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By Mr. Mulumba Moses
Experts met this week for the Fourth Global Symposium on Health Systems Research in the beautiful Canadian city of Vancouver. This particular symposium theme was built around resilient and responsive health systems for a changing world. Simply put, on the one hand, health systems must be resilient in ways that enable them to absorb shocks and sustain gains and on the other hand, the systems should be responsive by anticipating change, respecting rights, and engaging politics.
I got an invitation as part of the closing panel to particularly share thoughts from a retrospective look at how lessons learnt from key moments in the field of health policy and systems research and practice might shape and inform the field going forward. This offered me a moment of reflection on the global developments in health policy and how these have continued to shape and affect our health systems nationally. In my reflection, the Global Agenda on health policy has shifted from a broader focus on strengthening resilient and responsive health systems to an approach of sustaining health systems in the most economically efficient manner with minimal public sector investments.
The spirit of building such resilient and responsive health systems was very inscribed in the earlier global health agenda as illuminated in key documents such the 1974 Lalonde Report, the 1978 Alma Ata Declaration on Primary Health and the 1986 Ottawa Charter from the first International Conference on Health Promotion. At the core of these proclamations were health systems built on prevention of health problems and promotion of good health.
The Alma Ata Declaration, for instance, emphasised investments in primary health care and highlighted that people have a right and duty to participate individually and collectively in the planning and implementation of their healthcare. The focus then was to move away from just medicalised health systems to more inclusive ones with a community-engagement component.
In my view, if well implemented, this approach would provide an impetus for building resilient and responsive health systems.
There was, however, a shift in the mindset of theory informing health policy-making towards the early 1990s. At this time, Primary Healthcare approaches and health promotion strategies were criticised for being unmanageable, lacking clear measurable, and very costly to sustain. In the alternative, a selective approach that is disease specific, measurable, and more cost effective was proposed.
It is not surprising that global decisions on health have bred the current famous disease specific projects in areas of HIV/AIDS, Tuberculosis, Malaria and lately maternal health. As such, all funding for the health sector has been moved to these projects. The impacts on the overall health systems especially in the low and middle income countries have been severe.
These range from destruction of Primary health care structures of community participation in health decision making, through to emergency of neglected diseases and parallel programming siphoning key human resources from the mainstream health system to the more resourced disease-specific projects. The disaster in the end has been the non-resilient and unresponsive health systems which are manifested by the outbreak and failures in the control of diseases like Ebola in West Africa.
In my view, the change in mindset could be largely attributed to the major role played by the neoliberal approaches introduced in the early 1990s when the World Bank together with the IMF aggressively introduced Structural Adjustment Programs as condition for receiving bailout loans.
This approach advocated for major budget cuts from social sectors, including health. The call for cutting public expenditure severely affected investment in health systems. They were replaced by projects focused more on diseases and less on Primary Health Care Investments.
This approach has led to development frameworks being highly skewed towards a free market economy. With this thinking continuing to influence national policy making through the famous Poverty Reduction Strategy Papers now metamorphosed as National Development Plans, countries including Uganda continue to conceptualize their national health policies and strategies from an economic perspective more than as a public health concern.
In my opinion, this has by and larger resulted into selling health systems to the market place and commoditising the provision of health care. This has been very carefully crafted to slowly but surely weaken the role of the State in building resilient and responsive health systems. It is, therefore, not surprising that in a number of health systems in low income countries including Uganda, the private sector is providing close to fifty percent (50%) of healthcare. No health system largely run by the private sector can be described as resilient and responsive.
Such implications are not just at the national level, but the entire architect of global health governance. The would be global leaders have to highly depend on the private sector not just for their funding but also agenda setting and proposing the global health priorities. The current proposals on universal health coverage are, therefore, not surprisingly dominated by the role of health insurance. This is understood as a business model.
I will propose that in looking forward, we need to situate health systems research in interrogating a paradigm shift in the current health governance structure. At the global level, health governance should question the agenda setting and toning down on the role of the private sector. At the national level, the state needs to reclaim its role in the social contract, including emphasis on its unfettered regulatory function and – at the community level, health governance should bring back communities in priority setting, involvement, informing evidence, and not merely acting as vehicles for facilitating health provision because of limited resources. In this way, we could talk about a resilient and responsive health system.
Moses Mulumba is a lawyer practicing Health Law and Policy at the Center for Health, Human Rights and Development.
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The Executive Director of Center for Health Human Rights and Development is this week representing the organization during a with Global leaders in Health Systems Research for the Fourth Global Symposium on Health Systems Research in Vancouver.
Mr. Mulumba will be part of the Key note speakers and he will be sharing thoughts from a retrospective look at how lessons learnt from key moments in the field of health policy and systems research and practice might shape and inform the field going forward. For more Information please follow this LINK
Center for Health, Human Rights and Development (CEHURD) in partnership with the Open Society Justice Initiative organized an Africa Regional Strategy Meeting on Access to Information and the Right to Health. The meeting was held on October 12th – 14th, 2016 at Lake Victoria Serena Hotel, Entebbe – Uganda.
The right of Access to Information is essential for improvement of governance, promotion of transparency and accountability and the use of information to ensure that other human rights are exercised.
