Population health deals with health beyond the individual. It addresses the combined impact of social determinants such as environment and social structure and includes health care. With the role of pharmacists traditionally centering on the supply and distribution of medicines, pharmacists, particularly in low and middle income countries, have been viewed as having little to do with population health. Yet ironically, the community pharmacy is often the first port of call for most people with minor ailments. Pharmacists are thus strategically positioned to provide essential services that promote, maintain and improve the health of the population in the broadest sense.
Pharmacy is an age old profession that deals with the science of making and administering medicines. Over the years, the profession has evolved to encompass a wide range of service areas. In high income countries these areas and roles are well defined and structured. In low and middle income countries, this is not the case. Often pharmacists in these counties have to carve their own individual career pathways that may not bear any relationship to their professional training. In most cases however, pharmacists in low and middle income countries work in dispensing roles, mainly in community pharmacies.
In high income countries, pharmacists routinely engage in public health programs such as disease screening, pregnancy testing and counseling, immunization and counseling for at-risk populations among others roles. In lower income countries, where ironically the need is greater, pharmacists’ involvement in population health is at best minimal.
Economic growth in low and middle income country economies is taking place at a rate faster than ever, but key health and demographic indicators remain stunted. The time is ripe for the profession of pharmacy to stand up and be counted, and for pharmacists to play a more central role in population health.
The community pharmacy holds a number of benefits as a setting for public health interventions. With extended opening hours and no appointment needed for advice, community pharmacies are more accessible than other settings. In some high income countries it has been reported that on average at least nine in every ten residents visit a community pharmacist at least once a year. In lower income countries, even though this frequency may be smaller, the services that local pharmacies provide to the community could have much greater impact. For instance, community pharmacies could be a source of information related to health and well-being that could have far-reaching impact in communities that lack access to such information. Clients who visit a pharmacy to seek information may also obtain other products they need, giving a return to both the pharmacist and the client.
For pharmacists to assume population based roles both they as a profession and the community they work in need to believe that they are capable and suitably trained for it. This calls for a change in the way pharmacists are viewed and ere behave. Pharmacists must be comfortable with roles in population health and view them as opportunities. Studies have reported that while pharmacists valued population health functions, they were more comfortable with achieving health improvements through medicines. There is thus need for interventions to improve the confidence of pharmacists in using their skills for population health. From the community side, the public need to shift their view of pharmacists to see them as professionals that are also involved in population health services.
There are many ways that pharmacists could be involved in health promotion. They could carry out or be involved in education programmes on safe and effective medication as well as on other community health-related topics, such as exercise, health and nutrition. In major cities in Africa where pharmacies are readily accessible, this is a ready-made opportunity to provide valuable information on HIV and AIDS, on teen pregnancy and on other health risks. The increased use of the emergency contraceptive pill in some Africa countries may make people less concerned about pregnancy, but raise the risk of HIV transmission, undermining prevention programmes. On issues such as these, pharmacists should be in the frontline of providing information and protecting the public from such unintended consequences. Pharmacists can be involved in educational programmes that start at an early age, such as through school health programmes, to help children develop good health practices that can continue into adulthood. Their education programmes could also reach out to community leaders, legislators, regulators, public officeholders, school officials, religious leaders among others.
We also suggest that pharmacists participate in population health policy development. By linking social factors, lifestyles and the environment, in a holistic manner, to utilization of medicines, pharmacists can broaden the scope of prevention and population health. They can ensure that policies are formulated with a better understanding of the relationship between drug therapy and the many other factors that affect health outcomes.
These are some examples, and we propose that there be wider dialogue on how pharmacists can play a vital role in maintaining and promoting population health, especially in low and middle income countries. This should include participating in global, national, state, and institutional efforts to promote population health and integrating these efforts into their practices. There should be a role for pharmacists in improving community health through population-based care; in developing disease prevention and control programs; in providing health education; and in collaborating with local authorities to address local need.
To achieve this, the onus is on the profession to view such roles as opportunities and not as unnecessary burdens, and to take the next steps.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org, http://www.muchs.ac.tz/ and www.pharmasystafrica.com
Editorial
Walk into many international meetings on health in Africa and you will hear discussion on development aid, and international support for programmes to respond to major diseases. The Global Forum for Health Research (Forum 2012) held in Cape Town had a different focus: it provided a platform for how countries across all income groups could invest in research and development (R&D) as a source of innovation to meet their health needs and as an investment in development and job creation.
Held under the title “Beyond Aid: Research and Innovation as key drivers for Health, Equity and Development”, Forum 2012 was organised by the Coalition on Health Research for Development (COHRED), which merged in 2011 with the Global Forum on Health Research (GFHR).
Dr. Francisco Songane, Chair of the Steering Committee for Forum 2012, reflected “There is a misconception that developing countries rely on international aid. National Governments may find it hard to meet targets for R&D spending, but they remain the major funders of research”.
