanitation; food sovereignty, energy and technology;
• Organise evidence and raise awareness on health implications of trade and intellectual property regimes and of new technologies and strengthen negotiating power to ensure that they protect health, particularly given the corporate control of resources;
Build universal, redistributive and people centred health systems:
• Identify and advocate for clear, comprehensive and integrated health care entitlements that secure universal coverage of health systems;
• Identify and implement options to strengthen, resource and organise primary health care and inter-sectoral action for health as a priority in health systems;
• Generate and share evidence on and implement options to close gaps in access to key services for priority health conditions, including for maternal, family and child health, for mental health and for improved nutrition;
• Organise the evidence, advocacy and political support to meet and go beyond the 2001 Abuja commitment of 15% government spending on health - excluding external funding; and to promote increased per capita spending on health, supported by debt cancellation;
• Meet the “people’s Abuja” of at least 25% of government spending in health allocated to the primary care and community level of the health system;.
• Support plans and strategies for harmonising the various health financing schemes into one framework for universal coverage, reducing out of pocket payments, providing for cross subsidies and pooling resources from progressive tax funding and prepayment schemes;
• Support the removal of user fees through a sustainable, planned strategy that strengthens the health system;
• Support the development and implementation of plans to deploy and retain health workers in decent working conditions and to ensure consistent availability of vital and essential drugs and supplies at primary and district levels of health systems;
• Draw on the growing body of evidence on the causes of health worker migration and measures for health worker retention, promote constructive engagement across health workers, trade unions and governments to ensure that country driven strategies for retention are negotiated, resourced, implemented and monitored;
• Strengthen public sector systems and capacities, including for financial management, to improve equity in the allocation of resources, and to absorb and effectively use the resources for health;
• Through civil society and parliaments, monitor how funds are used and how services are provided;
• Ensure effective regulation of the private-for-profit sector so that it complements public sector provision and to prevent negative impacts on health equity;
• Identify, make visible and overcome the barriers that disadvantaged and vulnerable communities face in accessing and using health and essential services;
• Noting that AIDS is one of a number of disease burdens and that approaches to HIV and AIDS should integrate with programmes for all major health problems, resource and strengthen rights based, holistic, integrated primary health care oriented approaches to prevention, treatment and care for HIV and AIDS, that recognize and act on the social barriers to access and uptake of services; that build links between communities and services; that recognize and train traditional healers, community health workers, peer support networks and non-medical health providers; that provide prevention and treatment to health care workers; that strengthen local safety nets and that address disparities in access to services across gender, area and income and for children, commercial sex workers and other vulnerable groups.
Recognise and support the central role of people – communities and health workers –leadership and alliances in advancing health equity:
• Recognise and formally provide in laws, budgets, mechanisms and programmes for the central role of people in health systems; to build informed empowered communities and health workers and participatory processes for community involvement in health;
• Demand and strengthen capable strategic leadership, stewardship and management in health systems; who consult, engage with and harness the range of constituencies and resources needed to advance health equity;
• Develop the communication, engagement, capacities and networking to strengthen government, civil society, health worker, parliament and researcher alliances to shape, advocate, implement and monitor the policies that promote health equity;
Monitor and make visible progress and gaps in advancing health equity:
• Monitor and make visible the progress and gaps in advancing health equity through implementing an Equity Watch at country and regional level, in a manner that builds alliances across actors; that analyses health disparities, including gender differentials; that makes visible progress against benchmarks and drivers of health equity; that complements a core framework of parameters with deeper district and household level assessment and that combines different forms of evidence, including from community level photography, to stimulate action on equity.
• Develop and promote investment in and capacities for a research agenda on health equity, including on new challenges, such as how climate change and globalisation are affecting health; on operational issues, such as how health systems are functioning after the removal of user fees; and to inform policy development, such as on the effects of the private-for-profit sector and of commercialisation in health systems on health equity;
• Build capacities amongst researchers to involve stakeholders from the earliest stages of research and to effectively communicate evidence.
We call for these efforts to be supported by wider levels of social justice globally and for a more just return for east and southern African countries from the global economy. The net outflow of resources from Africa must be reversed and the strategic resources of Africa used for the development and security of its populations.
