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.
Editorial
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 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/
There has been growing engagement around the inequitable benefit from the extraction of minerals, genetic and biological resources from the continent. Attention is now also growing on the exploitation of local and indigenous knowledge, and as captured in some of the articles in this newsletter, the injustice of knowledge systems that extract empirical evidence for analysis in other countries, and impose barriers to those most directly exposed to conditions being able to travel and participate in scientific programmes and forums, to bring direct knowledge on those conditions into global health forums. This international context contrasts with the experience described in this month's editorial of a sustained initiative within east, central and southern Africa to facilitate dialogue between researchers, service implementers, civil society and government policy makers in and from the region, to share and review knowledge for health and health systems within the region. How actively do we use, engage in and benefit from such platforms? What do we need to do reclaim, build and assert the knowledge systems in the region - and from the region, globally- to advance health equity? We invite you to share your experiences and perspectives as comments, opeds, or links to relevant papers and reports for our next newsletter.
From July 2019 the EQUINET newsletter will be coming out quarterly in March, June, September and December of every year. The next issue will thus be in September 2019. After discussion in the EQUINET steering committee we will try where feasible to have a stronger thematic focus on issues, while still keeping a wide range of coverage of resources, announcements and updates and publications. As a reminder we are keen to share information on and about the region and invite you to share news, information, papers, reports, briefs, announcements and resources of different types and are happy to receive editorials from or on the region. Please submit by visiting the newsletter on the EQUINET site and selecting "submit news" on the online menu. We are also keen to get your feedback on how to improve the newsletter as a resource for you so please do submit your feedback!
Global meetings and processes can seem very distant from the realities at local level, despite the fact that the policies being made in global meetings have profound influence on these local realities. The People’s Health Movement (PHM) has for several years implemented a ‘WHO watch programme’ to follow and provide information, analysis and critical commentary for people on the global health debates taking place at the World Health Organisation (WHO).
In its Global Health Watch activities, PHM follows range of WHO meetings, including the World Health Assembly (WHA) and the WHO Executive Board (EB) and at regional level in the WHO Regional Committees, such as the one for the AFRO region. The analysis that PHM does explores how far these global processes and resolutions respond to local, regional and global contexts and priorities and how far states and other relevant stakeholders’ implement, comply with and are publicly accountable for the resolutions made.
The recently ended ‘WHA72’ that took place in end May 2019 was one such global meeting.
There were many debates at the WHA72, but two merit attention. One was on improving the transparency of markets for medicines, vaccines and other health-related products and technologies. A second was on the Ebola epidemic in the Democratic Republic of Congo (DRC) and the public health emergency response. Both were critical debates for African countries. Both issues need strong intervention from states, by galvanizing comprehensive workforces and capacities for both health systems and emergency responses, to address disease burdens and respond to disease outbreaks.
After the scrutiny and criticism of its response to the Ebola epidemic in West-Africa in 2014, WHO restructured its health emergencies program in 2016 to provide a more effective response. However, the virtual freeze in member state contributions has meant that the core funding for the program has not improved. The current Ebola outbreak in the DRC thus provided an opportunity to assess how successful the measures and resources are for such emergency responses. The DRC outbreak provided a tough test: it has been termed a complex emergency due to its occurrence in a highly volatile and extremely insecure conflict zone, politicizing the epidemic and raising the challenge of dealing with an outbreak in a war zone. At the recent WHA, WHO reported that its use of vaccination strategies enabled it to achieve unprecedented survival rates. It also pointed to other factors that enabled the response and improved survival, including significant investment in planning and capacities for epidemic preparedness, sustained testing for Ebola, improved screening, vaccination of frontline healthcare-workers and training of multidisciplinary teams for a rapid response mechanism.
