This editorial is drawn from a speech by Dr Halfdan Mahler to the World Health Assembly in May 2008. Dr Mahler was the Director General of WHO at the time of the 1978 Alma Ata declaration on Primary Health Care. He stated at the 2008 WHA:
Milan Kundera wrote in one of his books: "The struggle against human oppression is the struggle between memory and forgetfulness." So allow me to remind all of us today, of the transcendental beauty and significance of the definition of health in WHO's Constitution: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
This definition is immediately followed by: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Most importantly, the very first constitutional function of WHO reads: "To act as the directing and coordinating authority on international health work." Please do note that the Constitution says "the" and not "a" directing and coordinating authority.
So please, allow this old man in front of you to insist that unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.
My memory tells me that the World Health Assembly had this in mind when, in 1977, it decided that the main social target for governments and WHO in the coming decades should be the attainment of what is known as "Health for All".
And, the Health Assembly described that as a level of health that will permit all the people of the world to lead socially and economically productive lives. The Health Assembly did not consider health as an end in itself, but rather as a means to an end.
That is, I believe as it should be.
When people are mere pawns in an economic and profit growth game, that game is mostly lost for the underprivileged.
Let me postulate that if we could imagine a tabula rasa in health without having to deal with the constraints - tyranny if you wish - of the existing medical consumer industry, we would hardly go about dealing with health as we do now in the beginning of the 21st century.
To make real progress we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactoral causation of disease, have for a long time, called attention to the association between health problems of great importance to man and social, economic and other environmental factors. Yet, considering the tremendous political, social, technical and economic implications of such a multidimensional awareness of health problems I still find most of today's so-called health professions very conventional, indeed.
It is, therefore, high time that we realize, in concept and in practice, that a knowledge of a strategy of initiating social change is as potent a tool in promoting health, as knowledge of medical technology.
Primary health care is indeed conditioned by its holistic framework and as such, may use different expressions. For example, in some countries health management has to be considered along with such things as producing more or better food, improving irrigation, marketing products, etc. It is not that people consider health services as unimportant, but there are things like getting food, or a piece of land, or house or an accessible source of water which are more of a life and death nature and must, in the wisdom of the people, come first to make other things meaningful. We have rarely considered these needs as falling within our expressed policies for health development and therefore, we risk being restricted, unilateral and ineffective in our action.
Again, I am afraid that conventional or medical wisdom has done very little to provide scientific and political credibility to the alleged importance of individual, family and community participation in health promotion.
These concerns, to which I have just alluded prompted an organizational study on "Methods of promoting the development of basic health services" by WHO's Executive Board in 1973 in which it is bluntly stated that:
"There appears to be widespread dissatisfaction of population about their health services for varying reasons. Such dissatisfaction occurs in the developed as well as in the Third World. The causes can be summarized as a failure to meet the expectations of the populations; an inability of the health services to deliver a level of national coverage adequate to meet the stated demands and the changing needs of different societies; a wide gap (which is not closing) in health status between countries, and between different groups within countries; rapidly rising costs without a visible and meaningful improvement in service; and a feeling of helplessness on the part of the consumer who feels (rightly or wrongly) that the health services and the personnel within them are progressing along an uncontrollable path of their own which may be satisfying to the health professionals but which is not what is most wanted by the consumer".
It was this organizational study by WHO's Executive Board that led to the decision by WHO in co-sponsorship with UNICEF to convene "The International Conference on Primary Health Care" in the city of Alma-Ata in 1978.
Let me then repeat with awe and admiration, the consensus concept of primary health care as contained in the Declaration of Alma-Ata 1978:
"Primary Health Care 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."
Let me also quote from the Declaration of Alma-Ata, that primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. In my opinion, an admirable summation of key priorities.
Are you ready to address yourselves seriously to the existing gap between the health "haves" and the health "have-nots" and to adopt concrete measures to reduce it?
Are you ready to ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors, in order to 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?
Are you ready to make preferential allocations of health resources to the social periphery as an absolute priority?
Are you ready to mobilize and enlighten individuals, families and communities in order to ensure their full identification with primary health care, their participation in its planning and management and their contribution to its application?
Are you ready to introduce the reforms required to ensure the availability of relevant human resources and technology, sufficient to cover the whole country with primary health care within the next two decades at a cost you can afford?
Are you ready to introduce, if necessary, radical changes in the existing health delivery system so that it properly supports primary health care as the overriding health priority?
Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care?
Are you ready to make unequivocal commitments to adopt primary health care and to mobilize international solidarity to attain the objective of health for all by the year 2000?
Alma-Ata was, in my biased opinion, one of the rare occasions where a sublime consensus between the haves and the have-nots in local and global health emerged in the spirit of a famous definition of consensus: "I am not trying to convince my adversaries that they are wrong, quite to the contrary, I am trying to unite with them, but at a higher level of insight."
The Alma-Ata primary health care consensus also reflects a famous truism: "The Health Universe is only complete for those who see it in a complete light, it remains fragmented for those who see it in fragmented light!"
In conclusion, my personal view is that the Alma-Ata primary health care consensus has had major inspirational and operational impacts in many countries having a critical mass of political and professional leadership combined with adequate human and financial resources to test its adaptability and applicability within the local realities through a heavy dose of systems and operations research.
Mind you, it is much easier to be rational, audacious and innovative when your are rich! But, please, let us not forget that the inspirational energies and the evidence base came from the developing countries themselves, be they governmental or non-governmental sources.
For a majority of these countries, financial support from so-called donors was essential to carry out a broad array of studies, in appropriate technology, human resources development, infrastructure development, social participation, financing etc. in order to integrate the Alma-Ata vision into heavily constrained local contexts.
Most donors, after an initial outburst of enthusiasm quickly lost interest or distorted the very essence of the Alma-Ata Health for All Vision and Primary Health Care Strategy under the ominous name of selective primary health care which broadly reflected the biases of national and international donors and not the needs and demands of developing countries.
But in spite of these brutal impediments many developing countries have shown, before and after the Alma-Ata happening, courageous adhesion to its health message of equity in local and global health. Civil society movements have also been prime shakers and movers in these admirable efforts.
And so, being an inveterate optimist I do believe that the struggle between memory and forgetfulness can be won in favour of the Alma-Ata Health for All Vision and its related Primary Health Care Strategy. Let us not forget that visionaries have been the realists in human progression.
And so, distinguished audience, let us use the complete light generated by WHO's Constitution and the Alma-Ata Health for All Vision and Primary Health Care Strategy to guide us along the bumpy, local and global health development road.
Thank you.