We call on our international partners to advocate and engage with us to achieve:
• The global commitment to and resourcing of the universal rights to health in the International Convention on Economic and Social Rights, the Convention on the Rights of Children and the Convention on the Elimination of Discrimination against Women,
• G8 targets of universal access to prevention, treatment and care for HIV and AIDS and the UN Millennium Development Goals;
• Debt cancellation, with the resources released channelled to human development;
• Economic justice, fair trade, and democracy in the governance of global financial institutions;
• Bilateral and multilateral agreements that recognise and redress the resource outflows that affect African health and health systems, particularly from health worker migration.
• Genuine partnerships and external funding aligned to national priorities, that are developed through participatory and informed consultation with the people.
We will all take these commitments forward into our various organisations and forums. The conference has set a programme of work and action for all of us. EQUINET, as a consortium of institutions from the region, is committed to take and support these actions to advance health equity, to produce and share evidence and good practice and to advocate and monitor equity and social justice, especially through the equity watch. EQUINET is committed to building the intergovernmental, parliamentary, civil society, health worker and academic forums in East and Southern Africa to strengthen our values based leadership, democratic states and regional integration and co-operation in Africa, to reclaim the resources for health and advance health equity.
In the face of injustice it is imperative that we act.
A note from the editor: This oped presents the resolutions made and adopted by delegates at the EQUINET Regional Conference September 2009. In future issues of the newsleter we will give profile to specific areas of and reflections from the conference, whose ideas, community and exchanges re-energised and informed our work, actions and interactions towards advancing health equity. The abstract book for the conference is available at http://www.equinetafrica.org/bibl/docs/EQ%20Conf%20Sep09%20abstract%20bk.pdf and the conference report will be available on the EQUINET website in November. Please contact the EQUINET secretariat admin@equinetafrica.org for any queries or feedback on issues relating to the conference or resolutions. For further information on the conference, the papers presented or EQUINET work please visit the EQUINET website at www.equinetafrica.org.
* “Equity in health implies addressing differences in health status that are unnecessary, avoidable and unfair. Equity in health implies directing more resources for health to those with greater health need. Equity in health means having the power to influence decisions over how resources for health are shared and allocated.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “In the highly unequal societies of southern Africa, our health challenges demand health systems that assertively redistribute the resources for health and policies that reflect values of equity, solidarity and universality. This can be achieved through rising investment through the state and public sector.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “The gains of neoliberal globalisation?
- 4% GDP lost in unfair terms of trade 1970-1990
- Africa's FDI share from MNC investment 25% in 1970's, 5% in 1990s.
- Income gap richest to poorest 53x in 1960 and 121x in 2000
- 185 million people out of work
- 55 million people live on <$1 a day
- Southern outflows increased.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “Despite a hostile global environment, which has the potential to subjugate us to political and economic imperatives not of our choosing, we can and must mobilize collective action to chart and implement our positive vision and policies on the equitable health systems that we want.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “ Impact of malnutrition on development:
- [A study of the long term impacts of the 1982-84 Zimbabwe drought on 665 children]…resulted in a loss of stature of 2.3 centimeters, 0.4 grades of schooling, and a delay in starting school of 3.7 months.
- [It is estimated] that this loss of stature, schooling and potential work experience results in a loss of lifetime earnings of at least 7 - 12%.” - From a presentation on 'Household Food Security, Nutrition and Equity.'
* “Only 3 out of 10 African countries show a decrease in severe maternal nutritional status in the last decade.” - From a presentation on 'Household Food Security, Nutrition and Equity.'
* “31 countries in Africa do not meet the 'Health for All' standard of a minimum of one doctor per 5000 people.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
“External debt of the USA is $2.2 trillion - almost the same as the $2.5 trillion owed by the entire developing world…Every American citizen owes the rest of the world $7,333 while every citizen of all the developing countries only owes the rest of the world $500.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
* “Estimating the cost of training a GP in the SADC Region to be $US60 000, then it can be assumed that there is a reverse subsidy from the developing world of $500m per annum for health personnel alone.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
* “UNCTAD estimates that US$184,000 is saved in training costs per professional and that US saved US$3.86 billion as a result of importing 21 000 Nigerian doctors.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
* “Things are pretty bad here you know. South Africa is not the Tropicana Hotel [in Durban, where the conference took place]. Since independence the rich have been getting richer and the poor poorer.” - Trevor Ngwane, Anti-Privatisation Forum, commenting in a parallel workshop session.
