The word “crisis” is becoming more common than water. Multiple crises are converging- economic, climate, energy, food and social. After a long period of speculative financial boom, media in the wealthy countries of North America and Europe are filled with apocalyptic stories of financial crisis, unnerving the people in these countries, who still collectively hold almost 90% of total world wealth. For the half of the world’s adult population who own barely 1% of global wealth, however, the crisis has been going on for decades.
The chronic crisis for this significant majority of the world’s people has been evident in more than a generation of unemployment, landlessness, loss of assets, and deprivation, that has further grown during the financial booms of the last decades. During a period characterised as “economic success” in the highest income countries, malnutrition and food insecurity grew in the poorest countries in Africa, falling international prices reduced returns on production and a food supply chain increasingly controlled by a few transnational corporations was able to further drive down producer prices, especially threatening women smallholder food producers. What was a boom for the import/ export firms, shipping companies, large-scale farm enterprises, financiers and officials who tapped into these commercial and financial circuits, was a deepening economic and social crisis for women and children.
In 2008 attention began to be paid to this food crisis. Like the financial crisis, the food crisis has been growing over decades of aggressive agribusiness. The scale and cost of this liberalized and speculative food production system is now, however, outstripping the possibilities of the usual emergency relief response. The alarming increase in child malnutrition in east and southern Africa post 1990 signals the failure of this model of agriculture for the populations of the region, even while it offered growing profits for largely foreign owned agribusiness.
Repeated outbreaks of disease also signal that people, usually in poor communities, are bearing the brunt of failed policies. Cholera is an avoidable disease that is prevented through safe water and sanitation systems. Zimbabwe has experienced a growing cholera crisis since August. By the first of December the United Nations reported 11,735 confirmed cases of cholera and 484 deaths in Zimbabwe. With the decline in functioning of clean water supplies, people’s mobility and a breakdown of the health sector’s capacity to contain the disease, the cases and fatalities continue to rise. Notwithstanding the economic decline in the country, Zimbabwe has the national wealth to secure basic water supplies and health care. The Zimbabwe Doctors for Human Rights correctly call the failure to do so a violation of human rights.
The globalization of media brings these crises to public attention with increasing speed. But does increasing awareness of such crises bring change?
While change often emerges from crisis, the last three decades suggest that this is not inevitable, particularly if the response fails to challenge the causes of the crisis.
The current financial crisis is possibly the deepest in recent history, but not the first. When the long boom of post-war economic growth ground to a halt in the 1970s, the response to financial decline was an aggressive pursuit of market policies, liberalisation and the opening of countries to transnational corporations. In the 1980s, after a spree of private bank lending, when heavily indebted countries were unable to pay back loans, the International Monetary Fund stepped into the financial crisis to bail out the Northern banks by offering loans to the indebted countries, restructuring their economies towards even greater liberalisation and market reform. These responses have generally served to protect existing wealth and the liberalised and speculative models of economic development that have both deepened inequality and that have been associated with the current crisis.
The response to the current financial crisis has starkly demonstrated the choices made over what merits protection. We have for some time known from United Nations data that saving several million lives annually by bringing safe water and sanitation to all would cost $10 billion a year. This money has never been found. Yet in October 2008, in one week, the US government provided a bail out package to the banks of $250 billion, 25 times this amount.
We are also seeing signs in the response of an efficient global machinery shifting the burdens of the financial and food crisis to the most vulnerable. According to the international non government organisation, GRAIN, players in the finance market - investment, equity and other funds – are turning to land as a strategic investment asset and haven for investment funds, even while the food and fuel crisis are driving acquisition of land for wealthy populations food and fuel needs. The organisation’s website lists over 20 such large investments in African countries alone, and notes an escalating trend. This month the South Korean firm Daewoo unveiled plans to lease one million acres of land (a land area the size of Belgium) in Madagascar, to meet Korean food needs. While loss of faith in markets may be triggering business to seek these deals, and deepening financial insecurity may trigger governments in Africa to make such deals, local farmers and communities are least consulted, and from the evidence of trends to date, are most likely to lose control over land, food and economic security.
So while powerful interests are oddly comfortable today talking about financial, energy, food, climate and other crises, there is silence on the crisis of injustice.
The increasing control of the world’s wealth by a diminishing number of players in the face of wide deprivation of the majority of people is a crisis of injustice. The pursuit of private wealth through appropriating collective natural, social and economic resources in a manner that undermines long term survival is a crisis of injustice. The failure of governments, nationally and globally, to meet basic human rights and needs when the resources are there is a crisis of injustice.
The quest for justice thus becomes a focus of ordinary people’s responses. There are many examples of this. In Zimbabwe this week, the Chitungwisa Residents and Rate Payers Association filed a lawsuit this month against the Zimbabwe National Water Authority for the lack of safe drinking water. While overshadowed by the scale of and necessary emergency responses to the cholera crisis, this action is nevertheless one by affected residents to call to account those in authority for how decisions are being made, how resources are being used and for whom power is being exercised. In this newsletter there is similar report of health activists calling leaders of high income countries to account: “For the developed country governments now to use their dominant position in our current system of global economic governance to deal with their own (largely self-inflicted) problems, while ignoring the much greater and longer-standing grievances of the developing world and the profound and urgent global challenges of ill-health, poverty and climate change, would be a betrayal”. As the legitimacy of current policies and institutions are being fundamentally challenged by the multiplicity of crises, more people are beginning to call it what it is- a crisis of injustice.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.
Editorial
“We demand the inclusion of the Right to Health in the new Zimbabwe constitution!”
This was the slogan at the Community Working Group on Health 15th national conference. The conference was held in October 2008 in Harare and coincided with the organisation’s 10th anniversary celebrations.
The CWGH was born in early 1998, to lead and give visibility to community processes in health. Ten years later over ninety participants attended the conference, including CWGH national members, partners, activists, health cadres and Health Literacy facilitators from 21 of the 25 CWGH districts. The conference reviewed the path that the CWGH has walked through the past ten years. We noted that as much as the CWGH has over the years positioned itself as a voice in the health sector and built community power, still the health sector has continued to deteriorate. The current socio-economic and political environment has not only perpetuated the deterioration, but has also made it increasingly difficult for civil society to offer alternatives for health problems. It was thus noted that the network needed to not only strengthen the existing structures and processes in the network, but also to re-strategise on how best to use these to engage on and advance health under the prevailing harsh environment.