Naledi Pandor, South African Minister of Science and Technology and co-host of the Forum confirmed this and the power of investment in R&D. She observed that “the ability to cycle between the laboratory, clinic and field site provides a very powerful platform for translational research”. Investing in this link in South Africa gave the country an advantage over countries that focused on the basic sciences or clinical research, but not both. According to Minister Pandor, this positions South Africa to respond to health need and to emerging markets in Africa, to advance African-led innovation in drugs, diagnostics, vaccine development and other product-oriented innovation, including in relation to gene therapy, cell therapies and tissue engineering.
Dr Songane, Dr Carel Ijsselmuiden, executive director of COHRED, and other speakers at the Forum raised that achieving these synergies between innovation and economic and social benefit means that “we, in the health sector, need to open the doors of our community, and actively work with the other sectors”. They proposed that we need to shift from an aid paradigm to negotiating investment in and benefit from R&D in health.
The Pharmaceutical Manufacturing Plan for Africa, adopted by the Summit of the African Union in 2007, was raised as a promising example, with its emphasis on a coordinated approach to local medicines production based on countries needs. The research agenda to support the plan seeks to produce evidence on the productive capacities, intellectual property, political, geographical, economic and financing issues that affect the manufacture of medicines, to inform the necessary interactions across multiple government ministries, regulatory authorities, financial investors and private and public research, development, teaching and healthcare delivery institutions.
The Forum also raised issues of equity, at both global and regional levels.
Firstly there are inequities in the current distribution of both capacities to invest and in the sharing of benefits from investments in R&D. For example, Carel Ijsselmuiden pointed to a recent report on the impact of sequencing of the human genome. This report demonstrated that the potential economic return on the initial investment had gone to the global north, rather than the south, where there was no capacity to build on knowledge produced by the project. "The south has to develop the capacity to compete in this type of domain," he said. "The continuing emphasis on aid may stop us seeing this new picture of the world that is emerging."
‘Beyond aid’ should be taken to not mean ‘beyond solidarity and fairness’. In the past the GFHR has drawn attention to the highly uneven distribution of resources for health research between high and low income countries. At regional level, Forum delegates in various sessions pointed, therefore, to the need for collaboration and pooling of resources and knowledge within and across regions, to avoid a widening gap. The technological possibilities for such collaboration are growing. As stated by Dr Songane, “new communication technologies are making up for a lack of infrastructure and resources. The possibilities are exciting – virtual collaboration, sharing of data, and the use of mobile health technology to reach even remote rural areas”.
At global level, a Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG) established by the World Health Assembly (WHA) has in 2010 been examining the current financing and coordination of R&D globally, particularly in relation to neglected diseases and the needs of developing countries. In its report (www.who.int/phi/CEWG_Report_Exec_Summary.pdf) the CEWG proposed minimum shares of gross domestic product to be set for government funded health research and a global convention to address issues of equity and sustainability in financing for R&D. Minister Pandor welcomed new models, like UNITAID’s patent pool for AIDS medicines, which allows generics producers to make cheaper versions of patented medicines by enabling patent holders to license their technology in exchange for royalties.
Raising a second dimension of equity, young researchers at the Forum raised in a communiqué that work on R&D must be framed as a public responsibility, given that health is a human right, and must thus reach and benefit all communities. Youth and other delegates raised that communities’ local or indigenous knowledge should be respected, protected and integrated within research and knowledge systems, and innovations developed in ways that ensure fair partnerships, sharing of evidence and benefit, and collective, social entrepreneurship.
Further, in a session on the Equity Watch work in EQUINET, presenters from research institutions, Ministries of Health, regional and international agencies in east and southern Africa pointed to the need to overcome inequities in access to already known technologies for health, including the housing, food, water, primary health care and other key social determinants of survival. Their country and regional analysis highlighted economic growth paths that raise inequity in access to these resources, such as through unplanned urbanisation, insecure employment, or poor investment in small holder farming. They also presented evidence of public policies and measures within the health system and in other sectors such as education that close the gap.
Forum 2012 called for a different mindset, for innovation and research to be given more attention, given their role as drivers of health, equity and development. Discussions in the Forum raised that equity in health, while desired, cannot be assumed to be an outcome of research and innovation. It is also not adequately addressed by aid. The policies and measures for ensure equity as an outcome- whether through fair sharing of benefits, solidarity and collaboration on capacities and resources, inclusion of communities and their knowledge, or equitable access to existing technologies for health - need to be explicitly negotiated, implemented and monitored.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit http://www.forum2012.org/presentations/ and www.equinetafrica.org
Following meetings of senior African education sector officials, experts and stakeholders on the eve of the Conference of Ministers of Education of the African Union (COMEDAF) in April in Abuja, Nigeria, the Africa Public Health Alliance and 15% plus Campaign called on African Education Ministers to prioritise the development of an African Multi-sectoral Human Resources Development Plan as a pre requisite to meeting Africa's development goals.
