At the 3rd Global Forum on Human Resources for Health, Recife, Brazil, November 2013 a group of civil society organisations and regional networks produced a statement of commitment on the key role of health workers in universal systems. The statement from EQUINET, European Public Health Alliance, Health Poverty Action, Health Workers for All and All for Health Workers, Latin-America Association of Social Medicine ALAMES , Medicus Mundi International Network MMI, People’s Health Movement PHM, Public Services International PSI, The Centre for Health Sciences Training, Research and Development CHESTRAD and WEMOS is shown below.
The health workforce crisis remains a core barrier to achieving the Millennium Development Goals (MDGs) for health with only 31% and 12% respectively of 75 Countdown countries likely to attain MDGs 4 and 5. Despite donor and country commitments at the 1st and 2nd Global Forums on Human Resources for Health, the global health workers’ shortage persists. Of the 57 countries identified as falling below the WHO target only 19 have seen an improvement in their aggregate health worker density. Earlier commitments to increase domestic resources or external aid, as well as implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, remain largely unfulfilled.
National and international funds have been channelled to strengthen health workforce programs, like task shifting and the scaling-up of community health worker’s programmes. However, too little investment has been targeted at the recurrent costs of health workforce development, for instance on salaries, education and social protection measures for health workers. The inequitable distribution of health workers through increased mobility and migration within and between countries adversely affects access to health.
Health workers and a robust health system are essential for universal health coverage (UHC), and realizing the right to health through universal health systems.
Therefore at the 3rd Global Forum on Human Resources for Health in Recife, Brazil, we, the undersigned representatives of civil society organizations hereby commit that we will:
• Help amplify the voices of health workers, especially those at the lower levels of care and support their work to influence national and global health policies and plans.
• Assist local civil society organizations to ensure their voices are heard in global and national health workforce policy discussions.
• Assist in strengthening the capacity of patient groups to advocate for equitable and quality services staffed by sufficient, competent and equipped health workers at all levels of care.
• Recognise the gender dimensions of the health workforce and champion the rights of women health workers, and
To catalyse a strong movement for health workers, we will:
• Advocate for governments at all levels to institute plans and allocate adequate resources for human resources for health (HRH) to ensure that every person has access to a trained, supported and equipped health worker.
• Press bilateral and multilateral organizations and civil society actors to increase health workforce development efforts and financing, including of national training institutions, in alignment with government plans.
• Work with training institutions, professional and regulatory bodies to achieve quality in health worker education, including on the social determinants, so that every health worker is competent to provide quality care and accountable to the populations they serve.
Strengthen the advocacy of health workers and civil society for improved infrastructure, support and working conditions
• Support the development of a strong, motivated, public workforce to counter some of the ill- effects of an increasingly globalised, inequitable and unstable economy and rapidly changing health and demographic patterns.
• Commit our own resources and expertise to assist in converting HRH policy and plans into action.
To ensure accountable HRH systems at national and global levels, we will:
• Work with governments, the Global Health Workforce Alliance, the World Health Organization, and other stakeholders to develop mechanisms to measure progress towards improved and equitable access to competent health workers
• Monitor and report on progress of public HRH commitments made by global actors and governments.
• Assist citizens and health workers in developing strategies to enhance accountability of national and global actors and challenge inequitable policies that impact on HRH development.
• Increase transparency of our programmatic and technical contributions to national HRH strategies and attempt to reduce onerous reporting requirements placed on countries. We will commit ourselves to supporting a strong public sector for health workforce development and be accountable in our own funding and technical programs to mitigate the ‘internal brain drain’ from the public to the private sector.
We will hold donors, government and multilateral actors accountable to:
• Ensure that economic governance arrangements and fiscal space enables the development of a strong national health workforce as a long-term investment in the wellbeing of the people and the economy of a country. The return on investment to employ a health worker is many times higher than to bail out a bank.
• Provide the leadership, resources and stewardship needed to fulfil commitments made to urgently and effectively address the health workforce crisis and ensure improved and equitable access for every person to competent health services.
• By 2015, develop, finance, and implement HRH action plans, including strengthening national training institutions, with concrete targets and integrate them into national health plans.
• Ensure that health workers and civil society organizations are active partners in the health workforce policies, planning and development.
• Promote equitable access to health care by investing especially in health workers at primary and community levels and in community structures to facilitate citizens’ voices.
• Improve investment in health workforce development, including salaries and social protection, and in national training institutions in order to rapidly increase numbers of HRH.
• Assist in development of robust HRH information systems to facilitate improved planning and management and
• Respect and implement the Global Code of Practice on the International Recruitment of Health Personnel including additional enforceable legislation and redistribution mechanisms to compensate for the international ‘brain drain’ that exacerbates global health inequalities.
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
Editorial
Google the words “universal health” and in under 3 seconds you’ll get 165 million results. There is a crescendo of talk on universal health coverage. But has it been translated into terms that can engage social debate? The two editorials in this month’s newsletter and several of the papers suggest that such debate across all of society is critical, given how deep the consequences for society of the choices made. In the first editorial, Latin American social medicine and health scientists warn of the negative impacts of segmented insurance options. The second editorial, drawn more from African experience, argues a similar case. Both urge for exploration of tax funding, particularly given that universal systems are a right of all citizens not a benefit of particular employees or contributors. There are clearly debates and choices- are they reaching the people who will be most affected by them?