Editorial
Uganda has implemented a number of reforms to its health sector to make services more accessible to poor communities, including abolishing user fees, introducing public-private partnerships in service delivery, and decentralizing the management of health services to district and lower local government levels. Yet poor people continue to face barriers to use of health services. Costs of health services are still cited by poor people as being a barrier to using services, as are long distances to health centers, particularly for rural residents. Access to health care is thus an important equity issue in Uganda: Poor and disadvantaged people experience a greater burden of disease - but have poorer access to health care than those who have higher incomes.
These were the challenges discussed at a recent national meeting on health equity in Uganda hosted by HEPS Uganda, Makerere University School of Public Health and EQUINET. The meeting included presentations of work on disparities in health and access to health care, from researchers from academic, government and non government organisations. While the presentations reported on a range of initiatives to improve health in the poorest communities, they also gave evidence of the continuing challenges the country faces.
For instance, one study reported by the Institute of Public Health at Makerere University found in three districts of Uganda that the poorest households were 2.4 times more likely to suffer ill health than the richest. Infant and child mortality among the poorest Ugandans are reported to be double that in the richest group. Such inequities are also common in vulnerable groups that have greater need for health care. Addressing the needs of the poorest communities can be overshadowed by deficits in access to care for a much wider group of people. For example, the meeting was informed that despite a significant improvement in access to antiretroviral therapy (ART), demand for ART has continued to outstrip supply, and only about 60% of people who need ART can access it. Older persons were also described as having high health needs that may not be met due to wider poverty and isolation.
Not surprisingly a number of papers in the meeting thus explored the way resources are allocated to address these challenges. The first issue that arose was the overall shortfalls in health financing. The US$14 per capita reported to be spent on health was noted to be about a third of the resources needed for minimum health care services. While new resources have been mobilised nationally and internationally for AIDS, presenters reported that there is still a significant shortfall in funding for AIDS, especially at the district level. It was reported that out-of-pocket payments continue to exceed public sector spending, even though most poor people use public services and through fees have been abolished in the public sector. This is a barrier to health care for poor communities, and the source of these charges needs to be better understood to address them. The continued shortfall in overall financing also draws attention to whether budgets give special consideration to vulnerable groups. Concern was expressed in one presentation that district councils set budget priorities using a narrow definition of gender health needs within the community. Women have weak control over productive resources and household finances, and unless services give additional attention to this situation they will also lack command over the resources they need to protect their health.
Such disparities remain an issue to be addressed to promote health and access to health care in Uganda. There was wide agreement that such inequalities were avoidable and thus merited attention and action. Some actions were presented and discussed: The experience of community health insurance schemes was reviewed as one option for supplementing health resources. A study was presented showing that 81% of households surveyed in one rural district expressed willingness to enroll in Community Heath Insurance schemes and were willing to contribute on average Ushs.5,977 (US$3.4) per person per year. Further work needs to be done on how equitable and sustainable these schemes are, especially for the poorest. It was argued that strengthening decentralisation, through resource allocation that prioritises districts and community level, could also go a long way to strengthening the health care system used by low income groups, and thus addressing inequity. Various examples were presented of strategies to empower and mobilise communities to engage with their health services, including the Village Health Team Strategy and the use of media, drama and of participatory reflection and action methodologies.
Across these options it was agreed that ensuring fair opportunities for health should not be left only to the Ministry of Health, but should be a matter for all sectors. According to the Ministry of Health in Uganda, over the past fourteen years, considerable effort has been made to restore the functional capacity of the health sector, through increasing public health spending, reactivating disease control programmes and re-orienting services to primary health care in Uganda. However, the ministry observed in a 2007 report that there still remain significant challenges in matching need for health services with available resources, making equity or fairness an important issue for advancing national policies for the population as a whole (http://www.health.go.ug/policies.htm).
The people and organisations at the national meeting agreed to continue networking to advance health equity work, and formed a new Ugandan health equity network. This will create a platform and ignite further action for health equity at national level. With leadership from different institutions working in these areas the network will share evidence, knowledge and strengthen advocacy on areas of health equity that include: resource mobilisation and allocation to the health sector; addressing health needs of vulnerable groups; protecting health in trade policies and agreements; and advancing health rights, community empowerment and effective governance in health. While it was evident in the meeting that a lot of work is underway, it is not always shared and communicated within Uganda and in the East and Southern Africa region. The delegates thus agreed to strengthen and widen links between people and institutions working on equity in health, to promote research and practice in this vital area of national health policy.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. For more information on the health equity network in Uganda, contact HEPS Uganda at heps@utlonline.co.ug, working with Makerere University School of Public Health. Further information on the issues raised and the report of the Uganda national meeting is also available at the EQUINET website at www.equinetafrica.org.
Two meetings took place in the last month.
On 18-20 April, the Southern Africa Development Community (SADC) held an international conference on poverty and development in Pailles, Mauritius. Background material for the conference prepared by SADC showed the threat posed by critical levels of HIV and AIDS, TB and Malaria to achievement of the Millennium Development Goals (MDGs). Countries were recommended to reprioritise their spending to curb the spread of diseases and other health problems impacting on development, including by meeting commitments to the 2001 Abuja Declaration commitment of 15% of national budgets on public health.
The AU Ministers of Finance and Planning and Economic Development meeting held in Addis Ababa- Ethiopia from 26 March to 2 April also noted with concern the necessity for long-term sustainable financing of and investment in health created by AIDS and other diseases. However, they were publicly silent on the commitment made by African heads of state in 2001 to allocate 15% of their annual national budget to health as a means towards this. Indeed, there are unconfirmed reports from people attending the meeting that some Ministers of Finance argued for the Abuja target adopted by their heads of state in 2001 to be abandoned.
That the region needs to increase its public sector investment in health is not in dispute. Poorer groups continue to have considerably worse health than the better off; economic growth and achieving the Millennium Development Goals (MDGs) in the region is seriously undermined by the prevalence of HIV and AIDS, TB, Malaria and other diseases. Eleven of the sixteen countries in east and southern Africa spend less in their public sectors than the US$34 needed for the most basic interventions for these conditions, let alone the US$60 or more needed for more comprehensive health services. So far, only three countries in the SADC Region have reached the Abuja target, although more are moving in a positive direction. Ten of the sixteen countries in the region would, if they met the Abuja target, increase their public financing to health above the basic level of US$34/capita needed for these basic health programmes.
There is significant potential gain when such increased spending is directed towards primary health care and district services, providing improvements in early detection, access and treatment for disadvantaged groups and in under-served areas. Many of the actions that improve health in poor communities are indeed taken outside the health sector, to improve physical, economic and social environments. However, evidence and experience shows that levering such actions for health across a range of sectors still calls for strong public health leadership, with adequate resources and political support to encourage shared mandates and co-ordinated action for health across all sectors.
The SADC meeting documents made it clear that a public sector led response is vital: Governments have the primary and most important role, responsibility and means for implementing systemic changes and sustaining them in the long run. Government action to reprioritise spending on health and develop sustainable, progressive strategies for financing health care is thus essential to create a basis for complementary strategies and inputs from other sources.
