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Innovative Approaches and Key Actions for Sustainable Community Health

Innovative Approaches and Key Actions for Sustainable Community Health. David Sanders Emeritus Professor: School of Public Health University of the Western Cape Member of Global Coordinating Council, Peoples Health Movement.

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Innovative Approaches and Key Actions for Sustainable Community Health

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  1. Innovative Approaches and Key Actions for Sustainable Community Health David SandersEmeritus Professor: School of Public HealthUniversity of the Western Cape Member of Global Coordinating Council, Peoples Health Movement A WHO Collaborating Centre for Research and Training in Human Resources for Health

  2. Acknowledgements PaulinBasinga, KedarBaral, Titus Divala

  3. Outline of Presentation • Equity and equality • Health trends in the era of Primary Health Care - 1980 to 2004 – with special emphasis on Africa’s health situation • Impact of globalisation, conservative health policies and HIV/AIDS on health equity, poverty, health “determinants” and health systems • The role of Community Health and Primary Health Care. Examples of key actions to improve access to and quality of health care AND address the determinants of ill-health.

  4. EQUITY Equity is an ethical concept of social justice, fairness and human rights, where need rather than privilege is the foundation for the allocation of resources (Braveman & Gruskin 2003, Braveman & Tarimo 2002). Whitehead (1992) defines health inequities as “differences in health that are unnecessary, avoidable, unfair and unjust”.

  5. EQUITY Equity was one of the founding principles of the Primary Health Care approach, ratified in the Alma Ata Declaration of 1978 (WHO 1978) and a priority of the WHO Health For All Strategy (WHO 1981). Equity concerns are also prominent considerations in the 2000 Millennium Declaration, which gave rise to the Millennium Development Goals (WHO Task Force and WHO Equity Team, 2005).

  6. AFRICA and SOUTH ASIA’S CRISISMortality 1 - 4 year olds Territory size shows the proportion of all deaths of children aged over 1 year and under 5 years old, that occurred there in 2002. www.worldmapper.org

  7. AFRICA and SOUTH ASIA’S CRISISTB cases Territory size shows the proportion ofworldwide tuberculosis cases found there. www.worldmapper.org

  8. Despite successes, growing inequalities in global health

  9. What are the key ‘Underlying Causes’ of Global Health Inequities and Africa’s Health Crisis? • HIV/AIDS • Increasing poverty and inequality worsened by inequitable globalisation • and selective PHC and inappropriate health sector “reform” • ….. result in slow progress and reversals.

  10. The debt crisis, structural adjustment and globalisation A crucial development in the current phase of globalisation…

  11. Inequitable GlobalisationExternal debt and meagre aid • Between 1970 and 2002, African countries borrowed $540 billion from foreign sources, paid back $550 billion (in principal and interest), but still owe $295 billion (UNCTAD 2004) • Africa spends more on debt servicing each year than on health and education

  12. Inequitable Globalisation …includes imposed and unfair trade

  13. Unfair Trade • “..drawing the poorest countries into the global economy is the surest way to address their fundamental aspirations” (G8 Communiqué, Genoa, July 22, 2001) • BUT… many developing countries have destroyed domestic economic sectors, such as textiles and clothing in Zambia (Jeter 2002) and poultry in Ghana (Atarah 2005), by lowering trade barriers and accepting the resulting social dislocations as the price of global integration .

  14. “Transnational corporations .have flourished as trade liberalization has broadened and deepened. The revenues of Wal-Mart, BP, Exxon Mobil, and Royal Dutch/Shell Group all rank above the GDP of countries such as Indonesia, Norway, Saudi Arabia, and South Africa (EMCONET, 2007). The combination of binding trade agreements .. and increasing corporate power and capital mobility have arguably diminished individual countries’ capacities to ensure that economic activity contributes to health equity, or at least does not undermine it”.

  15. SAPs, by lowering public expenditures and workers’ salaries, abetted low level corruption as a means of survival (Hanlon, How Northern Donors Promote Corruption, The Corner House,2004) Superpowers in Africa “backed venal despots who were less interested in developing their national economies than in looting the assets of their countries…” Amongst worst MNC bribery offenders are those located in G8 countries (Transparency International) Governance - Bribery & Corruption

  16. The result… unequal growth of wealth between countries

  17. AFRICA and SOUTH ASIA’S CRISISGDP wealth Territory size shows the proportion of worldwide wealth, that is Gross Domestic Product based on exchange rates with the US$, that is found there. www.worldmapper.org

  18. According to the World Bank’s most recent figures, in sub-Saharan Africa 313 million people, or almost half the population, live below a standardized poverty line of $1/day or less (Chen and Ravallion 2004). • Sub-Saharan Africa is the only region of the world in which the number of people living in extreme poverty has increased – indeed, almost doubling between 1981 and 2001. ..and growth of poverty in Africa

  19. ..and unequal distribution of global income UNDP 1997

  20. Why should a Japanese cow enjoy a higher income than an African citizen?

  21. Health Policy Trends and their Impact on the Health System

  22. WHO/UNICEF Alma Ata Conference (1978) • Alma Ata, the capital of Kazakhstan, now called Almaty • Site of the 1978 WHO/UNICEF conference ‘Health for All by the Year 2000’

  23. Primary Health Care is more than health services The concept of PHC had strong sociopolitical implications. It explicitly outlined a strategy which would respond more equitably, appropriately and effectively to basic health care needs and ALSO address the underlying social, economic and political causes (determinants) of poor health.