While this work has been a significant contribution to addressing the Ebola emergency in DRC, there are still issues to address. PHM observe that WHO should mobilise member states and other relevant-stakeholders to find ethical and valid ways of more rapidly testing interventions to combat diseases like Ebola. A rapidly spreading emergency like Ebola calls for an urgent response, including quick advice on the most effective treatments to use. The concern is that the pace of development of new vaccines, drugs and diagnostics is not meeting the pace of rapid spread of health emergencies, such as that faced in the DRC. The time consuming nature and wide population enrolment of current medicine trials doesn’t match the urgency needed for responding to such rapidly spreading epidemics. This raises debate on what flexibilities can be introduced that do not compromise the quality and safety of trials.
At the same time, there is also a more general demand for improved access to medicines. Accessing medicines would have been critical for the approximately 1.6 million Africans who died of malaria, tuberculosis and HIV-related illnesses in 2015. While many of the diseases in Africa can be prevented or treated with timely access to appropriate and affordable medicines, vaccines and other health interventions, less than two percent of medicines consumed in Africa are produced on the continent. Many people cannot access locally produced drugs and many may not afford imported medicines.
The WHA discussed a draft roadmap on access to medicines, vaccines and other health products for 2019-2023. The roadmap proposes strategies to support quality, safety, efficacy and equitable access of health-products. The strategies include strengthening regulation, assessing the quality, safety and efficacy or performance of health products, including through market surveillance and investing in research and development (R&D) that meets public health needs. The strategies also include managing intellectual property so that it contributes to innovation and promotes public health, and ensuring evidence-based selection, fair and affordable pricing, procurement and supply chain management and appropriate prescribing, dispensing and rational use of health products.
The resolution on transparency of markets for medicines, vaccines, and other health-related products and technologies adopted at this year’s WHA is a substantial stride towards improving the affordability of and access to medicines and other technologies. For example, there is currently an information gap on what different countries pay for medicines and on the actual cost of R&D and manufacture of medicines. The lack of transparency on this gives pharmaceutical corporations a significant advantage and allows them to charge extortionate prices, maximizing profit over human life.
Despite the obvious benefit of improved transparency in these issues, the resolution received mixed reactions. Germany, Hungary and the United Kingdom dissociated themselves from the resolution, using a range of procedural reasons. They claimed that the roadmap was “rushed through” and breached procedure, with inadequate consultation with all experts. The dissociation raised governance concerns. However the resolution was approved by a majority of states and will support the space for governments in Africa to negotiate medicine prices. Given the current crisis of unaffordable pricing of many medical technologies, the resolution, if implemented, will support greater public disclosure of prices of medicines and other health-related products. This information should help to reduce the prices of these products, now needed also for rising levels of chronic conditions such as cancers, hepatitis and diabetes, many of which are too costly for universal access in low and middle income countries.
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The resolution was thus welcomed by African countries. It needs to be further monitored for its implementation to assess if it achieves its purpose and goal in relation to universal health coverage (UHC). At the same time, as raised by PHM during a debate at the WHA on UHC, accessing medicines also depends on investing in comprehensive primary health care. Further, as was the original intention of Alma Ata, we need to apply human rights-based and comprehensive approaches not just to treating disease, but also to ensuring health. As we address issues of transparency and of responsiveness to emergencies, that also depends on a deeper redistribution of power and wealth.
You can read more about PHM ‘watch’ activities and findings in the Global Health Watch at https://www.ghwatch.org/wha72 . Commentaries, statements and policy briefs can be found on the WHO Tracker at https://who-track.phmovement.org/.
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.
Isaac is a 20 year old with aspirations of a better life. He came to urban Harare a few years ago after finishing school to start a new life. In his life in the city he has done this in ways he didn’t predict. He lives as a lodger in a small, smoky backyard shack and earns money from gathering and selling plastic waste. His most prized possession is a smart phone that is his link to friends, humour and, when he can afford data, to social media and market ideas. Behind a ‘healthy’ appearance he hides stress, hunger, worry about his future and frustration that he cannot afford the food, services, entertainment and life that he sees around him in the city.
Our growing cities are full of such young people, in urban areas that concentrate opportunities, information, social connections, ideas, enterprise, wealth, technology and services together with substandard living environments, pollution, food and income insecurity, violence and exclusion.