The concept that access to health information is key in protecting the right to health was the basis of the meeting. The meeting gathered health rights advocates from Malawi, Kenya Uganda, Zimbabwe Tanzania and Nigeria to share insights on Access to Information in their countries of origin.
In his remarks, Mr. Mulumba Moses proposed that, “the issue of Access to Information needs to have a regional perspective given that each country perceives it differently, leading to the creation of strong networks in the region.”
In Uganda, the right of Access to Information pursuant to Article 41 of the Constitution grants every citizen the right to access information in the possession of the state or any other state agency except when the release of information affects state sovereignty or interferes with privacy rights.
Zeroing in on Access to Information (ATI) in the health sector, The Ministry of Health in Uganda has made progress in achieving ATI in Health. In 2011, the ministry introduced the DHIS-2 for online access of electronic health information.
Dr. Mukooyo Eddie said, “The ministry is yet to launch the Uganda Integrated Health Information System to which all service providers whether public or private will subscribe to.”
Although Uganda has made progress in implementing ATI in health, there are gaps hindering effective implementation of the law for example; the law is limited to public and not private institution, intimidation by the custodians of the information, weakness in the judicial system, lack of awareness about the Access To Information Act, poor attitudes and perceptions of public officials towards openness in sharing information.
Such shortfalls have led to scanty or no information on issues to do with; organ theft (an increasingly common practise in health facilities), drug stock outs, drugs expiring and allocation of health resources among others; yet these are critical issues of public concern.
To mitigate the inaccessibility of health information participants suggested the need for more awareness on the Access to Information Act at community level, effective implementation of the Access to Information Act, building coalitions and networks for information sharing.
Through the meeting, the teams got opportunity to share best practises from countries that successfully applied ATI.
Mariana Mas from the Open Society Initiative said, “Mexico used the social monitoring strategy to investigate the disparities in payment of medical staff as compared to what the Ministry of Health was required to pay them.”
She narrated, that in Uruguay, ATI was used to ensure that the Ministry of Education provided public schools with fire extinguishers, given that it was found that 94% of the public schools did not have these fire protection devices. Other strategies she mentioned included litigation and public demonstrations.
Ms. Mariana called for the need to go through the information request process, putting in mind that one strategy that works in Uganda may not necessarily work in Zimbabwe and therefore a need to critically assess the environment is important.
For countries like Kenya, being the newest country to pass the ATI law in August 2016, their representatives used the meeting as an opportunity to learn from countries that had the Access to Information law, way before them. With a few challenges they are facing like violation of human rights, and less media engagement, the Kenyan participants believe that they still have the opportunity to develop a road-map for implementation of the law.
Some of the critical concepts participants went with at the end of the meeting included; proactive disclosure by the custodians of public information and the need to expand the ATI discourse to the private sector.
The meeting was closed by Dr. Mukooyo who in his remarks called for more partnerships with government for implementation of the Access to Information Act.
Press Release
For immediate release
November 4th, 2016
Kampala – Uganda. On October 18th, 2016, the Center for Health Human Rights and Development (CEHURD) filed two cases against the Attorney General of Uganda in its representative capacity for Uganda Cancer Institute and Uganda Atomic Energy Council challenging their refusal to grant access to information requests made for access to public information.
CEHURD filed two access to information requests to Uganda Atomic Energy Council requesting to be granted access to copies of licenses and inspection reports relating to radiotherapy equipment at Uganda Cancer Institute. CEHURD also filed four access to information requests to the Uganda Cancer Institute requesting for access to information regarding how many patients had been affected by the breakdown of the radio therapy machine, the alternatives available for treatment of patients affected by the breakdown of the radiotherapy machine and the licenses which have been received by the Institute in relation to radiotherapy equipment. Both the Uganda Cancer Institute and the Uganda Atomic Energy Council have refused to provide the information requested.
The Constitution of the Republic of Uganda under Article 41 provides for the right to access information in possession of a public body when it states that “Every citizen has a right of access to information in the possession of the State or any other organ or agency of the State except where the release of the information is likely to prejudice the security or sovereignty of the State or interfere with the right to the privacy of any other person.”
The Access to Information Act, 2005 also provides under Section 16 that an information officer to whom a request for access is made should as soon as reasonably possible, but in any event, within twenty one days after the request is received, determine in accordance with this Act, whether to grant the request and notify the person requesting the access of the decision to grant or not to grant access to the information requested.
“Uganda Atomic Energy Council and Uganda Cancer Institute both have a constitutional and statutory duties to provide access to information which is in their possession when any member of the public requests for it in accordance with the law. Having failed in their obligation to provide such information, they left CEHURD with no option other than to seek courts intervention.” – Epongu Edmond – Program Officer at CEHURD.
Information is power that can be wielded for and against the public depending on who controls the information and who is allowed to access it. UAEC and UCI can protect and empower society by making such information available to their website and to all persons desiring to access it at any time even if with costs for accessing it.
The judiciary has been called upon to compel UAEC and UCI to provide access to the documents requested because the constitution protects the right of Ugandans to access the information.
For more information contact info@cehurd.org, or call +256-414-532283, or Epongu Edmond on epongu@cehurd.org