ALAMES and CEBES, in the framework of the Second Brazilian Congress of Policy , Planning and Management in Health of the Associacao Brasileira de Saúde Coletiva (ABRASCO) affirm that the path to full exercise of the right to health for the peoples of Latin America involves building, strengthening and developing universal public health systems (the ‘SUS’), as opposed to the campaign launched by international financial institutions and neoliberal governments around ‘universal health coverage’ based on the expansion of different forms of insurance, with a limited package of services for the poor and through promoting private investment in health.
This position is based on the following considerations:
• Universal health care systems are expressions of public and social commitment in each country to implement the principles of universality, equality, integrity and non-discrimination in relation to peoples’ health needs. They are part of state policies aimed at ensuring social rights.
• A single universal and public health system (a national health service) contributes to the implementation of universal policies, in the context of social and human development, that break with the social inequalities and inequities that are inherent in the logic of the market. Their management and financing can be sustained through fair tax policies that promote a fairer distribution of wealth.
• The neoliberal reforms in various countries in the region to date demonstrate that systems of health insurance based on targeting and limited service packages have deepened social differences in care by placing at the core of their design alleged financial constraints and greater private sector roles in health services.
• The momentum that agencies, foundations and corporations are giving to the debate and implementation of so-called ‘universal health coverage’ is an expression of an interest in locating health as a key field of capital accumulation. This can rob countries of resources that are vital for health and reproduces injustices and inequities in health care.
We should be alert to the efforts being made to deepen exclusionary insurance systems and loss of health rights in Peru, Colombia and Mexico.
We call on the Latin American and global movement for the right to health to express their rejection of deepening processes of market insurance and privatization that are advancing right now in Peru, Colombia and Mexico.
• In Peru, using a questionable granting of legislative powers to the Executive Branch to drive the process that bypasses the Congress, the Ministry of Health and Ministry of Finance intend to introduce new laws that seek to deepen market participation in the health sector through the promotion of public-private partnerships, contracting of services and deregulated insurance. This lowers the possibility of equalizing the access to comprehensive health care and social security that only a third of Peruvians currently enjoy. The first laws passed under these legislative powers have violated the labour rights of health workers, undermining their security of pay, with further uncertain implications. This is despite a constant demand from social movements and professional associations in health in most parts of the country to build a reform based on universal principles.
• In Colombia, universal coverage based on insurance has had disastrous consequences, with the collapse of national insurance funding declared by government itself to be a national health emergency. Despite this, the reform initiated today merely changes names on the same entities and processes that have for twenty years undermined access to health, blocked avenues for claiming the right to health and subordinated claims on the right to health to macro-economic considerations. The reforms do not address any of these underlying factors and despite the flow of funds, the health system is literally dismembered. The fact that health is only a business for insurance companies has been associated with a rise in corruption and paramilitarism in the sector.
• Mexico is currently presented as a promising example of neoliberal reform. However, claims in the reform of having achieved universal coverage hide the fact that a significant share of the insured population has no real access to care, that there has been a reduction in benefits covered by insurance, and that the introduction of private insurers seeking to make profits in the sector is raising the risk for millions of people of losses in social security health benefits.
All countries need universal health systems.
• Recognizing the complexities and particularities of each country, it is urgent that social movements drive and ensure the formation of Universal Health Systems, understood as an inalienable responsibility of the state and society, to build institutions that guarantee the right to health universally and equally outside the logic of the market and profit. This requires progressively overcoming the fragmentation of sub-systems through innovative management and through a commitment to sustainable financing.
• We recognize the national health system (the ‘SUS’) in Brazil as an example of social momentum based on universalist principles, and call for its defense and for deepening it in all necessary areas. We especially support popular demands to allocate 10% of the gross federal revenue to support the expansion of the SUS and to limit the growth of private services. We defend Brazil's SUS as a source of inspiration and an example of the real possibility of reversing the expansion of an individualist model of health insurance that breaks the concept of and responsibility for public health.
• In this regard we urge the Brazilian government to publicize and defend the SUS internationally, presenting it as an alternative to guarantee the right to health of the people.
For the right to health, universal public health systems for all countries of Latin America!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For the original declaration in Spanish see http://www.alames.org , entry two for October.
Social health insurance schemes, introduced in the name of universal health coverage (UHC), are excluding the majority of people and leaving the poor behind. So argues a new report from Oxfam ‘Universal health coverage: why health insurance schemes are leaving the poor behind’.
The growing momentum for universal health coverage (UHC) is certainly cause for celebration. But in some cases health financing reforms are widening inequality by prioritising already advantaged groups in the formal sector and leaving the most poor and marginalised people – especially women – as last in line to benefit.
This raises the question of why there is an almost exclusive focus on contributory-based health insurance schemes as the way to achieve UHC. Although no country in the world has achieved anything close to UHC using voluntary insurance, private and community-based voluntary schemes are still being promoted by governments and external funders. India’s voluntary India’s voluntary Rashtriya Swasthya Bima Yojana insurance scheme for people below the poverty line is widely praised as a success. However evidence cited in the Oxfam report indicates that the scheme offers limited financial protection against impoverishing out of pocket spending on health and has skewed public resources to curative rather than preventative care.