In a statement by the organisation, its coordinator Mr Rotimi Sankore stated that "While universal free, or affordable education is a development goal in its own right, the education sector also has a special role in developing the human resources that are a pre-requisite for meeting all of Africa's overall development goals"
Elaborating further he observed that in virtually every key sector of the economy and society, most African countries are operating at between 25 percent to 75 percent of the required human resources capacity, with the health sector particularly affected. Citing the conference host country Nigeria as an example, he noted that Nigeria has only about 25 percent of the doctors it needs, about 45 percent of nurses and midwives, and about 12 percent of pharmacists, a feature linked to poor performance in key areas such as maternal and child health.
With similar or worse gaps in various areas such as the engineering fields, it's no surprise that many African countries are lagging behind in overall human and social development.
Along side this is the crucial matter of overall poor investment in health, human and social development issues, with 33 African countries investing well below $40 per capita in health, compared to Cuba at $642 per capita, or Costa Rica at $413 per capita, both countries closer to African country development levels but with better health outcomes.
As the Africa Public Health Alliance 15% + Campaign we note that even if we suddenly had all the financial resources required for health services tomorrow morning, we would well find that most African countries do not have the human resources capacity to effectively absorb and utilise the financial investment.
No entrepreneur will ever purchase a hundred airplanes for an airline, and then employ only twenty five pilots and expect the other seventy five planes to fly. Yet this is the scenario in most African countries, where there is a strange expectation that we can meet the Millennium Development Goals and other development targets without the pre requisite human resources and infrastructure.
Considering that Africa's population is set to double from current one billion to two billion by 2050, it is imperative that Africa's education ministers work with other sectors of economy and society to prioritise in each country and at reqional level, the development of a Human Resources Development Plan that identifies what level of human resources are required for each sector, what is currently available, and what policy and investment is required to fill the gaps in the shortest possible time.
Public statement of the Africa Public Health Alliance 15% + Campaign 25 April 2012 at the Conference of African Ministers of Education Abuja 26/27 April 2012. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please contact media@africapublichealth.net.
This newsletter includes the Istanbul Declaration, adopted by delegates to the first Global Human Development Forum in Istanbul in March 2012. The Declaration calls on the world community, gathering soon at the United Nations Conference on Sustainable Development (Rio+20) in June 2012, to set and implement global and national development strategies that emphasise social inclusion, social protection, and equity. This is in recognition of the fact that economic development has too often gone hand in hand with environmental degradation and increased inequality. Who sets those development strategies matters. One paper in this newsletter points, for example, to the disproportionate power over the global economy of just over 100 transnational corporations. Another questions the influence of private wealth in the underfunded global 'protector' of public health, the World Health Organisation. Within such asymmetries of power and influence the work at Rio+20 cannot end with aspirations. It also needs to tackle how institutions and processes need to change to deliver on these aspirations.
Pneumonia is one of the top five deadly diseases for children in Malawi. It causes more deaths than measles, malaria and AIDS combined. Infection with Streptococcus pneumonia and can cause a range of illness, from relatively mild ear infections to fatal pneumonia, meningitis and sepsis. It was estimated by Ministry of Health in 2011 that childhood pneumonia accounted for 18 percent of deaths of children under five years.
This death is avoidable and unnecessary. Childhood pneumonia is preventable through living in a well ventilated housing, avoiding indoor pollution through using improved stoves, pot lids and clean fuels among other factors. It can also be prevented with a simple vaccine.
In November 2011, World Pneumonia Day, Malawi launched and added the new pneumonia vaccine (Pneumococcal Conjugate Vaccine (PCV 13) to its routine immunization chart. Bright Masangwi Chisale (male) was the first child to receive the new oral vaccine in Lilongwe-Malawi. His immunization was presided by Malawi’s Minister of health Hon Dr Jean Kalirani. In 2012, 1.2 million Malawian children under the age of one will be vaccinated against pneumonia. This is being co-financed by the Government of Malawi, with government putting in $0.20c per dose and the Global Alliance for Vaccine and Immunization(GAVI Alliance) putting in $11.17 over three years for each of the 1.2 million children immunized to cover the systems, vaccine and outreach costs. These are huge investments and their effectiveness will need to be tracked in the expected improvements in child mortality.
Vaccines are one of the best technical options for disease prevention. Many vaccines, not all, protect a child for a lifetime. As they are one of the most cost effective interventions to prevent illness, they should be given priority in the allocation of resources, particularly in a low income country like ours with many competing health priorities.
However without GAVI support the introduction of the vaccine would not have been possible as the cost would have been too high. It is encouraging that in 2011 vaccine manufactures gradually reduced vaccine prices. However the costs remain high. Malawi pays 15 cents to 20 cents per dose for its vaccines. But it is estimated that the vaccine for pneumonia cost $2.50 to $3.50 per dose. With Malawi’s total government expenditure on health at $22.00, this cost would be unaffordable. Unless there are further reductions in vaccine price it will be difficult for countries like Malawi to afford these effective technologies to prevent childhood and adult mortality, without depending on external funders.