* “The green rooms [negotiating forums at the World Trade Organisation criticised for their lack of transparency] are basically where the bully countries call in the smaller countries, beat them up and then send them home with a message to their mothers.” - Riaz Tayob, SEATINI, replying to a question on a presentation on global trade and health.
In just over a month delegates from all over southern African will be converging at the third EQUINET Southern African Regional Conference on Equity in Health being held in Durban, South Africa on the theme ‘Reclaiming the state: Advancing peoples Health, Challenging Injustice’. This conference theme has been chosen to reflect the commitment by EQUINET to go beyond mapping the problems in and challenges to health equity and social justice in southern Africa and to proactively build the alternative vision, analysis, perspective and practice needed to meet those challenges.
The conference will debate the actions and systems needed to advance people’s health equitably, fairly and within the broader context of social justice. EQUINET proposes that such systems must integrate principles and practice:
- of public health, viz the protection and promotion of population health and prevention of ill health
- of providing relevant, quality health services and care for all according to need and financed according to ability to pay
- of building the human resources and knowledge to shape and deliver public health and health services, and
- of protecting and ensuring the social values, ethics and rights that underlie health systems, including to participation and involvement.
The conference will also review through various areas of work the proposal that health must be supported by redistribution of the resources for health in an equity oriented policy agenda supported by the state. The conference will explore options for policies and systems that are explicitly centred on rising investment in health through the state and public sector. What does it mean conceptually and practically at national and global level to reclaim the central role of the state for equitable health systems?
Efforts by states and citizens in the region to equitably meet the health needs of their people confront the challenge posed by a globalization process based on unfair global trade relations, dominance of transnational corporation interests, reduced role and authority of the state and political and economic marginalization of southern and low income populations. Such conditions contribute to a huge ‘brain drain’ of health personnel, growing household food insecurity, massive constraints in meeting the drug and other inputs to health care and privatization of essential services, all with damaging implications for equity in health.
The conference will present and discuss the perspectives, shared values and options for challenging the injustices undermining people’s health. We will draw from the experiences of work with government, parliaments and civil society. We will examine the rights and governance approaches that are needed to support such action for health.
We invite all those with ideas, issues and options to contribute to this process, whether or not you are coming to the conference! Send us your feedback, resolutions, and contributions with your name and institution to admin@equinetafrica.org and we will integrate it into the inputs to the conference resolutions and keep you informed on the outcome. What do you see as the major challenges and contributions to advancing people’s health in southern Africa? What policies and actions are needed to strengthen the role and performance of the state and public sector in health? How can southern Africans more effectively challenge the injustices that undermine health? What should EQUINET do, as a network based on shared vision and values of equity and social justice, to strengthen our analysis, actions and institutions to better deliver on our collective aspirations for health equity and social justice? What role would you like to play in this?
Noting:
* The 1997 Kasane meeting on Equity in Health that confirmed the commitment to equity in health at all levels in southern Africa; the 1999 Southern African Development Community (SADC) Protocol on Health, the 2003 Maseru Declaration on HIV and AIDS and the resolutions of the SADC Heads of States Summit on food security held in Tanzania, 2004;
* The formation of EQUINET and our work since 1998 in support of these commitments, to strengthen the understanding of, the evidence for, advocacy of and implementation of this policy commitment to equity and social justice;
* Our conception of equity and social justice in health, which aims to address unfair differences in health and in access to health care through the redistribution of the societal resources for health, including the power to claim and the capabilities to use these resources;
* The widening constituency we are building for equity and social justice in health amongst governments, parliamentarians, health professionals, trade unions and other organs of civil society, researchers and communities at national and regional level;
* The challenges posed by neoliberal globalisation to our values of equity and social justice, to government ability and flexibility to implement the public policies that we choose and to the public sector health and essential services and that are critical for our health;
The June 2004 EQUINET conference in Durban South Africa affirmed that we stand for:
* Equity and social justice in health;
* Public interests over commercial interests in health;
* International and global relations that promote equity, social justice, people's health and public interests;
* Increased unconditional resource flows from the North and fairer terms of trade;
* Reduction and where possible restitution of flows of resources from South to North;
* A conception of human rights that affirms the agency of communities in claiming social and economic entitlements, the primacy of vulnerable groups and that captures African traditions of communitarianism;