For those who recognise the pitfalls of voluntary schemes, social health insurance (SHI) has emerged as the model of choice. SHI has worked to achieve UHC in a number of high-income countries. However attempts to replicate the same kind of employment-based models in low- and middle-income countries have proved unsuccessful. Even high-income countries struggled to achieve rapid scale up via SHI. In Germany UHC took 127 years to achieve using a SHI model. Surely people in low and middle income countries (LMICs) should not have to wait that long!
In low and middle income countries SHI schemes are typically characterised by large-scale exclusion. Ten years after the introduction of SHI schemes in Tanzania, according to a National Health Insurance Fund 2011 report, coverage had reached only 17 per cent. Kenya’s National Hospital Insurance Fund – established nearly 50 years ago – today insures just 18 per cent of Kenyans. Ghana’s National Health Insurance Scheme (NHIS), widely promoted as an SHI success story, covers only 36 per cent of the population.
Hopes that insurance contributions from those outside of formal employment would raise significant revenue have not been realised. In Ghana, cash premiums paid directly by those in the informal sector contribute just five per cent towards the cost of the NHIS, that also draws funds from earmarked tax and other sources. Governments also face huge bills to cover the SHI contributions of their workers. According to 2010 National Health Insurance Fund Tanzania and WHO evidence cited in the report, the Government of Tanzania spent $33m on employer contributions in 2009/10; this equated to $83 per employee – six times more than it spent per person, per year on health for the general population.
Instead of importing inappropriate health financing models from high-income countries, governments in LMICs should surely learn from the increasing number of home-grown UHC success stories in other, more comparable countries.
The countries making most progress towards UHC agree that entitlement to health care should be based on citizenship and/or residency and not on employment status or financial contributions. While their specific journeys differ, these countries fall into two broad camps. First there are examples of countries at all income levels, including Sri Lanka, Malaysia, and Brazil, which use tax revenues to fund UHC. Crucially, the 2009 report of a Task Force on Global Action for Health System Strengthening found that the only low-income countries to achieve universal and equitable health coverage did so by relying mainly on tax financing. A second option increasingly being adopted by another set of successful UHC countries, including Thailand, Mexico, and Kyrgyzstan, is to collect insurance premiums only from those in formal salaried employment, and to pool these where possible with tax revenues to finance health coverage for the entire population.
The growing momentum for UHC is welcome, exciting, and challenging. UHC has the potential to transform the lives of millions of people by bringing life-saving health care to those who need it most. But rather than focus efforts on collecting contributions from people who are too poor to pay, governments and external funders should focus on financing options that will work to deliver universal and equitable health care for all. The preoccupation with health insurance as the ‘default’ UHC model has left the crucial question of how to generate more tax revenues for health largely unexplored. This blind spot should be urgently addressed.
At its core, UHC is about the right to health. This means moving away from the idea of an employment or contributory basis for entitlement. People must be entitled to receive benefits by virtue of their citizenship and/or residency and not because they are formally employed or have paid to join a scheme. Women and men living in poverty must benefit at least as much as the better off every step of the way.
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 see the Oxfam report ‘Universal health coverage: why health insurance schemes are leaving the poor behind’ at www.oxfam.org/uhc
Addressing inequities in access to quality needed care and financial risk protection must be a first priority in efforts to achieve Universal Health Coverage (UHC). We have the opportunity to implement equitable pathways towards UHC by including appropriate targets and measures in the post-2015 development framework. These are the main messages of a joint report titled ‘Universal Health Coverage: A commitment to close the gap’ launched this month by Save the Children, the Rockefeller Foundation, UNICEF and WHO and available at http://www.savethechildren.org.uk/resources/online-library/universal-health-coverage.
Prioritising equity in pathways towards UHC is not just the right thing to do from a moral perspective, but it also brings value for money. Research implemented for the report reveals that the deaths of 1,8 million children under-five and 100 000 mothers could be averted each year by eliminating wealth related inequities that occur within countries in the coverage of essential maternal and child health interventions in 47 of the 75 countries where more than 95% of all maternal and child deaths occur (http://www.countdown2015mnch.org/). If in 2013 to 2015 all groups were able to reach the coverage levels of the highest fifth of people by wealth, this would reduce maternal and child mortality by almost one-third and one-fifth respectively.
We present evidence in the report that more equitable health financing saves lives. Pooled funding comes from prepayments and pooling makes it available to distribute to those with higher need. If the share of health financing that is pooled were to increase by ten percentage points, while keeping total health expenditure constant, we estimate in the report that there would be fifteen fewer deaths in children under five years of age for every 1000 live births in the same 75 countries on average. This could enable thirteen countries that are currently off-track to achieve their Millennium Development Goal (MDG) 4 target of a two-thirds reduction in the rate of child mortality. In countries where health services are more equitably distributed, the reduction in child deaths may be even greater.
It is thus possible to make huge improvements in health outcomes and access to health care. It is possible, for instance, to reduce by almost half the number of children who die each year when compared to the rates in 1990. Despite this, too many people are denied their right to health. In 2012 for instance, 6,6 million children died before the age of five and most of these deaths could have been prevented. High levels of out-of-pocket payments (cash at point of care) for health care act as a barrier for poor people to access the care they need or can lead to an increase in poverty due to health spending. About 150 million people are estimated to incur catastrophic (impoverishing) expenditures for health care each year. This is a scandal that must be addressed.