Even the most effective vaccines will only have an impact if they are actually made available to the children who need them. The need is clearly higher in low income countries like Malawi. So should the funding of vaccines be a matter of ad hoc external funding? Or should vaccines rather be considered a global public good, to be funded more predictably at global level, and equitably allocated to countries based on their populations and need.
It will then be up to the country to ensure vaccine outreach. Low income countries like Malawi are able to achieve high vaccination coverage rates through primary care services and outreach campaigns. Malawi has achieved such high coverage as immunization services are administered by the cadre closest to communities, the Health Surveillance Assistants (HSA), who are trained to administer the vaccine. These cadres are found in the most hard to reach areas, and are given support from Ministry of Health. While the programme has support from World Health Organisation, UNICEF, the GAVI Alliance and civil society, the delivery system through primary care cadres is a primary responsibility of the government.
It is possible to ensure that no child dies from a vaccine preventable disease. However this needs the vaccine industry to continue to make vaccines cheaper and more accessible. It needs global level funding for vaccines with a mechanism for predictable and equitable collection and allocation of global funding of vaccines as a public good. It needs governments to resource a health system that ensures a chain of delivery of the vaccines to the community level cadres and facilities, and to all the adults and children who need them. It needs communities to take up the vaccines.
While the discussion today is on the vaccine for childhood pneumonia, tomorrow it may be other vaccines, such as those for malaria, typhoid or dengue fevers. It is a welcome development to hear that malaria vaccine trials are showing positive results in the sites where they have been tested. A vaccine for malaria will be a major contribution to public health in Africa.
Vaccines alone are not enough to solve all of our persistent health problems. We still need to focus on the deeper causes such as improving indoor air quality, improved nutrition, improved case management/ treatment and strengthening health systems, as this will produce much wider and long term health gain than vaccinations. However, ensuring access to pneumococcal vaccines should be something we do today to protect children’s right to life.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org
In the 1990s and early 2000s leaders of African countries persistently called for compensation for the loss of publicly trained health workers from low income African communities to the high income communities of Europe, North America and Australia. A November 2011 British Medical Journal paper by Edward Mills et al reported on the magnitude of the loss to health worker training investments in African countries to be US$2.17bn, ranging from $2.16m for Malawi to $1.41bn for South Africa. At the same time the benefit to destination countries of recruiting trained doctors was estimated at $2.7bn for the United Kingdom and $846 mn for the United States.
Despite acknowledgement that migration is driven by social, political and economic causes, it was deemed justifiable to take actions to more fairly manage these flows and their consequences. African countries made submissions in various international forums for governments of destination countries to notify governments of source countries on the number of health workers employed, their professional status and their contractual rights and obligations, and to provide equal treatment to migrant and local health workers. In addition, the African countries urged for restrictions on unethical recruitment and employment practices and proposed that compensation for losses from permanent migration could be organised through investment and tax remittance arrangements, and through technical and other resource inflows to support health professional training in Africa.
Responding to these pressures in the context of a crisis of health worker shortages in many African countries, in 2004 the World Health Assembly resolved to develop a multilateral response through a non-binding code of practice on the international recruitment of health workers. After consultation and negotiation, the Code of Practice on the International Recruitment of health workers was adopted at the 2010 World Health Assembly, almost 20 years since the World Health Organisation members agreed on such a code, the 1981 International Code of Marketing of Breast Milk Substitutes. Strong compliance by African countries with provisions of this code would advance us towards the diplomatic “finishing line” in the effort to more fairly manage health worker migration.
Regrettably however, by June 2011 (the latest reporting available) only 48 countries had reported even their National Authority for the code to WHO, with only 13 of these from Sub-Saharan Africa and only seven from the 16 in east and southern Africa (Kenya, Mauritius, Swaziland, Uganda, Democratic Republic of Congo, Angola and Namibia). More may have reported since then. The low reporting of even this administrative information raises concern about how far the code is known and implemented, and whether the reporting at the 2012 WHA will be an active tool to raise both its positive impacts and its shortfalls, or a passive bureaucratic ritual.
The 2010 code sets out the responsibilities, rights and ethical responsibilities of stakeholders to ensure fair recruitment and equitable treatment practices for the health workers who would have migrated, including to avoid recruiting health workers within existing domestic contractual obligations. Health workers are also obliged to be transparent about their contractual obligations.
In relation to health workforce development and health systems sustainability, the code discourages active recruitment from countries with critical health workforce shortages; encourages utilization of code norms as a guide when entering into bilateral, regional, and multilateral arrangements to further international cooperation and coordination; identifies the need to develop and support circular migration policies between source and destination countries; encourages countries to develop sustainable health systems that would allow for domestic health services demand to be met by domestic human resources; and places particular focus on the need to develop health workforce policies and incentives in all countries that support the retention of health workers in underserved areas.