* Equitable health systems that provide healthcare for all and redistribute and direct resources towards those with greatest needs;
* Rising investments in the state and public sector in health;
* Health (care) systems which promote collective, population oriented strategies for health and comprehensive primary health care;
* Trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production;
* At least 15% of government budgets invested in the public health sector, as committed in Abuja, together with debt cancellation;
* Progressive tax-based funding of health systems;
* Fair financing for health, in which the rich contribute a greater share of their income to health than the poor, with strengthened cross subsidies for solidarity and risk pooling;
* Equitable and affordable access to generic drugs, with application of essential drug policies across all health providers;
* Ethical and equitable human resource policies at national, regional and international level, backed by compensation for regressive south-north subsidies incurred through health personnel migration;
* Equitable public health and multisectoral responses to HIV and AIDS for prevention and health promotion, treatment and care and to mitigate the impact of the epidemic, particularly within and for young people and vulnerable groups;
*The expansion of access to anti-retroviral therapy for people living with AIDS in Southern Africa as an urgent priority, through funding and approaches that strengthen, and do not compromise, our public health services and systems;
* Democratic and accountable states, with full authority to exercise policy measures necessary to protect the health of people;
* Powerful and effective participatory and representative mechanisms at all levels of our health and social sectors and in the state more generally;
* Effective and accountable mechanisms for public and stakeholder contribution to decision making in health;
* Regional integration and co-operation within Africa to strengthen democratic states, advance the health of people and challenge injustices to health;
* Values based leadership across organisations working to promote equity in health.
The conference set out a programme of work and action for EQUINET and its partners to implement these goals.
* * Visit the Values, Policies and Rights, Health equity in economic and trade policies, Poverty and health, Human Resources, Resource allocation and health financing, Equity and HIV/AIDS and Governance and participation in health sections of the newsletter for more details about papers presented at the conference. The full abstract book and other conference documents will be available on the EQUINET website (www.equinetafrica.org) by the end of this month. Please send all comments to admin@equinetafrica.org
Six months after Cyclone Idai ravaged the eastern province of Manicaland in Zimbabwe, the devastating effects show that there is need for more work to do for the recovery. The survivors are still in dire straits, psychologically, emotionally and materially.
The traumatic events of 15 March 2019 remain etched on the minds of the survivors. Any rumbling sound, even light rain, sends them quaking, as a reminder of the tragic events of that ‘night of death’, when torrential rains and heavy winds claimed their loved ones and left them scarred.
Cyclone Idai resulted in a massive loss of life and injury, as well as destruction of critical infrastructure, including clinics, schools, roads, bridges, electricity base stations and houses. Manicaland province was the most affected, followed by Masvingo and Mashonaland East. The destruction also affected parts of neighbouring Mozambique and Malawi.
Government statistics indicate that 341 people died, 344 were missing, 183 were injured and 2213 people were displaced. Further, 230 dams burst and 20 000 livestock were lost. The loss of electricity compromised communication systems and hampered search and rescue efforts. The damage to communication networks means that many communities remain cut off from essential services. Despite government, with assistance from South Africa, having mobilized earth-moving equipment, some roads are still not passable.
This situation presented a public health threat of water and vector borne diseases, such as cholera, typhoid and malaria. Malaria deaths have spiked in Manicaland following the Cyclone. The trauma and loss has certainly led to mental health problems. The damage to infrastructure has impeded access to health services, raising the risk that people cannot access or default on treatment and care. In addition, local health services are understaffed and lack adequate medicines.
The magnitude of the disaster was greater than government alone could cope with. The international community, United Nations agencies, civil society organisations and individuals all contributed. For example, the Community Working Group on Health (CWGH) with Medico International provided relief and aid to 171 households in holding camps in April to June 2019. This interaction also led to input to recommendations to the Civil Protection Unit and other inter-ministerial committees responsible for preventing disease outbreaks and ensuring provision of safe and clean water in the holding camps. Yet the high death toll from Cyclone Idai indicated the lack of disaster preparedness and planned mitigation by government, considering the earlier heavy loss from Cyclone Eline in 2000. Many lives could have been saved had the warnings for Cyclone Idai been widely disseminated in the local media to warn households and a response mobilized to evacuate people from the affected areas.
The situation continues to be precarious up to today. Manicaland Provincial Affairs Minister Dr Ellen Gwaradzimba noted that the situation in that province is now worsened by drought, affecting about 1.7 million people, in a situation where food reserves and fields were destroyed. Even while the response moves from an emergency to a recovery phase, the need to both learn from the experience and to sustain intervention is clear, including to respond to continuing vulnerability and to resettle internally-displaced people.