Published evidence shows that these risks and benefits are unequally distributed amongst urban residents. Recent migrants, residents of informal settlements and those living in informal housing, as lodgers or ‘backyard shacks’ have a vastly different experience of urban life than wealthier, more secure groups. These urban conditions pose particular challenges for people at different stages of life, whether as children, adolescents, adults or elderly people. We have for decades measured and implemented measures to address the social gap between urban and rural areas, with the disadvantage in the latter. However the growth in poverty and disadvantage and rising inequality within urban areas now demand attention. Published evidence appears to chase, lag behind or miss the rapid, diverse changes taking place in urban areas and is often silent on the features of urbanisation and social assets that promote wellbeing.
In 2016-18 we gathered and analysed diverse forms of evidence and experience on the social distribution of health in urban areas and on the opportunities for promoting health and wellbeing. In Harare, with the Civic Forum on Human Development and Harare youth, and in Lusaka, with the District Health Office and Lusaka youth, we listened to the perceptions and experiences of young people (18-25 year olds) from diverse settings and socio-economic groups in these two cities. We explored how far their experiences were captured in the evidence we collect across the countries in the region.
For young people in Harare and Lusaka, ‘health’ was a biomedical concept, linked to ‘absence of disease’, and to the various problems they see their health services treating. Indeed, the ‘health’ data we routinely collect in our region also commonly focuses on mortality, morbidity and negative indicators such as suicide and obesity, and on immediate determinants of these diseases such as food, water, sanitation, education and health care. This is problematic for young people like Isaac. They appear to be in ‘good health’, despite lacking decent standards of many of these immediate determinants, but this hides the mental and social challenges they experience, and ignores conditions and determinants that have longer term effects across their lives, including for the rising burden of chronic conditions and the growing challenge this poses to our urban health services.
For young people in Harare and Lusaka, having secure incomes, opportunities for entrepreneurship, education, shelter, public spaces, participation in government decisions and self-esteem were important for them to be and remain healthy. They believed these issues would become more challenging in the future, envisaging that as the city grew, it would become more competitive and overcrowded, threatening resources for health, including green spaces. Cities would demand even more of young people’s capacities for innovation and entrepreneurship, with a diminishing, rather than an increasing level of social solidarity.
How ready are we to address these concerns? The indicators we collect across the countries of the region provide a picture of disconnected facets and fragments that weakly reflect the combined current and future impact of these features of urban life on the different groups in the city. Not surprisingly, therefore, the systems and services that respond to them are also segmented and silo’ed. In 2016, the World Health Organisation (WHO) and UN Habitat suggested that we need to reclaim a more multidimensional understanding of equity to address the challenges in urban areas.
So what would such a more holistic, integrated and affirmative approach look like? One starting point may be to go back to the first principle of the WHO Constitution, that health is not merely the ‘absence of disease or infirmity’, it is “a state of complete physical, mental and social wellbeing. A concept of ‘wellbeing’ – or ‘buen vivir’ as applied in some countries – holds the potential to integrate psychosocial, social, time use, political, material, economic, service, governance and ecological determinants, all of which are affecting urban health.
By bringing them together, the concept draws attention to what balance (and imbalances) we are generating between these different dimensions of wellbeing and the current and future consequences of imbalances. The structural adjustment programmes exposed the inequalities that grow when economic strategies pursue growth at the cost of social deficits. The recent global student school strikes over climate justice point to young people’s concern that decisions made globally are dominated by certain economic interests to the cost of the degradation of nature and extinction of species. Achieving equity in wellbeing takes us beyond measuring and closing gaps between different groups of people to the strategies needed and assets we have to use to redress the imbalances that are generating these gaps and that have long term consequences.
The health sector has tried, through ‘health in all policies’ approaches, to persuade other sectors to adopt policies that promote health. To some extent this is still seen as a ‘health sector’ campaign, often taking place in parallel with increasingly biomedical personal care services and declining investment in public health capacities and authority.