The code appears to be a milder instrument than what African countries pushed for given that it is not legally binding. Its voluntary nature makes it a weak instrument as there are no specific commitments to return investments in stabilising the socioeconomic conditions of health workers or supporting training in low income countries. The code has become ‘the response’ to policy discussions on the relative costs and benefits of health worker migration. It does not fully address the African concerns that motivated to its negotiation and final adoption, but its presence has curtailed further discussion of these concerns.
One of the measures to assess the impact of the code is through monitoring its implementation and tracking the action taken by WHO member states. Member states are obliged to report to the WHO Secretariat on their actions on the code every three years, beginning in 2012. Given that the code is not fixed, and that its contents are considered as dynamic and subject to review, monitoring becomes one of the tools for keeping alive issues and concerns that were not fully addressed.
With the WHA only three months away, states, civil society and health worker associations should look for signs of progress, or otherwise, in the areas covered by the code, and ensuring that these are raised at the Assembly. Some of the questions this raises are:
Are there national coordination mechanisms for all relevant stakeholders and partners to facilitate policy dialogue and implementation on health workers?
Has there been any development of policies and practices since 2010 encouraging circular migration (such as migration within countries in east and southern Africa) and return migration from destination countries?
Is there policy or law requiring recruiters to follow ethical recruitment practices that covers state and private and non state actors?
Are there positive developments in collaboration of source countries and destination agencies or countries to sustain health worker development and training? Are there any new bilateral, regional, multilateral arrangements – soft law instruments – on health workers between source and destination countries?
Are there any new development assistance efforts (including mechanisms for compensation) to support coordination and collaboration on health worker migration between destination and source countries?
Are the regional bodies keeping and publicly reporting an annual scorecard of performance in the region against the agreed key indicators?
If the feedback on these questions indicate that the global code, as has been the case for many of its international precursors, is a useful signal of policy intent but not effective for managing costs and benefits, then the initial demand of the African countries for a more fair deal on the migration of health workers fairness still needs to be raised and addressed. African countries should use the forthcoming WHA in May of 2012, to strongly scrutinize developments around the implementation of the code. The results of this first assessment should help point towards concrete action to be taken on the implementation of the code.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org. For further information on the code visit http://www.equinetafrica.org/bibl/docs/Polbrief28%20Code.pdf
The number of people in the global South without access to adequate basic services is staggering, not least in Africa. For more than two decades, international financial institutions have prescribed private sector participation as the remedy, often with disastrous consequences. Recently, critics of this approach have given new visibility to ‘alternatives to privatization’ to counter this trend.
Although the debate about alternatives to privatization in the water sector has been particularly dynamic, the health sector has been slower to recognize and promote new models. Similarly, Africa has developed fewer alternatives than Asia and Latin America – although the African health sector has seen some innovative community health insurance schemes and reliable non-state provision on a not-for-profit basis.
The Municipal Services Project (www.municipalservicesproject.org) is at the forefront of such research and action, and is releasing a new book this February – Alternatives to Privatization: Public Options for Essential Services in the Global South – in an effort to stimulate further debate and research in this field. The authors who contributed to this book address questions of what constitutes alternatives to privatization, what makes them successful (or not), and what lessons are to be learned for future service delivery debates. The analysis is backed up by a comprehensive examination of initiatives in over 50 countries in Africa, Asia and Latin America, looking at three sectors: electricity, health care and water/sanitation. As the first global survey of its kind, it provides the most rigorous platform to evaluate alternatives to date, and compares them across regions and sectors.
We conceive of alternatives to privatization as those involving public entities that are state-owned and operated, or non-state organizations functioning on a non-profit basis. We propose a normative set of ‘criteria for success’ to make sense of case studies because we believe that some universal claims are necessary if we are going to have a coherent global dialogue about the kinds of service delivery alternatives we want to promote. We have focused on current efforts to make public services more democratic, participatory, equitable, transparent and environmentally sound.
Equity emerges as an important criterion for alternatives because inequity is arguably the single largest concern with privatization, leaving scores of marginalized groups with little or no access to health care and other services. We are particularly interested in equity along class, gender and ethnic lines, and how public services have attempted to overcome these disparities.
Our aim has been to construct a bridge between universal criteria (such as equity) and the particularity of different locations. We recognize the unique realities of each region and the fact that there are no ideal models (in opposition to the neoliberal approach that sweeps away differences and pushes a one-size-fits-all solution). Uganda is not Uruguay is not Ulan Bator, but there are core values and objectives that underscore our definitions of what it means to provide a successful public service and consistent ways to evaluate this success.
Africa may be the weakest region in terms of such successful initiatives, as identified by our researchers, but there is robust popular resistance to privatization and it may play to the continent’s advantage that lessons can be drawn from experiments in other parts of the world.