The health system’s response to this challenge must be Universal Health Coverage – which we define as ensuring “that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them”. Momentum for UHC is soaring at country and global levels, and this must be seized to ensure the needs of the poor and vulnerable are prioritised as countries design and implement the policy reforms for UHC.
In the report we identify a number of policy lessons for equitable pathways towards UHC in low- and middle-income countries, particularly in relation to health financing. One policy lesson is that countries increase equitable funding for health through mandatory, progressive prepayment mechanisms, including revenues from taxation, and eliminate out-of-pocket spending. Risk and resource pools must be consolidated to facilitate effective redistribution. A universal benefit package should be designed for all, and delivered in a manner that meets the needs of the poorest and most vulnerable in society, through strategic purchasing of services and through providing incentives that ensure health providers promote quality of care. The policy lessons point to the importance of taking a ‘whole-system’ approach to UHC, and for coordinating reforms across health system building blocks such as financing, health workers, commodities, social participation and others. To overcome pervasive inequities in the coverage of quality health services and to ensure that people are not impoverished from health spending we need to also act on the wider social determinants of health. Political will and strong mechanisms for effective accountability are critical for implementing the measures needed for equitable pathways towards UHC.
As the MDGs have shown, what gets measured is more likely to get done. Negotiations on the sustainable development agenda must guide equitable progress towards UHC, with clear indicators of and targets for such measures that strengthen health systems and close the equity gap.
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 visit www.savethechildren.org.uk/resources/online-library/universal-health-coverage and www.equinetafrica.org
As she walks away from the clinic Sarah’s back is straight and she has a smile on her face. She has heard confirmation from the nurse that there have been no cases of cholera in her area this year, unlike in previous years, when many died of the disease. She can’t wait to get back to tell the others - “we did it!”
This is not a fiction. It was achieved, for example, in parts of Lusaka district, Zambia, after the joint activities of health literacy facilitators, communities and health workers. At a time of scarce resources and mounting disease we may overlook that our health systems have one of the most critical resources in abundance - people.
The power and ability that people and social groups have to know, act on and direct resources towards promoting health and addressing their health needs are key contributors to health. Health systems that are organised around social participation and empowerment create powerful constituencies to protect and advance public interests in health. Aware and organised communities support early detection of and response to problems and uptake of services, reducing the need for costly treatment of advanced disease. Despite high levels of poverty, East and Southern Africans have high literacy levels and strong social capabilities and social networks that are all assets for health.
But do we effectively tap these assets? We praise the benefits of social participation in health, but do we really practice it? Are there national scale programmes for ensuring that the population is not only literate but ‘health literate’? Do we recognize in law and invest in the capacities and functioning of mechanisms for dialogue and joint planning by health workers and communities as a core part of health systems? Do we ‘lecture’ to and ‘mobilise’ communities, or work in a way that builds on their experience and facilitates their own learning, reflection and collective action?
Studies carried out in the pra4equity network in EQUINET over the last decade suggest that our health systems don’t have strong or sustained investment in these social roles and mechanisms, give limited incentives for health workers to put time into them, have top down planning and weakly address barriers and facilitators to health service uptake and adherence, leading to resource inefficiencies.
Investing in health literacy should, however, be as central to our health systems in the region as supplying medicines or training health workers. Health literacy is a process that empowers people to understand and act on health information to advance their health and improve their health systems. It isn’t only about sharing information, however. Literacy implies functional capacity. Health literacy draws on local experience, encourages reflection on that experience, identifies shared problems, and draws in new information on those problems for community level diagnosis and action on health.
Work on health literacy (HL), co-ordinated through TARSC, has been implemented in the pra4equity network in EQUINET over the past five years. HL addresses the major health issues faced at all stages of life, and includes information on how the health and other sectors are (or should be) organized to address these issues and on social rights and organization. Health literacy was initiated in Zimbabwe, where the Community Working Group on Health now covers nearly half of all districts with the programme. It then spread to Malawi, Botswana, Zambia and Uganda. After pilot work in Uganda in 2011, with Cordaid support, five civil society organisations formed a network co-ordinated by HEPS Uganda to extend health literacy into new areas and communities. Organisations such as the National Forum for People Living with HIV and AIDS (NAFOPHANU) are building health literacy onto work on treatment literacy, with actions taking place on prevention of malaria, typhoid and brucellosis. In Zambia, the Lusaka District Health Office first implemented health literacy in selected communities in the city, building on participatory work strengthening communication between health workers and communities. After realizing the impact the programme had achieved in reducing diseases such as cholera, the Ministry of Health officially adopted the programme for national scale up in 2012.
The work in the past year has highlighted the potentials of scaling up HL and the challenges to be addressed.
HL brings together a wide range of stakeholders, including health workers, community leaders and members, youth and vulnerable groups. This demands facilitation that is sensitive to inequalities in voice and power in these groups. However the discussion and analysis of health problems and their causes across these groups can lead to a deepening understanding of the different experiences and views in communities, and build shared decision making that leads to more inclusive action. CEHURD HL sessions with youth and health workers in Uganda revealed for example a perception amongst students that health workers only interact with students when the school administration wants to identify those who are pregnant for expulsion. Dialogue between health workers and youth in the HL sessions helped to strengthen their mutual relations and opened discussion of ideas from each on how to strengthen youth friendly health services. In Zambia, the HL programme has overcome past suspicions and built communication between communities and health workers, with both working together and with local authorities to clear waste dumps that had grown over years, to improve safe water and sanitation, food hygiene and other public health issues. Healthy environments are often identified as high priority by communities.