At the conference our health literacy facilitators from 21 districts reviewed the work they were doing to widen social awareness and action on health. Despite the political volatility, we heard from district after district that of actions being taken, including in engaging with the political leadership on health issues. The work of the facilitators has increased the involvement of communities in health actions within communities and around Primary Health care, whether within the community on environmental health, or mobilising resources to support health centres. These are being done through community level initiative with limited external support. It was clear to us that we need to strengthen the programme and these cadres, to cement the work we are doing at community level and translate information into action.
One of the clearest messages was to revive the Primary Health Centre (PHC) concept and comprehensive PHC , if there is hope for change in the health sector. Mary Sandasi, a CWGH national member pointed to the relevance of PHC even 30 years after the Alma Ata declaration to re-build the declining health sector, particularly as it puts the people at the centre of the health system. The CWGH will consistently engage with stakeholders and government to make PHC a more central policy principle, and we will strengthen community structures such as health centre committees and boards and committees at district and national level to organise public efforts to achieve this principle.
As the health sector deteriorates, the gap between rich and poor has continued to widen. Poor people struggle to access health, and higher income groups claim a larger share of public health sector resources. We see EQUINET’s ‘Reclaiming Resources for Health’ book as a resource to inform how we can address unfair, avoidable differences in health. For example, the CWGH has over the past decade taken up equity issues with the Parliamentary Portfolio Committee on Health (PPCH), the Ministry of Health and Child Welfare (MoHCW) and other stakeholders to push for resources to go to services that support poor communities. We have for many years raised attention to the need for more resources to go to disease prevention, for example, and continue to see this as an issue, to ensure that we have safe living environments and communities.
While we commemorated our tenth anniversary, it was difficult to call it a celebration given the collapse of our health care delivery system. What we did celebrate was the dedication and commitment that people have put into the organisation and the struggle for health in the past ten years. The CWGH has grown to be a prominent voice in health, has won the hearts of many to champion peoples health issues and has given greater profile to the positive force that people provide in dealing with health problems. We have grown from strength to strength, but so too have the challenges we face!
To back our efforts to address these, the CWGH membership unanimously endorsed that the network champion the right to health, and push its inclusion in the production of a new Zimbabwe constitution. Taking the theme for the year; ‘CWGH @ 10: In Pursuit of Equity in Health through People Centred Health Systems’ we see that embedding the right to health in our constitution will give us the bottom line we need to make it clear that everyone has a claim to health and health care, no matter what the economic, socio-political, race, creed, gender or other feature. It will be a right that we will fight to include, through social action, and that we will ensure is not left on paper, but protected and promoted, through social action.
Further information on Community Working Group on Health can be found at www.cwgh.org.zw. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.
In the context of Africa’s present health crisis, only people suffering from policy blindness can fail to see that Africa’s survival as a continent depends on going beyond merely declaring emergencies, and actually financing and implementing universal primary health care (PHC).
In September 1978, the International Conference on Primary Health Care was held in Alma-Ata, Kazakhstan, then part of the Union of Socialist Soviet Republics (USSR). Led by the World Health Organisation (WHO), the conference produced the Alma-Ata Declaration, which underlined the need for governments to protect the health of all citizens and emphasised that health for all is both a socio-economic (or development issue), and also a human right. The conference also highlighted the inequalities between developed and developing countries, and between the elite and ordinary people within countries.
One of the most significant outcomes of the conference through the Alma-Ata Declaration identified primary health care as ‘the most efficient and cost effective way to provide health care’. This has been recently reemphasised by the current Director General of the WHO Dr Margaret Chan.
Going by its definition of ‘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 the principle that ‘[h]ealth services must be shared equally by all people irrespective of their ability to pay and all (and rich or poor, urban or rural) must have access to health services’, it was assumed at the time that with effective implementation PHC would lead to health for all by the magical year 2000.
Based also on the understanding of health agencies, professionals and academic institutions that ‘primary health care needs to be delivered close to the people’ through ‘maximum use of both lay and professional health care practitioners’, experts have distilled down the basic principles of primary health care to several core factors, including: • Public education for the identification, prevention, and control of prevailing health challenges • Education on and provision of proper food supplies and nutrition, including adequate supply of safe water and basic sanitation • Provision of maternal and child care, including sexual and reproductive health education, and family planning • Immunisation and vaccinations against major infectious diseases. • Prevention and control of locally endemic diseases • Appropriate treatment of common diseases using the most up-to-date, cost effective and appropriate technology • Promotion of mental, emotional and spiritual health • Provision of essential drugs and commodities.
It cannot be emphasised enough that these primary health care principles can only be possible through long-term sustainable and combined financing of both health systems, and disease specific interventions. The phantom debate over ‘health systems versus disease specific interventions’ is a false one and a diversion equivalent to asking if food is more important than water to human life. It should be reasonably obvious that health systems without medicines and commodities are as useless as medicines and commodities without health systems. This applies to all health issues, whether malaria, TB or HIV/Aids.
Sustainable and long-term health financing must therefore mean identifying the specific challenges and obstacles to primary health care, and on the basis of costed plans work out clear and timely frameworks for resolving these obstacles. In addition to disease specific and wider health system challenges, this includes focusing on the resolution of key obstacles such as the lack of policies and financing sustainable plans for reproductive and sexual health, and resolving Africa’s critical health workforce shortage.
This editorial comes from the joint EQUINET newsletter issue with Pambazuka for the thirty years of Primary Health Care. The Africa Public Health Alliance & 15% Now Campaign engages African governments, global and African and institutions on implementation of the AU Africa Health Strategy, Health MDGs and fulfilling the AU Abuja pledge to allocate 15% of domestic national resources to health. For further information on the issues raised contact admin@equinetafrica.org
In 1974, four years before the International Conference on Primary Health Care (PHC) was convened in Alma-Ata, USSR, the Canadian Ministry of National Health and Welfare published the Lalonde Report, named after the incumbent Liberal Party health minister Marc Lalonde.
Taking its cue from Thomas McKeown’s findings on the historical decline of tuberculosis mortality in England and Wales, the Lalonde Report challenged the presumption that improvements in human health by and large flowed from advances in (bio)medical knowledge, feeding through to professional practice and individual care.