At a Provincial All-stakeholder Dialogue Meeting on Cyclone Idai in June concern was raised over the weak execution of the disaster emergency plans for evacuation and rescue and the absence of community-based emergency plans. For example, the reluctance of people to leave their ancestral land, even after being alerted of the disaster, was one factor that impeded evaluation. The dialogue meeting recommended that a government emergency response fund be set up; that communities be educated on first aid and disaster risk management in schools and in the community; and that campaigns be undertaken on disaster preparedness and mitigation.
While much effort has already been made in improving access to public and social services, resources are needed to restore roads, bridges, houses and sanitary facilities. Survivors need counseling and psychosocial support services. Displaced people and affected communities need new land for more rapid permanent resettlement and investments in their livelihoods and social services.
In all these inputs the planning, preparations, decisions and responses need to be people-centered. Putting people at the centre of the next steps, including in the planning for any future emergencies, is central to the response.
In the last weeks of 2009, the UN held a meeting in Copenhagen to thrash out a comprehensive global agreement that could be converted into an internationally legally binding treaty to prevent dangerous global warming. By the end of the Copenhagen conference, the outcome was far from this: The conference accord preserved the Kyoto protocol, and while it recognised that global warming be limited to an increase of less than two degrees centigrade, it did not set targets for greenhouse gas cuts. While it set an aim to provide $30bn a year for poor countries to adapt to climate change rising to $100bn a year by 2020, it did not detail the source of these funds. It set no deadline for the conclusion of the climate talks.
The failure at Copenhagen has deep implications for people’s health, particularly in Africa, where the Intergovernmental Panel on Climate Change warn that consequences of global warming, such as loss of wetlands, will lead to increased frequency and severity of drought, further jeopardising food security (http://www.ipcc.ch/ipccreports/tar/wg2/index.php?idp=667). But what role do health activists play in this struggle? What are the special interests of health activists in relation to climate change and what special leverage might people’s health networks contribute in controlling the drivers of global warming? With the prevailing global inequities and the heavy disease burden and high barriers to health care in low income countries, such as in Africa, we need to understand the North- South dimensions of the Copenhagen fiasco.
It appears that the high income countries approached Copenhagen with low ambitions and high conditions, including conditions that tied their own action to comparable commitments from the big developing countries like South Africa, downplaying the role that emissions from high income countries have played in the historical accumulation of greenhouse gases. It appears that the big developing countries, led by China and India, were unwilling to accept the kind of restrictions on their economic development that were being canvassed and were unwilling to slow down what they described as the liberation of millions of desperately poor people from poverty. With pathways to less harmful economic development dependant on access to the necessary non-polluting technologies, the developing countries were not happy with the offers from the rich countries on this front.
Control of global warming and opportunities for economic development are both framed by the wider regime of global economic governance. The inequities, imbalances and instabilities of the global economy, manifest in the global food crisis and the global financial crisis, are direct reflections of this regime. Neoliberal globalisation is built upon a consumerism (with concomitant carbon pollution) that marginalises a billion humans, who are required neither for their labour power nor their buying power. In Copenhagen these inequities were again unmasked, in relation to the crisis of global warming.
It is untenable that these global policy challenges should be allowed to force a choice in low income and developing countries between economic development OR a mitigation of global warming. Rather we need to work towards a regime of global economic governance which reconciles the need for sustainable economic development for countries in Africa and other parts of the global south, and the need to contain global CO2 levels to 350ppm. Such a regime is technically and economically possible. The main challenge is political.
What does this mean for health activists? It raises four imperatives:
Firstly, we need to get our facts straight and build a robust analysis. We need to understand clearly the positions that were advanced by the various groups of countries at Copenhagen, put them in the context of the political economy of energy and global economic governance, and explore their health implications.
Secondly, we need to put sustainable economic development at the forefront of a shared struggle for health and for tackling global warming. This is not the high consumption, low employment, neoliberal globalised production model of development, but a more sustainable autonomous development, based to a large degree on local production and supply.
Thirdly, we need to build pressure on all governments, north and south, to accelerate the reform of domestic energy production and energy use, while continuing to work for binding international agreements.