From the work in Zambia and Uganda we have seen features of HL programmes that would seem to be essential for any efforts to scale HL to national level. They include national political and technical support; a core of experience and capacities in participatory reflection and action; HL materials that integrate regional good practice with national content; and a co-ordinating group that is able to plan, review and support the horizontal roll out of HL activities, mentor and evaluate the work and share learning. Perhaps the most central feature are young, old, male, female, urban and rural HL facilitators that recognize local knowledge and creativity, are able to use participatory methods to support people to explore, discuss and plan their health actions, and that are evidently passionate about health! The work in Zambia has shown that the best way of scaling up is through a bottom up and horizontal roll out, where communities can take leadership and facilitators in existing areas can mentor in new areas. This can take time, but it also yields more sustainable results.
Like any element of a functioning health system, building a health literate population calls for policy support, planning, resources, organization and capacities to be applied. Surely an informed, active and organized population is too valuable an element of the health system to leave to ad hoc inputs and external funding? Its time all countries in the region followed Zambia’s example and adopt health literacy as a core activity of national health systems!
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
The private for-profit sector in east and southern African (ESA) countries cannot be ignored. With private health insurance growing, considerable out-of-pocket payments at point of service, rising investment in private for-profit hospitals including for medical tourism and a widening spread of informal providers, ESA countries need to pay attention to this sector as part of measures towards achieving universal health coverage (UHC).
The for-profit sector can add new resources and services to the health sector. But if left unregulated it can also lead to distortions in the quantity, distribution, price and quality of health services that affect the ability of countries to provide adequate and accessible services. For example, for-profit providers may concentrate in areas where wealthy populations live, ignoring areas of high health care need. The cost of both private health care and insurance tends to be high and unaffordable for low income communities. The presence of a for-profit private sector in countries that have a shortage of health workers may lead to an internal brain drain of skilled health workers from the public sector, due to better pay, leaving poor people with poorly staffed public sector services.
A review of laws on the private sector in east and southern Africa for a forthcoming EQUINET discussion paper shows that while many ESA countries have laws to register or license new private providers, few, except Namibia, South Africa and Zimbabwe, have adequate laws to regulate private health insurance. Few countries monitor the type and quality of services provided by private practitioners, clinics and hospitals once they are registered. Charges for health care services or insurance do not seem to be controlled, directly or indirectly, to any meaningful extent in any ESA country, while there is evidence from some countries of unfair business practices. This means that the law does not adequately address the affordability, access or quality issues that are central to achieving UHC.
The current situation suggests that it is time to move from an over-reliance on voluntary self-regulation by private health professionals and associations to developing policies, laws and instruments that clarify and organise the operations of private for-profit health care providers and insurers in line with national health goals. Several countries have recognised this and are beginning to update and improve their laws, although in most cases without clear policy guidance.
So one starting point may be for Ministries of Health to develop with stakeholders, including Ministries of Finance, an over-arching policy on the private for-profit health sector to guide and set the objectives for the law, separating the roles and duties of funders, purchasers and providers. This requires proactive consultation, building communication and trust between stakeholders and the introduction of laws governing the sector. It would seem timely to initiate this in all ESA countries, given the growth of the sector, even if the private for-profit health sector is not yet large.
The policy and subsequent laws should facilitate and create incentives for private health professionals and organisations to address the health needs of disadvantaged populations. They should also control against any health market distortions that jeopardise national health goals.
The laws should set standards on service quality, on emergency services and on the benefit packages, enrolment practices and sustainability of health insurance plans. The law should set obligations for the private sector to report to regulators and inform patients, health insurance beneficiaries and the public at large of their entitlements. Penalties should be set at appropriate levels to discourage breaches of these obligations, but at the same time there should be positive incentives, such as alternative reimbursement mechanisms, that help to shift the behaviour of the private health sector.
Having the laws on paper is only one step of the process. Enforcement of the law is still a challenge in many ESA countries. Maintenance of appropriate databases and monitoring of the law is still not well developed. In some countries private stakeholders greatly influence the content and degree of enforcement of regulations. Governments thus need to invest in the resources and capacities to develop, use and enforce the law, whether at central level or in a decentralised system. For this, legal, financial and public health skills are required, as well as the ability to collect, analyse, use and communicate information. Governments need to ensure that the legal requirements of multiple pieces of legislation are well-understood by regulators, health sector institutions and personnel, and the public.
Licensing and facility inspection should be strengthened and extended to examining the quality of care. Anti-competitive behaviour should be investigated and acted against. Regulators need to negotiate and apply mechanisms to reduce rising costs within both the hospital and insurance sector and ensure that laws are regularly updated in line with public health and other objectives. From the lens of service providers, government should harmonise the functions of different regulatory authorities, to avoid multiple, burdensome and costly requirements.
In conclusion, in a globalising world, with liberalised economies and growing private markets, including in health, leaving such an influential and growing sector poorly regulated would be a major obstacle on the path to universal health coverage. Governments need to act soon to address this gap in their stewardship of the health system.