McKeown’s writings on the main drivers of population growth and mortality decline in the early industrializing countries spawned vigorous debates. In addition to economic growth and improvements in food intake and nutritional status which McKeown himself highlighted, others argued also for the population health impacts of birth spacing and family size, housing and sanitary reforms (sewage disposal), and clean water and safe milk supplies (pasteurisation and eradication of bovine TB from livestock herds).
Mortality from typhus fever, a major killer in the 19th century, had shown continuous decline over the ensuing decades in the UK, such that by 1906, three years before Charles Nicolle discovered that the body louse transmitted typhus, London County Council reported no more deaths from that disease. Typhus fever, closely associated with poverty, poor housing, overcrowding, and poor hygiene was much less common among the middle and upper classes in 19th century England. Its decline was arguably linked to the increased availability of public baths, wash-houses, and widening use of cotton clothing, particularly underwear, which allowed for improved personal cleanliness.
Sonja and John McKinlay similarly concluded from their historical analyses that the fall in infectious diseases between 1900-1973, which accounted for 69% of the overall decline in US mortality during that period, could only be explained to a very limited extent (about 3%) by medical intervention.
In retrospect, the Lalonde Report might perhaps be judged prophetic (or lucky), given the as yet limited evidence base which might have restrained a more cautious technocracy professing evidence-based policy and practice. In any case, the thesis was reinforced by subsequent findings from Sweden, France, Ireland, and Hungary, which supported the view that social and environmental changes were the key factors in their decline in infectious mortality.
By the time of the Alma-Ata declaration, these findings from medical history and population healh were resonating strongly with more contemporary experiences from community-based primary health care in China, Bangladesh, Kerala, and Cuba. Notably, both perspectives shared a similarly broad vision of disease causation, rooted in what might be called a social ecology of health and disease.
Population health strategies in particular, according to the Canadian Advisory Committee on Population Health, address the entire range of factors that determine health, in contrast to traditional health care which focuses on risks and clinical factors related to particular diseases. Population health strategies furthermore are designed to affect the entire population, rather than individuals one at a time who already have a health problem or are at significant risk of developing one.
By the late 1980s, critics had highlighted weaknesses in the arguments of McKeown: the relative contributions of fertility and mortality changes to population growth during the period in question, the early conflation of TB mortality with pneumonia and bronchitis (affecting the timing of TB’s decline), the under-emphasis of water supply and sanitary reforms from the 1870s on, and to a lesser extent, the contribution of isolation and quarantine to the control and reduction of infectious disease. The decline of child labor (and its associated early life effects on adult health) has been proposed more recently as a contributory factor from the 1850s onwards, but this too is contested.
On the limited contribution of medical interventions to population health however, there was much less disagreement. Simon Szreter, who had played a prominent role in the critical re-appraisal of McKeown’s work, summed up the consensus thus: ‘The medical profession’s scientific leaders have, since McKeown’s time, had to change their tack and concentrate on the future, rather than the past, as the field in which they can stake the claim that they can save humanity from all its ailments with science.’
In less grandiose terms, the claim might be more plausible in the less developed countries, which still had (and for many still continue to have) large burdens of infectious disease in the mid-20th century, at a time when modern biomedical science in principle could have had a more significant impact on public health and in patient care (with vaccines, antimicrobials and control of disease transmitting organisms).
The availability of diagnostics and the ongoing campaigns for access to anti-retrovirals for instance testify to the potential impact of biomedical science for the public health control of the HIV pandemic. Access to lifesaving treatment for infected individuals is emphatically a moral and ethical imperative. But a public health approach to anti-retroviral treatment goes beyond an individual focus. Equally important, the availability of effective therapy may in some situations encourage those at high risk to come forward for voluntary testing, and hence reduce the pool of infected-but-unaware individuals who constitute one of the drivers of the pandemic.
It is nonetheless noteworthy that the population health perspectives pioneered and promoted by McKeown and Lalonde continue to be relevant to modern epidemics. The SARS epidemic outbreak of 2002-2003 subsided largely in the absence of reliable diagnostics, vaccines, or efficacious therapies, notwithstanding the rapid success in isolating and sequencing the SARS coronavirus. Its control was credited to established public health measures such as isolation, contact tracing, ring fencing, and quarantines, and the economic and financial stakes involved ensured that SARS would not be a ‘neglected disease’.
Likewise, the Nipah outbreak in Malaysia (1998-1999) was rapidly brought under control without vaccines or efficacious therapies, once the modes of transmission were established. The knowledge that Nipah encephalitis was linked to a newly recognised paramyxovirus which could be transmitted through close proximity to live, infected pigs but not via insects, or suspended airborne particulates, or contact with raw or prepared meats (ascertained from virological studies, field epidemiology, and clinical medicine), allowed for its rapid control in humans, even as this control decimated the pig farming industry in parts of Southeast Asia.
These recent experiences, thirty years on, teach us that modern biomedical science has an important integral role to play in informing the social ecological perspective which undergirds PHC for the 21st century.
In appraising this contribution of modern biomedical science to disease control and population health, it is, however, useful to distinguish between its contribution to knowledge-based practices and coping responses, as opposed to an undue focus on commodifiable consumables. This distinction (neatly demonstrated by the Nipah example) is especially pertinent in ensuring that advances in biomedical science in support of PHC are not left the strategic priorities of market-driven research and product development, but are backed by publicly funded and rationally deployed needs-driven research in the biomedical sciences.
This editorial comes from the joint EQUINET newsletter issue with Pambazuka for the thirty years of Primary Health Care. For further information on the issues raised contact admin@equinetafrica.org or ckchan50@yahoo.com.
Thirty years after the 1978 Declaration of Alma Ata, it seems the world is still at odds on how best to implement the principles of primary health care. The slow progress in improving health outcomes for all raises questions about the effectiveness of current ways of doing business. A concerted global alliance of global and country actors need to set positive and realistic paths to implement the intentions of Alma Ata.