In contrast, we found many integrated, collaborative approaches addressing these imbalances and the issues raised by Harare and Lusaka youth in different cities globally, from participatory urban planning in Kenya, to strengthening community safety in Honduras, environmental regeneration and urban agriculture in Brazil and urban youth collaborative engagement on school reforms in the USA. They point not only to the importance of public spaces for bringing together diverse services and interventions in area-based approaches, but also to the opportunities that exist in urban areas for encouraging local competencies and innovation and for facilitating the involvement of affected residents, like Isaac, as knowledge producers and participants in planning and action for health and wellbeing.
More detailed information on the evidence and processes referred to in this oped and the different people involved in this work can be found in EQUINET Discussion paper 117 Responding to inequalities in health in urban areas: Report of multi-method research in east and southern Africa, http://tinyurl.com/y3dv4pvm and other reports referred to in that document.
A little over 20 years ago the health and social inequities within our region and the opportunity to act on them motivated the founders of EQUINET to come together as an ‘equity catalyst’. The intention was to bring together our collective knowledge and experiences and to explore the challenges and possible solutions to the broad range of economic, social and environmental factors that determine the opportunities for and deficits in health in our region. Since then, we have built evidence, analysis and dialogue in different communities across the region on where and how to reclaim the resources for health, including through comprehensive, primary health care oriented, people-centred and publicly-led health systems.
Participating for EQUINET at the fourth People’s Health Assembly (PHA4) in Savar, Bangladesh in November last year we found that the People’s Health Movement (PHM) and the over 1200 participants from 80 countries raised the same demands that we are raising in our region. Yes, there has been growing wealth in the world over the last 20 years, improved access to information and technological innovations, and some people have seen improved life expectancy and falling infant mortality. But the reality is that health is anything but ‘healthy’ at a global level.
As PHM’s Amit Sengupta succinctly put it: “Eight people in the world have more wealth than 50% of the world population. Medicines exist, but only for some. We are seeing massive migration of populations in search of a more secure life. Our planet stands on the edge of destruction, while our health is for sale in the market.” We shared evidence at PHA4 of how the majority of people are not even able to meet their most basic needs for health and of how inequality within and between countries and regions in the world has grown and not fallen over the past decades. .
Why is this? Delegate after delegate at the PHA4 answered this question with a scathing critique of the neoliberal policies that have dominated the world order for the last four decades. From different countries people pointed to how a neoliberal ideology, which favours the unrestricted flow of capital between countries globally, drives minimal government social spending and limits regulations on the activities of private transnational corporations, has massively impacted on the health of people throughout the world.
This situation makes having a strong, vocal World Health Organisation (WHO) important. But in a plenary session at PHA4, David Legge explained the crisis in the WHO. When it was formed in 1948, its main funding came from its member states, who paid ‘assessed contributions’ according to the size of their population and their economy. Since a 1980 vote in the World Health Assembly to freeze assessed contributions, today only 20% of WHO’s budget is from member states – barely enough to cover their administrative costs – while the remaining 80% comes from voluntary contributions from member states, intergovernmental bodies and to a large extent from philanthrocapitalists like the Gates Foundation, often tied to particular programmes.
As a consequence, David raised that WHO’s work is controlled by these external funders rather than by its assembly of member states, affecting its independence and distorting its priorities and the coherence of its programmes. This has had a profound impact on WHO’s ability to support the implementation of comprehensive primary health care as set out in the Alma Ata Declaration and adopted by 134 countries in 1978.