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 the forthcoming EQUINET Discussion paper 99: Doherty J (2013) Legislation on the for-profit private health sector in east and southern Africa
Access to essential medicines is a necessary requirement for equitable health systems and improved population health. According to the United Nations Conference on Trade and development (UNCTAD) the number of people with regular access to essential medicines in developing countries increased from two to four billion in the five years between 1997 and 2002. However, UNCTAD also report that nearly 2 billion people do not access essential medicines, most living in least developed countries (LDCs). High medicine costs relative to incomes, inadequate public or international funding for medicines relative to need, limited local production and the limiting effects of intellectual property have contributed to this gap, together with weaknesses in health services.
The African Union (AU) seeks to strengthen local manufacturing of medicines on the continent as one remedy to this situation. AU leaders identified an over reliance on imports of medicines from outside the region as a key challenge. For example, Chaudhuri in 2008 observed that of Tanzania’s US$110 million pharmaceutical market in 2004/2005, $78 million or 71 percent came from imports and only 29 percent from local production. Out of the 3388 drugs registered for sale in Tanzania, only 269 products (or about 8%) were from Tanzanian local manufacturers. In contrast in Zimbabwe in the early 2000s the local pharmaceutical industry supplied nearly half of the country’s essential medicine requirements, according to the United Nations Industrial Development Organisation (UNIDO). Further as only South Africa has limited primary production of active pharmaceutical ingredient and intermediates, the local production underway in Africa is reliant on imported active ingredients. UNIDO indicates for Zimbabwe, for example, that while imports of finished pharmaceutical products do not face tariffs, inputs for the manufacture of pharmaceuticals do, with import duties ranging from 5 to 15 per cent, raising production costs.
To address the constraints and widen capacity for local production in the continent the AU set a Pharmaceutical Manufacturing Plan for Africa that was adopted by the AU Summit in 2007.
The AU Pharmaceutical Manufacturing Plan was complemented by a Pharmaceutical Manufacturing Business Plan (PMPA) that identified priority areas for actions, such as mapping of productive capacities, addressing intellectual property issues and capital requirements. The plan also raises the bottlenecks to medicine production in Africa. According to the text of the plan: “This Business Plan is based on the belief that industrial development and the development of the pharmaceutical sector is not in conflict with public health imperatives and that the industry should in fact be developed with the long term aim of promoting access to quality essential medicines.” Complementing the AU plan, the Southern African Development Community and the East African Community have also developed similar plans and proposed policy measures to overcome barriers to medicines access, such as pooling procurement to make medicines more affordable.
Despite the presence of these plans, there is still limited local medicine production on the continent. Setting up a pharmaceutical plant requires massive investments in infrastructure, technology, skilled professionals and strategic leadership. Many of these critical inputs were also identified as bottlenecks in the AU plan. Many African countries do not have adequate capital, and investors may be discouraged by high tariffs for and erratic supplies of electricity and water, ageing transport infrastructure, old plant and equipment and shortages of skilled industrial pharmacists and scientists. African countries also have lower capacities and resources for pharmaceutical research and development. One of the reasons therefore for the plans not being operationalized was the absence of strategic allies, resources and leadership to translate them into practice.
In recent years that scenario is beginning to change. New actors and partnerships are emerging in production of pharmaceuticals on the continent, providing new opportunities to deal with bottlenecks. These include the US$23 million Brazil-Mozambique plant for manufacture of anteretrovirals (ARVs), and the US$38 pharmaceutical plant set up in Uganda as a co-operation between Cipla (of India) and Quality Chemicals (Uganda) for the manufacture of ARVs and anti-malarials. These partnerships provide capital and strategic expertise that can be crucial for ESA countries in their efforts to set up local production. However to take advantage of this, ESA countries need an industrial policy that taps into the knowledge that exists in these countries, and that ensures the same technology transfer into Africa as these countries secured from high income countries.
These new opportunities for south-south co-operation provide a window of possibility for overcoming bottlenecks identified in the AU plan, but only if this is negotiated for as a key element of these emergent partnerships. South-south co-operation also needs to be complemented by, and not to displace regional processes. Regional level production and distribution agreements provide wider markets for medicines produced, generating economies of scale, better use of installed capacities, and greater possibilities of local supply of active ingredients and other raw materials. For example Varichem Pharmaceuticals, Zimbabwe, one of the first companies in Sub-Saharan Africa to manufacture generic antiretrovirals (ARVs), was issued with a compulsory licence to manufacture generic ARVs in April 2003 and produced its first generic ARVs in October 2003. Namibia and Botswana gave manufacturing licences to Varichem to supply medicines in their countries. Regional co-operation has been important to tap larger markets, to make full use of capacities that do exist, to harmonise medicine regulation and support skills development. It will continue to play a role in strengthening the negotiating position of countries in the region in ensuring that new partnerships in medicine production play a role in overcoming the bottlenecks identified in the AU plan to localise medicine production on the continent.
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
At the just ended World Health Assembly (WHA 66) member states reviewed progress in implementing the WHO Global Code of Practice on International Recruitment of Health Personnel. This was the first review report since the adoption of the Code three years ago. The Secretariat report tabled at the WHA showed that few African countries had designated authorities for monitoring and reporting on the Code, and that only one African country had submitted a report on implementation. This low response has been commented on in April 2013 EQUINET newsletter (http://www.equinetafrica.org/newsletter/index.php?issue=146)
When the report on the health workforce, which included progress on the Code, was discussed at the WHA, the discussion was somewhat muted. Only fourteen member states commented on the report, and only eleven made reference to the Code. African countries speak as a group on issues through a nominated delegate. Burkina Faso spoke for the 46 WHO-AFRO member states, and Ethiopia spoke in support of Burkina Faso. Those that attended the WHA in 2010 when the Code was adopted observed the contrast to the exciting atmosphere of intense debates and the large number of voices that were heard at that stage.