Sixty years ago, the World Health Organisation (WHO) stated in its constitution that health is a “a state of physical, mental and social wellbeing, not only the absence of disease or infirmity’. Thirty years later, the Alma Ata declaration on Primary Health Care (PHC) among other things declared that “health is a fundamental right” and set a thirteen point understanding to ensure this right. This understanding captured concepts of essential care, universally accessible and affordable to individuals and families in the community through their full participation, in a spirit of self determination. It located PHC as an integral part both of the country’s health system, but involving all related sectors and aspects of national and community development.
The WHO constitution’s definition of health and the Alma Ata declaration together prompt a diametrical but complementary state that need to be concurrently addressed if health is to be attained: The first deals with the clinical determinants of health, pushing for the absence of disease in individuals. The second addresses the determinants of health that predispose or prevent individuals from attaining a state of mental, physical and social wellbeing as a fundamental right. These include appropriate governance, the absence of war, economic and infrastructure development, adequate infrastructure and aid policies. A unique moment occurred in 1978 to bring these complementary understandings together.
Before the ink could dry on the Alma Ata declarations it had, however, already generated polarised antagonism. It was considered too socialist with an excessive preference of government providing state managed intervention. From a capitalist standpoint, it was a ridiculous proposition, too costly and defying economic reasoning. The conservative duo of JA Walsh and KS Warren launched the Selective PHC debate, arguing that it is probably more efficient to save children and limit population growth. The two main PHC proponents, WHO and UNICEF soon drifted apart, as UNICEF promoted a selective package of low cost interventions. With resource flows following selective PHC, Primary Health Care was translated in most countries to mean a basic package of services to be delivered at district and community levels based on a selected number of interventions with some outreach services, with a watered down district health strengthening based on this.
Why nobody asked at the time whether there was any moral significance to be attached to a person’s life or pointed out that choices based on state preferences for total health gain can be justified over financial resource allocation efficiency is difficult to comprehend. Aside from efficiency based arguments being ridiculous propositions founded on utility based preference or embodying unattractive equity assumptions; the economic bargain in a healthy population should at least have also appealed to responsible international choice.
Alot has since been achieved from the advance in technology in dealing with specific clinical determinants of specific diseases. It could be argued that a saturation point has been reached, where increases in financial and human investments in existing technologies are yielding less than proportional gains. Despite this the selective interventions approach continues to define health and health services delivery. It was given a new lease on life by the World Bank through its World Development Report 1993, ‘Investing in Health’. This report, which hardly acknowledged PHC, commoditised and delinked health from development and moved the world closer to the interventionist approach to health – intervening at a selective point in the epidemiology of a disease or health system.
This approach has since had wide global appeal. Currently there are over thirty WHO resolutions on AIDS, TB or Malaria alone, more than all other subjects. The health Millennium Development Goals (MDGs) have further entrenched this disease specific approach to resource mobilisation. There are over eighty major global health initiatives linked to the health MDGs, providing over US$ 100 million annually. The Italian Global Health Watch reported in 2008 that the Global Fund has allocated approximately US$ 3.5 billion to countries for interventions on AIDS, TB and Malaria, mainly in Africa. Together, these initiatives have thrown billions of dollars at addressing diseases and improving clinical health conditions and made up a significant part of health sector budgets.
PHC is hardly mentioned in these initiatives. Member States went to sleep on PHC except for anniversaries, and the occasional mention linked to district health system strengthening. For various reasons the world assumed an emergency mode to address what are considered new and urgent public health issues. Single disease interventions that lend themselves to easily recognisable financial accountability, quantitative monitoring and evaluation held greater appeal for funders, especially when twinned with arguments of weak domestic governance and public policy failures and capacity limitations.
While these initiatives on clinical determinants hummed with measurable outcomes on specific diseases, the nexus of poverty and ill health was exacerbated. As a result, inequalities in health have deepened to a significantly greater level than thirty years ago. There is a growing trend in urban slum development, a decline in state services, market failures in privatised economies, growing food insecurity and massive deprivation of rights to health care.
Hence while a lot has been done in the past thirty years to deal with disease in individuals, the unique opportunity provided by the Alma Ata Declaration to also address the determinants of health have largely been lost. Thirty years later we see the costs of this omission in a burden of poverty and disparity related ill health that ill matches the level of knowledge or technological advance achieved globally.
As we approach another anniversary for PHC expectations are high. People expect that their physical and mental health will be promoted in a safe social, economic and political environment. They expect to have quality health systems that provide preventive services, diagnose, treat and manage disease injury, and reduce the severity and repeated occurrence of disease. They do not expect to see wide social and economic disparities in these basic entitlements. In Africa, furthest from delivery on these expectations globally, the Ouagadougou declaration on Primary Health Care issued on April 30th 2008 called for a renewal of the Principles of Primary Health Care and its implementation in developing countries and by the international community.
Such declarations are encouraging. However their implementation calls for resolution of the longstanding debate of the past thirty years. These debates are not academic. They present in choices made over the policy measures, relative allocation of institutional, social and financial resources and complementary systems for dealing with the social determinants of health (mostly dealt with by actions outside the health sector) and those reducing the health, social and economic inequalities that arise due to the burden of disease (mostly dealt with within the health sector). There are no clear answers for how a conceptual framework of Primary Health Care in 2008 will address this.
And while there is a massive coalition of global initiatives dealing with diseases, there is no clear coalition of global institutions supporting or funding the determinants of health, the second factor in the PHC equation. At global level, Bretton Wood institutions and OECD initiatives for debt relief and poverty reduction have led in some African countries to short lived increases in spending on health and education, no global initiatives so far adequately address the determinants of health.
This leaves PHC as an orphan with no global home. WHO’s attempt to foster parent PHC is inadequate given the pluralistic global environment. The state of poverty and the winds of change in international health resource priorities will make rational choices among the various dimensions impossible and predispose countries to the dictate of new interventions and their implementation. While the debates over the conceptual understanding of PHC will not end in 2008, at least 2008 could mark the turning point for a new institutional response, that builds a Global Alliance to generate the momentum and support for countries to implement PHC and that generates policy learning based on practice from the bottom up, reminiscent of another basis for the Alma Ata declaration.
A WHO or UN resolution creating such a global alliance would be a befitting PHC birthday gift for the millions of people seeking more than another conference. It will squarely put implementation right at the door step of a recognisable entity that can mobilise the needed funds and support countries with implementation.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
Stifled by perennial under-funding, inadequate health care workers and a critical shortage of infrastructure, Uganda’s modest primary health care system has a more significant challenge to contend with – building effective demand among poor and vulnerable people. The Alma Ata declaration on Primary Health Care (PHC) declared health to be a fundamental right, but also observed that this called for full participation of communities in their health services.