It has also weakened the protection of health by other global actors. Many conversations in the PHA4 were about the impact of trade agreements on health. Jane Kelsey, a New Zealand lawyer, gave a shocking expose on how new generation agreements between countries and multinational investors are often negotiated in secret, preventing legislatures and the public from getting information on or regulating the health impacts of these corporate activities. She cautioned that this practice could lead to longer monopolies for medicines, to kerbing restrictions on standards for food and alcohol and for tobacco labelling, and to limits on governments’ ability to regulate private hospitals. Such agreements have led to situations where foreign investors can sue governments if state regulation in areas such as patents, mining licenses, privatised water contracts and health insurance substantially affect their profits. In 2017 alone 65 such claims were laid against 48 countries, with the sums claimed ranging from USD15million to USD1.5billion. These court cases can act as a form of intimidation of governments who try to put the health and wellbeing of their citizens ahead of corporate interests.
While this situation can leave us feeling despondent, in contrast PHA4 left us energised as we shared experiences of action and resistance from local to international level. At PHA4 we found a growing understanding that if we want change we will have to shape our own future, building alliances between community and civil society groups, academics, civil servants, journalists, international organisations and others.
We have seen evidence of this in our region. The successful campaign for universal access to antiretrovirals undertaken by the Treatment Action Campaign in South Africa in the 1990s, for example, saw such an alliance challenging the ethical basis for restricting global access to medicines. We heard at PHA4 about similar national and global struggles to campaign and litigate on critical issues related to the quality of and access to healthcare, to stop mining interests harming health and to advocate for more democratically led global health governance. These struggles for health are struggles for a more caring world.
EQUINET is taking forward and is part of this in our region. We are building collective ideas and action in a range of areas, including on the health effects of our extractive industries, on food security, on living and social conditions, on comprehensive primary health care and our laws and rights in health. PHA4 showed us how many activists there are in the same struggles in all corners of the world and that working at all levels, locally, nationally, regionally and with our comrades internationally is more important than ever.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. Read more about PHA4 at https://phmovement.org/peoples-health-assembly-dhaka-3/
In the same month that it reaffirmed the 1978 Alma Ata Declaration’s commitment to “the fundamental right of every human being to the enjoyment of the highest attainable standard of health” in its October 2018 Declaration of Astana, the World Health Organisation (WHO) launched, with much fanfare and hubris, its “first investment case” for 2019-2023, as a proposal that could “save up to 30 million lives”.
Despite the rhetoric of the Astana Declaration, the WHO appears to be in a political moment where it is under pressure to justify, in economic terms, its existence as a global governance structure for health. To convince the doubting reader, the investment case promised “economic gains of US$ 240 billion” as the return to be made on increasing annual country contributions by US$10 billion to enable the WHO to meet its annual budget of US$14 billion.
Two things are striking. Firstly, the investment case purports to lay the basis for “a stronger, more efficient, and results-oriented WHO …and … highlights new mechanisms to measure success, ensuring a strict model of accountability and sets ambitious targets for savings and efficiencies.” This is the language of the private sector.
There is nothing wrong with working more efficiently, but the WHO should be placing health equity and human rights at the centre of its work and should guard against efficiency and managerialism coming at the expense of equity and social justice. The bureaucracy and inefficiency of the WHO needs addressing, but the idea that the solution lies in the application of New Public Management is a political choice, rather than a necessary outcome of clear analysis.
Secondly, the parlous state of WHO funding is not a coincidence. It is the result of a systematic decline in assessed contributions by member states, particularly the United States, over past decades. Whereas assessed contributions were 75% of WHO’s budget in 1971, the Peoples Health Movement and others showed in 2017 that this is now about 25% of the institution’s budget and that countries that do pay, choose to put most funding into voluntary contributions. Voluntary contributions can be tied to particular programmes, meaning countries can determine the work of WHO through funding dependence. WHO’s budget has also been stagnant for the past eight years, which is why the organisation now has to go cap-in-hand, clutching a seemingly miraculous investment case argument, to beg for the budgets it has been starved of for the past decade.
It is astonishing, but deeply revealing, that the WHO has to justify human life in monetary or investment’ terms. Who would have thought the Constitution of the World Health Organization which 70 years ago heralded the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being would end up in such abysmal decline?
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. The WHO Investment case referred to in the editorial can be found at https://tinyurl.com/yavqzjvk