There is consensus that states have an obligation to ensure Universal coverage (UC), through creating and realising an entitlement for everyone to be protected against the costs of health services and to have access to the effective, quality services they need. From an equity perspective, social solidarity is essential to achieve UC, through income cross-subsidies (from the rich to the poor) so that payments are based on the ability to pay, and risk cross-subsidies (from the healthy to the ill) so that people access health services based on need and not ability to pay.
So what options do east and southern African (ESA) countries have to reach this goal? While there may be some distance before reaching UC, the choices made at this stage are critical for ensuring steady progress towards it.
The 2010 World Health Organisation’s World Health Report unequivocally states that it is not feasible to achieve UC through voluntary enrolment in health insurance schemes. A number of ESA countries are introducing community-based health insurance (CBHI) as one means of pre-payment. These schemes will not move a country towards UC, although they may temporarily assist vulnerable households until mandatory pre-payment funding increases considerably and user fees are removed. However there is a potential danger that their existence may allow governments to abrogate their responsibility to promote mandatory pre-payment funding mechanisms.
Voluntary schemes can only be complementary or supplementary to mandatory pre-payment financing mechanisms, including tax and mandatory insurance. From international experience, mandatory pre-payment funding is well over 60% (and often over 70%) of all health service expenditure in countries that have health systems that are regarded as universal.
Many African countries are now discussing or introducing mandatory health insurance (MHI) schemes. However, caution should be exercised. If MHI contributions are placed in a separate pool to benefit the contributors only (which often is the case) this creates a tiered and inequitable system that does not ensure that all have the same service benefit entitlements. If the goal is to achieve universal coverage, then it is critical to minimise fragmentation in funding pools to achieve cross-subsidies. This means that if MHI is introduced, the funds collected from it should be pooled with those from government revenue to fund benefits for the whole population.
There has also been some investigation into introducing MHI contributions by those outside the formal employment sector. This should receive more critical assessment than there has been to date, especially as such contributions are strongly regressive and generate little revenue. If there is political insistence on generating funding from those outside the formal employment sector, indirect taxes, such as VAT, are a more equitable and efficient mechanism for achieving this goal, particularly in low-income countries. However, in the context of the large income inequalities present in many east and southern African countries, efforts to improve the collection of taxes from high net-worth individuals and multinational corporations may be more appropriate. Further, some countries are generating revenue for health from royalties on natural resources such as gold, copper and oil, and not only from taxes.
There is often an almost automatic assumption that there is no ‘fiscal space’ to increase funding of health services from government revenue. It is important to critically examine this assumption.
Government revenues in ESA countries range widely from about 12% of GDP in Madagascar to 33% in the DRC, while government expenditure ranges from less than 13% of GDP in Madagascar to 33% in Mozambique. These ranges are considerably lower than the levels in advanced economies for both government revenue (36%) and expenditure (44%). Government debt levels are considerably lower in ESA countries, ranging from less than 26% of GDP in Zambia to 64% in Madagascar, than the average for advanced economies of over 100%. Given that all of these measures are expressed relative to GDP and that some lower-income countries are able to attain higher levels of revenue and expenditure, there does appear to be scope to explore increasing the fiscal space within the so-called emerging markets and low-income countries.
Health financing policy choices not only relate to how revenue is mobilised for UC. Purchasing involves determining service benefit entitlements (what services are purchased with the pooled funds and how people will be able to access these services) and how service providers will be paid. Attention should be given to more active purchasing. This requires identifying the health service needs of the population, aligning services to these needs, paying providers in a way that creates incentives for the efficient provision of quality services, monitoring the performance of providers and taking action against poor performance. Active purchasing is critical for ensuring that available funds translate into effective health services accessible to all.
Moving towards universal coverage also requires improvements in service delivery and management. In particular, emphasis should be placed on improving services at the primary health service level, which are effective in reaching the poor and which are able to address most of the health service needs of the population in ESA countries. Improving primary health services offers the greatest potential for increasing population coverage affordably. In addition, it is important to broaden the decision-space of managers at facility and district level, so that they can be more responsive to patients’ and staff needs and to the incentives created through active purchasing. Equally decentralisation of management responsibility should be accompanied by development of governance structures that allow for accountability to the local community.