Official statistics show, however, that only a third of the population uses the government-supported health system in Uganda – both public and private-not-for-profit. This means that a large share of poor and vulnerable people, including disabled people, families led by single mothers, orphans and internally displaced people, are not reached by public investments in health. They may seek services in private clinics, or buy medication from pharmacies or herbalists, but many poor people are likely to self-medicate at home, or hope for a natural healing process.
This still limited uptake of public sector health services obviously has many roots. The Coalition for Health Promotion and Social Development (HEPS-Uganda), a local health rights civil society organisation, advocates for access to affordable health care and essential medicines, especially for disadvantaged people. The evidence HEPS-Uganda has gathered from the eight of the eighty five districts of the country where it operates suggests that both service providers and users lack awareness of their rights and responsibilities in health. The Uganda Human Rights Commission confirmed this picture in 2007, observing that health rights of many Ugandans are being violated, especially the right to information, dignity and access to essential medicines. This is surely one contributor to the poor use of services, and a barrier to effective organisation of the health system around PHC.
Through its Community Outreach and Health Complaints and Counselling (C&C) programmes, HEPS-Uganda has worked with communities and health providers in eight districts of Uganda to implement initiatives aimed at increasing public and community participation in planning and implementing primary health care, including in the rational use of medicines.
The results have been telling. When expectant mothers in Kamwenge District in western Uganda, in Kawempe Division of the capital Kampala, in the districts of Pallisa and Budaka in eastern Uganda, and in the Lira District in the North of the country have increased their understanding of their health rights and the services that meet them, their uptake of antenatal services and their delivery at health centres under professional supervision has in some cases doubled over a year to eighteen months.
Through the C&C programme, HEPS-Uganda has established an independent feedback mechanism that receives complaints of health rights violations from health consumers, which it then tries to resolve through mediation with health providers and counselling. The process creates awareness of health rights and responsibilities in both sides, and has proved an effective way to identify and improve the whole system, within the community and within the local level health services.
The Uganda Human Rights Commission has observed that the violation of health rights has not been given adequate attention in Uganda. But programmes like HEPS-Uganda’s C&C programme create confidence and hope: Community members can approach health providers in an informed manner and demand the services they are entitled to. On the other side, health providers also recognize their duties and play their roles more effectively. The benefits are tangible for poor communities. In Pallisa and Budaka districts, community representation on health centre management committees is now more effective in the programme areas, and decisions are more responsive to community needs and preferences. Health centres have scrapped illegal charges that consumers have continued to incur across the country, despite government abolishing cost-sharing as far back as 2001. The end result is a more people centred, friendlier health care environment for communities as well as health workers, and the initiative is successfully demonstrating the people’s power in improving their health.
It is not that the country’s policy makers do not appreciate the value of community empowerment in the effort to achieve “Health for All”. Uganda is among the countries that adopted the Alma-Ata Declaration 30 years ago, committing itself among other things to a human rights approach to health in which “the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.”
At the country level, the national health policy commits the Government “to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.”
With ill-health identified in official surveys as the leading cause of high levels of poverty, national development plans, including the Health Sector Strategic Plan and the Poverty Eradication Action Plan, contain planned activities aimed at empowering communities for health.
There are numerous examples of how communities are playing a role in efforts to create a community-based primary health care system. Community drug distributors dispense anti-malarial medicines door-to-door; village health teams mobilise communities for sanitation and HIV prevention and treatment and community members are involved in implementing the “directly-observed treatment” strategy to manage tuberculosis (TB). There have also been policies to entrust management of lower level health units to local governments and to management committees with community representatives.
However, with the exception of the TB management strategy, the performance of the rest of the initiatives still leaves alot to be desired. Other planned activities that would have empowered communities and consolidated the success of those already underway remain at the planning level, nearly a decade since the policy and other development plans were published. For example, there has not been any national programme of community capacity building “for effective participation of health problems, planning of health services, in resource mobilization and in the monitoring of health activities”.
Uganda has made the important step of guaranteeing a minimum health care package, but with minimal resources. It is trying to attain universal access to primary health care, but with US$8 per person, instead of the estimate of $34 made by the Macroeconomic Commission on Health. Without effective and collective demand from community level people will carry on ‘making do’ with poorly resourced health systems, and under-using the resources that are applied.
Effective and collective demand calls, however, for a system that involves the intended beneficiaries in planning and implementation, and for an informed and empowered community, able to demand and use the services it needs. In a resource poor setting like Uganda, the case for community empowerment for health is even stronger. It is needed in setting priorities, deciding on resource allocation, monitoring the performance of service providers and in building health care seeking behaviours. Government will have to live to its commitment to empower communities health if it is to guarantee their right to quality health care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
“I started volunteering [as a community health worker] in 1996. During that time, the most common disease in my village was tuberculosis (TB). We worked together and visited those who were infected with TB. We also went to fetch their pills from hospital and distributed them accordingly. We were to ask the sick people to cough out the sputum and save it inside specimen bottles that we took to a certain sister at the hospital.” (Eastern Cape community health worker)
Community members have been rendering certain basic health services to their communities for at least 50 years. All over the world, but particularly in countries in Asia, Africa, and Latin America community or village health workers (CHWs) have been providing health education to their communities, helping pregnant mothers and new-born babies and treating basic illnesses. They are often mature women, with little formal education. The quotes from CHWs in Eastern Cape South Africa highlight this experience.
“My first encounter with the health programmes was in 1986. Our training was to help people who had been swept by the river waters and nearly drowned. ….We went to all the homes teaching people about TB and how to avoid it. To those who had it already we continued to train them on how to take care of themselves and prevent further spreading of the disease. We encouraged people to have toilets, to build chicken runs and pig sties and avoid animals running loose all over the place to keep ourselves in good health.” (Eastern Cape community health worker)
Since the arrival of HIV, community health workers have also been counselling community members, providing peer support and home-based care and ensuring that people on antiretroviral therapy take their treatment. In some countries they have also been involved with HIV testing.
