23 June 2011

Africa: Thinking Local to Build Health Systems

Photo: IRIN
A child suffering from sleeping sickness being injected with arsenic, in the Democratic Republic of the Congo, May 2006.

Francis Omaswa is executive director of the African Centre for Global Health and Social Transformation (ACHEST), an initiative incorporated in Uganda and promoted by a network of African and International leaders in health and development. While attending the recent 38th Annual International Conference on Global Health held in Washington, DC, Dr. Omaswa spoke to AllAfrica about Africa's experience in the global health community and the challenges of building up the continent's health systems and capacity.

Your experience in global health is extensive. How would you describe Africa's role when it comes to health and development?

[After] attending meetings at the United Nations and the World Health Assembly, it became very clear that Africa was getting a raw deal. We were not prepared for the debates as well as we should be prepared.

Sometimes decisions were made which we didn't support, but we did not come with evidence to combat the other side of the debate. Also we are stretched. You go to the World Health Assembly or to the Global Fund meeting and the U.S government will come with a delegation of maybe 30-40 people and Uganda will go with a delegation of two people. The developed world comes to these meetings with very clear positions.

African officials, even at home, have got so many other things calling for your attention; you get on the plane to go for a very important international meeting and might be reading your conference papers on the plane. ACHEST was created to address that challenge. ACHEST does health research and modeling of what works and what doesn't work. For example, one of the significant studies carried out between 2008-2009 by ACHEST and the New York Academy of Medicine was "Strong Ministries for Strong Health Systems" looking at the strengths of health ministries and capabilities of ministers of health.

With professional expertise returning to the continent after the global recession has it had an impact on health? Is the problem of African health worker migration a thing of the past?

The situation is better now than 15 years ago. There was a very, very bad time in the late 1990s when the World Bank and International Monetary Fund (IMF) imposed structural adjustment programs. In many countries in Africa we were producing health workers paid for by government but they were not allowed to be recruited into the public service; the IMF loan conditions imposed spending caps on governments, which didn't allow many countries to recruit any new health workers.

Those qualified people started going out of the country because there were no jobs for them. There was an outcry from African health ministers and for three consecutive years they came to the World Health Assembly and forced down resolutions on health workforces, including health worker migration. The debate resulted in a code on international recruitment of health workers and investment to train health workers globally. The demographic structures (fewer young people) in the developed world adds to the increase in demand of health workers from the developing world. We need a package of incentives plus functioning health facilities to keep qualified health workers on the continent.

The current buzzwords in health development circles are 'health systems and capacity building'. Can you explain?

The background is that the donors started by focusing on putting resources into diseases - i.e. HIV-Aids, malaria, TB etc. And then lo and behold they found out that when they buy TB or HIV drugs they expire on the shelves because there is no way of getting them to the patients. That is when the word 'health system' then came to the fore.

There are a number of steps from diagnosis to laboratory tests and a decision made as to which drug is suitable for the patient. That whole chain of getting the patient to swallow the drugs after a diagnosis requires a system. Health systems need financing, human resources, laboratories, leadership, governance, organization and policies. The word 'capacity' is about putting in place all those things.

However, because there is always a local version of health delivery already in place, one of the challenges in using the word 'health system' is that it puts off some of the people who should be helping us.

It has become necessary to simplify the definition of a health system. I have been advocating for a very simple definition. I would define health systems as the arrangements which a country or society puts into place to take care of the health of its people. In other words, in a country or society there is already a health system there; there is always something there - good or bad - that can be worked on and improved.

Managing the health system has got to be responsive to the culture of the country, the way the people relate to each other, the governance arrangements, the power arrangements, the resources the country has got: infrastructure, roads and so on. That's what you build on over time. The health of the people is vital. People value their health and my message has been that every society should integrate into its governance arrangement taking care of the health of its people.

Can you tell us something about the Ministerial Leadership Initiative for Global Health?

The initiative is working in five countries to try and model what I have just said about health systems and strengthening capacity. But it is something we have been struggling with for a long time. It has worked well in some countries for some time, and then up and down. What to do is to articulate it and how to do it is also articulate it. But like in every society, things fluctuate. Sometimes you get good leaders and then bad leaders and less committed people.

But it would seem that health ministers all agreeing on the same goal of capacity building would represent enough political commitment and will to push health policies through in their individual countries.

That is true. But there are also structural strictures there that are difficult like the economies. The expenditure per capita for health in African countries is very low and that's an impediment. In the United States you are talking about maybe U.S.$4-5,000 per capita. In Africa, you are talking about 10 dollars per capita and that limits what can be done, like the with the salary of health workers, availability of equipment and facilities and the way in which they are managed. So we end up depending on donors. Then managing donors becomes a job in itself.

You have served in Uganda and Kenya. In your experience how do the different styles of governance affect health policy?

Kenya, Uganda, Tanzania and most of the countries in that area have very strong similarities and common policies because of the East African Community (EAC) and it has been like that since colonial times. The same colonial masters were ruling all those countries so they set up identical systems.

What we are all doing in all these countries is what is called 'sector-wide approaches'. This is a way of planning and delivering health services that involves sitting together with all the stakeholders and agreeing on one plan, and then the plan is implemented by the government of the country. But you also have one mechanism of monitoring and you monitor together.

Because resources are limited, each country chooses its priorities and develops its own basic or essential healthcare package. Then you set your health system to deliver essentially those services through this plan and resources envelope that you have. But it leaves a lot of people who cannot access this essential healthcare package - or whose disease conditions are outside the package - to have to fend for themselves. The expenditure of individuals out of their pocket is always higher than the expenditure of per capita by government.

In which areas is the sector-wide system lacking? What can be done better?

The one crucial area is in the increase in flows of money into health by increasing the health resource envelope. That would be done through a variety of national health financing initiatives. Taxes and insurance - i.e. insurance for former employees, community insurance schemes. For example, rural people, when they harvest their crops, they can deposit them somewhere and when they are sick later on in the year they have already contributed to that community insurance scheme.

So a combination of those should be able to bring in more money than just the taxes that the government puts in. To me, this combination of taxes and insurance in the form of innovative health financing is the one most important effort that counties in Africa should make.

What are the impediments to achieving the health-related Millennium Development Goals (MDGs) in Uganda and on the rest of the continent?

The biggest impediment is the resource envelope we talked about. We are spending too little money on health. The second is we need to close the implementation gap, which is the things we know we want to do, have decided to do, and coming around to actually doing them. And that brings us back to capacity building and strengthening of health systems.

The other thing is leadership and political commitment to put in the sufficient effort it takes to achieve the MDGs. Take a country like Eritrea, for example. It is a very small country but they are very committed to achieving the MDGs. They have virtually eradicated malaria and the same goes for Rwanda. Ethiopia is getting serious as well as it began to train a lot of health workers.

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