  24. A Split in the PHC Movement In 1980s, an exclusive focus on cost-effective technologies and a neglect of social and environmental determinants and processes led to substitution of “selective” for “comprehensive” primary health care (PHC) – e.g. UNICEF “Child Survival and Development Revolution” Growth Monitoring Oral Rehydration Therapy Breast Feeding Immunisation

  25. EXAMPLE: A comprehensive approach to diarrhoea

  26. Selective PHC has continuities with aspects of Health Sector ‘Reform’ as promoted in the 1990s

  27. Health sector ‘reform’: Quest for efficiency Cost-effectiveness analysis has focused only on certain easily measurable interventions and proposed limited ‘packages’ of mainly personal preventive and personal curative care – reminiscent of selective PHC..

  28. Access to water and hygienic sanitation • Only 44 percent of rural SSA ie 60 percent of SSA population, has access to adequate water supplies and good sanitation in 2004 • Over the period 1990 – 2004, the number of people without access to drinking water increased by 23% and those without sanitation increased by over 30%

  29. The changing donor funding architecture and the emergence of Global Health ‘Partnerships’ have reinforced ‘selective’, technocratic and vertical approaches

  30. GHPs, established1974-2003, (overall) <www.ippph.org>

  31. 9000 8000 7000 US$ million 6000 5000 4000 PEPFAR 3000 2000 1000 0 Total annual resources available for AIDS 1986‒2005 8297 Signing 2001 UN Declaration of Commitment on HIV/AIDS (UNGASS ) World Bank MAP launch UNAIDS Less than US$ 1 million 1623 Global Fund 292 257 212 59 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Notes: [1] 1986-2000 figures are for international funds only [2] Domestic funds are included from 2001 onwards [i] 1996-2005 data: Extracted from 2006 Report on the global AIDS epidemic (UNAIDS, 2006) [ii] 1986-1993 data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996)

  32. Donor practices5 highest burdens for LMICs * 1. donor driven priorities and systems 2. difficulties with donor procedures 3. uncoordinated donor practices 4. excessive demands on government time 5. delays in disbursements * survey of 11 recipient countries cited in: Guidelines for harmonising donor practices for effective aid delivery OECD Development Assistance Committee, 2003 Brugha 2007

  33. AIDS and Aid may both disrupt health systems… In 2000, Tanzania was preparing 2,400 quarterly reports on separate aid-funded projects and hosted 1,000 donor visit meetings a year. Labonte, 2005, presentation to Nuffield Trust

  34. Challenges: Sustainability eg EthiopiaHIV/AIDS especially ART is donor dependent—HIV Spending (in Birr) by Source of Funds: Donor Vs Government (source HAPCO documents till 2005) Banteyerga, 2007

  35. Challenges: Effects on Non-Focal Health Care Services eg Ethiopia “Health providers are shifted from the medical and surgical departments to the ART clinic. This is creating work burden on health providers, for they have to cover services that used to be offered by the shifted staff”. Regional hospital, head of the ART clinic. Banteyerga, 2007

  36. Burden of disease Share of population Share of health workers Our Common Interest 2005:184

  37. Extent of health professional migration from Africa, cont. • Between 1985 and 1995, 60% of Ghana’s medical graduates left. • In 1999, 78% of physicians in South Africa’s rural areas were non-South Africans. • During the 1990s Zimbabwe lost 840 of 1,200 medical graduates; • 2,114 South African nurses left for the UK during 2001.

  38. Unfair trade International migration- Winners • Importing countries accrue significant economic and political benefits from international migration. • The United Nations Conference on Trade and Development (UNCTAD) estimates that for each professional aged between 25 and 35 years, US$ 184,000 is saved in training costs by developed countries (UNECA, 2000).

  39. In summary: health status is stagnant or declining and public health systems in many African (and some European)countries are weak, poorly staffed and fragmented … reversing previous gains in PHC implementation

  40. Slide Date: October 03 Global Immunization 1980-2002, DTP3 coverage global coverage at 75% in 2002 Source: WHO/UNICEF estimates, 2003

  41. The role of Primary Health Care in improving health equity

  42. Achievements of CPHC. • In countries where CPHC has been implemented, dramatic improvements occurred eg greatly improved coverage, especially of MCH care and particularly EPI, and steep declines in child mortality eg Brazil, Thailand, Iran, Costa Rica, Cuba, Nepal and Rwanda when political commitment sustained.

  43. Nepal

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