In the past CHWs have been seen as advocates for health in their communities and agents for social change. This made them central to comprehensive primary health care. In recent years a much more technical understanding has taken hold, which views CHW programmes as a strategy to address health worker shortages in most countries. This view is reflected in the 2006 World Health Report which advocates the delegation of tasks to lay health workers.
The renewed enthusiasm for community health workers presents great opportunities to seriously review how community health is organized and rendered and to empower communities. However, questions have to be asked about the rationale and intention of this enthusiasm:
• Is it realistic to expect commununity members from invariably impoverished communities to take responsibility for what in effect are essential health services, often with very little training and hardly any supervision?
• Are governments in fact not abdicating their responsibility for ensuring appropriate health care for their citizens, in particular the most vulnerable ones?
• Under what circumstances are CHW programmes empowering communities and under what circumstances are they shifting the burden of health care to those most vulnerable in society?
• What roles can CHWs realistically play?
There is ample rigorous evidence from different parts of the world that CHWs can play a crucial role in broadening access and coverage of health services in remote areas and can undertake actions that lead to improved health outcomes in a range of areas, including child health, TB and HIV/AIDS care. CHW programmes hold the potential of enabling countries to build sustainable, cost-effective and equitable health care systems, thus contributing towards moving closer to achieving the Millennium Development Goals. However, the challenge of achieving success cannot be underestimated. Programmes need careful planning, secure funding and active government leadership and community support. To render their tasks successfully, CHWs need regular training and supervision and reliable logistical support. Importantly, governments have to retain their responsibility for essential health services at all levels, including for CHWs programmes. It is their responsibility to ensure that CHWs are, in fact, appropriately and adequately trained and supported by health service staff and communities and that their roles are clearly understood by all role players. This requires political leadership and substantial and consistent resourcing.
Given present pressures on health systems and their proven inability to respond adequately, the existing evidence strongly suggests that, particularly in poor countries, while CHW programmes are not easy, they are a good investment. This is particularly true given that the alternative in reality is NO care for the poor living in geographically peripheral areas.
They represent far more than improved service provision and access, however.
The continued testimony from the community health worker in South Africa’s rural Eastern Cape province demonstrates the personal and social dimensions of health actions that CHWs bring:
“Then the disease called HIV/AIDS started attacking people till it came to my house and attacked my own son. I could not understand this disease which he came with from Cape Town, but I took him to hospital. I was very hurt and heartbroken to see how his whole body was covered with sores, from head to toe, even the softest parts. I took him to hospital. At the hospital I was not told that it was HIV/AIDS, I was told he had TB. After reading his forms carefully, because I could read a little, I discovered that they had diagnosed him with thing [HIV/AIDS]. My frustration worsened, and that is when I decided to give myself to the whole of the village to help other people, especially that I had this bad experience firsthand. I went up and down the ravines of the village working. Many more people were discovered to be infected till this day. I worked harder and harder though, unfortunately, some of those I tried to help could not make it, they died. Some had very bad sores and we frequently washed them. I would take a flask from home and boil water for my patients to keep in it so I could prepare something to eat for them before taking their medication. For some, I would get there and start making fire with wood as we normally do in the rural areas, and warm water to use for his bath. They looked very bad during those days but today you wouldn’t think it’s the same person that I had nursed to recovery” (Eastern Cape community health worker).
Village health workers (VHWs) were key to Zimbabwe`s successful expansion of primary health care (PHC) in the early 1980s. They played a central role in closing the gap between public health services and communities at local levels, bringing health services outreach to communities, and facilitating community roles in the health delivery system. For example, village health workers and community based distributors were instrumental in implementing the successful Zimbabwe Family Planning Programme, as they helped raise awareness on family planning methods such as condoms and combined oral contraceptives (commonly known as ‘the Pill’), as well as the advantages of child spacing. These efforts are reflected in the expansion of coverage of contraception and reported decrease in fertility rates in the country from 6.5 children per woman in the early 1980s to 4.3 children per woman in 2001.
VHWs continue up to today to augment the work being done by the mainstream health sector: raising awareness, giving health advice, monitoring growth of children under five years, and mobilising communities during out-reach programmes and for immunisation. Mrs. Kaseke a VHW in Mwanza ward (Goromonzi district) echoes these sentiments. One of her roles as a VHW is to mobilise food for chronically ill and home based patients in her area. She also runs community-based growth monitoring clinics on Saturdays. ‘I have a scale that was allocated to me by the clinic when I started as a VHW. Women from my area bring their babies to my homestead. I weigh the babies and record their weight on cards, as it is done at the clinic. I then use the weight records to check if the child is growing well; otherwise I refer the child to the clinic for further assessment’.
VHWs see an important role for themselves in bridging the gap between the community and the health services, as explained by another VHW from Gokwe South District, Musatyanika Wushe: ‘We are the link between the community and the health department. We advise and refer the community to seek medical attention early, care for home-based ridden patients, and chronic and TB patients on DOTS’.
Despite these vital functions, the numbers of VHWs and the role played by VHWs has diminished over the past two decades in Zimbabwe. While communities cite low morale due to lack of incentives as the major setback, the VHWs and other health staff point to lack of incentives and supporting resources and protective equipment as a major barrier to their performance.
In their early years, VHWs benefited from incentives such as uniforms, bicycles and allowances, which were meant to enhance their work and motivate them. Bicycles were both a token of appreciation and a tool to enable these volunteers to take their services to a wider population. The allowances they received helped them to buy basic necessities such as soap, so that they could look presentable while they carried out their duties. These incentives are now a thing of the past; and the remaining cadres are at times compelled to use their own resources to ensure that they can continue to serve their communities.
Highlighting the plight of VHWs, Mr. Wushe said, ‘We, as village health workers, are surprised about how we are handled. The problem is, out of all these duties, our allowances are still as low as ZW$20,000 (about US$0.01) per month, which is received after 12 months. One may be surprised to hear that allowances for December 2006 were received on the 26 of November 2007! We are very much exposed to the world of infection because we do not have protective clothing to put on when attending to home-based patients, most of which may have open wounds. From 2002 up to now ,we have tried in vain to request this protective clothing from our district hospital but the response is disheartening’.