In the chapter on alternatives to privatization in the African health care sector – African Triage – Yoswa Dambisya and Hyacinth Eme Ichoku identify and evaluate promising models for more equitable health systems. First, they explore community-based health insurance schemes (or mutuelles de santé), which aim to extend benefits to populations excluded from traditional social protection programs and operate on voluntary and non-profit bases, promoting principles of mutual aid, solidarity, and pooling of risk. These systems offer protection from catastrophic health costs and facilitate cross-subsidization. In Rwanda and Tanzania, it appears that such schemes would increase the chances of seeking assistance from formal health care providers rather than opting for self-medication or traditional healers. Ghana also developed an interesting alternative at the community level, sending nurses to live in villages to reduce barriers to geographical access, and setting up local health oversight committees. However, these schemes can also suffer from limited revenue due to low population coverage and can result in a situation where the poorest cross-subsidize the less poor. In short, these types of insurance models can complement, but not substitute, strong government involvement in health system financing.
Second, Dambisya and Ichoku review national health insurance schemes. These are more formal than community-based models but also allow pooling of risk and cross-subsidization of health services, equalizing financial access. Important shortcomings are that they do not erase geographical barriers, leaving rural populations at a disadvantage, and that they cover those in the informal sector last – even though these groups are probably the neediest. Further, such initiatives may not be viable where there is rampant corruption and high mistrust of authorities, as the failure to implement plans for national health insurance in Uganda and Zimbabwe may indicate.
Finally, faith-based organizations emerge as the largest single health care provider outside of government in most of Sub-Saharan Africa. Mission hospitals appear to offer the best quality care, generally operate in an efficient manner, and have stood the test of time. What may be more problematic is the issue of accountability and community participation. Policy makers should look into ways of better integrating these large players into national health systems.
Findings from Latin America and Asia present a very different picture of alternatives to privatization in the health sector, however, and offer some intriguing lessons for Africa, as do lessons from the water and electricity sectors in all regions studied. But despite the differences it is the commonalities that are most encouraging, highlighting a commitment from policy makers, frontline workers, activists and academics to a world that is not dictated by the demands of the market, celebrating public systems that work and pushing for innovative reforms where they don’t.
In the end, the book is just a start and the final chapter concludes with a series of future research and activist priorities, pointing to a long-term and exciting challenge for those committed to a world of social and economic equity.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read the book Alternatives to Privatization: Public Options for Essential Services in the Global South published in Africa by HSRC Press and available at http://www.hsrcpress.ac.za.
In recent years, many low and middle-income countries have removed user fees in their health care sector. However providing free health care is more complex than it is usually thought.
Researchers have studied these policies in Afghanistan, Burundi, Burkina Faso, Mali, Nepal to see what lessons can be learned from them. These country experiences highlight that decisions to remove user fees are often taken by authorities at the highest level in countries, sometimes during electoral campaigns. Many countries are opting for selective free health care, such as for children under five years, free delivery for mothers. This aligns access to areas of the Millennium Development Goals. It is probably reasonable, given the costs to governments of free health care policies. Leadership developed by African leaders in favour of vulnerable populations such as young children and pregnant women has to be praised. Good outcomes for these groups however require a long term commitment in terms of public resources and policies which are sound from a technical perspective.
The country assessments found, for example, that when these decisions are taken in a hasty manner, without sufficient consultation of stakeholders, including of the technicians working for the concerned ministries, health systems may experience a shock. They are found to have difficulties with coping with the increase in patients and drug shortages. Lucy Gilson, Professor at the London School of Hygiene & Tropical Medicine and at the University of Cape Town said “As leaders take important decisions to strengthen health systems for the benefit of the poorest, their engagement with communities, health workers and technicians is vital in bringing those decisions alive in the day to day practice of health care delivery”.
In contrast, when the policies are well-designed, implemented with the appropriate accompanying measures and sufficiently funded, they can improve access to health services. Funding levels are important. Insufficient funding may lead to a situation where the increased utilisation of services by the population after fees are lifted paradoxically leads households to spend more for their treatment. This happens, for instance, when there are drug shortages in free public health facilities, so that households have to buy their drugs in private pharmacies.
There are different ways to reduce financial barriers to health care. Free health care is one option. Another option is to introduce health insurance, so that any changes are paid in advance and people are charged according to their ability to pay and not their health need. Any good solution, that works for both vulnerable people and for the public budget requires a certain level of complexity. It is therefore important that leaders consult their technicians who plan and deliver services. They can help leaders to build fair, efficient and sustainable health care systems.
External funders, aid agencies and Northern Non-Governmental Organizations were also found in the country studies to play a role, such as in assisting countries to monitor and evaluate their policies, a step overlooked in too many countries. It is however important to note that any involvement of international agencies should be in full respect of sovereign choices made by low-income countries. Abdelmajid Tibouti of UNICEF New York observed for example that equity is a major challenge in many countries. “Technical and financial partners have probably a stronger support role to play, in full respect of course of options chosen by countries themselves. A first track is to network countries implementing similar policies”.