East and southern African countries have some way to go in moving toward UC. The choices made at various points in the journey will be important for achieving that goal. While the detail of those choices will depend on the context in each country, international experience and regional evidence suggest that far more emphasis should be placed on government revenue funding for health services and that funds from mandatory health insurance schemes should be pooled with funds from government revenue. We also need a richer body of evidence, including from research, to support active purchasing of services and measures for addressing service delivery and management challenges, as these are essential if universal access to services of appropriate quality is to be achieved.
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 and read EQUINET Discussion paper 95: McIntyre D (2012) ‘Health service financing for universal coverage in east and southern Africa’
Editorial
Over the last eight years there has been an increased interest in the use of performance based funding to ‘strengthen’ African health systems. Performance based funding has been used in different ways in the past within countries. With its growing popularity at global level, we need to be clearer about how these funding models work in practice and how far the performance based agenda being advanced at global level integrates meaningful participation and partnership in building health systems in Africa. How much are African actors setting and shaping this emerging global agenda?
Performance based funding refers to the idea of transferring resources (money, material goods) for health on condition that measurable action will be taken to achieve predefined health system performance targets. These performance targets may relate to particular health outcomes, to indicators of delivery of effective interventions (such as immunization coverage), to the utilization of certain services (like HIV counseling and testing), or to meeting targets in relation to quality of care. Because performance based financing offers incentives for positive action, many global institutions promote it as a way to efficiently and effectively reform the way that health systems are planned, financed, coordinated and steered. This is particularly true of external funding in many low and middle-income African countries, where there is growing evidence to suggest that performance based funding is being championed by global and bilateral funders as a key innovation in health financing. Funding agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank claim that performance based funding promotes reform in a way that can also be locally owned and accountable. This argument is based on a claim that performance targets and indicators will be developed through the active participation of local actors from within various African states, rather than being set by global agencies from the top-down.
Despite increasing use of these arguments for performance based funding within global health policy, there is still a lack of consensus about what performance based funding actually means, and little evidence to support the assumed causal pathways through which diverse African health systems theoretically achieve the governance outcomes claimed. There is also limited evidence about the extent of local participation in the design of performance based initiatives, and particularly in how far African actors – governments, civil society, health services, individuals and the private sector – have participated in the design, implementation and delivery of performance based funding initiatives. It is thus not clear who is participating in shaping, deciding and adopting performance based funding agendas and goals and how these decision-making processes work. There are questions about how targets are set, who sets these targets, as well as about how ‘performance’ is measured, and what exactly constitutes ‘good’ performance.
These ambiguities raise concern about how performance based funding complements other key processes that aim to broaden participation within ‘global health partnerships.’ Partnership has, for example, become a key concept within the Global Fund, World Bank and WHO processes. Millennium Development Goal 8 refers to developing a partnership for development, and the Paris Declaration aims to increase the ability of national and local governments and stakeholders to engage with and shape health policy at national, regional and global levels. However, if we don’t know how far African actors do actually participate in the formulation, implementation and evaluation of initiatives such as performance base funding, it is unclear how far they meet these commitments towards more cooperative processes, where all stakeholders engage with and shape health policy. Given that participation is a key normative aim in debates about furthering more equitable health diplomacy, it is important to know whether and how far performance based funding, as it is currently being practiced, fulfills these normative aims and is (or is not) an effective strategy for reforming health system governance in a participatory and equitable manner.
These questions are being explored in collaborative research currently underway in EQUINET, through the University of Sheffield, Queen Mary University, the University of Zambia, the University of Dar es Salaam, the Ministry of Health Zambia and the University of Kwazulu-Natal, as one input to regional dialogue on global health partnership and equitable health system strengthening.
Performance based financing initiatives have potentially powerful effects on health systems. Their agendas and preferred performance targets become embedded in, and potentially shape, local and national forms of state governance, participation and authority. The current context of global actors devising and advancing such models makes it is critical for African actors to proactively and effectively access and engage in the processes that shape these emerging global health policies: from design (agenda setting) through to implementation and delivery. It is equally critical to know the possibilities and limits of the spaces and places for such participation, especially those provided for by global actors such as the WHO, World Bank and Global Fund .
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
A growing number of the world’s workers are invisible to mainstream occupational health and safety (OHS): The vendor in Maputo or Nairobi trading on a city pavement, the person sorting waste on Durban’s municipal garbage dump, or the garment worker using her own home to make clothes for the local or international market.
These ‘atypical’ places of work have existed for many years, especially in developing countries. But OHS generally deals with formal workers in formal workplaces such as shops, factories, offices and mines. It does not accommodate much understanding of the social determinants of health, that is the relationship between risk, poverty and informal work, or how community health is affected by the conditions people work in.