In contrast, diluting or failing to meet commitments to public funding for health undermines the necessary response to a major development challenge with greatest cost to poor households. As the SADC conference on poverty and development was informed, SADC Member States account for 35% of the people living with HIV globally and there are over 5.2 million orphans in the region. The region has the world’s worst TB infection rate and the rate has increased in the last 15 years, while the resources needed to cope with the epidemic have dwindled. New epidemics of multi-drug resistant tuberculosis (MDR-TB) and extreme drug-resistant tuberculosis (XDR-TB) pose grave and rising public health threats, particularly where health resources are limited. There are an estimated 30 million cases of malaria and 400 000 deaths from malaria in the region, with particular risk for children and pregnant women.
Such illness impacts on household income, diverting time and money for caring - sometimes at the expense of food consumption or school enrolment in children - with longer term consequences for poverty and production, especially for agricultural production and food security. Ill health places particular demands on women and children to provide or pay for care. As public funding for health has fallen, the region has also experienced rising charges and out-of-pocket payments for health care. When public services are under-funded or inaccessible and out-of-pocket payments for health increase, this has a particularly impoverishing effect on women, lower income and socially marginalised groups.
So meeting the heads of state commitment in Abuja is important to directly address significant and rising disease burdens; provide the necessary public and health sector leadership to lever other contributions to health; and protect against rising impoverishment and inequality resulting from unaffordable levels of household spending on health care in the lowest income households.
This is clearly not only a matter of increasing resources for health, but of redirecting resources towards greatest health needs. However review of experience in African countries shows that equitable allocation of public sector health care resources is more likely in a situation of increasing resources to health, backed by a policy commitment to equity and explicit mechanisms for achieving reasonable allocation targets.
Not surprisingly therefore, the paper produced by the SADC secretariat for the conference on responses to the economic impact of the three communicable diseases was clear and unequivocal: ‘SADC Member States and governments have committed themselves to many declarations including Abuja 2001 on the three communicable diseases, the Maputo Declaration of 2005 on declaring TB an emergency and UNGASS to name a few. They need to fulfill these obligations and put a mechanism in place to monitor and evaluate them.’
The commitment made by the heads of state in Abuja 2001 towards allocating 15% of their national budgets for health was an important contribution to poverty reduction and equity, and a challenge to international partners to eliminate debt and meet their own commitments to overseas development aid. We would expect a similar level of explicit commitment to the goal from the Ministers of Finance in the region, and more than that delivery on the 15% government funding to health.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET calls for “Abuja plus” i.e. 15% government spending to health, increased local and international per capita funding, debt cancellation, abolishing user fees, increasing the share of progressive tax funding, and 50% of government spending to district levels and primary health care. EQUINET work on fair financing in health is available at www.equinetafrica.org.
Beyond the call for governments to meet their commitment to spend 15% of their budgets on health, we are concerned to see that government spending reaches those with greatest health needs. So how well do governments perform in equitable allocation of their health spending?
In many African countries, health care spending levels are very different between different provinces, regions and districts. This is largely a historical inheritance. Health services, particularly hospitals which consume the major share of health care resources, are heavily concentrated in the largest urban areas, and rural areas are relatively under-resourced. Yet almost all countries in east and southern Africa have policy goals to provide equitable access to health care for their citizens. This implies that health care resources (financial, human and facilities) should be fairly distributed between geographic areas on the basis of health needs.
Internationally, it has been found that using a needs-based resource allocation formula is a helpful strategy for breaking the historical inertia in resource allocation patterns. Such formulae are used to distribute public sector health care resources between geographic areas (such as provinces or regions and districts) according to the relative need for health services in each area.
The indicators commonly used to identify relative levels of need for health services, and thus applied in these resource allocation formulae internationally are:
• population size;
• composition of the population, as young children, elderly people and women of childbearing age tend to have a greater need for health services;
• levels of ill-health, with mortality rates usually being used as a proxy for illness levels; and
• socio-economic status, given that there is a strong correlation between ill-health and low socio-economic status and that poor people rely most on publicly funded services.
A growing number of African countries have also adopted such needs-based formulae to guide the allocation of health care resources, using a mix of these indicators. How well then are we doing in the region in matching government spending on health to health needs?
A questionnaire survey of researchers and senior government officials in selected countries in the region (Namibia, South Africa, Zambia and Zimbabwe) carried out in the EQUINET work on fair financing showed that there has been progress in the equitable allocation of public sector health care resources over the past few years in the region. However, the extent of progress and pace of change varies between countries.
In both Zambia and Namibia, the most under-resourced provinces and regions have seen increased allocations, while allocations to provinces whose share of resources is proportionately greater than their share of health needs have been gradually reduced. Although South Africa has a different system where it allocates domestic public sector resources for health and other services as a ‘block grant’ to provinces, there has also been considerable progress towards equity in the distribution of health care resources in the past few years. In Zimbabwe, progress towards equity targets has been constrained by significant absolute shortfalls in health care resources, due to wider economic difficulties. In the main, however, the countries surveyed were generally making progress applying some form of needs based formulae in the region, with positive gains for districts with greater health needs.
Achieving this progress is underpinned by an explicit policy commitment to equity and to redistribution of resources. For example, the Namibian 1998 health policy states that “Particular emphasis shall be paid to resource distribution patterns in Namibia to identify and accelerate the correction of disparities”. South Africa, Zambia and Zimbabwe have made similar declarations.
Experience from countries in the region point to some of the actions countries need to take to overcome barriers in implementing equitable redistribution of their health care resources.
Countries need to set explicit annual allocation targets to provide clear goals against which progress can be planned and monitored. These targets need to set a reasonable pace of change for the relative redistribution of health care resources to facilitate appropriate planning and avoid unnecessary disruption to services.
Even where these targets exist, countries may need to overcome further difficulties in successfully pursuing these targets. There may be a lack of senior staff at the national level to drive the process. Numerous vertical programs that protect allocations to specific services reduce the pool of general health sector funds available for equitable allocation between geographic areas. It is difficult to translate budget shifts into real changes in expenditure without achieving the more difficult task of also changing the distribution of staff, given their importance in the uptake of resources. Strategies must thus be put in place to facilitate a relative redistribution of staff. This may include negotiations with trade unions and initiatives such as offering additional allowances, preferential training opportunities and other incentives to attract health workers to rural areas.
Resource allocation is a highly politicised process and the resource allocation policy development and implementation process requires careful management in order for it to be successful. The progress reported from the countries surveyed is a sign that these issues can be addressed.