In addition to the resource gaps for VHWs, there have also been some changes in roles and responsibilities that have affected their work on health. During the period 1988-1999, the government introduced a multi-purpose cadre, the ‘village community worker’ (VCW). They were introduced under the Ministry of Political Affairs to take up a number of roles, including taking over some roles previously implemented by VHWs. However, unlike the VHWs, VCWs were political appointees, appointed by the ruling party leadership and then employed and trained by the Ministry of Political Affairs. This reporting and accountability structure weakened the link between the community and the health authorities. After calls by communities for the re-introduction of VHWs, the Community Working Group on Health (CWGH), among other civil society groups, lobbied government through the Ministry of Health and Child Welfare to re-introduce this cadre. VHWs were subsequently re-introduced in Zimbabwe in 2001 and over 2,000 VHWs were trained across the nation. While this has been welcome, there is still need to address the barriers to their morale and functioning.
VHWs have been proposed as one measure to deal with a gap in health worker numbers. While they cannot replace adequately trained staff at primary and district levels of health systems, they are a key cadre in the health system because they are aware of the health needs and aspirations of their communities. This makes them an invaluable asset in advancing community-orientated health delivery and they should be supported. Although the 2008 national health budget in Zimbabwe had a sizable allocation towards VHWs, meetings held in 25 districts where CWGH is operating suggested that this budget is yet to reach the cadres on the ground. The CWGH has thus urged government to work with other stakeholders to create a plan to fully revive the VHW programme, support their work and ensure that resources allocated in the budget for VHWs reach them.
This is not just a matter for government. As part of civil society, we see that the presence of VHWs in our communities is essential in our quest for equity in health and accessibility of health services. We too need to be part of this support. Towards this end, CWGH will be documenting the roles and impacts of VHWs in our communities to engage government and other stakeholders to value and resource these roles in the spirit of health for all.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. The CWGH is a network of membership based civic organisations focusing on advocacy, action and networking around health issues in Zimbabwe. www.cwgh.co.zw
In the next six months countries in the east and southern African region will be negotiating the agreements on services in the European Union (EU) – East and Southern Africa (ESA) Economic Partnership Agreements. These services negotiations are already halfway through and are expected to be complete by the end of 2008. The negotiations currently cover mainly financial and telecommunications services, and say little about protecting social services. Yet many countries in the region are facing pressures to privatise health services, even though the growth of a private sector in health services withdraws resource and staff to service a wealthier minority at the cost of universal access to health care services for the majority.
Protecting the health of the populations in the sixteen eastern and southern Africa in the region is a development priority. Twelve of them are least developed countries (LDCs) with the lowest human development indicators in the world. Almost all these countries experience negative economic growth and falling disposable incomes, one in six children dies before their fifth birthday and more than half the population is still living on less than US$1 a day. The EU on the other hand, with whom the agreements are being negotiated, consists mainly of developed economies, five of which are among the ten largest economies in the world and most of their people enjoy high standards of living. These negotiations are clearly taking place between unequal partners.
Countries in ESA experienced a wave of liberalisation of health services under the Structural Adjustment Programmes (SAPs), with a fall in funding of and access to services by the poorest communities. Further liberalisation is opening up services to commercial players whose aim is to generate profit. Trade in health services is argued to increase access to health care in remote and under-serviced areas; to generate foreign exchange; to provide new employment, give access to new technologies; and to reap economic gains from remittances of health workers who migrate. However, these benefits are often only obtained in the private for profit health care sector, promoting internal migration from the public health sector to private health care, with unaffordable costs of care for poor and vulnerable members of society, whose needs must be assured by governments.
Governments in the region have recognised the need for public sector led services for access to health care in poor populations, even while some have permitted the growth of private services. Universal access to basic health services is a stated development goal in many ESA countries. Health is a human right enshrined in many national constitutions and various signed and ratified international legal instruments.
Yet there is little protection of the right to health or to health care in the interim EPA agreements initialled in 2007. When these were concluded, despite significant opposition from the region, their sections on development cooperation should have provided for protection of public health, but no such protection was included.
The SADC-EU EPA Article 3 (2) provided that ‘The Parties understand this objective to apply in the case of the present Economic Partnership Agreement as a commitment that:(a)the application of this Agreement shall fully take into account the human, cultural, economic, social, health and environmental best interests of their respective population and of future generations (my emphasis)’ This gives some basis for ensuring that the rest of the EPA negotiations protect health rights, and it will be important to keenly follow the SADC EPA negotiations to hold negotiators to the commitment to protect their people’s best interests in health. Despite lobbying from civil society, the ESA-EU EPA on the other hand does not contain any mention of protecting health except reaffirming the parties’ commitments to the realisation of the millennium development goals in the preamble to the agreement.
Both interim EPAs however included a clause opening the way for further negotiations in areas relevant to health, such as services, intellectual property rights, and investment. These further negotiations appear likely to motivate liberalisation of services. This is promoted in the guidelines set out in the General Agreement on Trade in Services (GATS) of the World Trade Organisation (WTO) and the EPA is modelled along GATS. It is likely to cover similar areas, including health and health related services, migration of health professionals, and health care financing.
How can ESA countries protect their health services in the negotiations?
Firstly, as a minimum, it is important that the EPA negotiations do not go beyond the framework agreed at the WTO in the GATS and do not include GATS-plus obligations. Negotiators should live up to the commitment of the 4th Ordinary Session of the AU Conference of Ministers of Trade in April 2006: ‘We shall not make services commitments in the EPAs that go beyond our WTO commitments and we urge our EU partners not to push our countries to do so.’
However countries can go further. Under the terms of the interim EPAs, countries are free to exclude a wide range of sensitive goods and sectors from liberalisation. Our governments should take advantage of this flexibility to exclude health and related social services from liberalisation. For governments like Zambia and Malawi whose health service sectors are already open under GATS, they should not further entrench liberalisation under EPAs.
Negotiators must protect government policy space to remain key providers of health services in the EPA negotiations. Negotiators need to ensure that governments have full authority to regulate and control private for profit provision and financing of health services. Governments should also do formal health impact assessments in any health-related sector where liberalisation is being proposed, whether under GATS or the EPA. Commitments should be explicitly made in the EPAs on ethical recruitment and treatment of health workers and on EU investment in public budgets to produce and retain health workers in source countries.