Some risks are general to all forms of informal work, such as the low and unreliable incomes earmed, and the lack of cover by work-related health insurance. In addition, the different places of work present different types of specific risk: for example, street vendors are exposed to the sun and to vehicle fumes; stall holders in built markets face fire hazards; and those sorting waste are exposed to broken glass, putrid meat and discarded batteries on waste dumps. The different employment relationships, including self-employment, disguised waged work and informal waged work, also influence the risks that workers and their families face.
These employment patterns present challenges to the discipline and the practice of OHS. Profound institutional disconnects are becoming more apparent because of the numbers of workers involved, in the global north and south, and because of the growing public awareness of the informal economy.
OHS policies, norms and standards are usually set nationally, but it is local government that has most control over day-to-day working conditions. For example, street vendors’ conditions of work are vitally affected by the presence or absence of local government provision of public toilets, shelters for trading, lighting and refuse removal. Industrial out-workers who use their homes as places of production are affected by zoning and planning regulations, housing density and roads (including for access to health services and to markets). While calls are being made nationally for job creation through support to informal enterprises, local governments have in contrast smashed people’s livelihoods through evictions and confiscation of assets, undermining workers incomes and health. Better vertical institutional coherence between local and national levels could enhance opportunities for informal workers to earn better and more reliable incomes.
There are also horizontal institutional tensions and gaps. At national level, macro-economic policies lead to increased poverty and inequality that cannot easily be redressed by social policies. At local government level, informal workers engage with local government officials from departments such as sanitation, public health and environmental health that may have different policies and practices for regulating informal work, and that have limited understanding of the positive economic role played by the informal workers.
Is a reformed and more inclusive occupational health and safety possible, not only conceptually, but also in terms of enabling realistic compliance, with shared responsibilities between the state, informal workers, and employers (where these exist)?
Innovative work done by the ILO and others have tended to allocate most of the responsibility for ensuring health and safety to the informal workers themselves. But it is known that poorer informal workers do not easily prioritise their own health above their need to earn better incomes and thus may not invest in improving the safety of their working conditions. For example, industrial outworkers earning piece rates for stitching garments may not take regular breaks; waste pickers may not use personal protective equipment if it slows their work down; or headload porters may not carry lighter loads when they earn according to loadweight.
New evidence of opportunities for informal workers to engage constructively with local government over improved OHS is emerging from a five-country research and advocacy study in Brazil, Ghana, India, Peru and Tanzania, being done by Women in Informal Employment: Globalizing and Organizing (WIEGO). WIEGO is a network that seeks to improve the status of the working poor in the informal economy, especially women, through support for increased organization and representation; improved statistics and research; more inclusive policy processes; and more equitable trade, labour, urban planning, and social protection policies. The network implemented participatory research with worker groups, many of whom are affiliates of WIEGO, followed by institutional mapping of OHS in each country and in selected major cities. The studies highlighted that new worker movements – organizations and associations, often structured along sectoral lines – are critical for effective engagement over recognition and improved conditions. These movements emphasise the right to work, advocate for recognition of informal work and many are collecting rigorous data about the contribution of informal work to the local and national economy, in order to strengthen their position. Their highest expressed priority, after higher and more reliable returns to their labour, is for access to health services.
We are now exploring pathways of policy influence, engaging in international and national OHS platforms and dialogues, and encouraging a change in the curriculum for OHS training. Powerful vested interests are obviously stacked against such reforms, including from within mainstream OHS disciplines, and from global owners of capital who are presently ‘off the hook’ in terms of their responsibility for the health and safety of the millions of workers who produce for them. However the research in each of the countries has identified encouraging points of entry and increasingly organized advocacy for a more inclusive OHS.
For more information on the issues raised in this op-ed please visit www.wiego.org and the OHS newsletter at http://wiego.org/ohs/newsletter , or write to Francie Lund lundf@ukzn.ac.za or Laura Alfers Laura.Alfers@wiego.org
There is longstanding stated policy support for health equity in East and Southern Africa. Social protest over inequality and pressure around delivery on these policies is equally longstanding, from struggles for political and economic rights to recent struggles over constitutional rights to food, water, shelter, healthy environments and health care, to hold the state and corporates accountable in relation to these entitlements, or to negotiate fairer benefit for Africa from use of its resources in the global economy.