So what has happened over the last few years? At a side event at the WHA, participants took stock of the progress, or lack thereof, in the implementation of the Code. The side event was organised by Medicus Mundi Internationales together with the Governments of Malawi and Belgium, EQUINET and AMREF. Participants raised various challenges that member states faced in getting the implementation of the code off the ground, including their lack of preparedness, the poor mobilisation of national level stakeholders and limited engagement of civil society since the Code was adopted. Ministries of Health were also reported to be overwhelmed with other issues. WHO and some countries reassured that despite low reporting, work was underway. The fact that many countries had reported was seen as a positive sign, given the voluntary nature of the code, as was the commitment of Northern countries, (USA, EU) and WHO Secretariat to support its implementation.
The muted African member state reaction to the report at the WHA by the Secretariat may, as raised above, be explained by the diplomacy process of the Africa Group, where African ministers reach agreed positions, as they did on this issue, giving little added value in countries making further individual statements. While shared position and voice is an important feature and strength of African diplomacy, it is also common practice for countries to state/restate their position as they “align themselves with the statement made by the delegate for...... region”. This allows countries to give force behind specific areas and for country experiences to add weight to positions raised. African countries may also have been reluctant to raise their voice in the WHA process given lack of input to the Secretariat report, as raised earlier.
Whatever the reason, and this needs to be further explored, the low profile adopted by African member states on this occasion may have sent a message that the Code is not perceived to be a key policy instrument for the region to address its continuing challenges over the production, retention and migration of health workers. If so, then given the energy that went into its adoption, where are the shortfalls?
There are lessons from other processes at the WHA. Voluntary codes may fall out of attention as other issues demand more urgent government attention. If this is the case then the implementation of the only other WHO Code - on breast milk substitutes – provides a lesson on the role of civil society to galvanise countries into action, particularly with technical support of WHO. Civil society has kept the code on breast milk substitutes alive and current and generated pressure within countries to ensure that it is implemented. Is this possible for the Code of Practice on International Recruitment of Health Personnel? In theory it is achievable. The loss of health workers in countries of highest health need is still a concern, and communities and health workers have an interest in the issue, as it affects their rights and services.
Civil society organisation on health worker issues has partly been through the Global Health Worker Alliance (GHWA). The fact that the GHWA currently has no executive director weakens its support for civil society input, and creates uncertainty about its future. The third global forum on health workers organised by WHO and the GHWA will be held in Recife, Brazil in November 2013. It should provide an opportunity to review and give profile to the role of the Code in addressing health worker issues, and give new momentum to the role of civil society in its implementation. This however does need civil society, health worker organisations and academics within countries to ask questions on the implementation of the Code, to ask delegations for feedback from the discussions held at the WHA, and to know, share information on and support implementation of the Code.
It is also a matter of concern that reforms at the WHO Secretariat have diminished the capacity of the unit dealing with health worker issues. Fewer people are now contending with an increasing workload, weakening the capacity of that unit to play a leading role in support of member states and the wider community.
A number of civil society organisations, including MMI/Peoples Health Movement, and the International Federation of Medical Students Associations (IFMSA) spoke as observers at the WHA deliberations on the Code. Most of the presentations raised the weakening of these institutional capacities for supporting its implementation and called for a stronger Health Systems Policies and Workforce unit at WHO Secretariat and a stronger GHWA.
In a world of rapidly shifting policy attention, it seems to be important to organise and secure the resources, institutional roles and capacities for implementation when negotiating new instruments, particularly if they are voluntary as the Code is. The next few years will be a test of whether the slow implementation is a feature of countries preparing for a marathon rather than a sprint, or whether it is a feature of diminishing interest in the race. Issues are also sustained when they have a place in the current focus of policy attention. The focus of this year’s WHA and of much current global engagement in heath was on universal health coverage (UHC). It was thus important that health workers were identified as a central element of that policy.
This then may be the important message that we need to send. Delivering on UHC is not possible without health workers, and one sign of that delivery at global level is the extent to which countries are operationalizing the Code and implementing its intentions. The international agreements negotiated by member states at the WHO are instruments for achieving UHC, whether voluntary or not, as are the global and national capacities in governmental and non-state institutions for leading and being accountable on their implementation.
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
When I joined the Global Fund in 2003, my main responsibility, as the Manager of Online Communications, was to help the organisation deliver on its commitment to transparency. One of the conditions set forth by donors was the ability to trace every granted dollar to make aid recipients accountable for how it would be spent. This meant, among other things, developing and maintaining a website that quickly became a central repository of all Global Fund data and information. We were praised for the unprecedented level of openness that this made possible. But over time, I realised that something was (and still is) missing.
If you Google “Global Fund” + AIDSfor news stories, the overwhelming majority of results are articles that are reactive (i.e. based on official announcements, press releases and conferences) or that make reference to the Fund only indirectly or anecdotally.