It is politically and technically easier to address these issues and redistribute health care resources when the overall health budget is increasing. Our still limited progress by 2008 towards achieving the Abuja target of devoting 15% of government funds to the health sector thus limits our progress towards more equitable resource allocation. Those countries that are increasing the overall allocations to the health sector have more leeway to effectively redistribute health care resources. All of the additional budget available annually can be allocated to the most under-resourced areas while keeping the budgets of relatively over-resourced areas static in real terms (only allowing a small increase to take account of inflation). It is also an issue for those advocating the Abuja target to monitor that these additional funds are allocated to these areas of greatest health need.
The progress made in the region needs to be protected and advanced: Governments need to engage with and involve key stakeholders, including parliamentarians to ensure their ‘buy in’ to and understanding of the strategies for an equitable sharing of available resources. We have an increasing number of champions for the Abuja commitment. We also need ‘policy champions’ at senior level in Ministries of Health, civil society and parliament to motivate for and monitor progress in making sure that these resources for health are equitably allocated to where they are needed most..
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET work on fair financing in health is available at the EQUINET website at www.equinetafrica.org.
The World Health Organisation Director General (D-G) Margaret Chan described the recent WHO Executive Board meeting on 21-26 January 2008 as ‘stimulating, constructive and instructive.’ Chan challenged member states’ to provide her with direction regarding the contentious issues facing the WHO but the meeting failed to break the deadlock on issues regarding the selection criteria of the D-G and on how to deal with the International Migration of Health Personnel.
Developed countries opposed the inclusion of regional rotation in the selection criteria for the D-G, alleging that this may undermine the selection of competent candidates. However, many developing countries supported regional rotation as a selection criterion in order to promote balance amongst the regions who have had candidates as Directors-General, while not compromising on competence. The current selection process includes expensive campaign programmes that poor countries cannot afford to mount. Inclusion of the principle of rotation will go a long way to levelling the playing field.
The options presented in the Executive Board report on what the options were for addressing the proposed selection criteria changes were: (1) maintaining the status quo; (2) special consideration to candidates from certain regions; (3) and (4), two related options, considering geographical representation as the criterion for the establishment of the shortlist; (5) considering geographical representation as the criterion for the eligibility of candidates; and (6) using the same system of regional rotation as that applied to candidatures for elective office.
Board members supporting regional rotation of the post of D-G emphasised the need to ensure an equitable selection process and a level playing field among regions. They noted that no D-G had been appointed from three of the six WHO regions, even though qualified candidates from those regions had been proposed in past elections. Board members in favour of maintaining the current system said a pattern of regional rotation would necessarily restrict the choice of candidates, and would not therefore ensure that the most qualified person was elected.
One proposal was that the D-G be elected for 5 years with contribution until all the regions have contributed a D-G. Then it will start again, with the exclusion of the region of the outgoing D-G. While some supported this proposal, others, particularly from high income countries did not. It was proposed that the matter be set aside for two years, to give regions a chance to discuss the issue and the board would decide on it in 2009.
Member states were similarly divided on largely North-South lines on the issue of the international migration of health personal. Issues related to a global strategy, a code of practice, compensation mechanisms, a look into the failing training practices in the developed countries and better data for managing international health worker migration were raised in the discussions.
The developed countries position on WHO’s role on international migration was mainly for collecting information and developing non-binding codes of practice. Many developing countries, on the other hand sought effective actions including a global strategy and compensation. Member states adopted polarised positions and decision making was again deferred, which effectively maintains the existing status quo. Countries in Europe and North America pointed out that migration can have positive effects, such as migrants returning home with useful experience. However it was noted by other states that only 23 percent of the 130,000 health worker personnel abroad came back.
Attention was given to WHO work on the global code of practice, a matter seen to be a high priority for Africa. Without health workers, the Millennium Development Goals in Africa could not be achieved, and it was felt by some that the D-G should work with member states to come up with mechanisms for receiving countries to invest in training health workers in originating countries and assist with incentives.
Particularly raised by low and middle income member states was the observation that developed countries have failed in their own training policies and are now armed with ways of getting health personal from lower income countries, handicapping national health plans and deeply weakening the health systems of these source countries . It was raised that financial, equipment and technical support should be given in compensation, that certain discriminatory policies should come to an end and migrant workers receive the same salaries and benefits as paid to nationals of host countries. Further, headway was urged in developing effective measures to manage migration.
However, it was also noted that migration was a personal choice and that countries dealing with the impact of migration should create ‘task shifting to broaden the types of health workers’ who can provide care. Some members felt that a code of practice would not carry the weight of a ‘soft law’ as it was non-binding and not any kind of law, whether soft or otherwise.
While the WHO Secretariat reported that it was now getting better data and dialogue in place on migration a consultative process should now take place at the Executive Board meeting in 2009.
The debate on these two widely different issues signal that there is yet weak consensus within the WHO Executive Board on key contentious issues facing the WHO. There appears to be agreement on the need to act on such issues, but not yet on the direction of action. A division on “north-south” lines has maintained a deadlock on issues regarding the selection criteria of the D-G and on how to deal with the migration of health personnel. Their deferral for further consultation and review in 2009 contradicts the need for clear leadership on action, with action on health worker migration and retention particularly essential and urgent for developing countries affected.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET work on health worker migration is available at the EQUINET website at www.equinetafrica.org.
Can criminalising deliberate HIV infections curb the HIV transmission rate, and so be good for public health? Or would such legislation negatively impact on voluntary counselling and testing (VCT), and therefore be bad for public health? With many countries in east and southern Africa either enacting or amending legislation to criminalise deliberate HIV infections, there has been mixed response to these questions and mixed reaction to such law reform.
Kenya, Tanzania and Uganda are currently introducing or amending laws to criminalise wilful HIV transmission as they view such laws as an effective tool to curb behaviour that carries the risk of HIV transmission and a legal contribution to the supportive environment for behavior change. These laws generally provide for sanctions when an individual who knows their HIV status knowingly and wilfully infects another individual with HIV. They are proposed as a measure to protect people with less power. By providing sanctions against wilful transmission of HIV, such laws are argued to protect the more vulnerable groups, usually women and young girls, in their sexual relations with those who are more powerful - usually men and wealthy people. They intend to reduce the impunity with which the powerful coerce others into sex, through acts such as rape and defilement, or into practicing unsafe sex (for example through commercial sex work), and so act as a deterrent against these practices.
However, a range of stakeholders involved in HIV related work, from legal, health rights and public health backgrounds, argue that ordinary criminal law provides sufficient legal mechanisms to hold someone accountable for wanton and deliberate infection of sexual partners. A special law to mandate criminalisation of HIV transmission could be bad for public health, harming initiatives such as voluntary counseling and testing (VCT) by deterring individuals engaged in high-risk or criminal sexual behavior from finding out their HIV status, in order to avoid prosecution under this law. Knowledge of HIV status is an entry point to many public health interventions to both prevent HIV and manage AIDS. With women commonly tested for HIV status through antenatal programmes, such laws may increase women’s vulnerability. Laws criminalising deliberate HIV infections could increase stigma, and violate the rights of persons living with HIV to life, health, treatment and freedom from cruel, inhuman or degrading treatment if effective care is lacking, or discontinued, through imprisonment. Emmanuel Mziray, GIPA Adviser to UNAIDS in Tanzania, observes that: ‘prohibiting alcohol and other drugs, consensual sex, or prostitution has never succeeded in preventing these behaviors’.