So it confronts widely held social values when inequalities in health persist or widen, notwithstanding aggregate progress and economic growth. Why should women in Africa have 39 times the risk of dying in pregnancy and childbirth than those in high-income countries? Why, across the countries of East and Southern Africa should there be seven-fold differences in under five year mortality and 22-fold differences in the rate of women dying due to pregnancy and childbirth? Within some countries of the region nearly one in five children under five years die in the poorest households. Children of mothers with lowest education are five times more likely to be under-nourished than those with highest education.
People ask: Why shouldn’t all children, adolescents, mothers or households expect the nutrition, health and mortality outcomes of the most educated, wealthiest households or best performing geographical region of their country?
We live in an integrated regional community and global economy. Money, trade, raw materials and goods cross porous national borders. How then can such enormous differences between communities and countries be acceptable, particularly for conditions that can be prevented through technologies that have been known for over a century, including safe water, toilets, adequate food, decent shelter, access to midwives and so on? Why should huge numbers of people continue to suffer diseases of injustice?
In a 2007 Regional Equity analysis (http://tinyurl.com/9lrpl4e) , the EQUINET steering committee analysed the inequalities in health in East and Southern Africa and identified the policies and measures that could close them. The steering committee resolved to track what progress was being made in these areas, in a process called the Equity Watch. In 2012, EQUINET has produced a Regional Equity Watch that updates the 2007 analysis, drawing on a framework developed with review input from the East, Central and Southern African Health Community, WHO and UNICEF. The book is now available on the EQUINET website (www.equinetafrica.org) and acknowledges the many people and institutional contributors and processes that made input to it.
The 2012 Regional Equity Watch is essentially a watch on progress of what we know works to close gaps in health. It provides evidence on numerous policies and interventions that are being applied in health systems, agriculture, safe water and sanitation, in relation to employment and urbanisation and other areas that have closed gaps in inequality within the region. For example, investments in smallholder food production, especially for women farmers, have reduced inequalities in nutrition. Many countries have successfully implemented measures to encourage female children to enrol and stay in primary education. There are examples of activities that reduce urban poverty by enhancing employment, improving living conditions and investing in participatory planning, particularly in unplanned urban settlements. There are initiatives that have aligned national and international resources to support community management of safe water or to fund and support primary health care services and community health. There is promising practice in overcoming geographical differentials in access to health care through investments at primary care and community level, including through community health workers, community outreach, social organisation and participation, moving away from fee payments at point of care and integrating specific programmes within comprehensive primary care services. These practices underway repeatedly point to the possible.
However the 2012 Regional Equity Watch also asks why we are not making more progress in implementing the possible. It highlights that while there has been positive economic growth across most countries of the region in the whole of the 2000s, in many countries growth is occurring with increasing poverty and inequality, generating social disadvantage. Rapid, unserviced urbanisation, inadequate investment of profits and surpluses in new jobs, and significant disparities in access to agricultural resources, are common pathways found for growth with inequity. The Regional Equity Watch reports unacceptably slow progress in improving coverage of safe water and sanitation, low and unequal coverage of early childhood education and care and secondary education; inadequate public investment in improving access to land and other inputs for female smallholder food producers and inadequate resources - people, medicines and money- reaching and being absorbed by the community and primary care level of health systems. It raises concern about inadequate progress in formalising and resourcing mechanisms and capacities for participatory democracy and social power in health systems, particularly when observing the growing power that transnational corporates have in areas fundamental to health, such as in social determinants like food security or health service inputs like medicines.
Inequality within the region is overshadowed and underpinned by the scale of inequality globally. It points to a scale of inequality that needs to be more centrally and explicitly addressed in global dialogue, including on global development goals. At current rates of progress in narrowing the global gap in incomes, it would take more than 800 years for the bottom billion people – many of whom live in east and southern Africa – to achieve even 10 per cent of global income. The Watch points to the continuing net outflow of resources for health from the region, including through debt servicing, skilled worker out-migration, unfavourable terms of trade and extraction of unprocessed minerals and biodiversity. It questions the pro-cyclical, deflationary macroeconomic model that has dominated economic policy globally, given its failure to yield the sustained, inclusive or equitable growth needed to achieve social goals, and the unacceptable depths of deprivation and unacceptably wide and avoidable gaps in health and survival, and in coverage of services in our region. It raises frustration that slow progress in the strength, power and effectiveness of African voice in global decision making is being outstripped by a rapid pace of global extraction of African resources.