Apart from experts in donor governments and a handful of technical partners, Aidspan and the likes, very few local organisations or people take advantage of Global Fund transparency to trigger open and well-informed discussions on aid effectiveness. How can this be when all the data and documents are “just a mouse click away”? Close to $20 billion were disbursed in a few years. Where did it all go? Who got it? To do what? With what success?
The Fund’s website should be an extraordinary tool to get the facts right on those questions. It should be a gold mine of stories for local journalists, civil society organisations (CSOs), activists and parliamentarians in recipient countries. But, for the most part, they aren’t panning for this gold. What is transparency all about if it doesn’t translate into increased accountability at country level, and if people and communities for whom the Global Fund was created don’t use it to keep pressure on grantees, to voice their concerns and claim their rights?
The reality is that using Global Fund data to make recipients accountable is out of reach to most concerned people because they lack access to the Internet, because they don’t have enough time or the technical skills – and because there are obstacles to freedom of information and speech.
Global Fund transparency, as it is practised today, is more of a barrier to journalists and in-country activists than anything else: intimidating piles of reports filled with obscure language, countless files and downloadable materials that reassure technocrats in donor capitals but that don’t say much about the reality of what happens to the funds when they hit the ground. Understanding, processing and making use of this information requires learning about technical jargon, Global Fund internal processes, and the roles and responsibilities of different local partners. One needs to be familiar with web searching techniques and data processing methods, and to have some basic communication skills to translate often indigestible data into a plain, common language that non-technical audiences can understand.
Last, but not least, trying to make the powerful accountable in countries with no such tradition is a risky game for the few activists and concerned citizens who dare to do so. With the rise of the “Open Government” and “Open Data” movements in Africa and elsewhere, people may fear less for their lives than they used to, but threats and intimidation are still very much a daily reality for local watchdogs.
This leads to a strange paradox. As I heard recently: “That is almost the flip side of transparency. It’s very easy to use transparency if actually you want to drown people in information. I know it’s a tactic for lawyers: just give too much information to people, and it will be difficult for them to really figure out what is important.” Certainly, the Global Fund did not create this complexity consciously and voluntarily, but the result is the same: mountains of data and files that have the effect of shielding grantees and the Fund’s bureaucracy from too much scrutiny.
Today, in the wake of the Global Fund, a growing number of international organizations have committed to making their information on aid spending easier to find, use and compare. More than 120 UN agencies, multilateral banks, bilateral donors and NGOs have already endorsed the IATI (the International Aid Transparency Initiative) and have agreed to convert their data into a common standard. While this is a major step in the right direction, a simple lesson should be drawn from the Global Fund’s experience: Opening up databases is not enough for change to occur in the way local accountability happens. Rather, change requires a real commitment to accompany those for whom this data is made available as they make their first steps in the maze of aid transparency.
Here is what I think needs to happen.
Build capacity to use Global Fund data. Local watchdogs need help to stay afloat in the aid data deluge, to learn how to use the tools of transparency to have impact. While their work may not require the same level of technical sophistication as global watchdogs, they need training. They need to be able to understand who does what and where to find the information. They need to acquire watchdogging skills, using real-life case studies and guidance based on local needs. Watchdogs usually don’t focus on one single aid provider; no organisation would be justified in developing such a programme in isolation. Therefore, the capacity building should be a shared responsibility, and a combined and coordinated effort, by all concerned parties, such as the IATI signatories and some global or regional players in the field of transparency. The Global Fund has the credibility to take the lead on this. It should sit down with IATI partners to explore how a step-by-step, scalable, replicable and carefully targeted capacity-building programme could be implemented. As a critical side effect, such an initiative could provide some recognition to participating local aid monitors, thus breaking their isolation and protecting them in the exercise of their democratic rights.
Declare war on gobbledygook. Besides data, transparency is first and foremost about communicating in plain language. How much sense does it make for thousands of people, including the Secretariat’s own staff, to have to turn to a newsletter like the GFO to understand the rules of the game of a multi-billion dollar transparent organisation? The Global Fund should elevate proper communications with implementers (and others) to a top priority. The Fund should stop relying on technical staff to draft documents that are meant for wide distribution. It should reinforce the capacity of its Communication Department by adding writers who can translate complex policies and procedures into plain language.
If the Global Fund were to support and encourage local watchdogs, this would constitute a valuable early warning system for the Fund – one that complements the work of the local fund agents and the Office of the Inspector General. Building the capacity of local watchdogs to use transparency could greatly reinforce the Fund’s own risk management and fraud prevention efforts, at little cost. The Global Fund should also tackle its poor communications with implementing countries by addressing the Secretariat’s capacity issues in this field. With the 2015 MDG deadline on the horizon and the development community bracing for what comes next, with pressure on the Fund to improve its oversight mechanisms, and with the need for the Fund to position itself for a possible redefinition of its mandate, these measures could reassure donors about its capacity to be a truly different business model in international development.
The Global Fund should renew its commitment to transparency and take bold steps to promote wide use of its transparency in recipient countries. Information is power. It’s time to give power to those for whom the Global Fund was created so that transparency can fully achieve what it is meant for.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Robert Bourgoing joined the Global Fund in its early days, in 2003, and was a senior member of its communications team until last year. He is a trained lawyer and an experienced journalist, and currently works as an independent consultant. This commentary was originally published in Global Fund Observer (GFO) Issue No. 215 on 23 April 2013, produced by Aidspan.