Fourthly, in addition to energy efficiency and the move to renewables, we need to profile energy equity, or the fair distribution of energy resources across countries, social groups and generations. This has implications for high income countries, where the profligate use of carbon based energy is embedded in culture, economy and infrastructure. It also has implications for the elites and middle classes of low income countries. It calls for an alternative culture of global solidarity.
These four imperatives have implications for the work of health activists.
Comprehensive primary health care is fundamental for improving access to health care and action on the social determinants of health. It is also a strategy of social change through community mobilisation based on partnerships between PHC practitioners and the communities they are serving. It follows that energy reform must be included in the discourse on ‘the social determinants of health’ and community mobilisation for health. It must also be clearly contextualised in relation to the same problems of current economic globalisation that drive inequity in health, raising the challenge of global economic reform.
Global solidarity is central to taking forward comprehensive PHC. This calls for health activists to build communication channels and opportunities for collaboration across various axes of difference (nation, race, gender, religion as well as class) so that the forces for progressive global change can be more coherent and effective. Energy reform (including energy equity as well as efficiency and the use of renewables) must be included in this communication, in the context of economic globalisation.
Intersectoral collaboration is a core principle of all public health work. This calls on health social movements, like Peoples Health Movement, to build relationships with social movements who share common perspectives and values within other sectors, including with those engaging on global warming, environmental justice and energy reform.
Under the banner of the ‘right to health’, health as a basic human right de-normalises the status quo and inspires communities in their struggle for access and for decent living conditions. This is a political struggle as much as it is a moral claim. The political analysis which guides this practice must take us beyond the noise of Copenhagen to explain the workings of neo-liberal globalisation in relation to health, economic development and global warming. Opportunities like the Third People’s Health Assembly, planned for Cape Town in July 2011, are thus important for us to deepen our understanding of these relationships and what this means for our work as health activists in Africa, and globally.
Editor's comment: This issue EQUINET includes a focus on what the climate change discussions mean for health in east and southern Africa. We welcome materials, comments and editorial input from others working in this area, to further develop our work and understanding in the region. Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please also visit the websites of the People’s Health Movement http://www.phmovement.org/ and International People’s Health University http://www.phmovement.org/iphu/
Every three months, together with others, I read and capture a wide range of materials on health equity in the region for the EQUINET newsletter. But the East and Southern Africa Regional People’s Health University (RPHU) has been a learning curve for me in many ways! I learned a lot in terms of the struggles for health equity. The information shared depend my understanding of the political economy of health, reclaiming the resources for health, of equity in health technology, and the commodification, privatisation in health and on building a movement for health equity. The sessions provided me with insight on how the corporate world is affecting health in the region and why. I learned about multiple dimensions of injustice bedevilling our health systems and our need to strengthen our various platforms that are engaging on health equity.
Our sessions were organised and flowed. From the coordination between PHM and EQUINET we were exposed to different areas of expertise from within our region, and to people who shared vast experience with us. We heard contributions, rich in evidence based research, and exchanged ideas and experiences from countries in the region that demonstrated solidarity in action. COVID-19 was not dealt with separately on the agenda but was a topical issue in different sessions as many countries in the region are grappling with funding, vaccines and information related to the pandemic and its impacts. What I heard towards the end of the sessions about how solidarity movements are built has made me rethink what I must do in my own actions towards health equity. The RPHU raised the value of actively participating in platforms that might contribute to the health equity agenda through sharing information and experiences and acting upon this.
Overall, I realised from the sessions on reclaiming the resources for health, reclaiming public health, the discussions on trade and health, on health rights and on social participation in health of the link of local to national to regional links that we need to build to champion health equity issues. The group work we did gave me a lot of ideas on regional contributions towards health equity through organised work.
My expectations of the RPHU were surpassed! Despite my own experience in this area, the sessions opened me to thinking more critically about what the individuals could do better to advance health equity. Building a consortium is a fantastic way of information dissemination and sharing. In that we need to keep doing better in ensuring equity in our own work. Health equity is about not leaving anyone behind. While most voices were heard in the RPHU, we did not hear the perspectives of people living with disability, including on their concerns around COVID-19, and we need to. The regional organisers (PHM and EQUINET) have spread to different countries in the region, but the grassroots level still remains too silent, including in our networks. I realised that strengthening grassroots level participation and action will be critical, if we are to build an effective movement for health equity across the countries of the region.