Many of the policy choices for a cohesive healthy society in East and Southern Africa raised in the 2012 Watch appear to be a matter of common sense. Beyond technical knowledge, therefore, their implementation depends on leadership and social action. In analysing progress and highlighting both the gaps and the possible, the 2012 Equity Watch aims to nurture and inform both the social intolerance for injustice and the affirmative leadership and demand for just alternatives.
Please send feedback or queries on the issues raised in this briefing or requests and comments in relation to the Regional Equity Watch 2012 to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org or download the 2012 Regional Equity Watch at http://tinyurl.com/8t2fqqf and http://tinyurl.com/8g6obf9.
In a changing global environment, African countries have made clear their intention for the World Health Assembly (WHA) to hold its global leadership in health. At the WHA in 2012, reforms of the World Health Organisation (WHO) were under discussion, with the aims of improving outcomes in agreed global health priorities, ensuring greater coherence in global health, and effective, efficient, responsive, objective, transparent and accountable performance. In a context of a multitude of new global institutions, foundations and alliances involved in health, African countries at the WHA collectively, through Senegal, raised that the WHO provides an organisational means for global processes to value multilateralism, inclusivity and respect for the authority of member states through the WHA. The Africa Group of countries called for the reform process to contribute “to the shaping of a stronger, more effective, more responsive and more responsible WHO.” In the discussion on the reforms, African countries unanimously urged for countries to ensure that whatever the reforms achieve, they must strengthen WHO’s position as the leading global agency for health.
Achieving this calls for more than rhetoric and statements of intent. In the past decades, the World Health Assembly provided a forum for states to review policies and strategies in health and make resolutions that they would implement. In recent years, a host of new players from non health sector agencies, non-governmental organizations, non-state providers of health, industry, faith-based organizations, civil society, foundations and corporates have become involved in decision making on and implementation of health strategies. Over the past decade more than 100 private global foundations have emerged working on different issues related to health. This multiplicity of actors bring multiple visions, mandates and modes of functioning to global policy processes. Alliances such as the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Health Workforce Alliance are now working on issues that the WHO has been working on over the years.
A Ugandan delegate to the 2012 WHA questioned the number of partnerships that WHO was now involved in, arguing that this detracted from its major mandate and role. African countries at the WHA observed that navigating this complex environment calls for WHO to rather strengthen its own intergovernmental nature and particularly the role of countries in its decision making processes. Permanent secretary of the Ministry of Health in Swaziland, Mr. Stephen Shongwe, said for example “As Swaziland we want to reiterate that the WHA is the supreme organ of the WHO and should have the final say in all the decisions. There should be flexibility for the WHA to make decisions. Resolutions should not just be crafted based on the recommendations of the Executive Board. Member states should be able to raise issues that may arise and not just be confined to the defined issues in the agenda.”
African countries’ concerns were addressed in part when the 65th WHA in 2012 resolved that any reform of the organisation be guided by the principle that the intergovernmental nature of WHO’s decision-making be paramount. The Director General was requested to present draft papers on WHO’s engagement with non governmental organisations and with private commercial entities.
However, while this may be a necessary condition for the organisation to claim global leadership in heath, will it be enough? Without the funds coming from the same member states, how will it deliver on its decisions? And will member states use their strengthened and collective decision making to safe guard public health, even in the face of corporates and foundations whose earnings exceed the GDP of many member states?
Global leadership in health demands an organisation that fearlessly and strategically protects public health. At a Special Session of the WHO Executive Board convened in November 2011 to consider the Reform Agenda, the WHO director General Margaret Chan then said that WHO, in "the interest of safeguarding public health", was "not afraid to speak out against entities that are far richer, more powerful, and better connected politically than health will ever be", adding that "we need to maintain vigilance against any real or perceived conflicts of interest."
Civil society actors at the WHA supported this role of public health protector, but questioned whether it is being delivered. They argued that the prospect of money has led the organisation to engage in partnerships that have weakened this leadership role. They held member states liable for this situation, observing that WHO can only become a stronger intergovernmental institution when member states increase their funding support.