Criminalising deliberate HIV infections also raises a number of issues relevant to application of the law. It raises questions, for example, about the whether people living with HIV have a legal duty to disclose their HIV status before engaging in sexual activities that can lead to transmission of the virus? If so, then how do you prove in court that the person breached this legal duty? Further there are difficulties in proving the link between the sexual activity and the HIV transmission.
In a bid to address these concerns, USAID recently produced a policy options paper (See: http://data.unaids.org/Publications/IRC-pub02/JC733CriminalLaw_en.pdf) proposing some principles to guide thinking about, and development of, law and policy on the question of criminal law and HIV/AIDS. The paper identifies a number of public policy considerations that countries should consider when making decisions about using criminal law to tackle deliberate HIV infections. It warns that government officials and the judiciary involved in the development and implementation of such policies should be knowledgeable of the best available scientific evidence regarding modes of HIV transmission. Risk levels should form the basis for rationally determining if, and when, conduct should attract criminal liability. This is very challenging in settings where the judiciary may not be familiar with latest scientific evidence regarding on HIV transmission, particularly where there may be debate about levels of risk.
USAID propose that any legal or policy responses to HIV, particularly through the coercive use of state power, should not only be pragmatic in the overall pursuit of public health, but should also conform to international human rights norms, particularly the principles of non-discrimination and due process. State action which infringes on human rights must be adequately justified and policy-makers should always assess the impact of law or policy on human rights, choosing the ‘least intrusive’ measures possible to achieve the demonstrably justified objective of preventing disease transmission. As pointed out by Shanaaz Mathews in the April 2006 edition of the South African Medical Journal, international guidelines on HIV and human rights developed by UNAIDS and the Office of the United Nations High Commissioner for Human Rights (OHCHR) point out that criminal or public health legislation should not include specific offences against deliberate transmission of HIV, but that the latter should be tried under general criminal law, a position endorsed by the South African Law Commission (SALC) in 2001.
The development of such laws in Kenya, Uganda and Tanzania, amongst other ESA countries, suggest that these guidelines are not being followed. In Tanzania the proposed law is under debate, and article 47 of the HIV and AIDS (Prevention and Control) Bill, 2007 provides: ‘Any person who willfully and intentionally transmits HIV to another person commits an offence, and on conviction shall be liable to life imprisonment’. In Kenya, section 26 of the Sexual Offences Act, 2006 makes it an offence for any person who with actual knowledge that he or she is infected with HIV or any other life threatening sexually transmitted disease intentionally, knowingly and willfully infects another person. Though Uganda has not enacted specific legislation criminalising deliberate HIV infections, it has amended its Penal Code Act to create the offence of aggravated defilement and aggravated rape where the offender was infected with HIV.
These laws do not appear to have addressed the human rights or public health concerns raised above, and assign the matter to courts who may have weak expertise in assessing the public health evidence. More generally, the public health impact of these measures are not monitored, neither the costs nor the potential benefits raised above. It is thus difficult to argue that they have been adequately justified, or that they are the ‘least intrusive’ measures possible to achieve their intention. The argument that the issue should be tried under general criminal law perhaps provides a legal remedy for clear violations of rights, without the negative consequences of a specific provision.
Policy and legal reforms are important in tackling the HIV epidemic. If human rights and public health issues are to be respected then it is vital that professionals and activists working on AIDS and people living with HIV be involved in and debate the legal reform processes in this area.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. Further information on health rights and AIDS can be found on the EQUINET website at www.equinetafrica.org
The Gates and Rockefeller Foundations propose to increase food production on the African continent, “eliminating hunger for 30-40 million people and sustainably moving 15-20 million people out of poverty,” through their initiative of an Alliance for a Green Revolution for Africa (www.agra.com).
We all share in the goal of eliminating hunger on the African continent. However, we are also aware of the risks to health and nutrition posed by the previous green revolution in Asia and Latin America. As farmers dedicated more and more land to growing new varieties of wheat, rice, and maize, less land was available to women to grow vegetables (vitamins, minerals), and the commercial production of pulses (protein) stagnated. How will this proposed “green revolution” affect production, food security and human health in Africa?
Similar to the green revolution of the 1960-70s, increasing yields of a few crops to provide food for the hungry remains the central justification for this proposed African green revolution. The 1960s varieties of seed required fertilisers, pesticides, and water at very specific times or the yield was worse than traditional varieties. Indian farmers, for example, did increase production of wheat ten-fold and of rice three-fold. Learning from this experience, the current AGRA initiative also includes training African scientists, setting up marketing networks of small seed companies, and credit schemes. Other major differences are that the seeds will be genetically modified (GMOs) and patented, in the 1960s in India, they remained in the public domain.
The benefit of increased yields, however, came with many environmental, economic and social costs in the green revolution on the 1960-70’s.. The massive increases in the use of fertilisers and pesticides contaminated the water and soil. Small-scale farmers could not sustain the purchase of all the inputs and had to sell their land. Studies in India show that only farmers with at least 6-8 hectares of land could afford the high-tech agricultural production. Inequality within villages increased, with many moving to the cities. As Secretary General U Thant summarised in 1970, “There is already a growing a body of relevant literature on the experience in various regions and localities which strongly suggests that the prosperity resulting from the Green Revolution is shared by a relatively few.”
The economic and social dangers of a “green revolution” for Africa are similar to those related to the commercialisation of health care: 1) piracy of both indigenous knowledge and plants (used for medicine and/or food); 2) privatisation of bioresources necessary for human health through patenting of plants; 3) privatisation of research which directs priorities and agendas. Rather than reducing hunger, these adverse outcomes could in fact reduce the food security of Africans, increase undernutrition and thus reduce immunity against disease.
Increased yields of one or two strains of one or two crops (“monoculture within monoculture,” as stated by a Tanzanian botanist) will not provide the basis for food security to support nutritional needs. The key to ending hunger is sustaining Africa’s food biodiversity, not reducing it to industrial monoculture. Currently, food for African consumption comes from about 2,000 different plants; in contrast, the US food base derives mainly from 12 plants. Narrowing plant diversity of food increases vulnerability for all because it a) reduces the variety of nutrients needed for human health, b) increases crop susceptibility to pathogens, and c) minimises the parent genetic material available for future breeding.