The final session of what was without a doubt one of the best symposiums in health lent itself to reflection on four days of sessions that sparked debate and hopefully action on people centred health systems. As a funder of health systems research in low and middle income countries for over a decade, International Development Research Centre has supported the Health Systems Research Symposium from its birth, with an aspiration that be one of the processes that contribute to access to health and health care for all.
So what were the key messages that I heard and have taken home.
Professor Thandika Mkandawire began by articulating that we need health systems to be democratic, social, inclusive and to contribute to development. At the same time Prof Irene Agyepong reminded us of a Nigerian proverb that a “goat that belongs to the whole village belongs to nobody - this is how health systems can be described, but we must not let it go that way.”
So as a funder I ask myself whether I will stick to, as one panelist said “the politics of the achievable”? My answer is no, as it would not do justice to the energy, excellence and commitment that I witnessed from participants over the course of the last three days and more importantly it would not do justice to the people who have no access to health or do not have a voice.
I’ve organised what I have heard into: the “not to dos”, the “must dos”, and the “how to do”.
As a ‘not to do’ Rene Loewenson reminded us that by simply putting people in the middle does not make it a people centred health system.
So what must we do? In terms of how we do people centred health system research, the knowledge that matters is the knowledge that facilitates change, as we were reminded by Kumanan Rasanathan. As Nancy Edwards suggested we must move from gold standards to platinum standards of methods. In practice this means, quoting several people from the conference:
• Firstly, that people’s knowledge and role in the production, analysis and interpretation is a critical driver of people centred health systems. It means that people are in control and researchers are the facilitators of the process.
• Secondly, making data work for people rather than have people work for data. In one session someone spoke about “chasing data to fit with multiple donors’ agendas”. We need to incorporate multiple types of evidence and to bring in other practices and methods.
• Thirdly, while strengthening capacities are key, we cannot assume that none exist. We should recognise that capacity strengthening goes beyond training to actually shifting power, as noted by Aku Kwamie.
As a further ‘not to do’ Gita Sen reminded us that we cannot confuse the PC of People Centred with the PC of Political Correctness. We must break divides of race, gender, class, caste, culture or language and come together. This was illustrated eloquently despite the English language barrier by Lina Roso Polomo, a researcher from Mexico, as she explained how international guidelines do not always recognise the cultural diversity of our countries.
So if accountability is brought in by people, then as Kausar Khan eloquently relayed, the ‘must do’s’ include duties for us to reduce ethnic and racial divides as we facilitate, mobilise, fund, engage and catalyse people-centred health systems. It cannot be ‘us’ and ‘them’ as Martin McKee reminded us. At the conference I saw reflected in the program the silos being reduced as ‘systems’ sessions starting to integrate with ‘disease’ sessions, and discussions moved to bridge social movements with think tanks. Inclusion and integration are key. After all, as Lucy Gilson said on the first day of the symposium, the challenge that we must squarely address is governance.
Throughout the conference there was concern about the double-edged sword of Ebola, that has served this community with deep and significant challenges. The West African Health Organisation is demonstrating commitment to work with all of us to address Ebola and the system failures that it has starkly uncovered. WHO, UNICEF and European funders are advancing initiatives that address both basic science and health systems but as a global community we must do more and USAID and the World Bank called a number of meetings throughout the symposium to discuss this.
Moving from the ‘not to dos’ and the ‘must dos’ to the ‘how to do’, the wisdom of the Emerging Leaders (young researchers) is the take home lesson for all of us here. They said that to change mindsets we need to see, talk about and deal with the gorilla in the room. To make an impact we need to take the time to stop and reflect, with others that are like minded and also with those who are not. Lastly they told us that in each of us we have the capacity to lead as we bridge divides to build collective ownership of health systems that - quoting Sheik, Ranson and Gilson from the Health Policy and Planning Supplement on the Science and Practice of People-Centred Health Systems - truly “serve people and society”.
These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the global symposium visit http://hsr2014.healthsystemsresearch.org/
User fees are once again a hot topic of policy debate. This time the question is whether to remove primary care fees. At its conference in June this year, EQUINET took a clear position on the issue. We called for these fees to be removed. But we also stated that this action is not a cure-all for the problems facing health systems in Africa. User fee removal must be accompanied by actions that increase overall national resources for public sector health services and that deal with international conditions and policies that undermine this.
The two reasons why primary care fees must go are that:
- They contribute to the unaffordable cost burdens imposed on poor households;
- They signal to poor households that society does not care about them.