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
Health systems in sub-Saharan Africa have been in a state of decline since the debt crisis of the 1980s and the subsequent effects of structural adjustment, chronic public under-investment and health sector reform. Zimbabweans experience a heavy burden of disease dominated by preventable diseases such as HIV infection and AIDS, malaria, tuberculosis, diarrheal diseases, nutritional deficiencies, vaccine preventable diseases and health issues affecting pregnant women and neonates. According to the latest Zimbabwe Demographic and Health Survey, the number of women dying due to maternal causes for the past 7 year period has increased in Zimbabwe from 725 deaths for every 100 000 live births in 2009 (2002-2009) to 960 deaths for every 100 000 live births in 2010/11 (2003-2010).
With this high burden of ill health, efforts to make sustained and equitable improvements in health are being made by various state and non state actors. One of the clearest objectives is to revive the Primary Health Care (PHC) concept. Primary health care, as contained in the Declaration of Alma-Ata 1978, is: " Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part, both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process."
Zimbabwe’s national health policy commits the Government “to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.”
Health Centre Committees (HCCs) are a mechanism through which community participation can be effectively integrated to achieve a sustainable people centered health system at the primary care level of the health system. They complement vital community level initiatives like community health workers, and mechanisms for public participation at all levels of the health system. In Zimbabwe, Health Centre Committees (HCCs) were originally proposed by the Ministry of Health and Child Welfare in the early 1980s to assist communities to identify their priority health problems, plan how to raise their own resources, organize and manage community contributions, and tap available resources for community development. In 2010 Health Centre Committees in two districts in Mashonaland East province collaborated with Village Health Workers to mobilize expectant mothers to deliver at health facilities nearest to them, contributing to improving maternal and neonatal survival. In Chikwaka community in Goromonzi district, the HCC has in 2011-2012 taken the lead in mobilizing financial and material resources- bricks, quarry, river, pit sand and labour- to construct a Maternity Waiting Home at a primary care facility in their ward. These are examples of how HCCs are able to organize, identified local health problems, tap into their own available resources and take action for community development.
Despite setting their roles and functions as early as the 1980’s, HCCs still do not yet have a statutory instrument that specifically governs their roles and functions. This is a gap in the formal provisions for how communities should organize on health and PHC at primary care (health centre) level. While PHC is not only an issue for the health sector, and is thus taken up by more general local government structures, it is necessary that mechanisms exist within the health sector to align the health system to PHC and community issues, as well as to link and give leadership input to these more general structures.
The absence of formal recognition may mean that other sectors do not act on health as it is not adequately profiled in their wider deliberations. The 2009-2013 National Health Strategy recognized this gap and made specific note of the importance of establishing health centre committees within the health system. The strategy identifies that “…during the next three years, communities, through health centre committees or community health councils will be actively involved in the identification of health needs, setting priorities and managing and mobilizing local resources for health”.
A 2009 Training and Research Support Centre (TARSC) and CWGH assessment on PHC (http://tinyurl.com/5rdnh7v) found Health Centre Committees (HCCs) functioning (ie having met) in only 40% of the 20 districts surveyed. The HCCs present these were found to lack coherent integration with planning systems, and to be functional in only a third of sites. Nevertheless HCCs were found in this survey to be associated with higher levels of satisfaction with services, attributed to the communication, improved understanding and support for morale that they build between communities and health workers.
HCCs offer an opportunity to take forward the shared local priorities across health workers and communities and to discuss how to accommodate differing priorities between them. In a 2004 study by Loewenson et al (http://tinyurl.com/c8bd86k) , HCCs were associated with improved PHC outcomes compared to areas where they did not exist.
HCCs ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors. In doing this, they promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development. Primary Health Care (PHC) approaches seek to build and depend on a high level of ownership and participation from involved and affected communities. The HCC is the mechanism by which people get involved in health service planning at local level. In Zimbabwe Health Centre Committees (HCCs) identify priority health problems with communities, plan how to raise their own resources, organize and manage community contributions, and advocate for available resources for community health activities. They discuss their issues with health workers at the HCC, report on community grievances about quality of health services, and discuss community health issues with health workers.
CWGH and TARSC in partnership with the Primary Health Care taskforce have developed HCC guidelines that have been proposed as the basis for a Statutory Instrument to formally recognize the role of these structures. An HCC Training Manual developed by TARSC and CWGH has been peer reviewed by the Ministry of Health and Child Welfare to strengthen the capacities to deliver on their roles, backed by health literacy activities that strengthen the wider community literacy on health to encourage wider input to and hold these mechanisms accountable. While community participation demands much more than HCCs, institutionalizing and giving a formal mandate to HCCs is critical and key to achieving a sustainable people centered health system in Zimbabwe.
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
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
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.