In this respect, there are some positive trends. African experts working on these issues have organised themselves in a community of practice and are using information and communication technology to share their experience and knowledge. An African regional meeting was held in Bamako in November 2011 where those involved from 10 Anglophone and Francophone countries gathered to review free care policies in maternal health. This direct exchange between countries in such communities of practice provides a critical means for learning by doing, as countries face the complex challenges of providing free health care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit http://heapol.oxfordjournals.org/content/26/suppl_2.toc to access the Health Policy & Planning supplement with the findings of the studies. You can contact the Financial Access Community of Practice at cdp.afss@gmail.com.
We always hear that maternal deaths are avoidable, yet they remain a main cause of mortality. Whenever a woman dies while giving birth, we absorb the fact as though it was normal, despite the pain caused to her family, her children and her partner. Silence engulfs the mourners and after burial, the deceased woman is registered into the records and included in public health statistics.
These are the facts: According to Cook, Dickens and Fathalla in 2003, every year more than 500 000 women die from pregnancy complications or childbirth globally, and 99 percent of these deaths occur in developing countries. According to the Road Map for Accelerating the Reduction of Maternal and Neonatal mortality and morbidity in Uganda 2007-2015, sixteen women die every day in Uganda due to maternal mortality. This means that 6000 women die every year and leads to an estimated maternal mortality rate of 345 per 100 000 live births.
This tide of death due to pregnancy and childbirth occurs for various reasons. The health sector is chronically underfunded compared to health need, leading to lack of available, well supervised trained midwives in services close to communities. Referrals for complicated cases face problems of lack of ambulances and of emergency obstetric care in referral hospitals. Health workers may be demoralized in such conditions and show poor attitudes to clients. Within communities, partners may give women inadequate support and resources to make timely use of services, especially when poorly equipped local services mean that they have to travel some distance to facilities. Participatory research carried out by HEPS (Uganda) in 2008/9 found that women get weak support in maternal health issues from their male partners.
These problems have contributed to the deaths of many women, especially the poorest women, who constitute a large share of the population. These women are also the bread winners of and carers for many rural families. The Ugandan government acknowledges in its Road Map for Accelerating the Reduction of Maternal and neonatal mortality and morbidity that maternal mortality occurs because of the three delays. The first of these is a delay in making the decision to seek care. The second delay is in identifying and reaching a medical facility, while the last is in receiving of adequate and appropriate treatment. It is a duty of government to address these delays, including any shortfalls in funding of the health sector that may be connected to the weaknesses in service delivery that lead to these maternal deaths.
In 2011, building on civil society advocacy on these three delays, the Centre for Health, Human Rights and Development (CEHURD) took a further step of petitioning the constitutional court, seeking declaration(s) that the non-provision of healthcare in government health facilities leading to the death of mothers is an infringement on rights to life and health.
The petition draws on maternal death reviews from government hospitals, where the cause of death has been cited as lack of facilities, equipment or consumables. Health workers cite that they did not have equipment for monitoring the deliveries in the theatre and labour suites, including materials like gloves, and noted that there were inadequate trained heath workers.
When complications happen, if women report late to services this reduces their chances of survival. However, the reported shortfalls in health care services have meant that even when they arrived early at hospitals, when labour pains started, women were still at risk. Two cases were cited in the petition. In one, a young woman arrived at 8:00am and died at around 9:00pm when her uterus ruptured, due to obstructed labour. In the second, the woman went to a government Health centre first before being taken to a government district hospital. She could not be saved after she had a retained twin. This woman was reported to have arrived at 2:30pm but to have not been attended to by health workers until she died just after midnight at 12:30am. In both instances, the hospital reports point to lack of basic equipment and supplies for deliveries and lack of staffing.
The petition contends that these deaths, arising from the non-provision of basic maternal health care services in government hospitals, is a violation of the right to life guaranteed under Article 22 of the Constitution of Uganda. The petition contends that the right to health under Objectives XIV and XXII is violated when government health workers and government fail to provide the required essential care during the period before and after childbirth. This happens when there is inadequate staffing for maternal health, specifically midwives and doctors, frequent stock-outs of essential drugs for maternal health and lack of Emergency Obstetric Care Services at Health Centres III, IV and hospitals.