Fees at primary care are relatively low. Even so, there is widespread evidence to show that fees encourage self-treatment (using herbs or poor quality medicine bought in unregulated market places), deter people from taking full doses (so increasing the chances of drug resistance), and act as a barrier to early, or even any, use of health facilities. In these ways the small level of fees can increase the costs poor people bear when ill. So even though fees represent a smaller proportion of the total costs of accessing health care than transport or lost income, they contribute to levels of cost burden that can, in some instances, impoverish poor households. At one level, impoverishment results from selling key assets, cutting down on other necessary expenditures, or borrowing, often at exorbitant interest rates, to pay for health care. At another level, charging fees adds cost to the other immense barriers of accessing care, such as distance and abusive treatment. It signals to poor people that they are not valued or cared for by society.
However, removing primary care fees is not enough by itself to tackle the range of existing health care challenges in Africa. Other actions are also required.
First, the levels of funding available for health care must be increased. At least 15% of government budgets should be invested in the public health sector, as committed by African governments in Abuja. Only one country in southern Africa, Mozambique, is currently reported to be achieving this. This will support the sustained quality increases necessary to improve health system performance, as well as allowing the system to respond effectively to the utilization increases likely to result from fee removal.
Linked to this African country debt should be cancelled. The EQUINET June 2004 Conference called for international action to remove the debt burdens imposed on African countries, and for national action to increase the level of government funding to health systems. These changes in financing also need to be underpinned by changes in terms of trade for African countries that result in huge resource outflows from Africa, including market barriers in industrialized countries to trade in food products and the poaching of health personnel.
Second, the removal of fees must be undertaken in a way that actively strengthens the health system.
In particular, the responses of health workers and managers must be deliberately managed to avoid negative impacts on morale and performance. As front-line providers and managers are the point at which patients meet the health system, their morale and performance has a direct influence over how patients experience health care, and how policies are implemented. In South Africa, while the removal of fees had a powerful positive effect on health outcomes, health workers said they were not adequately informed or involved, and were thus unprepared for the resulting increases in utilization. This can lead to unnecessary tensions at primary care level, and patients complaining that health workers treat them badly. In countries where fees have been retained, they have allowed managers and local communities some control over the decision of how to use the revenue. In others they have been used to fund agreed incentives for staff. These issues need to be managed and alternative ways found of providing for local resource control and staff incentives to avoid demoralisation.
Experience from a wide range of policy actions indicates that managing this policy change must involve:
1. Giving a specific government unit the task of implementing fee removal in ways that strengthen the health system;
2. An effective public relations campaign to communicate the change with the general public, and to signal that removal of fees is about valuing patients and providers;
3. Ensuring that the policy goals are clearly explained to managers and health workers to promote support for the policy at all levels of the health system;
4. Preparatory planning to ensure adequate levels of drug and staff availability to cope with the likelihood of initial utilization increases -
and longer-term planning for how to tackle wider drug and staffing, including motivation, problems;
5. Establishing new, manager-controlled funds at local level that allow management freedom on small-scale spending decisions;
6. Clear communication with health workers and managers about what and when actions will be taken - through meetings, supervision visits, special information letters;
7. Expect that there will be unanticipated problems with implementation, and so set up monitoring systems that provide a basis for identifying what other actions need to be taken: monitoring utilization trends, including the relative use of preventive versus curative care, and giving health workers and managers opportunities to feed back on health facility experiences.
Tackling the human resource barriers to effective fee removal will inevitably require the wider action that is necessary to address the overall human resource crisis in Africa. On this issue EQUINET has called for human resource policies and measures at national, regional and international level that promote the retention and improved working conditions of health personnel in public sector health systems, backed by compensation for regressive south-north subsidies incurred through health personnel migration. An editorial later this year will provide more detail on this.
User fee removal clearly provides an opportunity to begin to address the needs of poor people. However, their removal is not enough by itself. EQUINET calls for this to be backed at national level by increased public financing for health and at international level by a cancellation of debt. In addition, user fee removal must be implemented in ways that strengthen the health system. User fees were actively promoted internationally during periods of efficiency and market led health sector reforms that produced a huge cost to equity in health in southern Africa. User fee removal must be underpinned by actions at international and national levels that provide for the resources to achieve human rights to health and health equity goals.
* Information on EQUINET work on fair financing is available on the EQUINET website at www.equinetafrica.org EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org