Manufacturing plants for food is very similar to manufacturing them for medicine. Indigenous knowledge designates a plant as important for nutrition or for medicinal purposes. But often, corporations simply take both the plants and the knowledge with no recognition, monetary or otherwise, to the original breeders of new medicine and foods. This biopiracy of food and medicinal plants is made legal by the patenting of living organisms, through international trade agreements.
Because African farmers will have to buy the new seeds, and the pesticides and fertilisers they require for increased yields, this green revolution initiative becomes a privatisation offensive against small-scale farmers who still retain control over their seeds. Of the seeds used for food crops in Africa, 80 percent is seed saved by the farmer herself or locally exchanged with family and neighbours. Farmers do not have to buy seed every season, with cash they do not have, for they possess a greater wealth in their indigenous seeds, freely shared and developed over centuries. The very best food seed breeders in Africa, the “keepers of seed,” are women who often farm less than one hectare of land. Across Africa, women are also the food producers, tending “gardens” full of diverse crops for local consumption, while the men concentrate on cash crop production. Even when the cash crop fails, food will most likely be available for the family, for those plots are intensively farmed and carefully watered.
The proposed green revolution would shift the food base away from this treasure of seed. Instead, African farmers would have to purchase patented seeds each season, thus putting cash into the hands of the corporations providing the seed, much as already has happened with plants used in medicinal compounds. Loss of control over seed reduces the control women farmers have over production, with risks to food security and nutrition. For AGRA, the seeds will not only be patented, but new varieties will undoubtedly be genetically modified organisms (GMOs). The perils of GMOs to environmental sustainability are well documented. Most African governments have ratified the biosafety protocol which allows them to deter research and production of GM food crops until sufficient data is available about its impact on human health and the environment, but AGRA is lobbying for governments to “fast track” approval for new varieties to be planted.
Research on African food crops certainly needs financing. The US National Research Council concluded in 19996 that a major African food crop, sorghum “is a relatively undeveloped crop with a truly remarkable array of grain types, plant types, and adaptability….most of its genetic wealth is so far untapped and even unsorted. Indeed, sorghum probably has more undeveloped genetic potential than any other major food crop in the world.”
As nutritious as maize is for carbohydrates, vitamin B6, and food energy, sorghum is even more nutritious in a range of essential nutrients for health. One of the most versatile foods in the world, sorghum can be boiled like rice, cracked like oats for porridge, baked like wheat into flatbreads, popped like popcorn for snacks, or brewed for nutritious beer. Because sorghum can tolerate dry areas and poor soil better than maize, it can provide nutritious food security in semi-arid regions and therefore, should become even more important under conditions of global warming.
Engaging African scientists to discover the potential genetic wealth of sorghum would assist African food security. In a first glimpse of foundation expenditures, however, we see funds directed to the Wambugu Consortium (founded by Pioneer Hi-Breed, part of DuPont) for experiments in genetically modified sorghum. By adding a gene, rather than mining the genetic wealth already there, the consortium can patent and sell the “new” sorghum at a premium price for DuPont.
Private expenditure on research and marketing of a few crops directs attention to crops that are profitable. Similar to health care, International Monetary Fund requirements for structural adjustment programs, supported by all donor governments, the World Bank, and the African Development Bank, have been removing African government expenditures on agricultural research and extension. Governments had to spend less on agriculture in order to repay their debts. Now, more two decades later, the private foundations step in to “save” food-deficit Africa.
High-tech answers to Africa’s food crises are no answers at all if they undermine human nutrition, privatise both indigenous knowledge and bioresources through patenting of plants, and transform the genetic wealth of the continent into cash profits for a few corporations. Public policy choices around the AGRA proposals have not yet been made within Africa. There is thus still an opportunity to call for assessment and debate on the health and nutrition impacts of these proposals, including by civil society working in health, and by parliaments, and by UN agencies. We need to openly challenge its goals, motives and methodologies before Africa’s political leaders accept them, and before universities and research centres divert their agendas away from other applied research that may offer a more sustainable and nutritious future for African food production. The future of African health depends on it.
For references used in this editorial and a more detailed analysis of how Africa’s food biodiversity provides alternatives to chemical industrial agriculture, see Andrew Mushita and Carol B. Thompson, Biopiracy of Biodiversity (Trenton, NJ: Africa World Press, 2007), carol.thompson@nau.edu. Further information on nutrition and health issues can be found on the EQUINET website at www.equinetafrica.org or contact admin@equinetafrica.org
One by one in December, African countries in east and southern Africa signed interim Economic Partnership Agreements (EPA’s) with the European Union (EU). In a massive fragmentation of regional integration, first these agreements were negotiated in configurations that undermined African regional trading blocks (See EQUINET newsletter editorial May 2007). In November the fragmentation deepened as the east African countries broke from the ESA block to sign interim EU-EPA’s, as did Mauritius, Seychelles, Botswana, Swaziland, Mozambique, Madagascar, Zimbabwe and Namibia, individually. At the same time at the EU – Africa summit in Lisbon in December President Abdoulaye Wade of Senegal said "We are not talking any more about EPAs, we've rejected them", while countries like Namibia signed, but signalled intention to keep negotiating on protections for fledgling industries.
Its not only from Africa that conflicting signals are being sent. From the EU there is stated commitment to the two central goals of the 2000 "Cotonou Agreement": to eradicate poverty and to enhance the gradual integration of African, Caribbean and Pacific countries into the global economy. The EU has signed on to numerous UN and G8 commitments, including those on the Millennium Development Goals, and its own Treaty of Amsterdam. These commit the EU to policy coherence between development objectives and impacts and its policies in other areas, including trade. At the same time the interim EPAs being concluded are clearly focused on establishing free trade agreements strictly compatible with World Trade Organisation (WTO) requirements. While there is some reference to development issues, this is secondary and largely deferred to later dialogue.
Take for example the protection and promotion of public health as a fundamental issue not only for the MDGs, but in the International Covenant on Economic, Social and Cultural Rights (ICESR) (1976) and particularly Article 12. All parties to the agreement have ratified this convention. The EU founding document, the Treaty of Amsterdam commits that “A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities”. The African Charter on Human and Peoples’ Rights (1986) in Article 16, obliges ESA countries to take the necessary measures to protect the health of their people.
Despite this the Interim EPA texts made available in the region:
• Make no mention, as WTO agreements do, of the fact that clauses should be interpreted and implemented in a manner supportive of countries’ right to protect public health.
• Make no provisions for ESA countries to protect their infant industries, especially in small enterprises and in the small scale farming sector that underpins household food security and child nutrition in Africa.
• Make no exceptions to the elimination of import or export prohibitions or trade restrictions in areas such as trade in health workers, health services, essential services and other areas where governmental authorities and restrictions on trade are necessary to regulate provisioning or redistribute resources to meet social development goals, or to protect public health.
• Make no exceptions in clauses relating to internal taxes or charges in the interests of public health.