ESA negotiators cannot treat health and health care services as a market matter, divorced from social issues. What is discussed in these negotiations are not just a matter of people’s survival, but also affect the cohesiveness and solidarity of societies and the support ESA countries are able to give to vulnerable communities. The negotiations on health services are thus a matter of public interest, and civil society should be involved. Public consultation on negotiations will surely strengthen the hand of negotiators by ensuring there is a strong public mandate to take firm positions on these vital health issues. Civil society should track the services negotiations, parliaments should ask questions about them, and we should continue to lobby for an EPA that respects the rights of the African people, especially the right to health. This means continuing to demand that ESA governments and the EU member states respect their obligations to international human rights instruments as they negotiate EPAs and that the people’s welfare takes priority.
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 or the full please visit SEATINI (www.seatini.org) or EQUINET www.equinetafrica.org.
On 28 May 2008, the Institute of Tropical Medicine (ITM, Antwerp) hosted a workshop at the World Health Organization (WHO, Geneva) to review the evidence on positive and negative impacts of the global AIDS response in low-income countries in sub-Saharan Africa on general health systems and services. The workshop involved people working in AIDS and health services, in civil society and in academia with and from Sub-Saharan Africa.
The original question was simple and straightforward: what is the evidence to support or refute recent claims that global resources allocated to fight AIDS are over inflated and do little to support, and may even undermine, health systems?
Discussions quickly moved beyond this original question. The Alma Ata concept of Primary Health Care (PHC) – comprehensive PHC rather than selective PHC – proved to be a uniting concept. The real question became: how can the global AIDS response best contribute to the realisation of Comprehensive PHC? Most participants agreed that there are lessons to be learned – good and bad – from the global AIDS response, that will help us move closer towards Comprehensive PHC for all.
There is evidence of the global AIDS response strengthening general health systems and services, and there is also evidence of the global AIDS response weakening general health systems and services.
The most important point of stress identified related to the overall shortage of health workers. In some countries, the AIDS response was reported to have led to an ‘internal brain drain’, with health workers abandoning their previous occupations to work on AIDS programmes. In other countries, the AIDS response enabled improved working conditions of health workers across the board, helping to attract and or retain more health workers.
Without systematic reviews, or an agreed score card allowing us to add up the strengthening effects and to subtract the weakening, we cannot conclude if the overall result is predominantly negative or positive. However, the positive effects of strengthening general health systems and services seem be more likely where national public sector led strategies explicitly aimed for these positive synergies. This finding suggests that if recipient countries want AIDS funding to strengthen general health systems and services, they need to negotiate the needed flexibility from donors for this.
Therefore, we felt it would be more productive to focus on what measures promote positive synergies and avoid negative synergies - to support this, rather than trying to make a conclusive statement on whether the balance is currently positive or negative.
One key issue is the under-funding of health care in developing countries. Whether the objective is Comprehensive PHC for all, fulfilling the Right to Health obligation, or achieving the health-related Millennium Development Goals (MDGs), neither national nor international funding of health care measures up.
Scarcity of human and financial resources was observed to drive competition and rivalry. At the same time, health funding should not only increase, but also become more reliable in the long run. For ministries of health to embark to an ambitious health workforce programme, for example, a long term financing perspective is needed. It doesn’t make sense to increase training capacity today, if 10 years from now the additional health workers’ salaries cannot be secured to employ trained personnel. A new concept of sustainability adopted for AIDS treatment – where sustainability is based on domestic resources and sustained international funding – should be expanded to health systems and services, including salaries of health workers.
Most participants to the meeting acknowledged that AIDS activists have been more successful than the proponents of PHC at getting their priority high on the political and funding agendas. However, within the spirit of Comprehensive PHC, they saw this could be an opportunity rather than a threat, if this is used to equally raise the profile on general health systems and services, not to depress the profile given to AIDS responses.
Delegates felt the means to this was through renewed impetus for what is fundamentally a shared and uniting paradigm of Comprehensive PHC, including AIDS prevention and treatment, where:
• Health (and health care) is a human right, and an entitlement
• Programming and financing is adapted to needs and not to scarcity of human and financial resources
• Macroeconomic policies are adjusted to vital needs and not the other way around
• Concerns about the sustainability of health care is addressed as a shared global responsibility, depending as much on sustained national funding as on sustained international funding
• The people whose health is at stake are involved in the decision-making process
Where the global AIDS response has made significant progress on these issues, the benefits of this progress must be extended to general health systems and services.
Therefore:
• Governments must live up to their promises: governments of low-income countries must allocate 15% of their domestic government revenue to health while governments of high-income countries must allocate the equivalent of 0.7% of their Gross Domestic Product (GDP) to global solidarity, and 15% of that (0.1% of GDP) to health.
• These commitments should be open-ended (as long as needed), without aiming for national financial resources to replace international financial resources as soon as possible, as this would undermine the crafting of ambitious health plans, including workforce plans.
• Ceilings on health expenditure (included in policies imposed by the International Monetary Fund) must not hamper the realisation of the right to health or Comprehensive PHC for all.
• The people whose right to Comprehensive PHC is at stake have the right and the duty to be involved in critical decisions that affect their health.
• The global aid architecture must be reorganised in such a manner that it supports Comprehensive PHC for all, not one part of Comprehensive PHC at the expense of another; andGeneral health systems and services not only need strengthening, but also transforming: involving and working with communities as participants of health systems and services, rather than merely ‘clients’ or passive recipients of health services.
We found that the global AIDS response created real challenges for health systems and services, but also that there are ways to tackle and minimise them. The global AIDS response also created real opportunities, which should be maximized.
Comprehensive PHC is a uniting goal for all constituencies. It demands a significant mobilisation of knowledge, experience and additional funding. We cannot afford to repeat the mistake of three decades ago, when the ideal of Comprehensive PHC was abandoned as unaffordable, leaving us with the present health and health systems deficit.
This oped is not intended to be an accurate record of the meeting referred to which can be obtained from the authors located at Institute of Tropical Medicine, Antwerp [http://www.itg.be/itg/GeneralSite/Generalpage.asp]. EQUINET welcomes further opeds on the issues raised in this oped and on Comprehensive PHC, particularly from an equity perspective. Please send debate, comment or queries on the issues raised, or communications for oped authors to the EQUINET secretariat, email admin@equinetafrica.org.