In taking on this public interest litigation case, CEHURD, and the wider civil society groups who support the petition have acted for a wider concern in society on unacceptable levels of maternal death. Principal State Attorney Patricia Mutesi was reported on Sunday 23 October’s Monitor (www.monitor.co.ug) to have argued that a court determination would amount to usurping of power of the Executive and the Parliament to determine on economic policies. However, Mr David Kabanda, the petitioners’ attorney, said the State objection was misconceived because the matter before court is seeking for court interpretation whether the acts and omissions at the various health centres contravene the Constitution. Irrespective of its outcome, the petition has widened awareness of the right to health and social expectations on maternal health. Uganda National Health Consumers Organisation (UNHCO) has raised advocacy on the issue (http://unhco.or.ug/news) and a coalition of over 35 civil society organizations has since been formed on maternal health, which is taking up wider health issues, including budget monitoring. This coalition is providing learning and networking on health rights generally, building social activism using evidence from the real situation in health services and the social concerns in communities.
The petition sets a precedent on one of the ways of progressively realising the right to health in a resource constrained setting. It may inform the way we address other obligations and entitlements, like access to medicines. Social action through constitutionally set channels is one way society can act to prevent unacceptable death in vulnerable women and to advance health equity in Uganda.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the CEHURD website: www.cehurd.org
The WHO and Government of Brazil sponsored Conference on the Social Determinants of Health held in late October turned out to be a case study of how expectations materialized in a war of brackets added to the text of the original Rio Political Declaration on Social Determinants of Health (www.who.org ). The rich countries’ brackets and ‘toning-down-relativisation-adjectives’ won, despite fierce debate. This begs the question: Are United Nations declarations predictable?
The frustration in the halls ran so high that no less than three alternative declarations made it to the floor of the final day. One from the Peoples Health Movement (www.phmovement.org ), one from the Latinamerican Association of Social Medicine (www.alames.org ) and one from the International Federation of Medical Students’ Associations (www.ifmsa.org).
Dr Michael Marmot, chair of the Commission on Social Determinants of Health that produced the 2008 report said: …”Closing the gap in a generation is a rousing call. Did the World Health Organization’s Commission on Social Determinants of Health really believe it to be possible? Technically, certainly. …the evidence suggests that we can make great progress towards closing the health gap by improving the conditions in which people are born, grow, live, work and age. …..In the three years since ‘Closing the Gap in a Generation’ was published, there is no question that there is much to make us gloomy: the global financial crisis and the steps put in place to deal with it have worse impacts on the poor and relatively disadvantaged; the persistence of bad governance nationally and globally; climate change and inequitable measures for mitigation and adaptation and, in many countries, an increase in health inequalities….”
The weaknesses were clear. WHO Member States were reluctant to discuss or redress the power relations that year-in-year-out reproduce health inequalities. The social determinants of health cannot be addressed by just fixing policy coherence and inter-sectoral action in health as is being called for. Obscuring these realities of power under platitudes about inter-sectoral action and policy coherence across sectors only helps to perpetuate the continuing violation of the right to health. In fact there is significant policy coherence across sectors, including the health sector, influenced by currently dominant conservative economic policies which have also promoted a market approach in health care financing. Irrational global trade liberalization, capital flight and a continued unfair regime of patents, especially of medicines are clearly maintaining health inequalities. Comprehensive primary health care, with proactive community involvement, is the fundamental guide for an equitable health system. The progressive privatization of health care provision over the last three decades has seriously weakened capacities to organise comprehensive primary health care.
It is thus the stubborn combination of poor social policies and programmes, unfair economic arrangements, and bad politics that are depriving large numbers of people of opportunities to lead healthy lives. Reducing health and nutrition inequalities is critically dependent upon changes in the functioning of the global economy. Differences among countries; between social classes; between men and women; between corporations and communities result from the interaction of the different axes of power which end up critically determining which actions will be taken and which will not on the social determinants of health and nutrition. A willingness to transfer real power to communities is thus key to deal with the existing unequal power relations and with the measures taken to tip them in favour of dire community needs.
Despite the committed role all representatives of the Brazilian government and civil society in bringing out the deficiencies above, in the final Declaration, no mention was made of redressing the unequal power relations that lie at the base of the determinants. The Declaration thus proposes an apolitical agenda. In this respect it is a step back from the recommendations of the WHO Report on the Social Determinants of Health.
Peoples Health Movement and Alames in their declarations insist that the institutions, corporations and governments which promote the current state of affairs need to be confronted if there are to be any shifts in the way the social determinants of health are addressed. These declarations make specific proposals for how to do this. For example, WHO has led the way in developing a global regulatory regime for tobacco control and should do the same for the food industry. The financial sector needs to be held accountable for the economic crisis and contribute to addressing the vast resource gap in health by paying a small tax on financial transactions.
The Conference at best served for leaders to acknowledge social determinants of health as an ‘issue’. But it leaves us with the lingering question: Can the health and nutrition sector take upon its shoulders the tackling of the social determinants of health? We are the sector that picks up the pieces of a sick society. Putting our own house in order will not be enough.
The declarations referred to in this editorial are included in the newsletter. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The views expressed in this editorial are the authors. For more information on the issues raised in this op-ed please visit the website of the World Conference on Social Determinants of Health http://www.who.int/sdhconference/en/ and of Peoples Health Movement at www.phmovement.org