• Make no reference to “human development” or “social development” in the objectives of the section on economic and development co-operation
• Set no obligations for administrative arrangements or resources to assess or manage the public health implications of the liberalised trade measures proposed, including of obligations to carry out prior health impact assessments of specific areas of trade where there is a likelihood of risk to public health.
Such failure to address human development issues has led to criticism that the current EPA texts do not align with the 2006 adopted European Consensus on Development (2006/C 46/01) or the 2005 adopted EU measures to accelerate the progress towards attaining the MDGs [COM(2005) 132/final 2, COM(2005) 133/ final 2 and COM(2005) 134 final].
While there is pressure to secure WTO compatible agreements, the detailed tariff reduction commitments in the interim EPAs are argued to go beyond the strict demands of multilateral rules for the WTO-compatibility of free trade agreements, with costs to ESA countries. Gains from greater exports to the EU could be overshadowed by the damage done by the largely reciprocal market openings that ACP countries would have to undertake. The interim agreement accessed provides for 80% liberalisation in a period of 15 years. This would allow subsidised European food products, with which local producers would be in no position to compete, to effectively swamp ESA markets. Under the interim deals with East Africa, for example, taxes on two-thirds of imports from the EU would be eliminated with negative consequences for government revenue.
Such agreements are being signed at a time when the Doha Round on development is not yet concluded at the WTO, with Article 24 of GATT still being negotiated. Signing an interim EPA may pre-empt, or worse still weaken these WTO level negotiations. Reminiscent of the days of Structural Adjustment, it has been said that “there is no alternative” to the current trade focused EPAs. But trade experts indicate that alternatives do exist. Beyond significantly greater protection of human development issues in the EPAs’ as exemplified for health above, trade experts suggest that the EU could also have offered alternative trading arrangements under its Generalised System of Preferences (GSP+), particularly given the level of economic poverty and vulnerability in most ESA countries. It was possible for the EU to seek an extension of the waiver at the WTO, particularly given the delay in resolving the Doha round on development, given its significance for Africa. These options were not pursued, suggesting, as noted in an October 2007 analysis by the NordikAfrica Institute, that the primary EU goal for the EPAs was to secure free trade agreements within a strict interpretation of WTO rules.
The interim EPAs send signal an understanding of development and poverty reduction as being essentially driven by trade liberalisation, with development aid as a means of coping with the temporary, negative impacts of this agenda. It suggests that development will follow trade liberalisation and thus that other aspects of development should adjust to the terms of this free trade focused interim EPA.
The singular prioritisation of trade liberalisation, even while argued as “interim” fails to adequately protect basic social rights, such as the rights to health noted earlier. It also fails to adequately meet the EU’s own commitments and treaties and to draw on the EU’s own development experience, and the regulation and subsidies used in the EU to promote industrial and social development and services.
It also contradicts analysis and experience in ESA. After two decades of trade liberalisation policies, Africa Union and UN Economic commission for Africa reports in 2007 highlight uneven growth and growth with poor returns to human development and poverty reduction. Rapid, wide trade liberalisation policies have been associated with falling public revenues, increasing dependency on food imports, increased chronic undernutrition, reduced coverage and quality of and access to essential services, including health care services. In the health care sector, trade liberalization increases growth in formal and informal for profit health care services, with negative impacts on access, quality and segmentation in services, and increased fee barriers to care. Even the World Bank in a 2002 working paper concluded that rapid trade-related integration in Africa had caused or exacerbated social inequality and that those who benefited most were the import/ export firms, transport and shipping companies, large-scale commercial farmers, and financiers and the politicians and bureaucrats who are tapped into these commercial and financial circuits.
A model of development that is driven first through trade liberalization, with later “development” adjustments, negates the lived and historical experience, documented evidence and policy demands of Africa and of many development actors in the EU. Trade Commissioner Peter Mandelson said at a speech to the Civil society Dialogue Group in January 2005, “… I intend this to be a new start for the EPAs – to give the negotiations a new impetus – and to ensure that from now on, until the final implementation of what we will negotiate by 2008, development concerns have pride of place” . It appears his “pride of place” was the same marginalized exclusion the majority of disadvantaged communities in Africa occupy.
The process is not yet over. Some countries have yet to sign. For others, the interim agreements signed in 2007 still need to be ratified and deemed domestically operational, a process that will take to July 1 2008. Ratification in many ESA countries requires parliamentary endorsement. Could the parliaments in Africa and in the EU bring new “people’s” voice to this process and to future negotiations on the EPAs, and with it new attention to the health and development concerns?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit EQUINET www.equinetafrica.org. or SEATINI (www.seatini.org)
Civil society and communities should have a far greater direct involvement in the implementation of HIV and AIDS programmes for them to have a meaningful impact. This calls for an effective mechanism to channel funding to support and strengthen the capacity of civil society organisations. This was the resounding consensus at the Civil Society, HIV/AIDS and Africa: capacity, sustainability, partnerships conference being held in Johannesburg, South Africa from December 5 to 7. The meeting was co-hosted by the International HIV/AIDS Alliance and the UK Government's Department for International Development, and co-organised by UNAIDS and the Global Fund to Fight AIDS, TB and Malaria.
‘We need a shift in the way civil society relates to universal access and away from a lesser role to being an equal partner in the implementation of national strategies,’ Mark Stirling, UNAIDS' director for the regional support team for Eastern and Southern Africa, said at the opening ceremony of the conference. Stirling said Southern Africa in particular was hamstrung by bottlenecks that currently translated into an average of more than 80% of interventions falling behind targets to achieve universal access by 2010. There therefore needed to be a properly planned response to significantly ramp up the capacity and participation of civil society organisations to fill this gap.
‘We need funding models to move away from the status quo, and need a quantum shift for an effective response,’ Stirling said. The Chair of the International HIV/AIDS Alliance's Board of Trustees, Callisto Madavo, noted that good models exist for channelling money to support community-based responses, and these need to be expanded: ‘We have many examples of successful models and it is imperative that these experiences are shared so that we can accelerate our responses.’
Madavo said that ‘the most successful responses to HIV and other development challenges are built on local leadership, commitment and responsibility’. As communities are closest to people affected by HIV and often make the first response in addressing HIV, ‘without the active and influential participation of communities there is a real danger that the increased funding now available for HIV could not be well spent and not reach those most in need’. He said this could only be overcome through changes in policies and approaches that incorporated the experience over the past two years.
One of the major funders of HIV and AIDS programmes, the Global Fund, wants to encourage more civil society organisations to be amongst the principal recipients of their funding. Principal recipients are local stakeholder institutions (and there can be more than one in a country) who co-ordinate partnership, provide technical leadership, manage funds and monitor, evaluate and report on programmes. Christopher Benn, the Global Fund's executive director of external relations indicated that change was needed to ‘make sure that civil society is a principal recipient in more countries’. He added that the perception that funds for HIV programmes was drying up was unfounded and that ‘unprecedented’ resources were available. He said that $10-billion had been pledged for the Fund, while PEPFAR was expected to announce the extension of its mandate, to the tune of $30-billion over the next two to five years. Therefore, he said, the availability of resources was not the most critical issue, instead ‘capacity building for scaling up responses is the most critical, and we need to scale up dramatically.’
