Agnes Nanyonjo & Eleanor Namusoke, two Emerging Voices 4 Global Health from a low-income country, Uganda
The draft report ‘Health in the post-2015 development agenda’ draws our attention to the fact that MDGs played a key role in keeping countries focused on achieving specific goals. We share this view and hope the post-MDG health goals will do the same. The post-MDG draft is, for the time being, tailored towards maximizing healthy life expectancy and universal health coverage (UHC). Most of the international debate centers on UHC, however. If only UHC were to be the post-MDG goal, this would clearly not suffice, at least if you view UHC through the lens of its implementation in low-income countries (LICs).
UHC is a means to an end. Adopting it as the sole post-MDG health goal with a view on achieving health for all would thus be simplistic, and the report has rightly criticized this. In addition, we believe that setting UHC as the sole goal would be simplistic for a number of other reasons.
UHC intrinsically demands access to quality services and financial risk protection for all and as such clear global targets and indicators for UHC that can easily be applied to country levels will need to be stated.
One challenge that LICs struggle with on a daily basis is the lack of human resources for health (HRH). Although HRH are briefly mentioned in the report, the lack of HRH is not adequately addressed in the report, we feel. It is known that HRH are part and parcel of the WHO pillars of health system strengthening and are crucial in ensuring UHC, but below optimal attention has been given to HRH even after the Kampala Declaration. We are not convinced that the current UHC momentum will manage to change this. There have been efforts to address issues with low staffing levels in many LICs through task shifting but even with this intervention, the patient to health worker ratio is still high leading to long waiting times at the health facilities and compromised quality of services. The well-to-do patients are forced to go to private for profit health facilities to get faster and better quality services that are quite expensive. As for the less wealthy patients, you can do the math yourself. We worry that lumping HRH together with other health system strengthening pillars might not give this issue the attention it so much requires. Hence, addressing the human resources for health gap (while taking into account HRH’s role as key players on the international and domestic health market) should be an explicit global post-MDG health target. Obviously this global goal needs to be tailored to national contexts then.
Governmental bodies in low income countries have made efforts to provide “free” medical services but these often remain inaccessible to those who most need them and the quality of services especially in the rural areas needs to be improved. Access to specialized care in LICs also remains a challenge and is out of reach for those who most need it. These services are mainly accessible to the relatively well-off in big cities. For instance in Uganda, there is only one cancer treatment centre. Patients who can not afford transport costs will die in their villages. It is also at the National referral hospital only that a patient with renal failure can receive dialysis services. Hence, we recommend that as a way forward more attention should be given in the post-MDG health agenda to policies regulating the quality of (1) health services provided for free by the governments and (2) to health services purchased from the private health markets. Also, decentralization of specialized health services to the regional level needs to be given more emphasis in the post-MDG health framework if the quality of health services is to improve.
The report critically acknowledges the need to see health as a consequence of the social determinants of health, a view with which we concur. However the term “social determinants “ of health is rather broad in itself and the report does not explicitly state the social determinants of health that should be prioritized in LICs. Whether the social determinants referred to in the draft report are the underlying determinants of health as stated in the ECOSOC general comment nr 14 (food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment) or correspond to the definition from the WHO Commission on Social Determinants of Health (which more explicitly includes power relations, poverty, discrimination etc), is not clear. The social determinants of health that are to be prioritized in the post-MDG health framework should be made explicit. This is absolutely vital for LICs, even more so than elsewhere.
In our view, the global threat of climate change has also not been adequately addressed in the report, although we acknowledge that tackling climate change is a multisectoral endeavor in which the health sector can just play its role, albeit an important one. Yet, we would like to stress that many people in LICs depend exclusively on agriculture for their livelihood and that there is a rising prevalence of diseases due to climate change in LIC contexts. These same people are, however, in the worst possible position to deal with the harmful impacts of climate change. We argue along with others that – in the general post-2015 development agenda, which should be framed around sustainable development, adaptation policies addressing the adverse effects of climate change and mitigation policies regulating carbon emissions should be prioritized as global targets. It would be good if the post-MDG health document (and thus the health community) advocated for this, even if strictly speaking this challenge goes beyond the health sector. Tackling climate change should get the priority it deserves in the 21st century. In addition, the health sector should do its share, even more so because there are obvious synergies between a good health, equity and an ecologically sustainable world, as WHO already emphasized at the Rio SDG conference in 2011 for example. Within the health niche, specific sub-goals on climate change could be: (1) focusing on interventions that improve both health and reduce carbon emissions (climate interventions with so-called health co-benefits); (2) sustainability in the health care sector and, most importantly for LICs, (3) building climate resilient health systems. During natural disasters, health facilities and supply systems often collapse and are unable to provide shelter and care at a time the population is in urgent need. We hope these sub-goals will get the attention warranted in the current circumstances.
As a result of poverty there has been increased interaction between human beings and the ecosystem, as mankind has been in search of fertile soil for agriculture. In many cases, this has led to emerging and re-emerging diseases in LICs who have the least resources to detect, diagnose and treat these diseases. We strongly recommend that a “One Health approach” involving the collaboration of multiple disciplines and (animal and human medical) communities is given more attention in the report. Practitioners, veterinarians, environmental researchers and public health professionals need to be brought together, and this should be an explicit sub-goal.
Some of the health problems of LICs stem from conflicts with firearms. The firearms are often supplied by HICs, perfectly legally in many cases. Although the report mentions human rights and equity as core values, a viewpoint to which we agree, we believe that the report should be more open about the impact of international (trade or other) treaties on the right to health, and if necessary argue for a revision of these treaties if they negatively affect health. Firearms are just one example. Too often, a real “whole-of-government” approach on the part of HICs is lacking. If HICs take human rights and equity seriously, they should review international treaties on the basis of their impact on health. Curbing the sale of firearms would be a good start.
One factor that has largely undermined health development in many LICs is corruption at both national and sub-national levels. Following the Millennium Declaration, many HICs dedicated themselves to helping LICs through increased donor funding as a way of showing their commitment to the MDGs. It is undeniable that health aid to LICs will remain needed, at least in the short to medium term, but if we are serious about health financing, then more commitment to fighting corruption and funding governance (capacity) is needed. The report in its current form barely acknowledges the challenges LICs face with corruption and governance of health funds. It would be good if the report acknowledged that some corruption probably stems from the form and very mechanisms of aid provided by HICs to LICs (in spite of all the talk about accountability). In our view, these aid forms and mechanisms need to be revisited urgently. For example, aid in the form of capacity building like the one offered by South Korea is less prone to corruption compared to the fragmented pools of funds provided by the United Kingdom.
Finally, measurement of progress towards MDGs requires strong monitoring & evaluation and medical record systems. Many people in LICs are born and die without ever being entered into any form of official register. Tracking MDGs and UHC would therefore require capacity building across LICs in form of registration to allow for proper estimates of the progress indicators. Although nearly all MDG indicators (aim to) track progress, there is so far little mention of a proper registration system as a goal in itself. Along with the experts present at last week’s global health estimates meeting in Geneva, we argue this is absolutely essential.