Although the Global Fund recently approved a budget of US$1,1 billion in Round 7 of funding proposals, only 50% of proposals had been approved and there were concerns about implementation capacity: ‘I hope we don't find ourselves in a position where we had the resources, but could not implement them,’ Benn said.
While the conference provided success stories of civil society roles in effectively reaching communities, both funding organisations and civil society need to take on the challenges of channelling resources to community level on a vastly increased scale. As Madavo indicated, ‘A consensus seems to be emerging on a new paradigm for effective capacity development centred on building effective states and forging engaged societies. The challenge is to unleash, nurture, and retain capacity. That requires a political environment that encourages participation, excellence, learning, and innovation. The new paradigm for capacity development emphasises the dual objectives of building effective states and forging engaged societies.’ And the conference also had a resounding consensus on the test for how successful new approaches are – that they effectively channel resources to communities, where they are most needed for the response to HIV.
The International HIV/AIDS Alliance, established in 1993, is a global partnership of nationally-based organisations working to support community action on AIDS, support south-south co-operation, and undertake operations research, training and good practice development and policy analysis and advocacy. They can be contacted via their website at http://www.aidsalliance.org/. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
Recognition of the health worker crisis in Africa has stimulated debate on what works to deploy and retain health workers in critical levels of African health systems. Most east and southern African (ESA) countries suffer a critical shortage of health workers with fewer than 2.5 skilled health workers per 1000 population, less than the level needed for the most necessary health interventions. The shortfall contributes to the persistence of high disease burdens and poorly developed health systems. These factors together with poor management systems and lack of appreciation of health workers drive further losses of health workers in a vicious cycle. With a Malawian woman having a probability of dying during childbirth that is 130 times greater than that of her American counterpart and faltering progress towards achieving millennium development goals in the region, acting on this health worker crisis has become a matter of global concern. While many policies and strategies are being proposed, answering the question what makes health workers stay in African health systems provides one direction for action.
Many factors responsible for health worker shortages, especially those related to global migration of health workers, are beyond the control of individual countries in ESA and call for wider international action. However there are important ways in which ESA countries can act to deploy and retain health workers in the health systems in the region, and there is learning to exchange from the combination of financial and non-financial incentives being used with varying degrees of success to retain available staff.
As an immediate measure many countries are using financial incentives like salary increases and allowances to send an early signal to attract or stem losses of health workers. To stabilize and sustain these, including in more inflationary environments, a range of non-financial incentives are also being used, such as training and career path-related opportunities, housing, transport, childcare facilities, free food, employee support centres, improvements in working conditions, better facilities and workplace security and improvements in management and human resource information systems.
Recognising the specific contexts affecting the approaches used in countries, there is scope for learning from the impact of measures being used in the region.
The Malawian health worker retention strategy, for example, is a combination of financial and non-financial incentives through a six-year, $272 million emergency human resources programme with budget support from the Government of Malawi, the Department for International Development (DFID) and The Global Fund for AIDS, Tuberculosis and Malaria. Blending these significant sources of budget support, the measures have (at least in the short term) managed to overcome the massive absolute shortfall across the system as a whole and to attract and retain health workers in Malawi. Some incentives address the factors that push workers out of the health system more directly. Swaziland responded for example to the high HIV and AIDS burden among the health workforce through the establishment of a wellness centre for health workers in collaboration with the Swaziland Nursing Association and the International Council of Nurses (ICN). Some countries have reduced the bureaucracy slowing the recruitment of health workers. Tanzania and Kenya have for example involved partners from the private sector to implement more easily administered emergency hiring plans for hard-to-staff areas.
Many countries face issues of internal migration and use incentives to more effectively retain workers in remote or underserved areas. Zambia, has for example, been able to attract staff to rural areas using a comprehensive package of financial and non-financial incentives, originally for doctors but currently extended to other health workers. Uganda made government service more attractive than the private sector through salary enhancement and non-financial incentives like training opportunities, support for research and a Yellow Star Award programme that recognises facilities that have consistently excellent performance. South Africa has used financial incentives in the form of rural and scarce skills allowances for under-served areas, in addition to compulsory community service.
Implementing these incentives and monitoring their impact calls for improved strategic management skills with greater flexibility to respond to rapidly changing conditions. A number of countries have set up autonomous health service boards and commissions to address health worker needs independently of the public service commissions to provide flexibility. This has had mixed results, depending on the resources and power that these boards have. The Zambian Health Service Board had a difficult beginning largely because most of the powers remained with the central public service commission. The Uganda Health Service Commission and the Health Board in Zimbabwe have been reported to function more effectively although their impact on health worker outcomes are not yet well assessed. Approaches that have evolved through consultation with all stakeholders, including the health workers and development partners, that are linked to strategic plans and funded from national budget or pooled funds, instead of vertical schemes, have tended to be more successful. Vertical schemes have suffered from lack of continuity and sustainability.
While experience is growing in the region around incentives for retention, assessing and sharing what works and what doesn’t work is constrained by lack of systematic documentation and limited monitoring and evaluation mechanisms. Success stories and success factors are thus not always well recognized locally or accessible to other countries. Weaknesses in monitoring and review systems also slow the response to unanticipated negative outcomes of schemes. For instance, in both Uganda and Tanzania, introduction of better pay for public sector health workers was accompanied by a net movement of health workers from faith-based facilities to government services, leaving many areas where only faith-based services were available to poor communities underserved. Recognising this, national and regional organizations in EQUINET are documenting experience and impacts in selected countries in the region.
There are good reasons for investing in retention incentives and for more effectively managing this aspect of health systems. Firstly, training health workers is costly and takes long; and without measures for retention there is no guarantee that the trainees will stay after completion of their studies. The loss of public sector training investments is an area of high cost of outmigration to the public health systems of Africa. Secondly, failure to retain staff has direct and knock-on costs, such loss of institutional memory, loss of morale and increased workload for the remaining workers and higher costs to the community to seek care at higher levels. In contrast retention strategies send an affirmative message to health workers that they are valued and this sends positive signals to attract more health workers. Further, measures for retention of health workers have positive implications for equity as they direct resources towards hard-to-staff facilities in rural, remote areas or those serving poor populations who have limited capacity to pay for private health care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. EQUINET Theme work on health worker retention is co-ordinated at Unversity of Namibia and is being implemented in co-operation with the ECSA Health Community. For further information and publications on this issue please visit www.equinetafrica.org.